产科麻醉英文版课件

,单击此处编辑母版标题样式,*,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,Obstetric Anesthesia,Obstetric Anesthesia,1,Physiologic Changes Of Pregnancy,Cardiovascular System : cardiac output , heart rate,Hematologic System : blood volume increases by up to 45% , red cell volume increases by only 30% physiologic anemia,Physiologic Changes Of Pregnan,2,Respiratory System :,increase in the respiratory minute volume and work of breathing,Gastrointestinal System :,risk of incidence of aspiration,endotracheal intubation,Renal System,:,GFR rises 50%,; glycosuria,Central Nervous System :,sensitivity to anesthetics.,Physiologic Changes Of Pregnancy,Respiratory System : increase,3,Changes,Of,Respiratory System,O,2,(,Consumption 消耗,) +20 to +50%,MV(,Minute,Ventilation分钟通气量,)+50%,TV +40%,P,a,O,2,+10%,P,a,CO,2,-15%,HCO,3,-15%,FRC -20%,Changes Of Respiratory System,4,Placental Transfer Of Anesthetic Drugs,Placenta transport :,Simple diffusion,Facilitated diffusion,Active transport,Pinocytosis,Readily cross,:,low molecular weights,high lipid solubility,non-ionized,Approximately 50%,of the umbilical venous blood,bypasses the liver.,Placental Transfer Of Anesthet,5,Narcotic analgesic morphine pethidine fentanyl alfentanil sufentanil,General anesthetics propofol,吗啡、哌替啶、芬太尼,Narcotic analgesic morphin,6,Morphine,Placental transfer is rapid,Mother: uterus reactiveness,orthostatic hypotension,nausea,vomiting,delayed gastric emptying,Fetus: respiratory depression,Morphine Placental transfer is,7,Pethidine,Most commonly used,during labor,intramuscular dose,:,50 -100 mg,Time of IM: before expulsion 1 h or 4 h,uterine contraction, frequency and intension,Pethidine Most commonly used,8,Fentanyl Alfentanil Sufentanil,Placental transfer is rapid,Low,dose,:,10 -25 g fentanyl or 5-10 g sufentanil in subarachnoid space,PCEA: low dose of fentanyl and 0.1%-0.3% ropivacaine,Fentanyl Alfentanil Sufentanil,9,Tramadol,Placental transfer,No inhibiting uterine contraction,No Respiratory depression,Tramadol Placental transfer,10,Diazepam,Readily cross the placenta,H,alf-lives: 48 hours,Problems: sedation, hypotonia,cyanosis, impaired,metabolic responses to stress.,Diazepam Readily cross the pl,11,Midazolam,Plasma protein binding: 94%,Respiratory depression: depended on dose,0.075 mg/kg no problem,0.15 mg/kg different degree,Midazolam Plasma protein bindi,12,Droperidol,Pregnant woman,:,慎用,Apgar score,Droperidol Pregnant woman: 慎,13,Thiopental sodium,Neonatus sleep: little,Premature and intrauterine embarrass: carefully using,Thiopental sodium Neonatus sle,14,Ketamine,High doses (,greater than 2 mg/kg,) may cause low Apgar scores and abnormalities in neonatal muscle tone,Labor pains,of,uterine contraction,Uterine muscular tension and contraction force,Contraindication: psychosis,gestational hypertension syndrome or preeclampsia,metrorrhexis,Ketamine High doses (greater t,15,Propofol,Recommendation:,induction: 2.5 mg/kg,maintenance: 2.5-5.0 mg/kg/h,Discontinue gravidity only,Propofol Recommendation:,16,N,2,O,Placental transfer is rapid,Mothers respiration, circulation and Uterine muscular contraction force,20-30s before of first stage of labor: 50% O,2,and 50% N,2,O, maximumhalothane,Sevoflurane Placental transfer,19,Succinylcholine,Cholinesterase: normal dose,no placental transfer,Dose 300 mg or single dose is larger: still have p,lacental transfer,Succinylcholine Cholinesteras,20,Nondepolarizing Muscle Relaxants,Onset is quick, maintanence is short and placental transfer is least,Atracurium: 0.3 mg/kg,Nondepolarizing Muscle Relaxan,21,Local anesthetics,Factors:,Protein binding:,Molecular weight,Liposolubility,Catabolism in the placent,Local anestheticsFactors:,22,Local anesthetics,Procaine,Lidocaine,Bupivacaine,Ropivacaine,Local anesthetics Procaine,23,Anesthesia For Sesarean Section,Choice depends on :,the indications for the surgery,the degree of urgency,maternal status,desires of the patient,Anesthesia For Sesarean Sectio,24,Spinal Anesthesia,Hyperbaric bupivacaine,Advantages,: rapid onset, little,risk,of local anesthetic toxicity, minimal transfer to the fetus, infrequent failure.,Disadvantages,: finite duration,hypotension,headache,Spinal Anesthesia Hyperbaric,25,Epidural Anesthesia,L,23,or L,12,1.5%2% Lidocaine or 0.5% Ropivacaine,emergency cesarean section,Epidural Anesthesia,26,Combined Spinal-Epidural Technique,Increased dramatically in popularity,Advantage,s,:,rapid onset,supplemented at any time,anesthetic dose,sacral nerves block is sufficient,Combined Spinal-Epidural Techn,27,General Anesthesia,rapid induction:,obviate positive pressure ventilation,oppress the cricoid cartilage,mainterance: light anesthesia,vomiting, backstreaming and aspiration:,atropine, 0.5 mg, IM,or glycopyrolate, 0.2 mg, IM,General Anesthesia rapid induc,28,Supine hypotensive syndrome,Incidence: 2%30%,Time: after 28 weeks, specially 3236 weeks,Symptoms:,hypotension,dizziness,nausea,chest distress,cold sweat,to yawn,pulse rate,pallescence,Supine hypotensive syndrome I,29,High risk pregnancy,Emergency operation :,late trimester of pregnancy: hemorrhage,gestational hypertension syndrom and eclampsia,Selective operation :,hypertension,cardiac disease,diabetes,multifetation,High risk pregnancy Emergency,30,Placenta Previa and Placental Abruption,Preanesthtic preparation:,blood coagulation function,DIC sifting test,acute renal failure,Principle:,general anesthesia,: active bleeding, hypovolemic shock, definite blood coagulation disfunction or DIC,intraspinal anesthesia,: condition of mother and fetus is okay,Management,Placenta Previa and Placental,31,degrees of abruptio placentae.,A,Concealed hemorrhage.,B,External hemorrhage.,C,Complete placental separation,.,degrees of abruptio placentae.,32,Types of placenta previa.,33,Management of anesthesia,Announcements of the induction:,difficult airway,cricoid cartilage,backstreaming and aspiration,Prepare to salvage the blood coagulation disfunction and the hemorrhoea.,Prevent the acute renal function failure:,urine volume,urea nitrogen and creatinine,Prevention and cure of DIC,Management of anesthesia Annou,34,Pregnancy-induced hypertension syndrome,Incidence: 10.3%,Cause of death:,cerebrovascular accident,pneumonedema,liver necrosis,Pathophysiology:,systemic arteriola systole, fetus,Management:,Severe Pregnancy-induced hyper,37,HELLP syndrome,cardiac failure,cerebral hemorrhage,placental abruption,blood coagulation disfunction,haematolysis,hepatic enzyme,thrombocytopenia,acute renal failure,HELLP syndrome cardiac failur,38,Management 1,trying stable anesthesia:,stress reaction: fentanyl,avoid to use ketamine,SBP: 140150 mmHg, DBP: about 90 mmHg,ganglioplegic or nitroglycerin,maintain heart, kindey and lung function:,treatment of complication:,Management 1 trying stable ane,39,Management 2,basic monitoring:,ECG,SpO2,NIBP,CVP,urine volume,blood gas analysis,prepare to salvage the neonatal asphyxia,ICU,postoperation analgesia,Management 2 basic monitoring:,40,Multiple Births,pathophysiology:,abdominal aorta and inferior vena cava compression;,fetal lung maturity;,incidence of postpartum hemorrhage.,anesthesia: epidural anesthesia,management:,addition of volume: colloid,oxygen,prevention and cure of Supine hypotensive syndrome,preparation of resuscitation of newborn,Multiple Births pathophysiolo,41,Neonatal asphyxia and emergency treatment,Neonatal asphyxia and emergenc,42,ASSESSMENT OF THE FETUS AT BIRTH,Apgar score,is a simple, useful guide,-,The Apgar scoring system,Score,*,Sign,0,1,2,Heart rate,Absent,Less than 100/min,More than 100/min,Respiratory effort,Absent,Slow, irregular,Good, crying,Color,Blue, pale,Body pink, extre,mities blue (acrocyanosis),Completely pink,Reflex,irritability (response to,insertion of a nasal catheter),Absent,Grimace,Cough, sneeze,Muscle tone,Limp,Some flexion of extremities,Active motion,ASSESSMENT OF THE FETUS AT BIR,43,Apgar score,1-minute score - degree of asphyxia,5-minute score - prognosis,evaluated at 1 and 5 minutes.,should not wait until 1 minute has passed before initiating resuscitation.,normal: 7-10,mild asphyxia: 4-6,severe asphyxia: 0-3,Apgar score 1-minute score -,44,Resuscitation of newborn,A ( Airway),B ( Breathing),C (Circulation),D (Drug),E (Evaluation),Resuscitation of newborn A (,45,Initial resuscitation,Incubation: 2731,Position:,Suctioning: mouth and nose,Stimulate:,Complete it within 20s,Initial resuscitation Incubat,46,Evaluation and further treatment,Evaluation: according to breath, heart rate and skin colour,Normal: stop resuscitation,No spontaneously brathing, HR100/min:,bag respirator,HR80/min:,closed cardiac massage,; tracheal intubation, medication,Evaluation and further treatme,47,Bag respirator,Maniphalanx pressurize,Tidal volume: 2040ml,I : E = 1.5:1,RP: 3040/min,first twice: pressure 3040 cmH,2,O,subsequently: pressure 1020 cmH,2,O,Bag respirator Maniphalanx pre,48,RESUSCITATION EQUIPMENT,RESUSCITATION EQUIPMENT,49,Closed cardiac massage,HR: 120/min,Depth: 12cm,Closed cardiac massage HR: 120,50,产科麻醉英文版课件,51,RESUSCITATION DRUGS,30s,after the closed cardiac massage, still cant recovery : drug,Epinephrine: 0.10.2mg/kg, intratracheal drop in,RESUSCITATION DRUGS 30s after,52,Hypovolemia,causes,umbilical cord was clamped and cut earlier,intrauterine asphyxia,placental abruption,hemorrhage too much:,antepartum or intrapartum,Hypovolemia causes umbilical,53,Detection of Hypovolemia,arterial blood pressure,and,CVP,pale skin,poor capillary refill,extremities are cold,pulses are weak or absent,Detection of Hypovolemia arte,54,Treatment of Hypovolemia,intravascular volume expansion,blood, plasma ,crystalloid , Albumin,10 mL/kg of normal saline, 1 to 2 g/kg of 25% albumin, or 10 mL/kg of plasma.,Care must be taken,Treatment of Hypovolemia intr,55,Correction of Acidosis,Respiratory acidosis is corrected by controlling ventilation,Metabolic acidosis is corrected by infusing sodium bicarbonate.,Requisite amount of,sodium bicarbonate(mmol):,= 0.6BW(kg)(normal BE-present BE)/4,sodium bicarbonate 1 mmol/kg/min,Sodium bicarbonate should not be infused unless ventilation is adequate.,Correction of Acidosis Respira,56,Monitoring After resuscitation,temperature,breath,heart rate,blood pressure,urine volume,Monitoring After resuscitation,57,Gynecologic anesthesia,Special position:,head down and lithotomy position,Old age: comorbidities,Emergency case: exfetation, ovarian cyst intortion, perineal position trauma, uterine perforation,More other: selective operation,Hysteroscope and Laparoscopic Surgery:,Gynecologic anesthesia Special,58,