李井柱,刘延莉,王明山,时飞,毕燕琳,马福国



经皮电刺激不同耳穴对剖宫产术恶心呕吐发生率影响的比较

李井柱,刘延莉,王明山,时飞,毕燕琳,马福国

(青岛市市立医院,青岛 266071)

比较经皮电刺激耳神门穴与眼点穴对剖宫产产妇恶心及呕吐发生率的影响。将160例择期剖宫产产妇随机分为经皮电刺激耳神门穴组(A组)和经皮电刺激耳眼穴组(B组),每组80例。A组产妇入手术室后经皮电刺激耳神门穴,频率为1.5 Hz,强度由产妇自控,30 min后进行腰-硬联合麻醉,术中持续刺激至术后2 h;B组电刺激耳眼穴,操作方法同A组。观察时间分别为开始麻醉至剖出胎儿(T1)、剖出胎儿至缝合子宫完毕(T2)、探查腹腔至缝合皮肤切口(T3)、硬膜外腔给予吗啡至术后2 h(T4)。观察项目分别为①恶心及呕吐发生率,低血压、低心率发生率;②胃复安、缩宫素、麻黄碱、阿托品使用率;③新生儿Apgar评分及出血量。A组较B组在T3、T4时间段的恶心及呕吐发生率降低(＜0.05),在T1、T2时间段两组无差异(＞0.05);A组较B组术中胃复安使用率降低(＜0.01);两组低血压、低心率发生率、缩宫素、麻黄碱、阿托品使用率,术中出血量及新生儿Apgar评分无差异(＞0.05)。经皮电刺激耳神门穴较眼穴具有更为明显的抗恶心呕吐作用。

针刺疗法;耳针;经皮电刺激;剖宫产术;手术后并发症

剖宫产手术常在腰-硬联合麻醉下进行,围术期易发生恶心呕吐,不仅给产妇带来痛苦也有碍于手术的顺利进行,几乎所有抗呕吐药物均存在一定副反应,是否进入乳汁尚未明确,对新生儿的安全构成潜在威胁,如何安全有效地防治恶心呕吐是剖宫产麻醉的难点问题之一[1]。有研究报道,耳穴刺激用于经腹胆囊切除术患者,使术后呕吐发生率显著降低[2],但对于不同耳穴刺激对剖宫产产妇恶心及呕吐发生率影响如何,国内外少见报道。笔者通过比较经皮电刺激耳神门穴与眼穴对剖宫产产妇恶心及呕吐发生率的影响,初步探讨其机理,旨在为经皮电刺激耳神门穴的临床应用提供参考。

1 资料与方法

1.1 研究对象及分组

经医院伦理学委员会批准并与产妇签订知情同意书,选择择期剖宫产产妇160例,单胎初产,ASAⅠ级。随机分为经皮耳神门穴电刺激组(A组)及经皮耳眼穴电刺激组(B组),每组80例。所有患者均排除产科合并症、腹部手术史、长期服用安定类药物史、神经病及精神病病史、头痛腰痛等疼痛病史、腰-硬联合麻醉禁忌证。

1.2 刺激与麻醉方法

A组产妇入室后,取耳神门穴,连接微电流刺激仪主机(Sun-Sleep-Stim SCS、Ansliip Medical Technology Group,America)频率为1.5 Hz,双极性非对称连续长方波,强度由产妇自己掌握,以刺激后出现酸、麻、胀、重,略感疼痛为原则。监测SPO2、无创血压、心电图,面罩吸氧,开放上肢静脉,刺激30 min后经L3-4行腰-硬联合麻醉,控制无痛平面至T6。以15 mLkg－1h－1速度静脉滴注复方氯化钠与羟乙基淀粉1:1混合液。若MAP下降大于麻醉前25%则静脉注射麻黄碱10 mg,心率下降低于55 bpm则静脉注射阿托品0.5 mg,宫缩不良者静脉滴注缩宫素10m。持续刺激至术后2 h。术毕,硬膜外注射吗啡2 mg(生理盐水稀释至5 mL)。B组采用相同的方法刺激耳眼穴。两组产妇均不使用镇静镇痛剂,如发生恶心呕吐则注射胃复安10 mg。穴位定位见图1。

图1 耳神门穴与眼点穴的定位

1.3 观察指标

观察时间分别为麻醉开始至胎儿剖出(T1)、胎儿剖出至子宫缝合完毕(T2)、探查腹腔至缝合皮肤切口(T3)、硬膜外腔给予吗啡至术后2 h(T4)。观察项目分别为①各时间段恶心及呕吐发生率(呕吐一定恶心,但恶心未必呕吐),低血压低心率发生率(MAP下降大于麻醉前25%为低血压、心率下降低于55 bpm为低心率);②胃复安、缩宫素、麻黄碱、阿托品使用率(每个产妇只统计1次);③新生儿1、5 minApgar评分,术中出血量及其他相关不良反应。

1.4 统计学方法

用SPSS17.0统计学软件进行统计学处理,数据用均数±标准差表示,计量资料采用方差分析,计数资料采用卡方检验。以＜0.05表示差异有统计学意义。

2 结果

两组产妇基础资料(年龄、体重、身高、孕周)比较差异无统计学意义(＞0.05)。由表1可见,A组在T3、T4时间段的恶心及呕吐发生率较B组低(c2=11.815、9.928、5.636、5.000,＜0.05),在T1、T2时间段两组比较差异无统计学意义(＞0.05)。由表2可见,两组产妇低血压、低心率发生率比较差异无统计学意义(＞0.05)。由表3可见,A组胃复安使用率较B组低(c2=20.050,＜0.01),两组产妇缩宫素、麻黄碱、阿托品使用率,术中出血量及新生儿1、5 min’Apgar评分比较差异均无统计学意义(＞0.05)。

3 讨论

中医学认为,位于耳窝三角顶点的神门穴具有明显的抗痛、抗焦虑、催眠、抗呕吐、降血压、抗感染等作用。Sahmeddini等[2]针刺耳穴,将经腹胆囊切除术后24 h呕吐发生率降低为零(同期对照组为66%)而无任何副反应;Kim等[3]针刺耳穴,将经腹子宫切除术后12 h呕吐发生率降低为30%(同期对照组为66%);徐韶怡等[4]用耳穴针刺贴压防治妇科术后恶心呕吐取得了良好的疗效;Bi HD[5]施耳穴贴压治疗化疗后呕吐有较好的疗效。经皮电刺激耳神门穴无创方便,患者主动参与控制,符合现代医疗绿色环保的要求,将电刺激耳神门穴用于防治剖宫产围术期的恶心呕吐值得深入探讨。

恶心呕吐是腰-硬联合麻醉下剖宫产术常见的并发症。本研究为探讨经皮电刺激耳神门穴防治恶心呕吐的机理,根据剖宫产术恶心呕吐发生原因将剖宫产术分为4个时间段,①从开始麻醉至剖出胎儿,此时间段交感神经迅速阻滞,相应区域血管扩张,产妇常发生仰卧位低血压,血压骤降,脑供血骤减,缺氧兴奋恶心呕吐中枢是主要原因[6];②从剖出胎儿至缝合子宫完毕,此时间段产妇情况相对平稳,恶心呕吐发生较少;③从探查腹腔至缝合皮肤切口,此时间段探查牵拉腹腔脏器,迷走神经功能亢进,内脏神经传入的冲动刺激呕吐中枢引起的反射性恶心呕吐是主要原因;④硬膜外腔给予吗啡后,此时间段吗啡通过兴奋呕吐中枢化学触发带阿片受体,诱发中枢性恶心呕吐是主要原因。

本研究显示经皮电刺激耳神门穴较眼穴更为明显地降低剖宫产腹腔探查后与硬膜外注射吗啡后恶心及呕吐的发生率,其机制可能是,①神门穴处分布着丰富的迷走神经,耳穴刺激可能通过外周机制调控迷走神经张力,减少迷走神经冲动的传入,减少反射性呕吐的发生;②电刺激耳神门穴可能直接抑制呕吐中枢,减少吗啡引起的中枢性呕吐;③刺激耳神门穴可能对低血压缺氧兴奋呕吐中枢的机制作用不明显,因而无法降低低血压缺氧引起恶心及呕吐发生率。对于刺激耳穴产生的镇静镇痛效应[7-11]是否参与了抗恶心呕吐机制的调控,本研究无法提供证据。

表1 两组产妇不同时间段恶心、呕吐发生率比较 [n(%)]

注:与B组比较1)＜0.05

表2 两组产妇不同时间段低血压、低心率发生率比较 [n(%)]

表3 两组产妇胃复安、缩宫素、麻黄碱、阿托品使用率、术中出血量及新生儿1、5 minApgar评分比较 (±s)

注:与B组比较1)＜0.01

本研究经皮耳神门穴电刺激组刺激30 min后,刺激的叠加效应在神门穴上形成紫红色的“刺激斑”,局部产生酸、麻、胀、重、略微热痛、轻度头晕的感觉,总体感觉愉悦,持续时间较长,胃复安使用率明显减少,未见其他不良反应,新生儿Apgar评分亦无差异,说明经皮耳神门穴电刺激防治恶心呕吐具有较高的安全性。

本研究结果表明经皮耳神门穴电刺激对降低剖宫产术中术后恶心及呕吐发生率具有特异性,但其具体机理需要进一步探讨。

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Comparison of the Effects of Transcutaneous Electrical Stimulation of Different Auricular Points on Cesarean Section- induced Nausea and Vomiting Incidence

-,-,-,,-,-.

,266071,

To compare the effects of transcutaneous electrical stimulation of auricular points Shenmen and Eye on nausea and vomiting incidence in parturients undergoing cesarean section.One hundred and sixty parturients for elective cesarean section were randomly allocated to a transcutaneous electrical stimulation of auricular point Shenmen group (group A) and a transcutaneous electrical stimulation of auricular point Eye group (group B), 80 cases each. In group A parturients after being sent into the operating room, transcutaneous electrical stimulation of auricular point Shenmen was performed at a frequency of 1.5 Hz and an intensity controlled by the parturient, lumbar epidural anesthesia was carried out 30 min later and the stimulation continued during the operation and until 2 hrs after the end of it. In group A, electrical stimulation of auricular point Eye was performed and the procedure was the same as in group A. The observation times were from the beginning of anesthesia to the delivery of a fetus through caesarean incision (T1), from the delivery of a fetus to the completion of uterine suture (T2), from abdominal exploration to dermal incision suture (T3) and from peridural administration of morphine to 2 hrs after the operation (T4). The observation items were 1) nausea, vomiting, hypotension and low heart rate incidences; 2) the usage rates of metoclopramide, oxytocin, ephedrine and atropine; 3) the Apgar score for newborns and amount of bleeding.Nausea and vomiting incidence was lower during T3 and T4 periods in group A than in group B (＜0.05). There was no statistically significant difference during T1 and T2 periods between the two groups (＞0.05). The usage rate of metoclopramide was lower in group A than in group B (＜0.01). There were no statistically significant differences in low heart rate incidence and the usage rates of oxytocin, ephedrine and atropine between the two groups (＞0.05).Transcutaneous electrical stimulation of auricular point Shenmen has a more marked relieving effect on nausea and vomiting.

Acupuncture therapy; Ear acupuncture; Transcutaneous electrical stimulation; Cesarean section; Postoperative complications

R246.3

A

10.3969/j.issn.1005-0957.2012.09.656

1005-0957(2012)09-0656-03

李井柱(1971 - ),男,主治医生

王明山(1963 - ),男,主任医师,硕士生导师,E-mail:liazhe 2000@163.com

2011-11-20