產(chǎn)科麻醉英文版1資料課件

ObstetricAnesthesia

ObstetricAnesthesia1PhysiologicChangesOfPregnancy

CardiovascularSystem:cardiacoutput, heartrateHematologicSystem:bloodvolume increasesbyupto45%,redcell volumeincreasesbyonly30% physiologicanemiaPhysiologicChangesOfPregnan2RespiratorySystem:increaseinthe respiratoryminutevolumeandworkof breathingGastrointestinalSystem:riskofincidenceofaspiration↑ endotrachealintubation↑

RenalSystem:GFRrises50%;glycosuriaCentralNervousSystem:↑

sensitivityto anesthetics.PhysiologicChangesOfPregnancy

RespiratorySystem:increase3ChangesOfRespiratorySystem

O2(Consumption消耗) +20to+50%MV(Minute

Ventilation分鐘通氣量) +50%TV +40%PaO2 +10%PaCO2 -15%HCO3 -15%FRC -20%ChangesOfRespiratorySystem4PlacentalTransferOfAnestheticDrugs

Placentatransport:SimplediffusionFacilitateddiffusionActivetransportPinocytosisReadilycross:

lowmolecularweights,

highlipidsolubility,non-ionized

Approximately50%oftheumbilical venousblood

bypassestheliver.PlacentalTransferOfAnesthet5NarcoticanalgesicmorphinepethidinefentanylalfentanilsufentanilGeneralanestheticspropofol嗎啡、哌替啶、芬太尼Narcoticanalgesicmorphin6MorphinePlacentaltransferisrapidMother:uterusreactiveness↓orthostatichypotensionnauseavomitingdelayedgastricemptyingFetus:respiratorydepressionMorphinePlacentaltransferis7PethidineMostcommonlyused

duringlabor

intramusculardose:50-100mg

TimeofIM:beforeexpulsion1hor4huterinecontraction,frequencyandintension↑PethidineMostcommonlyused8FentanylAlfentanilSufentanilPlacentaltransferisrapid

Lowdose:10-25μgfentanylor5-10μg sufentanilinsubarachnoidspacePCEA:lowdoseoffentanyland0.1%- 0.3%ropivacaineFentanylAlfentanilSufentanil9TramadolPlacentaltransferNoinhibitinguterinecontractionNoRespiratorydepressionTramadolPlacentaltransfer10Diazepam

Readilycrosstheplacenta

Half-lives:48hoursProblems:sedation,hypotonia,cyanosis,impairedmetabolicresponsestostress.

DiazepamReadilycrossthepl11Midazolam

Plasmaproteinbinding:94%Respiratorydepression:dependedon dose0.075mg/kg–noproblem0.15mg/kg–differentdegreeMidazolamPlasmaproteinbindi12Droperidol

Pregnantwoman:慎用Apgarscore↓DroperidolPregnantwoman:慎13Thiopentalsodium

Neonatussleep:littlePrematureandintrauterineembarrass: carefullyusingThiopentalsodiumNeonatussle14Ketamine

Highdoses(greaterthan2mg/kg)maycause lowApgarscoresandabnormalitiesin neonatalmuscletoneLaborpains

ofuterinecontraction↓Uterinemusculartensionandcontraction force↑Contraindication:psychosis,gestational hypertensionsyndromeorpreeclampsia,metrorrhexisKetamineHighdoses(greatert15Propofol

Recommendation:

induction:<2.5mg/kgmaintenance:2.5-5.0mg/kg/hDiscontinuegravidityonlyPropofolRecommendation:16N2O

PlacentaltransferisrapidMother’srespiration,circulationand Uterinemuscularcontractionforce↑20-30sbeforeoffirststageoflabor: 50%O2and50%N2O, maximum<70%N2OPlacentaltransferisrapi17EnfluraneandIsofluraneLightanesthesia:noinhibitionDeepanesthesia:mother:inhibitionofuterinecontraction,uterinebleedingfetus:disadvantageEnfluraneandIsofluraneLig18Sevoflurane

Placentaltransferismorerapidthan halothane

Inhibitionofuterinecontraction: >halothaneSevofluranePlacentaltransfer19Succinylcholine

Cholinesterase:normaldose→no placentaltransferDose>300mgorsingledoseislarger:stillhaveplacentaltransferSuccinylcholineCholinesteras20NondepolarizingMuscleRelaxants

Onsetisquick,maintanenceisshort andplacentaltransferisleastAtracurium:0.3mg/kgNondepolarizingMuscleRelaxan21LocalanestheticsFactors:Proteinbinding:MolecularweightLiposolubilityCatabolismintheplacentLocalanestheticsFactors:22Localanesthetics

ProcaineLidocaineBupivacaineRopivacaineLocalanestheticsProcaine23AnesthesiaForSesareanSection

Choicedependson:

theindicationsforthesurgerythedegreeofurgencymaternalstatusdesiresofthepatientAnesthesiaForSesareanSectio24SpinalAnesthesia

HyperbaricbupivacaineAdvantages:rapidonset,littleriskof localanesthetictoxicity,minimal transfertothefetus,infrequentfailure.Disadvantages:finitedurationhypotensionheadacheSpinalAnesthesiaHyperbaric25EpiduralAnesthesia

L2～3orL1～2

1.5%～2%Lidocaineor0.5%RopivacaineemergencycesareansectionEpiduralAnesthesia26CombinedSpinal-EpiduralTechnique

Increaseddramaticallyinpopularity

Advantages:rapidonsetsupplementedatanytimeanestheticdose↓

sacralnervesblockissufficientCombinedSpinal-EpiduralTechn27GeneralAnesthesiarapidinduction:obviatepositivepressureventilationoppressthecricoidcartilagemainterance:lightanesthesiavomiting,backstreamingandaspiration:atropine,0.5mg,IMorglycopyrolate,0.2mg,IMGeneralAnesthesiarapidinduc28Supinehypotensivesyndrome

Incidence:2%～30%Time:after28weeks,specially32～36 weeksSymptoms:

◆hypotension,◆dizziness,

◆nausea,◆chestdistress,

◆coldsweat,◆toyawn,

◆pulserate↑,◆pallescenceSupinehypotensivesyndromeI29HighriskpregnancyEmergencyoperation:latetrimesterofpregnancy:hemorrhagegestationalhypertensionsyndromand eclampsiaSelectiveoperation:hypertensioncardiacdiseasediabetesmultifetation

HighriskpregnancyEmergency30PlacentaPreviaandPlacentalAbruption

Preanesthticpreparation:

bloodcoagulationfunctionDICsiftingtestacuterenalfailurePrinciple:

generalanesthesia:activebleeding, hypovolemicshock,definitebloodcoagulation disfunctionorDIC

intraspinalanesthesia:conditionofmother andfetusisokay

ManagementPlacentaPreviaandPlacental31degreesofabruptioplacentae.A,Concealedhemorrhage.B,Externalhemorrhage.C,Completeplacentalseparation.

degreesofabruptioplacentae.32

Typesofplacentaprevia.

33Managementofanesthesia

Announcementsoftheinduction:difficultairwaycricoidcartilagebackstreamingandaspirationPreparetosalvagethebloodcoagulation disfunctionandthehemorrhoea.Preventtheacuterenalfunctionfailure:urinevolumeureanitrogenandcreatininePreventionandcureofDICManagementofanesthesiaAnnou34Pregnancy-inducedhypertensionsyndrome

Incidence:10.3%Causeofdeath:cerebrovascularaccident,pneumonedema,livernecrosisPathophysiology:systemicarteriolasystole,<200

μm,calciumion,pachemia,hypovolemia→wholebloodandplasma viscosity↑andhyperlipemia→microcirculation perfusion↓→intravascularcoagulationPregnancy-inducedhypertension35Pregnancy-inducedhypertensionsyndromecomplicatingcardiacfailure

Digitalization,diuresis,morphine,↓BP.Anesthesia:

epiduralanesthesia

generalanesthesiaManagement: 毛花苷C--maintenancedose:0.2-0.4mgfurosemide(呋塞米）--20-40mgoxygenmaintainstabilizationoftherespiratoryand circulatorysystemPregnancy-inducedhypertension36SeverePregnancy-inducedhypertensionsyndromePreanesthesiaprepare:

★informationofmedication

★magnesiumsulfate

★hypotensivedrug

★liquidintakeandoutputvolumeAnesthesia:terminationofpregnancy

epiduralanesthesia:nobloodcoagulation disfunction,noDIC,noshockandno cataphorageneralanesthesia:safeofmother>fetus

Management:SeverePregnancy-inducedhyper37HELLPsyndromecardiacfailurecerebralhemorrhageplacentalabruptionbloodcoagulationdisfunctionhaematolysishepaticenzyme↑thrombocytopeniaacuterenalfailureHELLPsyndromecardiacfailur38Management1tryingstableanesthesia:↓stressreaction:fentanylavoidtouseketamineSBP:140～150mmHg,DBP:about90mmHgganglioplegicornitroglycerinmaintainheart,kindeyandlungfunction:treatmentofcomplication:Management1tryingstableane39Management2basicmonitoring:

◆ECG◆SpO2

◆NIBP◆CVP

◆urinevolume◆bloodgasanalysispreparetosalvagetheneonatalasphyxiaICUpostoperationanalgesiaManagement2basicmonitoring:40MultipleBirths

pathophysiology:

◆abdominalaortaandinferiorvenacava compression;

◆fetallungmaturity;

◆incidenceofpostpartumhemorrhage.anesthesia:epiduralanesthesiamanagement:

◆additionofvolume:colloid

◆oxygen,

preventionandcureofSupinehypotensive syndrome

◆preparationofresuscitationofnewbornMultipleBirthspathophysiolo41NeonatalasphyxiaandemergencytreatmentNeonatalasphyxiaandemergenc42ASSESSMENTOFTHEFETUSATBIRTH

Apgarscore

isasimple,usefulguide

-

TheApgarscoringsystem

Score

*

Sign

0

1

2

Heartrate

Absent

Lessthan100/min

Morethan100/min

Respiratoryeffort

Absent

Slow,irregular

Good,crying

Color

Blue,pale

Bodypink,extre

mitiesblue(acrocyanosis)

Completelypink

Reflex

irritability(responsetoinsertionofanasalcatheter)

Absent

Grimace

Cough,sneeze

Muscletone

Limp

Someflexionofextremities

Activemotion

ASSESSMENTOFTHEFETUSATBIR43Apgarscore1-minutescore---degreeofasphyxia5-minutescore---prognosisevaluatedat1and5minutes.shouldnotwaituntil1minutehaspassed beforeinitiatingresuscitation.normal:7-10mildasphyxia:4-6severeasphyxia:0-3Apgarscore1-minutescore-44ResuscitationofnewbornA(Airway)B(Breathing)C(Circulation)D(Drug)E(Evaluation)ResuscitationofnewbornA(45InitialresuscitationIncubation:27～31℃Position:Suctioning:mouthandnoseStimulate:Completeitwithin20sInitialresuscitationIncubat46EvaluationandfurthertreatmentEvaluation:accordingtobreath,heartrate andskincolourNormal:stopresuscitationNospontaneouslybrathing,HR<100/min: bagrespiratorHR<80/min:closedcardiacmassage;trachealintubation,medicationEvaluationandfurthertreatme47BagrespiratorManiphalanxpressurizeTidalvolume:20～40mlI:E=1.5:1RP:30～40/minfirsttwice:pressure–30～40cmH2Osubsequently:pressure–10～20cmH2OBagrespiratorManiphalanxpre48RESUSCITATIONEQUIPMENTRESUSCITATIONEQUIPMENT49ClosedcardiacmassageHR:120/minDepth:1～2cmClosedcardiacmassageHR:12050產(chǎn)科麻醉英文版1資料課件51RESUSCITATIONDRUGS

30saftertheclosedcardiacmassage, stillcan’trecovery:drugEpinephrine:0.1～0.2mg/kg, intratrachealdropinRESUSCITATIONDRUGS30safter52Hypovolemia

causesumbilicalcordwasclampedandcut earlierintrauterineasphyxiaplacentalabruptionhemorrhagetoomuch:antepartumorintrapartumHypovolemia

causesumbilical53DetectionofHypovolemia

arterialbloodpressureandCVP

↓paleskinpoorcapillaryrefillextremitiesarecoldpulsesareweakorabsentDetectionofHypovolemiaarte54TreatmentofHypovolemia

intravascularvolumeexpansionblood,plasma,crystalloid,Albumin10mL/kgofnormalsaline,1to2g/kg of25%albumin,or10mL/kgofplasma.Caremustbetaken

TreatmentofHypovolemiaintr55CorrectionofAcidosis

RespiratoryacidosisiscorrectedbycontrollingventilationMetabolicacidosisiscorrectedbyinfusingsodiumbicarbonate.Requisiteamountof

sodiumbicarbonate(mmol):=[0.6×BW(kg)×(normalBE-presentBE)]/4sodiumbicarbonate<1mmol/kg/minSodiumbicarbonateshouldnotbeinfused－unlessventilationisadequate.CorrectionofAcidosisRespira56MonitoringAfterresuscitationtemperaturebreathheartratebloodpressureurinevolumeMonitoringAfterresuscitation57GynecologicanesthesiaSpecialposition:headdownandlithotomypositionOldage:comorbiditiesEmergencycase:exfetation,ovariancyst intortion,perinealpositiontrauma, uterineperforationMoreother:selectiveoperationHysteroscopeandLaparoscopicSurgery:GynecologicanesthesiaSpecial58ObstetricAnesthesia

ObstetricAnesthesia59PhysiologicChangesOfPregnancy

CardiovascularSystem:cardiacoutput, heartrateHematologicSystem:bloodvolume increasesbyupto45%,redcell volumeincreasesbyonly30% physiologicanemiaPhysiologicChangesOfPregnan60RespiratorySystem:increaseinthe respiratoryminutevolumeandworkof breathingGastrointestinalSystem:riskofincidenceofaspiration↑ endotrachealintubation↑

RenalSystem:GFRrises50%;glycosuriaCentralNervousSystem:↑

sensitivityto anesthetics.PhysiologicChangesOfPregnancy

RespiratorySystem:increase61ChangesOfRespiratorySystem

O2(Consumption消耗) +20to+50%MV(Minute

Ventilation分鐘通氣量) +50%TV +40%PaO2 +10%PaCO2 -15%HCO3 -15%FRC -20%ChangesOfRespiratorySystem62PlacentalTransferOfAnestheticDrugs

Placentatransport:SimplediffusionFacilitateddiffusionActivetransportPinocytosisReadilycross:

lowmolecularweights,

highlipidsolubility,non-ionized

Approximately50%oftheumbilical venousblood

bypassestheliver.PlacentalTransferOfAnesthet63NarcoticanalgesicmorphinepethidinefentanylalfentanilsufentanilGeneralanestheticspropofol嗎啡、哌替啶、芬太尼Narcoticanalgesicmorphin64MorphinePlacentaltransferisrapidMother:uterusreactiveness↓orthostatichypotensionnauseavomitingdelayedgastricemptyingFetus:respiratorydepressionMorphinePlacentaltransferis65PethidineMostcommonlyused

duringlabor

intramusculardose:50-100mg

TimeofIM:beforeexpulsion1hor4huterinecontraction,frequencyandintension↑PethidineMostcommonlyused66FentanylAlfentanilSufentanilPlacentaltransferisrapid

Lowdose:10-25μgfentanylor5-10μg sufentanilinsubarachnoidspacePCEA:lowdoseoffentanyland0.1%- 0.3%ropivacaineFentanylAlfentanilSufentanil67TramadolPlacentaltransferNoinhibitinguterinecontractionNoRespiratorydepressionTramadolPlacentaltransfer68Diazepam

Readilycrosstheplacenta

Half-lives:48hoursProblems:sedation,hypotonia,cyanosis,impairedmetabolicresponsestostress.

DiazepamReadilycrossthepl69Midazolam

Plasmaproteinbinding:94%Respiratorydepression:dependedon dose0.075mg/kg–noproblem0.15mg/kg–differentdegreeMidazolamPlasmaproteinbindi70Droperidol

Pregnantwoman:慎用Apgarscore↓DroperidolPregnantwoman:慎71Thiopentalsodium

Neonatussleep:littlePrematureandintrauterineembarrass: carefullyusingThiopentalsodiumNeonatussle72Ketamine

Highdoses(greaterthan2mg/kg)maycause lowApgarscoresandabnormalitiesin neonatalmuscletoneLaborpains

ofuterinecontraction↓Uterinemusculartensionandcontraction force↑Contraindication:psychosis,gestational hypertensionsyndromeorpreeclampsia,metrorrhexisKetamineHighdoses(greatert73Propofol

Recommendation:

induction:<2.5mg/kgmaintenance:2.5-5.0mg/kg/hDiscontinuegravidityonlyPropofolRecommendation:74N2O

PlacentaltransferisrapidMother’srespiration,circulationand Uterinemuscularcontractionforce↑20-30sbeforeoffirststageoflabor: 50%O2and50%N2O, maximum<70%N2OPlacentaltransferisrapi75EnfluraneandIsofluraneLightanesthesia:noinhibitionDeepanesthesia:mother:inhibitionofuterinecontraction,uterinebleedingfetus:disadvantageEnfluraneandIsofluraneLig76Sevoflurane

Placentaltransferismorerapidthan halothane

Inhibitionofuterinecontraction: >halothaneSevofluranePlacentaltransfer77Succinylcholine

Cholinesterase:normaldose→no placentaltransferDose>300mgorsingledoseislarger:stillhaveplacentaltransferSuccinylcholineCholinesteras78NondepolarizingMuscleRelaxants

Onsetisquick,maintanenceisshort andplacentaltransferisleastAtracurium:0.3mg/kgNondepolarizingMuscleRelaxan79LocalanestheticsFactors:Proteinbinding:MolecularweightLiposolubilityCatabolismintheplacentLocalanestheticsFactors:80Localanesthetics

ProcaineLidocaineBupivacaineRopivacaineLocalanestheticsProcaine81AnesthesiaForSesareanSection

Choicedependson:

theindicationsforthesurgerythedegreeofurgencymaternalstatusdesiresofthepatientAnesthesiaForSesareanSectio82SpinalAnesthesia

HyperbaricbupivacaineAdvantages:rapidonset,littleriskof localanesthetictoxicity,minimal transfertothefetus,infrequentfailure.Disadvantages:finitedurationhypotensionheadacheSpinalAnesthesiaHyperbaric83EpiduralAnesthesia

L2～3orL1～2

1.5%～2%Lidocaineor0.5%RopivacaineemergencycesareansectionEpiduralAnesthesia84CombinedSpinal-EpiduralTechnique

Increaseddramaticallyinpopularity

Advantages:rapidonsetsupplementedatanytimeanestheticdose↓

sacralnervesblockissufficientCombinedSpinal-EpiduralTechn85GeneralAnesthesiarapidinduction:obviatepositivepressureventilationoppressthecricoidcartilagemainterance:lightanesthesiavomiting,backstreamingandaspiration:atropine,0.5mg,IMorglycopyrolate,0.2mg,IMGeneralAnesthesiarapidinduc86Supinehypotensivesyndrome

Incidence:2%～30%Time:after28weeks,specially32～36 weeksSymptoms:

◆hypotension,◆dizziness,

◆nausea,◆chestdistress,

◆coldsweat,◆toyawn,

◆pulserate↑,◆pallescenceSupinehypotensivesyndromeI87HighriskpregnancyEmergencyoperation:latetrimesterofpregnancy:hemorrhagegestationalhypertensionsyndromand eclampsiaSelectiveoperation:hypertensioncardiacdiseasediabetesmultifetation

HighriskpregnancyEmergency88PlacentaPreviaandPlacentalAbruption

Preanesthticpreparation:

bloodcoagulationfunctionDICsiftingtestacuterenalfailurePrinciple:

generalanesthesia:activebleeding, hypovolemicshock,definitebloodcoagulation disfunctionorDIC

intraspinalanesthesia:conditionofmother andfetusisokay

ManagementPlacentaPreviaandPlacental89degreesofabruptioplacentae.A,Concealedhemorrhage.B,Externalhemorrhage.C,Completeplacentalseparation.

degreesofabruptioplacentae.90

Typesofplacentaprevia.

91Managementofanesthesia

Announcementsoftheinduction:difficultairwaycricoidcartilagebackstreamingandaspirationPreparetosalvagethebloodcoagulation disfunctionandthehemorrhoea.Preventtheacuterenalfunctionfailure:urinevolumeureanitrogenandcreatininePreventionandcureofDICManagementofanesthesiaAnnou92Pregnancy-inducedhypertensionsyndrome

Incidence:10.3%Causeofdeath:cerebrovascularaccident,pneumonedema,livernecrosisPathophysiology:systemicarteriolasystole,<200

μm,calciumion,pachemia,hypovolemia→wholebloodandplasma viscosity↑andhyperlipemia→microcirculation perfusion↓→intravascularcoagulationPregnancy-inducedhypertension93Pregnancy-inducedhypertensionsyndromecomplicatingcardiacfailure

Digitalization,diuresis,morphine,↓BP.Anesthesia:

epiduralanesthesia

generalanesthesiaManagement: 毛花苷C--maintenancedose:0.2-0.4mgfurosemide(呋塞米）--20-40mgoxygenmaintainstabilizationoftherespiratoryand circulatorysystemPregnancy-inducedhypertension94SeverePregnancy-inducedhypertensionsyndromePreanesthesiaprepare:

★informationofmedication

★magnesiumsulfate

★hypotensivedrug

★liquidintakeandoutputvolumeAnesthesia:terminationofpregnancy

epiduralanesthesia:nobloodcoagulation disfunction,noDIC,noshockandno cataphorageneralanesthesia:safeofmother>fetus

Management:SeverePregnancy-inducedhyper95HELLPsyndromecardiacfailurecerebralhemorrhageplacentalabruptionbloodcoagulationdisfunctionhaematolysishepaticenzyme↑thrombocytopeniaacuterenalfailureHELLPsyndromecardiacfailur96Management1tryingstableanesthesia:↓stressreaction:fentanylavoidtouseketamineSBP:140～150mmHg,DBP:about90mmHgganglioplegicornitroglycerinmaintainheart,kindeyandlungfunction:treatmentofcomplication:Management1tryingstableane97Management2basicmonitoring:

◆ECG◆SpO2

◆NIBP◆CVP

◆urinevolume◆bloodgasanalysispreparetosalvagetheneonatalasphyxiaICUpostoperationanalgesiaManagement2basicmonitoring:98MultipleBirths

pathophysiology:

◆abdominalaortaandinferiorvenacava compression;

◆fetallungmaturity;

◆incidenceofpostpartumhemorrhage.anesthesia:epiduralanesthesiamanagement:

◆additionofvolume:colloid

◆oxygen,

preventionandcureofSupinehypotensive syndrome

◆preparationofresuscitationofnewbornMultipleBirthspathophysiolo99NeonatalasphyxiaandemergencytreatmentNeonatalasphyxiaandemergenc100ASSESSMENTOFTHEFETUSATBIRTH

Apgarscore

isasimple,usefulguide

-

TheApgarscoringsystem

Score

*

Sign

0

1

2

Heartrate

Absent

Lessthan100/min

Morethan100/min

Respiratoryeffort

Absent

Slow,irregular

Good,crying

Color

Blue,pale

Bodypink,extre

mitiesblue(acrocyanosis)

Completelypink

Reflex

irritability(responsetoinsertionofanasalcatheter)

Absent

Grimace

Cough,sneeze

Muscletone

Limp

Someflexionofextremities

Activemotion

ASSESSMENTOFTHEFETUSATBIR101Apgarscore1-minutescore---degreeofasphyxia5-minutescore---prognosisevaluatedat1and5minutes.shouldnotwaituntil1minute