剖宫产术中预防性输注去氧肾上腺素可增加鞘内重比重布比卡因的半数有效剂量：前瞻性随机研究
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Prophylactic infusion of phenylephrine increases the median effective dose of intrathecal hyperbaric bupivacaine in cesarean section: A prospective randomized study.
背景：输注去氧肾上腺素预防椎管内麻醉后低血压可减少鞘内布比卡因向头侧扩散。因此，本实验旨在探究在剖宫产术中使用去氧肾上腺素预防椎管内麻醉后低血压时鞘内布比卡因所需剂量的变化情况。我们设计了一项前瞻性的、随机的研究，在有或无预防性输注去氧肾上腺素预防椎管内麻醉后低血压的情况下探究健康产妇在腰-硬联合麻醉下实施剖宫产术时重比重布比卡因的半数有效剂量（ED 50）的变化情况。
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方法：本研究共纳入2016年7月至2017年2月在嘉兴大学附属妇幼医院产科实施择期剖宫产且ASA在Ⅰ/Ⅱ级的产妇60例。 登记后，用计算机产生随机分配序列对密封不透光的信封进行排序，将患者随机分为2组，每组30人。 由不参与结果测量的麻醉医生制备溶液。患者和搜集数据的麻醉医生均不知分组情况。P组(去氧肾上腺素组)产妇在鞘内注射时点预防性输注去氧肾上腺素。 S组(生理盐水组)产妇则输注相同体积的生理盐水。采用序贯法确定每例患者鞘内布比卡因的注射剂量。 初始剂量为7mg，将有效剂量定义为鞘内给药后10min内双侧T6或以上感觉消失时所需的剂量，术中疼痛无需硬膜外补充利多卡因。使用Dixon和Massey公式计算ED 50值。
结果：在组P和组S中，重比重布比卡因的ED 50分别为7.0mg(95%可信区间[CI]：6.6-7.4mg)和4.9mg(95%CI：4.4-5.4mg)(P<0.001)。 在组S和组P中,低血压的发生率分别为60%和10%，P=0.04, 脐动脉血的pH分别为 7.31±0.0 4 和 7.28±0.0 6，P=0.00 3，差异有统计学意义(P<0.0 5)。
结论：用去氧肾上腺素预防椎管内麻醉后低血压时鞘内重比重布比卡因的ED 50高于不使用者。
Zhang YF, Xiao F, Xu WP,et al. Prophylactic infusion of phenylephrine increases the median effective dose of intrathecal hyperbaric bupivacaine in cesarean section: A prospective randomized study. Medicine (Baltimore) 2018 Aug ;97(32) DOI：10.1097/MD.0000000000011833
BACKGROUND:Phenylephrine infusion to prevent spinal-induced hypotension can attenuate cephalic spread of intrathecal bupivacaine. Therefore, we suspected the intrathecal dose requirement for bupivacaine may differ when using phenylephrine infusion to prevent spinal-induced hypotension in cesarean section. We designed a prospective, randomized study to determine the ED50 of hyperbaric bupivacaine for cesarean section under combined spinal-epidural anesthesia in healthy parturients with and without prophylactic phenylephrine infusion to prevent spinal-induced hypotension.
METHODS:Sixty healthy parturients rated American Society for Anesthesiology status I/II undergoing elective cesarean section were enrolled in this study, which was conducted July 2016 to February 2017 in the labor and delivery department of Jiaxing University Affiliated Women and Children Hospital.After enrollment, patients were randomized into 2 groups of 30 by blinded opaque envelopes sorted by computer-generated random allocation.Solutions were prepared by an anesthesiologist not involved in outcome measurement. Patients and anesthesiologists collecting data were blinded to group allocation. Group P (phenylephrine group) parturients received prophylactic infusion of phenylephrine at the time of intrathecal injection. Group S (saline group) parturients receive the same volume of saline. Doses of intrathecal bupivacaine for each patient were determined using an up-down allocation method; initial dose was 7mg. Effective dose was defined as bilateral T6 or above sensory block level achieved within 10minutes of intrathecal drug administration and no additional epidural lidocaine required for intraoperative pain. The Dixon and Massey formula was used to calculate ED50 values.
RESULTS:The ED50 values for hyperbaric bupivacaine were 7.0mg (95% confidence interval [CI]: 6.6-7.4mg) and 4.9mg (95% CI: 4.4-5.4mg) for groups P and S, respectively (P<0.001). There were significant differences in incidence of hypotension and pH of umbilical arterial blood between groups S and P (60% vs 10%, P=.04 and 7.31±0.04 vs 7.28±0.06, P=.003, respectively).
CONCLUSION:The ED50 of intrathecal hyperbaric bupivacaine is higher when phenylephrine infusion is used to prevent spinal-induced hypotension than when it is not used.
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