文献导读|哪种硬膜外分娩镇痛技术好?

 

硬脊膜穿破硬膜外阻滞技术与标准硬膜外阻滞技术用于肥胖产妇分娩镇痛的质量：一项双盲随机对照研究

 

背    景：

 

硬脊膜穿破硬膜外阻滞技术可以通过确定中线位置和增加硬膜外药物鞘内扩散来提高镇痛质量。

这将有利于阻滞失败风险增加的肥胖产妇。

该研究假设，与标准硬膜外技术相比，硬脊膜穿破硬膜外阻滞技术可以改善肥胖产妇的分娩镇痛质量。

 

方    法：

 

体重指数大于或等于35 kg·m^-2、宫颈扩张2-7 cm、疼痛评分大于4（0表示无疼痛，10表示可想象的最严重疼痛）的足月产妇随机分为两组：硬脊膜穿破硬膜外阻滞技术组（使用25号Whitacre针）或标准硬膜外阻滞技术组。

使用15 ml 0.1%罗哌卡因和2µg·ml^-1芬太尼开始镇痛，然后进行程序性间歇推注（每45分钟6 ml），患者控制硬膜外镇痛（PCEA）。

产妇对分组不知情。

数据由盲法研究者每3分钟收集一次，持续30分钟，然后每2小时收集一次，直到分娩。

主要指标是：

（1）不对称阻滞，

（2）硬膜外补液，

（3）导管调整，

（4）导管更换，

（5）失败，转为区域麻醉下剖宫产。

次要指标包括：

疼痛评分为1分或以下的时间、

30分钟时的感觉水平、

运动阻滞、

最大疼痛评分、

患者自控硬膜外镇痛的使用、

硬膜外药物消耗、

第二产程的持续时间、

分娩方式、

胎心率变化、

Apgar评分、

产妇不良事件

和镇痛满意度。

 

结    果：

 

141例随机产妇中，每组66例纳入分析。

硬脊膜穿破硬膜外阻滞技术组和标准硬膜外阻滞技术组在综合主要指标（66例中34例，52%对32例，49%；比值比，1.1[0.5-2.4]；P=0.766）。

单个指标或任何次要指标方面也没有统计学或临床显著差异。

 

结    论：

 

该研究中两种技术在分娩镇痛质量上的差异不支持肥胖产妇常规使用硬膜外穿刺技术。

 

 

Quality of Labor Analgesia with DuralPuncture Epidural versus Standard Epidural Technique in Obese Parturients ADouble-blind Randomized Controlled Study

 

Background:

 

The dural puncture epidural techniquemay improve analgesia quality by confirming midline placement and increasingintrathecal translocation of epidural medications. This would be advantageousin obese parturients with increased risk of block failure. This studyhypothesizes that quality of labor analgesia will be improved with duralpuncture epidural compared to standard epidural technique in obese parturients.

 

Methods:

 

Term parturients with body mass indexgreater than or equal to 35 kg · m-2, cervical dilation of 2 to 7 cm, and painscore of greater than 4 (where 0 indicates no pain and 10 indicates the worstpain imaginable) were randomized to dural puncture epidural (using 25-gaugeWhitacre needle) or standard epidural techniques. Analgesia was initiated with15 ml of 0.1% ropivacaine with 2 µg · ml-1 fentanyl, followed by programedintermittent boluses (6 ml every 45 min), with patient-controlled epiduralanalgesia. Parturients were blinded to group allocation. The data werecollected by blinded investigators every 3 min for 30 min and then every 2 huntil delivery. The primary outcome was a composite of (1) asymmetrical block,(2) epidural top-ups, (3) catheter adjustments, (4) catheter replacement, and(5) failed conversion to regional anesthesia for cesarean delivery. Secondaryoutcomes included time to a pain score of 1 or less, sensory levels at 30 min,motor block, maximum pain score, patient-controlled epidural analgesia use,epidural medication consumption, duration of second stage of labor, deliverymode, fetal heart tones changes, Apgar scores, maternal adverse events, andsatisfaction with analgesia.

 

Results:

 

Of 141 parturients randomized, 66 pergroup were included in the analysis. There were no statistically or clinicallysignificant differences between the dural puncture epidural and standardepidural groups in the primary composite outcome (34 of 66, 52% vs. 32 of 66,49%; odds ratio, 1.1 [0.5 to 2.4]; P = 0.766), its individual components, orany of the secondary outcomes.

 

Conclusions:

 

A lack of differences in quality oflabor analgesia between the two techniques in this study does not supportroutine use of the dural puncture epidural technique in obese parturients.