（美文欣赏）使用28G导管进行持续鞘内分娩镇痛与持续硬膜外分娩镇痛的比较

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.使用28G导管进行持续鞘内分娩镇痛与持续硬膜外分娩镇痛的比较――一项随机双盲多中心研究

背景：持续鞘内分娩镇痛可以产生快速镇痛或麻醉，同时在用药上有多种药物可供灵活选择。1992年有报道指出鞘内微导管对非产科患者造成神经损伤后，美国食品药品管理局废除了鞘内微导管(27-32G)在临床的应用。本实验采用前瞻性随机多中心研究，探讨了28G鞘内导管在分娩镇痛中的安全和有效性。方法：代产患者随机分为使用28G导管的连续鞘内镇痛组(n = 329)和持续硬膜外镇痛组(n = 100)，镇痛药物均使用布比卡因和苏芬太尼。主要预后指标为神经并发症的发生率，分别在产后24和48小时由神经检查盲法测定，并于产后7－10天，产后30天电话随访。次级指标为分娩镇痛的程度，产妇满意度，新生儿状态等。结果：没有病人发生持久的神经系统改变。与持续硬膜外镇痛相比，持续鞘内镇痛的患者早期镇痛效果更佳，运动阻滞更少，搔痒症更多，由于更好的减轻了产后24小时疼痛获得的产妇满意度更高。鞘内导管显然比硬膜外导管更难拔除。两组对新生儿状态，腰穿后头痛，血液动力学状态和产科预后的影响无明显差异。结论：与持续硬膜外镇痛相比，使用28G导管给予布比卡因和苏芬太尼进行鞘内镇痛，其神经并发症的发生率低于1％，同时能更有效的减轻初始疼痛，产妇满意度更高，但它存在更多技术上的困难，且更易损坏导管。
10. Anesthesiology. 2008 Feb;108(2):286-98.
A randomized, double-masked, multicenter comparison of the safety of continuous intrathecal labor analgesia using a 28-gauge catheter versus continuous epidural labor analgesia.
Arkoosh VA, Palmer CM, Yun EM, Sharma SK, Bates JN, Wissler RN, Buxbaum JL, Nogami WM, Gracely EJ.

University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA. [email protected]

BACKGROUND: Continuous intrathecal labor analgesia produces rapid analgesia or anesthesia and allows substantial flexibility in medication choice. The US Food and Drug Administration, in 1992, removed intrathecal microcatheters (27-32 gauge) from clinical use after reports of neurologic injury in nonobstetric patients. This study examined the safety and efficacy of a 28-gauge intrathecal catheter for labor analgesia in a prospective, randomized, multicenter trial. METHODS: Laboring patients were randomly assigned to continuous intrathecal analgesia with a 28-gauge catheter (n = 329) or continuous epidural analgesia with a 20-gauge catheter (n = 100), using bupivacaine and sufentanil. The primary outcome was the incidence of neurologic complications, as determined by masked neurologic examinations at 24 and 48 h postpartum, plus telephone follow-up at 7-10 and 30 days after delivery. The secondary outcomes included adequacy of labor analgesia, maternal satisfaction, and neonatal status. RESULTS: No patient had a permanent neurologic change. The continuous intrathecal analgesia patients had better early analgesia, less motor blockade, more pruritus, and higher maternal satisfaction with pain relief at 24 h postpartum. The intrathecal catheter was significantly more difficult to remove. There were no significant differences between the two groups in neonatal status, post-dural puncture headache, hemodynamic stability, or obstetric outcomes. CONCLUSIONS: Providing intrathecal labor analgesia with sufentanil and bupivacaine via a 28-gauge catheter has an incidence of neurologic complication less than 1%, and produces better initial pain relief and higher maternal satisfaction, but is associated with more technical difficulties and catheter failures compared with epidural analgesia.