妇产科手术的麻醉

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,*,CHAPTER 26,ANESTHESIA FOR GYNECOLOGIC,AND OBSTETRIC PROCEDURES,主要内容,SCETION 1,妇科手术的麻醉,妇科手术麻醉的特点,妇科麻醉的选择,常见妇科手术的麻醉,SECTION 2,产科手术的麻醉,产科麻醉的特点,麻醉药对母体和胎儿的影响,胎盘屏障对麻醉药的影响,产科手术的麻醉,新生儿窒息与急救,The characters of anesthesia for gynecologic procedures,完善的镇痛与肌松；特殊体位的影响及防护,Satisfactory analgesia and muscular relaxation;,Trenderlenberg,position and its effect.,中老年；合并症；贫血等；术前治疗与纠正,Middle and aged;Pre-exist diseases and abnormalities;Preoperative treatment and correction.,多为择期手术；术前充分准备,Most are selective and should be well prepared.,Choice of anesthesia,椎管内阻滞麻醉（硬膜外麻醉和腰麻）,Epidural,block(EA,)and spinal,anesthesia(SA,),EA,分为一点、两点穿刺法和联合阻滞,(spinal-epidural combined anesthesia),；,经腹手术麻醉平面应达,T6-8,；子宫全切及经阴道手术还需阻滞骶从神经。,全身麻醉,General,anesthesia(GA,),主要用于有椎管内麻醉禁忌者。,The anesthesia for common gynecologic procedures,子宫及附件切除术,hysterotomy,and,salpingo-oophorrectomy,年龄较大；合并症多；慢性贫血突出；,应作好术前准备；,常选用硬膜外麻醉；必要时全麻；,宫颈癌根治术范围广、创伤大、时间长，应注意术中监测和体液平衡的管理。,巨大卵巢肿瘤切除术,resection of giant oval tumor,腹内压升高、膈肌抬高，影响呼吸；压迫下腔静脉,-,前负荷降低；压迫腹主动脉,-,后负荷增加；,术前应检测和评估心、肺功能，作好充分准备；,可酌情选用,EA,或,GA,；,术中应特别注意术中监测血流动力学的变化并及时纠正低血压。,宫外孕破裂,rupture of ectopic pregnancy,最常见急症；易发生失血性休克；,术前应积极抗休克治疗；尽快手术；,可酌情选用,EA,（失血较少、循环功能较好）,GA,（大量失血、严重休克）或局麻,(LA),（生命垂危）；,术中积极抗休克处理的同时，应特别注意术中监测血流动力学的变化，维护循环功能稳定。,宫腔镜检查和手术的麻醉,hysteroscopy and,hysteroscopic,procedures,膨宫介质的影响：,CO,2,-,气拴；低黏度液体,-,体液超负荷；高粘度液体,-,过敏、肺水肿、凝血机能障碍；,单纯检查可无需麻醉，实行手术则可酌情选用,EA,、,GA,或局麻,(Local anesthesia),；,术中注意迷走神经紧张综合症（表现：恶心、出汗、心动过缓、低血压，甚至心跳骤停）的发生和处治。,产科麻醉的重点是确保,母婴,安全,The Characters of obstetric anesthesia,妊娠有关的生理、器官显著变化；,Remarkable changes in physiologic and organic functions due to pregnancy;,可存在各种合并症及病理妊娠；,Pre-exist diseases&pathologic pre-,gnancies,;,必须注意麻醉及麻醉药对母婴的影响；力求简单、安全；,Effective,simple,产科急症，更需了解产程情况及评估母子状况；,Abnormal states,注意产妇呕吐误吸的防治、避免胎儿抑制，维护产妇呼吸、循环功能及氧合。,Vomiting&aspiration well prevented&neonatal resuscitation always standby.,EFFECTS OF ANSTHETICS ON PARTURIENT AND FETUS,麻醉性镇痛药,非阿片类中枢性镇痛药,非巴比妥类镇静安定药,巴比妥类镇静药,局部麻醉药,全身麻醉药,肌肉松弛药,Almost all narcotic anesthetics are easily to pass through placenta and therefore inhibit fetus.,吗啡,morphine,哌替啶,pethidine,芬太尼,fentanyl,阿芬太尼,alfentanil,舒芬太尼,sufentanil,瑞芬太尼,remifentanil,吗啡易引起母体低血压,(positional hypotension),、恶心呕吐,(nausea and vomiting),、,胃排空延迟,(delayed stomach-emptying),、,宫缩乏力,(lessened uterine contraction),、,产程延长,(prolonged labor),，以及新生儿呼吸抑制,(neonatal respiration depression),。,已少用。,哌替啶对母婴有与吗啡相似的影响，但程度较轻。对宫缩 和产程无明显影响。宜在胎儿娩出前,4h,或,1h,内肌肉注射。麻醉中也已少用。,芬太尼对母婴有与吗啡相似的影响，特别是胎儿娩出前短时间内静脉注射。小剂量可安全用于产程中鞘内镇痛。瑞芬太尼因其特殊的药理学特点，能安全用于产科麻醉。,曲马多,(,tramal,),能透过胎盘，但治疗量很少抑制宫缩和胎儿（新生儿）呼吸。可安全用于产科麻醉和镇痛。,Its a non-,opioid,central analgesic.It can also penetrates placenta,but rarely inhibits uterine contraction and neonatal respiration in theoretical dose.Therefore its safe for obstetric anesthesia and pain-relieving.,Almost all non-barbital sedatives are easily to pass through placenta and therefore inhibit fetus.,安定,valume,diazepam,咪唑安定,midazolam,氯丙嗪,Chlorpromazine,异丙嗪,Promethazine,氟哌啶,droporidol,安定易透过胎盘，并且半衰期长，可影响新生儿阿帕加评分,(poor neonatal,Apgars,score),及神经行为评分,(neurobehavioral score),。慎用。已少用。,咪唑安定药理作用与安定相似。因其高蛋白结合率,(,higher maternal plasma protein-binding rate),，透过胎盘的药物较少，半衰期,(,half life),明显较安定短。静脉注射可抑制母体呼吸。慎用。,氯丙嗪易透过胎盘。过量,(overdose),可导致中枢抑制,(central depression),。,慎用。已少用。,氟哌啶易透过胎盘。可影响新生儿,Apgar,评分及神经行为评分。慎用。已少用。,Barbiturates,巴比妥类药物如硫喷妥钠、巴比妥钠等极易透过胎盘，可影响新生儿阿帕加评分及神经行为评分。慎用。已少用。,Barbiturates may rapidly appear in umbilical blood after use and may result in poor neonatal,Apgars,score and neurobehavioral score.,Local anesthetics 1,影响透过胎盘速度的因素,蛋白结合度,protein-binding rate,分子量,molecular weight,脂质溶解度,lipid solubility,胎盘内降解,intra-placental degradation,蛋白结合度因药而异。罗派卡因,(,Ropivocaine,),为,94%1%,布比卡因,(,Bubivocaine,),为,84%85%,利多卡因,(,Lignocaine,),为,51%64%,。结合度越高，透过胎盘越少。,分子量越小（如,350-450),，越易透过胎盘。常用局麻药分子量均在,400,以下，故都容易透过胎盘。,脂溶性越高，越易透过胎盘。取决于药物,pH,值和油,/,水分布系数。常用局麻药中利多卡因易透过胎盘。,酰胺类局麻药可被胎盘分解，酯类局麻药则不能。能被胎盘分解的药物透过胎盘向胎儿移行的药物较少，使用较安全。,Local anesthetics 2,普鲁卡因,procaine,利多卡因,lidocaine,布比卡因,bupivacaine,罗哌卡因,ropivacaine,普鲁卡因局部浸润,(local infiltration),后,3-5min,透过胎盘，但很少对母婴造成不良影响,(undesirable effects),。,利多卡因硬膜外注射,(epidural injection),后,3min,胎儿血药浓度达到母体的一半，但临床用量很少影响新生儿评分。,布比卡因因其心肌毒性,(cardiac intoxication),及中毒后救治困难，故不宜用于产科麻醉。,罗哌卡因因其高蛋白结合度、半衰期较布比卡因短、收缩外周血管,(peripheral,vaso,-constriction),等特性，故常用于产科麻醉。,General anesthetics,氯胺酮,-,ketamine,羟丁酸钠,-r-OH,硫喷妥钠,-sodium thiopental,丙泊酚,-,propofol,氧化亚氮,-N,2,O,氟烷,-,fluothane,安氟醚、异氟醚,-,enflurane,isoflurane,七氟醚、地氟醚,-,sevoflurane,desflurane,氯胺酮可透过胎盘、增强宫缩及子宫和胎儿肌肉张力。精神病患者,(psychological problem),、,高血压、妊高症,(hypertensive syndrome),、,子痫,(,eclampsia,),、,子宫破裂,(uterus rupture),则禁用。,硫喷妥钠易透过胎盘，不影响宫缩。大量使用可抑制新生儿。用量不宜超过,7mg/kg,。,异丙酚易透过胎盘，母婴血药浓度比,=0.7,。诱导剂量,2.5mg/kg,，维持量,2.5-5mg/kg,。过量则影响新生儿阿帕加评分。产后乳汁中所含药物对新生儿不利。除终止妊娠外,(terminating pregnancy),，,不宜用于产科麻醉。,氟烷已透过胎盘，母婴间药物转移率为,59.2%,7%,。低浓度吸入显著抑制第一产程,(first stage of delivery),宫缩。但不影响子宫对催产素的敏感性。可改善胎儿及新生儿氧合。禁用于经阴道分娩,(vaginal deliverer),。,已少用。,和氟烷相比，安氟醚、异氟醚低浓度吸入对宫缩影响轻微，但深麻醉抑制宫缩明显并对胎儿不利。,七氟醚、地氟醚对宫缩的影响较氟烷更强，并且迅速透过胎盘。,Muscular relaxants rarely inhibit fet