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1、产科麻醉意外的预防产科麻醉意外的预防和处理和处理区分几个概念区分几个概念n n麻醉意外n n麻醉并发症n n责任事故麻醉意外的影响因素麻醉意外的影响因素病人因素：特异体质；术前状况麻醉因素：麻醉选择；麻醉操作；麻醉管理仪器设备因素麻醉医生因素业务技术水平工作责任心真正的意外真正的意外n n过敏反应n n肺栓塞n n恶性高热麻醉质量控制麻醉质量控制n n规范科室管理人员素质教育业务学习和技术培训术前准备仪器设备产科麻醉常见的问题产科麻醉常见的问题n n全麻困难插管困难插管肺误吸肺误吸n n椎管内麻醉腰麻后低血压心搏骤停腰麻后低血压心搏骤停全脊麻全脊麻硬膜外穿破后头痛（硬膜外穿破后头痛（PDPHP
2、DPH）神经并发症神经并发症吗啡引起的术后呼吸抑制吗啡引起的术后呼吸抑制全麻全麻n n尽管全麻在产科麻醉中的比例非常低，但在某些情况下是必须的n n美国的一项调查显示：产妇中麻醉相关的死亡率，全麻与区域阻滞相比大约在16倍以上n n英国的调查：产妇死亡的主要原因是插管困难和肺误吸n n重在术前评估和预防Millers Anesthesia. 6th ed.一、预防误吸一、预防误吸n n无并发症的产妇可以进饮中等量的清亮液体n n择期剖宫产的无并发症的产妇麻醉诱导前2h可以进饮中等量的清亮液体： water, fruit juices without pulp, carbonated bever
3、ages, water, fruit juices without pulp, carbonated beverages, clear tea, black coffee, and sports drinksclear tea, black coffee, and sports drinksn n摄入液体的容量大小不比是否含颗粒物质更重要ASA Practice Guidelines for Obstetric Anesthesia. Anesthesiology, 2007, 106(4): 843n n具具 有有 误误 吸吸 危危 险险 因因 素素 的的 病病 人人 (e.g., (e.g
4、., morbid morbid obesity, obesity, diabetes, diabetes, difficult difficult airway) airway) 或或者者是是具具有有剖剖宫宫产产风风险险的的病病人人(e.g., (e.g., nonreassuringnonreassuring fetal fetal heart heart rate rate pattern) pattern) 应应基基于于个个体体病病人人的的情情况况进进一一步步限限制制摄入物摄入物n n正在分娩的产妇应禁食固体食物正在分娩的产妇应禁食固体食物n n择择期期手手术术病病人人根根据据摄摄入入
5、食食物物类类型型(e.g., (e.g., fat fat content)content)应禁食应禁食6 68h8hn n应应在在手手术术前前及及时时使使用用非非颗颗粒粒抗抗酸酸剂剂、H2H2受受体体拮拮抗剂和抗剂和/ /或胃复安预防误吸或胃复安预防误吸ASA Practice Guidelines for Obstetric Anesthesia. Anesthesiology, 2007, 106(4): 843二、困难气道二、困难气道nThe incidence of failed tracheal intubation in the pregnant population is pe
6、rhaps 8 times higher than in the nonpregnant population.nThe first national study of anesthesia-related maternal mortality in the USA revealed that 52% of the deaths resulted from complications of general anesthesia predominantly related to airway management problems.nSoft tissue changes such as air
7、way edema are an invariable association of pregnancy, and this may contribute to difficult intubationKodali BS, et al. Anesthesiology 2008; 108:357ASA Practice Guidelines for Obstetric Anesthesia. Anesthesiology, 2007, 106(4): 843椎管内麻醉椎管内麻醉n n腰麻后低血压心搏骤停n n全脊麻n n硬膜外穿破后头痛（PDPH）n n神经并发症n n吗啡引起的术后呼吸抑制一、
8、腰麻后低血压一、腰麻后低血压n n低血压是产妇腰麻后最常见的一种并发症n n其发生率远高于非妊娠妇女 n n低血压对产妇的影响 恶恶心心、呕吐甚至呕吐甚至意意意意识丧识丧失失失失、心搏骤停、心搏骤停、心搏骤停、心搏骤停n n低血压对胎儿的影响 子子宫宫胎胎盘盘血流减少，可能引起胎儿缺氧、酸中毒甚至中枢血流减少，可能引起胎儿缺氧、酸中毒甚至中枢神神经经系系统统的的损伤损伤产妇更易发生低血压的原因产妇更易发生低血压的原因1.1.妊娠后对局麻药的敏感性增强妊娠后对局麻药的敏感性增强 2.2.下腔静脉受巨大子宫的压迫引起回心血量减下腔静脉受巨大子宫的压迫引起回心血量减少少 3.3.妊娠时自主神经平衡发
9、生改变，妊娠时自主神经平衡发生改变，交感神经活交感神经活性相对副交感而言增强性相对副交感而言增强，使产妇易于发生脊使产妇易于发生脊麻后的低血压麻后的低血压4.4.妊娠后外周血管对内源性和外源性血管收缩妊娠后外周血管对内源性和外源性血管收缩剂或血管扩张剂的反应均降低，但剂或血管扩张剂的反应均降低，但以以 1 1受体受体介导的血管收缩受到削弱的程度更显著介导的血管收缩受到削弱的程度更显著预防低血压的预防低血压的方法方法n n减少局麻药剂量n n减慢注药速度n n麻醉前预扩容n n预防性使用升压药n n早期识别易于发生低血压的高危产妇胶体溶液扩容胶体溶液扩容n n晶体液在产妇中的扩容效率约晶体液在产
10、妇中的扩容效率约3030，而胶体液，而胶体液可以达到可以达到100100n n麻醉前预扩容尤其是胶体溶液扩容的优点：麻醉前预扩容尤其是胶体溶液扩容的优点：增加循环血量增加循环血量增加心输出量增加心输出量有效维持脊麻血流动力学的稳定有效维持脊麻血流动力学的稳定预防低血压的发生预防低血压的发生尤其是显著减少严重低血压的发生率尤其是显著减少严重低血压的发生率n n随扩容的胶体剂量增大，预防作用也越有效随扩容的胶体剂量增大，预防作用也越有效n n扩容的优点更主要的反映在:1.1.能够降低产妇过强的交感神经张力2.2.降低子宫血管阻力3.3.增加子宫胎盘血流4.4.子宫胎盘血流的增加先于母亲动脉压的改变
11、Gogarten W, et al. Eur J Anaesthesiol, 2005, 22(5): 359 麻醉前预测麻醉前预测n n妊娠后自主神经平衡发生改变，交感神经活性妊娠后自主神经平衡发生改变，交感神经活性相对副交感神经而言明显增强相对副交感神经而言明显增强n n回顾性分析显示，脊麻时由于交感神经被阻断，回顾性分析显示，脊麻时由于交感神经被阻断，发生中到重度低血压的产妇其麻醉前基础交感发生中到重度低血压的产妇其麻醉前基础交感张力明显高于发生轻度低血压者张力明显高于发生轻度低血压者n n基础交感张力更高的产妇可能脊麻后更容易发基础交感张力更高的产妇可能脊麻后更容易发生低血压。生低血压
12、。Hanss R, et al. Anesthesiology, 2005, 102(6): 1086 HRVn n一个客观反映自主神经平衡的指标一个客观反映自主神经平衡的指标n n麻醉前将产妇按基础的低频高频比（麻醉前将产妇按基础的低频高频比（LF/HFLF/HF）分为两组分为两组结果：结果：n n低低LF/HFLF/HF组（组（ 2.52.5）中）中1717例产妇只有例产妇只有3 3例出现了例出现了脊麻后低血压脊麻后低血压 平均最低平均最低SBPSBP为为105105 14mmHg14mmHgn n高高LF/HFLF/HF组（组（ 2.52.5）中）中2323例产妇有例产妇有2020例发生
13、了例发生了脊麻后低血压脊麻后低血压 平均最低平均最低SBPSBP为为7878 15mmHg15mmHgHanss R, et al. Anesthesiology, 2006, 104(4): 635 仰卧位应激试验仰卧位应激试验n n麻醉前分别测量产妇左侧卧位和仰卧位的血压、心率麻醉前分别测量产妇左侧卧位和仰卧位的血压、心率n n如果产妇有易于发生主动脉、腔静脉压迫的倾向，则如果产妇有易于发生主动脉、腔静脉压迫的倾向，则麻醉前在从侧卧位转成仰卧位时就会有阳性的变化麻醉前在从侧卧位转成仰卧位时就会有阳性的变化仰卧位应激试验预测脊麻后低血压的敏感度、特异度分别为69、92 Dahlgren G,
14、 et al. Int J Obstet Anesth, 2007, 16(2): 128 二、全脊麻二、全脊麻n n硬膜外穿刺操作仔细防止穿破硬脊膜硬膜外穿刺操作仔细防止穿破硬脊膜n n硬膜外导管加药前回抽防止药物误注蛛网膜下腔硬膜外导管加药前回抽防止药物误注蛛网膜下腔n n给药后密切观察病人给药后密切观察病人n n发生硬脊膜穿破并不可怕，可怕的是没有发现！发生硬脊膜穿破并不可怕，可怕的是没有发现！发生硬脊膜穿破并不可怕，可怕的是没有发现！发生硬脊膜穿破并不可怕，可怕的是没有发现！n n一旦发生全脊麻，气管插管控制呼吸，使用大剂一旦发生全脊麻，气管插管控制呼吸，使用大剂量血管活性药物维持循环
15、量血管活性药物维持循环三、硬脊膜穿破后头痛（三、硬脊膜穿破后头痛（PDPH）n n误穿破硬脊膜后PDPH的发生率高达70%, 但也并非所有的产后头痛都源于硬膜穿破n n其它原因包括: 非特异性头痛非特异性头痛, , 偏头痛偏头痛, , 颅内积气颅内积气, , 脑皮质小静脉血栓形成以及大脑脑皮质小静脉血栓形成以及大脑内病理改变内病理改变n nPDPH有体位性头痛体位性头痛的典型特征: 直立位加重, 平卧位缓解预防预防PDPH的方法的方法n n通过硬膜外穿刺针或留置于硬膜外的导管将2030ml的胶体液注入硬膜外腔n n硬脊膜穿破后导管鞘内原位留置24hn n术后平卧三天，加强补液Baraz1 R,
16、 et al. Anaesthesia, 2005, 60:673PDPH的治疗的治疗n n加强补液n n咖啡因: 缺点药效一过性、失眠n n非甾体抗炎药n n阿片类镇痛药n n5-羟色胺受体激动剂舒马曲坦n n硬膜外血填充硬膜外血填充硬膜外血填充n nThe definitive treatment for PDPH The definitive treatment for PDPH n nIn 71% of units, it was performed after the failure of In 71% of units, it was performed after the fai
17、lure of conservative measures.conservative measures.n nComplications: Complications: thethe risk of another risk of another duraldural puncture, back pain and infection puncture, back pain and infectionn nBefore blood patchingBefore blood patching : : check the patients temperaturecheck the patients
18、 temperature count white blood cell count white blood cell take blood for culture and sensitivity take blood for culture and sensitivity Baraz1 R, et al. Anaesthesia, 2005, 60:673四、神经并发症四、神经并发症Commonly associated factors:Commonly associated factors:n nneurotoxicneurotoxic drugs drugsn nantiseptic so
19、lutionsantiseptic solutionsn ntrauma to nervous tissuetrauma to nervous tissuen nbacteriologic contaminationbacteriologic contaminationn n epinephrine epinephrinen nhypotensionhypotensionn nbleedingbleedingn ncerebrospinal fluid leakagecerebrospinal fluid leakagen npatient positioning patient positi
20、oning n nthe nature of the surgical the nature of the surgical (obstetric) procedure. (obstetric) procedure. Common mechanisms of injury Common mechanisms of injury : :n ndirect traumadirect trauman nmeningealmeningeal inflammation inflammationn nneural tissue compressionneural tissue compressionn n
21、chronic progressive chronic progressive degenerative processesdegenerative processesn nvascular compromisevascular compromisen nlow cerebrospinal fluid low cerebrospinal fluid pressurepressuren npositioning with resultant positioning with resultant peripheral nerve damageperipheral nerve damageDiagn
22、osis of a suspected neurologic compromise History n nIdentify preexisting diseaseIdentify preexisting diseasen nAscertain distribution of symptomsAscertain distribution of symptomsExaminationn nClinical neurologic assessmentClinical neurologic assessmentn nEvaluation of muscle groupsEvaluation of mu
23、scle groupsLaboratory n nElectromyography Electromyography n nCerebrospinal fluid examinationCerebrospinal fluid examinationn n MRI MRIprevention of neurologic complications 1Preoperative assessment: Preoperative assessment: n nidentify any preexisting neurologic condition or risk factors identify a
24、ny preexisting neurologic condition or risk factors that could produce a neurologic lesion .that could produce a neurologic lesion .n nDocument any previously present neurologic impairment.Document any previously present neurologic impairment.n nIdentify factors that are contraindications to the use
25、 of Identify factors that are contraindications to the use of regional anesthesia.regional anesthesia.Technique:Technique:n nObserve meticulous sterile technique. Observe meticulous sterile technique. n nAvoid introducing preparation solutions into the spinal or Avoid introducing preparation solutio
26、ns into the spinal or epidural space. epidural space. n nUse preservative-free agents. Use preservative-free agents. n nDo not inject in the presence of pain or Do not inject in the presence of pain or paresthesiaparesthesia; redirect ; redirect or reinsert the needle in a different location.or rein
27、sert the needle in a different location.prevention of neurologic complications 2Anesthetic course:n nAvoid persistent hypotension. Avoid persistent hypotension. n nEnsure proper positioning, and avoid Ensure proper positioning, and avoid hyperflexionhyperflexion of the of the hips for pushing at vag
28、inal delivery.hips for pushing at vaginal delivery.Postoperative: n nDocument any changes that might have occurred.Document any changes that might have occurred.n nObtain neurologic consultation when appropriate.Obtain neurologic consultation when appropriate.n nRemove epidural catheter in Remove ep
29、idural catheter in anticoagulatedanticoagulated patients when patients when the effect of the drug(s) is at a minimum and observe the effect of the drug(s) is at a minimum and observe closely for 2 to 4 h.closely for 2 to 4 h.Kuczkowski K M. Obstet Gynecol Surv. 2004,59:47五、吗啡引起的术后呼吸抑制五、吗啡引起的术后呼吸抑制n硬膜外或鞘内吗啡术后镇痛非常有效n吗啡(脂溶性最低的阿片类药物)易于随脑脊液扩散，所以镇痛部位较广，但如药物扩散到较高水平的CNS，将会导致延迟的呼吸抑制n一般在注药后410 h左右呼吸抑制表现明显，注药后23 h呼吸功能多能恢复正常 n n纳络酮可拮抗，但需多次用药纳络酮可拮抗，但需多次用药n n高危因素：年龄、剂量、合并呼吸系统疾病高危因素：年龄、剂量、合并呼吸系统疾病n持续输注比单次剂量安全 重视术前评估重视术前评估培养良好的临床思维培养良好的临床思维n n附病例
