麻醉及麻醉藥對(duì)胎兒和新生兒的影響-首都醫(yī)大

麻醉及麻醉藥對(duì)胎兒和新生兒的影響

精選課件精選課件胎盤屏障與胎盤血液循環(huán)一、胎盤與胎盤屏障胎盤是哺乳動(dòng)物妊娠期特有的器官，它連接母體與胎兒，通過(guò)子宮和滋養(yǎng)層血管化部分的對(duì)合，實(shí)現(xiàn)提供內(nèi)分泌激素，選擇性交換可溶性非顆粒物質(zhì)，保證胎兒的正常營(yíng)養(yǎng)供應(yīng)和廢物排泄。精選課件胎盤屏障與胎盤血液循環(huán)精選課件精選課件圍產(chǎn)期藥理學(xué)圍產(chǎn)期藥理學(xué)：涉及藥物在母親及胎兒兩者體內(nèi)的吸收、分布、生物轉(zhuǎn)化及排泄。圍產(chǎn)期：胎盤藥物轉(zhuǎn)運(yùn)的決定因素：母體、胎盤、胎兒三方面因素來(lái)決定。精選課件圍產(chǎn)期藥理學(xué)母體因素劑量：注射部位：佐劑：藥動(dòng)學(xué)：精選課件圍產(chǎn)期藥理學(xué)胎盤因素?cái)U(kuò)散主動(dòng)運(yùn)輸大量運(yùn)輸吞飲作用中斷精選課件圍產(chǎn)期藥理學(xué)胎盤因素一、擴(kuò)散Fick公式：Q/t=K·A（Cm-Cf）/D精選課件決定通透性的三個(gè)方面

分子量

通透性Ｋ脂溶性

離子化｛精選課件麻醉藥分子量蛋白結(jié)合率(%)脂溶性鹽酸利多卡因288.82702.9鹽酸丁卡因300.837680鹽酸布比卡因342.919528鹽酸羅哌卡因328.9394-丙泊酚178.398咪達(dá)唑侖362.295嗎啡23-26枸櫞酸芬太尼528.6084舒芬太尼578.6993瑞芬太尼412.9170精選課件圍產(chǎn)期藥理學(xué)胎兒因素一旦藥物透過(guò)胎盤，胎兒對(duì)藥物的攝取、分布、代謝、排泄決定藥物的清除和生理作用。流向胎盤組織物質(zhì)交換部位的臍血流是影響胎兒藥物攝取的根本因素。胎兒紅細(xì)胞和血清蛋白比母體紅細(xì)胞和血清蛋白與局麻藥的結(jié)合程度低。胎兒藥物代謝和排泄。精選課件妊娠期麻醉及藥物對(duì)胎兒的影響妊娠期間接受外科手術(shù)：0.3%～2.2%未知妊娠接受外科手術(shù)：0.3%1-2%的孕婦在孕期需要接受手術(shù)：

闌尾切除術(shù)（1:1500次妊娠）膽囊切除術(shù)（1:2000-10000次妊娠）

精選課件妊娠期麻醉及藥物對(duì)胎兒的影響

妊娠各孕期的孕婦常進(jìn)行的外科手術(shù)手術(shù)類型第一孕期第二孕期第三孕期１～３月（%）4～6月（%）7～9月（%）CNS耳鼻喉腹部19.930.122.6泌尿生殖-婦科10.623.324.4腹腔鏡檢查矯形外科8.99.313.7內(nèi)鏡檢查3.6118.6皮膚MazzeRL,KallenB:Reproductiveoutcomeafteranesthesiaandoperationduringpregancy.Aregistrystudyof5405case.AmJObstetGynecol161:1178-1185,1989.精選課件精選課件妊娠期麻醉及藥物對(duì)胎兒的影響精選課件妊娠期麻醉及藥物對(duì)胎兒的影響麻醉醫(yī)師應(yīng)注意以下幾點(diǎn)：①母體安全；②避免應(yīng)用致畸藥物；③避免發(fā)生胎兒宮內(nèi)窘迫；④防止流產(chǎn)和早產(chǎn)。精選課件剖宮產(chǎn)麻醉及藥物對(duì)新生兒的影響新生兒狀況的評(píng)價(jià)指標(biāo):Apgar評(píng)分碳酸氫根神經(jīng)和適應(yīng)能力評(píng)分（NACS）精選課件剖宮產(chǎn)麻醉及藥物對(duì)新生兒的影響ApgarScoringSign0points1point2pointsAActivity

(Muscletone)limplimbsflexedactivemovementPPulse

(heartrate)absent<100/min

>100/minGGrimace

(responsetosmellorfootslap)absentgrimacecoughorsneeze(nose)

cryandwithdrawaloffoot(footslap)AAppearance

(color)bluebodypink

extremitiesbluepinkalloverRRespiration

(breathing)absentirregular

weakcryinggoodstrongcry精選課件FORIMMEDIATERELEASEStampNewsRelease#94-041NEWSTAMPSCORESA"10"ONTHEAPGARSCALE

WASHINGTON,DC(AUGUST15,1994)

A20-centdefinitivestamphonoringDr.ViriginiaApgarwillbeissuedbythePostalServiceonOctober24,1994.AfirstdayofissueceremonyforthenewstampwillbeheldattheAmericanAcademyofPediatricsannualmeetinginDallasonOctober24.MillionsofbabiesaroundtheworldhavealreadybeenblessedwithDr.Apgar'sown"stampofapproval."In1953,shepublishedtheApgarscore,asimpleassessmentmethodthatallowsdoctorsandnursesinthedeliveryroomtomakeanimmediateevaluationofanewbornbaby'sgeneralcondition,aidingidentificationofthoseinfantswhoneedimmediatemedicalattention.Dr.ApgarwasbornonJune7,1909inWestfield,NewJersey.ShegraduatedfromMountHolyokeCollegein1929andwentontoColumbiaforhermedicaldegree,andwasthefirstwomenselectedforafullprofessorshipatColumbiaUniversityCollegeofPhysiciansandSurgeons.Sheaspiredtobeasurgeon,andthenmovedintothethenrelativelynewfieldofanesthesiology,placingspecialemphasisontheeffectsofobstericanesthesiaonnewbornbabies.Dr.ApgarcontinuedhercontributionstomedicinebyservingtheNationalFoundation-MarchofDimes,whereshedirectedprogramsofresearchinthecauses,preventionandtreatmentofbirthdefects.ThePerinatalSectiionoftheAmericanAcademyofPediatricsnameditsannualawardtoher.TheApgarAwardisgivenannuallytothepersonwhohasdonethemosttofurtherthecausetocareofnewbornbabiesandtheirmothers.Inadditiontohermedicalachievements,Dr.Apgarwasknownforhersenseofhumorandempathyforhumanity.Someofherotherinterestsincludedchambermusicandstampcollecting.Asapreludetothestampdedicationceremony,agroupofphysicians/musicianscalledtheApgarStringQuartestwillperformsomeofDr.Apgar'sfavoriteselectionsoninstrumentsshecraftedherself.

Dr.ApgardiedonAugust7,1974.精選課件剖宮產(chǎn)麻醉及藥物對(duì)新生兒的影響B(tài)righam婦產(chǎn)醫(yī)院精選課件剖宮產(chǎn)麻醉及藥物對(duì)新生兒的影響476/51093.3%34/5106.7%精選課件剖宮產(chǎn)麻醉及藥物對(duì)新生兒的影響麻醉劑對(duì)孕婦及胎兒的影響（全身麻醉）硫噴妥鈉：氯胺酮：依托咪酯：氧化亞氮：鹵化劑：精選課件剖宮產(chǎn)麻醉及藥物對(duì)新生兒的影響

丙泊酚丙泊酚是美國(guó)FDA確認(rèn)的對(duì)孕婦及胎兒不良影響比較小的一種麻醉藥物。丙泊酚在產(chǎn)婦全身麻醉中的應(yīng)用以及對(duì)母體、胎兒的影響均有研究，認(rèn)為采用常規(guī)劑量時(shí)，對(duì)胎兒、新生兒沒(méi)有明顯影響。

HeinHAT,PutmanJM.Ispropofolaproperpropositionforreproductiveprocedures.JClinAnesth,1997,9:611-613.宴馥霞.異丙酚在剖宮產(chǎn)全麻中的應(yīng)用.國(guó)外醫(yī)學(xué)麻醉學(xué)與復(fù)蘇分冊(cè),1997,18:293-295.

AlcarazAS,QuintanaMB,LaguardaM.Placentaltransferandneonataleffectsofpropofolincaesareansection·JClinPharTherapeut,i1998,3:19-23.精選課件剖宮產(chǎn)麻醉及藥物對(duì)新生兒的影響麻醉劑對(duì)孕婦及胎兒的影響（全身麻醉）丙泊酚：UV/MA=0.7100ug/Kg/minor2.5mg/Kg

√√150ug/Kg/min精選課件99.45±29.40min3.36±1.87L﹒Kg81.27±18.87min2.66±0.63L/Kg39.32±8.07ml/min/kg29.40±8.72ml/min/kg晏馥霞,李樹人.異丙酚在剖宮產(chǎn)全麻中的應(yīng)用.《國(guó)外醫(yī)學(xué)》麻醉學(xué)與復(fù)蘇分冊(cè),1997,18(5):293-295.精選課件剖宮產(chǎn)麻醉及藥物對(duì)新生兒的影響瑞芬太尼表瑞芬太尼血液濃度與胎盤轉(zhuǎn)運(yùn)n瑞芬太尼MA(ug/ml)161.32±0.80UV(ug/ml)150.73±0.27UA(ug/ml)100.20±0.07UV/MA150.88±0.78

0.85±0.18UA/UV100.29±0.07

0.81±0.18MA.母體動(dòng)脈；UV，臍帶靜脈，UA，臍帶動(dòng)脈KanRE,HughesSC,RosenC,enMA,etal.Intravenenousremifentanil:Placentaltransfer,maternalandneonataleffects.Anesthesiology1998;88:1467-1474.精選課件剖宮產(chǎn)麻醉及藥物對(duì)新生兒的影響肌松藥肌松藥由于其分子量大，蛋白結(jié)合率高，10~25min內(nèi)經(jīng)胎盤轉(zhuǎn)運(yùn)至胎兒的量很小而并不具有臨床效應(yīng)。IwamaH,KanekoT,TobishimaS,etal.timedependencyoftheratioofumbilicalvein/maternalarteryconcentrationsofvecuroniumincesareansection[J].ActaAnesthsiolScand,1999;43(1):9.精選課件剖宮產(chǎn)麻醉及藥物對(duì)新生兒的影響表2兩組新生兒NBNA測(cè)定結(jié)果比較(x±s)組別分娩后天數(shù)總評(píng)分第2天第14天第28天E組36.82±2.5238.61±1.8539.06±1.4238.16±1.98G組38.17±1.5039.45±1.0239.78±0.48△39.13±1.08△與硬膜外組相比,△P<0.05精選課件剖宮產(chǎn)麻醉及藥物對(duì)新生兒的影響表兩組新生兒NBNA比較(分,x±s)組別行為能力被動(dòng)肌張力主動(dòng)肌張力原始反射一般狀態(tài)總分G組12·6±0·77·2±0·77·4±0·65·6±0·85·9±0·338·2±1·4E組13·4±0·87·3±0·57·3±0·85·6±0·65·9±0·339·5±1·6李崇華,朱春仙,賀晶.全身麻醉對(duì)剖宮產(chǎn)產(chǎn)婦分娩新生兒的影響.中華婦產(chǎn)科雜志,2006,41(3):162-164.

精選課件剖宮產(chǎn)麻醉及藥物對(duì)新生兒的影響剖宮產(chǎn)全身麻醉關(guān)鍵點(diǎn)：Ｉ－Ｄ時(shí)間：＜10minＵ－Ｄ時(shí)間：＜3minKamatSK,ShahMV,ChaudharyLS,etal.Effectofinductiondeliveryanduterine-deliveryonapgarscoringofthenewborn[J],JPostgradMed,1991;37:125.精選課件剖宮產(chǎn)麻醉及藥物對(duì)新生兒的影響精選課件剖宮產(chǎn)麻醉及藥物對(duì)新生兒的影響精選課件精選課件精選課件術(shù)后鎮(zhèn)痛對(duì)新生兒的影響母乳是嬰兒最理想的食品。術(shù)后鎮(zhèn)痛利于泌乳素（PRL）的分泌，利于母乳喂養(yǎng)。水溶性藥物在初乳中濃度高，脂溶性藥物在成熟乳汁中濃度較高。精選課件術(shù)后鎮(zhèn)痛對(duì)新生兒的影響不同鎮(zhèn)痛方式對(duì)剖宮產(chǎn)術(shù)后哺乳的影響PCEA組：芬太尼0.4mg+氟哌利多2.5mg+0.75%布比卡因25ml+生理鹽水至100ml持續(xù)劑量2ml/h，PCA劑量0·5ml/次。PCIA組：芬太尼1.2mg+氟哌利多2.5mg+生理鹽水至100ml持續(xù)劑量2.5ml/h,PCA劑量1.0ml/次。精選課件術(shù)后鎮(zhèn)痛對(duì)新生兒的影響

不同鎮(zhèn)痛方式對(duì)剖宮產(chǎn)術(shù)后哺乳的影響表1兩組產(chǎn)婦及新生兒尿液藥物及代謝產(chǎn)物陽(yáng)性率比較

新生兒尿液陽(yáng)性率(%)產(chǎn)婦尿液陽(yáng)性率(%)硬膜外組48·3560·32靜脈組86·8497·18P<0·01<0·01精選課件術(shù)后鎮(zhèn)痛對(duì)新生兒的影響

不同鎮(zhèn)痛方式對(duì)剖宮產(chǎn)術(shù)后哺乳的影響

表2兩組術(shù)后3小時(shí)新生兒呼吸、心率、睜眼時(shí)間、尿量比較

呼吸(分/次)心率(分/次)睜眼時(shí)間(分鐘)尿量(ml)硬膜外組25.34±2.14150.36±2.49120.37±2.9560.68±2.26靜脈組26.51±1.84153.27±1.92121.36±1.8461.82±1.67t1.611.781.921.54P＞0.05精選課件術(shù)后鎮(zhèn)痛對(duì)新生兒的影響

不同鎮(zhèn)痛方式對(duì)剖宮產(chǎn)術(shù)后哺乳的影響

表3

兩組產(chǎn)婦術(shù)后1天泌乳量比較