急诊剖宫产的麻醉选择和术中处理
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Hillemanns P, Strauss A, Hasbargen U, et al. Crash emergency cesarean section: decision-to-delivery interval under 30 min and its effect on Apgar and umbilical artery pH. Arch Gynecol Obstet 2005; 273:161–165.
Cesarean Section
Caedere –Seco Pompilius II
730 BC
not widely used until the 1920s
Indications for Cesarean Section
Repeat Scheduled Failed attempt at vaginal delivery
2-chloroprocaine lidocaine
1.8% lidocaine, 0.76% bicarbonate and 1 : 200 000 epinephrine
Allam J. Anaesthesia 2008; 63:243–249.
Epidural failure
24% fail to achieve a pain-free operation
Perianesthetic– Maternal Position
Avoid aortocaval compression
Kinsella SM. Editorial. Lateral tilt for pregnant women: why 15 degrees? Anaesthesia 2003; 58: 835–7.
Category 3 Category 4
Needing early delivery but no maternal or fetal compromise
At a time to suit the woman and maternity team
Category 1 Indication
Placental abruption uterine rupture cord prolapse Actively bleeding placenta praevia Intrapartum hemorrhage Presumed fetal compromise with
anaesthetist informed – delivery
Perianesthetic Evaluation
A directed history and physical examination
platelet count An intrapartum blood type and screen
Kinsella SM. A prospective audit of regional anaesthesia failure in 5080 caesarean sections. Anaesthesia 2008; 63:822–832.
Conversion to Spinal anesthesia?
Epidural ×
Risk of systemic local toxicity Greater placental transfer of drug than
with spinal BUT – does not affect neonatal Apgar score and of little clinical significance when appropriate doses used
Dystocia Abnormal presentation
Transverse lie Breech Multiple gestation
Fetal stress/distress Deteriorating maternal
medical illness Preeclampsia Heart disease Pulmonary disease Hemorrhage Placenta previa Placental abruption
急诊剖宫产的 麻醉选择和术中处理
费敏 2010-3-26
Definition
Abdominal delivery
a surgical procedure that permits delivery of the infant through incisions in the abdominal and uterine wall.
Maternal health and anesthetic history Relevant obstetric history Airway and heart and lung examination Baseline blood pressure Back examination when neuraxial
anesthesia is planned or placed
Platelet count
A routine intrapartum platelet count does not reduce maternal anesthetic complications
Suspected preeclampsia or coagulopathy Eclamptic - plt> 80*109 .l-1
Epidural anesthesia spinal anesthesia Combined Spinal/Epidural (CSE)
Epidural √
As fast as GA Titrated dosing and slower onset risk of
severe hypotension and reduced uteroplacental perfusion Duration of surgery not an issue Less intense motor blockade Lower extremity “muscle pump” may remain intact incidence of thromboembolic disease
Cesarean Section
>60% unplanned
More extensive peripartum monitoring
Lower threshold for surgical intervention
What is an ‘emergency’ Caesarean section? -Category 1 & 2
severely abnormal CTG and/or severe fetal acidosis
The 30-minute rule
a maximum decision-to-delivery
time of 30 min for Category 1 situation
Association of Anaesthetists of Great Britain and Ireland and ObstetricAnaesthesists’ Association. Guidelines for obstetric anaesthesia services; 2005.
Antacids, H2 Receptor Antagonists, and Metoclopramide reduces maternal complications
Perianesthetic– Maternal Position
Aortocaval compression 3 mechanisms uteroplacental perfusion
Risk of high spinal
Epidural
The speed of onset The choice of local anesthetic Possible adjuvants
Epidural
0.5% bupivacaine
0.75% ropivacaine
0.5% levobupivacaine
Grade
Definition (at time of decision to operate)
Category 1 Immediate threat to life of woman or fetus
Category 2
Maternal or fetal compromise, not immediately life-threatening
Aspiration Prophylaxis
clear liquids up to 2h before induction of anesthesia
A fasting period for solids 6–8 h(fat content?) Further restriction
morbid obesity, diabetes, difficult airway nonreassuring fetal heart rate pattern
unpredictable high-spinal blocks a relative contraindication to give spinal anaesthesia
following epidural analgesia in labour
the dose of local anesthesia by 20–30% and use addition of opioids
Moodley J, Jjuuko G, Rout C. Epidural compared with general anaesthesia for Caesarean delivery in conscious women with eclampsia. British Journal of Obstetrics and Gynaecology 2001; 108: 378–82.
venous return C.O. and BP Obstruction of uterine venous drainage
uterine venous pressure and uterine artery perfusion pressure Compression of aorta or common iliac arteries uterine artery perfusion pressure
Choices of Anesthesia
General anesthesia Regional anesthesia Local anesthesia
Choices of Anesthesia
depends on
the indications for the surgery the degree of urgency maternal and fetus status 源自文库bstetrician desires of the patient
for all parturients reduces maternal complications Perianesthetic recording of the fetal heart rate reduces fetal and neonatal complications
A directed history and physical examination
midwife anesthetist
Safest + most expedient
Regional anesthesia
>85% emergency Caesarean section
<3% Regional anesthesia require conversion to GA
Regional anesthesia
Cesarean Section
Caedere –Seco Pompilius II
730 BC
not widely used until the 1920s
Indications for Cesarean Section
Repeat Scheduled Failed attempt at vaginal delivery
2-chloroprocaine lidocaine
1.8% lidocaine, 0.76% bicarbonate and 1 : 200 000 epinephrine
Allam J. Anaesthesia 2008; 63:243–249.
Epidural failure
24% fail to achieve a pain-free operation
Perianesthetic– Maternal Position
Avoid aortocaval compression
Kinsella SM. Editorial. Lateral tilt for pregnant women: why 15 degrees? Anaesthesia 2003; 58: 835–7.
Category 3 Category 4
Needing early delivery but no maternal or fetal compromise
At a time to suit the woman and maternity team
Category 1 Indication
Placental abruption uterine rupture cord prolapse Actively bleeding placenta praevia Intrapartum hemorrhage Presumed fetal compromise with
anaesthetist informed – delivery
Perianesthetic Evaluation
A directed history and physical examination
platelet count An intrapartum blood type and screen
Kinsella SM. A prospective audit of regional anaesthesia failure in 5080 caesarean sections. Anaesthesia 2008; 63:822–832.
Conversion to Spinal anesthesia?
Epidural ×
Risk of systemic local toxicity Greater placental transfer of drug than
with spinal BUT – does not affect neonatal Apgar score and of little clinical significance when appropriate doses used
Dystocia Abnormal presentation
Transverse lie Breech Multiple gestation
Fetal stress/distress Deteriorating maternal
medical illness Preeclampsia Heart disease Pulmonary disease Hemorrhage Placenta previa Placental abruption
急诊剖宫产的 麻醉选择和术中处理
费敏 2010-3-26
Definition
Abdominal delivery
a surgical procedure that permits delivery of the infant through incisions in the abdominal and uterine wall.
Maternal health and anesthetic history Relevant obstetric history Airway and heart and lung examination Baseline blood pressure Back examination when neuraxial
anesthesia is planned or placed
Platelet count
A routine intrapartum platelet count does not reduce maternal anesthetic complications
Suspected preeclampsia or coagulopathy Eclamptic - plt> 80*109 .l-1
Epidural anesthesia spinal anesthesia Combined Spinal/Epidural (CSE)
Epidural √
As fast as GA Titrated dosing and slower onset risk of
severe hypotension and reduced uteroplacental perfusion Duration of surgery not an issue Less intense motor blockade Lower extremity “muscle pump” may remain intact incidence of thromboembolic disease
Cesarean Section
>60% unplanned
More extensive peripartum monitoring
Lower threshold for surgical intervention
What is an ‘emergency’ Caesarean section? -Category 1 & 2
severely abnormal CTG and/or severe fetal acidosis
The 30-minute rule
a maximum decision-to-delivery
time of 30 min for Category 1 situation
Association of Anaesthetists of Great Britain and Ireland and ObstetricAnaesthesists’ Association. Guidelines for obstetric anaesthesia services; 2005.
Antacids, H2 Receptor Antagonists, and Metoclopramide reduces maternal complications
Perianesthetic– Maternal Position
Aortocaval compression 3 mechanisms uteroplacental perfusion
Risk of high spinal
Epidural
The speed of onset The choice of local anesthetic Possible adjuvants
Epidural
0.5% bupivacaine
0.75% ropivacaine
0.5% levobupivacaine
Grade
Definition (at time of decision to operate)
Category 1 Immediate threat to life of woman or fetus
Category 2
Maternal or fetal compromise, not immediately life-threatening
Aspiration Prophylaxis
clear liquids up to 2h before induction of anesthesia
A fasting period for solids 6–8 h(fat content?) Further restriction
morbid obesity, diabetes, difficult airway nonreassuring fetal heart rate pattern
unpredictable high-spinal blocks a relative contraindication to give spinal anaesthesia
following epidural analgesia in labour
the dose of local anesthesia by 20–30% and use addition of opioids
Moodley J, Jjuuko G, Rout C. Epidural compared with general anaesthesia for Caesarean delivery in conscious women with eclampsia. British Journal of Obstetrics and Gynaecology 2001; 108: 378–82.
venous return C.O. and BP Obstruction of uterine venous drainage
uterine venous pressure and uterine artery perfusion pressure Compression of aorta or common iliac arteries uterine artery perfusion pressure
Choices of Anesthesia
General anesthesia Regional anesthesia Local anesthesia
Choices of Anesthesia
depends on
the indications for the surgery the degree of urgency maternal and fetus status 源自文库bstetrician desires of the patient
for all parturients reduces maternal complications Perianesthetic recording of the fetal heart rate reduces fetal and neonatal complications
A directed history and physical examination
midwife anesthetist
Safest + most expedient
Regional anesthesia
>85% emergency Caesarean section
<3% Regional anesthesia require conversion to GA
Regional anesthesia