先兆子痫病人的麻醉处理(双语)课件

AnestheticManagementofthePreeclampticPatient先兆子痫病人的麻醉处理福建医科大学附属协和医院麻醉规培住院医师

陈小芬Definitions定义Preeclampsia/Eclampsiapresentsafter20weeksgestationwithhypertension>140/90,proteinuria,andaspectrumofmulti-organsystemdysfunctionsuchasthrombocytopenia.先兆子痫表现为怀孕20周后的高血压（>140/90）、蛋白尿、一系列多器官功能障碍如血小板减少。PreventionandManagementofSeizures/Eclampsia癫痫/子痫发作的预防和管理

Eclampsiahasamaternalmortalityrateof~4%andaperinatalmortalityrateofupto30%.(子痫有达4％孕产妇死亡率和高达30％围产儿死亡率)Seizuresoccur

antepartumin50%ofpatients,intrapartumin25%andpostpartumin25%.(癫痫发作50%在产前患者，产程中及产后各占25%）。Nodrugissuperioratpreventingeclampsia.Magnesiumtherapycancausematernalmorbidityandunpleasantsideeffectshowever.在防止子痫方面没有药物优于镁。然而镁治疗可引起产妇发病率和不愉快的副作用。Ithastocolytic

propertiesthatprolonglaborandincreasebleedingatdelivery.Itdecreasesfetalheartratevariability,depresses

maternalandneonatalneuromuscularfunction,andcancausematernalrespiratorydepressionandcardiactoxicityat

highbloodlevels。它具有抗分娩特性：延长产程和增加分娩时出血。在血液中高浓度时，它能减少胎儿心脏心率变异性，抑制孕产妇和新生儿的神经肌肉功能，并能引起产妇呼吸抑制和心脏毒性。Clearanceisreducedwithrenalinsufficiency,andsignsoftoxicityareonlypartiallyreversed

withcalcium.肾功能不全时清除率下降，毒性可以被钙部分逆转。Sincemajorcomplicationsofpreeclampsiaprimarilyoccurinthe25%ofpatientswiththesevereformofthedisease,shouldmildpreeclampsiaevenbetreatedwithmagnesium?由于严重的子痫前症并发症主要发生在25％合并有严重疾病的患者，那么轻度子痫前期是否需要镁治疗？Whatistherisk/benefitratioforthemother?Adecisionanalyticmodelofmagnesiumtherapyornomagnesiumtherapyfoundthat400womenwithmildpreeclampsianeedtobetreatedtopreventoneseizure。对于一个母亲来说，什么是风险/效益比？一个关于镁治疗或完全没有镁治疗的决策分析模型的发现，400名轻度子痫前期的妇女需要处理，以防止一次发作。Thenumberneededtotreattopreventaseizure(NNT)fellto129inseverepreeclampsia,andtheNNTfelltoonly36inseverelypreeclampticwomenwhohadsymptomssuchasheadache,visualdisturbancesorepigastricpain.Notallwomenwithmildpreeclampsiawillneedtoreceivemagnesiumsulfatetherapy.在重度子痫前期中，需要治疗以防止发作的人数下降到129，在伴有头痛，视力障碍或上腹部疼痛的严重先兆子痫的女性中需要处理以防止发作的人数下降到仅仅36人。不是所有的轻度子痫前期都需要硫酸镁治疗。Administeranadditional2grammagnesiumsulfatebolus.给予2克硫酸镁静脉推注Monitorthefetusifpossible,butrealizethatheartrateabnormalitiesarecommonduringaseizureandusuallyresolvesoonaftertheseizureisterminated.Donotintervenetodeliverimmediatelyunlessabruptionorcordprolapsehasoccurred。如果可能的话，监测胎儿，但认识到在癫痫发作期间心率异常是常见，所以常在发作终止后监测胎儿。不要立即干预让孕妇分娩，除非发生胎盘早剥或脐带脱垂Althougheclampsiaisanindicationfordelivery,itisnotanindicationforcesareandelivery.Considerwhetherinductionisfeasibleorwhetherlaborisalreadyprogressing。虽然先兆子痫是一种分娩指征，但它不是剖宫产的指征。须考虑诱导是否可行或是否产程已经在进展中2)trialoflaborfollowedbyanurgentoremergentcesareanforfetalormaternalreasons,因为母体或婴儿的原因，试产后跟随的可能是急产或紧急剖宫产3)andplannedcesareanforthepatientwhoisnotacandidatetolabor.为不合适自然分娩的产妇计划剖宫产。Allplansmusttakeintoaccountwhetherneuraxialtechniquesareappropriatebasedonplateletcountorothermeasuresofcoagulopathy所有计划必须考虑到椎管内麻醉是不是合适，基于血小板数目和凝血功能Theadvantagesofneuraxialanalgesiaforlaborarenumerous.Itprovidesthebestqualityofpainrelief,attenuateshypertensiveresponsestopain,reducescirculatingcatecholamines。椎管内分娩镇痛的优势是多方面的，它能提供最优质的缓解疼痛，减轻疼痛的高血压反应，降低循环中的儿茶酚胺。anddoesnotrequirefluidpreloadwhendilutelocalanesthetic+opioidsolutionsareused.当稀释的局麻药复合和阿片类药物使用时，不需要液体负荷量。Twostudieshavecomparedtheuseofintravenouspatientcontrolledopioids(IVPCA)toepiduralanalgesiaforwomenwithseverepreeclampsia。有两个研究对重度子痫前期的妇女阿片类药物静脉PCA和硬膜外镇痛做比较。

738womenwererandomizedtoIVPCAorepidural,andcesareandeliveryratesweresimilar.

738名妇女中，静脉PCA和硬膜外麻醉剖宫产率是相同的。

NeonatesintheIVPCAgrouprequiredmorenaloxone(12%versus1%),butwomenintheepiduralgrouphadalongersecondstageoflabor,moreforcepsdeliveriesandrequiredephedrinemoreoften(11%versus0%).在静脉PCA组新生儿需要更多的纳洛酮（分别为12％及1％），但在硬膜外组的妇女有较长的第二产程，更多的产钳所需、麻黄碱（11％和0％）。Notsurprisingly,epiduralpainreliefwassuperior.Resultsweresimilarinthesecondstudy.Theyfoundwasnodifferenceincesareandeliveryrates,neonatesweremorelikelytoreceivenaloxoneintheopioidgroup(54%versus9%),andepiduralpatientshadsignificantlybetterpainreliefbutrequiredmoreephedrine(9%versus0%).不奇怪的是，硬膜外缓解疼痛是很好的。第二项研究的结果也相似，他们发现剖宫产分娩率无明显差异，阿片组新生儿更需要纳洛酮（54％比9％），硬膜外组能更好的缓解疼痛，​​但需要更多的麻黄碱（9％和0％）。Perhapsmostimportantly,therewerenodifferencesinpreeclampsia-relatedcomplications.也许最重要的是先兆子痫的相关并发症无差异。AsecondaryanalysisofwomenwithseverepreeclampsiaintheNICHDtrialoflow-doseaspirinreportedthatepiduralanesthesiawasnotassociatedwithanincreasedrateofcesareandelivery,pulmonaryedemaorrenalfailure.NICHD（国家儿童健康和人类发展研究所）对重度子痫前期妇女的二次分析表明低剂量阿司匹林组硬膜外麻醉与剖宫产率增加、肺水肿或肾功能衰竭是不相关的。Fluidmanagementhasbeenacontroversialsubjectbetweenobstetricianswhowanttorestrictfluidsandanesthesiologistswhowanttoadministerfluids,howevertheobstetricviewisprobablycorrect.在主张限制液体的产科医生和主张给予液体的麻醉医师之间，液体管理一直是一个有争议的话题，但产科的观点可能是正确的。

Typicalobstetricmanagementisto“rundry”at80-100mlperhourtotalfluidintakeincludingmagnesiumandoxytocininfusions.Anestheticfluidmanagementshouldcomplementtheirs,usingconservativepreloadforsurgicalregionalanesthesiaandnopreloadforlaboranalgesia.典型的产科管理是“干涸”，每小时80-100毫升总的液体摄入量，包括镁和催产素输注。麻醉液体管理应补偿液体丧失量，对外科的区域麻醉使用保守的液体负荷量，分娩镇痛不给液体负荷量。Manystudiesincludingasystematicreviewhaveshownlittleifanybenefitofpreloadinginpreventinghypotensionduringobstetricregionalanesthesia。许多包括一个系统的回顾研究显示，预给量在防止产科区域麻醉低血压方面几乎没有任何好处。

Despiteyearsofconcernandstudy,thereisstillnotestofplateletfunctionandnospecificplateletcountthatpredictsbleedingintotheneuraxisafterregionalanesthetictechniques尽管经过多年的关注和研究，但仍然没有血小板功能的测试和血小板计数预测椎管内麻醉后的出血Thromboelastography(TEG)canaddinformationifthetestisavailable,butthereisstillnocut-offvalueforanyTEGvariablethatpredictscomplications.如果测试是可用的，血栓弹力图可以增加信息，但血栓弹力图的变化仍然没有决定性的价值用来预测并发症。

Sincepregnancyisathrombophilicstate,parturientshavetremendousreservebeforebecomingcoagulopathic.由于怀孕是一个易栓状态，产妇在出现凝血障碍前有巨大的储备。

Areviewof1.7millionspinalorepiduralblocksfoundthatcomplicationsweremorecommonafterepiduralthanspinalanesthetics,andthatobstetricpatientswerelesslikelythansurgicalpatientstohaveaninjury(1:25,000obstetricpatientsversus1:3600aftersurgicalepiduralsinfemales).170万脊髓或硬膜外阻滞的回顾性研究发现，硬膜外麻醉比脊髓麻醉并发症更常见，产科患者比外科手术患者的受伤害的可能性更小（产科硬膜外麻醉并发症的发生率为1:25,000，外科硬膜外并发症的发生率为1:3600）

Therewere2obstetricpatientsintheirseriesthatdevelopedaneuraxialhematoma,foranincidenceof1:200,000.Oneoccurredafteraspinalandtheotherafterepiduralcatheterremoval;bothpatientshadHELLPsyndrome.Thislowincidenceisreassuring,butbalancetherisk-benefitratioforeachcaseandeachpatient.有2例产科病人发生了椎管内血肿，发生率为1:200,000。一个发生在脊髓麻醉后，另一个发生在拔除硬膜外导管后；两名患者均有HELLP综合征。这一低发病率是令人欣慰的，但应为每个病案和每个病人平衡风险及益处。Ifyoufeelthataneuraxialanestheticisnotappropriate,rememberthatanesthesiologistsareconsultantsinpainmanagement.如果你觉得椎管内麻醉是不恰当的，记住，麻醉医师是疼痛管理方面的顾问。OurobstetriccolleaguesmayappreciatehelpwithanIVregimenforthepatient’slaboranalgesia.Forexample,fentanylcanbeusedinanIVPCAasfollows:giveanIVbolusloadingdoseof2-3μg/kgtoinitiateanalgesia.我们产科同事可能喜欢静脉分娩镇痛方案。例如，芬太尼可以用在如下的IVPCA：给予静脉推注负荷剂量为2-3μg/kg作为起始镇痛量。SetthePCApumpfora50μgincrementalbolus,10minutelockoutintervalandnobasalrate.Aslaborprogressesandtitrationisneeded,decreasethelockoutfrom10to5minutes,thenincreasethebolusdosefrom50to75μg.设置PCA泵追加量50μg，10分钟锁定时间无基础速率。随着产程进展，精确给药是必要的，锁定时间从10分钟调整到5分钟，然后增加每次剂量为50至75微克。Thechoicesforcesareananesthesiaareepidural,spinal(orcombinedspinal-epidural)andgeneral。剖宫产的麻醉选择包括硬膜外、脊麻（腰硬联合）、全麻Inthepast,spinalanesthesiawasavoidedbecauseofconcernsthathypotensionwouldbemoresevereandlesstreatablethanthatseenaftersympathectomyfromanepiduralanesthetic.在过去，椎管内麻醉被避免，因为相比硬膜外麻醉，担心交感神经阻滞低血压会更严重和更难治疗。However,acomparisonofwomenwithseverepreeclampsiatohealthywomen,allhavingacesareandeliverywithspinalanesthesia,foundthatpreeclampticwomenactuallyhadlesshypotension(17%versus53%)despitereceivinglessfluidpreloadand(bychance)alargerdoseofbupivacaineintheirspinal.然而，进行脊麻剖宫产的严重先兆子痫和健康妇女的比较发现，先兆子痫的孕妇实际上低血压的发生率更低（17％比53％），尽管在椎管内麻醉时给予更少的液体负荷和更大剂量的布比卡因。Arandomizedcomparisonofspinalorepiduralanesthesiaforcesareandeliveryinwomenwithseverepreeclampsiafoundthatalthoughhypotensionwasmorefrequentafterspinalandrequiredslightlymoreephedrine,thedurationofhypotensionwasshortandneonataloutcomesweresimilarinbothgroups.在对重度子痫前期脊髓或硬膜外麻醉剖宫产的随机比较中发现，虽然脊麻后低血压发生更频繁，需要稍微更多的麻黄素，但是低血压持续时间很短，在两组中新生儿结局是相似的。Asmallstudyof“stable”eclampticpatientsdescribedtheircesareandeliveriesunderspinalanesthesiawithoutintraoperativecomplicationssuchasexcessivehypotensionoradditionalseizures.一项针对“稳定”子痫患者的小规模研究表明他们在脊麻下剖宫产分娩无术中并发症，如：过度低血压或癫痫的发作。Regardlessofthechoiceofneuraxialtechnique(spinalorepidural),pressorsmustbeimmediatelyavailabletotreatevenmildhypotensionsincethesefetusesmaynottolerateanydecreaseinuteroplacentalperfusion.无论椎管（脊髓或硬膜外）技术的选择，升压药必须随时可用于治疗甚至是轻度的低血压，因为胎儿不能耐受子宫胎盘灌注减少。Clinicalstudiesinhumanshaveconsistentlyshownthatuseofα-agonistssuchasphenylephrineproducebetterumbilicalpHvaluesinthenewbornthanuseofephedrine.在人类的临床研究一致表明，使用α-受体激动剂如去氧肾上腺素比使用麻黄素在新生儿中产生更好的脐血pH值。Astudyrandomizingwomenwithseverepreeclampsiatospinalorgeneralanesthesiaforcesareandeliveryfornon-reassuringfetalhearttonesfoundthatspinalanesthesiawasassociatedwithmoreacidoticfetalpHvaluesandhigherbasedeficits.一项随机研究严重先兆子痫孕妇，脊髓麻醉或全身麻醉行剖宫产，有胎儿心音变化者，脊麻与更多的胎儿酸中毒的pH值和较高的碱缺失有关。Maternalhemodynamicsweresimilarbetweengroups,butthepatientsreceivingspinalanesthesiareceivedmoreephedrine(14mgversus3mg)thanthoseinthegeneralanesthesiagroup.Phenylephrinewasnotused.Didtheuseofephedrineworsenfetalacidosis?Ifmaternalheartrateisabove70,choosephenylephrineasthefirst-linepressoragent.两组血流动力学相似，接受脊髓麻醉的患者比全身麻醉组需要更多的麻黄素（14毫克和3毫克）。未使用。难道使用麻黄素使胎儿酸中毒恶化？如果产妇心率是70以上，选用去氧肾上腺素作为一线升压用药。

Ifgeneralanesthesiaischosen,theareasofconcernareattenuatinghypertensiveresponsesduringlaryngoscopyandintubation,managingadifficultedematousairway,andtreatingcomplicationsrelatedtomagnesiumtherapysuchasuterineatonyandmaternalweakness.如果选择了全身麻醉，关注的方面在于减轻喉镜插管时的高血压反应，管理困难的水肿气道和与镁治疗有关的并发症如宫缩乏力和孕妇虚弱。

Anumberofadjunctstorapidsequenceinductionhavebeendescribedandusedsuccessfullytocontrolhypertensionassociatedwithlaryngoscopy,e.g.esmolol,labetalol,lidocaine,remifentanilandnitroglycerin.许多快速诱导的辅助用药被成功用来控制喉镜相关的高血压，如艾司洛尔、拉贝洛尔、利多卡因、瑞芬太尼和硝酸甘油。Includeatleastoneaspartofarapidsequenceinduction,orhavethemimmediatelyavailabletotreathypertensionifitoccurs.包括至少一种作为快速诱导用药的组成，或者随时可立即用于治疗高血压。Airwaymanagementmaybedifficult.Useofthelaryngealmaskairway(LMA)hasbeendescribedinthesettingofHELLPsyndromewhentherewasinabilitytointubateorventilate.气道管理可能比较困难。当HELLP综合征患者无法插管或通气时，可使用喉罩。Magnesiumtherapyhasanestheticinteractions.MagnesiumisauterinerelaxantandadditionaloxytocicssuchasCytotec®orHemabate®shouldbeavailabletotreatuterineatonyafterdeliveryinadditiontotheoxytocininfusion.Magnesiumalsocausesskeletalmuscleweakness。镁治疗有麻醉的相互作用。镁是子宫松驰剂，分娩后除了静滴催产素外，还应备用如Cytotec®或欣母沛®治疗宫缩乏力，镁还会导致骨骼肌软弱。Ifthemotherexhibitsmuscleweaknesspriortoinduction(i.e.,canshedoa5-secondheadliftbeforeheranesthetic？),itmaybebesttodiscontinuethemagnesiumsulfateinfusionduringthecaseandlethermagnesiumleveldecrease.如果母亲在诱导之前，就有肌肉软弱的表现（如她在麻醉前能抬头5秒吗？），最好是术中停止镁硫酸输液，让她的血镁水平降低。Non-depolarizingmusclerelaxantsshouldbeavoided.Ifshecannotmeetcriteriaforsafeextubationattheendofthecesarean,shemayrequireabriefperiodofmechanicalventilationuntilsheisstrongenoughtoprotectherairway.应该避免使用非去极化肌松药。如果在剖宫产结束时她不能满足安全拔管的标准，她可能需要短暂的机械通气直到她强大到足以保护她的气道。

Postpartumissueswillrequireintensemonitoring.Themothermayneedbothacuteandlongtermbloodpressurecontrolwithanti-hypertensives.Fluidmobilizationwillbegintooccurduringthefirst24hourspostpartum,andthisiswhensheismostatriskforpulmonaryedema.Monitorurineoutput,lungfieldsandpulseoximetry.产后应加强监测。产妇可能需要急性和长期的抗高血压控制。液体的转移将出现于产后第一个24小时内，这时发生肺水肿的危险最大。必须监测尿量、肺野和脉搏氧饱和度。Thrombocytopeniamaynotresolveforseveraldays.Ifshehasanepiduralcatheterinplace,decidewhenremovalisappropriatebasedonherplateletcountandcoagulationstudies.血小板减少症不可能几天内解决。如果有硬膜外导管，基于她的血小板计数、凝血功能，来决定何时拔管Aboutathirdofeclampticseizuresoccurpostpartum.Areviewof89casesofeclampsiafo