脊髓麻醉和重症妊娠高血压.ppt

SpinalAnesthesiaandSevereGestationalHypertension,Dr.AlisonMacarthurDepartmentofAnesthesiaUniversityofToronto,Outline,Reviewofpopulation/currentobstetricpracticesMethodsofanesthesiaforcesareandelivery(past/present)Suggestionsforfuturepractice,ClassificationofPIH,IncidenceofComplicatedGestationalHypertension,IncidenceofGH:(U.S.1979-86)26/1000livebirthscontrastthiswithothernations:20.3/1000livebirths(Taiwan1993-97)103/1000livebirths(Turkey1986)Incidenceofseveredisease:5.2/1000livebirths(U.S.1986)7.8/1000livebirths(Taiwan1993-7),IncidenceofGestationalHypertension,Incidenceofeclampsia:0.56/1000livebirths(U.S.)19/1000livebirths(Turkey)Mortality:(U.S.1979-92)1.5/100,000livebirths,Spinalanesthesia-introductionintopractice,Obstetricanesthesiologistsstartedusingspinalanesthesiaforcesareandelivery(1990s)inmild-moderatediseasechangefrom1stto2nded.ChestnutsObstetricAnesthesia:“Someanesthesiologistsconsiderspinalanesthesiacontraindicatedinpreeclampsiabecauseoftheriskofseverehypotension.”,OldEvidence,Hood-Hemodynamicresults,Epidural,Spinal,Wallace-Hemodynamicresults,Karinen-FetalOutcome(Pulsatilityindex),NewEvidence,SOAP2019;A34,SpinalAnesthesiaforEclamptics,No.ofantepartumeclampticparturientsrequiringimmediatedelivery:1505/1846(81.5%)No.ofcesareandeliveries:1185/1505(78.7%),SpinalAnesthesiaforEclamptics,Methodofanesthesiaforcesareandelivery:915/1185spinalanesthesia(77.2%)270/1185generalanesthesia(22.8%),SpinalAnesthesiaforEclamptics,No.ofdeathsamongstwomenrequiringLSCSdelivery:58/1505(3.9%)totaldeaths=176/1846(9.5%),SpinalAnesthesiaforEclamptics,No.ofdeathsbymethodofanesthesia:spinal=31/915(3.4%)general=27/270(10%)OddsRatio(general/spinal)3.17(95%C.I.1.86,5.41),SpinalAnesthesiaforEclamptics-RemainingQuestions?,1.Whatfactorsdeterminedtypeofanesthetic?2.Whatwerethecausesofdeathineachgroup?3.Wheretherecomplicationsineachgroup?4.Notallthewomenwithantepartumeclampsia(1846)delivered(1505).Whathappenedtothesewomen?,NewEvidence,RegionalAnesthesiaandPainMedicine2019;26:46-51,Ramanathan-StudyMethods,Design:caseseriesof46women,severepreeclampsiareceivingCSEforcesareandeliveryIntervention:intrathecalbupivicaine7.5mg+fentanyl25mcg(+epidurallidocaine2%),Ramanathan-StudyMethods,Outcomes:BP,Ephedrinedoses,Apgarscore,umbABGResults:8%epiduralsupplementation/34%priortoclosuremediansensorylevelT4(T2-T5)52%reqdephedrineuse,nadirw/i5minofspinal,Ramanathan-Hemodynamicchanges,SBP,DBP,MAP,Comments:Dr.Hood,Oralexampreparation:doestheclinicalscenarioleavetimeforanepidural?Urgentclinicalscenario:spinalanestheticResidentstaughttousespinalanesthesia2/3attendants2000OAAmeetingusespinalanesthetics,PersonalPearls,Choosingpatient:considerairway,bleedingdiathesis,neurologicalstatus,urgencyMethods:hyperbaricbupivicaine0.75%11.25-13.5mgpreservative-freemorphine0.1-0.2mgConsiderintra-arterialmonitorPre-determine%changeinMAPorsystolicbptorespondwithvasopressor,Conclusions,Futureresearch:AwaitRCThowever.1.Changingobstetricpractice:327/444(73.6%)labored2.Lackofclinicalequipoise:“.wecouldnotdoarandomisedepiduralversusspinaltrialforseverepre-eclamptics.”,FutureStudies,Sophisticatedevaluationoffetal/neonatalwellbeingduringcourseofregionalanesthesiaContinuedreportingofobservationaldata(specifically:morbidity),Concl