一个随机对照试验比较几种不同的方法来预防择期剖宫产脊麻后低血压的效果

JResMedSci.2011September;16(9):1129–1138.PMCID:PMC3430037Arandomizedcomparativetrialofcombinationalmethodsforpreventingpost-spinalhypotensionatelectivecesareandelivery*MitraJabalameli,1HassanAliSoltani,2JalalHashemi,2ShekoofeBehdad,3andBahramSoleimani4Authorinformation►Articlenotes►CopyrightandLicenseinformation►Goto:AbstractBACKGROUND:Variousmethodshavebeenappliedtopreventmaternalhypotensionafterspinalanesthesiaforcesareandelivery.Wecomparedtheefficacyofthreecombinationalmethodsinthisregardinthecurrentstudy.METHODS:Inthisrandomizedcomparativetrial,150candidatesofelectivecesareandeliveryunderspinalanesthesiawereassignedtothreegroups:crystalloidpreloadandlegbandage,colloidpreloadandlegbandage,andephedrineandlegbandage.Maternalhemodynamicchangesduring60minutesafterspinalinjectionandneonatalconditionwerecomparedamongthegroups.RESULTS:Thecumulativeincidenceofhypotensionwas54%,64%,and36%ingroups1to3,respectively(p=0.018).Spinalinjectiontohypotensionintervalwassimilaramongthegroups(p=0.828).Heartrateingroup3wassignificantlyloweratthemosttimemeasuresafteranesthesiacomparedwiththeothertwogroups(p0.05to0.001).Regardingneonataloutcomes,theintervalbetweenthebirthandthefirstbreathwaslongerandtheApgarscoreatminute1wasloweringroup3comparedwiththeothergroups(p0.001and0.038,respectively)butitwasnotclinicallyimportant.UmbilicalcordbloodpHwassimilaramongthethreegroups(p=0.248).CONCLUSIONS:Amongthethreestudiedmethods,administrationofephedrineplusbandageofthelowerextremitieswasthemosteffectiveoneinreducingtheincidenceofpost-spinalhypotension.Thegroupswerenotclinicallydifferentconcerningtheeffectoftreatmentonnewbornhealth.KEYWORDS:Hypotension,SpinalAnesthesia,Prophylaxis,CesareanDelivery,ApgarScoreHypotensionisthemostcommoncomplicationfollowingspinalanesthesiaforcesareandelivery.1Inseverecases,itcanhavedetrimentaleffectsonbothmother(unconsciousnessandpulmonaryaspiration)andneonate(hypoxia,acidosis,andneurologicalinjury).2,3Variouspreventivemethodsarecurrentlyusedtopreventorminimizehypotensionincludingleftuterinedisplacement,prophylacticephedrine,crystalloidorcolloidpreloading,andutilizingcompressionstockingontothelowerextremities.3Administrationoffluidsbeforetheadministrationofregionalanesthesiacanmaintainadequatevolumeaftertheonsetofsympatheticblockade.Administrationofalargebolusofcrystalloidmayexacerbatethedecreaseincolloidosmoticpressurethatoccursduringthefirst6-12hourspostpartum.4Also,itredistributestootherbodycompartments.Somephysiciansprefertogiveasyntheticcolloidforthispurpose.However,thesolutionsareexpensiveandmayalterbloodrheologyandplateletfunction,whichmayresultinincreasedbloodlose.Legwrappingpreventspoolingofamajorportionofthebloodvolumeinthelowerextremities,buttheincidenceofhypotensionwasreducedonlyafewpercentbythismethod.4However,accordingtosystematicreviewsandmeta-analyses,nosinglemethodcouldeffectivelyeliminatehypotension.3,5Intheirsystematicreview,Morganetal.introducedcolloidpreloadingandlegwrappingasthemosteffectivemethods5whereasEmmettetal.demonstratedthattheprophylacticadministrationofcrystalloidorcolloidsolutions,ephedrine,orlegwrappingcouldnotreliablypreventhypotension.3Accordingtoameta-analysisbyLeeetal.,theefficacyofprophylacticephedrineforthepreventionofhypotensionispooratsmallerdoses,whereasatlargerdoses,thelikelihoodofcausinghypertensionismorethanthatofpreventinghypotensionwithaminordecreaseinumbilicalarterialpH,aswell.Theauthors,therefore,didnotrecommendtheroutineadministrationofprophylacticephedrineinthisregard.6Thedegreeofeffectivenessofvariouspreventivemethodsiscontroversial.Thereisnoestablishedidealtechnique,andthereisalackofstudiesonneonataloutcome.Systematicreviewsrecommendedfutureresearchestobedirectedtowardassessingacombinationofthebeneficialinterventions,butfewreportsareavailableontheefficacyofcombinationalmethods7–10andmorestudiesareneededinthisregard.Thepresentstudywasperformedtocomparetheefficacyofthreecombinationalmethodsonpreventionofhypotensionfollowingspinalanesthesiainparturientsundergoingelectivecesareandelivery.Furthermore,thisstudyevaluatedtheeffectofthesemethodsonneonataloutcome.Thethreecombinationalmethodsofthestudywereasfollows:crystalloidpreloadpluslegbandage,colloidpreloadpluslegbandageandprophylacticephedrinepluslegbandage.Goto:MethodsThisrandomized,doubleblindclinicaltrialwasconductedintwouniversityhospitals(BeheshtiandShahidSadoughi,inIsfahanandYazdcities,respectively,Iran)fromsummer2005tospring2009.AfterobtainingapprovalfromtheEthicsCommitteeofIsfahanUniversityofMedicalSciences,werecruitedsingletonparturientswithAmericanSocietyofAnesthesiologists(ASA)physicalstatusIorIIwhowerescheduledforelectivecesareandeliveryunderspinalanesthesia.Writteninformedconsentwasobtainedfromallparturientsafterfullexplanationsofthegoalsandproceduresofthestudy.Parturientswithoutpreexistingsystemicdiseaseorpregnancy-inducedhypertension,pretermlabororsignsofonsetoflabor,knownfetalabnormalities,orwithoutcontraindicationstospinalanesthesiawereincludedinthestudy.Exclusioncriteriawereanysignificant