1、Obstetric Anesthesia Respiratory System : increase in the respiratory minute volume and work of breathingGastrointestinal System : risk of incidence of aspirationendotracheal intubation Renal System : GFR rises 50% ; glycosuriaCentral Nervous System : sensitivity to anesthetics. Respiratory SystemlO
2、2 (Consumption 消耗 ) +20 to +50%lMV(Minute Ventilation分钟通气量)+50%lTV +40%lPaO2 +10%lPaCO2 -15%lHCO3 -15%lFRC -20%Placenta transport : Simple diffusion Facilitated diffusion Active transport PinocytosisReadily cross : low molecular weights, high lipid solubility , non-ionized Approximately 50% of the u
3、mbilical venous blood bypasses the liver.lNarcotic analgesic morphine pethidine fentanyl alfentanil sufentanil lGeneral anesthetics propofol l吗啡、哌替啶、芬太尼Placental transfer is rapidMother: uterus reactiveness orthostatic hypotension nausea vomiting delayed gastric emptyingFetus: respiratory depression
4、Most commonly used during labor intramuscular dose : 50 -100 mg Time of IM: before expulsion 1 h or 4 huterine contraction, frequency and intension Placental transfer is rapid Low dose: 10 -25 g fentanyl or 5-10 g sufentanil in subarachnoid space PCEA: low dose of fentanyl and 0.1%-0.3% ropivacaine
5、Placental transfer No inhibiting uterine contraction No Respiratory depression Readily cross the placenta Half-lives: 48 hours Problems: sedation, hypotonia, cyanosis, impaired metabolic responses to stress. Plasma protein binding: 94% Respiratory depression: depended on dose 0.075 mg/kg no problem
6、0.15 mg/kg different degree Pregnant woman: 慎用Apgar score Neonatus sleep: little Premature and intrauterine embarrass: carefully usingHigh doses (greater than 2 mg/kg) may cause low Apgar scores and abnormalities in neonatal muscle toneLabor pains of uterine contractionUterine muscular tension and c
7、ontraction forceContraindication: psychosis, gestational hypertension syndrome or preeclampsia, metrorrhexis Recommendation: induction: 2.5 mg/kg maintenance: 2.5-5.0 mg/kg/h Discontinue gravidity only Placental transfer is rapid Mothers respiration, circulation and Uterine muscular contraction forc
8、e 20-30s before of first stage of labor: 50% O2 and 50% N2O, maximumhalothane Cholinesterase: normal doseno placental transfer Dose 300 mg or single dose is larger: still have placental transfer Onset is quick, maintanence is short and placental transfer is leastAtracurium: 0.3 mg/kgFactors:Protein
9、binding: Molecular weightLiposolubility Catabolism in the placent Procaine Lidocaine Bupivacaine RopivacaineChoice depends on : the indications for the surgery the degree of urgency maternal status desires of the patient Hyperbaric bupivacaine Advantages : rapid onset, little risk of local anestheti
10、c toxicity, minimal transfer to the fetus, infrequent failure. Disadvantages : finite duration hypotension headache L 23 or L 12 1.5%2% Lidocaine or 0.5% Ropivacaine emergency cesarean section Increased dramatically in popularity Advantages : rapid onset supplemented at any time anesthetic dose sacr
11、al nerves block is sufficient rapid induction: obviate positive pressure ventilation oppress the cricoid cartilage mainterance: light anesthesia vomiting, backstreaming and aspiration: atropine, 0.5 mg, IM or glycopyrolate, 0.2 mg, IM Incidence: 2%30% Time: after 28 weeks, specially 3236 weeks Sympt
12、oms: hypotension, dizziness, nausea, chest distress, cold sweat, to yawn, pulse rate, pallescence Emergency operation : late trimester of pregnancy: hemorrhage gestational hypertension syndrom and eclampsia Selective operation : hypertension cardiac disease diabetes multifetation Preanesthtic prepar
13、ation: blood coagulation function DIC sifting test acute renal failure Principle: general anesthesia: active bleeding, hypovolemic shock, definite blood coagulation disfunction or DIC intraspinal anesthesia: condition of mother and fetus is okay Managementdegrees of abruptio placentae. A, Concealed
14、hemorrhage. B, External hemorrhage. C, Complete placental separation. Types of placenta previa. Announcements of the induction: difficult airway cricoid cartilage backstreaming and aspiration Prepare to salvage the blood coagulation disfunction and the hemorrhoea. Prevent the acute renal function fa
15、ilure: urine volume urea nitrogen and creatinine Prevention and cure of DIC Incidence: 10.3% Cause of death: cerebrovascular accident, pneumonedema, liver necrosis Pathophysiology: systemic arteriola systole, fetus Management: cardiac failure cerebral hemorrhage placental abruption blood coagulation
16、 disfunction haematolysis hepatic enzyme thrombocytopenia acute renal failure trying stable anesthesia: stress reaction: fentanyl avoid to use ketamine SBP: 140150 mmHg, DBP: about 90 mmHg ganglioplegic or nitroglycerin maintain heart, kindey and lung function: treatment of complication: basic monit
17、oring: ECG SpO2 NIBP CVP urine volume blood gas analysis prepare to salvage the neonatal asphyxia ICU postoperation analgesia pathophysiology: abdominal aorta and inferior vena cava compression; fetal lung maturity; incidence of postpartum hemorrhage. anesthesia: epidural anesthesia management: addi
18、tion of volume: colloid oxygen, prevention and cure of Supine hypotensive syndrome preparation of resuscitation of newborn Apgar score is a simple, useful guide - The Apgar scoring system Score * Sign 0 1 2 Heart rate Absent Less than 100/min More than 100/min Respiratory effort Absent Slow, irregul
19、ar Good, crying Color Blue, pale Body pink, extre mities blue (acrocyanosis) Completely pink Reflex irritability (response to insertion of a nasal catheter) Absent Grimace Cough, sneeze Muscle tone Limp Some flexion of extremities Active motion 1-minute score - degree of asphyxia 5-minute score - pr
20、ognosis evaluated at 1 and 5 minutes. should not wait until 1 minute has passed before initiating resuscitation. normal: 7-10 mild asphyxia: 4-6 severe asphyxia: 0-3 A ( Airway) B ( Breathing) C (Circulation) D (Drug) E (Evaluation) Incubation: 2731 Position: Suctioning: mouth and nose Stimulate: Co
21、mplete it within 20s Evaluation: according to breath, heart rate and skin colour Normal: stop resuscitation No spontaneously brathing, HR100/min: bag respirator HR80/min: closed cardiac massage; tracheal intubation, medication Maniphalanx pressurize Tidal volume: 2040ml I : E = 1.5:1 RP: 3040/min fi
22、rst twice: pressure 3040 cmH2O subsequently: pressure 1020 cmH2OHR: 120/minDepth: 12cm 30s after the closed cardiac massage, still cant recovery : drug Epinephrine: 0.10.2mg/kg, intratracheal drop in umbilical cord was clamped and cut earlier intrauterine asphyxia placental abruption hemorrhage too
23、much: antepartum or intrapartum arterial blood pressure and CVP pale skin poor capillary refill extremities are cold pulses are weak or absent intravascular volume expansion blood, plasma ,crystalloid , Albumin 10 mL/kg of normal saline, 1 to 2 g/kg of 25% albumin, or 10 mL/kg of plasma. Care must b
24、e taken Respiratory acidosis is corrected by controlling ventilationMetabolic acidosis is corrected by infusing sodium bicarbonate.Requisite amount of sodium bicarbonate(mmol): = 0.6BW(kg)(normal BE-present BE)/4 sodium bicarbonate 1 mmol/kg/minSodium bicarbonate should not be infused unless ventila
25、tion is adequate. temperature breath heart rate blood pressure urine volume Special position: head down and lithotomy position Old age: comorbidities Emergency case: exfetation, ovarian cyst intortion, perineal position trauma, uterine perforation More other: selective operation Hysteroscope and Laparoscopic Surgery:
