急诊剖宫产的麻醉选择和术中处理.ppt

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1、急诊剖宫产的麻醉选择和术中处理 Still waters run deep.流静水深流静水深,人静心深人静心深 Where there is life,there is hope。有生命必有希望。有生命必有希望DefinitionoAbdominaldeliveryasurgicalprocedurethatpermitsdeliveryoftheinfantthroughincisionsintheabdominalanduterinewall.CesareanSectionoCaedereSecooPompiliusII730BConotwidelyuseduntilthe1920sInd

2、icationsforCesareanSectionoRepeatnSchedulednFailedattemptatvaginaldeliveryoDystociaoAbnormalpresentationnTransverselienBreechnMultiplegestationoFetalstress/distressoDeterioratingmaternalmedicalillnessnPreeclampsianHeartdiseasenPulmonarydiseaseoHemorrhagenPlacentaprevianPlacentalabruptionCesareanSect

3、ion60%unplannedoMoreextensiveperipartummonitoringoLowerthresholdforsurgicalinterventionWhatisanemergencyCaesareansection?-Category1&2GradeDefinition(at time of decision to operate)Category1ImmediatethreattolifeofwomanorfetusCategory2Maternalorfetalcompromise,notimmediatelylife-threateningCategory3Ne

4、edingearlydeliverybutnomaternalorfetalcompromiseCategory4AtatimetosuitthewomanandmaternityteamCategory1IndicationoPlacentalabruptionouterineruptureocordprolapseoActivelybleedingplacentapraeviaoIntrapartumhemorrhageoPresumedfetalcompromisewithseverelyabnormalCTGand/orseverefetalacidosisThe30-minuteru

5、leoamaximumdecision-to-deliverytimeof30minforCategory1situationAssociationofAnaesthetistsofGreatBritainandIrelandandObstetricAnaesthesistsAssociation.Guidelinesforobstetricanaesthesiaservices;2005.HillemannsP,StraussA,HasbargenU,etal.Crashemergencycesareansection:decision-to-deliveryintervalunder30m

6、inanditseffectonApgarandumbilicalarterypH.ArchGynecolObstet2005;273:161165.oanaesthetistinformeddeliveryPerianestheticEvaluationoAdirectedhistoryandphysicalexaminationoplateletcountoAnintrapartumbloodtypeandscreenforallparturientsreducesmaternalcomplicationsoPerianestheticrecordingofthefetalheartrat

7、ereducesfetalandneonatalcomplicationsAdirectedhistoryandphysicalexaminationoMaternalhealthandanesthetichistoryoRelevantobstetrichistoryoAirwayandheartandlungexaminationoBaselinebloodpressureoBackexaminationwhenneuraxialanesthesiaisplannedorplacedPlateletcountoAroutineintrapartumplateletcountdoesnotr

8、educematernalanestheticcomplicationsoSuspectedpreeclampsiaorcoagulopathyoEclamptic-plt80*109.l-1MoodleyJ,JjuukoG,RoutC.EpiduralcomparedwithgeneralanaesthesiaforCaesareandeliveryinconsciouswomenwitheclampsia.BritishJournalofObstetricsandGynaecology2001;108:37882.AspirationProphylaxisoclearliquidsupto

9、2hbeforeinductionofanesthesiaoAfastingperiodforsolids68h(fatcontent?)oFurtherrestrictionnmorbidobesity,diabetes,difficultairwaynnonreassuringfetalheartratepatternoAntacids,H2ReceptorAntagonists,andMetoclopramidereducesmaternalcomplicationsPerianestheticMaternalPositionAortocavalcompression3mechanism

10、suteroplacentalperfusionpvenousreturnC.O.andBPpObstructionofuterinevenousdrainageuterinevenouspressureanduterinearteryperfusionpressurepCompressionofaortaorcommoniliacarteriesuterinearteryperfusionpressurePerianestheticMaternalPositionoAvoidaortocavalcompressionKinsellaSM.Editorial.Lateraltiltforpre

11、gnantwomen:why15degrees?Anaesthesia2003;58:8357.ChoicesofAnesthesiaoGeneralanesthesiaoRegionalanesthesiaoLocalanesthesiaChoicesofAnesthesia depends onothe indications for the surgeryothe degree of urgencyomaternal andfetus statusodesires of the patientSafest +most expedientmidwifeanesthetistobstetri

12、cianRegionalanesthesiao85%emergencyCaesareansectiono3%RegionalanesthesiarequireconversiontoGARegionalanesthesiaoEpiduralanesthesiaospinalanesthesiaoCombinedSpinal/Epidural(CSE)EpiduralpAsfastasGApTitrateddosingandsloweronsetriskofseverehypotensionandreduceduteroplacentalperfusionpDurationofsurgeryno

13、tanissuepLessintensemotorblockadepLowerextremity“musclepump”mayremainintactincidenceofthromboembolicdiseaseEpiduralpRiskofsystemiclocaltoxicitypGreaterplacentaltransferofdrugthanwithspinalBUTdoesnotaffectneonatalApgar scoreandoflittleclinicalsignificancewhenappropriatedosesusedpRiskofhighspinalEpidu

14、raloThespeedofonsetoThechoiceoflocalanestheticoPossibleadjuvantsEpiduralo0.5%bupivacaineo0.75%ropivacaineo0.5%levobupivacaineo2-chloroprocaineolidocaine1.8%lidocaine,0.76%bicarbonateand1:200000epinephrineAllamJ.Anaesthesia2008;63:243249.Epiduralfailureo24%failtoachieveapain-freeoperationKinsellaSM.A

15、prospectiveauditofregionalanaesthesiafailurein5080caesareansections.Anaesthesia2008;63:822832.oConversiontoSpinalanesthesia?nunpredictablehigh-spinalblocksnarelativecontraindicationtogivespinalanaesthesiafollowingepiduralanalgesiainlabourothedoseoflocalanesthesiaby2030%anduseadditionofopioidsoanorma

16、ldoseoflocalanesthesiaafter30minsincethelastdoseofepiduralwithnodocumentedblockSpinalpSimplepRapidonsetpDenseblockadepNegligiblematernalriskofsystemiclocaltoxicitypMinimaltransferofdrugtoinfantpNegligibleriskoflocalanestheticdepressionofinfantSpinalpRapidonsetofsympatheticblockadeabrupt,severehypote

17、nsionpLimiteddurationSpinalpBupivacaine(isobaric/hyperbaric)plevobupivacaine,ropivacainelessmotorblockade&toxicitypadditionofopioid(Morphine,fentanylorsufentanil)nReducetheneededdoseoflocalanaesthesianshortenthetimetoreadinessforsurgerynenhancesblockadeofvisceralpainnpostoperativeanalgesiaSpinaloPeo

18、loadcoloadoApplicationofmonitorsoSupplementaloxygenoLeftuterinedisplacementoAggressivetreatmentofhypotensionAggressivetreatmentofhypotensionAggressivetreatmentofhypotensionpExaggeratedLUDpIVfluidspEphedrineand/orphenylephrineReflexbradycardia(HR45-50bpm)anticholinergicagentCombinedSpinalEpidural(CSE

19、)Initiallydescribedin1981(epiduralcatheteratL1-2andspinalatL3-4)CSEoRapidonsetanddensityofspinalanesthesiacombinedwithversatilityofepiduralanesthesiaoLow-dosespinalnreducetheincidencesofcardiovascularinstabilitynespeciallyusefulinhighriskcardiacpatientsCSEpInabilitytotestepiduralcatheterp18%rateoffa

20、ilurepextratimeconsumptionGeneralanesthesiao15%ofCSwasperformedundergeneralanesthesiainUSoMajorityofCSweredoneunderurgentoremergentsituationsIndicationsforGAoFetaldistressoSignificantcoagulopathyoAcutematernalhypovolemiaandHomodynamicinstabilityoSepsisorlocalskininfectionofailedregionalanesthesiaoMa

21、ternalrefusalofregionalanesthesiaGAoRapidonsetoControlledairwayandventilationohandsarefreeforfluidmanagementandhemodynamicscontrolincasesofmajorbleedingoAlmostneverfailsoMinimalcooperationneededfromthepatientGAp17XhigheranesthesiarelatedmortalitycomparedtoregionalanesthesiapRiskofdifficult/failedint

22、ubation10Xhigherthaninnon-obstetricpopulationpRiskofpulmunaryaspirationpContributetouterinerelaxation/atonypExtratimeneededatendofproceduretowakeupthethepatientpUsuallyfasteronsetofpostoperativepainpRiskofmalignanthyperthermiapRiskofintaoperativeawarenesspExposureoffetustodepressanteffectofGApMoreco

23、stlyMostimportantcausesofmortalityduetoGAoInabilitytointubateoInabilitytoventilateoAspirationpneumonitisSuggestedTechniqueforCesareanSectionoThepatientisplacedsupinewithawedgeundertherighthipforleftuterinedisplacement.oPreoxygenation100%O235minoThepatientispreparedanddrapedforsurgeryoarapid-sequence

24、inductionwithcricoidpressurepropofol,2mg/kg(orthiopental4mg/kg)succinylcholine,1.5mg/kgKetamine,1mg/kg,isusedinsteadofthiopentalinhypovolemicorasthmaticpatients.SuggestedTechniqueforCesareanSectionoSurgeryisbegunonlyafterproperplacementoftheendotrachealtubeisconfirmedbycapnography.oExcessivehyperven

25、tilation(PaCO225mmHg)shouldbeavoidedbecauseitcanreduceuterinebloodflowandhasbeenassociatedwithfetalacidosis.SuggestedTechniqueforCesareanSectiono50%N2Oinoxygenwithupto0.75MACofalowconcentrationofavolatileagentisusedformaintenanceoAmusclerelaxantofintermediateduration(mivacurium,atracurium,cisatracur

26、ium,orrocuronium)isusedforrelaxationSuggestedTechniqueforCesareanSectionoAfterdelivered,2030Uofoxytocinisaddedtoeachliterofintravenousfluid.oN2Oconcentrationmaythenbeincreasedto70%and/oradditionalintravenousagents,suchasadditionalpropofol,anopioidorbenzodiazepine,canbegiventoensureamnesiaSuggestedTe

27、chniqueforCesareanSectionoIftheuterusdoesnotcontractreadily,anopioidshouldbegiven,andthehalogenatedagentshouldbediscontinuedoMethylergonovine(Methergine),0.2mgintramuscularly,mayalsobegivenbutcanincreasearterialbloodpressureo15-MethylprostaglandinF2(Hemabate),0.25mgintramuscularly,mayalsobeusedSugge

28、stedTechniqueforCesareanSectionoAnattempttoaspirategastriccontentsmaybemadeviaanoralgastrictubetodecreasethelikelihoodofpulmonaryaspirationonemergenceoAttheendofsurgery,musclerelaxantsarecompletelyreversed,thegastrictube(ifplaced)isremoved,andthepatientisextubatedwhileawaketoreducetheriskofaspiratio

29、n.ObstetricHemorrhagicEmergenciesObstetricHemorrhagicEmergenciesoLarge-boreintravenouscathetersoFluidwarmeroForced-airbodywarmeroAvailabilityofbloodbankresourcesoEquipmentforinfusingintravenousfluidsandbloodproductsrapidlySuggestedResourcesforAirwayManagementduringInitialProvisionofNeuraxialAnesthes

30、iaoLaryngoscopeandassortedbladesoEndotrachealtubes,withstyletsoOxygensourceoSuctionsourcewithtubingandcathetersoSelf-inflatingbagandmaskforpositive-pressureventilationoMedicationsforbloodpressuresupport,musclerelaxation,andhypnosisoQualitativecarbondioxidedetectoroPulseoximeterSuggestedContentsofaPo

31、rtableStorageUnitforDifficultAirwayManagementforCesareanDeliveryRoomsoRigidlaryngoscopebladesofalternatedesignandsizefromthoseroutinelyusedoLaryngealmaskairwayoEndotrachealtubesofassortedsizeoEndotrachealtubeguidesoRetrogradeintubationequipmentoAtleastonedevicesuitableforemergencynonsurgicalairwayve

32、ntilationoFiberopticintubationequipmentoEquipmentsuitableforemergencysurgicalairwayaccess(e.g.,cricothyrotomy)oAnexhaledcarbondioxidedetectoroTopicalanestheticsandvasoconstrictorsSummaryoAdistinctionmustbemadebetweenatrueemergencyrequiringimmediatedeliveryandoneinwhichsomedelayispossibleoSpinalorepi

33、duralanesthesiaispreferredtogeneralanesthesiaforcesareansectionbecauseregionalanesthesiaisassociatedwithlowermaternalmortalityoHypotensionisthemostcommonsideeffectofregionalanesthetictechniquesandmustbetreatedaggressivelywithvasopressorsandintravenousfluidbolusestopreventfetalcompromiseSummaryoRegar

34、dlessofthetimeoflastoralintake,allobstetricpatientsareconsideredtohaveafullstomachandtobeatriskforpulmonaryaspirationoUterinedisplacement(usuallyleftdisplacement)shouldbemaintainedoDeliveryunitsshouldhavepersonnelandequipmentreadilyavailabletomanageairwayemergencies,consistentwiththeASAPracticeGuidelinesforManagementoftheDifficultAirwayThanks!精品课件资料分享SL出品精品课件资料分享SL出品