本文選題：瑞芬太尼 + 剖宮產(chǎn)��； 參考：《新鄉(xiāng)醫(yī)學(xué)院》2017年碩士論文

【摘要】：背景臨床上剖宮產(chǎn)手術(shù)大多采用椎管內(nèi)麻醉,對產(chǎn)婦和新生兒的影響小,但對于有椎管內(nèi)禁忌癥的患者,全身麻醉是一個(gè)合適的選擇。瑞芬太尼作為一種其鎮(zhèn)痛作用好,起效時(shí)間短,代謝速率快,無蓄積的短效藥物,但對呼吸和循環(huán)系統(tǒng)呈劑量依賴性的抑制,且易透過胎盤進(jìn)入胎兒體內(nèi),造成胎兒娩出后呼吸和循環(huán)的抑制。本研究使用瑞芬太尼實(shí)施產(chǎn)科全身麻醉誘導(dǎo),檢測它在母體,新生兒臍動(dòng)靜脈中的血藥濃度,評(píng)估其對新生兒呼吸和Apgar評(píng)分的影響,探討其在臨床上的應(yīng)用前景。目的本研究擬通過對行全身麻醉剖宮產(chǎn)手術(shù)的產(chǎn)婦采用不同劑量的瑞芬太尼進(jìn)行誘導(dǎo),評(píng)價(jià)其對產(chǎn)婦的血流動(dòng)力學(xué),新生兒的呼吸和Apgar評(píng)分以及血?dú)庵笜?biāo)的影響,同時(shí)測定產(chǎn)婦和臍帶血的瑞芬太尼血藥濃度,探討瑞芬太尼在全麻剖宮產(chǎn)中的適宜誘導(dǎo)劑量。方法擬行全身麻醉下剖宮產(chǎn)的擇期產(chǎn)婦90例,均為初產(chǎn)婦,年齡在20~45歲之間,手術(shù)切口為Ⅰ、Ⅱ類切口;體重在60~84kg之間,心、肺、肝、腎未見明顯異常,無妊娠期疾病史,有椎管內(nèi)麻醉禁忌癥的(如有凝血功能障礙,嚴(yán)重腰椎病變等),術(shù)前未見循環(huán)功能障礙,胎兒術(shù)前胎心正常,無宮內(nèi)窘迫。采用隨機(jī)數(shù)字表法,依據(jù)瑞芬太尼使用的劑量不同將患者隨機(jī)分為3組(n=30):A組(1.0μg/kg+丙泊酚1.5mg/kg+羅庫溴銨0.6mg/kg組),B組(1.5μg/kg+丙泊酚1.5mg/kg+羅庫溴銨0.6mg/kg組),C組(2.0μg/kg+丙泊酚1.5mg/kg+羅庫溴銨0.6mg/kg組)。三組患者采用丙泊酚+羅庫溴銨+瑞芬太尼行全麻誘導(dǎo),在胎兒娩出后三組麻醉維持均采用靶控輸注丙泊酚和瑞芬太尼以及間斷靜脈注射羅庫溴銨維持麻醉。潮氣量設(shè)置8ml/kg,吸入氧流量為2.0L/min,吸入氧濃度為80%,吸呼比為1:2,呼吸頻率為12次/分。記錄患者的年齡、體重、身高、孕周、術(shù)前胎心率、胎兒娩出時(shí)間等一般資料;于入室后麻醉誘導(dǎo)開始前(T1)、切皮時(shí)(T2)、氣管插管后(T3)記錄產(chǎn)婦的血流動(dòng)力學(xué)指標(biāo)如心率(HR)、收縮壓(SBP)、舒張壓(DBP);在氣管插管后即刻(T3)、胎兒娩出結(jié)扎臍帶后即刻(T4)抽取產(chǎn)婦橈動(dòng)脈血5ml測定瑞芬太尼的血藥濃度;同時(shí)在胎兒娩出結(jié)扎臍帶后即刻(T4)取胎盤側(cè)臍帶中臍靜脈血5ml,臍動(dòng)脈血5ml測定瑞芬太尼血藥濃度,同時(shí)進(jìn)行臍動(dòng)脈血的血?dú)庵笜?biāo)分析:如PH值、臍動(dòng)脈血二氧化碳分壓(Pa CO2)、臍動(dòng)脈血氧分壓(PaO_2);分別在娩出后1min、5min、10min三個(gè)時(shí)間點(diǎn)進(jìn)行Apgar評(píng)分及觀察并統(tǒng)計(jì)新生兒的呼吸抑制情況,新生兒的面罩給氧,氣管插管及納洛酮的處理情況。結(jié)果1一般情況A、B、C三組患者的身高、孕周、體重、年齡、、術(shù)前胎心率,胎兒娩出時(shí)間的比較,差異無統(tǒng)計(jì)學(xué)意義(P0.05);2血流動(dòng)力學(xué)指標(biāo)2.1收縮壓(SBP):A、B、C三組患者麻醉誘導(dǎo)前,組間比較,差異無統(tǒng)計(jì)學(xué)意義(P0.05);A組T2、T3與T1比較,差異有統(tǒng)計(jì)學(xué)意義(P0.05);與A組比較,B、C兩組T2、T3時(shí),差異有統(tǒng)計(jì)學(xué)意義(P0.05);B、C兩組T2、T3與T1比較,以及兩組間比較時(shí),差異無統(tǒng)計(jì)學(xué)意義(P0.05);2.2舒張壓(DBP):A、B、C三組患者麻醉誘導(dǎo)前,組間比較,差異無統(tǒng)計(jì)學(xué)意義(P0.05);A組T2、T3與T1比較,差異有統(tǒng)計(jì)學(xué)意義(P0.05);與A組比較,B、C兩組T2、T3時(shí),差異有統(tǒng)計(jì)學(xué)意義(P0.05);B、C兩組T2、T3與T1比較,以及兩組間比較時(shí),差異無統(tǒng)計(jì)學(xué)意義(P0.05)。2.3心率(HR):A、B、C三組患者麻醉誘導(dǎo)前,組間比較,差異無統(tǒng)計(jì)學(xué)意義(P0.05);A組內(nèi),T2與T1、T3與T1組內(nèi)比較,差異有統(tǒng)計(jì)學(xué)意義(P0.05);B、C兩組T2、T3時(shí)與A組相比,差異有統(tǒng)計(jì)學(xué)意義(P0.05);B、C兩組組內(nèi),T2與T1、T3與T1組內(nèi)比較,以及兩組間比較時(shí),差異無統(tǒng)計(jì)學(xué)意義(P0.05);3臍動(dòng)脈血?dú)夥治鯝、B、C三組患者組間比較PH值、臍動(dòng)脈血氧分壓(PaO_2)、臍動(dòng)脈血二氧化碳分壓(Pa CO2),差異無統(tǒng)計(jì)學(xué)意義(P0.05)。4臍帶血瑞芬太尼濃度4.1臍靜脈(UV)血瑞芬太尼濃度:A、B、C三組患者分別為0.63±0.14ng/ml、0.99±0.24ng/ml、1.39±0.29ng/ml;4.2臍動(dòng)脈(UA)血瑞芬太尼濃度:A、B、C三組患者分別為0.32±0.09ng/ml、0.60±0.36ng/ml、0.89±0.41ng/ml;4.3 UA/UV:A、B、C三組患者分別為0.62±0.06、0.65±0.21、0.64±0.33。5產(chǎn)婦橈動(dòng)脈血瑞芬太尼濃度A、B、C三組T3、T4時(shí)的血藥濃度是1.41±0.51ng/ml、2.14±0.88ng/ml、2.97±1.09ng/ml和0.89±0.38ng/ml、1.38±0.20ng/ml、1.89±0.40ng/ml。6 Apgar評(píng)分A、B、C三組在胎兒娩出后1min、5min、10min進(jìn)行比較,差異無統(tǒng)計(jì)學(xué)意義(P0.05);A組未出現(xiàn)呼吸抑制,B組出現(xiàn)1例輕度呼吸抑制,經(jīng)拍足刺激等措施后呼吸很快正常,C組出現(xiàn)2例輕度呼吸抑制,經(jīng)拍足刺激等措施后呼吸很快正常,新生兒在出生后5min、10min時(shí)未出現(xiàn)呼吸抑制。結(jié)論通過對不同誘導(dǎo)劑量瑞芬太尼在全麻剖宮產(chǎn)中的比較,誘導(dǎo)劑量為1.5μg/kg和2.0μg/kg時(shí),產(chǎn)婦的血流動(dòng)力學(xué)穩(wěn)定、新生兒呼吸無明顯抑制,Apgar評(píng)分以及臍動(dòng)脈血的血?dú)庵笜?biāo)無明顯影響,可推薦作為在全麻剖宮產(chǎn)中適宜的誘導(dǎo)劑量。
[Abstract]:The effect of intraspinal anaesthesia mostly in the clinical cesarean section is small, but for the patients with intraspinal contraindication, general anesthesia is a suitable choice. Remifentanil is a good analgesic, short acting time, fast metabolic rate and no accumulation of short effective drugs, but the respiratory and circulatory system is present. Dose-dependent inhibition, and easy to enter the fetus through the placenta, resulting in the inhibition of respiration and circulation after delivery of the fetus. This study used remifentanil to induce general obstetric anesthesia, to detect its blood concentration in the maternal and neonatal umbilical vein, to evaluate its effect on newborn infants' respiration and Apgar score, and to explore its clinical effects. The purpose of this study is to evaluate the effect of different doses of remifentanil on the maternal hemodynamics, the neonatal respiration and Apgar score and the blood gas index, and to determine the blood concentration of remifentanil in maternal and umbilical cord blood and to explore rifen Tai. Methods the suitable induction dose in caesarean section of general anesthesia. Methods 90 cases of cesarean section were given under general anesthesia, all of which were primipara. The age was between 20~45 years, the incision was I, the incision of class II, the body weight was between 60~84kg, heart, lung, liver and kidney, there was no history of pregnancy disease, and the contraindications of intraspinal anesthesia (such as clotting) The patients were randomly divided into 3 groups (n=30): A group (1 g/kg+ propofol 1.5mg/ kg+ rocuronium 0.6mg/kg group), and B group (1.5 u g/kg+ propofol 1.5mg/kg+ Luo). The 0.6mg/kg group (group 0.6mg/kg), group C (2 mu g/kg+ propofol 1.5mg/kg+ rocurbrominium). The three groups were induced by propofol + rocuronium + with general anesthesia. After the birth of the fetus, the three groups of anesthesia were maintained by target controlled infusion of propofol and Reventa Ni and intermittent intravenous injection of rocuronium. The tidal volume was set to 8ml/k. G, inhaled oxygen flow was 2.0L/min, inhaled oxygen concentration was 80%, respiration rate was 1:2, respiratory frequency was 12 times per cent. General data of age, weight, height, gestational age, fetal heart rate, fetal delivery time were recorded, before induction of anesthesia induction (T1), skin cutting (T2), and endotracheal intubation (T3), the hemodynamic indexes of parturients were recorded. Rate (HR), systolic pressure (SBP) and diastolic pressure (DBP); immediately after endotracheal intubation (T3), and immediately after the fetal delivery was ligation of the umbilical cord (T4), the blood concentration of remifentanil was measured by 5ml in the radial artery blood of the parturients (T4); at the same time, the umbilical vein blood 5ml of the placental side umbilical cord was taken immediately after the umbilical cord was ligated and the umbilical artery blood was used to determine the concentration of remifentanil in the umbilical artery. The blood gas index of umbilical artery blood was analyzed, such as pH value, Pa CO2 of umbilical artery blood (Pa), umbilical artery blood oxygen partial pressure (PaO_2), Apgar score of 1min, 5min, 10min after delivery, and observation of neonatal respiratory depression, neonatal mask oxygenation, tracheal intubation and naloxone treatment. Results 1 A, B, C three groups of patients with height, gestational age, weight, age, preoperative fetal heart rate, fetal delivery time comparison, the difference is not statistically significant (P0.05); 2 hemodynamic index 2.1 systolic pressure (SBP): A, B, C three groups before anesthesia induction, the difference is not statistically significant (P0.05); A T2, T3 and differences, there is a statistical difference Learning significance (P0.05); compared with group A, B, C two groups T2, T3, the difference was statistically significant (P0.05); B, C two T2, T3 and T1, and the two groups compared, there was no statistically significant difference; 2.2 diastolic pressure, three groups of patients before anesthesia induction, the difference was not statistically significant Significance (P0.05); compared with group A, B, C two groups T2, T3, the difference was statistically significant (P0.05); B, C two T2, T3 and T1, and the difference between the two groups, there was no statistically significant difference between the three groups before anesthesia induction. Statistical significance (P0.05); B, C two groups T2, T3 compared with the A group, the difference was statistically significant (P0.05); B, C two groups, T2 and T1, and the two groups compared, the difference was not statistically significant; 3 umbilical artery blood gas analysis, three groups of patients compared with the pH, umbilical artery blood oxygen pressure, umbilical artery blood carbon dioxide Partial pressure (Pa CO2), the difference was not statistically significant (P0.05).4 umbilical cord blood remifentanil concentration 4.1 umbilical vein (UV) blood remifentanil concentration: A, B, C three groups were 0.63 + 0.14ng/ml, 0.99 + 0.24ng/ml, 1.39 + 0.29ng/ml; 4.2 umbilical artery (UA) blood remifentanil concentration: 0.32 + three, 0.60 +, 0.89 +; 4.3 UA/UV:A, B, and C three groups were 0.62 + 0.06,0.65 + 0.21,0.64 + 0.33.5 respectively, the concentration of remifentanil in radial artery was A, B, C three T3, and the concentration of blood drug was 1.41 + 0.51ng/ml, 2.14 +, 2.97 and 0.89, 1.38 +, 1.89 +. The difference was not statistically significant (P0.05); there were no respiratory inhibition in group A, 1 cases of mild respiratory depression in group B and 2 cases of mild respiratory depression in group C. The breathing was quickly normal after the measures of foot stimulation, and the newborn infants had no respiratory inhibition when 5min and 10min were born after birth. The conclusion passed through the conclusion. The comparison of the different induced doses of remifentanil in general anesthesia for caesarean section of the caesarean section of general anesthesia, the induced dose of 1.5 g/kg and 2 mu g/kg, the maternal hemodynamics is stable, the newborn respiration has no obvious inhibition, the Apgar score and the blood gas index of the umbilical artery blood have no obvious influence, can be recommended as the suitable induction dose in the general anesthesia cesarean section.
【學(xué)位授予單位】：新鄉(xiāng)醫(yī)學(xué)院
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類號(hào)】：R614.2

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