摘要
目的 比较肥胖孕产妇剖宫产术椎管内麻醉时不同定位及穿刺方式的效果.方法 选取2023年7月至2024年4月在河南省人民医院择期椎管内麻醉下行剖宫产术的足月肥胖孕产妇175例,ASA分级Ⅰ或Ⅱ级,BMI＞30 kg/m2,采用随机数字表法分为4组:触诊法定位+正中入路穿刺组(PM组,n=44)、体表标志法定位+旁正中入路穿刺组(BP组,n=43)、超声辅助定位+旁正中入路穿刺组(UP组,n=45)和超声辅助定位+超声引导平面内穿刺组(UU组,n=43).分别由熟练掌握4种不同椎管内麻醉定位及穿刺方法的麻醉科住院医师进行操作.主要观察指标:一次穿刺成功率和总穿刺成功率;次要观察指标:穿刺次数、穿刺间隙改变情况、定位时间、穿刺时间、麻醉操作时间,穿刺后恶心呕吐、穿刺感觉异常、穿刺部位出血的发生情况和孕产妇满意率,以及术后7 d、1个月、2个月和3个月时腰痛发生情况.结果 PM组有2例、BP组有2例、UP组有2例、UU组有2例剔除本研究.总穿刺成功率:PM组为95％(40/42),BP组为98％(40/41),UP为93％(40/43),UU组为98％(40/41);4组总穿刺成功率比较差异无统计学意义(P＞0.05).与PM组比较,BP组一次穿刺成功率升高,穿刺间隙改变率降低,定位时间缩短,恶心呕吐发生率降低,满意率升高,术后7 d时腰痛发生率降低;UP组一次穿刺成功率升高,穿刺次数减少,穿刺间隙改变率降低,定位时间、穿刺时间和麻醉操作时间均缩短,满意率升高,术后7 d时腰痛发生率降低;UU组改变穿刺间隙率降低,定位时间缩短(P＜0.05).与BP组比较,UP组穿刺时间缩短,UU组穿刺次数增多,麻醉操作时间延长,恶心呕吐发生率升高,满意率降低(P＜0.05).与UP组比较,UU组一次穿刺成功率降低,穿刺次数增多,穿刺时间和麻醉操作时间延长,恶心呕吐发生率升高,满意率降低(P＜0.05).结论 超声辅助定位联合旁正中入路穿刺可提高剖宫产术肥胖孕产妇椎管内麻醉的一次穿刺成功率,减少穿刺相关并发症的发生,提高孕产妇满意度.
Abstract
Objective To compare the effects of different positioning and puncture methods for epi-dural anesthesia in obese parturients undergoing cesarean section.Methods In this prospective,random-ized,controlled study,175 obese parturients,of American Society of Anesthesiologists Physical Status clas-sification Ⅰ or Ⅱ,with a body mass index of＞30 kg/m2,who underwent elective cesarean section with epidural anesthesia at Henan Provincial People's Hospital from July 2023 to April 2024,were selected and assigned into 4 groups using a random number table method:palpation positioning+median approach to puncture group(PM group,n=44),body surface marker positioning+paramedian approach to puncture group(BP group,n=43),ultrasound-assisted positioning+paramedian approach to puncture group(UP group,n=45),and ultrasound-assisted positioning+ultrasound-guided in-plane approach to puncture group(UU group,n=43).The procedures were performed by anesthesiology residents skilled in the four different epidural anesthesia positioning and puncture methods.Main observation indicators:success rate of puncture at first attempt and total success rate of puncture.Secondary observation indicators:the number of puncture,changes in puncture interspaces,positioning time,puncture time,anesthesia operation time,postoperative nausea and vomiting,sensory abnormalities at the puncture site,bleeding at the puncture site,maternal satisfaction rates,and occurrence of low back pain at day 7,1 month,2 months,and 3 months postoperatively.Results In this study,2 cases were excluded from PM group,2 from BP group,2 from UP group,and 2 from UU group.The total success rates of puncture were as follows:95％(40/42)in PM group,98％(40/41)in BP group,93％(40/43)in UP group,and 98％(40/41)in UU group.There was no significant difference in the total success rates of puncture among the four groups(P＞0.05).Compared to PM group,the success rate of puncture at first attempt was significantly increased,the rate of changes in puncture interspaces was decreased,the positioning time was shortened,the incidence of nausea and vomi-ting was decreased,satisfaction rates were increased,and the incidence of low back pain was reduced at 7 days after operation in BP group;the success rate of puncture at first attempt was significantly increased,the number of puncture was reduced,the rate of changes in puncture interspaces was decreased,the positio-ning time,puncture time and anesthesia operation time were shortened,the satisfaction rates were in-creased,and the incidence of low back pain was decreased at 7 days after operation in UP group;the rate of changes in puncture interspaces was significantly decreased,and the positioning time was shortened in UU group(P＜0.05).Compared to BP group,the puncture time was significantly shortened in UP group,and the number of puncture was significantly increased,the anesthesia operation time was prolonged,the inci-dence of nausea and vomiting was increased,and the satisfaction rate was decreased in UU group(P＜0.05).Compared to UP group,the success rate of puncture at first attempt was significantly decreased,the number of puncture was increased,the puncture time and anesthesia operation time were prolonged,the in-cidence of nausea and vomiting was increased,and the satisfaction rates were decreased in UU group(P＜0.05).Conclusions Ultrasound-assisted positioning combined with the paramedian approach to puncture can raise the success rate of puncture at first attempt,reduce the development of puncture-related complica-tions,and increase the maternal satisfaction in obese parturients undergoing cesarean section.
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