硬膜外药物输注速率对分娩镇痛效果的影响：随机临床试验
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Effect of Epidural Infusion Bolus Delivery Rate on the Duration of Labor Analgesia：A Randomized Clinical Trial
背景与目的
研究表明，硬膜外分娩镇痛时局部麻醉药间断使用比持续输注有更好的镇痛效果，且硬膜外高速输注增加导管处的输送压力，并可改善硬膜外腔中的药物分布。本研究假设高速硬膜外输注可改善硬膜外分娩镇痛效果及药物使用量。
方 法
本研究为双盲、随机、对照试验，试验对象均为首次妊娠且宫口扩张≤5cm并要求性硬膜外镇痛的产妇；硬外膜导管置入后，芬太尼25ug推注；硬膜外维持药物及浓度分别为0.625mg／ml的布比卡因及0.625ug／ml的芬太尼，高速率组为300ml／h，低速率组为100 ml／h，病人自控镇痛剂量为5ml／次，锁定时间10min；主要结果为要求额外增加镇痛药物产妇的百分比。
结 果
高速率组共102名产妇，其中37人要求额外增加镇痛药物，百分比为36.3%，而低速率组共108名产妇，其中44人要求额外增加镇痛药物，百分比为40.7%（95%CI：-18.5～9.1%;P=0.67）;两组间每小时布比卡因使用量及镇痛药物额外用量无明显差异，所有产妇均无其他不良反应发生。
结 论
硬膜外输注速率的高低并不会影响硬膜外镇痛效果及药物使用剂量。
原始文献摘要
Elizabeth . Lange, Cynthia; Effect of Epidural Infusion Bolus Delivery Rate on the Duration of Labor Analgesia：A Randomized Clinical Trial; Anesthesiology 2018;XXX:00-00
Background: Programmed intermittent boluses of local anesthetic have been shown to be superior to continuous infusions for maintenance of labor analgesia. High-rate epidural boluses increase delivery pressure at the catheter orifice and may improve drug distribution in the epidural space. We hypothesized that high-rate drug delivery would improve labor analgesia and reduce the requirement for provider-administered supplemental boluses for breakthrough pain.
Methods: Nulliparous women with a singleton pregnancy at a cervical dilation of less than or equal to 5 cm at request for neuraxial analgesia were eligible for this superiority-design, double-blind, randomized controlled trial. Neuraxial analgesia was initiated with intrathecal fentanyl 25 μg. The maintenance epidural solution was bupivacaine 0.625 mg/ml with fentanyl 1.95μg/ml. Programmed (every 60 min) intermittent boluses (10 ml) and patient controlled bolus (5 ml bolus, lockout interval:10 min) were administered at a rate of 100 ml/h (low-rate) or 300 ml/h (high-rate). The primary outcome was percentage of patients requiring provider-administered supplemental bolus analgesia.
Results: One hundred eight women were randomized to the low- and 102 to the high-rate group. Provider-administered supplemental bolus doses were requested by 44 of 108 (40.7%) in the low- and 37 of 102 (36.3%) in the high-rate group(difference –4.4%; 95% CI of the difference, –18.5 to 9.1%; P = 0.67). Patient requested/delivered epidural bolus ratio and the hourly bupivacaine consumption were not different between groups. No subject had an adverse event.
Conclusions: Labor analgesia quality, assessed by need for provider- and patient-administered supplemental analgesia and hourly bupivacaine consumption was not improved by high-rate epidural bolus administration.
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