腰硬联合麻醉下凶险性前置胎盘剖宫产术低血压发生的诱导因素及列线图预测模型的构建

刘伟武; 曾伟兰; 徐秀英; 周树强; 梁妙; 刘丽梅; 陈恒

doi:10.7619/jcmp.20242893

腰硬联合麻醉下凶险性前置胎盘剖宫产术低血压发生的诱导因素及列线图预测模型的构建

广西壮族自治区玉林市妇幼保健院产科, 广西玉林, 537000

基金项目:

广西壮族自治区卫生健康委员会自筹经费科研课题 Z-K20221825

详细信息

中图分类号: R714.2;R614;R319
计量
- 文章访问数: 100
- HTML全文浏览量: 8
- PDF下载量: 7
出版历程
- 收稿日期: 2024-07-09
- 修回日期: 2024-09-17
- 刊出日期: 2024-10-27

Induction factors of hypotension during cesarean section for perilous placenta previa under combined spinal-epidural anesthesia and construction of a nomogram prediction model

Department of Obstetrics, Yulin Maternity and Child Healthcare Hospital of Guangxi Zhuang Autonomous Region, Yulin, Guangxi, 537000

摘要

摘要:
目的
探讨腰硬联合麻醉(CSEA)下凶险性前置胎盘剖宫产术中低血压发生的诱导因素并构建列线图预测模型。
方法
选取玉林市妇幼保健院2020年1月—2023年12月收治的腰硬联合麻醉(CSEA)下凶险性前置胎盘剖宫产术产妇130例作为研究对象，采用自编的一般资料调查表对研究对象基本资料及低血压发生情况进行调查，并依据术中低血压发生情况将其分为低血压组47例和无低血压组83例。对2组一般资料进行单因素分析，采用多因素Logistic回归分析法探讨术中发生低血压的诱导因素。
结果
单因素分析显示, 2组体质量指数、麻醉平面情况、是否为多胎妊娠、术前收缩压情况、手术时间、是否出现Bezold-Jarisch反射比较，差异有统计学意义(P < 0.05)。多因素Logistic回归分析显示，体质量指数≥24 kg/m²、麻醉平面≥T8、多胎妊娠、术前收缩压 < 90 mmHg、手术时间>1.5 h、出现Bezold-Jarisch反射是CSEA下凶险性前置胎盘产妇剖宫产术中发生低血压的独立危险因素(P < 0.05)。构建CSEA下凶险性前置胎盘剖宫产术中低血压发生的诱导因素回归方程: Logit(P)=-23.211+1.079×(体质量指数≥24 kg/m²)+1.101×麻醉平面(≥ T8)+3.193×多胎妊娠+2.214×术前收缩压(< 90 mmHg)+4.606×手术时间(>1.5 h)+2.011×出现Bezold-Jarisch反射。分析发现列线图对于存在术前收缩压 < 90 mmHg人群均有较高区分度及准确度; 对列线图模型进行Bootstrap重复抽样1 000次, 获得校准曲线，计算得到的一致性指数为0.850, 说明该列线图模型具备较好的校准度; 绘制受试者工作特征(ROC)曲线，其曲线下面积为0.896, 95%CI为0.802~0.956, 提示预测效能较好。
结论
体质量指数≥24 kg/m²、麻醉平面≥T8、多胎妊娠、术前收缩压 < 90 mmHg、手术时间>1.5 h、出现Bezold-Jarisch反射是CSEA下凶险性前置胎盘产妇剖宫产术中低血压发生的诱导因素。
- 凶险性前置胎盘 /
- 剖宫产 /
- 腰硬联合麻醉 /
- 低血压 /
- 诱导因素 /
- 预测价值
Abstract:
Objective
To investigate the induction factors of hypotension during cesarean section for perilous placenta previa under combined spinal-epidural anesthesia (CSEA) and to construct a nomogram prediction model.
Methods
A total of 130 parturients who underwent cesarean section for perilous placenta previa under CSEA from January 2020 to December 2023 in Yulin Maternity and Child Healthcare Hospital were selected as study subjects. A self-designed general information questionnaire was used to investigate the basic information and the occurrence of hypotension of the subjects. According to the occurrence of intraoperative hypotension, the patients were divided into hypotension group (47 cases) and non-hypotension group (83 cases). Univariate analysis was performed on the general information of the two groups, and multivariate Logistic regression analysis was used to explore the induction factors of intraoperative hypotension.
Results
Univariate analysis showed that there were statistically significant differences in body mass index, anesthesia level, presence of multiple pregnancy, preoperative systolic blood pressure, operative time, and the occurrence of Bezold-Jarisch reflex between the two groups (P < 0.05). Multivariate Logistic regression analysis revealed that body mass index≥ 24 kg/m², anesthesia level was in the eighth thoracic vertebra(T8) or above, multiple pregnancy, preoperative systolic blood pressure < 90 mmHg, operative time >1.5 h, and the occurrence of Bezold-Jarisch reflex were independent risk factors for hypotension during cesarean section for perilous placenta previa under CSEA (P < 0.05). A regression equation for the induction factors of hypotension during cesarean section for perilous placenta previa under CSEA was constructed: Logit(P)=-23.211+1.079×(body mass index ≥ 24 kg/m²)+1.101×anesthesia level (≥T8)+3.193×multiple pregnancy+2.214×preoperative systolic blood pressure (< 90 mmHg)+4.606×operative time (>1.5 h)+2.011×occurrence of Bezold-Jarisch reflex. The nomogram showed high discrimination and accuracy for patients with preoperative systolic blood pressure < 90 mmHg. After 1, 000 times of Bootstrap resampling for the nomogram model, a calibration curve was obtained, and the consistency index was calculated as 0.850, indicating good calibration of the nomogram model. The receiver operating characteristic (ROC) curve was plotted, with an area under the curve of 0.896 and 95% confidence interval of 0.802 to 0.956, suggesting good predictive performance.
Conclusion
Body mass index ≥24 kg/m², anesthesia level ≥ T8, multiple pregnancy, preoperative systolic blood pressure < 90 mmHg, operative time >1.5 h, and the occurrence of Bezold-Jarisch reflex are induction factors for hypotension during cesarean section for perilous placenta previa under CSEA.
- perilous placenta previa /
- cesarean section /
- combined spinal-epidural anesthesia /
- hypotension /
- induction factors /
- predictive value

HTML全文

图 1 CSEA下凶险性前置胎盘产妇剖宫产术中低血压发生的列线图预测模型

下载: 全尺寸图片幻灯片

图 2 列线图模型内部验证的ROC曲线

下载: 全尺寸图片幻灯片

图 3 列线图预测模型的校准曲线

下载: 全尺寸图片幻灯片

表 1 2组CSEA下凶险性前置胎盘剖宫产产妇一般资料比较(x ±s)[n(%)]

一般资料	分类	低血压组(n=47)	无低血压组(n=83)	χ²/t	P
年龄/岁		28.46±2.31	28.67±2.59	0.461	0.465
孕周/周		39.78±1.52	40.02±1.37	0.922	0.358
体质量指数	< 24 kg/m²	18(38.30)	58(69.88)	12.325	< 0.001
	≥24 kg/m²	29(61.70)	25(30.12)
ASA分级	Ⅰ级	23(48.94)	40(48.19)	0.007	0.935
	Ⅱ级	24(51.06)	43(51.81)
麻醉平面情况	< T8	17(36.17)	55(66.27)	10.999	0.001
	≥T8	30(63.83)	28(33.73)
羊水情况	>500 mL	29(61.70)	53(63.86)	0.060	0.807
	≤500 mL	18(38.30)	30(36.14)
胎儿体质量	>4 kg	14(29.79)	22(26.51)	0.161	0.688
	≤4 kg	33(70.21)	61(73.49)
是否贫血	否	36(76.60)	63(75.90)	0.008	0.929
	是	11(23.40)	20(24.10)
吸烟史	有	1(2.13)	2(2.41)	0.011	0.918
	无	46(97.87)	81(97.59)
饮酒史	有	5(10.64)	8(9.64)	0.033	0.855
	无	42(89.36)	75(90.36)
多胎妊娠	否	38(80.85)	78(93.98)	5.379	0.020
	是	9(19.15)	5(6.02)
合并妊娠期糖尿病	否	38(80.85)	62(74.70)	0.640	0.424
	是	9(19.15)	21(25.30)
术前收缩压情况	≥90 mmHg	18(38.30)	56(67.47)	10.414	0.001
	< 90 mmHg	29(61.70)	27(32.53)
距前次剖宫产时间	< 2年	16(34.04)	26(31.33)	0.101	0.750
	≥2年	31(65.96)	57(68.67)
手术时间	< 1.5 h	19(40.43)	59(71.08)	11.753	< 0.001
	≥1.5 h	28(59.57)	24(28.92)
出现Bezold-Jarisch反射	否	16(34.04)	54(65.06)	11.617	0.001
	是	31(65.96)	29(34.94)
CSEA: 腰硬联合麻醉; ASA: 美国麻醉师协会。

下载: 导出CSV

表 2 变量赋值表

自变量	赋值
体质量指数	<24 kg/m²=0, ≥24 kg/m²=1
麻醉平面情况	< T8=0, ≥T8=1
是否为多胎妊娠	否=0, 是=1
术前收缩压情况	≥90 mmHg=0, < 90 mmHg=1
手术时间	≤1.5 h=0, >1.5 h=1
是否出现Bezold-Jarisch反射	否=0, 是=1

下载: 导出CSV

表 3 CSEA下凶险性前置胎盘产妇剖宫产术中低血压发生的危险因素及Logistic回归模型

变量	分类	β	SE	Wald χ²	P	OR	95%CI
体质量指数	≥24 kg/m²	1.079	0.347	19.083	< 0.001	2.942	1.561~8.211
	< 24 kg/m^2*	—	—	—	—	—	—
麻醉平面情况	≥T8	1.101	0.421	6.840	0.009	3.006	1.982~8.621
	< T8^*	—	—	—	—	—	—
多胎妊娠	是	3.193	1.198	7.109	0.008	24.366	2.330~23.212
	否^*	—	—	—	—	—	—
术前收缩压情况	< 90 mmHg	2.214	0.633	12.217	< 0.001	9.150	2.644~31.660
	≥90 mmHg^*	—	—	—	—	—	—
手术时间	>1.5 h	4.606	1.181	15.200	< 0.001	18.211	3.212~56.211
	≤1.5 h^*	—	—	—	—	—	—
出现Bezold-Jarisch反射	是	2.011	0.621	10.486	< 0.001	8.211	2.801~10.456
	否^*	—	—	—	—	—	—
* 提示与该分类项进行对照。

下载: 导出CSV

参考文献(17)

[1]	ZHENG X X, LI X Q, XU J X, et al. Intelligent recognition algorithm-based color Doppler ultrasound in the treatment of dangerous placenta previa[J]. J Healthc Eng, 2021, 2021: 9886521.
[2]	杨焕程, 陈永露, 唐文艳, 等. 凶险性前置胎盘MRI危险评分系统对剖宫产术中出血量的预测价值[J]. 广东医学, 2022, 43(2): 192-196.
[3]	王毅, 朱彦霏, 叶丰蕾. 髂内动脉球囊阻断术联合大黄敷脐对凶险性前置胎盘剖宫产术产妇分娩结局的影响[J]. 中国妇幼保健, 2022, 37(17): 3134-3137.
[4]	ZHOU Y L, CHEN W, ZHOU S Q, et al. Comparison of different approaches to combined spinal epidural anesthesia (CSEA) under the guidance of ultrasound in cesarean delivery of obese patients: a randomized controlled trial[J]. Eur J Med Res, 2021, 26(1): 106. doi: 10.1186/s40001-021-00577-9
[5]	YU C, GU J, LIAO Z, et al. Prediction of spinal anesthesia-induced hypotension during elective cesarean section: a systematic review of prospective observational studies[J]. Int J Obstet Anesth, 2021, 47: 103175. doi: 10.1016/j.ijoa.2021.103175
[6]	黄锡强, 袁炳林, 凌泉. 连续无创血压监测系统预测腰硬联合麻醉下择期剖宫产术低血压的研究[J]. 中国计划生育和妇产科, 2022, 14(11): 35-39.
[7]	刘伟武, 曾伟兰, 徐敏兰, 等. 腰硬联合麻醉分娩镇痛相关产时发热危险因素模型构建及防范策略[J]. 实用临床医药杂志, 2023, 27(11): 38-42. doi: 10.7619/jcmp.20230040
[8]	中华医学会妇产科学分会产科学组. 前置胎盘的诊断与处理指南(2020)[J]. 中华妇产科杂志, 2020, 55(1): 3-8.
[9]	张栋栋, 王德朋, 翟乃良, 等. 子宫颈周围环扎下子宫下段"断流式"缝合在凶险性前置胎盘剖宫产术中的应用研究[J]. 中国实用妇科与产科杂志, 2021, 37(3): 367-372.
[10]	CAI L, JIANG J J, WANG T T, et al. Effects of combined spinal-epidural anesthesia on anxiety, labor analgesia and motor blocks in women during natural delivery[J]. World J Psychiatry, 2023, 13(11): 838-847.
[11]	刘佳. 个体化预测剖宫产椎管内麻醉发生低血压风险列线图模型的建立及验证[J]. 国际麻醉学与复苏杂志, 2024, 45(1): 65-71.
[12]	KUMAR K, LIN C, SYMONS T, et al. Narrative review on perioperative shivering during Caesarean section under neuraxial anaesthesia[J]. Rom J Anaesth Intensive Care, 2022, 29(1): 41-46.
[13]	YIN H Y, WAN L, HUANG H. Effective dose of prophylactic norepinephrine for preventing hypotension under combined spinal and epidural anesthesia during cesarean section in singleton versus twin pregnancies[J]. Sichuan Da Xue Xue Bao Yi Xue Ban, 2022, 53(5): 880-889.
[14]	陈培, 刘兰, 钟泰迪, 等. 剖宫产蛛网膜下腔阻滞产妇发生低血压的相关因素[J]. 中国现代医生, 2021, 59(7): 128-132.
[15]	陈琴, 祁美武, 邓颖, 等. 脑电双频指数预测剖宫产产妇腰麻后发生低血压的临床价值[J]. 中国性科学, 2022, 31(3): 106-111.
[16]	杜楚楚, 陈伟, 陈永权. 肾上腺素能类药物在剖宫产术患者腰麻后低血压防治中的应用进展[J]. 山东医药, 2022, 62(12): 95-99.
[17]	傅润乔. Bezold-Jarisch反射与临床麻醉[J]. 临床麻醉学杂志, 2023, 39(11): 1202-1206.