剖宫产麻醉后低血压研究进展

剖宫产麻醉后低血压研究进展CWIInternational

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Hospital产科麻醉与镇痛的困境这个矛盾为“产科麻醉

与镇痛的困境”,显

示

了产科麻醉的挑战和吸

引力CWI

International

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Hospital323篇，占26%口腰麻□硬膜外麻醉

口全身麻醉CWI

International

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Health

Hospital

剖宫产术中低血压Pubmed结

果

剖宫产低血压原因仰卧位低血压综合征，低血压发生还与麻醉平面，交感神经阻滞，特殊产科情况如妊高症，双胎巨大儿，出血等有关主要通过麻醉药物的心血管抑制作用影响血压和心率，

通常都在可控范围内交感神经阻滞，血管扩张，回心血流减少所致，部分患者可并发仰卧位低血压综合征CWIInternational

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Hospital硬膜外麻醉全身麻醉腰麻特点：血压骤然剧

烈下降，心率骤然

急

剧

升

高腰麻后循环变化特点CWI

International

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Health

Hospital特点：血压骤然剧烈下降，心率不

升

高

甚

至

剧

烈下

降

腰麻后循环变化特点CWIInternational

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Health

Hospital腰

麻

的

缺

点

·仰卧位低血压综合症发生率高：50%·骤然发生头晕恶心呕吐、心率加快、面色

苍白等一系列低血压症状，●

仰卧位低血压综合征极易导致产妇子宫胎盘血流量急剧下降，进而可导致胎儿发生功能性缺氧及酸中毒现象，严重时甚至还可导致新生儿室息及死亡，严重威胁着孕

产妇及婴儿的生命安全CWIInternational

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Hospital●

麻醉显效迅速·麻醉效果满意，镇痛完全，肌松充分●

麻醉药物用量少·穿刺针细，对硬脊膜损伤小，术后头痛发生率较低CWIInternational

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Maternity&Child

Health

Hospital

腰

麻

的

优

点ABSTRACT;Surinebypotnsvegyadnxischrastertiodbysesspinebyoknsioinlaspagmnxy,whogchialpsgntatianageston

minml

caniovxur

lkxntions

to

soce

sbctxatng

fmm

nicoor

vaicpa

captoon

by

gmid

uxms

We

xpot

a

cce

of141-yeur-dd39wkpmecmirtwminfoundtkidsups.Autbpyavealkdthefoloangynossof

thelirks;togationof

the

juulrandsthd1autopsyfindingsarepresent.CWIInternational

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Health

Hospital5ONSJFormsic

Sci

November2012,Vol57,No.6

dot:10.111Mj,1556-4029201202165xCASE

REPORT

Avilabkeonlime

at:PATHOLOGY/BIOLOGYFabio

De-Giorgio'M.D,Ph.D.;Vinceno

M.Grassi'M.D.;Giuseppe

Vetngno,'MD,Ph.D.;Emesto

dAloja²M.D,Ph.D.;Vincenzo

L.Pascali,MD.,PhD.;and

Vincemzo

Arena,³M.D,Ph.D.Supine

HypotensiveSyndromeastheProbableCauseofBoth

Maternal

and

FetalDeath仰卧位低血压综合症危害The

diagnostic

criteria

include

a

decrease

in

mean

arterial

pres-sure

of

more

than15mmHg

or

a

decreased

systolic

pressure

of15-30

mmHg

associated

with

a

persistent

elevation

of

heant

rate

of

20beats/min

over

baseline

in

supine

position(1),which

may

indi-cate

a20-25%decrease

in

circulatingblood

volume.Matemalhypotension

often

leads

to

transient

deficiency

of

the

uterine

circu-lation,and

this

may

result

in

fetal

distress

or

asphyxia

(9).In

conclusion,forensic

pathologistsshould

be

aware

thatsupine

hypotensive

syndrome

is

a

potential

source

of

sudden

death

and

a

cause

ofdeath

that

should

be

considered

when

no

other

significant仰卧位低血压综合症危害A

26-year-old

woman

presented

for

fetoscopic

sur-gery

for

twin-twin

transfusion

syndrome

at

20

weeksof

gestation.She

had

polyhydramnios

and

was

mor-

bidly

obese

(body

mass

index

45kg/m²).Symptoms

of

aortocaval

compression

had

been

noted

from

thefirst

trimester.InternationalJournalof

ObstetricAnesthesiaand

post-dural

puncture

headache

in

a

tertiary

obstetric

anaes-thetic

department.Int

JObstet

Anesth2009;17:329-35.An

intrathecaldose

of

hyperbaric

0.5%bupivacaine

9

mg

was

admin-

istered

and

an

epidural

catheter

was

sited.0959-289X/$-see

front

matter①2015Elsevier

Ltd.Allrights

reserved.http://dx.do/10.1016/j.ijoa.2015.05.003Maternal

collapse

secondary

toaortocaval

compressionCWIInternational

Peace

Maternity&Child

Health

HospitalEphedrine

12

mg,phenylephrine

200

μg

and

an

addi-tional500mLbolus

ofHartmann's

solutionwereadministered.A

sensory

block

to

T5

was

demon-

stratedusing

ice.Symptomspersisted

and

shebecamemorehypotensive

(50/20mmHg),increasingly

dizzy

and

nauseated.We

then

attempted

to

increase

the

tilt

by

manually

tilting

the

patient.This

wasineffective.She

was

then

positioned

in

the

full

left

lateral

posi-

tion.Additional

intravenous

access

was

obtained

andafurtherlitreofHartmann'ssolutioninitiated.Fur-thervasopressoragentswereineffective.Fourminutes

after

CSE

placement,she

lost

consciousness

and

wasintubatedfollowingadministrationof

suxamethonium

150

mgand

propofol50mg.Blood

pressure

was

unrecordable.Radial

and

brachial

pulses

were

impal-pable,although

carotid

pulsation

could

be

detected.

Intravenous

epinephrinewas

administered

in

increas-

ingincrementsbut

was

unsuccessful.The

decision

was

made

to

perform

a

hysterotomy

and

emergencycaesarean

delivery

of

the

twins

six

minutes

postCSE.For

this,she

was

returned

to

the

supine

position

with

the

wedge

left

in

place.After

evacuation

ofthe

uterus

peripheral

pulses

became

palpable

and

bloodpressure

was

recordable.No

further

inotropes

were

required.Transthoracic

echocardiography

showed

ahyperdynamic

heart.She

was

transferred

to

the

inten-sive

careunit

and

extubated

sixhours

later

andmade

a

complete

recovery;however,the

twins

died

shortlyafter

delivery.仰卧位低血压综合症危害under

the

right

hip

aiming

for

30

degrees

left

tilt.

NIBP

was

60/30

mmHg.CWIInternational

Peace

Maternity&Child

Health

HospitalIt

is

also

important

to

emphasize

that

overweight

(body

mass

index

≥25

kg/m²)and

obesity(body

mass

index

≥30

kg/m²)havebecome

common

health

problems

for

the

general

population,Moreover,the

risk

of

pregnancy-related

deaths

is

higher

in

women

aged

from

35

to

39

years

ifcompared

with

younger

women

and

even

higher

in

women

older

than

40

years

(5).pregnancy(6):(i)blood

volume

rises

byanaverage

of

50%inpregnancy,with

hemodilution;(ii)maximum

heart

rate

increase

isreachedinthethirdtrimesterandis

about10-20beats/min;(iii)cardiacoutputrisesbyanaverageof50%;(iv)systemicvascularresistancedecreasesandreachesthenadirat24weeksof

preg-nancy;(v)functionalresidualcapacityisreduced

from10%to

20%inlatepregnancy;(vi)oxygenconsumptionincreasesfrom20%to

33%becauseoffetaldemandsandincreasedmaternalmet-

abolicprocesses.CWIInternational

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Health

Hospital仰卧位低血压综合症高危因素腰麻后低血压的预测心率变异性·

反映自主神经系统活性和定量评估心脏交感神经与迷走神经张力及其平衡性·产妇腰麻后可引起自主神经功能改变：包括交感神经

张力降低和副较高神经张力升高·以上这些自主神经变化均可引起心率减慢与血压降低有学者试图用心率变异性来预测腰麻后低血压的发生CWIInternational

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Health

HospitalHF

I%EventsHeart

ratevariability

predictssevere

hypotensionafterspinalanesthesiaforelectivecesarean

delivery.Anesthesiology.2005;102(6):1086-93CWI

International

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Health

Hospital心率变异性Fig.1.Retrospective

heart

ratevariabilityanalysis.IMILD

MODERATESEVEREDBS:

手术前一天DOS-BL:手术当天基础

值PREHYD:

胶体扩容后腰麻后低血压的预测Events回顾性研究提示剖宫产腰麻后低血压的产妇术前的LF/HF的值较高，前瞻性研究提示术前LF/HF

值较高产妇腰麻后发生低血压的可能性越大CWIInternationalPeaceMaternity&ChildHealthHospital

腰麻后低血压的预测心率变异性LF

[%]正工DBS:DOS-BLiPREHYDFig.2.Prospective

heart

ratevariabilityanalysis.LF/HF<2.5

LF/HF>2.57.55.0

LF/HF2.50.0-Fig.2a,LF/HFHFI%灌注指数·P

l=检测部位的搏动性组织吸收光/非搏动性组织吸收光(动脉血液吸收光/皮肤、静脉、骨骼吸收光)·

PI低提示外周灌注不良，相反PI高灌注状况越好·妊娠子宫压迫髂动脉和下腔静脉，影响下肢的动脉血

流使PI降低·

交感神经系统通过影响动脉血流间接影响Pl值·

腰麻后局麻药通过阻断交感神经使下肢动脉扩张，PI

升高有

学

者

试

图

用

灌

注

指

数

来

预

测

腰

麻

后

低

血

压

的

发生CWIInternational

Peace

Maternity&Child

Health

Hospital腰麻后低血压的预测LCIV在前方RCIA

和后方前凸腰骶椎的共同压迫下，造成血流动力学改变，从而启动了某些相关基因或蛋白质的过度表达，,血管发生重塑，导致不同程度的管壁组织改变，引起力学构型改建CWI

International

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Hospital妊娠病理生理学LCIV受压段管壁塌陷、菲薄；受压段边界清晰，上缘增厚，条索状边缘增厚；受压段前后壁粘连CWIInternational

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Health

Hospital妊娠病理生理学特点：下肢灌注指数

(PI)剧烈下降，甚至

无

灌

注

→

胎

盘

灌注不足→胎儿窘迫?剖宫产腰麻后PI

变

化CWIInternational

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Health

HospitalPerfusion

indexderivedfromapulseoximetercan

predictthe

incidence

of

hypotension

duringspinal

anaesthesia

forCaesareandelivery

BritishJournalofAnaesthesia

111(2):235-41CWIInternational

Peace

Maternity&Child

Health

HospitalConclusions.

We

demonstrated

thathigher

baselinePI

was

associated

withprofound

hypotensionand

thatbaselinePIcouldpredicttheincidenceofspinalanaesthesia-灌注指数(手指)crease

inSAPduringspinalanaesthesiaforCaesareandelivery

[%

SAPdecrease=(baseline

SAP-lowest

SAP)/baseline

SAP]

(r=0.664,P<0.0001).The

solid

line

represents

the

linear

regres-sion

line

and

the

dotted

lines

represent

the95%CIs.Fig2

ROC

curves

for

the

baseline

PI

during

spinal

anaesthesia

forCaesarean

delivery.The

optimal

cut-off

value

forpredicting

theincidence

of

hypotension

in

PI

was3.5.AUC,area

under

theROC

curve,with95%CIs

givenin

parentheses.腰麻后低血压的预测inducedhypotensionduringCaesareandelivery.Fig

1Thecorrelation

between

baseline

PIandthedegreeofde-6050-A0BACKGROUND:

Aortocavalcompression

bythegraviduterus,low

baselinevasomotortone,

andspinalanesthesia-related

sympathetic

blockade

contribute

to

spinal

anesthesia-induced

hypoDifferential

Rolesofthe

Rightand

LeftToe

Perfusion

Index

in

Predictingthe

IncidenceofPostspinalHypotension

DuringCesarean

Delivery

gij

i

Z,

n,

h,

D,*T,

D

Zhao,MD,*Rui

Ma,MD,*Mazhong

Zhang,MD,PhD,t十Xu,MD,*PuwenPhaoMDgPheMDanXuJndeanZif腰麻后低血压的预测tensionduringcesareandelivery.Thefingerperfusionindex(Pl)can

predict

spinal

hypotensionbyreflectingbaselinevasomotortone,butcannotdirectly

reflectaortocaval

compression

bythegravid

uterus.This

study

aimed

to

examine

whether

baseline

toe

PIs

predict

the

incidence

ofmaternalhypotensionandreflectaortocavalcompression

by

the

gravid

uterus

during

cesareandelivery

underspinalanesthesia.METHODS:

One

hundred

parturients

undergoingelectivecesareandeliverywereenrolled.Therelationship

between

baseline

toe

PI

and

the

incidence

of

hypotension

following

induction

ofspinal

anesthesia

was

quantified

using

area

under

the

receiver

operator

curves,and

resultscomparedforthe

right

and

left

toe

Pls.RESULTS:

Thearea

underthe

receiveroperatorcurvesforleft

and

right

toe

baseline

Pls

were0.81(95%confidenceinterval,0.71-0.88)and0.76(95%confidenceinterval,0.66-0.84),respectively.Following

inductionofspinal

anesthesia,thetoe

Plsdid

not

change

in

parturientswithhypotension,butincreasedsignificantlyamongthosewhodid

not

develop

hypotension.CONCLUSIONS:

Ourstudydemonstratedthat

baselinetoe

Plswere

inverselyassociatedwiththeincidenceofpostspinalhypotensionduringcesareandelivery.Continuous

monitoring

oftoe

Plsduringinductionofspinalanesthesiamight

helpto

predictthe

development

of

postspinal

hypoten-sionandreflecttheaortocavalcompressionby

the

gravid

uterus.(AnesthAnalg

2017;XXX:00-00)CWIInternational

Peace

Maternity&Child

Health

Hospitalparisons.The

left

toe

area

under

the

ROC

curve

was

0.81

(95%CI,0.71-0.88).The

optimal

cutoff

point

of

the

preanes-

thetic

PI

to

predict

the

occurrence

ofpostspinal

hypoten-sion

was2.2(95%CI,1.4-2.2),with

a

sensitivity

of

92.9%

(95%CI,80.5%-98.5%)and

specificity

of

61.5%(95%CI,

47.0%-74.7%).The

right

toe

area

under

the

ROC

curve

was

0.76

(95%CI,0.66-0.84).The

optimal

cutoff

point

was1.3

(95%CI,0.99-2),with

a

sensitivity

of61.9%(95%CI,45.6%-

76.4%)and

specificity

of

84.6%(95%CI,71.9%-93.1%).Differential

Rolesofthe

Rightand

LeftToe

Perfusion

Index

in

Predictingthe

IncidenceofPostspinalHypotensionDuring

Cesarean

Delivery.Anesth

Analg.2017Aug8.0000000000002393.CWI

International

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Maternity&Child

Health

Hospital灌注指数(脚趾)100-SpecificityFigure2.The

receiving

operatorcharacteristic

curvesfor

baseline

toe

Pls.Red

dotted

line,left

baseline

toe

PI.Blue

dotted

line,right

baselinetoe

PI.Pl

indicates

perfusion

index.腰麻后低血压的预测腰麻后低血压的预测感觉阻滞平面升高速率·

高于T4同或T5感觉阻滞平面的脊麻容易引起低血压的

发生·

动静脉血管舒缩神经起源于T5-L1,

心脏加速神经起

源于T1-T4,

因此广发而迅速的高位阻滞容易引起血

流动力学剧烈变化·确定腰麻感觉神经阻滞平面的升高速率对预测低血压

可能有帮助CWIInternational

Peace

Maternity&Child

Health

HospitalFigure2.Ascending

range

ofsensoy

bocklevel

afterspnal

anesthesia.Box

plots

displaythe

25th,50oth,and

75th

percentiles

as

hoizontalines

on

a

bar,

wriskers

above

and

belbowthe

box

indicatedthe

9othand

10th

percentles,anddata

beyondthe

10th

and

90th

percentiles

are

showed

as

ndhidual

ponts.Levelofsensoryblockafterspinalanesthesiaasa

predictor

of

hypotension

in

parturient.Medicine

(Baltimore).2017Jun;96(25):e7184.CWIInternational

Peace

Maternity&Child

Health

HospitalB

腰麻后低血压的预测Sensoryblock

levelA发生低血压组的腰麻阻滞平面和阻滞平面的升高速率都高于未发生低血压组，

根据统计腰麻给药后三分钟阻滞平面超过T8最有可能引起低血压发生，其敏感性82%,特异性88%CWIInternational

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Health

Hospital腰麻后低血压的预测Fgure3.Timetoensoybocklenlahypdenson.Bcxpktsdspaythe25th,50th,and75thpercartlesashoizonta

ineson

abar,whiskesaboeardbeow

the

boxindcad

the

9Oh

and

10th

percenfles,and

dta

beyond

the

10th

and

90th

peroentles

xe

showBd

a

ndwdnl

ponts.bbcklovd

at

th

3d

rinute

ater

shal

snsoybboklevel.maSBL3°mirSBL=sersoyinjzcton,maSBL=maxnaFgure4.ReceineropentngchaactersicanesFOQajfor3mirSBLand1-SpeifkityCB腰麻后低血压的预测脑氧饱和度·

使用700到900

nm波长的近红外线可以鉴定脑血氧饱脑血氧饱和度降低5%,表明脑氧合受到影响，减少10%可能表明脑功能障碍·在体位性低血压实验中，ScO2在出现前期症状之前就开始下降，从而预测晕厥的发生CWIInternational

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Health

Hospital

和度(ScO2)·Hypotension(n=32)No

hypotension

(n=9)P

valueAge

(years)29.1±6.228.9±6.10.6258Body

weight

(kg)74.6±9.174.4±9.30.5632Height

(cm)161.8±63161.5±6.10.4566Body

mass

index

(kg

m-²)29.1±7.828.9.

±7.60.5547Baseline

ScO₂62%(59-64

%)63%(59-65%)0.4138Decrease

in

ScO₂7%(4-9%)3%(3-4%)0.0001Timefrom

injection

to

hypotension

(s)158(154-263)Time

from

injection

to

5%decrease

in

ScO₂(s)122Table

-152)(n

=24)Time

from

5%docrease

in

ScO₂

to

hypotension

(s)38(35-96)(n

=24)腰

麻

后

低

血

压

的

预

测Roleofcerebraloxygenationforpredictionofhypotension

afterspinalanesthesiafor

caesarean

sectionShen

Sun¹·Nai-he

Liu²·Shao-qiang

Huang¹CWIInternationalPeaceMaternity&ChildHealthHospitalORIGINAL

RESEARCHJClinMonit

ComputDOI

10.1007/s10877-015-9733-4Table

1SeO₂HypotensionafterspinalanesthesiaNohypotensionafterspinal

anesthesiaTotalPositive(24.5%decrease)24(tne

positive2(false

positive)26Negative(<45%decreac)8(false

megative)7(rue

negative)15Total32941腰麻后低血压的预测剖宫产腰麻后低血压组出现ScO2下降的人数明细较多，并且首先出现ScO2下降，而后出现血压降低，当ScO2至5%后38秒可出现血压下降，经统计引起血压降低的ScO2

阈值为4.5%Table

2Positivepredictivevalueandnegative

predictive

value

of

4.5%decrease

in

SaO₂for

predicting

hypotension

after

spinal

anesthesiaCWIInternational

Peace

Maternity&Child

Health

Hospitalwomen.In

pariclar

wedemonstrated

that

heart

ratesof<71

bpm,and

more

than89

bpm,are

clinicalyuseful

prognostic

values

to

hdp

predict

the

develop-

mentof

hypotension,whilethosein

the

range

betweenhaveredativedyweakprognosticvalue.Unlikesomepreviousstudies,weshowed

tat

pre-anaesthetic

PVI,PI,LF-to-HF

rati

and

entropy

of

HRV

are

not

useful

indicestopredicthypotensioninthispatientgroup.

腰麻后低血压的预测心率CWIInternationalPeaceMaternity&ChildHealthHospitalDiscussion

andconclusion:

Taking

into

accounthe

current

guidelines

and

literature

as

wellaseverydaycinialexperience,thefnststepfordereasingtheincidenceofIONVandPONVis

a

comprehensive

management

of

circulatory

parameters.This

management

includes

iberalperioperativefuidadministrationandtheapplicationof

vasopressorsasthe

circumstances

require.Byusinglow-doselocalanesthetics,anadditionalapplicationof

intrathecalorspinal

opioidsorhyperbaricolutionsforasuffcientcontrolablityofneuraxialdistributon,maternal

hypotensionmightbereduced.Performingacombinedspinal-epidunalanesthesiaorepidural

anesthesia

may

be

considered

as

an

altenative

to

spinal

anesthesia.Antiemetic

drugs

may

beadministeredrestainedlyduetoofflabeluseinpregnantwomenforIONVorPONVprophy-haxis

and

may

be

reservedfor

teatment.●减少局麻药的用量，●联合鞘内阿片类药物●腰硬联合或硬膜外麻醉●合理使用止吐剂Preventing

nausea

and

vomiting

in

women

undergoing

regional

anesthesia

for

cesarean

section:challenges

and

solutions.Local

Reg

Anesth.2017;10:83-90CWIInternational

Peace

Maternity&Child

Health

Hospital腰麻后低血压的处理●围术期药物容量治疗●血管活性药物的使用处理：腰麻后低血压的预防和治疗左倾斜位·孕妇在仰卧位期间，下腔静脉在分叉水平以上可能出

现完全阻塞，仅有少数孕妇由于侧支循环失代偿而未

出现明显的血流动力学变化·

腰麻的神经阻滞作用会抑制产妇的心血管代偿能力，

从而加重母体在仰卧位时的低血压，为避免这种由机

械原因所引起的血流动力学障碍，通常采用左倾斜位·

在然而实际工作中很少持续的采用这种方法，而且通

过一些血管活性药物同样可以维持血压的稳定，因此

学者对左倾斜位的必要性和有效性产生质疑CWI

International

Peace

Maternity&Child

Health

HospitalThe

values

are

means±SD.*Po₂values

lessthan

17

mmHgare

reported

bythelaboratoryas"lessthan17

mmHg"and

were

treated

as

17

mmHg

for

this

analysis.UA=umbilical

artery;UV=umbilical

vein.Left

LateralTableTiltforElectiveCesarean

Delivery

underSpinalAnesthesia

HasNoEffectonNeonatal

Acid-Base

Status.Anesthesiology.2017

Aug;127(2):241-249CWIInternational

Peace

Maternity&Child

Health

HospitalPositionSupine

GroupTiltGroupP

ValueUA

blood

gases(n=50)(n=47)pH7.28±0.057.28±0.040.39Pco₂(mmHg)55±755±110.69Po₂(mmHg)*19±319±50.57HCO₃(mmol/l)25±125±10.88Base

excess

(mmol/l)-0.5±1.6-0.6±1.50.64UV

blood

gases(n=49)(n=47)pH7.33±0.057.33±0.040.49Pco₂(mmHg)46±646±50.68Po₂(mmHg)26±526±50.95HCO₃(mmol)23±124±10.54Base

excess(mmol/)-1.7±1.3-1.6±1.50.91腰麻后低血压的预防和治疗Table2.NeonatalAcid-BaseStatusaccordingtoMaternal腰麻后低血压的预防和治疗在给予一定扩容和血管活性药物的支持下，左倾斜位与平卧位剖宫产术婴儿的

脐动脉与脐静脉酸碱度没有明显差异Fig

.

3.Mean

systolic

blood

pressure(mmHg±SD)by

groupover

first

15min

after

spinal

anesthesia

(supine

group,n=50;tilt

group,n=49).At

least

45

of

50

supine

and

at

least

44

of49tilt

subjects

had

systolic

blood

pressure(BPsys)measure-ments

at

each

minute.*Time

points

where

there

was

a

signifi-cantdifferencebetween

groups.Fig.2.Box

plot

of

umbilical

artery(UA)base

excess

(mmol/)by

group.Dots

represent

outliervalues.CWIInternational

Peace

Maternity&Child

Health

HospitalTimepost-spinalanesthesia

(mins)Bp

sy

s

(mmHg)BPsys腰麻后低血压的预防和治疗剖宫产术中左倾卧位不能改善新生儿的酸碱状态发表于2017-07-0823:21:21|浏览次数：18959产妇平卧时，妊娠子宫可能会压迫下腔静脉，影响下腔及

盆腔的静脉回流，使回心血量减少、右心房压下降、心搏

出量减少，从而引起产妇低血压以及胎儿宫内窘迫，即“仰卧位低血压综合征”。对此，目前普遍的做法是在胎

儿娩出前使产妇左倾15°,以减少子宫对下腔静脉的压迫。

临床上由于下肢静脉收缩等有效的代偿机制，大多数产妇

仰卧位时不会发生剧烈的血流动力学变化，也没有明显的

自述症状，表现为隐匿性的腹主动脉-腔静脉压迫(concealedACC),在实际工作中“仰卧位低血压综合征”

的发生率仅为8~10%。另外，围术期容量治疗以及血管活

性药物的应用也为母婴安全提供了保障。因此我们不免产

生疑问，在维持产妇血压平稳的前提下，剖宫产术中真的需要左倾体位吗?古麻今醉复大学铈第CWIInternational

Peace

Maternity&Child

Health

HospitalL

groupn=31LS

gioup

n=31C5

gioup

n=32Incidenceofhypotension3

(9.7%)17

(54.8%)18

(56.3%)Ephedrine

(mg)Pre-delverymedian

(range)0

(0-6)*6(0-24)6(0-18)Post-deliverymedian

(rangel0

(0-0)**0(0-12)6(0-12)Nausea

(n)286Vomiting

(n)244**ComparedwithgoupLS,PR<0.01.LL—左侧卧至手术开始；LS—

麻醉后右侧抬高平卧位；CS—麻醉后平卧位CWIInternational

Peace

Maternity&Child

Health

Hospital腰麻后低血压的预防和治疗Anaesthesia,2005,60,pages535-540A

comparison

ofthelateral,Oxfordand

sittingpositionsforperformingcombinedspinal-epiduralanaesthesiafor

elective

Caesarean

sectionM.W.M.Rucklidge,1,4M.J.Paech²andS.M.Yentis³1AnaestheticResearchFellow

and2AssociateProfessor

of

ObstetricAnaesthesia,School

of

Medicine

andPharmacology,

University

ofWesternAustralia,Perth,Australia;DepartmentofAnaesthesiaandPainMedicine,King

EdwardMemorial

Hospital

for

Women,374

Bagot

Road,Subiaco,Western

Australia6008,Australia3

Consultant,MagillDepartmentof

Anaesthesia,IntensiveCare

SPainManagement,Chelsea

andWestminster

Hospital,London

SW109NH,UK4

Currentposition:ConsultantAnaesthetist,DepartmentofAnaesthesia,Royal

Devon

andExeterHospital,Barrack

Road,Exeter

EX25DW,UK体位对产妇低血压的发生率、新生儿

Aparg

评分和脐带血氧分压没有影响腰麻后低血压的预防和治疗CWIInternational

Peace

Maternity&Child

Health

HospitalEphedrine

IV(mg)0102030脐动脉PH<7.2(%)11254222腰麻后低血压的预防和治疗phenylephrine

100μg/mlEphedrine3

mg/mlPhenylephrine

50μg/ml+

ephedrine

3

mg/ml胎

儿

酸

中

毒

发

生

率低高中提示：麻黄素治疗腰麻后低血压增加胎儿酸中毒meta-analysis

of

vasopressor

use

during

elective

caesarean

section,byVeeser

et

al,collated

data

from

20trials

(n

=1069),finding

the

rela-

tiverisk

for

true

fetal

acidosis

tobe5.29for

ephedrine

versus

phenyl-ephrine

[10].·麻黄素

曾经的一线药CWIInternationalPeaceMaternity&ChildHealthHospital腰麻后低血压的预防和治疗去氧/甲肾上腺素·去氧肾上腺素仅有α受体激动作用，没有β受体激动作

用，应用于剖宫产术常出现母体反射性心动过缓与心

排量下降·

去甲肾上腺素具有α-肾上腺素受体激动作用，同时还

具有部分β-肾上腺素受体激动作用·

因此，去甲肾上腺素在维持血压的同时，可能会有更

好的心率和心排量CWIInternational

Peace

Maternity&Child

Health

Hospital腰麻后低血压的预防和治疗Randomizeddouble-lindedcomparisonofnorepinephrineand

phenylephrinefor

maintenanceof

blood

pressure

during

spinal

anesthesia

for

cesarean

delivery.Anesthesiology.2015;122(4):736-45.CWIInternational

Peace

Maternity&Child

Health

HospitalRandomizeddouble-lindedcomparisonofnorepinephrineand

phenylephrineformaintenance

of

blood

pressure

during

spinal

anesthesia

for

cesarean

delivery.Anesthesiology.2015;122(4):736-45.CWIInternational

Peace

Maternity&Child

Health

HospitalNomall

zedS

turokeVolumeBTime/min)腰麻后低血压的预防和治疗30002500200015001000500N

PAreaUnderThe

Curve(%.min)NorepinephrineGroupPhenylephrineGroupP

ValueBirth

weight(kg)3.11

[2.85-3.37]3.19

[3.04-3.36]0.37Apgar

score

at

1min<800Apgar

score

at

5min<800Umbilicalarterialblood

gasespH7.30[7.28-7.33]7.29[7.28-7.32]0.45PoO,(mmHg)50[48-56]52[48-56]0.77Po₂(mmHg)15[13-18]14

[11-16]0.20Base

excess

(mmol)-2.0

[-3.7to-1.0]-2.4[-4.2

to

-0.8]0.87Oxygen

content

(mldl)6.0[4.4-7.7]5.2[3.8-7.0]0.29Umbilicalvenousblood

gasespH7.35[7.34-7.377.34[7.32-7.36]0.031Pco,(mmHg)41

[38-43]41

[38-45]0.69Po₂(mmHg)27[23-30]26

[23-28]0.23Base

excess(mmol/)-3.2

[-4.1

to

-2.0]-3.5[-5.6

to-2.4]0.06Oxygen

content(mldl12.7[11.3-14.4]11.8[9.6-13.7]0.047腰麻后低血压的预防和治疗腰麻后剖宫产使用去甲肾上腺素比去氧肾上腺素具有更好的心率和心排量，

出现心动过缓的概率更小，两组之间在血压，新生儿结局方面没有显著差异CWIInternationalPeaceMaternity&ChildHealthHospitalValuesaemedian[nterquartile

range]or

number.Table2.Neonatal

Outcome腰麻后低血压的预防和治疗去甲肾上腺素·

去甲肾上腺素是目前预防和治疗剖宫产腰麻后低血压

的首选药物·去甲肾上腺素是去氧肾上腺素较好的代替药物，因其

具有α-肾上腺素受体激动作用，同时还具有部分β-肾

上腺素受体激动作用·

通常去甲肾上腺素静脉维持给药用于维持血压，其单次静脉给药治疗治疗剖宫产腰麻后低血压的研究较少CWIInternational

Peace

Maternity&Child

Health

Hospital腰麻后低血压的预防和治疗NorepinephrineIntermittentIntravenous

Bolusesto

Prevent

Hypotension

DuringSpinalAnesthesiafor

Cesarean

Delivery:A

SequentialAllocation

Dose-Finding

Study.AnesthAnalg.2017;125(1):212-218.CWIInternational

Peace

Maternity&Child

Health

HospitalFigure2.Thepatient

allocation

sequence

andthe

response

to

the

assigned

dose.The

patient

sequence

number

(x-axis)is

the

order

o