急诊剖宫产的麻醉选择和术中处理课件

急诊剖宫产的麻醉选择和术中处理费敏2019-3-26DefinitionoAbdominaldeliveryasurgicalprocedurethatpermitsdeliveryoftheinfantthroughincisionsintheabdominalanduterinewall.CesareanSectionoCaedereSecooPompiliusII730BConotwidelyuseduntilthe1920sIndicationsforCesareanSectionoRepeatnSchedulednFailedattemptatvaginaldeliveryoDystociaoAbnormalpresentationnTransverselienBreechnMultiplegestationoFetalstress/distressoDeterioratingmaternalmedicalillnessnPreeclampsianHeartdiseasenPulmonarydiseaseoHemorrhagenPlacentaprevianPlacentalabruptionCesareanSection60%unplannedoMoreextensiveperipartummonitoringoLowerthresholdforsurgicalinterventionWhatisanemergencyCaesareansection?-Category1&2GradeDefinition(at time of decision to operate)Category1ImmediatethreattolifeofwomanorfetusCategory2Maternalorfetalcompromise,notimmediatelylife-threateningCategory3NeedingearlydeliverybutnomaternalorfetalcompromiseCategory4AtatimetosuitthewomanandmaternityteamCategory1IndicationoPlacentalabruptionouterineruptureocordprolapseoActivelybleedingplacentapraeviaoIntrapartumhemorrhageoPresumedfetalcompromisewithseverelyabnormalCTGand/orseverefetalacidosisThe30-minuteruleoamaximumdecision-to-deliverytimeof30minforCategory1situationAssociationofAnaesthetistsofGreatBritainandIrelandandObstetricAnaesthesistsAssociation.Guidelinesforobstetricanaesthesiaservices;2019.HillemannsP,StraussA,HasbargenU,etal.Crashemergencycesareansection:decision-to-deliveryintervalunder30minanditseffectonApgarandumbilicalarterypH.ArchGynecolObstet2019;273:161165.oanaesthetistinformeddeliveryPerianestheticEvaluationoAdirectedhistoryandphysicalexaminationoplateletcountoAnintrapartumbloodtypeandscreenforallparturientsreducesmaternalcomplicationsoPerianestheticrecordingofthefetalheartratereducesfetalandneonatalcomplicationsAdirectedhistoryandphysicalexaminationoMaternalhealthandanesthetichistoryoRelevantobstetrichistoryoAirwayandheartandlungexaminationoBaselinebloodpressureoBackexaminationwhenneuraxialanesthesiaisplannedorplacedPlateletcountoAroutineintrapartumplateletcountdoesnotreducematernalanestheticcomplicationsoSuspectedpreeclampsiaorcoagulopathyoEclamptic-plt80*109.l-1MoodleyJ,JjuukoG,RoutC.EpiduralcomparedwithgeneralanaesthesiaforCaesareandeliveryinconsciouswomenwitheclampsia.BritishJournalofObstetricsandGynaecology2019;108:37882.AspirationProphylaxisoclearliquidsupto2hbeforeinductionofanesthesiaoAfastingperiodforsolids68h(fatcontent?)oFurtherrestrictionnmorbidobesity,diabetes,difficultairwaynnonreassuringfetalheartratepatternoAntacids,H2ReceptorAntagonists,andMetoclopramidereducesmaternalcomplicationsPerianestheticMaternalPositionAortocavalcompression3mechanismsuteroplacentalperfusionpvenousreturnC.O.andBPpObstructionofuterinevenousdrainageuterinevenouspressureanduterinearteryperfusionpressurepCompressionofaortaorcommoniliacarteriesuterinearteryperfusionpressurePerianestheticMaternalPositionoAvoidaortocavalcompressionKinsellaSM.Editorial.Lateraltiltforpregnantwomen:why15degrees?Anaesthesia2019;58:8357.ChoicesofAnesthesiaoGeneralanesthesiaoRegionalanesthesiaoLocalanesthesiaChoicesofAnesthesia depends onothe indications for the surgeryothe degree of urgencyomaternal andfetus statusodesires of the patientSafest +most expedientmidwifeanesthetistobstetricianRegionalanesthesiao85%emergencyCaesareansectiono3%RegionalanesthesiarequireconversiontoGARegionalanesthesiaoEpiduralanesthesiaospinalanesthesiaoCombinedSpinal/Epidural(CSE)EpiduralpAsfastasGApTitrateddosingandsloweronsetriskofseverehypotensionandreduceduteroplacentalperfusionpDurationofsurgerynotanissuepLessintensemotorblockadepLowerextremity“musclepump”mayremainintactincidenceofthromboembolicdiseaseEpiduralpRiskofsystemiclocaltoxicitypGreaterplacentaltransferofdrugthanwithspinalBUTdoesnotaffectneonatalApgar scoreandoflittleclinicalsignificancewhenappropriatedosesusedpRiskofhighspinalEpiduraloThespeedofonsetoThechoiceoflocalanestheticoPossibleadjuvantsEpiduralo0.5%bupivacaineo0.75%ropivacaineo0.5%levobupivacaineo2-chloroprocaineolidocaine1.8%lidocaine,0.76%bicarbonateand1:200000epinephrineAllamJ.Anaesthesia2019;63:243249.Epiduralfailureo24%failtoachieveapain-freeoperationKinsellaSM.Aprospectiveauditofregionalanaesthesiafailurein5080caesareansections.Anaesthesia2019;63:822832.oConversiontoSpinalanesthesia?nunpredictablehigh-spinalblocksnarelativecontraindicationtogivespinalanaesthesiafollowingepiduralanalgesiainlabourothedoseoflocalanesthesiaby2030%anduseadditionofopioidsoanormaldoseoflocalanesthesiaafter30minsincethelastdoseofepiduralwithnodocumentedblockSpinalpSimplepRapidonsetpDenseblockadepNegligiblematernalriskofsystemiclocaltoxicitypMinimaltransferofdrugtoinfantpNegligibleriskoflocalanestheticdepressionofinfantSpinalpRapidonsetofsympatheticblockadeabrupt,severehypotensionpLimiteddurationSpinalpBupivacaine(isobaric/hyperbaric)plevobupivacaine,ropivacainelessmotorblockade&toxicitypadditionofopioid(Morphine,fentanylorsufentanil)nReducetheneededdoseoflocalanaesthesianshortenthetimetoreadinessforsurgerynenhancesblockadeofvisceralpainnpostoperativeanalgesiaSpinaloPeoloadcoloadoApplicationofmonitorsoSupplementaloxygenoLeftuterinedisplacementoAggressivetreatmentofhypotensionAggressivetreatmentofhypotensionAggressivetreatmentofhypotensionpExaggeratedLUDpIVfluidspEphedrineand/orphenylephrineReflexbradycardia(HR45-50bpm)anticholinergicagentCombinedSpinalEpidural(CSE)Initiallydescribedin1981(epiduralcatheteratL1-2andspinalatL3-4)CSEoRapidonsetanddensityofspinalanesthesiacombinedwithversatilityofepiduralanesthesiaoLow-dosespinalnreducetheincidencesofcardiovascularinstabilitynespeciallyusefulinhighriskcardiacpatientsCSEpInabilitytotestepiduralcatheterp18%rateoffailurepextratimeconsumptionGeneralanesthesiao15%ofCSwasperformedundergeneralanesthesiainUSoMajorityofCSweredoneunderurgentoremergentsituationsIndicationsforGAoFetaldistressoSignificantcoagulopathyoAcutematernalhypovolemiaandHomodynamicinstabilityoSepsisorlocalskininfectionofailedregionalanesthesiaoMaternalrefusalofregionalanesthesiaGAoRapidonsetoControlledairwayandventilationohandsarefreeforfluidmanagementandhemodynamicscontrolincasesofmajorbleedingoAlmostneverfailsoMinimalcooperationneededfromthepatientGAp17XhigheranesthesiarelatedmortalitycomparedtoregionalanesthesiapRiskofdifficult/failedintubation10Xhigherthaninnon-obstetricpopulationpRiskofpulmunaryaspirationpContributetouterinerelaxation/atonypExtratimeneededatendofproceduretowakeupthethepatientpUsuallyfasteronsetofpostoperativepainpRiskofmalignanthyperthermiapRiskofintaoperativeawarenesspExposureoffetustodepressanteffectofGApMorecostlyMostimportantcausesofmortalityduetoGAoInabilitytointubateoInabilitytoventilateoAspirationpneumonitisSuggestedTechniqueforCesareanSectionoThepatientisplacedsupinewithawedgeundertherighthipforleftuterinedisplacement.oPreoxygenation100%O235minoThepatientispreparedanddrapedforsurgeryoarapid-sequenceinductionwithcricoidpressurepropofol,2mg/kg(orthiopental4mg/kg)succinylcholine,1.5mg/kgKetamine,1mg/kg,isusedinsteadofthiopentalinhypovolemicorasthmaticpatients.SuggestedTechniqueforCesareanSectionoSurgeryisbegunonlyafterproperplacementoftheendotrachealtubeisconfirmedbycapnography.oExcessivehyperventilation(PaCO225mmHg)shouldbeavoidedbecauseitcanreduceuterinebloodflowandhasbeenassociatedwithfetalacidosis.SuggestedTechniqueforCesareanSectiono50%N2Oinoxygenwithupto0.75MACofalowconcentrationofavolatileagentisusedformaintenanceoAmusclerelaxantofintermediateduration(mivacurium,atracurium,cisatracurium,orrocuronium)isusedforrelaxationSuggestedTechniqueforCesareanSectionoAfterdelivered,2030Uofoxytocinisaddedtoeachliterofintravenousfluid.oN2Oconcentrationmaythenbeincreasedto70%and/oradditionalintravenousagents,suchasadditionalpropofol,anopioidorbenzodiazepine,canbegiventoensureamnesiaSuggestedTechniqueforCesareanSectionoIftheuterusdoesnotcontractreadily,anopioidshouldbegiven,andthehalogenatedagentshouldbediscontinuedoMethylergonovine(Methergine),0.2mgintramuscularly,mayalsobegivenbutcanincreasearterialbloodpressureo15-MethylprostaglandinF2(Hemabate),0.25mgintramuscularly,mayalsobeusedSuggestedTechniqueforCesareanSectionoAnattempttoaspirategastriccontentsmaybemadeviaanoralgastrictubetodecreasethelikelihoodofpulmonaryaspirationonemergenceoAttheendofsurgery,musclerelaxantsarecompletelyreversed,thegastrictube(ifplaced)isremoved,andthepatientisextubatedwhileawaketoreducetheriskofaspiration.ObstetricHemorrhagicEmergenciesObstetricHemorrhagicEmergenciesoLarge-boreintravenouscathetersoFluidwarmeroForced-airbodywarmeroAvailabilityofbloodbankresourcesoEquipmentforinfusingintravenousfluidsandbloodproductsrapidlySuggestedResourcesforAirwayManagementduringInitialProvisionofNeuraxialAnesthesiaoLaryngoscopeandassortedbladesoEndotrachealtubes,withstyletsoOxygensourceoSuctionsourcewithtubingandcathetersoSelf-inflatingbagandmaskforpositive-pressureventilationoMedicationsforbloodpressuresupport,musclerelaxation,andhypnosisoQualitativecarbondioxidedetectoroPulseoximeterSuggestedContentsofaPortableStorageUnitforDifficultAirwayManagementforCesareanDeliveryRoomsoRigidlaryngoscopebladesofalternatedesignandsizefromthoseroutinelyusedoLaryngealmaskairwayoEndotrachealtubesofassortedsizeoEndotrachealtubeguidesoRetrogradeintubationequipmentoAtleastonedevicesuitableforemergencynonsurgicalairwayventilationoFiberopticintubationequipmentoEquipmentsuitableforemergencysurgicalairwayaccess(e.g.,cricothyrotomy)oAnexhaledcarbondioxidedetectoroTopicalanestheticsandvasoconstrictorsSummaryoAdistinctionmustbemadebetweenatrueemergencyrequiringimmediatedeliveryandoneinwhichsomedelayispossibleoSpinalorepiduralanesthesiaispreferredtogeneralanesthesiaforcesareansectionbecauseregionalanesthesiaisassociatedwithlowermaternalmortalityoHypotensionisthemostcommonsideeffectofregionalanesthetictechniquesandmustbetreatedaggressivelywithvasopressorsandintravenousfluidbolusestopreventfetalcompromiseSummaryoRegardlessofthetimeoflastoralintake,allobstetricpatientsareconsideredtohaveafullstomachandtobeatriskforpulmonaryaspirationoUterinedisplacement(usuallyleftdisplacement)shouldbemaintainedoDeliveryunitsshouldhavepersonnelandequipmentreadilyavailabletomanageairwayemergencies,consistentwiththeASAPracticeGuidelinesforManagementoftheDifficultAirwayThanks!