上海交通大学学报（医学版）

上海交通大学学报（医学版） ›› 2022, Vol. 42 ›› Issue (10): 1428-1434.doi: 10.3969/j.issn.1674-8115.2022.10.008

• 论著 · 临床研究 • 上一篇    

罗哌卡因联合单次小剂量艾司氯胺酮用于择期剖宫产脊椎麻醉的双盲序贯研究

孙元青(), 徐韬, 张虓宇, 徐子锋, 柴静()   

  1. 上海交通大学医学院附属国际和平妇幼保健院麻醉科，上海市胚胎源性疾病重点实验室，上海 200030
  • 收稿日期:2022-05-09 接受日期:2022-08-16 出版日期:2022-10-28 发布日期:2022-12-02
  • 通讯作者: 柴静 E-mail:15000058831@163.com;dadachai@126.com
  • 作者简介:孙元青（1992—），女，住院医师，硕士；电子信箱：15000058831@163.com。
  • 基金资助:
    中国医学科学院创新单元(2019RU056);中国医学科学院医学与健康科技创新工程(2019-I2M-5-064)

Optimum spinal anesthesia dose of ropivacaine combined with a single low-dose S-ketamine during elective cesarean delivery: a double-blind sequential study

SUN Yuanqing(), XU Tao, ZHANG Xiaoyu, XU Zifeng, CHAI Jing()   

  1. Shanghai Key Laboratory of Embryo Original Diseases, Department of Anesthesiology, The International Peace Maternity and Child Health Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200030, China
  • Received:2022-05-09 Accepted:2022-08-16 Online:2022-10-28 Published:2022-12-02
  • Contact: CHAI Jing E-mail:15000058831@163.com;dadachai@126.com
  • Supported by:
    Chinese Academy of Medical Sciences Research Unit(2019RU056);Chinese Academy of Medical Sciences Innovation Fund for Medical Sciences(2019-I2M-5-064)

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摘要：

目的·探索择期剖宫产脊椎麻醉联合单次小剂量艾司氯胺酮静脉推注时罗哌卡因的最佳使用剂量，并观察这种方法下低血压的发生率。方法·40例产妇被纳入研究，行小剂量艾司氯胺酮（0.15 mg/kg）静脉推注联合罗哌卡因脊椎麻醉阻滞。首例产妇使用12 mg的罗哌卡因脊椎麻醉，如果产妇的感觉阻滞平面不低于胸6（T6）水平且分娩前视觉模拟量表（visual analogue scale，VAS）评分≤2分，则下一例产妇有1/9的机会接受较低剂量或8/9的机会接受与前一例产妇相同剂量的罗哌卡因。如果产妇分娩前VAS评分>2分或在分娩前需要额外追加硬膜外镇痛药物，则后续下一例产妇将使用更高剂量的罗哌卡因。主要观察指标为脊椎麻醉效果是否确切，即维持产妇分娩前VAS评分≤2分的罗哌卡因用量，以及脊椎麻醉后低血压的发生率。次要观察指标主要包括低血压的相关症状和药物干预情况、麻醉感觉阻滞平面、产妇镇静水平（以Ramsay镇静评分为评价标准）以及新生儿结局等。罗哌卡因的90%有效剂量（90% effective dose，ED90）及其95%置信区间（confidence interval，CI）通过Isotonic回归分析估算。结果·在小剂量艾司氯胺酮联合使用下，剖宫产脊椎麻醉罗哌卡因的ED90为11.8 mg（95%CI 11.7~12.7）。40例产妇麻醉后低血压的发生率为5.0%（2例），低氧血症发生率为2.5%（1例），未发生心动过缓。所有产妇均未补救性使用去氧肾上腺素静脉推注，未发生低血压相关的不良反应（呼吸困难、恶心、呕吐、寒战、视力模糊），无反流和误吸发生。分娩前仅1例产妇Ramsay镇静评分为2分（清醒，安静合作），其余产妇评分均为3分（嗜睡，对指令反应敏捷）。分娩后5 min，32例产妇Ramsay镇静评分为2分，8例产妇评分为3分。手术结束时所有产妇镇静评分为2分。产妇术中内脏牵拉痛的发生率为7.5%，梦魇发生率62.5%，头晕发生率52.5%。此外，40例新生儿出生后1 min和5 min的Apgar评分均为10分，脐静脉血气分析显示pH值为（7.37±0.03）。结论·在择期剖宫产脊椎麻醉时，罗哌卡因联合单次小剂量艾司氯胺酮的ED90为11.8 mg，并且这种方法可以有效降低低血压的发生率。

关键词: 罗哌卡因, 艾司氯胺酮, 90%有效剂量, 低血压, 剖宫产, 脊椎麻醉

Abstract:

Objective ·To explore the optimal dose of ropivacaine for elective cesarean section under spinal anesthesia combined with a single low-dose of intravenous S-ketamine, and observe the rates of hypotension associated with this method. Methods ·Forty eligible women were included in the study for spinal anesthesia block combined with intravenous low-dose S-ketamine (0.15 mg/kg). The first patient received a 12 mg spinal anesthesia dose of ropivacaine. If the upper sensory block level of the patient was not lower than the sixth thoracic vertebra (T6) and visual analog scale (VAS) score was ≤2 before delivery, the next patient had 1/9 chance of receiving a lower dose or 8/9 chance of receiving the same dose of ropivacaine as the previous patient. If the patient had VAS score>2 or needed an extra epidural analgesics before delivery, a higher dose of ropivacaine was used for the next patient. The primary outcome was whether the effect of spina anesthesia was accurate, that is, the amount of ropivacaine to maintain patients' VAS score ≤2 before delivery, and the incidence of post-spinal anesthesia hypotension. Secondary outcomes mainly included the rate of hypotension-related symptoms and drug interventions, upper sensory block level of anesthesia, level of sedation (Ramsay sedation scale was used as the evaluation standard) and neonatal outcomes. 90% effective dose (ED90) and 95% confidence interval (95% CI) of ropivacaine were estimated by Isotonic regression. Results ·In combination with low-dose S-ketamine, the ED90 of ropivacaine for cesarean section spinal anesthesia was 11.8 mg (95%CI 11.7－12.7). The incidence of hypotension and hypoxemia of forty parturients was 5.0% (2 cases) and 2.5% (1 case), respectively, and there was no bradycardia occurring. All parturients did not use phenylephrine injection as a remedy, and there was no adverse reactions related to hypotension occurring (dyspnea, nausea, vomiting, shiver and blurred vision). There was no reflux and aspiration occurring. Only one parturient before delivery had a Ramsay sedation score of 2 (awake, quiet and cooperative), and the rest scored 3 (sleepy but respond quickly to instruction). At 5 min after delivery, according to the Ramsay sedation scale, 32 parturients were 2 scores, and 8 parturients were 3 scores. At the end of the operation, the Ramsay sedation scale of all parturients was 2 scores. During the cesarean section, the incidence of visceral traction pain, nightmare and dizziness of patients was 7.5%, 62.5% and 52.5%, respectively. In addition, the Apgar scores of 40 newborns at 1 min and 5 min after birth were all 10, and the umbilical vein blood gas analysis showed that the pH was (7.37±0.03). Conclusion ·Combined with a intravenous single low-dose of S-ketamine during spinal anesthesia for elective cesarean section, the ED90 of ropivacaine is 11.8 mg, and this method can effectively reduce the incidence of hypotension.

Key words: ropivacaine, S-ketamine, 90% effective dose (ED90), hypotension, cesarean delivery, spinal anesthesia

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