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剖腹產(chǎn)的麻醉進展Introduction
Associatedwithhighmaternalmortality(二十世紀前,剖腹產(chǎn)由于產(chǎn)婦高死亡率,開展得并不多)untiltheturnofthe20thcentury,cesareandeliverynowaccounts
forapproximatelyonethirdofallbirthsin
developedcountries(發(fā)達國家三分之一分娩通過剖腹產(chǎn))
Thisincreasehasresultedfromimprovementsin
surgicalandanesthetictechniques,diminisheduseofforcepsforextractions,fewerbreechandmultiplegestation
vaginaldeliveries,andgreateruseofrepeatcesareandeliveries(得益于外科及麻醉技術的發(fā)展、產(chǎn)鉗使用的減少、臀位和復雜分娩的減少、以及二次剖腹產(chǎn)的發(fā)展).Introduction
TheupdatedPracticeGuidelinesforObstetricalAnesthesiafromtheASATaskForceonObstetricalAnesthesia
observethatneuraxialtechniques(spinal,epidural,CSE)areassociatedwithimprovedmaternalandfetaloutcomes
whencomparedtogeneralanesthesia(GA)(觀察到椎管內(nèi)麻醉與全麻相比,對于產(chǎn)婦和胎兒有更好的預后),particularlyinthepresenceofhighbodymassindexandairwayissues(特別是高體重指數(shù)和氣道問題的病人).
However,specificanestheticmanagementshouldbechosenonacase-by-caseassessmentofpatient,medical(具體麻醉方式必須建立在對病人完全評估之上),anesthetic,andobstetricissues.IntroductionAnestheticparticipationcanalsoreducetheincidence、ofcesareandeliveries[e.g.improvingforcep/vacuumanalgesia,increasingthesuccessofmultiplegestationvaginalbirths,reducingfetalheadentrapmentwithintravenousnitroglycerin,andimprovingexternalcephalicversion(ECV)success].(麻醉在自然分娩中的參與同樣可以減少剖腹產(chǎn)率,比如為使用產(chǎn)鉗時提供鎮(zhèn)痛,提高復雜分娩的成功率以及改善胎位不正回轉(zhuǎn)術的成功率)IntroductionNeuraxialtechniquesimproveECVsuccessbyrelaxingtheabdominalwallmuscles,improvingpatientcomfort,andallowingamoreconcertedattempt.(神經(jīng)阻滯可以松弛腹壁肌肉,提高病人舒適度,從而提高回轉(zhuǎn)術成功率)anesthesia(lidocaine45mgwithfentanyl10μg)combinedwithuterinetocolysis(nitroglycerin50μgiv,wait50sec)hasbeenassociatedwithahighsuccessrate(83%)forexternalcephalicversion(ECV).(使用45mg利多卡因+10ug芬太尼,同時用50ug硝酸甘油抑制子宮收縮,可以使回轉(zhuǎn)術成功率提高到83%)IsthereaPreferredAnestheticTechnique(什么是剖腹產(chǎn)首選麻醉方式)?
Complicationsrelatedtoanesthesiastillrepresentthesixthleadingcauseofperipartummaternalmortalityinthe
UnitedStates(麻醉相關并發(fā)癥是產(chǎn)婦圍生期第六大死亡原因).
Notsurprisingly,thesedeathsmostcommonlyresultfromfailuresinoxygenationandventilation(通常由氧合或通氣失敗導致),however,theseepisodesarecurrentlybeingwitnessedmorefrequentlyduringextubationandpostoperative
recovery,ratherthanwithintubation(通常在拔管及恢復期發(fā)現(xiàn),而不是插管時).IsthereaPreferredAnestheticTechnique?
Theestimatedcase-fatalityriskratioforGAversusneuraxialanesthesiahasundergoneasignificantreduction(全麻與椎管內(nèi)麻醉的死亡率比例經(jīng)歷了極大的下降).
Thischangemostlikelyrepresentstwo
Trends(代表了兩種趨勢):
1)areductioninGAuse,coupledwith
moresuccessfulmanipulation(e.g.Alternate
airwaydevices)ofthematernalairway(全麻的減少,和更多氣道替代設備的熟練操作).
2)agrowingacceptanceofneuraxialtechniqueuseinparturientswith
significantcomorbidities(e.g.obesity,severepreeclampsia,hematologicandcardiacdisease)(對合并有包括肥胖,嚴重子癇前期,凝血功能障礙及心臟病產(chǎn)婦使用椎管內(nèi)麻醉的接受程度)IsthereaPreferredAnestheticTechnique?
Thecombinedspinalepidural(CSE)techniquemayofferthemostflexibility(腰硬聯(lián)合提供更多的靈活度)
intermsofreducingtheinitialdrug
dose(通過減少初始劑量),allowingforpotentiallylesshypotensionandfasterrecovery(更少的低血壓發(fā)生率和更快的恢復),aswellasprolongingtheblockadeshould
operativecomplications(減少手術并發(fā)癥)
orpostoperativepainmanagement(術后鎮(zhèn)痛管理)
issuesoccur.ShouldNewerLocalAnestheticsbeused(新型局麻藥的使用)?
Potentiallyreducedrecoverytimesandtoxicityprofileshavefosteredaninterestinthenewerlocalanesthetics為了減少恢復時間和毒性反應,促使了新型局麻藥的發(fā)展),
ropivacaineandlevobupivacaine(羅哌卡因和左布比卡因).
Althoughestablishedtobesafeandacceptableforelectivecesareandeliveries(雖然被證實剖腹產(chǎn)時更安全),thesetwolocalanestheticsmaynotbesignificantlylesscardiotoxicthanbupivacaine(并沒有比布比卡因明顯減少心臟毒性)
Moreover,becausethetoxicityofbupivacainedoesnotappeartobeenhancedinpregnancy(因為布比卡因的毒性在懷孕期并沒有增加),cardiactoxicityshouldonlyoccurwithunintentionallargeintravasculardoses(心臟毒性只在血管內(nèi)意外大量注射后發(fā)生).ShouldNewerLocalAnestheticsbeused?
Withthecommonandmore
forgivinguseofchloroprocaine3%andlidocaine2%forconversionofepidurallaboranalgesiatocesarean
Anesthesia(隨著普魯卡因和利多卡因作為剖腹產(chǎn)硬膜外麻醉的藥物,coupledwithproperdrugadministrationpractices(e.g.attentiontoincrementaldosingpractices,total
doseguidelines,andtoxicitysymptoms,如果掌握正確的給藥方式(例如注意追加劑量、總劑量的給藥方法、掌握判斷毒性反應的方法),toxicintravascularlevelsshouldbearare(血管內(nèi)毒性水平可以降到很低).ShouldLowerDosesofBupivacainebeused(低劑量布比卡因的使用)?
Thedoseoflocalanestheticshasbeenreduced
asamethodtopotentiallyobtainlesshypotension,fastermotor
recoveryanddischargetimes,andimprovedmaternalsatisfaction(減少局麻藥用量可以作為預防低血壓,改善恢復時間和產(chǎn)婦滿意度的方法)
Suchdosereductionsmaybeachievedbyusingspinalversusepiduralanesthesia(通過使用腰麻),aswellaslesstotallocalanesthetic(減少局麻藥總用量);withthesechanges,reductionsintime,costs,andcomplicationshavebeenrealized.
Whenspinalbupivacaineinintermediatetolowdoses(3-9mg)areused(當腰麻布比卡因使用中到低劑量即3-9mg),theneedforsupplementalmedicationscanbesignificant(可能需要更多追加劑量),andthusacatheterbasedtechnique(以至于需要導管技術比如CSE)shouldbeused.CanHypotensionbeprevented?
(避免低血壓)
Neuraxial-inducedhypotension,whensevereandsustainedcanimpairuterineandintervillousbloodflowandresult
infetalhypoxia,acidosis,andneonataldepression(椎管內(nèi)麻醉后嚴重并且持續(xù)的低血壓會影響子宮及絨毛血供,導致胎兒缺血,甚至胎兒窘迫).
Leftuterinedisplacementandtreatmentorprophylaxiswith
vasopressorshavereducedtheincidenceofhypotensionwithvariablesuccess(子宮左旋或血管加壓藥可以預防).
Preloadingwithcrystalloidhas
limitedeffectsonmitigatinghypotension,evenwithlargedoses(即使給予大劑量晶體預充血容量,效果仍然有限);moreeffectiveispreloadingwith
colloids,orsimultaneouslygivingrapidcrystalloidorcolloidscoincident(co-loading)withthespinaltechnique(最好預充膠體液或晶膠同時預充).CanHypotensionbeprevented?
Hypotension
mayalsobereducedwiththeuseofsmallerspinallocalanestheticdoses(低血壓同樣可以通過較少的腰麻藥用量避免).
Prophylaxisandtreatmentofmaternal
hypotensionwithphenylephrine(去氧腎上腺素),versusincombinationwithephedrineorephedrinealone(合用或單用麻黃素),ismore
effectiveinimprovingmaternalhemodynamics(更好改善母體血流動力學)
andfetalacid-basevalues(胎兒酸堿水平);WhatAdjuvantMedicationsshouldbeused?輔助用藥的使用
Adjuvantmedicationsexpressanumberofbenefits,including
theabilitytoreducethedoseandsideeffectsoflocal
anesthetics(輔助藥可以減少局麻藥用量和副作用).
Neostigmineandclonidine(新斯的明和可樂定)
aretwonovelagentsundergoingclinicalinvestigation.
Inwomen
undergoingelectivecesareandelivery,neostigmineinspinaldosesupto100μgsignificantlyreducedpost-operative
pain(顯著減少術后疼痛)
withnoeffectonfetalheartrateorApgarscores(對胎兒心率\和Apgar評分無影響).WhatAdjuvantMedicationsshouldbeused?
However,inspinaldosesaslittleas6.25μg,ahighincidenceofsideeffects
includingprolongedmotorblockade,nausea,andvomitinghavebeenobserved(觀察到比如延長的運動阻滯、惡心嘔吐等副作用發(fā)生率較高).
Asa
consequence,thespinalroutewillmostlikelybeabandoned(因此最好放棄在腰麻中使用);however,somepromise
hasbeennotedwiththe
epiduralroute(可以嘗試使用硬膜外路徑)WhatAdjuvantMedicationsshouldbeused?
Clonidine(可樂定),inspinalandepiduraldosesvaryingfrom15-50μgand50-120μg,respectively,canprolonganalgesia
anddecreaseshivering(無論腰麻或硬膜外,都可以延長鎮(zhèn)痛,較少寒戰(zhàn));However,mildhypotensionandsedationarenotinfrequentsideeffects(可能出現(xiàn)不常見的輕微低血壓和催眠).
Currently
clonidinehasonlyonespecificneuraxialindication(intractablecancerpain,只有一種適應證即頑固性癌痛),FDAwarningthat
“epiduralclonidine(硬膜外可樂定)
isnotrecommendedforobstetrical,postpartum,andperioperativepainmanagement”(不建議使用于分娩、產(chǎn)后及圍手術期鎮(zhèn)痛).
WhatAdjuvantMedicationsshouldbeused?
Preservativefreemorphinesulfate(鹽酸嗎啡)
can
provide17-27hofpost-cesareananalgesia(17-27小時的產(chǎn)后鎮(zhèn)痛).Intrathecally(蛛網(wǎng)膜下腔給藥),acomparisonof0.025,0.05,0.1,0.2,0.3,0.4,and0.5mgdosesobservedthat0.1mgproducedanalgesiacomparabletodosesashighas0.5mg(0.1mg與高達0.5mg的效果無異).
Theincidenceofpruritus,butnotnauseaandvomiting,appeareddoserelated(瘙癢癥與劑量相關,但惡心嘔吐與劑量不相關).
Intheepiduralspace(硬膜外),a
comparisonof1.25,2.5,3.75,and5mgdosesobservedthatthequalityofpost-cesareananalgesiadidnotimprove
beyond3.75mg(鎮(zhèn)痛效果在達到3.75mg后就不再變化).Pruritus,nauseaandvomitingdidnotappeardoserelated.WhatAdjuvantMedicationsshouldbeused?
Extended-releaseepiduralmorphine(緩釋嗎啡,商品名Depodur)canprovideanalgesiafor48hrswith10and15mgdoses;However,cautionshouldbeappliedtodosing
theepiduralcatheter
withlocalanestheticimmediatelyaftertheDepodur(硬膜外導管給予緩釋嗎啡后立刻給予局麻藥時應該小心),andevenupto1hourbefore,asthe
maximumplasmaconcentrationsofmorphinewillbehigher(即使是1小時前給予的嗎啡,局麻藥會升高嗎啡的血漿峰值濃度).DoesaPerfectCocktailExist(最佳藥物組合)?
Themostrecentevidencewouldsuggestthefollowingcombinationsareoptimal:MedicationSpinalEpiduralLocalAnestheticBupivacaine
9-12mg2%Lidocaine+Bicarb8.4%(10mL/1mLratio)Fentanyl15-35μg50-100μgMorphine0.1mg3.75mgASSOCIATEDANESTHETICCONCERNSDURINGCESAREANDELIVERY(剖宮產(chǎn)麻醉相關問題)AntibioticUseandTiming
(抗生素使用)
Postpartuminfectionis5to20-foldgreaterinthosepatientsdeliveringbycesareanversusvaginalroutes(剖宮產(chǎn)的產(chǎn)后感染比自然分娩高5-20倍)
and
remainswithinthetopfivecausesofpregnancy-relatedmortality(產(chǎn)后五大死亡原因之一).
Thetraditionalpracticeofadministering
antibioticsafterinfantdeliveryandumbilicalcordclampingoriginatedtopreventfetalexposuretoantibiotics(傳統(tǒng)的使用方法是胎兒娩出、臍帶夾閉之后,為了避免胎兒接觸到抗生素).
However,recentstudiesofantibioticusepriortocesareanskinincision(切皮前)
haveobservedsignificantlyfewermaternalinfections(觀察到產(chǎn)婦感染的顯著減少)
withnodifferencesinthefrequencyofneonatalsepsiswork-upsorprovensepsiscases(胎兒膿毒血癥檢驗結(jié)果無差異)
OxytocinandUterotonicAgentUse(縮宮素使用)
Thecurrentguidelinesfortheadministrationof
oxytocinduringcesareandeliveryarediverse,
empiric,andvague,withnonevidence-baseddosesof20-40IUbeingadvocated(目前的縮宮素使用并沒有循證支持).
However,adequateuterinecontractions(足夠的子宮收縮)
duringelectivecesareandeliveriesinnon-laboringwomen(未進入產(chǎn)程的孕婦)
requireonlysmallloadingdosesofoxytocin(只需要少量的縮宮素負荷量)(ED90=0.35IU);asimilarlylowloadingdose(ED90=2.99IU)isrequiredinlaboringwomen(產(chǎn)程中的孕婦).OxytocinandUterotonicAgentUse
Consequently,aloweroxytocin,
hasbeenadvocated:OxytocinProtocolforCesareanDelivery:“RuleofThrees”3IUOxytocinIVLoadingDose(administeredbyrapidinfusion,ratherthanabolus,nofasterthan15seconds)3MinuteAssessmentIntervals(3分鐘評估間隔).Ifinadequateuterinetone,give3IUOxytocinIVrescuedose.3TotalDosesofOxytocin(InitialLoad+2RescueDoses)3IUOxytocinIVMaintenanceDose(3IU/Lat100mL/h)upto8hrs.3PharmacologicOptions(e.g.Ergonovine麥角新堿,carboprost卡前列素
andmisoprostol米索前列醇)ifinadequateuterinetonepersistsIntra-andPost-partumHemorrhage(產(chǎn)時產(chǎn)后出血)
Hemorrhageoccurringduringorfollowingcesareandeliveryisanincreasingcomplication(出血是日益增長的產(chǎn)時產(chǎn)后并發(fā)癥)
thatisassociatedwith
significantmaternalmorbidityandmortality.
Theidentificationofriskfactorsassociatedwithuterineatony(發(fā)現(xiàn)子宮收縮乏力高危因素證據(jù)后需輸血)requiringbloodt
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