急诊剖宫产的麻醉选择和术中处理名师编辑PPT课件.ppt
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1、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,
2、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/distressDet
3、eriorating 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
4、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 Pre
5、sumed 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 Obstet
6、ricAnaesthesists 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 inform
7、ed 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 reduce
8、s 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 an
9、esthesia 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 compare
10、d 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 peri
11、od 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 P
12、osition,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
13、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 anesthesiaRegi
14、onal 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
15、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
16、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 thromboembo
17、lic 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
18、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%b
19、icarbonate 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 200
20、8;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
21、 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
22、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 o
23、pioid(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
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