Olofsson C, Ekblom A, Sköldefors E, Wåglund B, Irestedt L
Department of Anesthesiology and Intensive Care, Karolinska Hospital, Stockholm, Sweden.
Acta Anaesthesiol Scand. 1997 Mar;41(3):332-8. doi: 10.1111/j.1399-6576.1997.tb04694.x.
It is often assumed that subarachnoid administration of local anesthetics produces a more profound blockade than epidural anesthesia. Furthermore, the addition of fentanyl has been reported to increase preferentially intraoperative analgesia. In the present study we set out to study these two issues in a randomized and controlled study with respect to perceived pain and discomfort during surgery and postoperative pain.
In the present study, 100 parturients subjected to elective cesarean section, 34 nullipara and 66 multipara, received one out of four combinations of the local anesthetic bupivacaine and the opioid fentanyl; group A--bupivacaine 12.5 mg + 10 micrograms fentanyl subarachnoidally, group B--bupivacaine 12.5 mg + saline subarachnoidally, group C--bupivacaine 100 mg + 100 micrograms fentanyl epidurally, group D--bupivacaine 100 mg + saline epidurally; N = 25 in each group. Pain intensity and discomfort during surgery was assessed with a visual analogue scale (VAS). Postoperative pain intensity and need for analgesics postoperatively, ketobemidone, was registered for 24 h following surgery.
Intraoperative pain intensity and discomfort did not differ significantly between parturients in any of the four groups Postoperative pain was significantly more intense in parturients receiving local anesthetics subarachnoidally as compared to the epidural groups during the first 6-h period. This difference was also reflected in a significantly increased consumption of analgesics during this period. No significant differences between the groups were observed with regard to hemodynamics (blood pressure), respiration (oxygen saturation) or other effects such as nausea or itching. All neonates had normal Apgar and neonatal adaptive capacity scores (NACS).
We conclude that subarachnoidal (12.5 mg) and epidural (100 mg) injections with bupivacaine both produced adequate anesthetic quality in women undergoing elective cesarean section. The addition of fentanyl (10 micrograms subarachnoidally or 100 micrograms epidurally) did not significantly improve the quality of these already profound blockades.
人们通常认为蛛网膜下腔给予局部麻醉药产生的阻滞比硬膜外麻醉更显著。此外，据报道添加芬太尼可优先增强术中镇痛效果。在本研究中，我们开展了一项随机对照研究，以探讨手术期间的疼痛和不适以及术后疼痛这两个问题。
在本研究中，100例行择期剖宫产的产妇，其中初产妇34例，经产妇66例，接受局部麻醉药布比卡因与阿片类药物芬太尼的四种组合之一；A组——蛛网膜下腔注射布比卡因12.5mg + 芬太尼10μg，B组——蛛网膜下腔注射布比卡因12.5mg + 生理盐水，C组——硬膜外注射布比卡因100mg + 芬太尼100μg，D组——硬膜外注射布比卡因100mg + 生理盐水；每组25例。采用视觉模拟评分法（VAS）评估手术期间的疼痛强度和不适程度。记录术后24小时的术后疼痛强度以及术后镇痛药酮贝米酮的使用需求。
四组产妇术中的疼痛强度和不适程度无显著差异。与硬膜外组相比，蛛网膜下腔给予局部麻醉药的产妇在术后最初6小时内的疼痛明显更剧烈。这一差异也体现在该时间段内镇痛药的消耗量显著增加。在血流动力学（血压）、呼吸（血氧饱和度）或其他影响如恶心或瘙痒方面，各组之间未观察到显著差异。所有新生儿的阿氏评分和新生儿适应能力评分（NACS）均正常。
我们得出结论，蛛网膜下腔（12.5mg）和硬膜外（100mg）注射布比卡因对接受择期剖宫产的女性均产生了足够的麻醉质量。添加芬太尼（蛛网膜下腔10μg或硬膜外100μg）并未显著改善这些已有的深度阻滞的质量。
