曲马多静脉自控给药与腰硬联合阻滞用于分娩镇痛的比较

刘野　徐铭军

[摘要] 目的 探讨曲马多实施静脉分娩镇痛的临床可行性和安全性。 方法 选择2011年3月～2012年6月北京妇产医院住院分娩的产妇75例，产妇均为单胎，足月妊娠。随机分成PCIA（曲马多静脉镇痛）组、PCEA（椎管内镇痛）组和对照组，每组25例。PCIA以及PCEA组产妇出现规律宫缩、宫口>3 cm时PCIA组静脉给予1.5 mg/kg曲马多注射液缓慢滴注，连接电子泵，患者自控镇痛（PCA）剂量2 mL，锁定时间10 min；PCEA组行L2～3间隙腰硬联合穿刺，鞘内注射3 mg罗哌卡因，硬膜外置管连接电子泵，PCA剂量5 mL，锁定时间10 min。对照组产妇不给予任何镇痛干预。观察三组产妇生命体征、镇痛效果、产程变化以及不良反应发生情况。 结果 PCEA组的产妇在镇痛后5、15 min时血压与镇痛前相比下降明显，差异有统计学意义（P < 0.05）。PCIA组仅在15 min时，血压有轻度下降，但差异无统计学意义（P > 0.05）。三组产妇实施镇痛前视觉模拟评分（VAS）比较差异无统计学意义，镇痛后PCEA组VAS评分明显低于PCIA组和对照组（P < 0.05），对照组VAS评分高于PCIA组（P < 0.05）。PCEA组产妇第二产程相对于其他两组均有所延长（P < 0.05）；PCEA组和对照组新生儿出生1 min后Apgar评分高于PCIA组，差异均有统计学意义（P < 0.05）。三组新生儿体重比较差异无统计学意义（P > 0.05）。对照组剖宫产例数明显高于分娩镇痛组，三组比较差异有统计学意义（P < 0.05）；PCIA组催产素使用例数低于PCEA组和对照组（P < 0.05）；PCIA组产妇不良反应主要有出汗、恶心、呕吐，PCEA组产妇不良反应主要有皮肤瘙痒和尿潴留，三组产妇不良反应发生情况比较，差异无统计学意义（P > 0.05）。 结论 椎管内分娩镇痛可安全、有效地用于分娩镇痛，应作为临床主要应用的方法。曲马多可以安全、有效应用于临床分娩镇痛，可作为椎管内分娩镇痛的有益的补充方法。

[关键词] 分娩镇痛；自控镇痛；曲马多；麻醉；腰硬联合阻滞

[中图分类号] R614.2 [文献标识码] A [文章编号] 1673-7210（2015）02（b）-0063-05

[Abstract] Objective To assess the clinical feasibility and safety of Tramadol in patient-controlled intravenous analgesia （PCIA） during labor. Methods From March 2011 to June 2012， in Beijing & Gynecology Hospital of Capital Medical University， 75 full term pregnant women who had a single fetus with vertex presentation were selected and randomly divided into PCIA group， PCEA group and control group， with 25 cases in each group. While regular uterine contraction was observed and the cervix uteri dilated more than 3 cm， the PCIA group was performed with a single dose of tramadol 1.5 mg/kg + PCA demand bolus 2 mL， 10 min lockout interval； the PCEA group was received combined L2～3 spinal epidural analgesia with ropivacine 3 mg + PCA demand bolus 5 mL， 10 min lockout interval， when the control group was given no analgesia. The intensity of pain was evaluated by patients using VAS， the time of each delivery paragraph， blood loss， oxytocin application， the rate of apparatus delivery， cesarean section and side effects of analgesia were recorded. Results The BP of PCEA group significantly reduced after analgesia had been practiced at 5， 15 min （P < 0.05）. At 15 min， the BP of PCIA group reduced mildly， but with no statistical significant difference （P > 0.05）. The VAS of PCEA group was significantly lower than that of PCIA group and control group （P < 0.05）， the VAS of the control group was higher than that of PCIA group （P < 0.05）. The duration of labor in group PCEA was longer than other groups （P < 0.05）， Apgar score at 1 minutes in PCIA group was higher than those in group PCEA and control group， the differences were statistically significant （P < 0.05）. The neonatal weight of three groups had not statistical significant difference （P > 0.05）. The rate of cesarean section in control group was significantly higher than those in group PCIA and PCEA， the differences were statistically significant （P < 0.05）； patients needed oxytocin in PCIA group were less than those in PCEA group and control group （P < 0.05）； The side effects in PCIA group were diaphoresis， nausea and vomiting， those in PCEA group were itching and uroschesis， there was no statistically significance between the three groups （P > 0.05）. Conclusion The PCEA with ropivacaine and sufentanyl is safe and effective for labor analgesia， it is the first technique choice. Tramadol is effective for labor analgesia without severe side effects and it can be used as a beneficial supplementary method for PCEA.

[Key words] Labor analgesia； Patient-controlled intravenous analgesia； Tramadol； Anaesthesia； Combined spinal epidural analgesia

目前在我国13亿多的人口中，约30%为育龄期妇女，已婚待生育女性占21%左右，即约有2.8亿，而且随着多地二胎政策的实施导致我国的分娩量进一步增加。许多研究均证实了分娩镇痛可以有效降低母体血浆中的儿茶酚胺水平，减轻疼痛和焦虑引起的应激反应对母儿体和胎儿的不良影响，有助于产程进展，降低剖宫产率，增加母婴安全[1]。为……