纳布啡联合右美托咪定多模式镇痛对疤痕子宫再次剖宫产术后镇痛的影响

金文然; 朱海娟; 陈红波; 李小朋; 汪胜友

doi:10.16766/j.cnki.issn.1674-4152.002417

纳布啡联合右美托咪定多模式镇痛对疤痕子宫再次剖宫产术后镇痛的影响

doi: 10.16766/j.cnki.issn.1674-4152.002417

合肥市妇幼保健院麻醉科，安徽合肥 230601

基金项目:

安徽省科技创新项目示范类项目 201707d08050003

合肥市卫生计生委2017年应用医学研究项目 hwk2017zd003

详细信息

通讯作者:
汪胜友，E-mail：hffywsy@sina.com

中图分类号: R614.4 R719.8
计量
- 文章访问数: 264
- HTML全文浏览量: 125
- PDF下载量: 5
- 被引次数: 0
出版历程
- 收稿日期: 2021-04-14
- 网络出版日期: 2022-08-20

The effect of nalbuphine combined with dexmedetomidine multimodal analgesia on postoperative analgesia for patients with repeat cesarean section

Department of Anaesthesiology, Hefei Women and Child Health Care Hospital, Hefei, Anhui 230601, China

摘要

摘要: 目的观察右美托咪定混合罗哌卡因行双侧腹横肌平面阻滞(TAPB)联合低剂量纳布啡病人静脉自控镇痛(PCIA)对疤痕子宫再次剖宫产术后宫缩痛的影响。方法选取2019年4—8月在合肥市妇幼保健院行腰麻下疤痕子宫再次剖宫产产妇60例，根据随机数字表法分为2组：纳布啡常规剂量组(NC组)，纳布啡低剂量联合罗哌卡因、右美托咪定TAPB组(NDT组)，每组30例。NDT组于术后在超声引导下行双侧TAPB，每侧注入罗哌卡因与右美托咪定混合液30 mL。记录2组术后VAS评分、睡眠时间、不良反应发生率、首次下床时间、镇痛满意度等。结果 NDT组术后6、12、24、36、48 h时点宫缩痛VAS评分[2.0(1.0, 3.0)分、3.0(2.0, 3.0)分、2.0(2.0, 3.0)分、2.0(2.0, 2.0)分、2.0(1.0, 2.0)分]均显著低于NC组[4.0(3.0, 5.0)分、4.0(4.0, 5.0)分、4.0(3.0, 5.0)分、3.0(2.8, 4.0)分、2.0(2.0, 3.0)分, 均P < 0.05)]；术后24、48 h睡眠时间显著长于NC组[8.0(7.0, 8.0)h/d、8.0(7.0, 8.0)h/d vs.5.0(4.8, 6.0)h/d、6.0(6.0, 7.0)h/d, 均P < 0.05)]。NDT组首次下床时间显著缩短，术后恶心呕吐、头晕发生率显著降低，产妇镇痛满意度显著增高。结论低剂量纳布啡PCIA联合罗哌卡因、右美托咪定TAPB多模式镇痛方案用于疤痕子宫再次剖宫产术后镇痛效果满意且不良反应少。
- 右美托咪定 /
- 腹横肌平面阻滞 /
- 纳布啡 /
- 疤痕子宫再次剖宫产
Abstract: Objective To observe the effect of dexmedetomidine plus ropivacaine in bilateral transverse abdominal plane block (TAPB) combined with patient-controlled intravenous analgesia (PCIA) in patients with low-dose naborphine on uterine contraction pain after cesarean section of scarred uterus. Methods From April to August 2019, 60 pregnant women who underwent cesarean section of scar uterus under spinal anesthesia in Hefei Maternal and Child Health Hospital were randomly divided into two groups: naborphine conventional dose group (NC group), naborphine low dose combined with ropivacaine and dexmedetomidine TAPB group (NDT group), with 30 cases in each group. The group of NDT received bilateral TAPB under ultrasound guidance after cesarean section, 30 mL of ropivacaine and dexmedetomidine mixture was injected into each side. Visual analog score (VAS), sleep time, incidence of adverse reactions, time of getting out of bed for the first time and satisfaction with analgesia were recorded in the two groups. Results The VAS scores of uterine contraction pain at 6, 12, 24, 36 and 48 hours after operation in NDT group [2.0 (1.0, 3.0), 3.0 (2.0, 3.0), 2.0 (2.0, 3.0), 2.0 (2.0, 2.0), 2.0 (1.0, 2.0) vs. 4.0 (3.0, 5.0), 4.0 (4.0, 5.0), 4.0(3.0, 5.0), 3.0 (2.8, 4.0), 2.0 (2.0, 3.0), all P < 0.05]. The sleep time at 24 and 48 hours after operation in NDT group was significantly longer than that in NC group [5.0 (4.8, 6.0) h/d, 6.0 (6.0, 7.0) h/d vs. 8.0 (7.0, 8.0) h/d, 8.0 (7.0, 8.0) h/d, all P < 0.05]. In NDT group, the first time out of bed was significantly shortened, the incidence of postoperative nausea, vomiting and dizziness were significantly reduced, and the satisfaction of maternal analgesia was significantly increased. Conclusion Low dose nalbuphine PCIA combined with ropivacaine, dexmedetomidine and TAPB multimodal analgesia regimen for postoperative analgesia of scar uterus after cesarean section has satisfactory effect and less adverse reactions.
- Dexmedetomidine /
- Transversus abdominis plane block /
- Nalbuphine /
- Repeated cesarean section

HTML全文

表 1 2组产妇一般情况比较

Table 1. Demographic and baseline characteristics of parturients

组别	例数	年龄[M(P₂₅, P₇₅), 岁]	BMI (x±s)	孕周[M(P₂₅, P₇₅), 周]	孕次[M(P₂₅, P₇₅), 次]	手术时间[M(P₂₅, P₇₅), min]	出血量[M(P₂₅, P₇₅), mL]
NC组	30	30.5(29.0, 35.0)	27.8±2.3	39.0(38.0, 39.0)	3.0(3.0, 4.0)	30.0(28.0, 35.5)	300.0(300.0, 400.0)
NDT组	29	32.0(29.0, 35.0)	27.9±2.5	39.0(38.0, 39.0)	3.0(2.0, 4.0)	33.0(25.0, 38.0)	300.0(300.0, 400.0)
统计量		-0.267^a	0.044^b	-0.193^a	-0.175^a	-0.076^a	-0.359^a
P值		0.790	0.965	0.233	0.861	0.939	0.719
注：^a为Z值，^b为t值。

下载: 导出CSV

表 2 2组产妇术后各时间点VAS、BCS及Ramsay评分比较[M(P₂₅, P₇₅), 分]

Table 2. Comparison of VAS, BCS and Ramsay scores between the two groups at each time point at postoperation[M(P₂₅, P₇₅), points]

组别	例数	切口静止痛VAS评分					切口运动痛VAS评分
组别	例数	6 h	12 h	24 h	36 h	48 h	6 h	12 h	24 h	36 h	48 h
NC组	30	3.0(2.0, 3.0)	3.0(3.0, 4.0)^a	3.0(3.0, 4.0)^a	2.5(2.0, 3.0)^a	1.0(1.0, 2.0)^a	5.0(4.0, 5.0)	5.0(4.0, 6.0)^a	5.0(4.0, 5.0)	3.0(3.0, 4.0)^a	3.0(2.0, 3.0)^a
NDT组	29	0.0(0.0, 1.0)	1.0(0.0, 1.0)^a	1.0(1.0, 2.0)^a	1.0(1.0, 1.5)^a	1.0(0.0, 1.0)	1.0(0.0, 2.0)	2.0(1.0, 2.0)^a	2.0(1.0, 3.0)^a	2.0(1.0, 3.0)^a	1.0(1.0, 2.0)^a
Z值		-6.535	-6.471	-5.933	-4.859	-3.341	-6.597	-6.618	-6.562	-5.431	-4.968
P值		< 0.001	< 0.001	< 0.001	< 0.001	0.001	< 0.001	< 0.001	< 0.001	< 0.001	< 0.001

组别	例数	宫缩痛VAS评分					按压宫底痛VAS评分
组别	例数	6 h	12 h	24 h	36 h	48 h	6 h	12 h	24 h	36 h	48 h
NC组	30	4.0(3.0, 5.0)	4.0(4.0, 5.0)	4.0(3.0, 5.0)	3.0(2.8, 4.0)^a	2.0(2.0, 3.0)^a	6.0(5.0, 7.0)	6.0(5.0, 6.0)	5.0(5.0, 5.3)^a	4.0(3.0, 4.3)^a	3.0(3.0, 4.0)^a
NDT组	29	2.0(1.0, 3.0)	3.0(2.0, 3.0)	2.0(2.0, 3.0)	2.0(2.0, 2.0)	2.0(1.0, 2.0)	3.0(3.0, 4.0)	4.0(3.0, 4.0)	3.0(3.0, 4.0)	3.0(3.0, 3.0)	2.0(1.5, 3.0)^a
Z值		-5.631	-5.567	-5.386	-4.715	-3.042	-5.965	-6.210	-5.739	-4.091	-3.953
P值		< 0.001	< 0.001	< 0.001	< 0.001	0.002	< 0.001	< 0.001	< 0.001	< 0.001	< 0.001

组别	例数	BCS舒适度评分					Ramsay镇静评分
组别	例数	6 h	12 h	24 h	36 h	48 h	6 h	12 h	24 h	36 h	48 h
NC组	30	0.0(0.0, 1.0)	0.0(0.0, 1.0)	1.0(0.8, 1.0)^a	1.0(1.0, 2.0)^a	2.0(1.0, 2.0)^a	1.0(1.0, 2.0)	1.0(1.0, 1.0)	1.0(1.0, 2.0)	2.0(2.0, 2.0)^a	2.0(2.0, 2.0)^a
NDT组	29	3.0(2.0, 3.0)	3.0(2.0, 3.0)	2.0(2.0, 3.0)^a	2.0(2.0, 3.0)^a	2.0(2.0, 3.0)	2.0(2.0, 3.0)	2.0(2.0, 3.0)	2.0(2.0, 3.0)	2.0(2.0, 3.0)	2.0(2.0, 3.0)^a
Z值		-6.360	-6.552	-5.584	-4.249	-4.750	-5.857	-6.255	-4.476	-3.377	-1.733
P值		< 0.001	< 0.001	< 0.001	< 0.001	< 0.001	< 0.001	< 0.001	< 0.001	0.001	0.083
注：与术后6 h比较，^aP < 0.05。切口静止痛，组间Wald χ²=128.342，P < 0.001；时间Wald χ²=111.932，P < 0.001；交互Wald χ²=96.395，P < 0.001。切口运动痛，组间Wald χ²=183.947，P < 0.001；时间Wald χ²=161.431，P < 0.001；交互Wald χ²=105.058，P < 0.001。宫缩痛，组间Wald χ²=183.947，P < 0.001；时间Wald χ²=161.431，P < 0.001；交互Wald χ²=105.058，P < 0.001。按压宫底痛，组间Wald χ²=85.220, P < 0.001；时间Wald χ²=491.742, P < 0.001；交互Wald χ²=55.580，P < 0.001。BCS舒适度评分，组间Wald χ²=134.479，P < 0.001；时间Wald χ²=74.947，P < 0.001；交互Wald χ²=55.243，P < 0.001。Ramsay镇静评分，组间Wald χ²=102.846，P < 0.001；时间Wald χ²=31.357，P < 0.001；交互Wald χ²=69.456，P < 0.001。

下载: 导出CSV

表 3 2组产妇各时间点睡眠时间比较[M(P₂₅, P₇₅), h/d]

Table 3. Comparison of sleeping time at each time point between the two groups [M(P₂₅, P₇₅), h/d]

组别	例数	术前	术后24 h	术后48 h
NC组	30	8.0(7.8, 9.0)	5.0(4.8, 6.0)^a	6.0(6.0, 7.0)^a
NDT组	29	8.0(8.0, 9.0)	8.0(7.0, 8.0)^a	8.0(7.0, 8.0)
Z值		-0.129	-6.129	-5.810
P值		0.897	< 0.001	< 0.001
注：与术前比较，^aP < 0.05。组间Wald χ²=73.968，P < 0.001；时间Wald χ²=136.301，P < 0.001；交互Wald χ²=55.631，P < 0.001。

下载: 导出CSV

表 4 2组产妇各观察指标比较

Table 4. Comparison of adverse reactions and analgesia outcomes between the two groups

组别	例数	恶心呕吐[例(%)]	腹胀[例(%)]	头晕[例(%)]	PCIA按压[M(P₂₅, P₇₅)，次]	补救镇痛[次(%)]	首次下床时间[M(P₂₅, P₇₅)，h]	镇痛满意度[M(P₂₅, P₇₅)，分]
NC	30	9(30.0)	9(30.0)	10(33.3)	11.0(8.8, 14.0)	8(26.7)	28.0(26.0, 29.0)	2.0(2.0, 3.0)
NDT	29	2(6.9)	1(3.4)	3(10.3)	1.0(0.0, 2.0)	1(3.4)	24.0(23.0, 25.0)	4.0(3.0, 4.0)
统计量		5.189^a	5.619^a	4.536^a	-6.641^b	4.484^a	-5.412^b	-5.397^b
P值		0.023	0.018	0.033	< 0.001	0.034	< 0.001	< 0.001
注：^a为χ²值，^b为Z值。

下载: 导出CSV

表 5 VAS、BCS及Ramsay评分的广义估计方程分析结果

Table 5. Analysis results of generalized estimation equation on VAS, BCS and Ramsay scores

变量	参数	OR值	95% CI	P值	变量	参数	OR值	95% CI	P值
静止痛VAS评分	NDT组	0.089	0.061~0.130	< 0.001	运动痛VAS评分	NDT组	0.032	0.020~0.053	< 0.001
	48 h	0.231	0.173~0.308	< 0.001		48 h	0.150	0.102~0.220	< 0.001
	36 h	0.670	0.489~0.918	0.013		36 h	0.356	0.268~0.473	< 0.001
	24 h	1.542	1.237~1.922	< 0.001		24 h	1.221	0.920~1.621	0.166
	12 h	1.649	1.275~2.132	< 0.001		12 h	1.542	1.125~2.115	0.007
宫缩痛VAS评分	NDT组	0.119	0.069~0.203	< 0.001	按压宫底痛VAS评分	NDT组	0.089	0.052~0.152	< 0.001
	48 h	0.155	0.114~0.209	< 0.001		48 h	0.077	0.052~0.113	< 0.001
	36 h	0.380	0.278~0.520	< 0.001		36 h	0.160	0.106~0.242	< 0.001
	24 h	0.792	0.585~1.071	0.130		24 h	0.531	0.349~0.806	0.003
	12 h	1.181	0.941~1.481	0.152		12 h	1.105	0.876~1.395	0.400
BCS舒适度评分	NDT组	7.544	5.389~10.560	< 0.001	Ramsay镇静评分	NDT组	3.046	2.389~3.884	< 0.001
	48 h	3.106	2.364~4.081	< 0.001		48 h	1.948	1.607~2.361	< 0.001
	36 h	2.226	1.762~2.812	< 0.001		36 h	1.948	1.645~2.306	< 0.001
	24 h	1.350	1.073~1.697	0.010		24 h	1.221	0.950~1.570	0.119
	12 h	0.936	0.779~1.124	0.476		12 h	0.875	0.732~1.046	0.143
注：组间比较均以NC组为参照，各时间点比较均以6 h为参照。

下载: 导出CSV

表 6 睡眠时间的广义估计方程分析结果

Table 6. Analysis results of generalized estimation equation on sleeping time

参数	OR值	95% CI	P值
NDT组	1.006	0.653~1.550	0.979
48 h	0.140	0.093~0.210	< 0.001
24 h	0.050	0.031~0.079	< 0.001
注：组间比较以NC组为参照，各时间点比较以术前为参照。

下载: 导出CSV

参考文献(15)

[1]	朱月英, 王曼, 刘盈盈. 硬膜外自控镇痛对剖宫产产妇镇痛效果、睡眠质量、泌乳、产后应激的影响[J]. 中华保健医学杂志, 2019, 21(4): 368-369, 371. https://www.cnki.com.cn/Article/CJFDTOTAL-JFJB201904024.htm ZHU Y Y, WANG M, LIU Y Y. Effects of patient-controlled epidural analgesia on analgesic effect, sleep quality, lactation and postpartum stress in parturients undergoing cesarean section[J]. Chin J Health Care Med, 2019, 21(4): 368-369, 371. https://www.cnki.com.cn/Article/CJFDTOTAL-JFJB201904024.htm
[2]	CARVALHO B, BUTWICK A J. Postcesarean delivery analgesia[J]. Best Pract Res Clin Anaesthesiol, 2017, 31(1): 69-79. doi: 10.1016/j.bpa.2017.01.003
[3]	JIANG Q, ZHANG R, LIU T. Effect of nalbuphine on patient controlled intravenous analgesia after radical resection of colon cancer[J]. Oncol Lett, 2020, 19(3): 2533-2538.
[4]	SARVESH B, SHIVARAMU B T, SHARMA K, et al. Addition of dexmedetomidine to ropivacaine in subcostal transversus abdominis plane block potentiates postoperative analgesia among laparoscopic cholecystectomy patients: A prospective randomized controlled trial[J]. Anesthesia, 2018, 12(4): 809-813.
[5]	LIU X, HU X, LI R, et al. Combination of post-fascia iliaca compartment block and dexmedetomidine in pain and inflammation control after total hip arthroplasty for elder patients: A randomized control study[J]. J Orthop Surg Res, 2020, 15(1): 42-48. doi: 10.1186/s13018-020-1562-6
[6]	谢言虎, 章敏, 高玮, 等. 纳布啡用于剖宫产术后PCIA适宜的配制剂量[J]. 中华麻醉学杂志, 2017, 37(4): 478-480. doi: 10.3760/cma.j.issn.0254-1416.2017.04.026 XIE Y H, ZHANG M, GAO W, et al. Optimum dose of nalbuphine prepared for patient-controlled intravenous analgesia after caesarean section[J]. Chin J Anesthesiol, 2017, 37(4): 478-480. doi: 10.3760/cma.j.issn.0254-1416.2017.04.026
[7]	MAO Y, CAO Y Y, MEI B, et al. Efficacy of nalbuphine with flurbiprofen on multimodal analgesia with transverse abdominis plane block in elderly patients undergoing open gastrointestinal surgery: A randomized, controlled, couble-blinded trial[J]. Pain Res Manag, 2018, 28(12): 3637013.
[8]	吴年生, 汪东学, 王玲. 右美托咪定联合瑞芬太尼和丙泊酚泵注对甲状腺术中神经电生理监测的影响[J]. 蚌埠医学院学报, 2020, 45(2): 207-210. https://www.cnki.com.cn/Article/CJFDTOTAL-BANG202002020.htm WU N S, WANG D X, WANG L. Effect of the pump injection of dexmetomidine combined with remifentanil and propofol on intraoperative nerve monitoring during thyroidectomy[J]. J Bengbu Med Coll, 2020, 45(2): 207-210. https://www.cnki.com.cn/Article/CJFDTOTAL-BANG202002020.htm
[9]	AMIN O A I, IBRAHEM M A, SALEM D A E. Nalbuphine versus midazolam as an adjuvant to intrathecal bupivacaine for postoperative analgesia in patients undergoing cesarean section[J]. J Pain Res, 2020, 13: 1369-1376. doi: 10.2147/JPR.S242545
[10]	王清兵, 路超, 于刚. 超声引导下腹横肌平面阻滞联合右美托咪定用于剖宫产的效果观察[J]. 中国基层医药, 2021, 28(4): 579-583. WU N S, WANG D X, WANG L. Effect of the pump injection of dexmetomidine combined with remifentanil and propofol on intraoperative nerve monitoring during thyroidectomy[J]. J Bengbu Med Coll, 2020, 45(2): 207-210.
[11]	KAME A A F, AMIN O A I, IBRAHEM M A M. Bilateral ultrasound-guided erector spinae plane block versus transversus abdominis plane block on postoperative analgesia after total abdominal hysterectomy[J]. Pain Physician, 2020, 23(4): 375-382.
[12]	BANSAL P, GARG S. Effect of adding dexmedetomidine to local anesthetic agents for transversus abdominis plane block: A meta-analysis[J]. Clin J Pain, 2019, 35(10): 844-854. doi: 10.1097/AJP.0000000000000742
[13]	YU H Y, WANG S Y, QUAN C X, et al. Dexmedetomidine alleviates postpartum depressive symptoms following cesarean section in Chinese women: A randomized placebo-controlled study[J]. Pharmacotherapy, 2019, 39(10): 994-1004. doi: 10.1002/phar.2320
[14]	刘世江, 彭培培, 蒋秀红, 等. 右美托咪定复合布托啡诺在剖宫产术后镇痛的应用[J]. 临床麻醉学杂志, 2018, 34(9): 841-844. https://www.cnki.com.cn/Article/CJFDTOTAL-LCMZ201809002.htm LIU S J, PENG P P, JIANG X H, et al. Effects and safety of intravenous dexmedetomidine combined with butorphanol for post caesarean section analgesia[J]. J Chin Anesthesiol, 2018, 34(9): 841-844. https://www.cnki.com.cn/Article/CJFDTOTAL-LCMZ201809002.htm
[15]	WANG C, LIU S, HAN C, et al. Effect and placental transfer of dexmedetomidine during caesarean section under epidural anaesthesia[J]. J Int Med Res, 2017, 45(3): 964-972. doi: 10.1177/0300060517698330