急诊剖宫产的麻醉选择和术中处理英文版课件

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DefinitionoAbdominaldeliveryasurgicalprocedurethatpermitsdeliveryoftheinfantthroughincisionsintheabdominalanduterinewall.DefinitionAbdominaldeliveryCesareanSectionoCaedereSecooPompiliusII730BConotwidelyuseduntilthe1920sCesareanSectionCaedereSecoIndicationsforCesareanSectionoRepeatnSchedulednFailedattemptatvaginaldeliveryoDystociaoAbnormalpresentationnTransverselienBreechnMultiplegestationoFetalstress/distressoDeterioratingmaternalmedicalillnessnPreeclampsianHeartdiseasenPulmonarydiseaseoHemorrhagenPlacentaprevianPlacentalabruptionIndicationsforCesareanSectiCesareanSection60%unplannedoMoreextensiveperipartummonitoringoLowerthresholdforsurgicalinterventionCesareanSection60%unplannedWhatisanemergencyCaesareansection?-Category1&2GradeDefinition(at time of decision to operate)Category1ImmediatethreattolifeofwomanorfetusCategory2Maternalorfetalcompromise,notimmediatelylife-threateningCategory3NeedingearlydeliverybutnomaternalorfetalcompromiseCategory4AtatimetosuitthewomanandmaternityteamWhatisanemergencyCaesareCategory1IndicationoPlacentalabruptionouterineruptureocordprolapseoActivelybleedingplacentapraeviaoIntrapartumhemorrhageoPresumedfetalcompromisewithseverelyabnormalCTGand/orseverefetalacidosisCategory1IndicationPlacentaThe30-minuteruleoamaximumdecision-to-deliverytimeof30minforCategory1situationAssociationofAnaesthetistsofGreatBritainandIrelandandObstetricAnaesthesistsAssociation.Guidelinesforobstetricanaesthesiaservices;2005.HillemannsP,StraussA,HasbargenU,etal.Crashemergencycesareansection:decision-to-deliveryintervalunder30minanditseffectonApgarandumbilicalarterypH.ArchGynecolObstet2005;273:161165.oanaesthetistinformeddeliveryThe30-minuteruleamaximumdePerianestheticEvaluationoAdirectedhistoryandphysicalexaminationoplateletcountoAnintrapartumbloodtypeandscreenforallparturientsreducesmaternalcomplicationsoPerianestheticrecordingofthefetalheartratereducesfetalandneonatalcomplicationsPerianestheticEvaluationAdirAdirectedhistoryandphysicalexaminationoMaternalhealthandanesthetichistoryoRelevantobstetrichistoryoAirwayandheartandlungexaminationoBaselinebloodpressureoBackexaminationwhenneuraxialanesthesiaisplannedorplacedAdirectedhistoryandphysicaPlateletcountoAroutineintrapartumplateletcountdoesnotreducematernalanestheticcomplicationsoSuspectedpreeclampsiaorcoagulopathyoEclamptic-plt80*109.l-1MoodleyJ,JjuukoG,RoutC.EpiduralcomparedwithgeneralanaesthesiaforCaesareandeliveryinconsciouswomenwitheclampsia.BritishJournalofObstetricsandGynaecology2001;108:37882.PlateletcountAroutineintrAspirationProphylaxisoclearliquidsupto2hbeforeinductionofanesthesiaoAfastingperiodforsolids68h(fatcontent?)oFurtherrestrictionnmorbidobesity,diabetes,difficultairwaynnonreassuringfetalheartratepatternoAntacids,H2ReceptorAntagonists,andMetoclopramidereducesmaternalcomplicationsAspirationProphylaxisclearliPerianestheticMaternalPositionAortocavalcompression3mechanismsuteroplacentalperfusionpvenousreturnC.O.andBPpObstructionofuterinevenousdrainageuterinevenouspressureanduterinearteryperfusionpressurepCompressionofaortaorcommoniliacarteriesuterinearteryperfusionpressurePerianestheticMaternalPositPerianestheticMaternalPositionoAvoidaortocavalcompressionKinsellaSM.Editorial.Lateraltiltforpregnantwomen:why15degrees?Anaesthesia2003;58:8357.PerianestheticMaternalPositChoicesofAnesthesiaoGeneralanesthesiaoRegionalanesthesiaoLocalanesthesiaChoicesofAnesthesiaGeneralaChoicesofAnesthesia depends onothe indications for the surgeryothe degree of urgencyomaternal andfetus statusodesires of the patientSafest +most expedientmidwifeanesthetistobstetricianChoicesofAnesthesiadependRegionalanesthesiao85%emergencyCaesareansectiono85%emergeRegionalanesthesiaoEpiduralanesthesiaospinalanesthesiaoCombinedSpinal/Epidural(CSE)RegionalanesthesiaEpiduralanEpiduralpAsfastasGApTitrateddosingandsloweronsetriskofseverehypotensionandreduceduteroplacentalperfusionpDurationofsurgerynotanissuepLessintensemotorblockadepLowerextremity“musclepump”mayremainintactincidenceofthromboembolicdiseaseEpiduralEpiduralpRiskofsystemiclocaltoxicitypGreaterplacentaltransferofdrugthanwithspinalBUTdoesnotaffectneonatalApgar scoreandoflittleclinicalsignificancewhenappropriatedosesusedpRiskofhighspinalEpiduralEpiduraloThespeedofonsetoThechoiceoflocalanestheticoPossibleadjuvantsEpiduralThespeedofonsetEpiduralo0.5%bupivacaineo0.75%ropivacaineo0.5%levobupivacaineo2-chloroprocaineolidocaine1.8%lidocaine,0.76%bicarbonateand1:200000epinephrineAllamJ.Anaesthesia2008;63:243249.Epidural0.5%bupivacaineEpiduralfailureo24%failtoachieveapain-freeoperationKinsellaSM.Aprospectiveauditofregionalanaesthesiafailurein5080caesareansections.Anaesthesia2008;63:822832.oConversiontoSpinalanesthesia?ounpredictablehigh-spinalblocksoarelativecontraindicationtogivespinalanaesthesiafollowingepiduralanalgesiainlabourothedoseoflocalanesthesiaby2030%anduseadditionofopioidsoanormaldoseoflocalanesthesiaafter30minsincethelastdoseofepiduralwithnodocumentedblockEpiduralfailure24%failtoacSpinalpSimplepRapidonsetpDenseblockadepNegligiblematernalriskofsystemiclocaltoxicitypMinimaltransferofdrugtoinfantpNegligibleriskoflocalanestheticdepressionofinfantSpinalSimpleSpinalpRapidonsetofsympatheticblockadeabrupt,severehypotensionpLimiteddurationSpinalRapidonsetofsympathSpinalpBupivacaine(isobaric/hyperbaric)plevobupivacaine,ropivacainelessmotorblockade&toxicitypadditionofopioid(Morphine,fentanylorsufentanil)nReducetheneededdoseoflocalanaesthesianshortenthetimetoreadinessforsurgerynenhancesblockadeofvisceralpainnpostoperativeanalgesiaSpinalBupivacaine(isobaricSpinaloPeoloadcoloadoApplicationofmonitorsoSupplementaloxygenoLeftuterinedisplacementoAggressivetreatmentofhypotensionSpinalPeoloadcoloadAggressivetreatmentofhypotensionAggressivetreatmentofhypoteAggressivetreatmentofhypotensionpExaggeratedLUDpIVfluidspEphedrineand/orphenylephrineReflexbradycardia(HR45-50bpm)anticholinergicagentAggressivetreatmentofhypoteCombinedSpinalEpidural(CSE)Initiallydescribedin1981(epiduralcatheteratL1-2andspinalatL3-4)CombinedSpinalEpidural(CSCSEoRapidonsetanddensityofspinalanesthesiacombinedwithversatilityofepiduralanesthesiaoLow-dosespinaloreducetheincidencesofcardiovascularinstabilityoespeciallyusefulinhighriskcardiacpatientsCSERapidonsetanddensityoCSEpInabilitytotestepiduralcatheterp18%rateoffailurepextratimeconsumptionCSEInabilitytotestepiduraGeneralanesthesiao15%ofCSwasperformedundergeneralanesthesiainUSoMajorityofCSweredoneunderurgentoremergentsituationsGeneralanesthesia15%ofCSwaIndicationsforGAoFetaldistressoSignificantcoagulopathyoAcutematernalhypovolemiaandHomodynamicinstabilityoSepsisorlocalskininfectionofailedregionalanesthesiaoMaternalrefusalofregionalanesthesiaIndicationsforGAFetaldistreGAoRapidonsetoControlledairwayandventilationohandsarefreeforfluidmanagementandhemodynamicscontrolincasesofmajorbleedingoAlmostneverfailsoMinimalcooperationneededfromthepatientGARapidonsetGAp17XhigheranesthesiarelatedmortalitycomparedtoregionalanesthesiapRiskofdifficult/failedintubation10Xhigherthaninnon-obstetricpopulationpRiskofpulmunaryaspirationpContributetouterinerelaxation/atonypExtratimeneededatendofproceduretowakeupthethepatientpUsuallyfasteronsetofpostoperativepainpRiskofmalignanthyperthermiapRiskofintaoperativeawarenesspExposureoffetustodepressanteffectofGApMorecostlyGA17XhigheranesthesiaMostimportantcausesofmortalityduetoGAoInabilitytointubateoInabilitytoventilateoAspirationpneumonitisMostimportantcausesofmortaSuggestedTechniqueforCesareanSectionoThepatientisplacedsupinewithawedgeundertherighthipforleftuterinedisplacement.oPreoxygenation100%O235minoThepatientispreparedanddrapedforsurgeryoarapid-sequenceinductionwithcricoidpressurepropofol,2mg/kg(orthiopental4mg/kg)succinylcholine,1.5mg/kgKetamine,1mg/kg,isusedinsteadofthiopentalinhypovolemicorasthmaticpatients.SuggestedTechniqueforCesareSuggestedTechniqueforCesareanSectionoSurgeryisbegunonlyafterproperplacementoftheendotrachealtubeisconfirmedbycapnography.oExcessivehyperventilation(PaCO225mmHg)shouldbeavoidedbecauseitcanreduceuterinebloodflowandhasbeenassociatedwithfetalacidosis.SuggestedTechniqueforCesareSuggestedTechniqueforCesareanSectiono50%N2Oinoxygenwithupto0.75MACofalowconcentrationofavolatileagentisusedformaintenanceoAmusclerelaxantofintermediateduration(mivacurium,atracurium,cisatracurium,orrocuronium)isusedforrelaxationSuggestedTechniqueforCesareSuggestedTechniqueforCesareanSectionoAfterdelivered,2030Uofoxytocinisaddedtoeachliterofintravenousfluid.oN2Oconcentrationmaythenbeincreasedto70%and/oradditionalintravenousagents,suchasadditionalpropofol,anopioidorbenzodiazepine,canbegiventoensureamnesiaSuggestedTechniqueforCesareSuggestedTechniqueforCesareanSectionoIftheuterusdoesnotcontractreadily,anopioidshouldbegiven,andthehalogenatedagentshouldbediscontinuedoMethylergonovine(Methergine),0.2mgintramuscularly,mayalsobegivenbutcanincreasearterialbloodpressureo15-MethylprostaglandinF2(Hemabate),0.25mgintramuscularly,mayalsobeusedSuggestedTechniqueforCesareSuggestedTechniqueforCesareanSectionoAnattempttoaspirategastriccontentsmaybemadeviaanoralgastrictubetodecreasethelikelihoodofpulmonaryaspirationonemergenceoAttheendofsurgery,musclerelaxantsarecompletelyreversed,thegastrictube(ifplaced)isremoved,andthepatientisextubatedwhileawaketoreducetheriskofaspiration.SuggestedTechniqueforCesareObstetricHemorrhagicEmergenciesObstetricHemorrhagicEmergencObstetricHemorrhagicEmergenciesoLarge-boreintravenouscathetersoFluidwarmeroForced-airbodywarmeroAvailabilityofbloodbankresourcesoEquipmentforinfusingintravenousfluidsandbloodproductsrapidlyObstetricHemorrhagicEmergencSuggestedResourcesforAirwayManagementduringInitialProvisionofNeuraxialAnesthesiaoLaryngoscopeandassortedbladesoEndotrachealtubes,withstyletsoOxygensourceoSuctionsourcewithtubingandcathetersoSelf-inflatingbagandmaskforpositive-pressureventilationoMedicationsforbloodpressuresupport,musclerelaxation,andhypnosisoQualitativecarbondioxidedetectoroPulseoximeterSuggestedResourcesforAirwaySuggestedContentsofaPortableStorageUnitforDifficultAirwayManagementforCesareanDeliveryRoomsoRigidlaryngoscopebladesofalternatedesignandsizefromthoseroutinelyusedoLaryngealmaskairwayoEndotrachealtubesofassortedsizeoEndotrachealtubeguidesoRetrogradeintubationequipmentoAtleastonedevicesuitableforemergencynonsurgicalairwayventilationoFiberopticintubationequipmentoEquipmentsuitableforemergencysurgicalairwayaccess(e.g.,cricothyrotomy)oAnexhaledcarbondioxidedetectoroTopicalanestheticsandvasoconstrictorsSuggestedContentsofaPortab急诊剖宫产的麻醉选择和术中处理英文版课件SummaryoAdistinctionmustbemadebetweenatrueemergencyrequiringimmediatedeliveryandoneinwhichsomedelayispossibleoSpinalorepiduralanesthesiaispreferredtogeneralanesthesiaforcesareansectionbecauseregionalanesthesiaisassociatedwithlowermaternalmortalityoHypotensionisthemostcommonsideeffectofregionalanesthetictechniquesandmustbetreatedaggressivelywithvasopressorsandintravenousfluidbolusestopreventfetalcompromiseSummarySummaryoRegardlessofthetimeoflastoralintake,allobstetricpatientsareconsideredtohaveafullstomachandtobeatriskforpulmonaryaspirationoUterinedisplacement(usuallyleftdisplacement)shouldbemaintainedoDeliveryunitsshouldhavepersonnelandequipmentreadilyavailabletomanageairwayemergencies,consistentwiththeASAPracticeGuidelinesforManagementoftheDifficultAirwaySummaryRegardlessofthetimeThanks!Thanks!