剖腹产的麻醉进展(双语)PPT课件

.,1,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,.,2,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）.,.,3,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.,.,4,Introduction,Anestheticparticipationcanalsoreducetheincidence、ofcesareandeliveriese.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),.,5,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(lidocaine45mgwithfentanyl10g)combinedwithuterinetocolysis(nitroglycerin50giv,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%）,.,6,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）.,.,7,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）,.,8,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.,.,9,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）.,.,10,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）.,.,11,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.,.,12,.,13,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）.,.,14,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）;,.,15,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,neostigmineinspinaldosesupto100gsignificantlyreducedpost-operativepain（显著减少术后疼痛）withnoeffectonfetalheartrateorApgarscores（对胎儿心率和Apgar评分无影响）.,.,16,WhatAdjuvantMedicationsshouldbeused?,However,inspinaldosesaslittleas6.25g,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）,.,17,WhatAdjuvantMedicationsshouldbeused?,Clonidine（可乐定）,inspinalandepiduraldosesvaryingfrom15-50gand50-120g,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）.,.,18,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.,.,19,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）.,.,20,DoesaPerfectCocktailExist（最佳药物组合）?,Themostrecentevidencewouldsuggestthefollowingcombinationsareoptimal:,.,21,ASSOCIATEDANESTHETICCONCERNSDURINGCESAREANDELIVERY（剖宫产麻醉相关问题）,.,22,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）,.,23,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）.,.,24,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andmi