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DefinitionoAbdominal delivery a surgical procedure that permits delivery of the infant through incisions in the abdominal and uterine wall.Cesarean Sectiono Caedere Secoo Pompilius II 730 BCo not widely used until the 1920sIndications for Cesarean Sectiono RepeatnSchedulednFailed attempt at vaginal deliveryo Dystociao Abnormal presentationnTransverse lienBreechnMultiple gestationo Fetal stress/distresso Deteriorating maternal medical illnessnPreeclampsianHeart diseasenPulmonary diseaseo HemorrhagenPlacenta previanPlacental abruptionCesarean Section60%unplannedo More extensive peripartum monitoringo Lower threshold for surgical intervention What is an emergency Caesarean section?-Category 1&2GradeDefinition(at time of decision to operate)Category 1 Immediate threat to life of woman or fetusCategory 2Maternal or fetal compromise,not immediately life-threateningCategory 3Needing early delivery but no maternal or fetal compromiseCategory 4At a time to suit the woman and maternity teamCategory 1 Indicationo Placental abruptiono uterine ruptureo cord prolapseo Actively bleeding placenta praeviao Intrapartum hemorrhage o Presumed fetal compromise with severely abnormal CTG and/or severe fetal acidosis The 30-minute ruleo 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.o anaesthetist informed deliveryPerianesthetic Evaluationo A directed history and physical examinationo platelet counto An intrapartum blood type and screen for all parturients reduces maternal complicationso Perianesthetic recording of the fetal heart rate reduces fetal and neonatal complicationsA directed history and physical examinationo Maternal health and anesthetic historyo Relevant obstetric historyo Airway and heart and lung examinationo Baseline blood pressureo Back examination when neuraxial anesthesia is planned or placedPlatelet count o A routine intrapartum platelet count does not reduce maternal anesthetic complicationso Suspected preeclampsia or coagulopathy o 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.Aspiration Prophylaxiso clear liquids up to 2h before induction of anesthesia o A fasting period for solids 68 h(fat content?)o Further restrictionnmorbid obesity,diabetes,difficult airwaynnonreassuring fetal heart rate patterno Antacids,H2 Receptor Antagonists,and Metoclopramide reduces maternal complicationsPerianesthetic Maternal PositionAortocaval compression 3 mechanisms uteroplacental perfusion p venous return C.O.and BPpObstruction of uterine venous drainage uterine venous pressure and uterine artery perfusion pressurepCompression of aorta or common iliac arteries uterine artery perfusion pressurePerianesthetic Maternal PositionoAvoid aortocaval compression Kinsella SM.Editorial.Lateral tilt for pregnant women:why 15 degrees?Anaesthesia 2003;58:8357.Choices of AnesthesiaoGeneral anesthesiaoRegional anesthesiaoLocal anesthesiaChoices of Anesthesiadependsono theindicationsforthesurgeryo thedegreeofurgencyo maternaland fetusstatuso desiresofthepatient+midwifeanesthetistobstetricianRegional anesthesiao 85%emergency Caesarean sectiono 3%Regional anesthesia require conversion to GARegional anesthesiao Epidural anesthesiao spinal anesthesiao Combined Spinal/Epidural(CSE)Epidural p As fast as GAp Titrated dosing and slower onset risk of severe hypotension and reduced uteroplacental perfusionp Duration of surgery not an issuep Less intense motor blockadep Lower extremity“muscle pump”may remain intact incidence of thromboembolic diseaseEpidural p Risk of systemic local toxicityp Greater placental transfer of drug than with spinal BUT does not affect neonatal Apgarscore and of little clinical significance when appropriate doses usedp Risk of high spinalEpiduralo The speed of onseto The choice of local anesthetic o Possible adjuvants Epiduralo 0.5%bupivacaine o 0.75%ropivacaineo 0.5%levobupivacaineo 2-chloroprocaineo lidocaine 1.8%lidocaine,0.76%bicarbonate and 1:200 000 epinephrine Allam J.Anaesthesia 2008;63:243249.Epidural failureo 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.o Conversion to Spinal anesthesia?nunpredictable high-spinal blocksna relative contraindication to give spinal anaesthesia following epidural analgesia in labouro the dose of local anesthesia by 2030%and use addition of opioidsoa normal dose of local anesthesia after 30 min since the last dose of epidural wit