去甲肾上腺素预防腰硬联合麻醉剖宫产术中腰麻相关性低血压：随机双盲剂量研究
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Norepinephrine for the prevention of spinal-induced hypotension during caesarean delivery under combined spinal–epidural anaesthesia:Randomised, double-blind, dose-finding study
背景与目的
在腰麻剖宫产术中，由于心动过缓和心输出量减少，低血压可优先选用去甲肾上腺素而非苯肾上腺素来控制。由于去甲肾上腺素的最佳预防剂量尚不清楚，因此，本研究旨在探讨去甲肾上腺素预防剖宫产术中腰麻后低血压的剂量反应。
方 法
选取2月1日~ 8月5日择期剖宫产患者99例，排除ASA分级Ⅲ级以上、先兆子痫或高血压、既往有糖尿病或妊娠期糖尿病、BMI>35 kg m-2、身高<150 cm或>175 cm、有局部麻醉禁忌症的患者。蛛网膜下腔注射布比卡因10 mg加舒芬太尼5μg后，立即预防性输注去甲肾上腺素0、0.04、0.05、0.06或0.07μg kg-1min-1。用概率分析法评估去甲肾上腺素半数有效剂量或95%有效剂量（ED50或ED95），比较不同剂量对血流动力学的影响。
结 果
0、0.04、0.05、0.06和0.07μg kg-1min-1剂量组低血压发生率分别为70%、47.4%、40%、20%和15%。各组之间的Apgar评分或脐动脉pH值相似。ED50值为0.029(95% CI 0.008~0.042 μg kg-1min-1)，ED80值为0.068(95%CI 0.055~0.099μgkg-1min-1)，ED95值为0.105 μgkg-1min-1(95%CI 0.082~0.172 μgkg-1min-1)。
结 论
ED50、ED80和ED95分别为0.029、0.068和0.105 μg kg-1min-1。蛛网膜下腔注射布比卡因10 mg联合舒芬太尼5 μg后，输注去甲肾上腺素0.07μgkg-1min-1可能是预防腰麻后低血压的最佳剂量。
原始文献来源及摘要
Wei C, Qian J, Zhang Y, et al. Norepinephrine for the prevention of spinal-induced hypotension during caesarean delivery under combined spinal–epidural anaesthesia:Randomised, double-blind, dose-finding study.[J].Eur J Anaesthesiol,2020,37(4):309-315. DOI:10.1097/EJA.0000000000001152
Abstract
BACKGROUND During caesarean delivery under spinal anaesthesia hypotension may be managed by norepinephrine in preference to phenylephrine due a perception of less bradycardia and fewer reductions in cardiac output.
OBJECTIVE As the optimum prophylactic dose of norepinephrine is unclear, we aimed to investigate its dose–response for preventing postspinal hypotension in caesarean delivery.
DESIGN A randomised, double-blinded, dose-finding study.
SETTING Jiaxing University affiliated Women and Children Hospital, Jiaxing, China.
PATIENTS Ninety-nine patients undergoing elective caesarean delivery from 1 February to 5 August: excluding patients with ASA III or above, preeclampsia or hypertension, pre-existing or gestational diabetes, BMI more than 35 kg m-2,height less than 150 cm or with more than 175 cm, or with
contraindications to local anaesthesia.
INTERVENTIONS Patients received 0, 0.04, 0.05, 0.06 or0.07μgkg-1min-1
preventive norepinephrine infusions immediately after intrathecal injection of 10 mg bupivacaine with 5μg sufentanil.
MAIN OUTCOME MEASURES The norepinephrine (Median effective dose) or (95% effective dose) ED50and ED95,which were estimated using Probit analysis to compare haemodynamic changes associated with the different doses.
RESULTS The incidence of hypotension was 70, 47.4, 40,20 and 15% in the 0, 0.04, 0.05, 0.06 and 0.07μgkg-1min-1groups, respectively. The ED50, ED80 and ED95 values were 0.029 (95% CI 0.008 to 0.042μg kg-1min-1), 0.068 (95% CI 0.055 to 0.099μgkg-1min-1) and 0.105 μg kg-1 min-1 (95% CI 0.082 to 0.172μg kg-1min-1), respectively. Apgar scores or umbilical arterial pH were similar among groups.
CONCLUSION The ED50, ED80 and ED95 were 0.029, 0.068 and 0.105μg kg-1 min-1 respectively. A 0.07 μg kg-1min-1 norepinephrine infusion may be optimum for preventing postspinal hypotension after intrathecal injection of 10 mg bupivacaine combined with 5μg sufentanil.
麻醉学文献进展分享
贵州医科大学高鸿教授课题组
翻译：牛振瑛 编辑：冯玉蓉 审校：曹莹