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麻醉選擇和術(shù)中處理2010-3-26DefinitionAbdominaldelivery

asurgicalprocedurethatpermitsdeliveryoftheinfantthroughincisionsintheabdominalanduterinewall.CesareanSectionCaedere–SecoPompiliusII

730BCnotwidelyuseduntilthe1920sCesareanSection>60%unplannedMoreextensiveperipartummonitoringLowerthresholdforsurgicalinterventionWhatisan‘emergency’Caesareansection?-Category1&2GradeDefinition(attimeofdecisiontooperate)Category1ImmediatethreattolifeofwomanorfetusCategory2Maternalorfetalcompromise,notimmediatelylife-threateningCategory3NeedingearlydeliverybutnomaternalorfetalcompromiseCategory4AtatimetosuitthewomanandmaternityteamCategory1

IndicationPlacentalabruptionuterinerupture

cordprolapse

ActivelybleedingplacentapraeviaIntrapartumhemorrhagePresumedfetalcompromisewithseverelyabnormalCTGand/orseverefetalacidosisPerianestheticEvaluationAdirectedhistoryandphysicalexaminationplateletcountAnintrapartumbloodtypeandscreenforallparturientsreducesmaternalcomplicationsPerianestheticrecordingofthefetalheartratereducesfetalandneonatalcomplicationsAdirectedhistoryandphysicalexaminationMaternalhealthandanesthetichistoryRelevantobstetrichistoryAirwayandheartandlungexaminationBaselinebloodpressureBackexaminationwhenneuraxialanesthesiaisplannedorplaced

PlateletcountAroutineintrapartumplateletcountdoesnotreducematernalanestheticcomplicationsSuspectedpreeclampsiaorcoagulopathyEclamptic-plt>80*109.l-1

MoodleyJ,JjuukoG,RoutC.EpiduralcomparedwithgeneralanaesthesiaforCaesareandeliveryinconsciouswomenwitheclampsia.BritishJournalofObstetricsandGynaecology2001;108:378–82.Perianesthetic–MaternalPositionAortocavalcompression3mechanismsuteroplacentalperfusionvenousreturnC.O.andBPObstructionofuterinevenousdrainageuterinevenouspressureanduterinearteryperfusionpressureCompressionofaortaorcommoniliacarteriesuterinearteryperfusionpressurePerianesthetic–MaternalPositionAvoidaortocavalcompressionKinsellaSM.Editorial.Lateraltiltforpregnantwomen:why15degrees?Anaesthesia2003;58:835–7.ChoicesofAnesthesiaGeneralanesthesiaRegionalanesthesiaLocalanesthesiaRegionalanesthesia>85%emergencyCaesareansection<3%RegionalanesthesiarequireconversiontoGARegionalanesthesiaEpiduralanesthesiaspinalanesthesiaCombinedSpinal/Epidural(CSE)Epidural√AsfastasGATitrateddosingandsloweronsetriskofseverehypotensionandreduceduteroplacentalperfusionDurationofsurgerynotanissueLessintensemotorblockadeLowerextremity“musclepump”mayremainintactincidenceofthromboembolicdiseaseEpiduralThespeedofonsetThechoiceoflocalanestheticPossibleadjuvantsEpidural0.5%bupivacaine0.75%ropivacaine0.5%levobupivacaine2-chloroprocainelidocaine1.8%lidocaine,0.76%bicarbonateand1:200000epinephrine

AllamJ.Anaesthesia2008;63:243–249.Epiduralfailure24%failtoachieveapain-freeoperation

KinsellaSM.Aprospectiveauditofregionalanaesthesiafailurein5080caesareansections.Anaesthesia2008;63:822–832.ConversiontoSpinalanesthesia?unpredictablehigh-spinalblocksarelativecontraindicationtogivespinalanaesthesiafollowingepiduralanalgesiainlabourthedoseoflocalanesthesiaby20–30%anduseadditionofopioidsanormaldoseoflocalanesthesiaafter30minsincethelastdoseofepiduralwithnodocumentedblockSpinal×Rapidonsetofsympatheticblockade–abrupt,severehypotensionLimiteddurationSpinalBupivacaine(isobaric/hyperbaric)levobupivacaine,ropivacaine

lessmotorblockade&toxicityadditionofopioid(Morphine

,fentanylorsufentanil)ReducetheneededdoseoflocalanaesthesiashortenthetimetoreadinessforsurgeryenhancesblockadeofvisceralpainpostoperativeanalgesiaAggressivetreatmentofhypotensionExaggeratedLUDIVfluidsEphedrineand/orphenylephrine

Reflexbradycardia(HR<45-50bpm)

anticholinergicagentCombinedSpinal–Epidural(CSE)

Initiallydescribedin1981(epiduralcatheteratL1-2andspinalatL3-4)CSE√RapidonsetanddensityofspinalanesthesiacombinedwithversatilityofepiduralanesthesiaLow-dosespinalreducetheincidencesofcardiovascularinstabilityespeciallyusefulinhighriskcardiacpatientsCSE×Inabilitytotestepiduralcatheter18%rateoffailureextratimeconsumptionGeneralanesthesia15%ofCSwasperformedundergeneralanesthesiainUSMajorityofCSweredoneunderurgentoremergentsituationsIndicationsforGAFetaldistressSignificantcoagulopathyAcutematernalhypovolemiaandHomodynamicinstabilitySepsisorlocalskininfectionfailedregionalanesthesiaMaternalrefusalofregionalanesthesia

GA

√RapidonsetControlledairwayandventilationhandsarefreeforfluidmanagementandhemodynamicscontrolincasesofmajorbleedingAlmostneverfailsMinimalcooperationneededfromthepatientGA×17

XhigheranesthesiarelatedmortalitycomparedtoregionalanesthesiaRiskofdifficult/failedintubation

10Xhigherthaninnon-obstetricpopulationRiskofpulmunaryaspirationContributetouterine

relaxation/atonyExtratimeneededatendofproceduretowakeupthethepatientUsuallyfasteronsetofpostoperativepainRiskofmalignanthyperthermiaRiskofintaoperativeawarenessExposureoffetustodepressanteffectofGAMorecostlyMostimportantcausesofmortalityduetoGAInabilitytointubateInabilitytoventilateAspirationpneumonitisSuggestedTechniqueforCesareanSectionThepatientisplacedsupinewithawedgeundertherighthipforleftuterinedisplacement.Preoxygenation100%O23–5minThepatientispreparedanddrapedforsurgeryarapid-sequenceinductionwithcricoidpressure

propofol,2mg/kg(orthiopental4mg/kg)succinylcholine,1.5mg/kgKetamine,1mg/kg,isusedinsteadofthiopentalinhypovolemicorasthmaticpatients.SuggestedTechniqueforCesareanSectionSurgeryisbegunonlyafterproperplacementoftheendotrachealtubeisconfirmedbycapnography.Excessivehyperventilation(PaCO2<25mmHg)shouldbeavoidedbecauseitcanreduceuterinebloodflowandhasbeenassociatedwithfetalacidosis.SuggestedTechniqueforCesareanSection50%N2Oinoxygenwithupto0.75MACofalowconcentrationofavolatileagentisusedformaintenanceAmusclerelaxantofintermediateduration(mivacurium,atracurium,cisatracurium,orrocuronium)isusedforrelaxationSuggestedTechniqueforCesareanSectionAfterdelivered,20–30Uofoxytocinisaddedtoeachliterofintravenousfluid.N2Oconcentrationmaythenbeincreasedto70%and/oradditionalintravenousagents,suchasadditionalpropofol,anopioidorbenzodiazepine,canbegiventoensureamnesiaSuggestedTechniqueforCesareanSectionIftheuterusdoesnotcontractreadily,anopioidshouldbegiven,andthehalogenatedagentshouldbediscontinuedMethylergonovine(Methergine),0.2mgintramuscularly,mayalsobegivenbutcanincreasearterialbloodpressure15-MethylprostaglandinF2(Hemabate),0.25mgintramuscularly,mayalsobeusedSuggestedTechniqueforCesareanSectionAnattempttoaspirategastriccontentsmaybemadeviaanoralgastrictubetodecreasethelikelihoodofpulmonaryaspirationonemergenceAttheendofsurgery,musclerelaxantsarecompletelyreversed,thegastrictube(ifplaced)isremoved,andthepatientisextubatedwhileawaketoreducetheriskofaspiration.ObstetricHemorrhagicEmergenciesObstetricHemorrhagicEmergenciesLarge-boreintravenouscathetersFluidwarmerForced-airbodywarmerAvailabilityofbloodbankresourcesEquipmentforinfusingintravenousfluidsandbloodproductsrapidlySuggestedResourcesforAirwayManagementduringInitialProvisionofNeuraxialAnesthesiaLaryngoscopeandassortedbladesEndotrachealtubes,withstyletsOxygensourceSuctionsourcewithtubingandcathetersSelf-inflatingbagandmaskforpositive-pressureventilationMedicationsforbloodpressuresupport,musclerelaxation,andhypnosisQualitativecarbondioxidedetectorPulseoximeterSuggestedContentsofaPortableStorageUnitfor

DifficultAirwayManagementforCesareanDeliveryRoomsRigidlaryngoscopebladesofalternatedesignandsizefromthoseroutinelyusedLaryngealmaskairwayEndotrachealtubesofassortedsizeEndotrachealtubeguidesRetrogradeintubationequipmentAtleastonedevicesuitableforemergencynonsurgicalairwayventilationFiberopticintubationequipmentEquipmentsuitableforemergencysurgicalairwayacc