高流量鼻导管吸氧在妊娠合并心脏病患者剖宫产中的随机对照研究

doi:10.12122/j.issn.1673-4254.2024.06.04

摘要/Abstract

摘要：

目的探讨高流量鼻导管（HFNC）吸氧在妊娠合并心脏病患者剖宫产中的应用。方法本研究为单中心、单盲、随机临床试验。拟行剖宫产的妊娠合并心脏病患者被随机分为2组：HFNC组接受HFNC疗法（n=27，吸气流量30 L/min，氧浓度40%），传统吸氧（COT）组接受传统氧疗（n=31，通过鼻导管输送，氧流量5L/min）。主要观察指标为母体血氧饱和度下降（SpO₂<94%，持续3 min以上，或PaO₂/F_IO2≤300 mmHg）。母体及新生儿不良事件数据分析中，对于近似高斯分布的连续变量，使用Student的t检验；对于倾斜分布的变量，进行Wilcoxon秩和检验。分类变量采用Fisher的确切检验或卡方检验。结果 HFNC组中有7.4% 的孕妇（n=2/27）出现母体血氧饱和度下降，而COT组中有32.3%的孕妇（n=10/31）出现。在围手术期间，没有任何病例需要气管插管。HFNC组在术后白细胞增多的发生率较高（P<0.05），但没有母体发热及其他与炎症相关的症状。在母体次要结局指标（呼吸支持需求、母体重症监护室入住时间、术后呼吸系统并发症和心血管系统并发症）以及新生儿结局方面，两组之间无显著差异（P>0.05）。结论 HFNC疗法显著降低了妊娠合并心脏病患者围手术期母体血氧饱和度下降的发生率，并且对母体或胎儿的短期临床结果没有不良影响。

关键词: 传统氧疗, 高流量鼻导管吸氧, 母体血氧饱和度下降, 术后白细胞增高, 妊娠合并心脏病

Abstract:

Objective To evaluate the beneficial effects of high-flow nasal cannula (HFNC) oxygen therapy during cesarean section in pregnant women with heart disease. Methods We conducted a single-center, single-blinded randomized trial of HFNC oxygen therapy in pregnant women with heart disease undergoing cesarean section under neuraxial anesthesia. The participants were randomly assigned to receive either HFNC oxygen therapy with inspiratory flow of 30 L/min with 40% FIO₂ (n=27) or conventional oxygen therapy (COT) with oxygen flow rate of 5 L/min via a nasal cannula (n=31). The primary outcome was maternal desaturation (SpO₂<94% lasting more than 3 min or PaO₂/FIO₂≤300 mmHg). Results Maternal desaturation was observed in 7.4% (2/27) of the women in HFNC group and in 32.3% (10/31) in the COT group. None of the cases required tracheal intubation during the perioperative period. The HFNC group had a significantly higher incidence of postoperative leukocytosis (P<0.05) but without pyrexia or other inflammation-related symptoms. There were no significant differences between the two groups in the secondary maternal outcomes (need for respiratory support, maternal ICU admission, postoperative respiratory complications, and cardiovascular complications) or neonatal outcomes (P>0.05). Conclusion In pregnant women with heart disease, HFNC therapy can significantly reduce the rate of maternal desaturation during the perioperative period of cesarean section without adverse effects on short-term maternal or fetal outcomes.

Key words: conventional oxygen therapy, high flow nasal cannula, maternal desaturation, postoperative leukocytosis, pregnancy with heart disease

胡家祺, 张建杏. 高流量鼻导管吸氧在妊娠合并心脏病患者剖宫产中的随机对照研究[J]. 南方医科大学学报, 2024, 44(6): 1040-1047.

Jiaqi HU, Jianxing ZHANG. High-flow nasal oxygen versus conventional oxygen therapy during cesarean section under neuraxial anesthesia in pregnant women with heart disease: a randomized controlled trial[J]. Journal of Southern Medical University, 2024, 44(6): 1040-1047.

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参考文献 41

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Characteristic	COT (n=31)	HFNC (n=27)	P
Age (year)	29.0±0.9	30.4±1.1	0.28
BMI (kg/m²)	24.7±0.4	25.7±0.8	0.29
Gestational age(weeks)	36.7±2.2	35.8±3.0	0.18
Primigravida	14 (45.2%)	10 (37%)	0.53
Primiparity	22 (71%)	17 (63%)	0.52
NYHA functional classification			0.33
I	26 (83.9%)	18 (66.7%)
II	1 (3.2%)	1 (3.7%)
III	4 (12.9%)	6 (22.2%)
IV	0 (0)	2 (7.4%)
mWHO classification			0.82
Missing^#	1 (3.2%)	2 (7.4%)
I	7 (22.6%)	4 (14.8%)
II	3 (9.7%)	2 (7.4%)
II-III	5 (16.1%)	4 (14.8%)
III	8 (25.8%)	5 (18.5%)
IV	7 (22.6%)	10 (37%)
Hemoglobin (115-150 g/L)			0.19
Low	15 (48.4%)	18 (66.7%)
Normal	16 (51.6%)	9 (33.3%)
High	0 (0)	0 (0)
Emergent CS	11 (35.5%)	8 (29.6%)	0.64
Maternal hypertension	2 (6.5%)	3 (11.1%)	0.66
Maternal gestational diabetes mellitus	4 (12.9%)	5 (18.5%)	0.72
Systolic pressure (mmHg)	108.4±1.9	111.6±3.0	0.36
Diastolic pressure (mmHg)	68.4±1.6	66.1±2.3	0.42
Heart rate (beat/min)	81.5±2.4	85.4±2.5	0.28
SpO₂ (%)	98.4±0.2	98.1±0.4	0.47
Oxygen flow rate (L/min)^##			0.64
3	29 (93.5%)	25 (92.6%)
4	2 (6.5%)	2 (7.4%)

Characteristic	COT (n=31)	HFNC (n=27)	P
Age (year)	29.0±0.9	30.4±1.1	0.28
BMI (kg/m²)	24.7±0.4	25.7±0.8	0.29
Gestational age(weeks)	36.7±2.2	35.8±3.0	0.18
Primigravida	14 (45.2%)	10 (37%)	0.53
Primiparity	22 (71%)	17 (63%)	0.52
NYHA functional classification			0.33
I	26 (83.9%)	18 (66.7%)
II	1 (3.2%)	1 (3.7%)
III	4 (12.9%)	6 (22.2%)
IV	0 (0)	2 (7.4%)
mWHO classification			0.82
Missing^#	1 (3.2%)	2 (7.4%)
I	7 (22.6%)	4 (14.8%)
II	3 (9.7%)	2 (7.4%)
II-III	5 (16.1%)	4 (14.8%)
III	8 (25.8%)	5 (18.5%)
IV	7 (22.6%)	10 (37%)
Hemoglobin (115-150 g/L)			0.19
Low	15 (48.4%)	18 (66.7%)
Normal	16 (51.6%)	9 (33.3%)
High	0 (0)	0 (0)
Emergent CS	11 (35.5%)	8 (29.6%)	0.64
Maternal hypertension	2 (6.5%)	3 (11.1%)	0.66
Maternal gestational diabetes mellitus	4 (12.9%)	5 (18.5%)	0.72
Systolic pressure (mmHg)	108.4±1.9	111.6±3.0	0.36
Diastolic pressure (mmHg)	68.4±1.6	66.1±2.3	0.42
Heart rate (beat/min)	81.5±2.4	85.4±2.5	0.28
SpO₂ (%)	98.4±0.2	98.1±0.4	0.47
Oxygen flow rate (L/min)^##			0.64
3	29 (93.5%)	25 (92.6%)
4	2 (6.5%)	2 (7.4%)

Outcomes	COT (n=31)	HFNC (n=27)	P
Level of block (Above T6)	2 (6.5%)	0(0)	0.37
Volume of local anesthetics (0.5% Bupivacaine, mL)	1.84±0.03	1.89±0.03	0.23
Intravenous opioid adjuvant	2 (6.5%)	1 (3.7%)	1.00
Arrhythmia	18 (58.1%)	16 (59.3%)	0.57
Nausea or vomiting	3 (9.7%)	0 (0)	0.24
Shivering	1 (3.2%)	0 (0)	1.00
Treatment of hypotension	9 (29%)	9 (33.3%)	0.78
Furosemide	0 (0)	3 (11.1%)	0.10
Blood loss (mL)	240.3±45.2	247±77.1	0.68
Duration of surgery (min)	69.8±16.3	70.3±19.8	0.91
Reduced respiratory rate^#	15 (48.4%)	16 (59.3%)	0.41
SpO₂≤94%^##	2 (6.5%)	0 (0)	0.49
Oxygen partial pressure increase(T2-T1, mmHg)^###	51.5±37.9	83.7±41.7	<0.01
Oxygen partial pressure increase(T3-T1, mmHg)^###	47.9±48.1	88.5±40.7	<0.01
Maternal desaturation (PaO₂:F_IO2, T2)^###	5 (16.1%)	1 (3.7%)	0.20
Maternal desaturation (PaO₂:F_IO2,T3)^###	10(32.3%)	2(7.4%)	0.02

Outcomes	COT (n=31)	HFNC (n=27)	P
Level of block (Above T6)	2 (6.5%)	0(0)	0.37
Volume of local anesthetics (0.5% Bupivacaine, mL)	1.84±0.03	1.89±0.03	0.23
Intravenous opioid adjuvant	2 (6.5%)	1 (3.7%)	1.00
Arrhythmia	18 (58.1%)	16 (59.3%)	0.57
Nausea or vomiting	3 (9.7%)	0 (0)	0.24
Shivering	1 (3.2%)	0 (0)	1.00
Treatment of hypotension	9 (29%)	9 (33.3%)	0.78
Furosemide	0 (0)	3 (11.1%)	0.10
Blood loss (mL)	240.3±45.2	247±77.1	0.68
Duration of surgery (min)	69.8±16.3	70.3±19.8	0.91
Reduced respiratory rate^#	15 (48.4%)	16 (59.3%)	0.41
SpO₂≤94%^##	2 (6.5%)	0 (0)	0.49
Oxygen partial pressure increase(T2-T1, mmHg)^###	51.5±37.9	83.7±41.7	<0.01
Oxygen partial pressure increase(T3-T1, mmHg)^###	47.9±48.1	88.5±40.7	<0.01
Maternal desaturation (PaO₂:F_IO2, T2)^###	5 (16.1%)	1 (3.7%)	0.20
Maternal desaturation (PaO₂:F_IO2,T3)^###	10(32.3%)	2(7.4%)	0.02

Variables	COT (n=31)	HFNC (n=27)	P
Respiratory complications	1 (3.2%)	2 (7.4%)	0.59
Cardiovascular complications	5 (16.1%)	8 (29.6%)	0.34
Pyrexia	1 (3.2%)	1 (3.7%)	1.00
Pelvic adhesion	8 (25.8%)	10 (37%)	0.40
Postoperative leukocytosis^#	12 (38.7%)	18 (66.7%)	0.04
Need for respiratory support^##	11(35.5%)	13(48.1%)	0.43
Maternal ICU admission	7 (22.6%)	10 (37%)	0.26
Admission time in ICU (h)^###	78.42 (32, 94)	142.43 (94, 253)	0.11
Length of stay (d)	9.5±4.9	10.3±4.4	0.50
Postoperative hospital stay (d)	5.8±2.3	7±3.6	0.16