曹天彪 宋文学

【摘要】 目的：探討盐酸罗哌卡因复合艾司氯胺酮用于剖宫产术腰麻的安全性和有效性，以及对新生儿Apgar评分、产妇术后镇痛和抑郁的影响。方法：选取2021年11月—2022年10月在酒泉市人民医院择期腰麻下行横切口剖宫产术的产妇300例。将产妇随机分为五组：0.5%等比重盐酸罗哌卡因10 mg复合艾司氯胺酮15 mg组（LA1组）、0.5%等比重盐酸罗哌卡因10 mg复合艾司氯胺酮12.5 mg组（LA2组）、0.5%等比重盐酸罗哌卡因10 mg复合艾司氯胺酮10 mg组（LA3组）、0.5%等比重盐酸罗哌卡因10 mg复合艾司氯胺酮7.5 mg组（LA4组）和0.5％等比重盐酸罗哌卡因10 mg组（对照组，L组），每组60例。记录产妇麻醉前（基础值，T0）、麻醉后1、3、5、10 min（T1、T2、T3、T4）、胎儿取出后1、3、5、10 min （T5、T6、T7、T8）及手术结束时（T9）的MAP、HR及SpO2；针刺法评价感觉阻滞起效及持续时间、麻醉阻滞平面、平面达T4比例及平面达峰时间；使用改良Bromage评分（MBS）评定运动阻滞起效及持续时间；记录出生后1、5、10 min的新生儿Apgar评分；记录围手术期不良反应及并发症发生情况；记录术后4、8、12、24、48 h的VAS评分和Ramsay镇静评分及PCEA按压情况；同时记录产妇术前1 d和术后3、7 d抑郁程度。结果：恶心呕吐发生率五组差异无统计学意义（P>0.05）；五组新生儿出生后1、5、10 min的Apgar评分均为8～10分，差异无统计学意义（P>0.05）。头晕发生率LA1组明显高于L组（P<0.05）；寒战发生率LA1组明显低于L组（P<0.05）；牵拉反应发生率LA1组明显低于L组（P<0.05）。与T0时比较，LA1组在T1、T2、T3、T5、T6、T7时MAP均明显降低（P<0.05）；LA2组、LA3组在T1、T2、T3、T5、T6时MAP均明显降低（P<0.05）；LA4组在T1、T2、T3、T5时MAP均明显降低（P<0.05）；L组在T1、T2、T3、T5、T6时MAP均明显降低（P<0.05）。与T0时比较，LA1组、LA2组、LA3组、LA4组在不同时间HR差异均无统计学意义（P>0.05）；L组在T2、T3、T5时HR明显加快（P<0.05）。不同时间五组的SpO2差异均无统计学意义（P>0.05）。与L组比较，LA1组、LA2组、LA3组、LA4组在不同时间时MAP差异均无统计学意义（P>0.05）；L组在T2时HR较LA1组明显快（P<0.05）；L组在T2、T3时HR均较LA2组、LA3组及LA4组明显快（P<0.05）。感觉阻滞起效时间LA1组明显早于LA4组和L组（P<0.05），LA2组明显早于L组（P<0.05）。感觉阻滞持续时间LA1组明显短于L组（P<0.05）。运动阻滞起效时间LA1组明显早于LA4组和L组（P<0.05），LA2组明显短于L组（P<0.05）。运动阻滞持续时间五组依次递增，但差异无统计学意义（P>0.05）。麻醉阻滞平面达T4比例LA1组明显多于L组（P<0.05）。麻醉阻滞平面达峰时间LA1组、LA2组均明显早于L组（P<0.05）。术后4、8、12、24、48 h时LA1组、LA2组、LA3组、LA4组VAS评分均明显低于L组（P<0.05）。LA1组、LA2组、LA3组、LA4组术后3、7 d的爱丁堡产后抑郁量表（EPDS）评分均明显低于L组和术前1 d（P<0.05）。PCEA按压次数LA1组、LA2组均明显少于L组（P<0.05），LA1组明显少于LA4组（P<0.05）。结论：盐酸罗哌卡因复合艾司氯胺酮腰麻可安全用于剖宫产术，产妇血流动力学平稳，明显改善了麻醉效果，加快了产妇运动恢复，并且不会引起新生儿Apgar评分下降。能有效预防剖宫产术后寒战反应，减少了术后PCEA按压次数，明显减轻产妇术后疼痛程度及产后早期抑郁程度。其中盐酸罗哌卡因10 mg复合艾司氯胺酮12.5 mg用于剖宫产术椎管内麻醉后的安全性和有效性更稳定。

【关键词】 盐酸罗哌卡因 艾司氯胺酮 剖宫产术 腰麻

The Effect of Ropivacaine Hydrochloride Combined with Esketamine on Perioperative Mother and Baby during Cesarean Section under Spinal Anesthesia/CAO Tianbiao， SONG Wenxue. //Medical Innovation of China， 2024， 21（07）： -140

[Abstract] Objective： To explore the safety and effectiveness of Ropivacaine Hydrochloride combined with Esketamine for spinal anesthesia during cesarean section， as well as its impact on neonatal Apgar score， postoperative analgesia， and depression in postpartum women. Method： A total of 300 postpartum women who underwent elective transverse incision cesarean section under lumbar anesthesia at the People's Hospital of Jiuquan from November 2021 to October 2022 were selected. The parturients were randomly divided into five groups： the 0.5% equal proportion Ropivacaine Hydrochloride 10 mg combined with Esketamine 15 mg group （LA1 group）， the 0.5% equal proportion Ropivacaine Hydrochloride 10 mg combined with Esketamine 12.5 mg group （LA2 group）， 0.5% equal gravity Ropivacaine Hydrochloride 10 mg combined with Esketamine 10 mg group （LA3 group）， 0.5% equal gravity Ropivacaine Hydrochloride 10 mg combined with Esketamine 7.5 mg group （LA4 group）， and 0.5% equal gravity Ropivacaine Hydrochloride 10 mg group （control group， L group）， with 60 cases in each group. The MAP， HR， and SpO2 of the pregnant woman before anesthesia （baseline value， T0）， 1， 3， 5， 10 min after anesthesia （T1， T2， T3， T4）， 1， 3， 5， 10 min after fetal removal （T5， T6， T7， T8）， and at the end of surgery （T9） were recorded. Acupuncture method was used to evaluate the onset and duration of sensory blockade， the level of anesthesia block， the rate of reaching T4 level， and the time of reaching peak level; the onset and duration of motor block were evaluated using the modified Bromage scale （MBS）; the newborns Apgar scores at 1， 5， 10 min were recorded; the occurrence of adverse reactions and complications during the perioperative period were recorded; postoperative VAS scores， Ramsay sedation scores， and PCEA compression at 4， 8， 12， 24， 48 h were recorded; the depression level of the postpartum woman

1 day before surgery and 3 and 7 days after surgery were recorded simultaneously. Result： There was no statistically significant difference in the incidence of nausea and vomiting among the five groups （P>0.05）. The Apgar scores of the five groups of newborns at 1， 5， 10 min after birth were all 8-10 points， the differences were not statistically significant （P>0.05）. The incidence of dizziness in the LA1 group was significantly higher than that in the L group （P<0.05）; the incidence of shivering in the LA1 group was significantly lower than that in the L group （P<0.05）; the incidence of traction reaction in the LA1 group was significantly lower than that in the L group （P<0.05）. Compared with T0， the levels of MAP of the LA1 group were significantly reduced at T1， T2， T3， T5， T6， T7 （P<0.05）; the levels of MAP of the LA2 group and LA3 group decreased significantly at T1， T2， T3， T5， T6 （P<0.05）; the levels of MAP of LA4 group decreased significantly at T1 T2， T3， T5 （P<0.05）; the levels of MAP of L group were significantly reduced at T1， T2， T3， T5， T6 （P<0.05）. Compared with T0， there was no statistically significant difference in HR between the LA1 group， LA2 group， LA3 group， and LA4 group from T1 to T9 （P>0.05）; the HR of L group significantly increased at T2， T3 and T5 （P<0.05）. There was no statistically significant difference in SpO2 among the five groups at different times （P>0.05）. Compared with L group， there was no statistically significant difference in MAP between LA1 group， LA2 group， LA3 group， and LA4 group from T1 to T9 （P>0.05）; the HR of L group increased significantly faster than that of LA1 group at T2 （P<0.05）; At T2 and T3， the HR of L group increased significantly faster than those of LA2 group， LA3 group， and LA4 group （P<0.05）. The onset time of sensory blockade in the LA1 group was significantly earlier than that in the LA4 group and L group （P<0.05）， and the LA2 group was significantly earlier than that in the L group （P<0.05）. The duration of sensory blockade in the LA1 group was significantly shorter than that in the L group （P<0.05）. The onset time of motor block in the LA1 group was significantly earlier than that in the LA4 group and L group （P<0.05）， and that in the LA2 group was significantly earlier than that in the L group （P<0.05）. The duration of motor block increased sequentially among the five groups， but the difference was not statistically significant （P>0.05）. The rate of anesthesia block level reaching T4 was significantly higher in the LA1 group than that in the L group （P<0.05）. The peak time of anesthesia block level in LA1 group and LA2 group were significantly shorter than that in L group （P<0.05）. At 4， 8， 12， 24， and 48 hours after surgery， the VAS scores of LA1 group， LA2 group， LA3 group， and LA4 group were significantly lower than those of L group （P<0.05）. The Edingburgh postnatal depression scale （EPDS） scores of LA1 group， LA2 group， LA3 group and LA4 group were significantly lower at 3 and 7 days after surgery than those of L group and 1 day before surgery （P<0.05）. The PCEA pressing frequency of LA1 group and LA2 group was significantly lower than that of L group （P<0.05）， while LA1 group was significantly lower than LA4 group （P<0.05）. Conclusion： Ropivacaine Hydrochloride combined with Esketamine spinal anesthesia can be safely used for cesarean section， the anesthesia effect is significantly improved， the recovery of postpartum movement is accelerated， and it does not cause a decrease in Apgar score of newborns. It can effectively prevent shivering reactions after cesarean section， reduce the number of PCEA compressions after surgery， and significantly reduce the degree of postoperative movement pain and early postpartum depression in postpartum women. The combination of 10 mg Ropivacaine Hydrochloride and 12.5 mg Esketamine is more stable in terms of safety and efficacy after spinal anesthesia for cesarean section.

[Key words] Ropivacaine Hydrochloride Esketamine Cesarean section Spinal anesthesia

First-author's address： Department of Anesthesiology， the People's Hospital of Jiuquan， Jiuquan 735000， China

doi：10.3969/j.issn.1674-4985.2024.07.031

目前剖宫产术麻醉方式以腰麻为首选。盐酸罗哌卡因用于剖宫产术腰麻，虽效果确切，镇痛肌松满意，但易出现寒战、恶心呕吐、血流动力学不稳定等问题。近年来研究表……