腰麻下左侧卧位行择期剖宫产术对新生儿酸碱状况无影响：一项随机对照试验
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Left Lateral Table Tilt for Elective Cesarean Delivery under Spinal Anesthesia Has No Effect on Neonatal Acid-Base Status: A Randomized Controlled Trial.
背景与目的
目前对剖腹产妇的建议包括左侧倾斜15°使子宫移位，以防止压迫腹主动脉，尽管几乎从未达到这种倾斜度。我们假设，在当代临床实践中，包括维持基础收缩压的晶体灌注和去氧肾上腺素输注，接受择期剖宫产分娩的脊髓麻醉产妇中，母亲体位对新生儿酸碱状态的没有影响。
方 法
择期剖宫产的健康妇女随机（非盲）分入脊髓麻醉（高比重布比卡因12 mg，芬太尼15μg，无防腐剂吗啡150μg）后仰卧水平（仰卧，n = 50）或手术台倾斜15°组（倾斜，n = 50）。鞘内注射后予乳酸林格氏液10 ml/kg 和去氧肾上腺素静脉滴注维持至100%基础收缩压。主要结局是脐动脉血碱剩余。
结 果
脐动脉血碱剩余或pH组间无差异。仰卧位组（n = 50）平均脐动脉血碱剩余（±SD）为-0.5 mM（±1.6），倾斜组为-0.6 mM（±1.5）（n = 47）（P = 0.64）。脊髓麻醉后15min内仰卧位组平均去氧肾上腺素需求量增大（P = 0.002），平均心输出量降低（P = 0.014）。
结 论
健康女性中，当母体收缩压以补液和去氧肾上腺素输注维持时，脊髓麻醉下择期剖宫产术后产妇仰卧位与左侧倾斜为15°相比不影响新生儿酸碱状态。这些发现可能不适用于紧急情况或不乐观的胎儿状态。
原始文献摘要
Lee A J, Landau R, Mattingly J L, et al. Left Lateral Table Tilt for Elective Cesarean Delivery under Spinal Anesthesia Has No Effect on Neonatal Acid-Base Status: A Randomized Controlled Trial[J]. Anesthesiology, 2017.
Abstract
BACKGROUND: Current recommendations for women undergoing cesarean delivery include 15° left tilt for uterine displacement to prevent aortocaval compression, although this degree of tilt is practically never achieved. We hypothesized that under contemporary clinical practice, including a crystalloid coload and phenylephrine infusion targeted at maintaining baseline systolic blood pressure, there would be no effect of maternal position on neonatal acid base status in women undergoing elective cesarean delivery with spinal anesthesia.
METHODS: Healthy women undergoing elective cesarean delivery were randomized (nonblinded) to supine horizontal (supine, n = 50) or 15° left tilt of the surgical table (tilt, n = 50) after spinal anesthesia (hyperbaric bupivacaine 12 mg, fentanyl 15 μg, preservative-free morphine 150 μg). Lactated Ringer's 10 ml/kg and a phenylephrine infusion titrated to 100% baseline systolic blood pressure were initiated with intrathecal injection. The primary outcome was umbilical artery base excess.
RESULTS: There were no differences in umbilical artery base excess or pH between groups. The mean umbilical artery base excess (± SD) was -0.5 mM (± 1.6) in the supine group (n = 50) versus -0.6 mM (± 1.5) in the tilt group (n = 47) (P = 0.64). During 15 min after spinal anesthesia, mean phenylephrine requirement was greater (P = 0.002), and mean cardiac output was lower (P = 0.014) in the supine group.
CONCLUSIONS: Maternal supine position during elective cesarean delivery with spinal anesthesia in healthy term women does not impair neonatal acid-base status compared to 15° left tilt, when maternal systolic blood pressure is maintained with a coload and phenylephrine infusion. These findings may not be generalized to emergency situations or nonreassuring fetal status.
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