【作者簡介】〖KG2〗〖HTSS〗蔣青(1963-),女,四川遂寧人,主管護師,碩士,Email:jq0987@yahoo.cn
【摘要】 目的 觀察小劑量氯胺酮在健忘鎮痛麻醉輔助局部麻醉（局麻）剖宮產中的應用。方法 選擇1200例剖宮產的孕婦,隨機分為單純局麻組(L組)、氟芬強化局麻組(F組)和健忘鎮痛麻醉組(J組),每組400例。L組單純局麻;F組局麻術中輔以氟哌利多500 mg,芬太尼015 mg;J組在F組基礎上輔以氯胺酮,觀察各組患者麻醉誘導至胎兒娩出時間;新生兒1、5 min Apgar評分;手術中血壓相對于基礎值的波動情況;手術中及手術后出血情況及麻醉滿意度。 結果 J組與L組和F組比較,胎兒娩出時間無顯著差別;Apgar評分提高;手術中孕婦血壓波動不明顯;手術中及手術后出血量無明顯增加,麻醉滿意度明顯提高。 結論 由小劑量氯胺酮輔助實施的健忘鎮痛麻醉在局麻剖宮產中優于單純局麻和氟芬強化局麻,在剖宮產中尤其急診剖宮產中值得推廣。【Abstract】 Objective To observe the application of lowdose ketamine during the local anesthesia in cesarean section assisted by analgestic and amnestic anesthesia. Methods A total of 1200 cases who need cesarean section were randomly divided into 3 groups (400 cases in each group): simple local anesthesia group (group L), droperidolfentanyl strengthen local anesthesia group (group F) and analgestic and amnestic anesthesia group (group J). Group L was only local anesthesia. Group F was local anesthesia supplemented by droperidol 500 mg, fentanyl 015 mg. Group J was supplemented with ketamine on the basis of group F. Then the time from anesthesia to the fetus delivery, Neonatal Apgar score of one and five minutes, the blood pressure fluctuations, amount of bleeding in or after surgery and the satisfaction of anesthesia were all observed. Results Compared with group L and F, the delivery time was no significant difference, Apgar score increased, blood pressure fluctuations in pregnant women was not obviously varied, amount of bleeding in or after surgery had no significantly increase, and the satisfaction of anesthesia improved markedly all in group J. Conclusions The analgestic and amnestic anesthesia assisted by lowdose ketamine, in cesarean section, is better than local anesthesia and strengthen local anesthesia by droperidolfentanyl, which is worthy to be popularized, especially in emergency caesarean section.
Objective To assess the efficacy and safety of chewing gum in promoting bowel recovery after cesarean section. Methods Such databases as The Cochrane Library, MEDLINE, EMbase and CBM were searched from their establishment to 2010 to include the randomized controlled trials (RCTs) of comparing chewing gum with other procedures for promoting postoperative bowel function after cesarean section. The risks of bias in the included studies were evaluated at randomization, allocation concealment, blinding, completeness of outcomes, and selective reporting. Meta-analyses were performed by RevMan 5.0.22 software. Results Three RCTs involving 745 participants were included. The results of meta-analyses showed chewing gum after cesarean section significantly shortened the time before getting the first postoperative flatus (MD= –6.54, 95%CI –7.82 to –5.27, Plt;0.000 01), reduced the risks of postoperative ileus (RR=0.54, 95%CI 0.34 to 0.87, P=0.01) and possibly shortened the length of hospital stay (MD= –0.21, 95%CI –0.39 to –0.03, P=0.02) compared with blank control. Currently, no adequate data supported the safety of chewing gum after cesarean section. Conclusion Chewing gum after cesarean section can promote the postoperative bowel recovery, and reduce the odds of postoperative ileus. However, more high quality RCTs are required for lack of included studies and poor quality of methodology.
Objective To study the clinical significance of the microorganism culture result of amniotic fluid in cesarean section in the treatment of anti-infection after operation. Methods From August 2016 to May 2017 in Women’s and Children’s Hospital of Sichuan Province, 502 amniotic fluid samples were collected in cesarean section to carry out bacteria culture. The correlations between the amniotic fluid culture result and the preoperative and intraoperative risk factors and the correlations between postoperative infection and the preoperative and intraoperative risk factors were analyzed. Results In the 502 amniotic fluid samples, there were 131 samples culture-positive. The microbiological culture results of amniotic fluid were statistically different between the puerperae with gestational age<37 weeks and the ones with gestational age≥37 weeks (P=0.001). Postoperative infection occurred in 6 puerperae, in whom the amniotic fluid culture results were positive in 3 puerperae. There was no statistical difference in the occurrence of postoperative infection between the puerperae with amniotic fluid culture-positive results and the ones with negative results (P=0.382). The occurrence of postoperative infection was associated with preoperative infections, gestational age, using time of antimicrobial, and preoperative rupture of membranes (P<0.05). Conclusions The contamination rate of amniotic fluid specimen was high, which was of low reference value to anti-infection treatment after operation. When an extension of anti-infection treatment be carried out after cesarean section, suitable specimens should be selected according to the infection site.
Objectives To analyze the efficacy and safety of different operation methods for patients with cesarean scar diverticulum. Methods The clinical data of patients with cesarean section scar diverticulum treated in West China Second University Hospital from July 2012 to December 2016 was collected and followed up. The data of the previous perioperative period data, recovery, the improvement of the symptoms and postoperative condition of incision healing were analyzed by SPSS 22.0 software. Results A total of 125 patients were included, in which 74 cases received hysteroscopy surgery for diverticulum electro section and electric coagulation (ESEC group), and 51 cases received other surgery focused on diverticulum dissection and sewing operations (DS group). Statistical analysis showed that, compared with DS group, bleeding, operation time, time of anal exsufflation and hospitalization duration after the operation of hysteroscopy in ESEC group were significantly reduced (P<0.001). In addition, the results showed that hysteroscopy group had optimal results in hemorrhage volume, operation time, anal exhaust time and hospitalization time indicators. However, the results of laparotomy group was not significant. Conclusions For the treatment of CSD, surgical treatment of this pathology by operative hysteroscopy may represent the best choice in symptomatic women because of its minimal invasiveness and beneficial therapeutic results. Hysteroscopy isthmoplasty appears to be the most popular treatment.
Objective To systemically review the clinical application of esketamine for postoperative analgesia in cesarean section. Methods Databases including CNKI, VIP, WanFang Data, PubMed, EMbase, Web of Science, and The Cochrane Library were searched for randomized controlled trials (RCTs) on esketamine in cesarean section from inception to January 2022. Two reviewers independently screened the literature, extracted data, and assessed the risk of bias of the included studies. Meta-analysis was then performed using RevMan 5.4 software. Results A total of 16 RCTs involving 1 715 cesarean section patients were included. The results of meta-analysis showed that esketamine decreased the patients’ visual analog scale scores after surgery (MD=?0.67, 95%CI ?0.86 to ?0.49, P<0.000 01) and reduced the need for analgesics for 48 hours after surgery (MD=?2.38, 95%CI ?3.15 to ?1.62, P<0.000 01) compared with the control drugs (such as opioids, ropivacaine, and normal saline), without increasing adverse reactions such as nausea and vomiting (RR=0.84, 95%CI 0.62 to 1.12, P=0.23), hallucinations (RR=3.00, 95%CI 0.37 to 24.43, P=0.30), drowsiness (RR=1.49, 95%CI 0.16 to 13.99, P=0.73), itching (RR=1.05, 95%CI 0.79 to 1.41, P=0.72), hypotension (RR=0.31, 95%CI 0.04 to 2.40, P=0.26), bradycardia (RR=0.40, 95%CI 0.01 to 11.24, P=0.59), and dizziness (RR=2.24, 95%CI 0.63 to 7.94, P=0.21). Compared with the control drugs, esketamine extended the operation time (MD=2.23, 95%CI 1.73 to 2.74, P<0.000 01), accelerated heart rate (MD=1.31, 95%CI 0.25 to 2.37, P=0.02), and increased the mean arterial pressure (MD=3.88, 95%CI 0.19 to 7.56, P=0.04) during surgery. Additionally, esketamine improved the Apgar score of neonates (MD=0.45, 95%CI 0.26 to 0.63, P<0.000 01) and the Edinburgh postnatal depression scale score of mothers (MD=?1.12, 95%CI ?1.87 to ?0.55, P=0.000 3), having no effects on the cord blood pH of neonates (MD=0.03, 95%CI ?0.01 to 0.07, P=0.14). Conclusion Esketamine has certain advantages when used for postoperative analgesia in cesarean section. Due to the limited quantity and quality of the included studies, more high-quality studies are needed to further verify the above conclusion.
Objective To summarize our diagnostic and treatment experience for patients with acute Stanford type A aortic dissection （AAAD） during pregnancy. Methods Clinical data of 3 AAAD gravida （age of 30，32，35） who received surgical treatment in Beijing Anzhen Hospital of Capital Medical University from May 2008 to July 2010 were retros-pectively analyzed. One gravida received Sun’s procedure （total arch replacement combined with stented elephant trunk implantation） 3 days after cesarean section，but the fetus died in the uterus. Another gravida successfully underwent Bentall procedure and Sun’s procedure immediately after cesarean section and hysterectomy. The third gravida received cesarean section with the uterus in situ followed by ascending aorta replacement and Sun’s procedure. Results All the 3 puerperasrecovered uneventfully，and the 2 newborns of the second and third puerperas also lived well. The 3 puerperas were followedup for 6 months after discharge. CT scan showed organized thrombus in the aortic false lumen. During follow-up，the 3 puerperas recovered well，and the 2 infants had normal growth and development. Conclusions Management principles of AAAD during pregnancy firstly include timely and accurate diagnosis，which is of prime importance. Secondly，gravidas’hemodynamics should maintain stable. Thirdly，intraoperative hemorrhage should be satisfactorily controlled. Lastly，multi-modality treatment is very important to improve the prognosis of both gravidas and fetuses.
Objective To systematically review the efficacy of maternal body temperature preservation during caesarean section. Methods Databases including PubMed, EMbase, The Cochrane Library (Issue 2, 2015), WanFang Data, CBM and CNKI were searched from inception to July 2015 to collect randomized controlled trials (RCTs) of body temperature preservation in patients with caesarean delivery. Two reviewers independently screened literature, extracted data and assessed the risk of bias of included studies. Then, meta-analysis was performed using RevMan5.3 software. Results A total of 15 RCTs involving 1 331 patients were included. The results of meta-analysis showed that patients in the temperature preservation group had a smaller body temperature variation (MD= –0.22, 95%CI –0.32 to –0.13, P < 0.000?01) and a lower incidence of shivering (RR=0.53, 95%CI 0.42 to 0.67, P < 0.000?01) than patients in the control group. There were no statistical differences between the two groups in blood loss (MD= –13.77, 95%CI –33.95 to 6.42, P=0.18) and newborn Apgar score (MD=0.12, 95%CI –0.37 to 0.6, P=0.64). Conclusions Current evidence shows that body temperature preservation measures can better protect patients with caesarean delivery. Specifically, body temperature preservation measures could reduce patients’ body temperature variation and incidence of shivering but had no effect on blood loss and newborn Apgar score. Due to limited quality and quantity of the included studies, more high quality studies are needed to verify the above conclusion.
Objective To explore the value of lower abdominal aorta compression in emergent hysterectomy during cesarean section because of pernicious placenta previa. Method We retrospectively analyzed the clinical data of four patients who underwent hysterectomy for pernicious placenta previa with the assistance of lower abdominal aorta compression between January 2016 and March 2017 in Sichuan Provincial Hospital for Women and Children. Result The four patients were cured successfully, and the mothers and babies were all well with no pelvic organ damage or complications related to lower abdominal aorta compression. Conclusions Lower abdominal aorta compression in hysterectomy for pernicious placenta previa during cesarean section is a feasible procedure; it can effectively reduce the amount of bleeding, less affect maternal blood circulation, make surgery area clear, and give the operators the chance to do hysterectomy calmly. Lower abdominal aorta compression presents more and more advantages to treat pernicious placenta previa and may be an effective emergency measure to reduce hemorrhage during perioperative period especially under the circumstances of no chance to carry out vascular intervention treatment.
Objective To discuss the effect of continuous phenylephrine infusion and single-dose phenylephrine injection on puerpera undergoing spinal and epidural combined anesthesia and the infant outcomes. Methods A total of 50 patients scheduled for selective cesarean section under combined spinal and epidural anesthesia were selected as the study subjects between July 2015 and June 2016. They were randomly allocated into two groups with 25 in each. Group CII underwent continuous phenylephrine infusion [0.5 μg/(kg·min)] immediately after anesthesia to adjust the blood pressure, while group CON accepted single-dose phenylephrine injection (50 μg) after anesthesia when systolic pressure was lower than 90 mm Hg (1 mm Hg=0.133 kPa) or when the decrease of mean arterial pressure (MAP) was higher than 20% of the base value. The infusion of phenylephrine was stopped after the fetus was taken out. MAP, cardiac output, cardiac index (CI) at the time when the patient went into the delivery room (T1), before anesthesia (T2), 1 minute after anesthesia (T3), 3 minutes after anesthesia (T4), 10 minutes after anesthesia (T5), and delivery (T6) were recorded. Blood gas analysis of fetal umbilical arterial blood was carried out and neonatal Apgar score was recorded. Results Hemodynamics was more stable in group CII compared with group CON. Heart rate at T4 and T5, and cardiac output at T5 and T6 in group CON were significantly lower than those in group CII (P<0.05). The neonatal umbilical arterial blood pH value, base excess and HCO3－ were all significantly lower, while partial pressure of carbon dioxide was significantly higher in group CON than group CII (P<0.05). Conclusion Compared with single-dose phenylephrine injection, continuous phenylephrine infusion has more stable hemodynamics, and exert less effect on maternal and infant outcomes for patients undergoing cesarean section under combined spinal and epidural anesthesia.