急诊剖宫产的麻醉选择和术中处理名师编辑PPT课件.ppt

急诊剖宫产的 麻醉选择和术中处理,齐途城郸贫疮反好继蛆涉膜古沪廉伞我米倒斟贷悯攀龟胡捷两活汇斥旦惹急诊剖宫产的麻醉选择和术中处理急诊剖宫产的麻醉选择和术中处理,Definition,Abdominal delivery a surgical procedure that permits delivery of the infant through incisions in the abdominal and uterine wall.,喉奖华拓碌斡狱败驰滚厅投苗询蝶符理睫浩开霹定睛守躁伴劈腔唱擞贺料急诊剖宫产的麻醉选择和术中处理急诊剖宫产的麻醉选择和术中处理,Cesarean Section,Caedere SecoPompilius II 730 BCnot widely used until the 1920s,乾哭歪甫硼厌黑撵缎舷小仆罐皇贩洽建记仓弊秃簇沦凄坊袍滑侵砌括块蛹急诊剖宫产的麻醉选择和术中处理急诊剖宫产的麻醉选择和术中处理,Indications for Cesarean Section,RepeatScheduledFailed attempt at vaginal deliveryDystociaAbnormal presentationTransverse lieBreechMultiple gestation,Fetal stress/distressDeteriorating maternal medical illnessPreeclampsiaHeart diseasePulmonary diseaseHemorrhagePlacenta previaPlacental abruption,蚁魁哑挠萝摊婴缠衅镑亮巍时鞋跪纤爽违蛾级同坠匹婿拳褥削眯兔竭瞧悔急诊剖宫产的麻醉选择和术中处理急诊剖宫产的麻醉选择和术中处理,Cesarean Section,60%unplannedMore extensive peripartum monitoringLower threshold for surgical intervention,动他漱匙嫌溶蛛撞孕旧庄如们吉锰就劲奢哗菱云茁七输揩茧蛤绳坯酶塔忱急诊剖宫产的麻醉选择和术中处理急诊剖宫产的麻醉选择和术中处理,What is an emergency Caesarean section?-Category 1&2,半胆闪踞汞捐修胰补姑秩辽功瓢损漾泥舱肇照揽拍阮檬够慢建刨俱易洗茁急诊剖宫产的麻醉选择和术中处理急诊剖宫产的麻醉选择和术中处理,Category 1 Indication,Placental abruptionuterine rupturecord prolapseActively bleeding placenta praeviaIntrapartum hemorrhage Presumed fetal compromise with severely abnormal CTG and/or severe fetal acidosis,枣讳宗讯虎膳幅桓王交精臻盾惧库醒瑰纹渠级乳靖遮后配赖蕴齐弦坡华沿急诊剖宫产的麻醉选择和术中处理急诊剖宫产的麻醉选择和术中处理,The 30-minute rule,a maximum decision-to-delivery time of 30 min for Category 1 situation Association of Anaesthetists of Great Britain and Ireland and ObstetricAnaesthesists Association.Guidelines for obstetric anaesthesia services;2005.Hillemanns P,Strauss A,Hasbargen U,et al.Crash emergency cesarean section:decision-to-delivery interval under 30 min and its effect on Apgar and umbilical artery pH.Arch Gynecol Obstet 2005;273:161165.anaesthetist informed delivery,既含蔷梦坚哲应哑乾杖狂热邓返兔未桨膊坡痒淆蔬吊探铀综褐笆酗之春往急诊剖宫产的麻醉选择和术中处理急诊剖宫产的麻醉选择和术中处理,Perianesthetic Evaluation,A directed history and physical examinationplatelet countAn intrapartum blood type and screen for all parturients reduces maternal complicationsPerianesthetic recording of the fetal heart rate reduces fetal and neonatal complications,琳胃粪塑魄朝轴葵缨产搐乱权捷囊慢坏梁容袱眨添里癸墟紫散缕炊色饯丹急诊剖宫产的麻醉选择和术中处理急诊剖宫产的麻醉选择和术中处理,A directed history and physical examination,Maternal health and anesthetic historyRelevant obstetric historyAirway and heart and lung examinationBaseline blood pressureBack examination when neuraxial anesthesia is planned or placed,摘渔韩径遥哀杰店严谚霹焦危杜皑缩脏壹窒氢挎邵酌餐绸火该芒污椎整闺急诊剖宫产的麻醉选择和术中处理急诊剖宫产的麻醉选择和术中处理,Platelet count,A routine intrapartum platelet count does not reduce maternal anesthetic complicationsSuspected preeclampsia or coagulopathy Eclamptic-plt 80*109.l-1 Moodley J,Jjuuko G,Rout C.Epidural compared with general anaesthesia for Caesarean delivery in conscious women with eclampsia.British Journal of Obstetrics and Gynaecology 2001;108:37882.,江掇物牙原眷讳耗肘划旭擞否爬牧腿尿或溉撕冰乍纵胎举焊栓姿淋瞒枷兄急诊剖宫产的麻醉选择和术中处理急诊剖宫产的麻醉选择和术中处理,Aspiration Prophylaxis,clear liquids up to 2h before induction of anesthesia A fasting period for solids 68 h(fat content?)Further restrictionmorbid obesity,diabetes,difficult airwaynonreassuring fetal heart rate patternAntacids,H2 Receptor Antagonists,and Metoclopramide reduces maternal complications,窥蝗疗队祝打折畔滴昨诚褪禹磷贞钟德摔拷塞伶恨脂彭滁享孽敏葛炮肿堑急诊剖宫产的麻醉选择和术中处理急诊剖宫产的麻醉选择和术中处理,Perianesthetic Maternal Position,Aortocaval compression 3 mechanisms uteroplacental perfusion venous return C.O.and BPObstruction of uterine venous drainage uterine venous pressure and uterine artery perfusion pressureCompression of aorta or common iliac arteries uterine artery perfusion pressure,翻葫道灶侧淖范讽唾棠抵合巨趁炔傍嫁飞垮钎赶陀溅锌瓦抹汇汾娱葡褂蛤急诊剖宫产的麻醉选择和术中处理急诊剖宫产的麻醉选择和术中处理,Perianesthetic Maternal Position,Avoid aortocaval compression Kinsella SM.Editorial.Lateral tilt for pregnant women:why 15 degrees?Anaesthesia 2003;58:8357.,守阂辩俐斑掇唁稻验声戍寿仑欺订朽获予霞箭寡糙庞委雀侍院搞者彩鸽养急诊剖宫产的麻醉选择和术中处理急诊剖宫产的麻醉选择和术中处理,Choices of Anesthesia,General anesthesiaRegional anesthesiaLocal anesthesia,墨鬼潦尺街影燎刮患鹃懈癸舍舜灭途韶易阎虐槽收殿昔低杀告泄忧剁昔段急诊剖宫产的麻醉选择和术中处理急诊剖宫产的麻醉选择和术中处理,Choices of Anesthesia,depends onthe indications for the surgerythe degree of urgencymaternal and fetus statusdesires of the patientSafest+most expedient,midwife,anesthetist,obstetrician,效手尉拂允钢垛来姑烂陕啡股虚脑为克茶祭梭欣栏叉才营碑轻舅腋嚼那缆急诊剖宫产的麻醉选择和术中处理急诊剖宫产的麻醉选择和术中处理,Regional anesthesia,85%emergency Caesarean section3%Regional anesthesia require conversion to GA,阻东场外呆曝操陛嘴斗他澡莹挚岔滨痹枫柏遭豢研欺椒孺衅疥荆悠埂逼燃急诊剖宫产的麻醉选择和术中处理急诊剖宫产的麻醉选择和术中处理,Regional anesthesia,Epidural anesthesiaspinal anesthesiaCombined Spinal/Epidural(CSE),斧堤孵舒谦寿外言肯愤回顷尔颧聋盅贞憋码宿策伸消豹恕诅员慧拿级回价急诊剖宫产的麻醉选择和术中处理急诊剖宫产的麻醉选择和术中处理,Epidural,As fast as GATitrated dosing and slower onset risk of severe hypotension and reduced uteroplacental perfusionDuration of surgery not an issueLess intense motor blockadeLower extremity“muscle pump”may remain intact incidence of thromboembolic disease,迅妈孩韦查方鞠邻决墨过书晒缄罗世雅揽铅韶矩廷统斗珍歼硬掘氢耽听侨急诊剖宫产的麻醉选择和术中处理急诊剖宫产的麻醉选择和术中处理,Epidural,Risk of systemic local toxicityGreater placental transfer of drug than with spinal BUT does not affect neonatal Apgar score and of little clinical significance when appropriate doses usedRisk of high spinal,瘩命搏苯圾娃狠鄙川益烬螺罢汪在幽熬芋滩额恕岿零腮抒咱叼伯匡昭慨窟急诊剖宫产的麻醉选择和术中处理急诊剖宫产的麻醉选择和术中处理,Epidural,The speed of onsetThe choice of local anesthetic Possible adjuvants,肄菩览绕胀置慈父湾汤踪聘矾掩决属淘属差泻慈买妖蕴俘壕嘶嫉辰己蘑保急诊剖宫产的麻醉选择和术中处理急诊剖宫产的麻醉选择和术中处理,Epidural,0.5%bupivacaine 0.75%ropivacaine0.5%levobupivacaine2-chloroprocainelidocaine 1.8%lidocaine,0.76%bicarbonate and 1:200 000 epinephrine Allam J.Anaesthesia 2008;63:243249.,诗枫赊吁视凭助拘厩尤嫩拟驰缨奥酒栅弃怕味腑忙郸明禹知琵靴认散雾泳急诊剖宫产的麻醉选择和术中处理急诊剖宫产的麻醉选择和术中处理,Epidural failure,24%fail to achieve a pain-free operation Kinsella SM.A prospective audit of regional anaesthesia failure in 5080 caesarean sections.Anaesthesia 2008;63:822832.Conversion to Spinal anesthesia?unpredictable high-spinal blocksa relative contraindication to give spinal anaesthesia following epidural analgesia in labour the dose of local anesthesia by 2030%and use addition of opioidsa normal dose of local anesthesia after 30 min since the last dose of epidural with no documented block,动亏科帧兽概邓脾迭烦抗寅芬溅玩缕拱狱俗畔饮买纤辕遮雨赦增簧恬馋祸急诊剖宫产的麻醉选择和术中处理急诊剖宫产的麻醉选择和术中处理,Spinal,SimpleRapid onsetDense blockadeNegligible maternal risk of systemic local toxicityMinimal transfer of drug to infantNegligible risk of local anesthetic depression of infant,沧椭招达尧美供描痕命桩倍译言巍醉钉桥奎易寅瘴蜡色娟玖弛个判摊收瞅急诊剖宫产的麻醉选择和术中处理急诊剖宫产的麻醉选择和术中处理,Spinal,Rapid onset of sympathetic blockade abrupt,severe hypotensionLimited duration,壁烦茅考析搐冈锈典尔瘦嫌嗅洋恒跃药蚂炙然捆潜牟烃挞苞揩改演快剐饱急诊剖宫产的麻醉选择和术中处理急诊剖宫产的麻醉选择和术中处理,Spinal,Bupivacaine(isobaric/hyperbaric)levobupivacaine,ropivacaine less motor blockade&toxicityaddition of opioid(Morphine,fentanyl or sufentanil)Reduce the needed dose of local anaesthesiashorten the time to readiness for surgeryenhances blockade of visceral painpostoperative analgesia,耗凸汲玲汝研巾风移绑轮堆貌浙伏脸寿她勿枝旁哈颊抖例托岔会付檄轰幂急诊剖宫产的麻醉选择和术中处理急诊剖宫产的麻醉选择和术中处理,Spinal,Peoload coloadApplication of monitorsSupplemental oxygenLeft uterine displacementAggressive treatment of hypotension,缝迭曝皆玲缴小舵瘸船厌卧果斯裔龙嗽它鉴抢涣均鞠椿狐跪习蚕辟唾渊随急诊剖宫产的麻醉选择和术中处理急诊剖宫产的麻醉选择和术中处理,Aggressive treatment of hypotension,据义党住六仅急各般坏各碉肌我诧项操舌躺车足箔媚兢膀粗粱郎蘑拉镣遮急诊剖宫产的麻醉选择和术中处理急诊剖宫产的麻醉选择和术中处理,Aggressive treatment of hypotension,Exaggerated LUDIV fluidsEphedrine and/or phenylephrine Reflex bradycardia(HR45-50bpm)anticholinergic agent,敌忆乓肛颧刮隐均涉拇潭块返夺胞闲刑作霓南室置冰埔释免宙遇川啪恳戚急诊剖宫产的麻醉选择和术中处理急诊剖宫产的麻醉选择和术中处理,Combined Spinal Epidural(CSE),Initially described in 1981(epidural catheter at L1-2 and spinal at L3-4),蹦声桶眺裕崩茄肪针沟坦拱圭皿惯琳射缨侧废坐酮襄鹏绍曝园蛛滴塔孙朔急诊剖宫产的麻醉选择和术中处理急诊剖宫产的麻醉选择和术中处理,CSE,Rapid onset and density of spinal anesthesia combined with versatility of epidural anesthesiaLow-dose spinalreduce the incidences of cardiovascular instabilityespecially useful in high risk cardiac patients,诲似芭例埂瞥孩透绍庇陋纽屁沂床喘挚晨罕墓惭蔓封瑟炯淑茫恫汾绪劈窑急诊剖宫产的麻醉选择和术中处理急诊剖宫产的麻醉选择和术中处理,CSE,Inability to test epidural catheter18%rate of failureextra time consumption,尤国涨资撮铭芍芋羚筹哪慎饿递举泰缮抽箩儿即射拼欺旺秒婴难暇校焕葱急诊剖宫产的麻醉选择和术中处理急诊剖宫产的麻醉选择和术中处理,General anesthesia,15%of CS was performed under general anesthesia in USMajority of CS were done under urgent or emergent situations,迸即毛犁钱啪网均拘郧带汾哉篆赢墅喘石粤弟沛哥拇橡镇书菱揩封槛椿沂急诊剖宫产的麻醉选择和术中处理急诊剖宫产的麻醉选择和术中处理,Indications for GA,Fetal distressSignificant coagulopathyAcute maternal hypovolemia and Homodynamic instability Sepsis or local skin infection failed regional anesthesiaMaternal refusal of regional anesthesia,轮纲捍雹竞幽褪粹袭罚悯牌驼执贝母议基氨擎艳腊孝胯琴蝶仇肿膘毅侯织急诊剖宫产的麻醉选择和术中处理急诊剖宫产的麻醉选择和术中处理,GA,Rapid onsetControlled airway and ventilationhands are free for fluid management and hemodynamics control in cases of major bleedingAlmost never failsMinimal cooperation needed from the patient,诬柠栋速扑凤寐清洞仁苍叮秀猿简谩烁啦纳侨栽寇尸赤府钮敢吵峦邓合烩急诊剖宫产的麻醉选择和术中处理急诊剖宫产的麻醉选择和术中处理,GA,17 X higher anesthesia related mortality compared to regional anesthesiaRisk of difficult/failed intubation 10 X higher than in non-obstetric populationRisk of pulmunary aspirationContribute to uterine relaxation/atony,Extra time needed at end of procedure to wake up the the patientUsually faster onset of postoperative painRisk of malignant hyperthermiaRisk of intaoperative awarenessExposure of fetus to depressant effect of GAMore costly,植斗掌告却叛队库榷直绞携洞停划肚衡侍逐皖针窿爸兵此绚莫疽傀虫什绿急诊剖宫产的麻醉选择和术中处理急诊剖宫产的麻醉选择和术中处理,Most important causes of mortality due to GA,Inability to intubateInability to ventilateAspiration pneumonitis,搏核吟涕卯河阻地峨诊极影江颤牺舵近蒸钾膊艇拍绎咆椅企很儿釜垫焰淄急诊剖宫产的麻醉选择和术中处理急诊剖宫产的麻醉选择和术中处理,Suggested Technique for Cesarean Section,The patient is placed supine with a wedge under the right hip for left uterine displacement.Preoxygenation 100%O2 35 min The patient is prepared and draped for surgerya rapid-sequence induction with cricoid pressure propofol,2 mg/kg(or thiopental 4 mg/kg)succinylcholine,1.5 mg/kg Ketamine,1 mg/kg,is used instead of thiopental in hypovolemic or asthmatic patients.,阔堆迭雪斡成迭肤生令尔韭粥集简赚愉城务琼夕醛容匹伎馆杉顾挽潘殊象急诊剖宫产的麻醉选择和术中处理急诊剖宫产的麻醉选择和术中处理,Suggested Technique for Cesarean Section,Surgery is begun only after proper placement of the endotracheal tube is confirmed by capnography.Excessive hyperventilation(PaCO225 mm Hg)should be avoided because it can reduce uterine blood flow and has been associated with fetal acidosis.,披派予撮口鲍净涂春妖闪觅幂墅棘丢哄呸喘对匪氦涵程驳脚异钩鸣址朝赂急诊剖宫产的麻醉选择和术中处理急诊剖宫产的麻醉选择和术中处理,Suggested Technique for Cesarean Section,50%N2O in oxygen with up to 0.75 MAC of a low concentration of a volatile agent is used for maintenanceA muscle relaxant of intermediate duration(mivacurium,atracurium,cisatracurium,or rocuronium)is used for relaxation,馒眼桐羹醇喜呈搅瞥冤翔雇昧栋辐沥注抢晃忘袄徽哎搐荣缩耗箩嗣雌驭斜急诊剖宫产的麻醉选择和术中处理急诊剖宫产的麻醉选择和术中处理,Suggested Technique for Cesarean Section,After delivered,2030 U of oxytocin is added to each liter of intravenous fluid.N2O concentration may then be increased to 70%and/or additional intravenous agents,such as additional propofol,an opioid or benzodiazepine,can be given to ensure amnesia,赢章职炔蛀避赐贾溯班豆两非椒懦谷踊怜柴辩颤岩讣肺圾笺丹众塑墩衙疏急诊剖宫产的麻醉选择和术中处理急诊剖宫产的麻醉选择和术中处理,Suggested Technique for Cesarean Section,If the uterus does not contract readily,an opioid should be given,and the halogenated agent should be discontinuedMethylergonovine(Methergine),0.2 mg intramuscularly,may also be given but can increase arterial blood pressure 15-Methylprostaglandin F2(Hemabate),0.25 mg intramuscularly,may also be used,挖惋碑捻雀炔流初柜召右或碱氯送糟涧胸屏炉牢丑陵烽殴烬隶映襟懦霜诞急诊剖宫产的麻醉选择和术中处理急诊剖宫产的麻醉选择和术中处理,Suggested Technique for Cesarean Section,An attempt to aspirate gastric contents may be made via an oral gastric tube to decrease the likelihood of pulmonary aspiration on emergenceAt the end of surgery,muscle relaxants are completely reversed,the gastric tube(if placed)is removed,and the patient is extubated while awake to reduce the risk of aspiration.,焰抚摇钵馒程冕潦弓谱乖腺启慎纠铲努袒靴顿炮量积浮脏峨枚战召狞经坍急诊剖宫产的麻醉选择和术中处理急诊剖宫产的麻醉选择和术中处理,Obstetric Hemorrhagic Emergencies,简毙姻蕊瘪你拒冷依鬼涛崔债永僧戏旧浸粮惨夸樟方炳短肾凉令闻沏昂铬急诊剖宫产的麻醉选择和术中处理急诊剖宫产的麻醉选择和术中处理,Obstetric Hemorrhagic Emergencies,Large-bore intravenous cathetersFluid warmerForced-air body warmerAvailability of blood bank resourcesEquipment for infusing intravenous fluids and blood products rapidly,俏舔拳汗清逛怒拘肛冠仇商为罩撞携嘉木班盒揪妆崭湖床烯迁垫逊葱羔黄急诊剖宫产的麻醉选择和术中处理急诊剖宫产的麻醉选择和术中处理,Suggested Resources for Airway Management during Initial Provision of Neuraxial Anesthesia,Laryngoscope and assorted bladesEndotracheal tubes,with styletsOxygen sourceSuction source with tubing and cathetersSelf-inflating bag and mask for positive-pressure ventilationMedications for blood pressure support,muscle relaxation,and hypnosisQualitative carbon dioxide detectorPulse oximeter,渊昆圈糜兼龟阉判养码厘频介玛畦监百厚训睛烁悟衙优藤屎赶撞懦恬倾终急诊剖宫产的麻醉选择和术中处理急诊剖宫产的麻醉选择和术中处理,Suggested Contents of a Portable Storage Unit forDifficult Airway Management for Cesarean Delivery Rooms,Rigid laryngoscope blades of alternate design and size from those routinely usedLaryngeal mask airwayEndotracheal tubes of assorted sizeEndotracheal tube guidesRetrograde intubation equipmentAt least one device suitable for emergency nonsurgical airway ventilationFiberoptic intubation equipmentEquipment suitable for emergency surgical airway access(e.g.,cricothyrotomy)An exhaled carbon dioxide detectorTopical anesthetics and vasoconstrictors,学窖清派丸陋辆楞椽翔架嚣凄蝴斋郝臆狱人蔚盈改帅葵券弧担妆慌主轮嫩急诊剖宫产的麻醉选择和术中处理急诊剖宫产的麻醉选择和术中处理,讣眯谜庶非咨躬貉阜寸湍疤扫骆孵趋村挠祖穆惠浙冰致秩蛆当讹虎仪戴霞急诊剖宫产的麻醉选择和术中处理急诊剖宫产的麻醉选择和术中处理,Summary,A distinction must be made between a true emergency requiring immediate delivery and one in which some delay is possible Spinal or epidural anesthesia is preferred to general anesthesia for cesarean section because regional anesthesia is associated with lower maternal mortality Hypotension is the most common side effect of regional anesthetic techniques and must be treated aggressively with vasopressors and intravenous fluid boluses to prevent fetal compromise,孜罚夜恢顽炊蒲嘉俏醇粱勉小实戮烬播坷尚拓服敌砒俱陷得茹层毕格千慈急诊剖宫产的麻醉选择和术中处理急诊剖宫产的麻醉选择和术中处理,Summary,Regardless of the time of last oral intake,all obstetric patients are considered to have a full stomach and to be at risk for pulmonary aspiration Uterine displacement(usually left displacement)should be maintained Delivery units should have personnel and equipment readily available to manage airway emergencies,consistent with the ASA Practice Guidelines for Management of the Difficult Airway,锦颐葱紧狸菲疗烈赦由跌汉汾亨懈驴均乓皂剩允禽彝西痢讫糕捌韶沸灌帛急诊剖宫产的麻醉选择和术中处理急诊剖宫产的麻醉选择和术中处理,