【摘要】 目的 观察小剂量氯胺酮在健忘镇痛麻醉辅助局部麻醉（局麻）剖宫产中的应用。方法 选择1200例剖宫产的孕妇,随机分为单纯局麻组(L组)、氟芬强化局麻组(F组)和健忘镇痛麻醉组(J组),每组400例。L组单纯局麻;F组局麻术中辅以氟哌利多500 mg,芬太尼015 mg;J组在F组基础上辅以氯胺酮,观察各组患者麻醉诱导至胎儿娩出时间;新生儿1、5 min Apgar评分;手术中血压相对于基础值的波动情况;手术中及手术后出血情况及麻醉满意度。 结果 J组与L组和F组比较,胎儿娩出时间无显著差别;Apgar评分提高;手术中孕妇血压波动不明显;手术中及手术后出血量无明显增加,麻醉满意度明显提高。 结论 由小剂量氯胺酮辅助实施的健忘镇痛麻醉在局麻剖宫产中优于单纯局麻和氟芬强化局麻,在剖宫产中尤其急诊剖宫产中值得推广。【Abstract】 Objective To observe the application of lowdose ketamine during the local anesthesia in cesarean section assisted by analgestic and amnestic anesthesia. Methods A total of 1200 cases who need cesarean section were randomly divided into 3 groups (400 cases in each group): simple local anesthesia group (group L), droperidolfentanyl strengthen local anesthesia group (group F) and analgestic and amnestic anesthesia group (group J). Group L was only local anesthesia. Group F was local anesthesia supplemented by droperidol 500 mg, fentanyl 015 mg. Group J was supplemented with ketamine on the basis of group F. Then the time from anesthesia to the fetus delivery, Neonatal Apgar score of one and five minutes, the blood pressure fluctuations, amount of bleeding in or after surgery and the satisfaction of anesthesia were all observed. Results Compared with group L and F, the delivery time was no significant difference, Apgar score increased, blood pressure fluctuations in pregnant women was not obviously varied, amount of bleeding in or after surgery had no significantly increase, and the satisfaction of anesthesia improved markedly all in group J. Conclusions The analgestic and amnestic anesthesia assisted by lowdose ketamine, in cesarean section, is better than local anesthesia and strengthen local anesthesia by droperidolfentanyl, which is worthy to be popularized, especially in emergency caesarean section.
ObjectiveTo discuss the clinical characteristics, treatment and prevention of abdominal wall endometriosis (AWE). MethodsA retrospective analysis of 295 cases of AWE from February 2007 to August 2011 in our hospital was performed. ResultsAll of the patients had abdominal operations before and 99% of them had a history of caesarean section. The mean age of the patients was (31.55±4.52) years old. The average size of the mass was (2.66±1.12) cm, significantly larger than the estimation of ultrasonography before operation which was (1.91±0.83) cm (P<0.001). No relapse was discovered five months to three years after the operation. ConclusionIt is easy to diagnose abdominal wall endometriosis through medical history, clinical characteristics, physical signs and ultrasonic assessment. The prevention of AWE is very important. Operation is still the best treatment for AWE.
Objectives To analyze the efficacy and safety of different operation methods for patients with cesarean scar diverticulum. Methods The clinical data of patients with cesarean section scar diverticulum treated in West China Second University Hospital from July 2012 to December 2016 was collected and followed up. The data of the previous perioperative period data, recovery, the improvement of the symptoms and postoperative condition of incision healing were analyzed by SPSS 22.0 software. Results A total of 125 patients were included, in which 74 cases received hysteroscopy surgery for diverticulum electro section and electric coagulation (ESEC group), and 51 cases received other surgery focused on diverticulum dissection and sewing operations (DS group). Statistical analysis showed that, compared with DS group, bleeding, operation time, time of anal exsufflation and hospitalization duration after the operation of hysteroscopy in ESEC group were significantly reduced (P<0.001). In addition, the results showed that hysteroscopy group had optimal results in hemorrhage volume, operation time, anal exhaust time and hospitalization time indicators. However, the results of laparotomy group was not significant. Conclusions For the treatment of CSD, surgical treatment of this pathology by operative hysteroscopy may represent the best choice in symptomatic women because of its minimal invasiveness and beneficial therapeutic results. Hysteroscopy isthmoplasty appears to be the most popular treatment.
ObjectiveTo systematically review the prevalence and risk factors of the chronic post-cesarean section pain (CPCSP). MethodsPubMed, EMbase, The Cochrane Library, CINAHL, PsycInfo, CBM, WanFang Data, VIP, and CNKI databases were electronically searched to collect studies on the prevalence and risk factors of CPCSP from inception to August 2021. Two reviewers independently screened literature, extracted data, and assessed the risk of bias of included studies. Meta-analysis was then performed using Stata 15.1 software. ResultsA total of 43 studies involving 12 435 participants were included. The results of meta-analysis showed that the prevalence of CPCSP for 2 to 5 months, 6 to 11 months, and at least 12 months were 19% (95%CI 15% to 23%), 13% (95%CI 9% to 17%), and 8% (95%CI 6% to 10%), respectively. The risk factors included preoperative pain present elsewhere, postoperative severe acute pain, low abdominal transverse incision, non-intrathecal administration of morphine, preoperative anxiety, postpartum depression, etc. ConclusionsThe current evidence shows that the overall prevalence of CPCSP is high. Preoperative pain presents elsewhere, postoperative severe acute pain, low abdominal transverse incision, non-intrathecal administration of morphine, preoperative anxiety and postpartum depression may increase the risk of CPCSP.
Objective To discuss the effect of continuous phenylephrine infusion and single-dose phenylephrine injection on puerpera undergoing spinal and epidural combined anesthesia and the infant outcomes. Methods A total of 50 patients scheduled for selective cesarean section under combined spinal and epidural anesthesia were selected as the study subjects between July 2015 and June 2016. They were randomly allocated into two groups with 25 in each. Group CII underwent continuous phenylephrine infusion [0.5 μg/(kg·min)] immediately after anesthesia to adjust the blood pressure, while group CON accepted single-dose phenylephrine injection (50 μg) after anesthesia when systolic pressure was lower than 90 mm Hg (1 mm Hg=0.133 kPa) or when the decrease of mean arterial pressure (MAP) was higher than 20% of the base value. The infusion of phenylephrine was stopped after the fetus was taken out. MAP, cardiac output, cardiac index (CI) at the time when the patient went into the delivery room (T1), before anesthesia (T2), 1 minute after anesthesia (T3), 3 minutes after anesthesia (T4), 10 minutes after anesthesia (T5), and delivery (T6) were recorded. Blood gas analysis of fetal umbilical arterial blood was carried out and neonatal Apgar score was recorded. Results Hemodynamics was more stable in group CII compared with group CON. Heart rate at T4 and T5, and cardiac output at T5 and T6 in group CON were significantly lower than those in group CII (P<0.05). The neonatal umbilical arterial blood pH value, base excess and HCO3－ were all significantly lower, while partial pressure of carbon dioxide was significantly higher in group CON than group CII (P<0.05). Conclusion Compared with single-dose phenylephrine injection, continuous phenylephrine infusion has more stable hemodynamics, and exert less effect on maternal and infant outcomes for patients undergoing cesarean section under combined spinal and epidural anesthesia.
ObjectiveTo compare the anesthetic potency and influence on maternal hemodynamics among spinal anesthesia (SA), epidural anesthesia (EA) and combined spinal epidural anesthesia (CSEA) for women undergoing cesarean sections. MethodsA total of 180 singleton term nulliparous pregnancies of American Sociaty of Anethesiologists physical status Ⅰor Ⅱ for cesarean sections in Guangyuan Central Hospital from January to December 2012 were allocated into three groups using the method of random number table. Patients in group SA received SA (n=60), group EA underwent EA (n=60) and patients in group CSEA accepted CSEA (n=60). Patients wderwent punere all placed in left lateral position. Group EA patients unctures at the L1-2 interspace and the volume of carbonated lidocaine used initially was 12-15 mL. Group SA and CSEA accepted the anesthesia at either L2-3 or L3-4 interspace. The volume for group SA was 0.75% bupivacaine 1.2 mL with 10% glucose solution 1 mL, and for group CSEA was 0.5% bupivacaine 1.4 mL with 10% glucose solution 0.8 mL. A catheter was inserted into the epidural space for 3-4 cm after spinal needle exit so as to add additional epidural medication according to the block level and the level of anesthesia subsidence. The values of the basis of blood pressure and heart rate, the lowest blood pressure and heart rate, umbilical venous blood gas, start effect and induction time of anesthesia and the highest block level of anesthesia were record. ResultsThere were statistically significant differences in terms of start effect time of anesthesia among the three groups (F=24.642, P<0.001). The start effect time of anesthesia in group SA and CSEA was significantly shorter than that in group EA (t=8.076, 7.996; P<0.05). The induction time of anesthesia in group SA was significantly shorter than those in group EA and CSEA (P<0.05). The lowest blood pressure and heart rate in group SA and CSEA were significantly lower than the values of basis (P<0.05). The lowest blood pressure and heart rate in group SA was significantly lower than that in group EA (P<0.05). The incidence of hypotension and bradycardia in group SA and CSEA was significantly higher than that in group EA (P<0.05). The block level of anesthesia in the three groups were at thoracic 8.12±1.22, 8.36±1.88 and 8.52±1.92 respectively, and there was no significant difference among the three groups (F=0.081, P=0.923). ConclusionEA and CSEA surpass SA in the choice of neuraxial anesthesia for cesarean sections, and 1.73% carbonated lidocaine for EA can improve anesthetic potency and better maintain relatively stable hemodynamic indexes.
Objective To summarize our diagnostic and treatment experience for patients with acute Stanford type A aortic dissection （AAAD） during pregnancy. Methods Clinical data of 3 AAAD gravida （age of 30，32，35） who received surgical treatment in Beijing Anzhen Hospital of Capital Medical University from May 2008 to July 2010 were retros-pectively analyzed. One gravida received Sun’s procedure （total arch replacement combined with stented elephant trunk implantation） 3 days after cesarean section，but the fetus died in the uterus. Another gravida successfully underwent Bentall procedure and Sun’s procedure immediately after cesarean section and hysterectomy. The third gravida received cesarean section with the uterus in situ followed by ascending aorta replacement and Sun’s procedure. Results All the 3 puerperasrecovered uneventfully，and the 2 newborns of the second and third puerperas also lived well. The 3 puerperas were followedup for 6 months after discharge. CT scan showed organized thrombus in the aortic false lumen. During follow-up，the 3 puerperas recovered well，and the 2 infants had normal growth and development. Conclusions Management principles of AAAD during pregnancy firstly include timely and accurate diagnosis，which is of prime importance. Secondly，gravidas’hemodynamics should maintain stable. Thirdly，intraoperative hemorrhage should be satisfactorily controlled. Lastly，multi-modality treatment is very important to improve the prognosis of both gravidas and fetuses.
Objective To systemically review the clinical application of esketamine for postoperative analgesia in cesarean section. Methods Databases including CNKI, VIP, WanFang Data, PubMed, EMbase, Web of Science, and The Cochrane Library were searched for randomized controlled trials (RCTs) on esketamine in cesarean section from inception to January 2022. Two reviewers independently screened the literature, extracted data, and assessed the risk of bias of the included studies. Meta-analysis was then performed using RevMan 5.4 software. Results A total of 16 RCTs involving 1 715 cesarean section patients were included. The results of meta-analysis showed that esketamine decreased the patients’ visual analog scale scores after surgery (MD=−0.67, 95%CI −0.86 to −0.49, P<0.000 01) and reduced the need for analgesics for 48 hours after surgery (MD=−2.38, 95%CI −3.15 to −1.62, P<0.000 01) compared with the control drugs (such as opioids, ropivacaine, and normal saline), without increasing adverse reactions such as nausea and vomiting (RR=0.84, 95%CI 0.62 to 1.12, P=0.23), hallucinations (RR=3.00, 95%CI 0.37 to 24.43, P=0.30), drowsiness (RR=1.49, 95%CI 0.16 to 13.99, P=0.73), itching (RR=1.05, 95%CI 0.79 to 1.41, P=0.72), hypotension (RR=0.31, 95%CI 0.04 to 2.40, P=0.26), bradycardia (RR=0.40, 95%CI 0.01 to 11.24, P=0.59), and dizziness (RR=2.24, 95%CI 0.63 to 7.94, P=0.21). Compared with the control drugs, esketamine extended the operation time (MD=2.23, 95%CI 1.73 to 2.74, P<0.000 01), accelerated heart rate (MD=1.31, 95%CI 0.25 to 2.37, P=0.02), and increased the mean arterial pressure (MD=3.88, 95%CI 0.19 to 7.56, P=0.04) during surgery. Additionally, esketamine improved the Apgar score of neonates (MD=0.45, 95%CI 0.26 to 0.63, P<0.000 01) and the Edinburgh postnatal depression scale score of mothers (MD=−1.12, 95%CI −1.87 to −0.55, P=0.000 3), having no effects on the cord blood pH of neonates (MD=0.03, 95%CI −0.01 to 0.07, P=0.14). Conclusion Esketamine has certain advantages when used for postoperative analgesia in cesarean section. Due to the limited quantity and quality of the included studies, more high-quality studies are needed to further verify the above conclusion.
ObjectiveTo evaluate the effect of different rehydration strategies on the incidence of spinal anesthesia-induced hypotension and neonatal outcomes during elective cesarean section.MethodsWe searched PubMed, Embase, the Cochran Library, China National Knowledge Internet, VIP database, Wanfang database, and China Biology Medicine database from inception to January 2018, to collect randomized controlled trials (RCTs) about the incidence of spinal anesthesia-induced hypotension during elective cesarean section and neonatal outcomes of preloading or coloading. Two researchers independently screened the literature, extracted data, and evaluated the risk of bias in the study. Meta-analysis was conducted using RevMan 5.3 software.ResultsA total of 11 RCTs were included, including 894 parturients, of whom 448 cases in the preload group and 446 cases in the coload group. Comparing with the preload group, the incidence of spinal anesthesia-induced hypotension during cesarean section in the coload group significantly decreased [risk ratio (RR)=1.27, 95% confidence interval (CI) (1.13, 1.43), P<0.000 1]. Subgroup analysis showed that in the crystalloid fluid group, the difference in the incidence of hypotension between the preload group and the coload group was statistically significant [RR=1.48, 95%CI (1.26, 1.73), P<0.000 01]; while in the colloidal fluid group, the difference in the the incidence of hypotension between the preload group and the coload group was not significant [RR=1.00, 95%CI (0.85, 1.17), P=0.96]. The lowest systolic blood pressure, the incidence of nausea and vomiting, and neonatal outcomes had no significant difference between the two groups.ConclusionsComparing with preloading crystalloid fluid, rapid infusion of crystalloid fluid at the same time implementation of spinal anesthesia could significantly reduce the incidence of hypotension during cesarean section while there was no superiority in infusion of colloid fluid. There was no significant effect on the severity of hypotension, nausea and vomiting, and neonatal outcomes. Due to the limitation of the quantity and quality of the included studies, the above conclusions need to be verified by more high-quality studies.
【作者简介】〖KG2〗〖HTSS〗蒋青(1963-),女,四川遂宁人,主管护师,硕士,Email:jq0987@yahoo.cn