椎管内使用吗啡并不能降低产妇硬脊膜穿破后头痛发生率
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Neuraxial morphine after unintentional dural puncture is not associated with reduced postdural puncture headache in obstetric patients
背景与目的
硬脊膜穿破后头痛（PDPH）是椎管内麻醉常见并发症之一，研究发现预防性椎管内吗啡可以降低产妇PDPH的发生,但椎管内吗啡使用后恶心呕吐、瘙痒的发生率较高。在硬膜外给予吗啡后，吗啡通过硬脊膜的破孔进入鞘内，增加了潜在的呼吸抑制风险。因此本研究旨在探讨意外硬脊膜穿破后椎管内使用吗啡降低PDPH的价值。
方 法
根据病史产妇被分入吗啡组或对照组，吗啡组的产妇通过硬膜外导管或鞘内导管给予吗啡。对照组则在发生意外硬脊膜穿破后不接受椎管内吗啡治疗。记录置入导管类型、产妇年龄、孕周、孕产次、BMI、分娩方式、产科相关合并症、PDPH发生情况及严重程度、EBP治疗情况、住院天数。主要观察结果是PDPH发生率，次要观察结果是EBP的比例、住院天数、头痛严重程度。
结 果
共80例发生硬脊膜穿破的产妇纳入了该研究，其中38例接受了椎管内吗啡治疗，42例未接受吗啡。1例出现了脑额叶出血，还有1例在发生意外硬脊膜穿破后使用吗啡治疗出现颈部僵硬。吗啡组子痫前期的产妇多于非吗啡组，吗啡组剖宫产的比例高于非吗啡组，阴道分娩的比例低于非吗啡组（P=0.001）；吗啡组和非吗啡组PDPH的发生率无差异（71%:69%）。多因素回归分析表明椎管内吗啡治疗不影响PDPH的发生率。各组间需要行EBP的比例、EBP的次数、头痛的严重程度差异均没有显著性，剖宫产吗啡组的住院天数较其他三组显著延长(P=0.01)
结 论
意外穿破硬脊膜后椎管内使用吗啡不能降低产妇PDPH的发生率、EBP治疗的需要以及和痛的严重程度。
原始文献摘要
Molly E. Brinser, David L. Seng, DO, Gordon L.etal; Neuraxial morphine after unintentional dural puncture is not associated with reduced postdural puncture headache in obstetric patients; Journal of Clinical Anesthesia Alhttps://doi.org/10.1016/j.jclinane.2018.09.009
Study objective: To examine the relationship between neuraxial morphine exposure after unintentional dural puncture and the risk for postdural puncture headache in obstetric patients.
Design: Retrospective cohort study.
Setting: Obstetrical unit at a tertiary care referral center.
Patients: Parturients receiving labor epidural analgesia with recognized unintentional dural puncture.
Interventions: Cases in which neuraxial morphine was given for any reason were compared to cases in which it was not for the outcome of postdural puncture headache.
Measurements: Development of postdural puncture headache, headache severity, number of epidural blood patches, hospital length of stay.
Main results: Of the 80 cases that were included, 38 women received neuraxial morphine and 42 did not. There was no significant difference in the incidence of headache between the two morphine groups (Headache
present:Morphine: 27/56 [48.2%], No morphine: 29/56 [51.8%]; Headache free: Morphine: 11/24 [45.8%], No morphine:13/24 [54.2%], P=0.84). There was no difference in the need for epidural blood patch (Morphine: 24/42 [57.1%], No morphine: 18/38 [47.4%], P=0.50) and headache severity (mean headache pain score:Morphine: 7.9 ± 1.8 vs. No morphine: 7.3 ± 2.4, P=0.58). Hospital length of stay was higher in the morphine group (4.4 ± 2.9 days vs. 3.0 ± 1.5 days respectively, P=0.008). Using logistic regression, morphine did not affect headache risk after controlling for covariates (morphine vs. no morphine: adjusted OR 1.24 [0.75]; P=0.72; pre-eclampsia vs. no pre-eclampsia: adjusted OR 0.56 [0.41], P=0.42; cesarean vs. normal spontaneous vaginal delivery: adjusted OR 0.97 [0.67]; P=0.96).
Conclusion: In cases of unintentional dural puncture, exposure to neuraxial morphine for any reason may not be protective against the risk of postdural puncture headache. Although an overall protective effect of neuraxial morphine was not observed in this study, its role in specific subsets of patients remains to be investigated.
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