硬膜外分娩镇痛产妇镇痛期间产时发热状况及其影响因素_王伟华.pdf

海南医学2023年4月第34卷第8期Hainan Med J,Apr.2023,Vol.34,No.8志,2020,19(12):1208-1213.11 Zhou X,Zhao JL,Ge LK,et al.Comparison of microscopical and en-doscopic microvascular decompression under neurophysiologicalmonitoring in the treatment of hemifacial spasm J.J Xinxiang MedColl,2022,39(6):537-543.周祥,赵锦丽,葛立可,等.神经电生理监测下显微镜和内镜微血管减压术治疗面肌痉挛疗效比较J.新乡医学院学报,2022,39(6):537-543.12 Li Y,Shi HW,Wang YZ,et al.Application of synchronous videomonitoring of lateral spread response in surgery for hemifacial spasmJ.Chinese Journal of Minimally Invasive Neurosurgery,2021,26(1):15-19.李洋,史皓威,王银占,等.同步视频监测侧方扩散反应在面肌痉挛手术中的应用J.中国微侵袭神经外科杂志,2021,26(1):15-19.13 Chen AB,Jiang XF,He F,et al.Relationship between the changingcharacteristics of abnormal muscle response in microvascular decom-pression for hemifacial spasm and treatment outcome after surgeryJ.Journal of International Neurology and Neurosurgery,2019,46(1):21-25.陈奥博,姜晓峰,何芳,等.面肌痉挛微血管减压术中异常肌反应变化特点与术后疗效关系探究J.国际神经病学神经外科学杂志,2019,46(1):21-25.14 Gong DS,Cui Y,Yue SY.Application of multibranch abnormal mus-cle response monitoring during microvascular decompression forhemifacial spasm J.Chinese Journal of Contemporary Neurologyand Neurosurgery,2020,20(11):987-992.宫达森,崔云,岳树源.多支肌肉异常肌反应监测在面肌痉挛微血管减压术中的应用J.中国现代神经疾病杂志,2020,20(11):987-992.(收稿日期：2022-07-22)硬膜外分娩镇痛产妇镇痛期间产时发热状况及其影响因素王伟华，朱艳，滕薇宝鸡市妇幼保健院麻醉科，陕西宝鸡721000【摘要】目的探讨硬膜外分娩镇痛产妇镇痛期间产时发热状况及其影响因素。方法回顾性分析2021年1月至2021年12月于宝鸡市妇幼保健院分娩的2 830例产妇的临床资料，依据硬膜外分娩镇痛期间是否出现产时发热分为产时发热组589例与无产时发热组2 241例。采用2检验对临床资料实施单因素分析，并将差异有统计学意义的单因素分析结果进行多因素Logistic回归分析。结果 单因素分析结果显示，产前抗菌药物使用、羊水污染、硬膜外镇痛给药方式、使用缩宫素、硬膜外镇痛时宫口扩张、总产程、镇痛时间与硬膜外分娩镇痛期间产时发热有关(P0.05)；经多因素Logistic回归分析结果显示，产前使用抗菌药物、硬膜外镇痛给药方式、使用缩宫素、硬膜外镇痛时宫口扩张、总产程、镇痛时间为硬膜外分娩镇痛期间产时发热的独立危险因素(P0.05)。结论硬膜外分娩镇痛期间产时发热的独立危险因素为产前使用抗菌药物、硬膜外镇痛给药方式、使用缩宫素、硬膜外镇痛时宫口扩张、总产程、镇痛时间。【关键词】产妇；硬膜外分娩镇痛；镇痛期间；产时发热；危险因素【中图分类号】R714.45【文献标识码】A【文章编号】10036350（2023）08111804Intrapartum fever and its influencing factors during epidural labor analgesia.WANG Wei-hua,ZHU Yan,TENGWei.Department of Anesthesiology,Baoji Maternal and Child Health Hospital,Baoji 721000,Shaanxi,CHINA【Abstract】Objectiveo investigate the status of intrapartum fever and its influencing factors during epidural la-bor analgesia.MethodsThe clinical data of 2 830 parturients who gave birth in Baoji Maternal and Child Health Hospi-tal from January 2021 to December 2021 were retrospectively analyzed.According to whether there was intrapartum feverduring epidural labor analgesia,the patients were divided into fever group(589 cases)and non-fever group(2 241 cases).Chi-square test was used for univariate analysis of clinical data,and the results of univariate analysis with statisticallysignificant difference were analyzed by multivariate Logistic regression.ResultsUnivariate analysis showed that pre-natal use of antibiotics,amniotic fluid contamination,administration of epidural analgesia,use of oxytocin,cervix dila-tion during during epidural analgesia,total labor process,and analgesia time were correlated with fever during epiduralanalgesia(P0.05).Multivariate Logistic regression analysis showed that prenatal use of antibiotics,administration ofepidural analgesia,use of oxytocin,cervix dilation during during epidural analgesia,total labor process,and analgesiatime were independent risk factors for intrapartum fever during epidural analgesia(P0.05).ConclusionThe indepen-dent risk factors for intrapartum fever during epidural labor analgesia were antenatal use of antibiotics,administration ofepidural analgesia,use of oxytocin,cervix dilation during epidural analgesia,total labor process,and analgesia time.【Key words】Parturients;Epidural labor analgesia;During analgesia;Intrapartum fever;Risk factors 论著 doi:10.3969/j.issn.1003-6350.2023.08.011基金项目：陕西省宝鸡市医学科学计划项目(编号：20180167)。第一作者：王伟华(1977)，男，副主任医师，主要研究方向为妇产科、儿科临床麻醉工作与应用型技术研究。通讯作者：滕薇(1973)，女，副主任医师，主要研究方向为妇产科临床诊疗工作，E-mail：。1118Hainan Med J,Apr.2023,Vol.34,No.8海南医学2023年4月第34卷第8期硬膜外镇痛属于分娩时广泛使用的镇痛手段，能够安全、有效地改善宫缩痛，同时使剖宫产率降低、新生儿结局改善1。伴随硬膜外镇痛方式的使用增多，发生镇痛期间产时发热的概率也逐渐增加，受到相关医学工作者的广泛关注2。硬膜外分娩镇痛产时发热指的是孕妇于镇痛期间发生体温身高的症状，虽然目前对体温度数还没有规定，然而大部分文献中均将体温界限设定为产妇口腔温度超过383-4。此类型体温升高往往是轻中等程度，且于镇痛4 h后逐渐升高，产时发热会对产妇及其胎儿产生不良影响，为干扰母婴安全的一种疾病5。目前，硬膜外分娩镇痛产时发热的病因仍然不清楚，其发热机制可能同体温调节中枢、感染、阿片类药物、无菌性炎症、局麻药等有关。明确硬膜外产时发热的相关机制，对有效、安全的防治措施实施及分娩期发热概率降低有利6。基于此，本研究将探讨硬膜外分娩镇痛产妇镇痛期间产时发热状况及其影响因素，现报道如下：1资料与方法1.1一般资料回顾性分析2021年1月至2021年12月于宝鸡市妇幼保健院分娩的2 830例产妇的临床资料。纳入标准：(1)阴道分娩；(2)单胎妊娠；(3)自愿进行硬膜外分娩镇痛；(4)临床资料完整。排除标准：(1)产前出现发热症状；(2)伴有较为严重的脏器疾病；(3)伴有精神疾病；(4)合并椎管畸形或具有剖宫产指征。产妇年龄2335岁，平均(26.273.16)岁；孕周3741周；平均(39.061.09)周。按照产程内硬膜外分娩镇痛后产妇口腔温度进行分组，将589例温度超过38为产时发热组，2 241例小于38为无产时发热组。1.2硬膜外分娩镇痛方法产妇保持侧卧位，在L23间隙实施硬膜外穿刺，同时在头侧置管，第一剂使用盐酸罗哌卡因注射液0.125%(生产商：江苏恒瑞医药股份有限公司；规格：10 mL：100 mg；国药准字：H20060137)同枸橼酸舒芬太尼注射液0.4 g/mL(生产商：宜昌人福药业有限责任公司；规格：1 mL：50 g；国药准字：H20054171)混合的10 mL镇痛液。第一剂使用10 min之后，未见不良反应，就将分娩镇痛泵连接，泵中的药物为盐酸罗哌卡因注射液0.08%同枸橼酸舒芬太尼注射液0.4 g/mL的混合液。将间隔时间、自控量、背景量、锁定时间分别设置为50 min、8 mL、1 mL/h、30 min。1.3观察指标收集所有产妇的病历信息，分析可能引起硬膜外分娩镇痛期间产时发热的因素，主要包括年龄、孕周、高血压、糖尿病、产前焦虑、产前使用抗菌药物、胎膜早破、羊水污染、硬膜外镇痛给药方式(间断或连续)、使用缩宫素、硬膜外镇痛时宫口扩张、阴道检查次数、总产程、镇痛时间等。1.4统计学方法应用SPSS21.0软件进行数据分析。计量资料以均数标准差(x-s)表示，组间比较采用t检验，计数资料比较采用2检验，并将差异有统计学意义的单因素分析结果进行多因素Logistic回归分析。以P0.05为差异有统计学意义。2结果2.1产时发热组和无产时发热组产妇的临床资料比较经单因素分析结果显示，产前抗菌药物使用、羊水污染、硬膜外镇痛给药方式、使用缩宫素、硬膜外镇痛时宫口扩张、总产程、镇痛时间均与硬膜外分娩镇痛期间产时发热有关(P0.05)，见表1。表1产时发热组和无产时发热组产妇的临床资料比较例(%)，x-sTable 1Comparison of clinical data between fever group and non-fever group n(%),x-s临床资料糖尿病高血压产前使用抗菌药物产前焦虑胎膜早破羊水污染硬膜外镇痛给药方式使用缩宫素年龄(岁)孕周(周)硬膜外镇痛时宫口扩张(cm)阴道检查次数(次)总产程(h)镇痛时间(h)分类有无有无是否有无是否是否间断连续是否产时发热组(n=589)75(12.73)514(87.27)67(11.38)522(88.62)151(25.64)438(74.36)134(22.75)455(77.25)209(35.48)380(64.52)214(36.33)375(63.67)304(51.61)285(48.39)358(60.78)231(39.22)26.253.0339.021.212.190.677.041.2411.433.625.020.51无产时发热组(n=2 241)305(13.61)1 936(86.39)278(12.41)1 963(87.59)928(41.41)1 313(58.59)531(23.69)1 710(76.31)726(32.40)1 515(67.60)557(24.85)1 684(75.15)562(25.08)1 679(74.92)386(17.22)1 855(82.78)26.083.1239.131.362.540.836.971.179.673.064.150.342/t值0.3080.46249.1910.2312.01030.999154.638456.6281.2041.91710.7021.23310.82739.176P值0.5790.4970.0010.6300.1560.0010.0010.0010.2290.0560.0010.2180.0010.0011119海南医学2023年4月第34卷第8期Hainan Med J,Apr.2023,Vol.34,No.83讨论分娩期间出现的剧烈疼痛会导致产妇出现诸多神经生理学改变，进而影响母婴代谢及机能变化，最终引发不良妊娠结局7。在确保母婴安全的基础上，探索最理想的分娩镇痛手段在临床上意义重大。现在，临床实践中应用最广泛、最有效的镇痛手段为硬膜外分娩镇痛，它能够灵活调整药物种类，进而使分娩镇痛浓度达到要求。Fusi 等8第一次公布了实施硬膜外分娩镇痛可增加产妇体温，镇痛时间超过4 h且产程长会使产妇体温增加0.58，然而并不会产生明显发热(即体温大于38)，同时也没有引发不良后果，他们表明此类型体温提升同感染没有关系，可能是因为硬膜外镇痛造成的体温调节、血管变化联合作用的结果。之后，国内外诸多文献显示，实施硬膜外分娩镇痛的孕妇于产时出现发热或体温上升的概率显著高于未实施受硬膜外分娩镇痛的孕妇，然而发热的机制及具体原因还不清楚9-11。相关文献表明，出现产时发热的孕妇于硬膜外分娩镇痛之前就保持较高的促炎因子表达，非感染性免疫抑制机制在产时发热中发挥重要作用，预防性使用糖皮质激素能够减少发生产时发热的概率12。同产程进展及妊娠状态有关的胎盘局部炎症和产时发热具有一定相关性，抗菌药物预防性使用不会使胎盘局部炎症和产时发热概率下降13。本研究显示，产前使用抗菌药物为硬膜外分娩镇痛期间产时发热的保护因素，同上述文献的结论有差异，需要后期深入分析。国内相关文献显示，宫口不足3 cm时行分娩镇痛会使产程延长、剖宫产率提升，宫口超过3 cm时行分娩镇痛不会提升剖宫产率，同时不干扰母儿预后，属于最佳时机14。但是，本研究显示，硬膜外分娩镇痛时给药时间较早的产妇出现产时发热的概率明显高于给药时间迟的产妇，且Logistic多因素回归分析显示，硬膜外镇痛给药方式为硬膜外分娩镇痛期间产时发热的独立危险因素。产时发热可出现于各个产程，其发生率同总产程互为因果，产程较长会使产妇消耗巨大，进而激活免疫系统反应，对产时发热的发展进行参与15。但是，产时发热会使产妇的产时管理方式发生变化，使器械助产率、剖宫产率、抗菌药物使用量增加，进而进一步延长总产程16。相关研究显示，行分娩镇痛产妇第二产程的延长会对新生儿临床指标产生消极影响，同时还会使盆脏器脱垂、盆底肌力损伤、压力性尿失禁发生率增加17。本研究显示，产程长为硬膜外分娩镇痛期间产时发热的独立危险因素。本研究还显示，硬膜外镇痛给药方式、使用缩宫素、镇痛时间也是硬膜外分娩镇痛期间产时发热的独立危险因素。间断给药会协助机体发挥散热功能，进而使发热风险降低。缩宫素能够使发挥正向调节发热中枢介质的前列腺素分泌增加，进而通过细胞信号转导引发其上移，最终导致发热。镇痛时间较长会阻滞孕妇的下肢交感神经，影响其排汗系统，使热量散失变慢，进而引发产时发热。综上所述，硬膜外分娩镇痛期间产时发热的独立危险因素为产前使用抗菌药物、硬膜外镇痛给药方式、使用缩宫素、硬膜外镇痛时宫口扩张、总产程、镇痛时间。参考文献1Morton S,Kua J,Mullington CJ.Epidural analgesia,intrapartum hy-perthermia,and neonatal brain injury:a systematic review and me-ta-analysis J.Br JAnaesth,2021,126(2):500-515.2 Fan QS,Lin JG,Xiao XS.Research progress of epidural analgesia inlabor and analgesia for fever during labor J.Progress in Obstetricsand Gynecology,2020,29(8):632-633,637.范杞森,林建国,肖晓山.硬膜外麻醉分娩镇痛产时发热的研究进展J.现代妇产科进展,2020,29(8):632-633,637.3Jiang SM,Shi BM.Research progress of epidural labor analge-sia-related intrapartum fever J.Zhejiang Medicine,2020,42(21):2.2影响硬膜外分娩镇痛期间产时发热的相关因素经多因素Logistic回归分析结果显示，产前使用抗菌药物、硬膜外镇痛给药方式、使用缩宫素、硬膜外镇痛时宫口扩张、总产程、镇痛时间为硬膜外分娩镇痛期间产时发热的独立危险因素(P0.05)，见表2。表2影响硬膜外分娩镇痛期间产时发热相关因素的多因素Logistic回归分析Table 2Multivariate Logistic regression analysis of related factors affecting intrapartum fever during epidural labor analgesia影响因素产前使用抗菌药物羊水污染硬膜外镇痛给药方式使用缩宫素硬膜外镇痛时宫口扩张总产程镇痛时间-0.8420.3440.6940.8190.3410.1630.660SE0.2930.3020.1620.3950.1520.0400.339Wald8.2581.29718.3524.2995.03316.6064.227P值0.0040.2550.0010.0380.0250.0010.040OR(95%CI)0.431(0.2430.765)1.411(0.7802.550)2.002(1.457 2.750)2.268(1.0464.919)1.406(1.0441.894)1.177(1.0881.273)1.935(1.0313.630)1120Hainan Med J,Apr.2023,Vol.34,No.8海南医学2023年4月第34卷第8期2368-2373.江松妙,石碧明.硬膜外分娩镇痛相关产时发热的研究进展J.浙江医学,2020,42(21):2368-2373.4 Li L,Yang Z,Zhang W.Epidural dexmedetomidine 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