Van de Velde Marc, Van Schoubroeck Dominique, Lewi Liesbeth E, Marcus Marco A E, Jani Jacques C, Missant Carlo, Teunkens An, Deprest Jan A
Department of Anaesthesiology, University Hospital Gasthuisberg, Katholieke Universiteit Leuven, Leuven, Belgium.
Anesth Analg. 2005 Jul;101(1):251-8, table of contents. doi: 10.1213/01.ANE.0000156566.62182.AB.
Obstetric endoscopy procedures are routinely performed at our institution to treat selected complications of monochorionic twin gestation. We perform these procedures under combined spinal epidural anesthesia plus maternal sedation. In the absence of general anesthesia, fetal immobilization is not achieved. We hypothesized that remifentanil would induce adequate maternal sedation and provide fetal immobilization, which is equal or superior to that induced by diazepam. Fifty-four second trimester pregnant women were included in this randomized, double-blind trial. After combined spinal epidural anesthesia, maternal sedation was initiated using either incremental doses of diazepam or a continuous infusion of remifentanil. Maternal sedation, hemodynamics, side effects, and fetal hemodynamics and immobilization were evaluated before, during, and for 60 min after surgery. Remifentanil produced adequate maternal sedation with mild but clinically irrelevant respiratory depression (respiratory rate 13 +/- 4 breaths/min and Pco(2) 38.6 +/- 4 mm Hg at 40 min of surgery), whereas diazepam resulted in a more pronounced maternal sedation but no respiratory depression (respiratory rate 18 +/- 3 breaths/min and Pco(2) 32.7 +/- 3 mm Hg at 40 min of surgery). Compared with diazepam, fetal immobilization with remifentanil occurred faster and was more pronounced, resulting in improved surgical conditions; the number of gross body and limb movements was 12 +/- 4 (diazepam) versus 2 +/- 1 (remifentanil) at 40 min of surgery. Because of this, the mean (range) duration of surgery was significantly shorter in the remifentanil-treated patients, 60 (54-71) min versus 80 (60-90) min in the diazepam group. We conclude that remifentanil produces improved fetal immobilization with good maternal sedation and only minimal effects on maternal respiration.
我院常规开展产科内镜手术，以治疗单绒毛膜双胎妊娠的特定并发症。我们在腰麻 - 硬膜外联合麻醉加产妇镇静的情况下进行这些手术。在没有全身麻醉的情况下，无法实现胎儿制动。我们假设瑞芬太尼能诱导足够的产妇镇静并实现胎儿制动，其效果等同于或优于地西泮。54名孕中期孕妇被纳入这项随机双盲试验。在腰麻 - 硬膜外联合麻醉后，使用递增剂量的地西泮或持续输注瑞芬太尼开始产妇镇静。在手术前、手术期间及手术后60分钟评估产妇镇静、血流动力学、副作用以及胎儿血流动力学和制动情况。瑞芬太尼产生了足够的产妇镇静效果，伴有轻度但临床上无显著意义的呼吸抑制（手术40分钟时呼吸频率为13±4次/分钟，二氧化碳分压为38.6±4毫米汞柱），而地西泮导致更明显的产妇镇静但无呼吸抑制（手术40分钟时呼吸频率为18±3次/分钟，二氧化碳分压为32.7±3毫米汞柱）。与地西泮相比，瑞芬太尼使胎儿制动出现得更快且更明显，从而改善了手术条件；手术40分钟时，全身和肢体的大幅度运动次数在使用地西泮组为12±4次，而在使用瑞芬太尼组为2±1次。因此，瑞芬太尼治疗组患者的平均（范围）手术时间显著更短，为60（54 - 71）分钟，而地西泮组为80（60 - 90）分钟。我们得出结论，瑞芬太尼能更好地实现胎儿制动，产妇镇静效果良好，且对产妇呼吸影响极小。
