摘要

　　目的：

　　1.探讨术中进行综合体温保护对剖宫产产妇体温及其凝血功能的影响。

　　2.为剖宫产术中运用综合体温保护措施来预防低体温及其并发症提供参考依据。

　　方法：

　　1.研究对象选择2016年11月到2017年2月邢台市人民医院椎管内麻醉下行择期剖宫产手术的初产妇82例，单胎，实验组41例，对照组41例。

　　2.研究方法本实验是实验性研究，采用便利抽样方法，按照抛硬币法将观察对象随机分到实验组和对照组。

　　实验组根据引起术中低体温的因素制定综合保温措施（预先调高环境温度，加盖棉被，铺变温毯，使用自制棉袖套、腿套和护肩，输液加温，冲洗液加温等）进行体温保护；对照组入室常规加盖棉被，使用自制棉袖套、腿套和护肩，术中输注（22~24℃℃）室温液体，室温（22~24℃℃）液体冲洗腹腔。

　　观察两组产妇体温、MAP、心率、寒战发生、凝血指标（TT、APTT、TT、FIB、PLT）的改变。采集数据，收集资料，采用SPSS19.0进行统计学分析。

　　结果：

　　1.一般情况比较实验组41人，对照组41人。两组在年龄、身高、体重、入室体温等一般情况上比较，差异无统计学意义（P＞0.05），有可比性。

　　2.两组体温比较组间比较，实验组入室体温与对照组入室体温相比，差异无统计学意义(P>0.05)；实验组切皮时体温和关闭腹腔后体温与对照组相比，差异有统计学意义（P<0.05）。

　　组内比较，实验组手术切皮时和关闭腹腔后体温与入室体温相比，差异无统计学意义（P>0.05）；对照组手术切皮时和关闭腹腔后体温与入室体温相比，差异有统计学意义（P<0.05）。对照组体温降低比实验组体温降低明显，波动幅度更大。

　　3.两组产妇MAP比较组间比较，实验组入室MAP与对照组入室MAP相比，差异无统计学意义(P>0.05)；实验组切皮时MAP和关闭腹腔后MAP与对照组相比，差异有统计学意义（P<0.05）。

　　组内比较，实验组关闭腹腔后MAP与入室MAP相比，差异无统计学意义（P>0.05）；实验组手术切皮时MAP与入室MAP相比，差异有统计学意义（P<0.05）；对照组手术切皮时和关闭腹腔后MAP与入室MAP相比，差异有统计学意义（P<0.05）。对照组MAP比实验组MAP升高明显，波动幅度更大。

　　4.两组产妇心率比较组间比较，实验组入室心率与对照组入室心率相比，差异无统计学意义(P>0.05)；实验组切皮时心率和关闭腹腔后心率与对照组相比，差异有统计学意义（P<0.05）。

　　组内比较，实验组关闭腹腔后心率与入室心率相比，差异无统计学意义（P>0.05）；实验组手术切皮时心率与入室心率相比，差异有统计学意义（P<0.05）；对照组手术切皮时和关闭腹腔后心率与入室心率相比，差异有统计学意义（P<0.05）。对照组心率加快比较明显，波动幅度更大，实验组心率维持相对稳定。

　　5.两组产妇手术中过程及术后寒战发生比较，差异有统计学意义（P<0.05）。

　　6.两组产妇TT、PT、APTT、FIB以及PLT比较组间比较，入室两组产妇TT、PT、APTT、FIB以及PLT相比，差异无统计学意义（P>0.05）。关闭腹腔后两组产妇TT、PT、APTT、FIB以及PLT相比，差异有统计学意义(P<0.05)。

　　组内比较，实验组关闭腹腔后TT、PT、APTT、FIB以及PLT与入室相比，差异无统计学意义（P>0.05）；对照组关闭腹腔后TT、PT、APTT、FIB以及PLT与入室相比，差异有统计学意义(P<0.05)。

　　结论：剖宫产术中进行综合体温保护可以更稳定的维持产妇的生命体征，降低术中术后低体温寒战的发生，预防产妇因低体温造成的凝血功能紊乱。

　　关键词：体温保护，剖宫产，低体温，凝血功能，寒战

ABSTRACT

　　Objective:

　　1. To explore the effect of intraoperative comprehensive body temperature protection on the body temperature and coagulation function of cesarean women.

　　2. Provide theoretical basis for the use of comprehensive body temperature protection to prevent hypothermia and its complications during cesarean section.

　　Method:

　　1. Research object

　　From November 2016 to February 2017, 82 primiparas who underwent elective cesarean delivery under intraspinal anesthesia in Xingtai people's hospital were selected, and the gestational age ranged from 38 weeks to 40 weeks, with one fetus . There were 41 cases in the experimental group and 41 cases in the control group.

　　2. Research methods

　　This experiment is an experimental study, using convenient sampling method. The subjects were randomly divided into experimental group and control group according to coin tossing method.

　　According to the factors causing hypothermia during operation, the experimental group formulated comprehensive thermal protection measures (raising the environmental temperature beforehand, covering the quilt, laying a variable temperature blanket, using self-made cotton sleeve, leg sleeve and shoulder protector, warming blood transfusion and flushing fluid, etc.); the control group entered the room and routinely covered the quilt, using self-made cotton sleeve, shoulder protector and so on. The leg sheath and shoulder protector were infused with room temperature liquid (22 ~24 C)　during operation, and the abdominal cavity was washed with room temperature liquid (22 ~24 C).

　　The changes of body temperature, MAP, heart rate, chills and coagulation indexes (TT, APTT, TT, FIB, PLT) were observed. Data were collected and analyzed by SPSS19.0.

　　Result:

　　1. General situation comparison

　　There were 41 in the experimental group and 41 in the control group. The two groups were compared on the general situation of age, height, weight, admission temperature, intraoperative infusion volume and operation time, and the differences were not statistically significant (P > 0.05), showing comparability.

　　2. Temperature comparison of the two groups

　　There was no statistically significant difference (P>0.05)in the admission temperature between the experimental group and the control group. Compared with the control group, the temperature during skin cutting and after closing the abdominal cavity was statistically significant (P<0.05).

　　In the experimental group,compared with the admission temperature,the temperature during skin cutting and after closing the abdominal cavity was not statistically significant (P>0.05).In the control group, compared with the admission temperature,the temperature during skin cutting and after closing the abdominal cavity was statistically significant (P<0.05). The hypothermia of the control group was more obvious than that of the experimental group.

　　3. Comparison of mean arterial pressure between the two groups

　　There was no statistically significant difference (P>0.05)in the admission MAP between the experimental group and the control group. Compared with the control group, the MAP during skin cutting and after closing the abdominal cavity was statistically significant (P<0.05).

　　In the experimental group,compared with the admission MAP ,the MAP after closing the abdominal cavity was not statistically significant (P>0.05),the MAP during skin cutting was statistically significant (P<0.05).In the control group, compared with the admission MAP,the MAP during skin cutting and after closing the abdominal cavity was statistically significant (P<0.05). Compared with the experimental group, the MAP in the control group increased significantly and fluctuated more significantly.

　　4. Comparison of maternal heart rate between the two groups

　　There was no statistically significant difference (P>0.05)in the admission heart rate between the experimental group and the control group. Compared with the control group, the heart rate during skin cutting and after closing the abdominal cavity was statistically significant (P<0.05).

　　In the experimental group,compared with the admission heart rate, the heart rate after closing the abdominal cavity was not statistically significant (P>0.05),the heart rate during skin cutting was statistically significant (P<0.05).In the control group, compared with the admission heart rate,the heart rate during skin cutting and after closing the abdominal cavity was statistically significant (P<0.05). The heart rate of the control group increased significantly, and the fluctuation range was larger. The heart rate of the experimental group remained relatively stable.

　　5. Comparison of the occurrence of postoperative chills between the two groups showed statistically significant differences (P<0.05).

　　6. Comparison of TT, PT, APTT, FIB and PLT between two groups There was no significant difference in TT, PT, APTT, FIB and PLT between the two groups before operation (P>0.05). Postoperative maternal TT, PT, APTT, FIB and PLT were significantly different between the two groups (P<0.05).

　　In the experimental group, compared with the admission TT, PT, APTT, FIB and PLT, the TT, PT, APTT, FIB and PLT after closing the abdominal cavity was not statistically significant (P>0.05);In the control group, TT, PT, APTT, FIB and PLT after closing the abdominal cavity were significantly different compared with that before operation (P<0.05).

　　Conclusion: Comprehensive body temperature protection during cesar-ean section can maintain the vital signs of puerpera more steadily, reduce the occurrence of hypothermia and chills during and after operation, prevent coagulation disorders caused by hypothermia.

　　Keywords: Body temperature protection, Cesarean section, Hypothermia, Coagulation function, Shivering
 

目 录

　　研究论文 术中综合体温保护对剖宫产产妇体温及凝血功能的影响

　　前言

　　剖宫产术是指妊娠期满28周以后，经腹腔切开子宫取出胎儿及胎盘的手术过程，是处理难产和高危妊娠的有效手段。剖宫产术显着地降低了孕产妇和新生儿的死亡率。随着医疗条件和环境的改善，剖宫产围手术期的各项医疗和护理问题不断被提出，各种研究层出不穷。剖宫产作为手术病人中的一类人群，易发生术中低体温。研究显示，接受椎管内麻醉的剖宫产产妇低体温发生率21-53%[1-2]，寒战发生率可达20-50%[3]。产妇从孕期开始到分娩期会经历较大的生理变化，手术中较易出现生理波动,出现低体温并发症。

　　引起产妇术中低体温的因素主要有以下几点：

　　1.环境因素有研究认为，手术室温度低于23℃是低体温发生的危险因素，高于26℃能够降低低体温的发生，但是会增加手术感染率和医务人员不适感[4]。因此手术室温度一般设定在22~24℃，一方面为了抑制细菌繁殖，另一方面避免温度设定太高，术者出汗，影响手术无菌环境和手术顺利进行。

　　2.麻醉因素剖宫产手术一般选择椎管内麻醉，这种麻醉方式会在一定程度上抑制机体正常的体温调节[5]。

　　3.室温消毒液消毒剖宫产手术消毒范围大，后背和腹部都需要消毒，根据碘伏消毒技术规范，必须擦拭两遍，作用时间1~2分钟才能起到消毒效果，消毒液挥发，产妇体表温度会急剧下降。

　　4.失血失液及输血输液术中产妇失血失液会带走机体热量，同时对产妇输注室温22~24℃℃液体和血液，会更进一步对外周血液进行冷稀释[6]，造成产妇低体温的发生。

　　5.开放腹腔并用室温液体冲洗腹腔术中长时间开放腹腔会造成机体热量散失，用室温液体冲洗腹腔也会造成体腔温度的大量丢失。

　　术中低体温可引发寒战，导致机体凝血功能紊乱，代谢紊乱，影响机体心血管功能，影响组织脏器的功能等。目前很多医院已经意识到围手术期低体温预防的重要性。回顾文献，国内外常采取体核温度监测、预暖、保温、液体加温等单一措施或者联合措施，将手术患者的体温维持在36℃以上，预防低体温，减少低体温对患者造成的不利影响。根据各级医院医疗条件的不同，各家对术中体温保护的措施也不尽相同。闫雨苗[7]等关于术中保温对全身麻醉的影响进行了Meta分析，得出结论：全身麻醉手术患者术中保温有利于维持患者术后正常体温，预防凝血功能的异常，减少低体温引起的并发症。李迎春[8]等关于不同保温措施对剖宫产产妇术中低体温预防效果做了系统评价，得出结论：单纯液体加温、液体加温联合空气加温均可有效预防剖宫产产妇术中低体温的发生。

　　本研究根据术中引起产妇低体温的原因制定了术中综合体温保护措施，意在探讨术中运用综合体温保护措施对产妇术中体温及凝血功能的影响。现从2016年11月到2017年2月来我院就诊，在椎管内麻醉下行剖宫产术的产妇中选择82例，对综合保温措施与常规护理措施在剖宫产手术中的应用进行对比观察，现报道如下：

【由于本篇文章为硕士论文，如需全文请点击底部下载全文链接】

　　材料与方法

　　结果

　　附表

　　讨论

结 论

　　综合体温保护措施应用在剖宫产手术中，能够更好的维持生命体征的平稳，降低低体温寒战的发生，有效预防低体温引起的凝血功能紊乱，在手术室临床护理工作中值得推广应用。

　　参考文献

　　附录

　　综述 剖宫产围手术期低体温及体温保护措施应用的研究进展25

　　致谢

TAG标签： 体温保护     低体温     凝血功