先兆子癇病人的麻醉處理(雙語)課件

AnestheticManagementofthePreeclampticPatient先兆子癇病人的麻醉處理福建醫(yī)科大學(xué)附屬協(xié)和醫(yī)院麻醉規(guī)培住院醫(yī)師

陳小芬Definitions定義Preeclampsia/Eclampsiapresentsafter20weeksgestationwithhypertension>140/90,proteinuria,andaspectrumofmulti-organsystemdysfunctionsuchasthrombocytopenia.先兆子癇表現(xiàn)為懷孕20周后的高血壓（>140/90）、蛋白尿、一系列多器官功能障礙如血小板減少。PreventionandManagementofSeizures/Eclampsia癲癇/子癇發(fā)作的預(yù)防和管理

Eclampsiahasamaternalmortalityrateof~4%andaperinatalmortalityrateofupto30%.(子癇有達(dá)4％孕產(chǎn)婦死亡率和高達(dá)30％圍產(chǎn)兒死亡率)Seizuresoccur

antepartumin50%ofpatients,intrapartumin25%andpostpartumin25%.(癲癇發(fā)作50%在產(chǎn)前患者，產(chǎn)程中及產(chǎn)后各占25%）。Nodrugissuperioratpreventingeclampsia.Magnesiumtherapycancausematernalmorbidityandunpleasantsideeffectshowever.在防止子癇方面沒有藥物優(yōu)于鎂。然而鎂治療可引起產(chǎn)婦發(fā)病率和不愉快的副作用。Ithastocolytic

propertiesthatprolonglaborandincreasebleedingatdelivery.Itdecreasesfetalheartratevariability,depresses

maternalandneonatalneuromuscularfunction,andcancausematernalrespiratorydepressionandcardiactoxicityat

highbloodlevels。它具有抗分娩特性：延長產(chǎn)程和增加分娩時出血。在血液中高濃度時，它能減少胎兒心臟心率變異性，抑制孕產(chǎn)婦和新生兒的神經(jīng)肌肉功能，并能引起產(chǎn)婦呼吸抑制和心臟毒性。Clearanceisreducedwithrenalinsufficiency,andsignsoftoxicityareonlypartiallyreversed

withcalcium.腎功能不全時清除率下降，毒性可以被鈣部分逆轉(zhuǎn)。Sincemajorcomplicationsofpreeclampsiaprimarilyoccurinthe25%ofpatientswiththesevereformofthedisease,shouldmildpreeclampsiaevenbetreatedwithmagnesium?由于嚴(yán)重的子癇前癥并發(fā)癥主要發(fā)生在25％合并有嚴(yán)重疾病的患者，那么輕度子癇前期是否需要鎂治療？Whatistherisk/benefitratioforthemother?Adecisionanalyticmodelofmagnesiumtherapyornomagnesiumtherapyfoundthat400womenwithmildpreeclampsianeedtobetreatedtopreventoneseizure。對于一個母親來說，什么是風(fēng)險(xiǎn)/效益比？一個關(guān)于鎂治療或完全沒有鎂治療的決策分析模型的發(fā)現(xiàn)，400名輕度子癇前期的婦女需要處理，以防止一次發(fā)作。Thenumberneededtotreattopreventaseizure(NNT)fellto129inseverepreeclampsia,andtheNNTfelltoonly36inseverelypreeclampticwomenwhohadsymptomssuchasheadache,visualdisturbancesorepigastricpain.Notallwomenwithmildpreeclampsiawillneedtoreceivemagnesiumsulfatetherapy.在重度子癇前期中，需要治療以防止發(fā)作的人數(shù)下降到129，在伴有頭痛，視力障礙或上腹部疼痛的嚴(yán)重先兆子癇的女性中需要處理以防止發(fā)作的人數(shù)下降到僅僅36人。不是所有的輕度子癇前期都需要硫酸鎂治療。Administeranadditional2grammagnesiumsulfatebolus.給予2克硫酸鎂靜脈推注Monitorthefetusifpossible,butrealizethatheartrateabnormalitiesarecommonduringaseizureandusuallyresolvesoonaftertheseizureisterminated.Donotintervenetodeliverimmediatelyunlessabruptionorcordprolapsehasoccurred。如果可能的話，監(jiān)測胎兒，但認(rèn)識到在癲癇發(fā)作期間心率異常是常見，所以常在發(fā)作終止后監(jiān)測胎兒。不要立即干預(yù)讓孕婦分娩，除非發(fā)生胎盤早剝或臍帶脫垂Althougheclampsiaisanindicationfordelivery,itisnotanindicationforcesareandelivery.Considerwhetherinductionisfeasibleorwhetherlaborisalreadyprogressing。雖然先兆子癇是一種分娩指征，但它不是剖宮產(chǎn)的指征。須考慮誘導(dǎo)是否可行或是否產(chǎn)程已經(jīng)在進(jìn)展中2)trialoflaborfollowedbyanurgentoremergentcesareanforfetalormaternalreasons,因?yàn)槟阁w或嬰兒的原因，試產(chǎn)后跟隨的可能是急產(chǎn)或緊急剖宮產(chǎn)3)andplannedcesareanforthepatientwhoisnotacandidatetolabor.為不合適自然分娩的產(chǎn)婦計(jì)劃剖宮產(chǎn)。Allplansmusttakeintoaccountwhetherneuraxialtechniquesareappropriatebasedonplateletcountorothermeasuresofcoagulopathy所有計(jì)劃必須考慮到椎管內(nèi)麻醉是不是合適，基于血小板數(shù)目和凝血功能Theadvantagesofneuraxialanalgesiaforlaborarenumerous.Itprovidesthebestqualityofpainrelief,attenuateshypertensiveresponsestopain,reducescirculatingcatecholamines。椎管內(nèi)分娩鎮(zhèn)痛的優(yōu)勢是多方面的，它能提供最優(yōu)質(zhì)的緩解疼痛，減輕疼痛的高血壓反應(yīng)，降低循環(huán)中的兒茶酚胺。anddoesnotrequirefluidpreloadwhendilutelocalanesthetic+opioidsolutionsareused.當(dāng)稀釋的局麻藥復(fù)合和阿片類藥物使用時，不需要液體負(fù)荷量。Twostudieshavecomparedtheuseofintravenouspatientcontrolledopioids(IVPCA)toepiduralanalgesiaforwomenwithseverepreeclampsia。有兩個研究對重度子癇前期的婦女阿片類藥物靜脈PCA和硬膜外鎮(zhèn)痛做比較。

738womenwererandomizedtoIVPCAorepidural,andcesareandeliveryratesweresimilar.

738名婦女中，靜脈PCA和硬膜外麻醉剖宮產(chǎn)率是相同的。

NeonatesintheIVPCAgrouprequiredmorenaloxone(12%versus1%),butwomenintheepiduralgrouphadalongersecondstageoflabor,moreforcepsdeliveriesandrequiredephedrinemoreoften(11%versus0%).在靜脈PCA組新生兒需要更多的納洛酮（分別為12％及1％），但在硬膜外組的婦女有較長的第二產(chǎn)程，更多的產(chǎn)鉗所需、麻黃堿（11％和0％）。Notsurprisingly,epiduralpainreliefwassuperior.Resultsweresimilarinthesecondstudy.Theyfoundwasnodifferenceincesareandeliveryrates,neonatesweremorelikelytoreceivenaloxoneintheopioidgroup(54%versus9%),andepiduralpatientshadsignificantlybetterpainreliefbutrequiredmoreephedrine(9%versus0%).不奇怪的是，硬膜外緩解疼痛是很好的。第二項(xiàng)研究的結(jié)果也相似，他們發(fā)現(xiàn)剖宮產(chǎn)分娩率無明顯差異，阿片組新生兒更需要納洛酮（54％比9％），硬膜外組能更好的緩解疼痛，??但需要更多的麻黃堿（9％和0％）。Perhapsmostimportantly,therewerenodifferencesinpreeclampsia-relatedcomplications.也許最重要的是先兆子癇的相關(guān)并發(fā)癥無差異。AsecondaryanalysisofwomenwithseverepreeclampsiaintheNICHDtrialoflow-doseaspirinreportedthatepiduralanesthesiawasnotassociatedwithanincreasedrateofcesareandelivery,pulmonaryedemaorrenalfailure.NICHD（國家兒童健康和人類發(fā)展研究所）對重度子癇前期婦女的二次分析表明低劑量阿司匹林組硬膜外麻醉與剖宮產(chǎn)率增加、肺水腫或腎功能衰竭是不相關(guān)的。Fluidmanagementhasbeenacontroversialsubjectbetweenobstetricianswhowanttorestrictfluidsandanesthesiologistswhowanttoadministerfluids,howevertheobstetricviewisprobablycorrect.在主張限制液體的產(chǎn)科醫(yī)生和主張給予液體的麻醉醫(yī)師之間，液體管理一直是一個有爭議的話題，但產(chǎn)科的觀點(diǎn)可能是正確的。

Typicalobstetricmanagementisto“rundry”at80-100mlperhourtotalfluidintakeincludingmagnesiumandoxytocininfusions.Anestheticfluidmanagementshouldcomplementtheirs,usingconservativepreloadforsurgicalregionalanesthesiaandnopreloadforlaboranalgesia.典型的產(chǎn)科管理是“干涸”，每小時80-100毫升總的液體攝入量，包括鎂和催產(chǎn)素輸注。麻醉液體管理應(yīng)補(bǔ)償液體喪失量，對外科的區(qū)域麻醉使用保守的液體負(fù)荷量，分娩鎮(zhèn)痛不給液體負(fù)荷量。Manystudiesincludingasystematicreviewhaveshownlittleifanybenefitofpreloadinginpreventinghypotensionduringobstetricregionalanesthesia。許多包括一個系統(tǒng)的回顧研究顯示，預(yù)給量在防止產(chǎn)科區(qū)域麻醉低血壓方面幾乎沒有任何好處。

Despiteyearsofconcernandstudy,thereisstillnotestofplateletfunctionandnospecificplateletcountthatpredictsbleedingintotheneuraxisafterregionalanesthetictechniques盡管經(jīng)過多年的關(guān)注和研究，但仍然沒有血小板功能的測試和血小板計(jì)數(shù)預(yù)測椎管內(nèi)麻醉后的出血Thromboelastography(TEG)canaddinformationifthetestisavailable,butthereisstillnocut-offvalueforanyTEGvariablethatpredictscomplications.如果測試是可用的，血栓彈力圖可以增加信息，但血栓彈力圖的變化仍然沒有決定性的價(jià)值用來預(yù)測并發(fā)癥。

Sincepregnancyisathrombophilicstate,parturientshavetremendousreservebeforebecomingcoagulopathic.由于懷孕是一個易栓狀態(tài)，產(chǎn)婦在出現(xiàn)凝血障礙前有巨大的儲備。

Areviewof1.7millionspinalorepiduralblocksfoundthatcomplicationsweremorecommonafterepiduralthanspinalanesthetics,andthatobstetricpatientswerelesslikelythansurgicalpatientstohaveaninjury(1:25,000obstetricpatientsversus1:3600aftersurgicalepiduralsinfemales).170萬脊髓或硬膜外阻滯的回顧性研究發(fā)現(xiàn)，硬膜外麻醉比脊髓麻醉并發(fā)癥更常見，產(chǎn)科患者比外科手術(shù)患者的受傷害的可能性更?。óa(chǎn)科硬膜外麻醉并發(fā)癥的發(fā)生率為1:25,000，外科硬膜外并發(fā)癥的發(fā)生率為1:3600）

Therewere2obstetricpatientsintheirseriesthatdevelopedaneuraxialhematoma,foranincidenceof1:200,000.Oneoccurredafteraspinalandtheotherafterepiduralcatheterremoval;bothpatientshadHELLPsyndrome.Thislowincidenceisreassuring,butbalancetherisk-benefitratioforeachcaseandeachpatient.有2例產(chǎn)科病人發(fā)生了椎管內(nèi)血腫，發(fā)生率為1:200,000。一個發(fā)生在脊髓麻醉后，另一個發(fā)生在拔除硬膜外導(dǎo)管后；兩名患者均有HELLP綜合征。這一低發(fā)病率是令人欣慰的，但應(yīng)為每個病案和每個病人平衡風(fēng)險(xiǎn)及益處。Ifyoufeelthataneuraxialanestheticisnotappropriate,rememberthatanesthesiologistsareconsultantsinpainmanagement.如果你覺得椎管內(nèi)麻醉是不恰當(dāng)?shù)?，記住，麻醉醫(yī)師是疼痛管理方面的顧問。OurobstetriccolleaguesmayappreciatehelpwithanIVregimenforthepatient’slaboranalgesia.Forexample,fentanylcanbeusedinanIVPCAasfollows:giveanIVbolusloadingdoseof2-3μg/kgtoinitiateanalgesia.我們產(chǎn)科同事可能喜歡靜脈分娩鎮(zhèn)痛方案。例如，芬太尼可以用在如下的IVPCA：給予靜脈推注負(fù)荷劑量為2-3μg/kg作為起始鎮(zhèn)痛量。SetthePCApumpfora50μgincrementalbolus,10minutelockoutintervalandnobasalrate.Aslaborprogressesandtitrationisneeded,decreasethelockoutfrom10to5minutes,thenincreasethebolusdosefrom50to75μg.設(shè)置PCA泵追加量50μg，10分鐘鎖定時間無基礎(chǔ)速率。隨著產(chǎn)程進(jìn)展，精確給藥是必要的，鎖定時間從10分鐘調(diào)整到5分鐘，然后增加每次劑量為50至75微克。Thechoicesforcesareananesthesiaareepidural,spinal(orcombinedspinal-epidural)andgeneral。剖宮產(chǎn)的麻醉選擇包括硬膜外、脊麻（腰硬聯(lián)合）、全麻Inthepast,spinalanesthesiawasavoidedbecauseofconcernsthathypotensionwouldbemoresevereandlesstreatablethanthatseenaftersympathectomyfromanepiduralanesthetic.在過去，椎管內(nèi)麻醉被避免，因?yàn)橄啾扔材ね饴樽?，?dān)心交感神經(jīng)阻滯低血壓會更嚴(yán)重和更難治療。However,acomparisonofwomenwithseverepreeclampsiatohealthywomen,allhavingacesareandeliverywithspinalanesthesia,foundthatpreeclampticwomenactuallyhadlesshypotension(17%versus53%)despitereceivinglessfluidpreloadand(bychance)alargerdoseofbupivacaineintheirspinal.然而，進(jìn)行脊麻剖宮產(chǎn)的嚴(yán)重先兆子癇和健康婦女的比較發(fā)現(xiàn)，先兆子癇的孕婦實(shí)際上低血壓的發(fā)生率更低（17％比53％），盡管在椎管內(nèi)麻醉時給予更少的液體負(fù)荷和更大劑量的布比卡因。Arandomizedcomparisonofspinalorepiduralanesthesiaforcesareandeliveryinwomenwithseverepreeclampsiafoundthatalthoughhypotensionwasmorefrequentafterspinalandrequiredslightlymoreephedrine,thedurationofhypotensionwasshortandneonataloutcomesweresimilarinbothgroups.在對重度子癇前期脊髓或硬膜外麻醉剖宮產(chǎn)的隨機(jī)比較中發(fā)現(xiàn)，雖然脊麻后低血壓發(fā)生更頻繁，需要稍微更多的麻黃素，但是低血壓持續(xù)時間很短，在兩組中新生兒結(jié)局是相似的。Asmallstudyof“stable”eclampticpatientsdescribedtheircesareandeliveriesunderspinalanesthesiawithoutintraoperativecomplicationssuchasexcessivehypotensionoradditionalseizures.一項(xiàng)針對“穩(wěn)定”子癇患者的小規(guī)模研究表明他們在脊麻下剖宮產(chǎn)分娩無術(shù)中并發(fā)癥，如：過度低血壓或癲癇的發(fā)作。Regardlessofthechoiceofneuraxialtechnique(spinalorepidural),pressorsmustbeimmediatelyavailabletotreatevenmildhypotensionsincethesefetusesmaynottolerateanydecreaseinuteroplacentalperfusion.無論椎管（脊髓或硬膜外）技術(shù)的選擇，升壓藥必須隨時可用于治療甚至是輕度的低血壓，因?yàn)樘翰荒苣褪茏訉m胎盤灌注減少。Clinicalstudiesinhumanshaveconsistentlyshownthatuseofα-agonistssuchasphenylephrineproducebetterumbilicalpHvaluesinthenewbornthanuseofephedrine.在人類的臨床研究一致表明，使用α-受體激動劑如去氧腎上腺素比使用麻黃素在新生兒中產(chǎn)生更好的臍血pH值。Astudyrandomizingwomenwithseverepreeclampsiatospinalorgeneralanesthesiaforcesareandeliveryfornon-reassuringfetalhearttonesfoundthatspinalanesthesiawasassociatedwithmoreacidoticfetalpHvaluesandhigherbasedeficits.一項(xiàng)隨機(jī)研究嚴(yán)重先兆子癇孕婦，脊髓麻醉或全身麻醉行剖宮產(chǎn)，有胎兒心音變化者，脊麻與更多的胎兒酸中毒的pH值和較高的堿缺失有關(guān)。Maternalhemodynamicsweresimilarbetweengroups,butthepatientsreceivingspinalanesthesiareceivedmoreephedrine(14mgversus3mg)thanthoseinthegeneralanesthesiagroup.Phenylephrinewasnotused.Didtheuseofephedrineworsenfetalacidosis?Ifmaternalheartrateisabove70,choosephenylephrineasthefirst-linepressoragent.兩組血流動力學(xué)相似，接受脊髓麻醉的患者比全身麻醉組需要更多的麻黃素（14毫克和3毫克）。未使用。難道使用麻黃素使胎兒酸中毒惡化？如果產(chǎn)婦心率是70以上，選用去氧腎上腺素作為一線升壓用藥。

Ifgeneralanesthesiaischosen,theareasofconcernareattenuatinghypertensiveresponsesduringlaryngoscopyandintubation,managingadifficultedematousairway,andtreatingcomplicationsrelatedtomagnesiumtherapysuchasuterineatonyandmaternalweakness.如果選擇了全身麻醉，關(guān)注的方面在于減輕喉鏡插管時的高血壓反應(yīng)，管理困難的水腫氣道和與鎂治療有關(guān)的并發(fā)癥如宮縮乏力和孕婦虛弱。

Anumberofadjunctstorapidsequenceinductionhavebeendescribedandusedsuccessfullytocontrolhypertensionassociatedwithlaryngoscopy,e.g.esmolol,labetalol,lidocaine,remifentanilandnitroglycerin.許多快速誘導(dǎo)的輔助用藥被成功用來控制喉鏡相關(guān)的高血壓，如艾司洛爾、拉貝洛爾、利多卡因、瑞芬太尼和硝酸甘油。Includeatleastoneaspartofarapidsequenceinduction,orhavethemimmediatelyavailabletotreathypertensionifitoccurs.包括至少一種作為快速誘導(dǎo)用藥的組成，或者隨時可立即用于治療高血壓。Airwaymanagementmaybedifficult.Useofthelaryngealmaskairway(LMA)hasbeendescribedinthesettingofHELLPsyndromewhentherewasinabilitytointubateorventilate.氣道管理可能比較困難。當(dāng)HELLP綜合征患者無法插管或通氣時，可使用喉罩。Magnesiumtherapyhasanestheticinteractions.MagnesiumisauterinerelaxantandadditionaloxytocicssuchasCytotec?orHemabate?shouldbeavailabletotreatuterineatonyafterdeliveryinadditiontotheoxytocininfusion.Magnesiumalsocausesskeletalmuscleweakness。鎂治療有麻醉的相互作用。鎂是子宮松馳劑，分娩后除了靜滴催產(chǎn)素外，還應(yīng)備用如Cytotec?或欣母沛?治療宮縮乏力，鎂還會導(dǎo)致骨骼肌軟弱。Ifthemotherexhibitsmuscleweaknesspriortoinduction(i.e.,canshedoa5-secondheadliftbeforeheranesthetic？),itmaybebesttodiscontinuethemagnesiumsulfateinfusionduringthecaseandlethermagnesiumleveldecrease.如果母親在誘導(dǎo)之前，就有肌肉軟弱的表現(xiàn)（如她在麻醉前能抬頭5秒嗎？），最好是術(shù)中停止鎂硫酸輸液，讓她的血鎂水平降低。Non-depolarizingmusclerelaxantsshouldbeavoided.Ifshecannotmeetcriteriaforsafeextubationattheendofthecesarean,shemayrequireabriefperiodofmechanicalventilationuntilsheisstrongenoughtoprotectherairway.應(yīng)該避免使用非去極化肌松藥。如果在剖宮產(chǎn)結(jié)束時她不能滿足安全拔管的標(biāo)準(zhǔn)，她可能需要短暫的機(jī)械通氣直到她強(qiáng)大到足以保護(hù)她的氣道。

Postpartumissueswillrequireintensemonitoring.Themothermayneedbothacuteandlongtermbloodpressurecontrolwithanti-hypertensives.Fluidmobilizationwillbegintooccurduringthefirst24hourspostpartum,andthisiswhensheismostatriskforpulmonaryedema.Monitorurineoutput,lungfieldsandpulseoximetry.產(chǎn)后應(yīng)加強(qiáng)監(jiān)測。產(chǎn)婦可能需要急性和長期的抗高血壓控制。液體的轉(zhuǎn)移將出現(xiàn)于產(chǎn)后第一個24小時內(nèi)，這時發(fā)生肺水腫的危險(xiǎn)最大。必須監(jiān)測尿量、肺野和脈搏氧飽和度。Thrombocytopeniamaynotresolveforseveraldays.Ifshehasanepiduralcatheterinplace,decidewhenremovalisappropriatebasedonherplateletcountandcoagulationstudies.血小板減少癥不可能幾天內(nèi)解決。如果有硬膜外導(dǎo)管，基于她的血小板計(jì)數(shù)、凝血功能，來決定何時拔管Aboutathirdofeclampticseizuresoccurpostpartum.Areviewof89casesofeclampsiafo