剖宮產(chǎn)麻醉后低血壓研究進(jìn)展

剖宮產(chǎn)麻醉后低血壓研究進(jìn)展CWIInternational

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Hospital產(chǎn)科麻醉與鎮(zhèn)痛的困境這個(gè)矛盾為“產(chǎn)科麻醉

與鎮(zhèn)痛的困境”,顯

示

了產(chǎn)科麻醉的挑戰(zhàn)和吸

引力CWI

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Hospital323篇，占26%口腰麻□硬膜外麻醉

口全身麻醉CWI

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Hospital

剖宮產(chǎn)術(shù)中低血壓Pubmed結(jié)

果

剖宮產(chǎn)低血壓原因仰臥位低血壓綜合征，低血壓發(fā)生還與麻醉平面，交感神經(jīng)阻滯，特殊產(chǎn)科情況如妊高癥，雙胎巨大兒，出血等有關(guān)主要通過(guò)麻醉藥物的心血管抑制作用影響血壓和心率，

通常都在可控范圍內(nèi)交感神經(jīng)阻滯，血管擴(kuò)張，回心血流減少所致，部分患者可并發(fā)仰臥位低血壓綜合征CWIInternational

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Hospital硬膜外麻醉全身麻醉腰麻特點(diǎn)：血壓驟然劇

烈下降，心率驟然

急

劇

升

高腰麻后循環(huán)變化特點(diǎn)CWI

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Health

Hospital特點(diǎn)：血壓驟然劇烈下降，心率不

升

高

甚

至

劇

烈下

降

腰麻后循環(huán)變化特點(diǎn)CWIInternational

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Hospital腰

麻

的

缺

點(diǎn)

·仰臥位低血壓綜合癥發(fā)生率高：50%·驟然發(fā)生頭暈惡心嘔吐、心率加快、面色

蒼白等一系列低血壓癥狀，●

仰臥位低血壓綜合征極易導(dǎo)致產(chǎn)婦子宮胎盤血流量急劇下降，進(jìn)而可導(dǎo)致胎兒發(fā)生功能性缺氧及酸中毒現(xiàn)象，嚴(yán)重時(shí)甚至還可導(dǎo)致新生兒室息及死亡，嚴(yán)重威脅著孕

產(chǎn)婦及嬰兒的生命安全CWIInternational

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Hospital●

麻醉顯效迅速·麻醉效果滿意，鎮(zhèn)痛完全，肌松充分●

麻醉藥物用量少·穿刺針細(xì)，對(duì)硬脊膜損傷小，術(shù)后頭痛發(fā)生率較低CWIInternational

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Hospital

腰

麻

的

優(yōu)

點(diǎn)ABSTRACT;Surinebypotnsvegyadnxischrastertiodbysesspinebyoknsioinlaspagmnxy,whogchialpsgntatianageston

minml

caniovxur

lkxntions

to

soce

sbctxatng

fmm

nicoor

vaicpa

captoon

by

gmid

uxms

We

xpot

a

cce

of141-yeur-dd39wkpmecmirtwminfoundtkidsups.Autbpyavealkdthefoloangynossof

thelirks;togationof

the

juulrandsthd1autopsyfindingsarepresent.CWIInternational

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Hospital5ONSJFormsic

Sci

November2012,Vol57,No.6

dot:10.111Mj,1556-4029201202165xCASE

REPORT

Avilabkeonlime

at:PATHOLOGY/BIOLOGYFabio

De-Giorgio'M.D,Ph.D.;Vinceno

M.Grassi'M.D.;Giuseppe

Vetngno,'MD,Ph.D.;Emesto

dAloja2M.D,Ph.D.;Vincenzo

L.Pascali,MD.,PhD.;and

Vincemzo

Arena,3M.D,Ph.D.Supine

HypotensiveSyndromeastheProbableCauseofBoth

Maternal

and

FetalDeath仰臥位低血壓綜合癥危害The

diagnostic

criteria

include

a

decrease

in

mean

arterial

pres-sure

of

more

than15mmHg

or

a

decreased

systolic

pressure

of15-30

mmHg

associated

with

a

persistent

elevation

of

heant

rate

of

20beats/min

over

baseline

in

supine

position(1),which

may

indi-cate

a20-25%decrease

in

circulatingblood

volume.Matemalhypotension

often

leads

to

transient

deficiency

of

the

uterine

circu-lation,and

this

may

result

in

fetal

distress

or

asphyxia

(9).In

conclusion,forensic

pathologistsshould

be

aware

thatsupine

hypotensive

syndrome

is

a

potential

source

of

sudden

death

and

a

cause

ofdeath

that

should

be

considered

when

no

other

significant仰臥位低血壓綜合癥危害A

26-year-old

woman

presented

for

fetoscopic

sur-gery

for

twin-twin

transfusion

syndrome

at

20

weeksof

gestation.She

had

polyhydramnios

and

was

mor-

bidly

obese

(body

mass

index

45kg/m2).Symptoms

of

aortocaval

compression

had

been

noted

from

thefirst

trimester.InternationalJournalof

ObstetricAnesthesiaand

post-dural

puncture

headache

in

a

tertiary

obstetric

anaes-thetic

department.Int

JObstet

Anesth2009;17:329-35.An

intrathecaldose

of

hyperbaric

0.5%bupivacaine

9

mg

was

admin-

istered

and

an

epidural

catheter

was

sited.0959-289X/$-see

front

matter①2015Elsevier

Ltd.Allrights

reserved.http://dx.do/10.1016/j.ijoa.2015.05.003Maternal

collapse

secondary

toaortocaval

compressionCWIInternational

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Maternity&Child

Health

HospitalEphedrine

12

mg,phenylephrine

200

μg

and

an

addi-tional500mLbolus

ofHartmann's

solutionwereadministered.A

sensory

block

to

T5

was

demon-

stratedusing

ice.Symptomspersisted

and

shebecamemorehypotensive

(50/20mmHg),increasingly

dizzy

and

nauseated.We

then

attempted

to

increase

the

tilt

by

manually

tilting

the

patient.This

wasineffective.She

was

then

positioned

in

the

full

left

lateral

posi-

tion.Additional

intravenous

access

was

obtained

andafurtherlitreofHartmann'ssolutioninitiated.Fur-thervasopressoragentswereineffective.Fourminutes

after

CSE

placement,she

lost

consciousness

and

wasintubatedfollowingadministrationof

suxamethonium

150

mgand

propofol50mg.Blood

pressure

was

unrecordable.Radial

and

brachial

pulses

were

impal-pable,although

carotid

pulsation

could

be

detected.

Intravenous

epinephrinewas

administered

in

increas-

ingincrementsbut

was

unsuccessful.The

decision

was

made

to

perform

a

hysterotomy

and

emergencycaesarean

delivery

of

the

twins

six

minutes

postCSE.For

this,she

was

returned

to

the

supine

position

with

the

wedge

left

in

place.After

evacuation

ofthe

uterus

peripheral

pulses

became

palpable

and

bloodpressure

was

recordable.No

further

inotropes

were

required.Transthoracic

echocardiography

showed

ahyperdynamic

heart.She

was

transferred

to

the

inten-sive

careunit

and

extubated

sixhours

later

andmade

a

complete

recovery;however,the

twins

died

shortlyafter

delivery.仰臥位低血壓綜合癥危害under

the

right

hip

aiming

for

30

degrees

left

tilt.

NIBP

was

60/30

mmHg.CWIInternational

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Maternity&Child

Health

HospitalIt

is

also

important

to

emphasize

that

overweight

(body

mass

index

≥25

kg/m2)and

obesity(body

mass

index

≥30

kg/m2)havebecome

common

health

problems

for

the

general

population,Moreover,the

risk

of

pregnancy-related

deaths

is

higher

in

women

aged

from

35

to

39

years

ifcompared

with

younger

women

and

even

higher

in

women

older

than

40

years

(5).pregnancy(6):(i)blood

volume

rises

byanaverage

of

50%inpregnancy,with

hemodilution;(ii)maximum

heart

rate

increase

isreachedinthethirdtrimesterandis

about10-20beats/min;(iii)cardiacoutputrisesbyanaverageof50%;(iv)systemicvascularresistancedecreasesandreachesthenadirat24weeksof

preg-nancy;(v)functionalresidualcapacityisreduced

from10%to

20%inlatepregnancy;(vi)oxygenconsumptionincreasesfrom20%to

33%becauseoffetaldemandsandincreasedmaternalmet-

abolicprocesses.CWIInternational

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Hospital仰臥位低血壓綜合癥高危因素腰麻后低血壓的預(yù)測(cè)心率變異性·

反映自主神經(jīng)系統(tǒng)活性和定量評(píng)估心臟交感神經(jīng)與迷走神經(jīng)張力及其平衡性·產(chǎn)婦腰麻后可引起自主神經(jīng)功能改變：包括交感神經(jīng)

張力降低和副較高神經(jīng)張力升高·以上這些自主神經(jīng)變化均可引起心率減慢與血壓降低有學(xué)者試圖用心率變異性來(lái)預(yù)測(cè)腰麻后低血壓的發(fā)生CWIInternational

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HospitalHF

I%EventsHeart

ratevariability

predictssevere

hypotensionafterspinalanesthesiaforelectivecesarean

delivery.Anesthesiology.2005;102(6):1086-93CWI

International

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Health

Hospital心率變異性Fig.1.Retrospective

heart

ratevariabilityanalysis.IMILD

MODERATESEVEREDBS:

手術(shù)前一天DOS-BL:手術(shù)當(dāng)天基礎(chǔ)

值PREHYD:

膠體擴(kuò)容后腰麻后低血壓的預(yù)測(cè)Events回顧性研究提示剖宮產(chǎn)腰麻后低血壓的產(chǎn)婦術(shù)前的LF/HF的值較高，前瞻性研究提示術(shù)前LF/HF

值較高產(chǎn)婦腰麻后發(fā)生低血壓的可能性越大CWIInternationalPeaceMaternity&ChildHealthHospital

腰麻后低血壓的預(yù)測(cè)心率變異性LF

[%]正工DBS:DOS-BLiPREHYDFig.2.Prospective

heart

ratevariabilityanalysis.LF/HF<2.5

LF/HF>2.57.55.0

LF/HF2.50.0-Fig.2a,LF/HFHFI%灌注指數(shù)·P

l=檢測(cè)部位的搏動(dòng)性組織吸收光/非搏動(dòng)性組織吸收光(動(dòng)脈血液吸收光/皮膚、靜脈、骨骼吸收光)·

PI低提示外周灌注不良，相反PI高灌注狀況越好·妊娠子宮壓迫髂動(dòng)脈和下腔靜脈，影響下肢的動(dòng)脈血

流使PI降低·

交感神經(jīng)系統(tǒng)通過(guò)影響動(dòng)脈血流間接影響Pl值·

腰麻后局麻藥通過(guò)阻斷交感神經(jīng)使下肢動(dòng)脈擴(kuò)張，PI

升高有

學(xué)

者

試

圖

用

灌

注

指

數(shù)

來(lái)

預(yù)

測(cè)

腰

麻

后

低

血

壓

的

發(fā)生CWIInternational

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Hospital腰麻后低血壓的預(yù)測(cè)LCIV在前方RCIA

和后方前凸腰骶椎的共同壓迫下，造成血流動(dòng)力學(xué)改變，從而啟動(dòng)了某些相關(guān)基因或蛋白質(zhì)的過(guò)度表達(dá)，,血管發(fā)生重塑，導(dǎo)致不同程度的管壁組織改變，引起力學(xué)構(gòu)型改建CWI

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Hospital妊娠病理生理學(xué)LCIV受壓段管壁塌陷、菲??；受壓段邊界清晰，上緣增厚，條索狀邊緣增厚；受壓段前后壁粘連CWIInternational

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Hospital妊娠病理生理學(xué)特點(diǎn)：下肢灌注指數(shù)

(PI)劇烈下降，甚至

無(wú)

灌

注

→

胎

盤

灌注不足→胎兒窘迫?剖宮產(chǎn)腰麻后PI

變

化CWIInternational

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HospitalPerfusion

indexderivedfromapulseoximetercan

predictthe

incidence

of

hypotension

duringspinal

anaesthesia

forCaesareandelivery

BritishJournalofAnaesthesia

111(2):235-41CWIInternational

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Health

HospitalConclusions.

We

demonstrated

thathigher

baselinePI

was

associated

withprofound

hypotensionand

thatbaselinePIcouldpredicttheincidenceofspinalanaesthesia-灌注指數(shù)(手指)crease

inSAPduringspinalanaesthesiaforCaesareandelivery

[%

SAPdecrease=(baseline

SAP-lowest

SAP)/baseline

SAP]

(r=0.664,P<0.0001).The

solid

line

represents

the

linear

regres-sion

line

and

the

dotted

lines

represent

the95%CIs.Fig2

ROC

curves

for

the

baseline

PI

during

spinal

anaesthesia

forCaesarean

delivery.The

optimal

cut-off

value

forpredicting

theincidence

of

hypotension

in

PI

was3.5.AUC,area

under

theROC

curve,with95%CIs

givenin

parentheses.腰麻后低血壓的預(yù)測(cè)inducedhypotensionduringCaesareandelivery.Fig

1Thecorrelation

between

baseline

PIandthedegreeofde-6050-A0BACKGROUND:

Aortocavalcompression

bythegraviduterus,low

baselinevasomotortone,

andspinalanesthesia-related

sympathetic

blockade

contribute

to

spinal

anesthesia-induced

hypoDifferential

Rolesofthe

Rightand

LeftToe

Perfusion

Index

in

Predictingthe

IncidenceofPostspinalHypotension

DuringCesarean

Delivery

gij

i

Z,

n,

h,

D,*T,

D

Zhao,MD,*Rui

Ma,MD,*Mazhong

Zhang,MD,PhD,t十Xu,MD,*PuwenPhaoMDgPheMDanXuJndeanZif腰麻后低血壓的預(yù)測(cè)tensionduringcesareandelivery.Thefingerperfusionindex(Pl)can

predict

spinal

hypotensionbyreflectingbaselinevasomotortone,butcannotdirectly

reflectaortocaval

compression

bythegravid

uterus.This

study

aimed

to

examine

whether

baseline

toe

PIs

predict

the

incidence

ofmaternalhypotensionandreflectaortocavalcompression

by

the

gravid

uterus

during

cesareandelivery

underspinalanesthesia.METHODS:

One

hundred

parturients

undergoingelectivecesareandeliverywereenrolled.Therelationship

between

baseline

toe

PI

and

the

incidence

of

hypotension

following

induction

ofspinal

anesthesia

was

quantified

using

area

under

the

receiver

operator

curves,and

resultscomparedforthe

right

and

left

toe

Pls.RESULTS:

Thearea

underthe

receiveroperatorcurvesforleft

and

right

toe

baseline

Pls

were0.81(95%confidenceinterval,0.71-0.88)and0.76(95%confidenceinterval,0.66-0.84),respectively.Following

inductionofspinal

anesthesia,thetoe

Plsdid

not

change

in

parturientswithhypotension,butincreasedsignificantlyamongthosewhodid

not

develop

hypotension.CONCLUSIONS:

Ourstudydemonstratedthat

baselinetoe

Plswere

inverselyassociatedwiththeincidenceofpostspinalhypotensionduringcesareandelivery.Continuous

monitoring

oftoe

Plsduringinductionofspinalanesthesiamight

helpto

predictthe

development

of

postspinal

hypoten-sionandreflecttheaortocavalcompressionby

the

gravid

uterus.(AnesthAnalg

2017;XXX:00-00)CWIInternational

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Health

Hospitalparisons.The

left

toe

area

under

the

ROC

curve

was

0.81

(95%CI,0.71-0.88).The

optimal

cutoff

point

of

the

preanes-

thetic

PI

to

predict

the

occurrence

ofpostspinal

hypoten-sion

was2.2(95%CI,1.4-2.2),with

a

sensitivity

of

92.9%

(95%CI,80.5%-98.5%)and

specificity

of

61.5%(95%CI,

47.0%-74.7%).The

right

toe

area

under

the

ROC

curve

was

0.76

(95%CI,0.66-0.84).The

optimal

cutoff

point

was1.3

(95%CI,0.99-2),with

a

sensitivity

of61.9%(95%CI,45.6%-

76.4%)and

specificity

of

84.6%(95%CI,71.9%-93.1%).Differential

Rolesofthe

Rightand

LeftToe

Perfusion

Index

in

Predictingthe

IncidenceofPostspinalHypotensionDuring

Cesarean

Delivery.Anesth

Analg.2017Aug8.0000000000002393.CWI

International

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Health

Hospital灌注指數(shù)(腳趾)100-SpecificityFigure2.The

receiving

operatorcharacteristic

curvesfor

baseline

toe

Pls.Red

dotted

line,left

baseline

toe

PI.Blue

dotted

line,right

baselinetoe

PI.Pl

indicates

perfusion

index.腰麻后低血壓的預(yù)測(cè)腰麻后低血壓的預(yù)測(cè)感覺(jué)阻滯平面升高速率·

高于T4同或T5感覺(jué)阻滯平面的脊麻容易引起低血壓的

發(fā)生·

動(dòng)靜脈血管舒縮神經(jīng)起源于T5-L1,

心臟加速神經(jīng)起

源于T1-T4,

因此廣發(fā)而迅速的高位阻滯容易引起血

流動(dòng)力學(xué)劇烈變化·確定腰麻感覺(jué)神經(jīng)阻滯平面的升高速率對(duì)預(yù)測(cè)低血壓

可能有幫助CWIInternational

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Health

HospitalFigure2.Ascending

range

ofsensoy

bocklevel

afterspnal

anesthesia.Box

plots

displaythe

25th,50oth,and

75th

percentiles

as

hoizontalines

on

a

bar,

wriskers

above

and

belbowthe

box

indicatedthe

9othand

10th

percentles,anddata

beyondthe

10th

and

90th

percentiles

are

showed

as

ndhidual

ponts.Levelofsensoryblockafterspinalanesthesiaasa

predictor

of

hypotension

in

parturient.Medicine

(Baltimore).2017Jun;96(25):e7184.CWIInternational

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Maternity&Child

Health

HospitalB

腰麻后低血壓的預(yù)測(cè)Sensoryblock

levelA發(fā)生低血壓組的腰麻阻滯平面和阻滯平面的升高速率都高于未發(fā)生低血壓組，

根據(jù)統(tǒng)計(jì)腰麻給藥后三分鐘阻滯平面超過(guò)T8最有可能引起低血壓發(fā)生，其敏感性82%,特異性88%CWIInternational

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Hospital腰麻后低血壓的預(yù)測(cè)Fgure3.Timetoensoybocklenlahypdenson.Bcxpktsdspaythe25th,50th,and75thpercartlesashoizonta

ineson

abar,whiskesaboeardbeow

the

boxindcad

the

9Oh

and

10th

percenfles,and

dta

beyond

the

10th

and

90th

peroentles

xe

showBd

a

ndwdnl

ponts.bbcklovd

at

th

3d

rinute

ater

shal

snsoybboklevel.maSBL3°mirSBL=sersoyinjzcton,maSBL=maxnaFgure4.ReceineropentngchaactersicanesFOQajfor3mirSBLand1-SpeifkityCB腰麻后低血壓的預(yù)測(cè)腦氧飽和度·

使用700到900

nm波長(zhǎng)的近紅外線可以鑒定腦血氧飽腦血氧飽和度降低5%,表明腦氧合受到影響，減少10%可能表明腦功能障礙·在體位性低血壓實(shí)驗(yàn)中，ScO2在出現(xiàn)前期癥狀之前就開始下降，從而預(yù)測(cè)暈厥的發(fā)生CWIInternational

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Maternity&Child

Health

Hospital

和度(ScO2)·Hypotension(n=32)No

hypotension

(n=9)P

valueAge

(years)29.1±6.228.9±6.10.6258Body

weight

(kg)74.6±9.174.4±9.30.5632Height

(cm)161.8±63161.5±6.10.4566Body

mass

index

(kg

m-2)29.1±7.828.9.

±7.60.5547Baseline

ScO?62%(59-64

%)63%(59-65%)0.4138Decrease

in

ScO?7%(4-9%)3%(3-4%)0.0001Timefrom

injection

to

hypotension

(s)158(154-263)Time

from

injection

to

5%decrease

in

ScO?(s)122Table

-152)(n

=24)Time

from

5%docrease

in

ScO?

to

hypotension

(s)38(35-96)(n

=24)腰

麻

后

低

血

壓

的

預(yù)

測(cè)Roleofcerebraloxygenationforpredictionofhypotension

afterspinalanesthesiafor

caesarean

sectionShen

Sun1·Nai-he

Liu2·Shao-qiang

Huang1CWIInternationalPeaceMaternity&ChildHealthHospitalORIGINAL

RESEARCHJClinMonit

ComputDOI

10.1007/s10877-015-9733-4Table

1SeO?HypotensionafterspinalanesthesiaNohypotensionafterspinal

anesthesiaTotalPositive(24.5%decrease)24(tne

positive2(false

positive)26Negative(<45%decreac)8(false

megative)7(rue

negative)15Total32941腰麻后低血壓的預(yù)測(cè)剖宮產(chǎn)腰麻后低血壓組出現(xiàn)ScO2下降的人數(shù)明細(xì)較多，并且首先出現(xiàn)ScO2下降，而后出現(xiàn)血壓降低，當(dāng)ScO2至5%后38秒可出現(xiàn)血壓下降，經(jīng)統(tǒng)計(jì)引起血壓降低的ScO2

閾值為4.5%Table

2Positivepredictivevalueandnegative

predictive

value

of

4.5%decrease

in

SaO?for

predicting

hypotension

after

spinal

anesthesiaCWIInternational

Peace

Maternity&Child

Health

Hospitalwomen.In

pariclar

wedemonstrated

that

heart

ratesof<71

bpm,and

more

than89

bpm,are

clinicalyuseful

prognostic

values

to

hdp

predict

the

develop-

mentof

hypotension,whilethosein

the

range

betweenhaveredativedyweakprognosticvalue.Unlikesomepreviousstudies,weshowed

tat

pre-anaesthetic

PVI,PI,LF-to-HF

rati

and

entropy

of

HRV

are

not

useful

indicestopredicthypotensioninthispatientgroup.

腰麻后低血壓的預(yù)測(cè)心率CWIInternationalPeaceMaternity&ChildHealthHospitalDiscussion

andconclusion:

Taking

into

accounthe

current

guidelines

and

literature

as

wellaseverydaycinialexperience,thefnststepfordereasingtheincidenceofIONVandPONVis

a

comprehensive

management

of

circulatory

parameters.This

management

includes

iberalperioperativefuidadministrationandtheapplicationof

vasopressorsasthe

circumstances

require.Byusinglow-doselocalanesthetics,anadditionalapplicationof

intrathecalorspinal

opioidsorhyperbaricolutionsforasuffcientcontrolablityofneuraxialdistributon,maternal

hypotensionmightbereduced.Performingacombinedspinal-epidunalanesthesiaorepidural

anesthesia

may

be

considered

as

an

altenative

to

spinal

anesthesia.Antiemetic

drugs

may

beadministeredrestainedlyduetoofflabeluseinpregnantwomenforIONVorPONVprophy-haxis

and

may

be

reservedfor

teatment.●減少局麻藥的用量，●聯(lián)合鞘內(nèi)阿片類藥物●腰硬聯(lián)合或硬膜外麻醉●合理使用止吐劑Preventing

nausea

and

vomiting

in

women

undergoing

regional

anesthesia

for

cesarean

section:challenges

and

solutions.Local

Reg

Anesth.2017;10:83-90CWIInternational

Peace

Maternity&Child

Health

Hospital腰麻后低血壓的處理●圍術(shù)期藥物容量治療●血管活性藥物的使用處理：腰麻后低血壓的預(yù)防和治療左傾斜位·孕婦在仰臥位期間，下腔靜脈在分叉水平以上可能出

現(xiàn)完全阻塞，僅有少數(shù)孕婦由于側(cè)支循環(huán)失代償而未

出現(xiàn)明顯的血流動(dòng)力學(xué)變化·

腰麻的神經(jīng)阻滯作用會(huì)抑制產(chǎn)婦的心血管代償能力，

從而加重母體在仰臥位時(shí)的低血壓，為避免這種由機(jī)

械原因所引起的血流動(dòng)力學(xué)障礙，通常采用左傾斜位·

在然而實(shí)際工作中很少持續(xù)的采用這種方法，而且通

過(guò)一些血管活性藥物同樣可以維持血壓的穩(wěn)定，因此

學(xué)者對(duì)左傾斜位的必要性和有效性產(chǎn)生質(zhì)疑CWI

International

Peace

Maternity&Child

Health

HospitalThe

values

are

means±SD.*Po?values

lessthan

17

mmHgare

reported

bythelaboratoryas"lessthan17

mmHg"and

were

treated

as

17

mmHg

for

this

analysis.UA=umbilical

artery;UV=umbilical

vein.Left

LateralTableTiltforElectiveCesarean

Delivery

underSpinalAnesthesia

HasNoEffectonNeonatal

Acid-Base

Status.Anesthesiology.2017

Aug;127(2):241-249CWIInternational

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Health

HospitalPositionSupine

GroupTiltGroupP

ValueUA

blood

gases(n=50)(n=47)pH7.28±0.057.28±0.040.39Pco?(mmHg)55±755±110.69Po?(mmHg)*19±319±50.57HCO?(mmol/l)25±125±10.88Base

excess

(mmol/l)-0.5±1.6-0.6±1.50.64UV

blood

gases(n=49)(n=47)pH7.33±0.057.33±0.040.49Pco?(mmHg)46±646±50.68Po?(mmHg)26±526±50.95HCO?(mmol)23±124±10.54Base

excess(mmol/)-1.7±1.3-1.6±1.50.91腰麻后低血壓的預(yù)防和治療Table2.NeonatalAcid-BaseStatusaccordingtoMaternal腰麻后低血壓的預(yù)防和治療在給予一定擴(kuò)容和血管活性藥物的支持下，左傾斜位與平臥位剖宮產(chǎn)術(shù)嬰兒的

臍動(dòng)脈與臍靜脈酸堿度沒(méi)有明顯差異Fig

.

3.Mean

systolic

blood

pressure(mmHg±SD)by

groupover

first

15min

after

spinal

anesthesia

(supine

group,n=50;tilt

group,n=49).At

least

45

of

50

supine

and

at

least

44

of49tilt

subjects

had

systolic

blood

pressure(BPsys)measure-ments

at

each

minute.*Time

points

where

there

was

a

signifi-cantdifferencebetween

groups.Fig.2.Box

plot

of

umbilical

artery(UA)base

excess

(mmol/)by

group.Dots

represent

outliervalues.CWIInternational

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Health

HospitalTimepost-spinalanesthesia

(mins)Bp

sy

s

(mmHg)BPsys腰麻后低血壓的預(yù)防和治療剖宮產(chǎn)術(shù)中左傾臥位不能改善新生兒的酸堿狀態(tài)發(fā)表于2017-07-0823:21:21|瀏覽次數(shù)：18959產(chǎn)婦平臥時(shí)，妊娠子宮可能會(huì)壓迫下腔靜脈，影響下腔及

盆腔的靜脈回流，使回心血量減少、右心房壓下降、心搏

出量減少，從而引起產(chǎn)婦低血壓以及胎兒宮內(nèi)窘迫，即“仰臥位低血壓綜合征”。對(duì)此，目前普遍的做法是在胎

兒娩出前使產(chǎn)婦左傾15°,以減少子宮對(duì)下腔靜脈的壓迫。

臨床上由于下肢靜脈收縮等有效的代償機(jī)制，大多數(shù)產(chǎn)婦

仰臥位時(shí)不會(huì)發(fā)生劇烈的血流動(dòng)力學(xué)變化，也沒(méi)有明顯的

自述癥狀，表現(xiàn)為隱匿性的腹主動(dòng)脈-腔靜脈壓迫(concealedACC),在實(shí)際工作中“仰臥位低血壓綜合征”

的發(fā)生率僅為8~10%。另外，圍術(shù)期容量治療以及血管活

性藥物的應(yīng)用也為母嬰安全提供了保障。因此我們不免產(chǎn)

生疑問(wèn)，在維持產(chǎn)婦血壓平穩(wěn)的前提下，剖宮產(chǎn)術(shù)中真的需要左傾體位嗎?古麻今醉復(fù)大學(xué)鈰第CWIInternational

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Health

HospitalL

groupn=31LS

gioup

n=31C5

gioup

n=32Incidenceofhypotension3

(9.7%)17

(54.8%)18

(56.3%)Ephedrine

(mg)Pre-delverymedian

(range)0

(0-6)*6(0-24)6(0-18)Post-deliverymedian

(rangel0

(0-0)**0(0-12)6(0-12)Nausea

(n)286Vomiting

(n)244**ComparedwithgoupLS,PR<0.01.LL—左側(cè)臥至手術(shù)開始；LS—

麻醉后右側(cè)抬高平臥位；CS—麻醉后平臥位CWIInternational

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Health

Hospital腰麻后低血壓的預(yù)防和治療Anaesthesia,2005,60,pages535-540A

comparison

ofthelateral,Oxfordand

sittingpositionsforperformingcombinedspinal-epiduralanaesthesiafor

elective

Caesarean

sectionM.W.M.Rucklidge,1,4M.J.Paech2andS.M.Yentis31AnaestheticResearchFellow

and2AssociateProfessor

of

ObstetricAnaesthesia,School

of

Medicine

andPharmacology,

University

ofWesternAustralia,Perth,Australia;DepartmentofAnaesthesiaandPainMedicine,King

EdwardMemorial

Hospital

for

Women,374

Bagot

Road,Subiaco,Western

Australia6008,Australia3

Consultant,MagillDepartmentof

Anaesthesia,IntensiveCare

SPainManagement,Chelsea

andWestminster

Hospital,London

SW109NH,UK4

Currentposition:ConsultantAnaesthetist,DepartmentofAnaesthesia,Royal

Devon

andExeterHospital,Barrack

Road,Exeter

EX25DW,UK體位對(duì)產(chǎn)婦低血壓的發(fā)生率、新生兒

Aparg

評(píng)分和臍帶血氧分壓沒(méi)有影響腰麻后低血壓的預(yù)防和治療CWIInternational

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HospitalEphedrine

IV(mg)0102030臍動(dòng)脈PH<7.2(%)11254222腰麻后低血壓的預(yù)防和治療phenylephrine

100μg/mlEphedrine3

mg/mlPhenylephrine

50μg/ml+

ephedrine

3

mg/ml胎

兒

酸

中

毒

發(fā)

生

率低高中提示：麻黃素治療腰麻后低血壓增加胎兒酸中毒meta-analysis

of

vasopressor

use

during

elective

caesarean

section,byVeeser

et

al,collated

data

from

20trials

(n

=1069),finding

the

rela-

tiverisk

for

true

fetal

acidosis

tobe5.29for

ephedrine

versus

phenyl-ephrine

[10].·麻黃素

曾經(jīng)的一線藥CWIInternationalPeaceMaternity&ChildHealthHospital腰麻后低血壓的預(yù)防和治療去氧/甲腎上腺素·去氧腎上腺素僅有α受體激動(dòng)作用，沒(méi)有β受體激動(dòng)作

用，應(yīng)用于剖宮產(chǎn)術(shù)常出現(xiàn)母體反射性心動(dòng)過(guò)緩與心

排量下降·

去甲腎上腺素具有α-腎上腺素受體激動(dòng)作用，同時(shí)還

具有部分β-腎上腺素受體激動(dòng)作用·

因此，去甲腎上腺素在維持血壓的同時(shí)，可能會(huì)有更

好的心率和心排量CWIInternational

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Hospital腰麻后低血壓的預(yù)防和治療Randomizeddouble-lindedcomparisonofnorepinephrineand

phenylephrinefor

maintenanceof

blood

pressure

during

spinal

anesthesia

for

cesarean

delivery.Anesthesiology.2015;122(4):736-45.CWIInternational

Peace

Maternity&Child

Health

HospitalRandomizeddouble-lindedcomparisonofnorepinephrineand

phenylephrineformaintenance

of

blood

pressure

during

spinal

anesthesia

for

cesarean

delivery.Anesthesiology.2015;122(4):736-45.CWIInternational

Peace

Maternity&Child

Health

HospitalNomall

zedS

turokeVolumeBTime/min)腰麻后低血壓的預(yù)防和治療30002500200015001000500N

PAreaUnderThe

Curve(%.min)NorepinephrineGroupPhenylephrineGroupP

ValueBirth

weight(kg)3.11

[2.85-3.37]3.19

[3.04-3.36]0.37Apgar

score

at

1min<800Apgar

score

at

5min<800Umbilicalarterialblood

gasespH7.30[7.28-7.33]7.29[7.28-7.32]0.45PoO,(mmHg)50[48-56]52[48-56]0.77Po?(mmHg)15[13-18]14

[11-16]0.20Base

excess

(mmol)-2.0

[-3.7to-1.0]-2.4[-4.2

to

-0.8]0.87Oxygen

content

(mldl)6.0[4.4-7.7]5.2[3.8-7.0]0.29Umbilicalvenousblood

gasespH7.35[7.34-7.377.34[7.32-7.36]0.031Pco,(mmHg)41

[38-43]41

[38-45]0.69Po?(mmHg)27[23-30]26

[23-28]0.23Base

excess(mmol/)-3.2

[-4.1

to

-2.0]-3.5[-5.6

to-2.4]0.06Oxygen

content(mldl12.7[11.3-14.4]11.8[9.6-13.7]0.047腰麻后低血壓的預(yù)防和治療腰麻后剖宮產(chǎn)使用去甲腎上腺素比去氧腎上腺素具有更好的心率和心排量，

出現(xiàn)心動(dòng)過(guò)緩的概率更小，兩組之間在血壓，新生兒結(jié)局方面沒(méi)有顯著差異CWIInternationalPeaceMaternity&ChildHealthHospitalValuesaemedian[nterquartile

range]or

number.Table2.Neonatal

Outcome腰麻后低血壓的預(yù)防和治療去甲腎上腺素·

去甲腎上腺素是目前預(yù)防和治療剖宮產(chǎn)腰麻后低血壓

的首選藥物·去甲腎上腺素是去氧腎上腺素較好的代替藥物，因其

具有α-腎上腺素受體激動(dòng)作用，同時(shí)還具有部分β-腎

上腺素受體激動(dòng)作用·

通常去甲腎上腺素靜脈維持給藥用于維持血壓，其單次靜脈給藥治療治療剖宮產(chǎn)腰麻后低血壓的研究較少CWIInternational

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Health

Hospital腰麻后低血壓的預(yù)防和治療NorepinephrineIntermittentIntravenous

Bolusesto

Prevent

Hypotension

DuringSpinalAnesthesiafor

Cesarean

Delivery:A

SequentialAllocation

Dose-Finding

Study.AnesthAnalg.2017;125(1):212-218.CWIInternational

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Health

HospitalFigure2.Thepatient

allocation

sequence

andthe

response

to

the

assigned

dose.The

patient

sequence

number

(x-axis)is

the

order

o