Ringer's Lactate Versus Normal Saline in Urgent Cesarean Delivery in a Resource-Limited Setting: A Pragmatic Clinical Trial.

晶體溶液常用于剖宮產(chǎn)圍術(shù)期的液體管理治療，但幾乎沒有研究指明產(chǎn)科麻醉中晶體溶液到底該如何選擇。因此，我們比較了資源匱乏醫(yī)院急診剖宮產(chǎn)中使用乳酸林格溶液（RL）與0.9%生理鹽水（NS）后產(chǎn)婦和新生兒血PH值和術(shù)后24h內(nèi)酸中毒的患病率。我們猜測，與NS相比，使用RL能減少產(chǎn)婦和新生兒30%的酸中毒發(fā)生率。

本研究是一項實用性兼前瞻性的隨機雙盲臨床對照試驗，收集了2011年9月至2012年5月期間穆拉戈國家轉(zhuǎn)診醫(yī)院產(chǎn)房的產(chǎn)婦相關(guān)信息，最終，共納入500名產(chǎn)婦，隨機分組后NS組252名和RL組248名，并通過檢測術(shù)前和術(shù)后產(chǎn)婦靜脈血氣和胎盤臍動脈血氣情況進行分析。其中，主要的結(jié)局指標(biāo)是產(chǎn)婦的酸中毒發(fā)生率（定義為術(shù)前產(chǎn)婦血氣正常的情況下術(shù)后其靜脈血PH低于7.32或剩余堿低于-3），次要結(jié)局指標(biāo)是產(chǎn)婦術(shù)后24h內(nèi)酸中毒的發(fā)生率，新生兒的血PH值以及剩余堿含量。本研究的臨床試驗注冊號為NCT01585740。

NS組和RL組的產(chǎn)婦酸中毒發(fā)生率分別為38% 和29%（相對危險度[RR]=1.29;95%置信區(qū)間[CI] 1.01-1.66;p=0.04）。產(chǎn)婦術(shù)后靜脈血PH值低于7.32的發(fā)生率中， RL組占19%而NS組占2/3（RR=1.65;95% CI 1.18-2.31;p=0.003）。但兩組間術(shù)后剩余堿低于-3發(fā)生率、術(shù)后產(chǎn)婦24h內(nèi)酸中毒發(fā)生率以及新生兒情況的差異并無統(tǒng)計學(xué)意義。

雖然NS的使用增加了代謝性酸中毒發(fā)生率，但其仍就可能同RL一樣是圍術(shù)期急診剖宮產(chǎn)液體管理治療中一種安全的選擇。

原始文獻摘要

Ayebale E T, Kwizera A, Mijumbi C, et al. Ringer's Lactate Versus Normal Saline in Urgent Cesarean Delivery in a Resource-Limited Setting: A Pragmatic Clinical Trial.[J]. Anesthesia and analgesia, 2017,125(2):533-539. DOI:10.1213/ANE.0000000000002229

BACKGROUND: Crystalloids are used routinely for perioperative fluid management in cesarean delivery. Few studies have determined the crystalloid of choice in obstetric anesthesia. We compared the effects of Ringer's lactate (RL) versus 0.9% normal saline (NS) on maternal and neonatal blood pH and 24-hour postoperative morbidity in urgent cesarean delivery in a low-resource setting. Our hypothesis was that RL would result in 30% less acidosis than NS.

METHODS: This was a pragmatic prospective double-blind randomized controlled trial in the  Mulago National Referral Hospital Labor Ward Theater from September 2011 to May 2012. Five hundred parturients were studied; 252 were randomly assigned to NS and 248 to RL groups. Preoperative and postoperative maternal venous blood gases and  placental umbilical arterial cord blood gases were analyzed. The primary outcome  was incidence of maternal acidosis, as defined by a postoperative drop in venous  pH below 7.32 or reduction in base excess below -3 in a previously normal parturient. Maternal 24-hour postoperative morbidity, neonatal pH, and neonatal base excess were the main secondary outcomes. The study was registered in ClinicalTrials.gov as NCT01585740.

RESULTS: The overall incidence of maternal acidosis was 38% in NS and 29% in RL (relative risk, 1.29; 95% confidence interval, 1.01-1.66; P = .04). Thirty-two percent of parturients in NS experienced a drop in venous pH below 7.32 postoperatively, compared with 19% in  RL (relative risk, 1.65; 95% confidence interval, 1.18-2.31; P = .003). The comparative drop in base excess postoperatively below -3 between the 2 groups was not statistically significant. There were no significant differences in the incidence of maternal 24-hour postoperative morbidity events and neonatal outcomes between the 2 groups.

CONCLUSIONS: NS may be a safe choice for intraoperative fluid therapy in urgent cesarean delivery as RL, albeit with an increased incidence of metabolic acidosis.