产科麻醉英文版课件

1、Obstetric Anesthesia Physiologic Changes Of Pregnancy Cardiovascular System : cardiac output , heart rate Hematologic System : blood volume increases by up to 45% , red cell volume increases by only 30% physiologic anemia Respiratory System : increase in the respiratory minute volume and work of bre

2、athingGastrointestinal System : risk of incidence of aspirationendotracheal intubation Renal System : GFR rises 50% ; glycosuriaCentral Nervous System :sensitivity to anesthetics.Physiologic Changes Of Pregnancy Changes Of Respiratory System O2 (Consumption 消耗 ) +20 to +50%MV(Minute Ventilation分钟通气量

3、)+50%TV +40%PaO2 +10%PaCO2 -15%HCO3 -15%FRC -20%Placental Transfer Of Anesthetic Drugs Placenta transport : Simple diffusion Facilitated diffusion Active transport PinocytosisReadily cross : low molecular weights, high lipid solubility , non-ionized Approximately 50% of the umbilical venous blood by

4、passes the liver.Narcotic analgesic morphine pethidine fentanyl alfentanil sufentanil General anesthetics propofol 吗啡、哌替啶、芬太尼Morphine Placental transfer is rapidMother: uterus reactiveness orthostatic hypotension nausea vomiting delayed gastric emptyingFetus: respiratory depressionPethidine Most com

5、monly used during labor intramuscular dose : 50 -100 mg Time of IM: before expulsion 1 h or 4 huterine contraction, frequency and intension Fentanyl Alfentanil Sufentanil Placental transfer is rapid Low dose: 10 -25 g fentanyl or 5-10 g sufentanil in subarachnoid space PCEA: low dose of fentanyl and

6、 0.1%-0.3% ropivacaineTramadol Placental transfer No inhibiting uterine contraction No Respiratory depressionDiazepam Readily cross the placenta Half-lives: 48 hours Problems: sedation, hypotonia, cyanosis, impaired metabolic responses to stress. Midazolam Plasma protein binding: 94% Respiratory dep

7、ression: depended on dose 0.075 mg/kg no problem 0.15 mg/kg different degree Droperidol Pregnant woman: 慎用Apgar score Thiopental sodium Neonatus sleep: little Premature and intrauterine embarrass: carefully usingKetamine High doses (greater than 2 mg/kg) may cause low Apgar scores and abnormalities

8、in neonatal muscle toneLabor pains of uterine contractionUterine muscular tension and contraction forceContraindication: psychosis, gestational hypertension syndrome or preeclampsia, metrorrhexisPropofol Recommendation: induction: 2.5 mg/kg maintenance: 2.5-5.0 mg/kg/h Discontinue gravidity onlyN2O

9、Placental transfer is rapid Mothers respiration, circulation and Uterine muscular contraction force 20-30s before of first stage of labor: 50% O2 and 50% N2O, maximumhalothaneSuccinylcholine Cholinesterase: normal doseno placental transfer Dose 300 mg or single dose is larger: still have placental t

10、ransfer Nondepolarizing Muscle Relaxants Onset is quick, maintanence is short and placental transfer is leastAtracurium: 0.3 mg/kgLocal anestheticsFactors:Protein binding: Molecular weightLiposolubility Catabolism in the placentLocal anesthetics Procaine Lidocaine Bupivacaine RopivacaineAnesthesia F

11、or Sesarean Section Choice depends on : the indications for the surgery the degree of urgency maternal status desires of the patientSpinal Anesthesia Hyperbaric bupivacaine Advantages : rapid onset, little risk of local anesthetic toxicity, minimal transfer to the fetus, infrequent failure. Disadvan

12、tages : finite duration hypotension headacheEpidural Anesthesia L 23 or L 12 1.5%2% Lidocaine or 0.5% Ropivacaine emergency cesarean sectionCombined Spinal-Epidural Technique Increased dramatically in popularity Advantages : rapid onset supplemented at any time anesthetic dose sacral nerves block is

13、 sufficientGeneral Anesthesia rapid induction: obviate positive pressure ventilation oppress the cricoid cartilage mainterance: light anesthesia vomiting, backstreaming and aspiration: atropine, 0.5 mg, IM or glycopyrolate, 0.2 mg, IMSupine hypotensive syndrome Incidence: 2%30% Time: after 28 weeks,

14、 specially 3236 weeks Symptoms: hypotension, dizziness, nausea, chest distress, cold sweat, to yawn, pulse rate, pallescenceHigh risk pregnancy Emergency operation : late trimester of pregnancy: hemorrhage gestational hypertension syndrom and eclampsia Selective operation : hypertension cardiac dise

15、ase diabetes multifetation Placenta Previa and Placental Abruption Preanesthtic preparation: blood coagulation function DIC sifting test acute renal failure Principle: general anesthesia: active bleeding, hypovolemic shock, definite blood coagulation disfunction or DIC intraspinal anesthesia: condit

16、ion of mother and fetus is okay Managementdegrees of abruptio placentae. A, Concealed hemorrhage. B, External hemorrhage. C, Complete placental separation. Types of placenta previa. Management of anesthesia Announcements of the induction: difficult airway cricoid cartilage backstreaming and aspirati

17、on Prepare to salvage the blood coagulation disfunction and the hemorrhoea. Prevent the acute renal function failure: urine volume urea nitrogen and creatinine Prevention and cure of DICPregnancy-induced hypertension syndrome Incidence: 10.3% Cause of death: cerebrovascular accident, pneumonedema, l

18、iver necrosis Pathophysiology: systemic arteriola systole, fetus Management: HELLP syndrome cardiac failure cerebral hemorrhage placental abruption blood coagulation disfunction haematolysis hepatic enzyme thrombocytopenia acute renal failureManagement 1 trying stable anesthesia: stress reaction: fe

19、ntanyl avoid to use ketamine SBP: 140150 mmHg, DBP: about 90 mmHg ganglioplegic or nitroglycerin maintain heart, kindey and lung function: treatment of complication: Management 2 basic monitoring: ECG SpO2 NIBP CVP urine volume blood gas analysis prepare to salvage the neonatal asphyxia ICU postoper

20、ation analgesiaMultiple Births pathophysiology: abdominal aorta and inferior vena cava compression; fetal lung maturity; incidence of postpartum hemorrhage. anesthesia: epidural anesthesia management: addition of volume: colloid oxygen, prevention and cure of Supine hypotensive syndrome preparation

21、of resuscitation of newbornNeonatal asphyxia and emergency treatment ASSESSMENT OF THE FETUS AT BIRTH Apgar score is a simple, useful guide - The Apgar scoring system Score * Sign 0 1 2 Heart rate Absent Less than 100/min More than 100/min Respiratory effort Absent Slow, irregular Good, crying Color

22、 Blue, pale Body pink, extre mities blue (acrocyanosis) Completely pink Reflex irritability (response to insertion of a nasal catheter) Absent Grimace Cough, sneeze Muscle tone Limp Some flexion of extremities Active motion Apgar score 1-minute score - degree of asphyxia 5-minute score - prognosis e

23、valuated at 1 and 5 minutes. should not wait until 1 minute has passed before initiating resuscitation. normal: 7-10 mild asphyxia: 4-6 severe asphyxia: 0-3 Resuscitation of newborn A ( Airway) B ( Breathing) C (Circulation) D (Drug) E (Evaluation)Initial resuscitation Incubation: 2731 Position: Suc

24、tioning: mouth and nose Stimulate: Complete it within 20sEvaluation and further treatment Evaluation: according to breath, heart rate and skin colour Normal: stop resuscitation No spontaneously brathing, HR100/min: bag respirator HR80/min: closed cardiac massage; tracheal intubation, medicationBag r

25、espirator Maniphalanx pressurize Tidal volume: 2040ml I : E = 1.5:1 RP: 3040/min first twice: pressure 3040 cmH2O subsequently: pressure 1020 cmH2ORESUSCITATION EQUIPMENTClosed cardiac massage HR: 120/minDepth: 12cmRESUSCITATION DRUGS 30s after the closed cardiac massage, still cant recovery : drug

26、Epinephrine: 0.10.2mg/kg, intratracheal drop inHypovolemia causes umbilical cord was clamped and cut earlier intrauterine asphyxia placental abruption hemorrhage too much: antepartum or intrapartumDetection of Hypovolemia arterial blood pressure and CVP pale skin poor capillary refill extremities are cold pulses are weak or absentTreatm