预输入胶体液联合晶体液与单独输入晶体液在腰麻下剖宫产术中的比较：随机对照试验
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Combined Colloid Preload and Crystalloid Coload Versus Crystalloid Coload During Spinal Anesthesia for Cesarean Delivery: A Randomized Controlled Trial
背景
在腰麻下剖宫产术中如何选择最佳补液方案，目前尚未明确。近来可采用下腔静脉造影术（IVC）来评估容量状态和预测补液反应。在一项随机双盲对照试验中，我们比较了联合预先补充500ml胶体液和500ml晶体液与单独补充1000ml后产妇的血流动力学。采用IVC测量基础和各时间点的血流动力学。
方 法
纳入200名ASA II级的拟在腰麻下行择期剖宫产术的足月单胎产妇，随机分为两组，联合组用输液加压器先补充500ml晶体液后再输入500ml胶体液，晶体组输入1000ml晶体液。当收缩压低于基础值的90%、80%和70%时分别给予3、5、10mg的麻黄碱处理。用肋下长轴影像评估基础值、腰麻给药后1分钟和5分钟及产后的IVC；测量IVC的最大和最小直径，使用公式计算IVC塌陷指数（CI）：IVC-CI=（IVC最大直径-最小直径）/最大直径。主要结局指标为麻黄碱的使用量。
结 果
分析了198名(每组99名)产妇的数据。联合组麻黄碱的使用总量为11（0-60）mg，晶体液组为13（0-61）mg；差值的中位数（95％非参数置信区间）为-2（-5至0.00005）mg，P = 0.22。两组在麻黄碱的使用量、低血压的发生率和严重程度、首次使用麻黄碱的时间和新生儿出生后1、5分钟Apgar评分上没有显著差异。两组的IVC最大值和最小值在腰麻和生产后均增大，其中联合组增大更明显。生产后晶体组的IVC-CI值较大。
结 论
与单独补充1000ml晶体液相比，500ml胶体液联合500ml晶体液并没有减少麻黄碱的使用量或改善产妇的结局。但在剖宫产术前和剖宫产术期间可靠地观察IVC，其直径随时间有明显变化并且在两组之间有差异。
原始文献摘要
BACKGROUND:
The optimal strategy of fluid administration during spinal anesthesia for cesarean delivery is still unclear. Ultrasonography of the inferior vena cava (IVC) has been recently used to assess the volume status and predict fluid responsiveness. In this double-blind, randomized controlled study, we compared maternal hemodynamics using a combination of 500-mL colloidpreload and 500-mL crystalloid coload versus 1000-mL crystalloid coload. We assessed the IVC at baseline and at subsequent time points after spinal anesthesia.
METHODS:
Two hundred American Society of Anesthesiologists physical status II parturients with full-term singleton pregnancies scheduled for elective cesarean delivery under spinal anesthesia were randomly allocated to receive either 500-mL colloid preload followed by 500-mL crystalloid coload (combination group) or 1000-mL crystalloid coload (crystalloid coload group) administered using a pressurizer. Ephedrine 3, 5, and 10 mg boluses were administered when the systolic blood pressure decreased below 90%, 80% (hypotension), and 70% (severe hypotension) of the baseline value, respectively. The IVC was assessed using the subcostal long-axis view at baseline, at 1 and 5 minutes after intrathecal injection, and immediately after delivery; the maximum and minimum IVC diameters were measured, and the IVC collapsibility index (CI) was calculated using the formula: IVC-CI = (maximum IVC diameter - minimum IVC diameter)/maximum IVC diameter. The primary outcome was the total ephedrine dose.
RESULTS:
Data from 198 patients (99 patients in each group) were analyzed. The median (range) of the total ephedrine dose was 11 (0-60) mg in the combination group and 13 (0-61) mg in the crystalloid coload group; the median of the difference (95% nonparametric confidence interval) was -2 (-5 to 0.00005) mg, P = .22. There were no significant differences between the 2 groups in the number of patients requiring ephedrine, the incidence of hypotension and severe hypotension, the time to the first ephedrine dose, and neonatal Apgar scores at 1 and 5 minutes. The maximum and minimum IVC diameters in each group increased after spinal anesthesia and after delivery, and they were larger in the combination group. The IVC-CI after delivery was higher in the crystalloid coload group.
CONCLUSIONS:
The combination of 500-mL colloid preload and 500-mL crystalloid coload did not reduce the total ephedrine dose or improve other maternal outcomes compared with 1000-mL crystalloid coload. The IVC was reliably viewed before and during cesareandelivery, and its diameters significantly changed over time and differed between the 2 groups.
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