剖腹产的麻醉进展.ppt

剖腹剖腹产的麻醉的麻醉进展展Introduction Associated with high maternal mortality（二十世纪前，剖腹产由于产妇高死亡率，开展得并不多）until the turn of the 20th century, cesarean delivery now accounts for approximately one third of all births in developed countries（发达国家三分之一分娩通过剖腹产） This increase has resulted from improvements in surgical and anesthetic techniques, diminished use of forceps for extractions, fewer breech and multiple gestation vaginal deliveries, and greater use of repeat cesarean deliveries（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）.Introduction The updated Practice Guidelines for Obstetrical Anesthesia from the ASA Task Force on Obstetrical Anesthesia observe that neuraxial techniques (spinal, epidural, CSE) are associated with improved maternal and fetal outcomes when compared to general anesthesia (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）, particularly in the presence of high body mass index and airway issues（特别是高体重指数和气道问题的病人）. However, specific anesthetic management should be chosen on a case-by-case assessment of patient, medical（具体麻醉方式必须建立在对病人完全评估之上）,anesthetic, and obstetric issues.Introduction Anesthetic participation can also reduce the incidence 、of cesarean deliveries [e.g. improving forcep/vacuum analgesia, increasing the success of multiple gestation vaginal births, reducing fetal head entrapment with intravenous nitroglycerin, and improving external cephalic version (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) Introduction Neuraxial techniques improve ECV success by relaxing the abdominal wall muscles, improving patient comfort, and allowing a more concerted attempt.（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 (lidocaine 45 mg with fentanyl 10 μg) combined with uterine tocolysis (nitroglycerin 50 μg iv, wait 50 sec) has been associated with a high success rate (83%) for external cephalic version (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%）Is there a Preferred Anesthetic TechniqueIs there a Preferred Anesthetic Technique（什么是剖腹产首选麻（什么是剖腹产首选麻醉方式）醉方式）? ? Complications related to anesthesia still represent the sixth leading cause of peripartum maternal mortality in the United States（麻醉相关并发症是产妇围生期第六大死亡原因）. Not surprisingly, these deaths most commonly result from failures in oxygenation and ventilation（通常由氧合或通气失败导致）,however, these episodes are currently being witnessed more frequently during extubation and postoperative recovery, rather than with intubation（通常在拔管及恢复期发现，而不是插管时）.Is there a Preferred Anesthetic TechniqueIs there a Preferred Anesthetic Technique? ? The estimated case-fatality risk ratio for GA versus neuraxial anesthesia has undergone a significant reduction（全麻与椎管内麻醉的死亡率比例经历了极大的下降）. This change most likely represents two Trends（代表了两种趋势）: 1) a reduction in GA use, coupled with more successful manipulation (e.g. Alternate airway devices) of the maternal airway（全麻的减少，和更多气道替代设备的熟练操作）. 2) a growing acceptance of neuraxial technique use in parturients with significant comorbidities (e.g. obesity, severe preeclampsia, hematologic and cardiac disease)（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）Is there a Preferred Anesthetic TechniqueIs there a Preferred Anesthetic Technique? ? The combined spinal epidural (CSE) technique may offer the most flexibility（腰硬联合提供更多的灵活度） in terms of reducing the initial drug dose (通过减少初始剂量），allowing for potentially less hypotension and faster recovery（更少的低血压发生率和更快的恢复）, as well as prolonging the blockade should operative complications（减少手术并发症） or postoperative pain management（术后镇痛管理） issues occur.Should Newer Local Anesthetics be usedShould Newer Local Anesthetics be used（新型局麻药的使用）（新型局麻药的使用）? ? Potentially reduced recovery times and toxicity profiles have fostered an interest in the newer local anesthetics为了减少恢复时间和毒性反应，促使了新型局麻药的发展）, ropivacaine and levobupivacaine（罗哌卡因和左布比卡因）. Although established to be safe and acceptable for elective cesarean deliveries（虽然被证实剖腹产时更安全）,these two local anesthetics may not be significantly less cardiotoxic than bupivacaine（并没有比布比卡因明显减少心脏毒性） Moreover, because the toxicity of bupivacaine does not appear to be enhanced in pregnancy（因为布比卡因的毒性在怀孕期并没有增加）,cardiac toxicity should only occur with unintentional large intravascular doses（心脏毒性只在血管内意外大量注射后发生）.Should Newer Local Anesthetics be usedShould Newer Local Anesthetics be used? ? With the common and more forgiving use of chloroprocaine 3% and lidocaine 2% for conversion of epidural labor analgesia to cesarean Anesthesia（随着普鲁卡因和利多卡因作为剖腹产硬膜外麻醉的药物, coupled with proper drug administration practices (e.g. attention to incremental dosing practices, total dose guidelines, and toxicity symptoms，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), toxic intravascular levels should be a rare（血管内毒性水平可以降到很低）.Should Lower Doses of Bupivacaine be used（低剂量布比卡因的（低剂量布比卡因的使用）使用）? The dose of local anesthetics has been reduced as a method to potentially obtain less hypotension, faster motor recovery and discharge times, and improved maternal satisfaction（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） Such dose reductions may be achieved by usingspinal versus epidural anesthesia（通过使用腰麻）, as well as less total local anesthetic（减少局麻药总用量）; with these changes, reductions in time, costs, and complications have been realized. When spinal bupivacaine in intermediate to low doses (3-9 mg) are used（当腰麻布比卡因使用中到低剂量即3-9mg）, the need for supplemental medications can be significant (可能需要更多追加剂量), and thus a catheter based technique(以至于需要导管技术比如CSE) should be used.Can Hypotension be preventedCan Hypotension be prevented? ?（避免低血压）（避免低血压） Neuraxial-induced hypotension, when severe and sustained can impair uterine and intervillous blood flow and result in fetal hypoxia, acidosis, and neonatal depression（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）. Left uterine displacement and treatment or prophylaxis with vasopressors have reduced the incidence of hypotension with variable success（子宫左旋或血管加压药可以预防）. Preloading with crystalloid has limited effects on mitigating hypotension, even with large doses (即使给予大剂量晶体预充血容量，效果仍然有限); more effective is preloading with colloids, or simultaneously giving rapid crystalloid or colloids coincident (co-loading) with the spinal technique（最好预充胶体液或晶胶同时预充）.Can Hypotension be preventedCan Hypotension be prevented？？ Hypotension may also be reduced with the use of smaller spinal local anesthetic doses（低血压同样可以通过较少的腰麻药用量避免）. Prophylaxis and treatment of maternal hypotension with phenylephrine（去氧肾上腺素）,versus in combination with ephedrine or ephedrine alone（合用或单用麻黄素）, is more effective in improving maternal hemodynamics（更好改善母体血流动力学） and fetal acid-base values（胎儿酸碱水平）; What Adjuvant Medications should be used?辅助用药的使用辅助用药的使用 Adjuvant medications express a number of benefits, including the ability to reduce the dose and side effects of local anesthetics（辅助药可以减少局麻药用量和副作用）. Neostigmine and clonidine（新斯的明和可乐定） are two novel agents undergoing clinical investigation. In women undergoing elective cesarean delivery, neostigmine in spinal doses up to 100 μg significantly reduced post-operative pain（显著减少术后疼痛） with no effect on fetal heart rate or Apgar scores（对胎儿心率\和Apgar评分无影响）.What Adjuvant Medications should be used? However, in spinal doses as little as 6.25 μg, a highincidence of side effects including prolonged motor blockade, nausea, and vomiting have been observed（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）. As a consequence, the spinal route will most likely be abandoned（因此最好放弃在腰麻中使用）; however, some promise has been noted with the epidural route（可以尝试使用硬膜外路径）What Adjuvant Medications should be used? Clonidine（可乐定）, in spinal and epidural doses varying from 15-50 μg and 50-120 μg, respectively, can prolong analgesia and decrease shivering（无论腰麻或硬膜外，都可以延长镇痛，较少寒战）; However, mild hypotension and sedation are not infrequent side effects（可能出现不常见的轻微低血压和催眠）. Currently clonidine has only one specific neuraxial indication (intractable cancer pain，只有一种适应证即顽固性癌痛), FDA warning that “epidural clonidine（硬膜外可乐定） is not recommended for obstetrical, postpartum, and perioperative pain management”（不建议使用于分娩、产后及围手术期镇痛）. What Adjuvant Medications should be used? Preservative free morphine sulfate（盐酸吗啡） can provide 17-27 h of post-cesarean analgesia（17-27小时的产后镇痛）. Intrathecally（蛛网膜下腔给药）, a comparison of 0.025, 0.05, 0.1, 0.2, 0.3, 0.4, and 0.5 mg doses observed that 0.1mg （与高达的效果无异）. The incidence of pruritus, but not nausea and vomiting, appeared dose related（瘙痒症与剂量相关，但恶心呕吐与剂量不相关）. In the epidural space（硬膜外）, a comparison of 1.25, 2.5, 3.75, and 5 mg doses observed that the quality of post-cesarean analgesia did not improve beyond 3.75 mg（镇痛效果在达到后就不再变化）. Pruritus, nausea and vomiting did not appear dose related.What Adjuvant Medications should be used? Extended-release epidural morphine(缓释吗啡，商品名Depodur) can provide analgesia for 48 hrs with 10 and 15 mg doses; However, caution should be applied to dosing the epidural catheter with local anesthetic immediately after the Depodur（硬膜外导管给予缓释吗啡后立刻给予局麻药时应该小心）, and even up to 1 hour before, as the maximum plasma concentrations of morphine will be higher（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）.Does a Perfect Cocktail Exist（最佳药物组合）（最佳药物组合）?•The most recent evidence would suggest the following combinations are optimal:MedicationSpinalEpiduralLocal AnestheticBupivacaine 9-12mg2%Lidocaine+Bicarb 8.4% (10 mL/1 mL ratio)Fentanyl15-35 μg50-100 μgMorphine0.1 mg3.75 mgASSOCIATED ANESTHETIC CONCERNS DURING CESAREAN DELIVERY（剖宫产麻醉相关问题）（剖宫产麻醉相关问题）Antibiotic Use and TimingAntibiotic Use and Timing（抗生素使用）（抗生素使用） Postpartum infection is 5 to 20-fold greater in those patients delivering by cesarean versus vaginal routes（剖宫产的产后感染比自然分娩高5-20倍） and remains within the top five causes of pregnancy-related mortality（产后五大死亡原因之一）. The traditional practice of administering antibiotics after infant delivery and umbilical cord clamping originated to prevent fetal exposure to antibiotics（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, recent studies of antibiotic use prior to cesarean skin incision（切皮前） have observed significantly fewer maternal infections（观察到产妇感染的显著减少） with no differences in the frequency of neonatal sepsis work-ups or proven sepsis cases（胎儿脓毒血症检验结果无差异） Oxytocin and Uterotonic Agent UseOxytocin and Uterotonic Agent Use（缩宫素使用）（缩宫素使用） The current guidelines for the administration of oxytocin during cesarean delivery are diverse, empiric, and vague, with nonevidence-based doses of 20-40 IU being advocated（目前的缩宫素使用并没有循证支持）. However, adequate uterine contractions（足够的子宫收缩） during elective cesarean deliveries in non-laboring women(未进入产程的孕妇） require only small loading doses of oxytocin（只需要少量的缩宫素负荷量）(ED 90 = 0.35 IU); a similarly low loading dose (ED 90 = 2.99 IU) is required in laboring women（产程中的孕妇）.Oxytocin and Uterotonic Agent UseOxytocin and Uterotonic Agent Use Consequently, a lower oxytocin, has been advocated:Oxytocin Protocol for Cesarean Delivery: “Rule of Threes”3 IU Oxytocin IV Loading Dose (administered by rapid infusion, rather than a bolus, no faster than 15 seconds)3 Minute Assessment Intervals（3分钟评估间隔）. If inadequate uterine tone, give 3 IU Oxytocin IV rescue dose.3 Total Doses of Oxytocin (Initial Load + 2 Rescue Doses)3 IU Oxytocin IV Maintenance Dose (3 IU/L at 100 mL/h) up to 8 hrs.3 Pharmacologic Options (e.g. Ergonovine麦角新碱, carboprost卡前列素 and misoprostol米索前列醇) if inadequate uterine tone persistsIntra- and Post- partum HemorrhageIntra- and Post- partum Hemorrhage（产时产后出血）（产时产后出血） Hemorrhage occurring during or following cesarean delivery is an increasing complication（出血是日益增长的产时产后并发症） that is associated with significant maternal morbidity and mortality. The identification of risk factors associated with uterine atony（发现子宫收缩乏力高危因素证据后需输血）requiring blood transfusion is of value, to allow preventative and therapeutic measures to be considered, including the use of intrauterine balloons, pro-coagulation and antifibrinolytic agents（抗纤溶药）, and interventional radiology and blood bank/hematology consultations（咨询输血科）Intra- and Post- partum HemorrhageIntra- and Post- partum HemorrhagePredictors of PPH Odds Ratio P （产后出血预测指标）Retained Placenta（前置胎盘） Antepartum Hemorrhage（产前出血） Multiple Gestation（多胎） Chorioamnionitis（绒毛膜羊膜炎） Hypertensive Diseases of Pregnancy（妊娠高血压） Polyhydramnios（羊水过多） Vaginal Delivery（初产）, Age 20-34 ReferenceCONCLUSION The rapidly changing field of obstetrical anesthesia has placed more emphasis on certain techniques and dosingRegimens（产科麻醉发展最快的领域往往关注在特定技术和药物剂量上）. By reflecting on and adopting many of these advances, more parturients (and anesthesiologists) will havea favorable experience before, during, and after a cesarean delivery(通过应用这些新进展，才能使麻醉医生和产妇获得最好的体验).Thank you Thank You世界触手可及世界触手可及携手共携手共进，，齐创精品工程精品工程。