《重视产科麻醉安全减少麻醉并发症课件》由会员分享，可在线阅读，更多相关《重视产科麻醉安全减少麻醉并发症课件（83页珍藏版）》请在金锄头文库上搜索。
1、医学资料,1,重视产科麻醉安全 减少麻醉并发症,武汉大学中南医院 王焱林,2,医学资料,Physiological Changes During Pregnancy,What are the implications?,3,医学资料,Average Maximum CV Changes,血容量 +35% 血浆容量 +45% Hb -20% plt -10 to 20% 凝血因子 +50 to +75% CO +40% SV +30% HR +15% to 30% SVR -15%,4,医学资料,Average Maximum Pulmonary Changes in Pregnancy,氧耗量
2、 +20 to +50% 分钟通气量 +50% TV +40% RR +15% PaO2 +10% PaCO2 -15% HCO3 -15% FRC -20%,5,医学资料,NS Changes in Pregnancy,CNS 抑制 MAC 减少达 60% 肺误吸危险增加 硬膜外或蛛网膜下腔麻醉局麻药剂量减少30 to 50%,6,医学资料,GI Changes in Pregnancy,Pylorus pushed up and backward Decreased motility Increased gastrin; decreased pH GE sphincter incompet
3、ence More likely and more acidic aspiration Metoclopramide, sodium citrate H2 blocker will not affect acid Already Produced,7,医学资料,Renal & Endocrine Changes,RBF +75 to 85% GFR +50% Cr 0.5 to 0.6 mg/dL BUN 8 to 9 mg/dL Glucosuria 1 to 10 gm/24 hr Proteinuria 0.3 g/day Normal 0.25 g/day Glucose tolera
4、nce is impaired Increased total T3 & T4 free T3 & T4 Unchanged,8,医学资料,Uteroplacental Circulation,600 700 mL/min at term No autoregulation = directly proportional to mean perfusion pressure across the uterus Uterine contractions decrease flow Ephedrine does not decrease uterine blood flow,9,医学资料,Nerv
5、e Blocks,In 1880, Halsted and Hall (U.S)reported Cocaine for peripheral nerve injection In 1885, Corning reported prolonging the effect of Cocaine with Esmarch bandage blocking local circulation,10,医学资料,产科麻醉的并发症,全脊髓麻醉 神经损伤 局麻药毒性反应 误入硬膜下间隙 导管折断 异常广泛阻滞 硬膜穿破和头痛,11,医学资料,Table 1. Most Common Adverse Outc
6、omes* Adverse Outcome % of Claims Median Payment Range of Payment Death 29 $ 417,880 $ 438 - 22,344,000 Nerve Damage 19 127,000 489 - 13,395,750 Perm Brain Damage 9 1,480,058 7,400 - 44,776,000 Airway Trauma 7 89,961 43 - 2,625,000 Eye Damage 4 145,900 46 - 4,147,000 Injury to Newborn 4 829,016 4,93
7、3 - 19,656,000 Stroke 3 370,000 8,750 - 30,967,685 Pneumothorax 3 75,600 574 - 17,370,000 Back Pain 3 38,500 2,800 - 2,540,000 Headache 3 23,970 1,096 - 1,089,000 Aspiration Pneumonitis 3 350,000 714 - 4,290,000 Myocardial Infarction 2 258,000 9,450 - 2,254,250 Burn, thermal 2 63,640 5,580 - 2,875,0
8、00 Skin Reaction 2 27,068 608 - 1,360,000 Awareness 1 51,480 924 - 1,050,000 Meningitis 1 122,850 5,700 - 1,080,000N=8495 *Total payments by defendants, excluding legal costs, adjusted to 2007 dollars,2009 ASA 年会：Refresher Course,12,医学资料,布比卡因“心脏毒性”反应,1979年报道bupicacaine的心脏毒性反应 （心律失常，循环衰竭，心搏停止） 1983年1
9、0月Albright向美国FDA和LSAC(life support advisory committee)递交49份有关bupivacine 过去10年使用中21死亡报告 其中主要是剖腹产硬膜外使0.75%bupivacaine FDA禁止美国医院剖腹产硬膜外使用0.75%bupivacaine,Albright GA. Anesthesiology 1979; 15 285-287,13,医学资料,脊髓麻醉和硬膜外麻醉期间突发心搏骤停,健康成人在按常规方法实施麻醉过程中突发心搏骤停 详尽分析： 阻滞平面T4以上，交感神经阻滞平面高 多使用镇静剂 脊麻后30分钟突发 约半数患者血流动力学和呼
10、吸稳定 立即心肺复苏，但肾上腺素在事件发生平均7分钟才开始使用,14,医学资料,脊髓麻醉和硬膜外麻醉期间突发心搏骤停,Several sources of evidence suggest that sudden cardiac arrest during spinal or epidural anesthesia is an ongoing and significant source of risk in current anesthesia practice In a recent review of high severity injuries associated with regi
11、onal anesthesia claims in the 1990s, Lee found 30 claims in which death occurred. 近期文献：41例完整记录的蛛网膜下腔或硬膜外麻醉突发心搏骤停死亡病例，死亡原因为循环系统原因（迷走神经反射如牵拉、恐惧、运动员心脏等）而非呼吸抑制,15,医学资料,脊髓麻醉和硬膜外麻醉期间突发心搏骤停,高位交感阻滞导致外周血管张力难以恢复,血液回流减少 The critical threshold is regained only after the administration of exogenous epinephrine o
12、r vasopressin. Rosenberg also found that non-spinalized animals have a significant increase in endogenous epinephrine and norepinephrine at 1 and 3 minutes after cardiac arrest, but spinalized animals do not show this response. 研究提示：椎管内麻醉期间心搏骤停复苏时尽早使用肾上腺素或血管紧张素恢复外周血管张力是复苏成败的关键,16,医学资料,神经系统损伤,索赔案件中第二
13、大类损伤是周围神经系统或脊髓损伤 An in-depth analysis of claims for nerve injury 1990-227 cases1999-610 cases 索赔案例占1990年的15，占1999年的16 尺神经损伤、臂丛损伤及腰骶部神经根损伤占50 区域麻醉中脊髓损伤的最常见原因是蛛网膜下腔或硬膜外血肿，43例患者（74）存在凝血机制异常，其中30例使用了抗凝治疗,17,医学资料,神经损伤,脊髓损伤 90年代占赔偿案例25% 80年代占赔偿案例10% 70年代占赔偿案例5% 区域麻醉导致神经损伤的最常见原因是椎管内血肿spinal or epidural hematoma (43/103 cases; 41%). 43例赔偿案例中, 32 (74%) 与凝血异常有关either from anticoagulant therapy (30 cases) or intrinsic coagulopathy(2 cases).,
