剖腹产的麻醉进展(双语).ppt

HailCaesar AnesthesiaforCesareanDelivery剖腹产手术麻醉LawrenceC Tsen M D 翻译 福建医科大学附属协和医院麻醉科规培住院医师石磊 Introduction Associatedwithhighmaternalmortality 二十世纪前 剖腹产由于产妇高死亡率 开展得并不多 untiltheturnofthe20thcentury cesareandeliverynowaccountsforapproximatelyonethirdofallbirthsindevelopedcountries 发达国家三分之一分娩通过剖腹产 Thisincreasehasresultedfromimprovementsinsurgicalandanesthetictechniques diminisheduseofforcepsforextractions fewerbreechandmultiplegestationvaginaldeliveries andgreateruseofrepeatcesareandeliveries 得益于外科及麻醉技术的发展 产钳使用的减少 臀位和复杂分娩的减少 以及二次剖腹产的发展 Introduction TheupdatedPracticeGuidelinesforObstetricalAnesthesiafromtheASATaskForceonObstetricalAnesthesiaobservethatneuraxialtechniques spinal epidural CSE areassociatedwithimprovedmaternalandfetaloutcomeswhencomparedtogeneralanesthesia GA 观察到椎管内麻醉与全麻相比 对于产妇和胎儿有更好的预后 particularlyinthepresenceofhighbodymassindexandairwayissues 特别是高体重指数和气道问题的病人 However specificanestheticmanagementshouldbechosenonacase by caseassessmentofpatient medical 具体麻醉方式必须建立在对病人完全评估之上 anesthetic andobstetricissues Introduction Anestheticparticipationcanalsoreducetheincidence ofcesareandeliveries e g improvingforcep vacuumanalgesia increasingthesuccessofmultiplegestationvaginalbirths reducingfetalheadentrapmentwithintravenousnitroglycerin andimprovingexternalcephalicversion ECV success 麻醉在自然分娩中的参与同样可以减少剖腹产率 比如为使用产钳时提供镇痛 提高复杂分娩的成功率以及改善胎位不正回转术的成功率 Introduction NeuraxialtechniquesimproveECVsuccessbyrelaxingtheabdominalwallmuscles improvingpatientcomfort andallowingamoreconcertedattempt 神经阻滞可以松弛腹壁肌肉 提高病人舒适度 从而提高回转术成功率 anesthesia lidocaine45mgwithfentanyl10 g combinedwithuterinetocolysis nitroglycerin50 giv wait50sec hasbeenassociatedwithahighsuccessrate 83 forexternalcephalicversion ECV 使用45mg利多卡因 10ug芬太尼 同时用50ug硝酸甘油抑制子宫收缩 可以使回转术成功率提高到83 IsthereaPreferredAnestheticTechnique 什么是剖腹产首选麻醉方式 ComplicationsrelatedtoanesthesiastillrepresentthesixthleadingcauseofperipartummaternalmortalityintheUnitedStates 麻醉相关并发症是产妇围生期第六大死亡原因 Notsurprisingly thesedeathsmostcommonlyresultfromfailuresinoxygenationandventilation 通常由氧合或通气失败导致 however theseepisodesarecurrentlybeingwitnessedmorefrequentlyduringextubationandpostoperativerecovery ratherthanwithintubation 通常在拔管及恢复期发现 而不是插管时 IsthereaPreferredAnestheticTechnique Theestimatedcase fatalityriskratioforGAversusneuraxialanesthesiahasundergoneasignificantreduction 全麻与椎管内麻醉的死亡率比例经历了极大的下降 ThischangemostlikelyrepresentstwoTrends 代表了两种趋势 1 areductioninGAuse coupledwithmoresuccessfulmanipulation e g Alternateairwaydevices ofthematernalairway 全麻的减少 和更多气道替代设备的熟练操作 2 agrowingacceptanceofneuraxialtechniqueuseinparturientswithsignificantcomorbidities e g obesity severepreeclampsia hematologicandcardiacdisease 对合并有包括肥胖 严重子痫前期 凝血功能障碍及心脏病产妇使用椎管内麻醉的接受程度 IsthereaPreferredAnestheticTechnique Thecombinedspinalepidural CSE techniquemayofferthemostflexibility 腰硬联合提供更多的灵活度 intermsofreducingtheinitialdrugdose 通过减少初始剂量 allowingforpotentiallylesshypotensionandfasterrecovery 更少的低血压发生率和更快的恢复 aswellasprolongingtheblockadeshouldoperativecomplications 减少手术并发症 orpostoperativepainmanagement 术后镇痛管理 issuesoccur ShouldNewerLocalAnestheticsbeused 新型局麻药的使用 Potentiallyreducedrecoverytimesandtoxicityprofileshavefosteredaninterestinthenewerlocalanesthetics为了减少恢复时间和毒性反应 促使了新型局麻药的发展 ropivacaineandlevobupivacaine 罗哌卡因和左布比卡因 Althoughestablishedtobesafeandacceptableforelectivecesareandeliveries 虽然被证实剖腹产时更安全 thesetwolocalanestheticsmaynotbesignificantlylesscardiotoxicthanbupivacaine 并没有比布比卡因明显减少心脏毒性 Moreover becausethetoxicityofbupivacainedoesnotappeartobeenhancedinpregnancy 因为布比卡因的毒性在怀孕期并没有增加 cardiactoxicityshouldonlyoccurwithunintentionallargeintravasculardoses 心脏毒性只在血管内意外大量注射后发生 ShouldNewerLocalAnestheticsbeused Withthecommonandmoreforgivinguseofchloroprocaine3 andlidocaine2 forconversionofepidurallaboranalgesiatocesareanAnesthesia 随着普鲁卡因和利多卡因作为剖腹产硬膜外麻醉的药物 coupledwithproperdrugadministrationpractices e g attentiontoincrementaldosingpractices totaldoseguidelines andtoxicitysymptoms 如果掌握正确的给药方式 例如注意追加剂量 总剂量的给药方法 掌握判断毒性反应的方法 toxicintravascularlevelsshouldbearare 血管内毒性水平可以降到很低 ShouldLowerDosesofBupivacainebeused 低剂量布比卡因的使用 Thedoseoflocalanestheticshasbeenreducedasamethodtopotentiallyobtainlesshypotension fastermotorrecoveryanddischargetimes andimprovedmaternalsatisfaction 减少局麻药用量可以作为预防低血压 改善恢复时间和产妇满意度的方法 Suchdosereductionsmaybeachievedbyusingspinalversusepiduralanesthesia 通过使用腰麻 aswellaslesstotallocalanesthetic 减少局麻药总用量 withthesechanges reductionsintime costs andcomplicationshavebeenrealized Whenspinalbupivacaineinintermediatetolowdoses 3 9mg areused 当腰麻布比卡因使用中到低剂量即3 9mg theneedforsupplementalmedicationscanbesignificant 可能需要更多追加剂量 andthusacatheterbasedtechnique 以至于需要导管技术比如CSE shouldbeused CanHypotensionbeprevented 避免低血压 Neuraxial inducedhypotension whensevereandsustainedcanimpairuterineandintervillousbloodflowandresultinfetalhypoxia acidosis andneonataldepression 椎管内麻醉后严重并且持续的低血压会影响子宫及绒毛血供 导致胎儿缺血 甚至胎儿窘迫 Leftuterinedisplacementandtreatmentorprophylaxiswithvasopressorshavereducedtheincidenceofhypotensionwithvariablesuccess 子宫左旋或血管加压药可以预防 Preloadingwithcrystalloidhaslimitedeffectsonmitigatinghypotension evenwithlargedoses 即使给予大剂量晶体预充血容量 效果仍然有限 moreeffectiveispreloadingwithcolloids orsimultaneouslygivingrapidcrystalloidorcolloidscoincident co loading withthespinaltechnique 最好预充胶体液或晶胶同时预充 CanHypotensionbeprevented Hypotensionmayalsobereducedwiththeuseofsmallerspinallocalanestheticdoses 低血压同样可以通过较少的腰麻药用量避免 Prophylaxisandtreatmentofmaternalhypotensionwithphenylephrine 去氧肾上腺素 versusincombinationwithephedrineorephedrinealone 合用或单用麻黄素 ismoreeffectiveinimprovingmaternalhemodynamics 更好改善母体血流动力学 andfetalacid basevalues 胎儿酸碱水平 WhatAdjuvantMedicationsshouldbeused 辅助用药的使用 Adjuvantmedicationsexpressanumberofbenefits includingtheabilitytoreducethedoseandsideeffectsoflocalanesthetics 辅助药可以减少局麻药用量和副作用 Neostigmineandclonidine 新斯的明和可乐定 aretwonovelagentsundergoingclinicalinvestigation Inwomenundergoingelectivecesareandelivery neostigmineinspinaldosesupto100 gsignificantlyreducedpost operativepain 显著减少术后疼痛 withnoeffectonfetalheartrateorApgarscores 对胎儿心率 和Apgar评分无影响 WhatAdjuvantMedicationsshouldbeused However inspinaldosesaslittleas6 25 g ahighincidenceofsideeffectsincludingprolongedmotorblockade nausea andvomitinghavebeenobserved 观察到比如延长的运动阻滞 恶心呕吐等副作用发生率较高 Asaconsequence thespinalroutewillmostlikelybeabandoned 因此最好放弃在腰麻中使用 however somepromisehasbeennotedwiththeepiduralroute 可以尝试使用硬膜外路径 WhatAdjuvantMedicationsshouldbeused Clonidine 可乐定 inspinalandepiduraldosesvaryingfrom15 50 gand50 120 g respectively canprolonganalgesiaanddecreaseshivering 无论腰麻或硬膜外 都可以延长镇痛 较少寒战 However mildhypotensionandsedationarenotinfrequentsideeffects 可能出现不常见的轻微低血压和催眠 Currentlyclonidinehasonlyonespecificneuraxialindication intractablecancerpain 只有一种适应证即顽固性癌痛 FDAwarningthat epiduralclonidine 硬膜外可乐定 isnotrecommendedforobstetrical postpartum andperioperativepainmanagement 不建议使用于分娩 产后及围手术期镇痛 WhatAdjuvantMedicationsshouldbeused Preservativefreemorphinesulfate 盐酸吗啡 canprovide17 27hofpost cesareananalgesia 17 27小时的产后镇痛 Intrathecally 蛛网膜下腔给药 acomparisonof0 025 0 05 0 1 0 2 0 3 0 4 and0 5mgdosesobservedthat0 1mgproducedanalgesiacomparabletodosesashighas0 5mg 0 1mg与高达0 5mg的效果无异 Theincidenceofpruritus butnotnauseaandvomiting appeareddoserelated 瘙痒症与剂量相关 但恶心呕吐与剂量不相关 Intheepiduralspace 硬膜外 acomparisonof1 25 2 5 3 75 and5mgdosesobservedthatthequalityofpost cesareananalgesiadidnotimprovebeyond3 75mg 镇痛效果在达到3 75mg后就不再变化 Pruritus nauseaandvomitingdidnotappeardoserelated WhatAdjuvantMedicationsshouldbeused Extended releaseepiduralmorphine 缓释吗啡 商品名Depodur canprovideanalgesiafor48hrswith10and15mgdoses However cautionshouldbeappliedtodosingtheepiduralcatheterwithlocalanestheticimmediatelyaftertheDepodur 硬膜外导管给予缓释吗啡后立刻给予局麻药时应该小心 andevenupto1hourbefore asthemaximumplasmaconcentrationsofmorphinewillbehigher 即使是1小时前给予的吗啡 局麻药会升高吗啡的血浆峰值浓度 DoesaPerfectCocktailExist 最佳药物组合 Themostrecentevidencewouldsuggestthefollowingcombinationsareoptimal ASSOCIATEDANESTHETICCONCERNSDURINGCESAREANDELIVERY 剖宫产麻醉相关问题 AntibioticUseandTiming 抗生素使用 Postpartuminfectionis5to20 foldgreaterinthosepatientsdeliveringbycesareanversusvaginalroutes 剖宫产的产后感染比自然分娩高5 20倍 andremainswithinthetopfivecausesofpregnancy relatedmortality 产后五大死亡原因之一 Thetraditionalpracticeofadministeringantibioticsafterinfantdeliveryandumbilicalcordclampingoriginatedtopreventfetalexposuretoantibiotics 传统的使用方法是胎儿娩出 脐带夹闭之后 为了避免胎儿接触到抗生素 However recentstudiesofantibioticusepriortocesareanskinincision 切皮前 haveobservedsignificantlyfewermaternalinfections 观察到产妇感染的显著减少 withnodifferencesinthefrequencyofneonatalsepsiswork upsorprovensepsiscases 胎儿脓毒血症检验结果无差异 OxytocinandUterotonicAgentUse 缩宫素使用 Thecurrentguidelinesfortheadministrationofoxytocinduringcesareandeliveryarediverse empiric andvague withnonevidence baseddosesof20 40IUbeingadvocated 目前的缩宫素使用并没有循证支持 However adequateuterinecontractions 足够的子宫收缩 duringelectivecesareandeliveriesinnon laboringwomen 未进入产程的孕妇 requireonlysmallloadingdosesofoxytocin 只需要少量的缩宫素负荷量 ED90 0 35IU asimilarlylowloadingdose ED90 2 99IU isrequiredinlaboringwomen 产程中的孕妇 OxytocinandUterotonicAgentUse Consequently aloweroxytocin hasbeenadvocated OxytocinProtocolforCesareanDelivery RuleofThrees 3IUOxytocinIVLoadingDose administeredbyrapidinfusion ratherthanabolus nofasterthan15seconds 3MinuteAssessmentIntervals 3分钟评估间隔 Ifinadequateuterinetone give3IUOxytocinIVrescuedose 3TotalDosesofOxytocin InitialLoad 2RescueDoses 3IUOxytocinIVMaintenanceDose 3IU Lat100mL h upto8hrs 3PharmacologicOptions e g Ergonovine麦角新碱 carboprost卡前列素a