硬膜外分娩镇痛转行剖宫产术麻醉失败的相关因素分析
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经助产士和产科医师评估后，产妇需中转行 剖宫产时需要进行如下监测：血压、心率、SpO］情
况等，对比产妇的VAS疼痛评分、产妇下肢活动 情况及感觉阻滞平面的情况，在通过硬膜外导管 回抽无血液或脑脊液的情况下，经导管注入1% 罗哌卡因8 ml,推注药物后20 min开始手术
切皮。 经过硬膜外麻醉起效时间后，出现椎管内阻滞
哌卡因100 mg（生产批号= 2018-06,阿斯利康公 司，英国）辅助50临舒芬太尼（生产批号： 01A07011,宜昌人福药业有限责任公司）为硬膜 外分娩镇痛的药物共100 ml,经硬膜外导管注射 产妇体内，首剂负荷量15 ml,背景量10 ml/h,产 妇自控镇痛量为4 ml,总使用量不超过20 ml/h , 锁定时间为15 min。 1.3中转剖宫产麻醉实施
近年来，卫生健康委在全国范围内大力推广 分娩镇痛工作。硬膜外阻滞是实施分娩镇痛最 为有效的镇痛方法，可大大缓解产痛，提高产妇 的舒适度，有助于降低我国居高不下的剖宫产 率旧。硬膜外分娩镇痛方式可以在产妇出现分 娩异常或危急情况时.通过预先留置的硬膜外导 管迅速给药，从而缩短剖宫产准备的时间，最大 程度地保证母婴安全％随着硬膜外分娩镇痛产 妇的增加，其分娩镇痛中转剖宫产麻醉的数量也 逐渐增加。有研究报道产妇实施分娩镇痛时若 分娩不正常，中转剖宫产手术其硬膜外阻滞效果 欠佳率高达38%同。不可预测的麻醉方法改变可 能导致严重的并发症。本研究旨在分析硬膜外 分娩镇痛转行剖宫产术麻醉失败的原因，为今后 降低产妇分娩镇痛中转剖宫产后麻醉失败率提 供参考。
【摘要】目的探讨硬膜外分娩镇痛中转剖宫产术麻醉失败的发生率以及失败的相关因素。方法回顾性纳入新疆 医科大学第一附属医院2019年1月至2019年11月实施硬膜外分娩镇痛孕妇1 143例。决定中转剖宫产后硬膜外腔给予1% 利多卡因3 ml作为试验剂量，观察5 min后给予1%罗哌卡因7 ml,罗哌卡因使用后超过20 min未起效者为硬膜外麻醉失败， 改用全身麻醉补救。收集产妇体重、身高、产次、ASA分级、硬膜外镇痛开始时宫口扩张情况、VAS疼痛评分、麻醉医师资历、 实施椎管内阻滞技术细节、椎管内分娩镇痛持续时间、暴发疼痛时需要通过硬膜外导管单次追加药物的次数以及新生儿体重 等；采用Logistic回归对硬膜外麻醉失败的相关因素进行综合分析，采用受试者T.作特征(receiver operating characteristic, ROC)曲线下面积(aera under curve, AUC)图检验模型拟合效果。结果经阴道分娩失败后中转剖宫产243例，中转率为 21.3%,硬膜外麻醉失败共计81(33.3%)例，暴发疼痛次数及硬膜外分娩镇痛持续时间>6 h对硬膜外麻醉效果影响差异有统 计学意义(P<0.05)。Logistic回归分析显示，在硬膜外分娩镇痛持续时间>6 h方面，其比值LL(odds ratio, OR)为0.536。当前 模型的预测结果.其ROC AUC为0.789,与AUC为0.5的随机模型相比，当前模型的预测效果明显优于随机模型(P<0.05)。 结论导致硬膜外分娩镇痛中转剖宫产麻醉失败与镇痛持续时间和镇痛效果不佳产妇主动增加药物剂量有关.可作为临床 参考依据。
【关键词】分娩镇痛；连续硬膜外麻醉；剖宫产术 基金项目：新疆维760/321761-20201216 -00304
Related factors for failed conversion of epidural labor analgesia to cesarean delivery anesthesia A Haiti Talaiti, Guo Hai, Hong Yi Department ofAnesthesiology^ the First Affiliated Hospital ofXinjiang Medical University, Urumqi 830011, China Corresponding author: Guo Hui, Email: gyraOO1@sina. com
[Key words] Labor analgesia; Continuous epidural anesthesia; Cesarean delivery Fund program: Xinjiang Uygur Autonomous Region Natural Science Foundation (2016D01C300) D01：10.3760/cma.j .cn321761 -20201216 -00304
国际麻醉学与复苏杂志2021年6月第42卷第6期 Int J Anesth Resus.June 2021, Vol. 42,No.6
605
-论著
硬膜外分娩镇痛转行剖宫产术麻醉失败的 相关因素分析
艾来提•塔来提 郭海 洪毅 新疆医科大学第一附属医院麻醉科，乌鲁木齐830011
通信作者：郭海,Email: gyra001@
[Abstract] Objective To investigate the incidence of failed conversion of epidural labor analgesia to cesarean delivery anes thesia and related factors. Methods A total of 1 143 pregnant women who underwent epidural labor analgesia in the First Affiliated Hospital of Xinjiang Medical University from January to November 2019 were retrospectively included. After conversion to cesarean de livery, 3 ml of 1% lidocaine was given as a test dose in epidural space, and 7 ml of 1% ropivacaine was given after observation for 5 min. If ropivacaine did not exert effects 20 min after administration, it was considered as epidural anesthesia failure, and general anesthesia was used for remedy. Then, the following data were collected: weight, height, parity, American Society of Anesthesiologists (ASA) grade, dilatation of uterine orifice at the beginning of epidural analgesia, Visual Analogue Scale (VAS) score, the qualification of anesthesiolo gists, the details of intraspinal block, the duration of intraspinal labor analgesia, the times of single drug-addition through epidural cath eter when pain broke out, and neonatal weight. The related factors of epidural anesthesia failure were analyzed by Logistic regression. The area of receiver operating characteristic (ROC) curve was used to fit the effects. Results There were 243 pregnant women who were transferred to cesarean delivery after vaginal delivery failure, with a transfer rate of 21.3%, and 81 (33.3%) of them showed epidur al anesthesia failure. There were statistical differences in the effects of the number of pain outbreaks and the duration of epidural labor analgesia for more than 6 h on epidural anesthesia (P<0.05). Logistic regression analysis showed that, the odds ratio (OR) was 0.536 for the duration of epidural labor analgesia for more than 6 h. The prediction results of the current model showed that the ROC area under curve (AUC) was 0.789. Compared with the random model with AUC of 0.5, the prediction effect of the current model was significantly
的资历、实施硬膜外阻滞技术细节、分娩镇痛持 续时间、暴发疼痛时需要通过硬膜外导管单次追 加药物的次数等。 1.2分娩镇痛方法
本研究实施硬膜外分娩镇痛依据最新分娩 镇痛指南。硬膜外穿刺时产妇取左侧卧位或右
侧卧位进行，行L3-L4间隙穿刺，硬膜外导管的置 管深度为3 cm ,首先给予30 mg利多卡因（生产批 号：1B2010101,河北天成药业股份公司）作为试 验剂量，5 min后观察产妇是否出现腹部、腿部痛 觉减退，若无全脊髓麻醉的症状后选取0.1%的罗
不完全（产妇痛感明显、肌肉不够松弛），阻滞范围 偏向一侧或过窄，无法达到剖宫产手术需要，此外 还包括硬膜外操作过程中常见并发症，如穿刺部位 出血、感染、神经损伤等情况均定义为麻醉失败。 由麻醉医师记录以下数据：硬膜外分娩镇痛延续是 否失败、失败最可能的原因以及硬膜外镇痛扩散的 时间。
606
国际麻醉学与复苏杂志2021年6月第42卷第6期 Int J Anesth Resus,June 2021, Vol. 42,No.6
better than that of the random model (P<0.05). Conclusions The failed conversion of epidural labor analgesia to cesarean delivery anesthesia is related to the duration of analgesia and poor analgesia effect when pregnant women actively increase drug doses, which provides clinical evidence for future studies.
1资料与方法
1.1研究对象 本研究通过新疆医科大学第一附属医院伦
理委员会审批（IACUC-20180214-06） 0纳入新疆 医科大学第一附属医院2019年1月至2019年11 月实施硬膜外分娩镇痛的孕妇1 143例。收集纳 入对象体重、身高、产次、ASA分级、硬膜外镇痛 开始时宫口扩张情况、疼痛VAS评分、麻醉医师
况等，对比产妇的VAS疼痛评分、产妇下肢活动 情况及感觉阻滞平面的情况，在通过硬膜外导管 回抽无血液或脑脊液的情况下，经导管注入1% 罗哌卡因8 ml,推注药物后20 min开始手术
切皮。 经过硬膜外麻醉起效时间后，出现椎管内阻滞
哌卡因100 mg（生产批号= 2018-06,阿斯利康公 司，英国）辅助50临舒芬太尼（生产批号： 01A07011,宜昌人福药业有限责任公司）为硬膜 外分娩镇痛的药物共100 ml,经硬膜外导管注射 产妇体内，首剂负荷量15 ml,背景量10 ml/h,产 妇自控镇痛量为4 ml,总使用量不超过20 ml/h , 锁定时间为15 min。 1.3中转剖宫产麻醉实施
近年来，卫生健康委在全国范围内大力推广 分娩镇痛工作。硬膜外阻滞是实施分娩镇痛最 为有效的镇痛方法，可大大缓解产痛，提高产妇 的舒适度，有助于降低我国居高不下的剖宫产 率旧。硬膜外分娩镇痛方式可以在产妇出现分 娩异常或危急情况时.通过预先留置的硬膜外导 管迅速给药，从而缩短剖宫产准备的时间，最大 程度地保证母婴安全％随着硬膜外分娩镇痛产 妇的增加，其分娩镇痛中转剖宫产麻醉的数量也 逐渐增加。有研究报道产妇实施分娩镇痛时若 分娩不正常，中转剖宫产手术其硬膜外阻滞效果 欠佳率高达38%同。不可预测的麻醉方法改变可 能导致严重的并发症。本研究旨在分析硬膜外 分娩镇痛转行剖宫产术麻醉失败的原因，为今后 降低产妇分娩镇痛中转剖宫产后麻醉失败率提 供参考。
【摘要】目的探讨硬膜外分娩镇痛中转剖宫产术麻醉失败的发生率以及失败的相关因素。方法回顾性纳入新疆 医科大学第一附属医院2019年1月至2019年11月实施硬膜外分娩镇痛孕妇1 143例。决定中转剖宫产后硬膜外腔给予1% 利多卡因3 ml作为试验剂量，观察5 min后给予1%罗哌卡因7 ml,罗哌卡因使用后超过20 min未起效者为硬膜外麻醉失败， 改用全身麻醉补救。收集产妇体重、身高、产次、ASA分级、硬膜外镇痛开始时宫口扩张情况、VAS疼痛评分、麻醉医师资历、 实施椎管内阻滞技术细节、椎管内分娩镇痛持续时间、暴发疼痛时需要通过硬膜外导管单次追加药物的次数以及新生儿体重 等；采用Logistic回归对硬膜外麻醉失败的相关因素进行综合分析，采用受试者T.作特征(receiver operating characteristic, ROC)曲线下面积(aera under curve, AUC)图检验模型拟合效果。结果经阴道分娩失败后中转剖宫产243例，中转率为 21.3%,硬膜外麻醉失败共计81(33.3%)例，暴发疼痛次数及硬膜外分娩镇痛持续时间>6 h对硬膜外麻醉效果影响差异有统 计学意义(P<0.05)。Logistic回归分析显示，在硬膜外分娩镇痛持续时间>6 h方面，其比值LL(odds ratio, OR)为0.536。当前 模型的预测结果.其ROC AUC为0.789,与AUC为0.5的随机模型相比，当前模型的预测效果明显优于随机模型(P<0.05)。 结论导致硬膜外分娩镇痛中转剖宫产麻醉失败与镇痛持续时间和镇痛效果不佳产妇主动增加药物剂量有关.可作为临床 参考依据。
【关键词】分娩镇痛；连续硬膜外麻醉；剖宫产术 基金项目：新疆维760/321761-20201216 -00304
Related factors for failed conversion of epidural labor analgesia to cesarean delivery anesthesia A Haiti Talaiti, Guo Hai, Hong Yi Department ofAnesthesiology^ the First Affiliated Hospital ofXinjiang Medical University, Urumqi 830011, China Corresponding author: Guo Hui, Email: gyraOO1@sina. com
[Key words] Labor analgesia; Continuous epidural anesthesia; Cesarean delivery Fund program: Xinjiang Uygur Autonomous Region Natural Science Foundation (2016D01C300) D01：10.3760/cma.j .cn321761 -20201216 -00304
国际麻醉学与复苏杂志2021年6月第42卷第6期 Int J Anesth Resus.June 2021, Vol. 42,No.6
605
-论著
硬膜外分娩镇痛转行剖宫产术麻醉失败的 相关因素分析
艾来提•塔来提 郭海 洪毅 新疆医科大学第一附属医院麻醉科，乌鲁木齐830011
通信作者：郭海,Email: gyra001@
[Abstract] Objective To investigate the incidence of failed conversion of epidural labor analgesia to cesarean delivery anes thesia and related factors. Methods A total of 1 143 pregnant women who underwent epidural labor analgesia in the First Affiliated Hospital of Xinjiang Medical University from January to November 2019 were retrospectively included. After conversion to cesarean de livery, 3 ml of 1% lidocaine was given as a test dose in epidural space, and 7 ml of 1% ropivacaine was given after observation for 5 min. If ropivacaine did not exert effects 20 min after administration, it was considered as epidural anesthesia failure, and general anesthesia was used for remedy. Then, the following data were collected: weight, height, parity, American Society of Anesthesiologists (ASA) grade, dilatation of uterine orifice at the beginning of epidural analgesia, Visual Analogue Scale (VAS) score, the qualification of anesthesiolo gists, the details of intraspinal block, the duration of intraspinal labor analgesia, the times of single drug-addition through epidural cath eter when pain broke out, and neonatal weight. The related factors of epidural anesthesia failure were analyzed by Logistic regression. The area of receiver operating characteristic (ROC) curve was used to fit the effects. Results There were 243 pregnant women who were transferred to cesarean delivery after vaginal delivery failure, with a transfer rate of 21.3%, and 81 (33.3%) of them showed epidur al anesthesia failure. There were statistical differences in the effects of the number of pain outbreaks and the duration of epidural labor analgesia for more than 6 h on epidural anesthesia (P<0.05). Logistic regression analysis showed that, the odds ratio (OR) was 0.536 for the duration of epidural labor analgesia for more than 6 h. The prediction results of the current model showed that the ROC area under curve (AUC) was 0.789. Compared with the random model with AUC of 0.5, the prediction effect of the current model was significantly
的资历、实施硬膜外阻滞技术细节、分娩镇痛持 续时间、暴发疼痛时需要通过硬膜外导管单次追 加药物的次数等。 1.2分娩镇痛方法
本研究实施硬膜外分娩镇痛依据最新分娩 镇痛指南。硬膜外穿刺时产妇取左侧卧位或右
侧卧位进行，行L3-L4间隙穿刺，硬膜外导管的置 管深度为3 cm ,首先给予30 mg利多卡因（生产批 号：1B2010101,河北天成药业股份公司）作为试 验剂量，5 min后观察产妇是否出现腹部、腿部痛 觉减退，若无全脊髓麻醉的症状后选取0.1%的罗
不完全（产妇痛感明显、肌肉不够松弛），阻滞范围 偏向一侧或过窄，无法达到剖宫产手术需要，此外 还包括硬膜外操作过程中常见并发症，如穿刺部位 出血、感染、神经损伤等情况均定义为麻醉失败。 由麻醉医师记录以下数据：硬膜外分娩镇痛延续是 否失败、失败最可能的原因以及硬膜外镇痛扩散的 时间。
606
国际麻醉学与复苏杂志2021年6月第42卷第6期 Int J Anesth Resus,June 2021, Vol. 42,No.6
better than that of the random model (P<0.05). Conclusions The failed conversion of epidural labor analgesia to cesarean delivery anesthesia is related to the duration of analgesia and poor analgesia effect when pregnant women actively increase drug doses, which provides clinical evidence for future studies.
1资料与方法
1.1研究对象 本研究通过新疆医科大学第一附属医院伦
理委员会审批（IACUC-20180214-06） 0纳入新疆 医科大学第一附属医院2019年1月至2019年11 月实施硬膜外分娩镇痛的孕妇1 143例。收集纳 入对象体重、身高、产次、ASA分级、硬膜外镇痛 开始时宫口扩张情况、疼痛VAS评分、麻醉医师