經(jīng)皮電刺激不同耳穴對剖宮產(chǎn)術(shù)惡心嘔吐發(fā)生率影響的比較

李井柱,劉延莉,王明山,時飛,畢燕琳,馬福國

?

經(jīng)皮電刺激不同耳穴對剖宮產(chǎn)術(shù)惡心嘔吐發(fā)生率影響的比較

李井柱,劉延莉,王明山,時飛,畢燕琳,馬福國

(青島市市立醫(yī)院,青島 266071)

比較經(jīng)皮電刺激耳神門穴與眼點穴對剖宮產(chǎn)產(chǎn)婦惡心及嘔吐發(fā)生率的影響。將160例擇期剖宮產(chǎn)產(chǎn)婦隨機分為經(jīng)皮電刺激耳神門穴組(A組)和經(jīng)皮電刺激耳眼穴組(B組),每組80例。A組產(chǎn)婦入手術(shù)室后經(jīng)皮電刺激耳神門穴,頻率為1.5 Hz,強度由產(chǎn)婦自控,30 min后進行腰-硬聯(lián)合麻醉,術(shù)中持續(xù)刺激至術(shù)后2 h;B組電刺激耳眼穴,操作方法同A組。觀察時間分別為開始麻醉至剖出胎兒(T1)、剖出胎兒至縫合子宮完畢(T2)、探查腹腔至縫合皮膚切口(T3)、硬膜外腔給予嗎啡至術(shù)后2 h(T4)。觀察項目分別為①惡心及嘔吐發(fā)生率,低血壓、低心率發(fā)生率;②胃復(fù)安、縮宮素、麻黃堿、阿托品使用率;③新生兒Apgar評分及出血量。A組較B組在T3、T4時間段的惡心及嘔吐發(fā)生率降低(＜0.05),在T1、T2時間段兩組無差異(＞0.05);A組較B組術(shù)中胃復(fù)安使用率降低(＜0.01);兩組低血壓、低心率發(fā)生率、縮宮素、麻黃堿、阿托品使用率,術(shù)中出血量及新生兒Apgar評分無差異(＞0.05)。經(jīng)皮電刺激耳神門穴較眼穴具有更為明顯的抗惡心嘔吐作用。

針刺療法;耳針;經(jīng)皮電刺激;剖宮產(chǎn)術(shù);手術(shù)后并發(fā)癥

剖宮產(chǎn)手術(shù)常在腰-硬聯(lián)合麻醉下進行,圍術(shù)期易發(fā)生惡心嘔吐,不僅給產(chǎn)婦帶來痛苦也有礙于手術(shù)的順利進行,幾乎所有抗嘔吐藥物均存在一定副反應(yīng),是否進入乳汁尚未明確,對新生兒的安全構(gòu)成潛在威脅,如何安全有效地防治惡心嘔吐是剖宮產(chǎn)麻醉的難點問題之一[1]。有研究報道,耳穴刺激用于經(jīng)腹膽囊切除術(shù)患者,使術(shù)后嘔吐發(fā)生率顯著降低[2],但對于不同耳穴刺激對剖宮產(chǎn)產(chǎn)婦惡心及嘔吐發(fā)生率影響如何,國內(nèi)外少見報道。筆者通過比較經(jīng)皮電刺激耳神門穴與眼穴對剖宮產(chǎn)產(chǎn)婦惡心及嘔吐發(fā)生率的影響,初步探討其機理,旨在為經(jīng)皮電刺激耳神門穴的臨床應(yīng)用提供參考。

1 資料與方法

1.1 研究對象及分組

經(jīng)醫(yī)院倫理學(xué)委員會批準并與產(chǎn)婦簽訂知情同意書,選擇擇期剖宮產(chǎn)產(chǎn)婦160例,單胎初產(chǎn),ASAⅠ級。隨機分為經(jīng)皮耳神門穴電刺激組(A組)及經(jīng)皮耳眼穴電刺激組(B組),每組80例。所有患者均排除產(chǎn)科合并癥、腹部手術(shù)史、長期服用安定類藥物史、神經(jīng)病及精神病病史、頭痛腰痛等疼痛病史、腰-硬聯(lián)合麻醉禁忌證。

1.2 刺激與麻醉方法

A組產(chǎn)婦入室后,取耳神門穴,連接微電流刺激儀主機(Sun-Sleep-Stim SCS、Ansliip Medical Technology Group,America)頻率為1.5 Hz,雙極性非對稱連續(xù)長方波,強度由產(chǎn)婦自己掌握,以刺激后出現(xiàn)酸、麻、脹、重,略感疼痛為原則。監(jiān)測SPO2、無創(chuàng)血壓、心電圖,面罩吸氧,開放上肢靜脈,刺激30 min后經(jīng)L3-4行腰-硬聯(lián)合麻醉,控制無痛平面至T6。以15 mLkg－1h－1速度靜脈滴注復(fù)方氯化鈉與羥乙基淀粉1:1混合液。若MAP下降大于麻醉前25%則靜脈注射麻黃堿10 mg,心率下降低于55 bpm則靜脈注射阿托品0.5 mg,宮縮不良者靜脈滴注縮宮素10m。持續(xù)刺激至術(shù)后2 h。術(shù)畢,硬膜外注射嗎啡2 mg(生理鹽水稀釋至5 mL)。B組采用相同的方法刺激耳眼穴。兩組產(chǎn)婦均不使用鎮(zhèn)靜鎮(zhèn)痛劑,如發(fā)生惡心嘔吐則注射胃復(fù)安10 mg。穴位定位見圖1。

圖1 耳神門穴與眼點穴的定位

1.3 觀察指標

觀察時間分別為麻醉開始至胎兒剖出(T1)、胎兒剖出至子宮縫合完畢(T2)、探查腹腔至縫合皮膚切口(T3)、硬膜外腔給予嗎啡至術(shù)后2 h(T4)。觀察項目分別為①各時間段惡心及嘔吐發(fā)生率(嘔吐一定惡心,但惡心未必嘔吐),低血壓低心率發(fā)生率(MAP下降大于麻醉前25%為低血壓、心率下降低于55 bpm為低心率);②胃復(fù)安、縮宮素、麻黃堿、阿托品使用率(每個產(chǎn)婦只統(tǒng)計1次);③新生兒1、5 minApgar評分,術(shù)中出血量及其他相關(guān)不良反應(yīng)。

1.4 統(tǒng)計學(xué)方法

用SPSS17.0統(tǒng)計學(xué)軟件進行統(tǒng)計學(xué)處理,數(shù)據(jù)用均數(shù)±標準差表示,計量資料采用方差分析,計數(shù)資料采用卡方檢驗。以＜0.05表示差異有統(tǒng)計學(xué)意義。

2 結(jié)果

兩組產(chǎn)婦基礎(chǔ)資料(年齡、體重、身高、孕周)比較差異無統(tǒng)計學(xué)意義(＞0.05)。由表1可見,A組在T3、T4時間段的惡心及嘔吐發(fā)生率較B組低(c2=11.815、9.928、5.636、5.000,＜0.05),在T1、T2時間段兩組比較差異無統(tǒng)計學(xué)意義(＞0.05)。由表2可見,兩組產(chǎn)婦低血壓、低心率發(fā)生率比較差異無統(tǒng)計學(xué)意義(＞0.05)。由表3可見,A組胃復(fù)安使用率較B組低(c2=20.050,＜0.01),兩組產(chǎn)婦縮宮素、麻黃堿、阿托品使用率,術(shù)中出血量及新生兒1、5 min’Apgar評分比較差異均無統(tǒng)計學(xué)意義(＞0.05)。

3 討論

中醫(yī)學(xué)認為,位于耳窩三角頂點的神門穴具有明顯的抗痛、抗焦慮、催眠、抗嘔吐、降血壓、抗感染等作用。Sahmeddini等[2]針刺耳穴,將經(jīng)腹膽囊切除術(shù)后24 h嘔吐發(fā)生率降低為零(同期對照組為66%)而無任何副反應(yīng);Kim等[3]針刺耳穴,將經(jīng)腹子宮切除術(shù)后12 h嘔吐發(fā)生率降低為30%(同期對照組為66%);徐韶怡等[4]用耳穴針刺貼壓防治婦科術(shù)后惡心嘔吐取得了良好的療效;Bi HD[5]施耳穴貼壓治療化療后嘔吐有較好的療效。經(jīng)皮電刺激耳神門穴無創(chuàng)方便,患者主動參與控制,符合現(xiàn)代醫(yī)療綠色環(huán)保的要求,將電刺激耳神門穴用于防治剖宮產(chǎn)圍術(shù)期的惡心嘔吐值得深入探討。

惡心嘔吐是腰-硬聯(lián)合麻醉下剖宮產(chǎn)術(shù)常見的并發(fā)癥。本研究為探討經(jīng)皮電刺激耳神門穴防治惡心嘔吐的機理,根據(jù)剖宮產(chǎn)術(shù)惡心嘔吐發(fā)生原因?qū)⑵蕦m產(chǎn)術(shù)分為4個時間段,①從開始麻醉至剖出胎兒,此時間段交感神經(jīng)迅速阻滯,相應(yīng)區(qū)域血管擴張,產(chǎn)婦常發(fā)生仰臥位低血壓,血壓驟降,腦供血驟減,缺氧興奮惡心嘔吐中樞是主要原因[6];②從剖出胎兒至縫合子宮完畢,此時間段產(chǎn)婦情況相對平穩(wěn),惡心嘔吐發(fā)生較少;③從探查腹腔至縫合皮膚切口,此時間段探查牽拉腹腔臟器,迷走神經(jīng)功能亢進,內(nèi)臟神經(jīng)傳入的沖動刺激嘔吐中樞引起的反射性惡心嘔吐是主要原因;④硬膜外腔給予嗎啡后,此時間段嗎啡通過興奮嘔吐中樞化學(xué)觸發(fā)帶阿片受體,誘發(fā)中樞性惡心嘔吐是主要原因。

本研究顯示經(jīng)皮電刺激耳神門穴較眼穴更為明顯地降低剖宮產(chǎn)腹腔探查后與硬膜外注射嗎啡后惡心及嘔吐的發(fā)生率,其機制可能是,①神門穴處分布著豐富的迷走神經(jīng),耳穴刺激可能通過外周機制調(diào)控迷走神經(jīng)張力,減少迷走神經(jīng)沖動的傳入,減少反射性嘔吐的發(fā)生;②電刺激耳神門穴可能直接抑制嘔吐中樞,減少嗎啡引起的中樞性嘔吐;③刺激耳神門穴可能對低血壓缺氧興奮嘔吐中樞的機制作用不明顯,因而無法降低低血壓缺氧引起惡心及嘔吐發(fā)生率。對于刺激耳穴產(chǎn)生的鎮(zhèn)靜鎮(zhèn)痛效應(yīng)[7-11]是否參與了抗惡心嘔吐機制的調(diào)控,本研究無法提供證據(jù)。

表1 兩組產(chǎn)婦不同時間段惡心、嘔吐發(fā)生率比較 [n(%)]

注:與B組比較1)＜0.05

表2 兩組產(chǎn)婦不同時間段低血壓、低心率發(fā)生率比較 [n(%)]

表3 兩組產(chǎn)婦胃復(fù)安、縮宮素、麻黃堿、阿托品使用率、術(shù)中出血量及新生兒1、5 minApgar評分比較 (±s)

注:與B組比較1)＜0.01

本研究經(jīng)皮耳神門穴電刺激組刺激30 min后,刺激的疊加效應(yīng)在神門穴上形成紫紅色的“刺激斑”,局部產(chǎn)生酸、麻、脹、重、略微熱痛、輕度頭暈的感覺,總體感覺愉悅,持續(xù)時間較長,胃復(fù)安使用率明顯減少,未見其他不良反應(yīng),新生兒Apgar評分亦無差異,說明經(jīng)皮耳神門穴電刺激防治惡心嘔吐具有較高的安全性。

本研究結(jié)果表明經(jīng)皮耳神門穴電刺激對降低剖宮產(chǎn)術(shù)中術(shù)后惡心及嘔吐發(fā)生率具有特異性,但其具體機理需要進一步探討。

[1] 鄧碩曾,周橋靈,周俊.剖宮產(chǎn)的麻醉與安全[J].臨床麻醉學(xué)雜志, 2011,27(7):714-715.

[2] Sahmeddini MA, Fazelzadeh A. Does auricular acupuncture reduce postoperative vomiting after cholecystectomy?[J]. Altern Complement Med, 2008,14(10):1275-1279.

[3] Kim Y, Kim CW, Kim KS. Clinical observations on post- operative vomiting treated by auricular acupun- cture[J]. Am J Chin Med, 2003,31(3):475-480.

[4] 徐韶怡,鄭士立,王慶來,等.耳穴針刺貼壓對婦科術(shù)后惡心嘔吐的抑制作用療效觀察[J].針刺研究,2009,32(2):143-144.

[5] Bi HD. Observation on the Effect of auricular point sticking for vomiting induced by chemotherapy[J]. J Acupunct Tuina Sci, 2011, 9(6):367-369.

[6] 莊心良,曾因明,陳伯奕.現(xiàn)代麻醉學(xué)[M].第3版,北京:人民衛(wèi)生出版社,2003:1088.

[7] Roberts GW, Bekker TB, Carlsen HH,. Postoperative nausea and vomiting are strongly influenced by postoperative opioid use in a dose-related manner[J]. Anesth Analg, 2005,101 (5):1343-1348.

[8] Wang SM, Punjala M, Weiss D,. Acupuncture as an adjunct for sedation during lithotripsy[J]. J Altern Complement Med, 2007,13(2):241-246.

[9] Karst M,Winterhalter M, Munte S,. Auricular acupuncture for dental anxiety: a randomized controlled trial[J]. Anesth Analg, 2007,104(2): 295-300.

[10] Wetzel B, Pavlovic D, Kuse R,. The effect of auricular acupuncture on fentanyl requirement during hip arthroplasty: a randomized controlled trial[J]. Clin J Pain, 2011,27(3):262-267.

[11] 張惠欣.針刺結(jié)合耳穴貼壓治療經(jīng)行乳房脹痛92例[J].上海針灸雜志,2002,21(2):24.

Comparison of the Effects of Transcutaneous Electrical Stimulation of Different Auricular Points on Cesarean Section- induced Nausea and Vomiting Incidence

-,-,-,,-,-.

,266071,

To compare the effects of transcutaneous electrical stimulation of auricular points Shenmen and Eye on nausea and vomiting incidence in parturients undergoing cesarean section.One hundred and sixty parturients for elective cesarean section were randomly allocated to a transcutaneous electrical stimulation of auricular point Shenmen group (group A) and a transcutaneous electrical stimulation of auricular point Eye group (group B), 80 cases each. In group A parturients after being sent into the operating room, transcutaneous electrical stimulation of auricular point Shenmen was performed at a frequency of 1.5 Hz and an intensity controlled by the parturient, lumbar epidural anesthesia was carried out 30 min later and the stimulation continued during the operation and until 2 hrs after the end of it. In group A, electrical stimulation of auricular point Eye was performed and the procedure was the same as in group A. The observation times were from the beginning of anesthesia to the delivery of a fetus through caesarean incision (T1), from the delivery of a fetus to the completion of uterine suture (T2), from abdominal exploration to dermal incision suture (T3) and from peridural administration of morphine to 2 hrs after the operation (T4). The observation items were 1) nausea, vomiting, hypotension and low heart rate incidences; 2) the usage rates of metoclopramide, oxytocin, ephedrine and atropine; 3) the Apgar score for newborns and amount of bleeding.Nausea and vomiting incidence was lower during T3 and T4 periods in group A than in group B (＜0.05). There was no statistically significant difference during T1 and T2 periods between the two groups (＞0.05). The usage rate of metoclopramide was lower in group A than in group B (＜0.01). There were no statistically significant differences in low heart rate incidence and the usage rates of oxytocin, ephedrine and atropine between the two groups (＞0.05).Transcutaneous electrical stimulation of auricular point Shenmen has a more marked relieving effect on nausea and vomiting.

Acupuncture therapy; Ear acupuncture; Transcutaneous electrical stimulation; Cesarean section; Postoperative complications

R246.3

A

10.3969/j.issn.1005-0957.2012.09.656

1005-0957(2012)09-0656-03

李井柱(1971 - ),男,主治醫(yī)生

王明山(1963 - ),男,主任醫(yī)師,碩士生導(dǎo)師,E-mail:liazhe 2000@163.com

2011-11-20