本文選題：產(chǎn)后　切入點：抑郁癥　出處：《南方醫(yī)科大學》2017年碩士論文

【摘要】：背景:產(chǎn)后抑郁是分娩常見的并發(fā)癥,并已經(jīng)成為了重要的公共衛(wèi)生問題。傳統(tǒng)的抗抑郁藥作用于單胺氧化酶系統(tǒng),需要數(shù)周才能起效,且臨床有效性低。近十幾年來有越來越多的臨床研究發(fā)現(xiàn)亞劑量的氯胺酮(0.5 mg/kg)具有快速抗抑郁的作用,其作用機制可能是氯胺酮介導了突觸的可塑性從而能引起長期的行為學變化。另外,有臨床研究表明疼痛是產(chǎn)后抑郁的危險因素,而有meta分析顯示小劑量氯胺酮應用可以降低術(shù)后疼痛強度和預防慢性疼痛,其機制可能與NMDA受體被拮抗從而減少中樞敏化和痛覺過敏有關(guān)。從氯胺酮以上兩個作用機制來看,我們認為氯胺酮可能具有預防產(chǎn)后抑郁的作用,因此我們設計了一項前瞻性、隨機、雙盲的臨床試驗來評價剖宮產(chǎn)術(shù)中小劑量的氯胺酮應用是否具有預防產(chǎn)后抑郁的作用。方法:本研究是一項隨機、雙盲、安慰劑對照、前瞻性的臨床試驗。所有的受試者被隨機分配到氯胺酮組或生理鹽水組。新生兒娩出后5min內(nèi)由麻醉醫(yī)師給產(chǎn)婦靜脈推注0.25 mg/kg氯胺酮或等量生理鹽水。受試者基本情況的數(shù)據(jù)采集包括年齡、體重指數(shù)(Body Mass Index,BMI)、此次妊娠相關(guān)的情況。術(shù)中的數(shù)據(jù)由麻醉醫(yī)師完成,包括去氧腎上腺素用量、術(shù)中出血量、手術(shù)持續(xù)時間、新生兒信息,并在給完試驗藥物后5分鐘、15分鐘和出室的時候詢問受試者是否存在瘙癢、惡心、嘔吐、頭痛、幻覺、眩暈、嗜睡、復視,同時進行鎮(zhèn)靜評分(Ramsay評分)。主要結(jié)局指標為產(chǎn)后第3天和6 周的 EPDS 評分(Edinburgh Postnatal Depression Scale score)。次要結(jié)局指標為產(chǎn)后第3天和6周的NRS(Numeric Rating Scale)疼痛評分。結(jié)果:共納入330例受試者,受試者的基本資料數(shù)據(jù)兩組之間沒有統(tǒng)計學意義。術(shù)中采集的產(chǎn)婦信息和新生兒的信息在兩組之間也沒有統(tǒng)計學意義。與對照組相比,氯胺酮組在給藥后5分鐘的頭痛、幻覺、頭暈、嗜睡、復視癥狀比對照組多,鎮(zhèn)靜評分3分的發(fā)生率比對照組高。給藥后15分鐘嘔吐、幻覺、頭暈、嗜睡、復視癥狀比對照組多,鎮(zhèn)靜評分(Ramsay評分)3分的發(fā)生率兩組之間沒有統(tǒng)計學差異。出手術(shù)間時兩組之間氯胺酮相關(guān)的副作用沒有統(tǒng)計學差異。兩組之間在術(shù)后第3天產(chǎn)后抑郁的發(fā)生率和NRS評分沒有統(tǒng)計學差異,術(shù)后6周產(chǎn)后抑郁的發(fā)生率沒有統(tǒng)計學差異。氯胺酮組在術(shù)后第6周的NRS疼痛評分要顯著低于對照組(P=0.014)。結(jié)論:氯胺酮0.25 mg/kg剖宮產(chǎn)術(shù)中應用不能有效地預防產(chǎn)后抑郁,但能夠減少剖宮產(chǎn)術(shù)后第6周疼痛的發(fā)生。有部分受試者在給藥后會出現(xiàn)氯胺酮相關(guān)的副作用,但緩解迅速,不延遲出室時間。
[Abstract]:Background: postpartum depression is a common complication of childbirth and has become an important public health problem.Traditional antidepressants act on monoamine oxidase systems, which take several weeks to take effect and have low clinical efficacy.In recent years, more and more clinical studies have found that the sub-dose of ketamine (0.5 mg / kg) has a rapid antidepressant effect, and its mechanism may be that ketamine mediates synaptic plasticity and causes long-term behavioral changes.In addition, clinical studies have shown that pain is a risk factor for postpartum depression, and meta analysis shows that low doses of ketamine can reduce postoperative pain intensity and prevent chronic pain.The mechanism may be related to the antagonism of NMDA receptor, which reduces central sensitization and hyperalgesia.From the above two mechanisms of ketamine, we think that ketamine may have a role in preventing postpartum depression, so we designed a prospective, randomized,A double blind clinical trial was conducted to evaluate whether low-dose ketamine use during cesarean section could prevent postpartum depression.Methods: this study was a randomized, double-blind, placebo-controlled, prospective clinical trial.All subjects were randomly assigned to either the ketamine group or the saline group.The anesthesiologist intravenously injected 0.25 mg/kg ketamine or the same amount of normal saline into the parturient after delivery.The subjects' basic data collection included age, body Mass index, and pregnancy related information.The intraoperative data were performed by the anesthesiologist, including the amount of norepinephrine, the amount of blood lost during the operation, the duration of the operation, the information on the newborn, and the subjects were asked if they had itching 5 minutes, 15 minutes after the trial and when they left the room.Nausea, vomiting, headache, hallucination, vertigo, lethargy, diplopia, sedation score and Ramsay score.The main outcome index was the EPDS score on the 3rd and 6th week postpartum.The secondary outcome was the NRS(Numeric Rating scale score on the 3rd and 6th week postpartum.Results: a total of 330 subjects were included, and there was no statistical significance between the two groups.There was also no statistical significance between the maternal and neonatal information collected during the operation.Compared with control group, ketamine group had more symptoms of headache, hallucination, dizziness, drowsiness, and diplopia, and the incidence of sedation score 3 was higher than that of control group 5 minutes after administration of ketamine.There was no significant difference in the incidence of vomiting, hallucination, dizziness, lethargy, diplopia symptoms, sedation score and Ramsay score between the two groups 15 minutes after administration.There was no significant difference in ketamine-related side effects between the two groups at the time of operation.There was no significant difference in the incidence of postpartum depression and NRS score between the two groups on the third day after operation, but there was no significant difference in the incidence of postpartum depression at 6 weeks after operation.The NRS pain score in ketamine group was significantly lower than that in control group at 6 weeks postoperatively.Conclusion: ketamine 0.25 mg/kg during cesarean section can not effectively prevent postpartum depression, but can reduce the incidence of pain 6 weeks after cesarean section.Some subjects had ketamine-related side effects after administration, but the response was rapid, without delay.
【學位授予單位】：南方醫(yī)科大學
【學位級別】：碩士
【學位授予年份】：2017
【分類號】：R614

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本文編號：1699366