Hail Caesar: Anesthesia for Cesarean Delivery 剖腹产手术麻醉 Lawrence C. Tsen, M.D. 翻译：福建医科大学附属协和医院麻醉科规培住院医师 石磊,Introduction,Associated with high maternal mortality（二十世纪前， 剖腹产由于产妇高死亡率，开展得并不多）until the turn of the 20th century, cesarean delivery now accounts for approximately one third of all births in developed countries （发达国家三分之一分娩通过剖腹产） This increase has resulted from improvements in surgical and anesthetic techniques, diminished use of forceps for extractions, fewer breech and multiple gestation vaginal deliveries, and greater use of repeat cesarean deliveries （得益于外科及麻醉技术的发展、产钳使用的减少、臀位和 复杂分娩的减少、以及二次剖腹产的发展）.,Introduction,The updated Practice Guidelines for Obstetrical Anesthesia from the ASA Task Force on Obstetrical Anesthesia observe that neuraxial techniques (spinal, epidural, CSE) are associated with improved maternal and fetal outcomes when compared to general anesthesia (GA) （观察到椎管内麻醉与全麻相比，对于产妇和胎儿有更好的预 后）, particularly in the presence of high body mass index and airway issues（特别是高体重指数和气道问题的病人）. However, specific anesthetic management should be chosen on a case-by-case assessment of patient, medical （具体麻醉方式必须建立在对病人完全评估之上）,anesthetic, and obstetric issues.,Introduction,Anesthetic participation can also reduce the incidence 、 of cesarean deliveries e.g. improving forcep/vacuum analgesia, increasing the success of multiple gestation vaginal births, reducing fetal head entrapment with intravenous nitroglycerin, and improving external cephalic version (ECV) success. (麻醉在自然分娩中的参与同样可 以减少剖腹产率，比如为使用产钳时提供镇痛，提高复杂 分娩的成功率以及改善胎位不正回转术的成功率),Introduction,Neuraxial techniques improve ECV success by relaxing the abdominal wall muscles, improving patient comfort, and allowing a more concerted attempt.（神经 阻滞可以松弛腹壁肌肉，提高病人舒适度，从而提高回 转术成功率） anesthesia (lidocaine 45 mg with fentanyl 10 g) combined with uterine tocolysis (nitroglycerin 50 g iv, wait 50 sec) has been associated with a high success rate (83%) for external cephalic version (ECV).（使用 45mg利多卡因+10ug芬太尼，同时用50ug硝酸甘油抑制 子宫收缩，可以使回转术成功率提高到83%）,Is there a Preferred Anesthetic Technique（什么是剖腹产首选麻醉方式）?,Complications related to anesthesia still represent the sixth leading cause of peripartum maternal mortality in the United States（麻醉相关并发症是产妇围生期第六大 死亡原因）. Not surprisingly, these deaths most commonly result from failures in oxygenation and ventilation（通常由氧合或 通气失败导致）,however, these episodes are currently being witnessed more frequently during extubation and postoperative recovery, rather than with intubation（通常 在拔管及恢复期发现，而不是插管时）.,Is there a Preferred Anesthetic Technique?,The estimated case-fatality risk ratio for GA versus neuraxial anesthesia has undergone a significant reduction （全麻与椎管内麻醉的死亡率比例经历了极大的下降）. This change most likely represents two Trends（代表了两 种趋势）: 1) a reduction in GA use, coupled with more successful manipulation (e.g. Alternate airway devices) of the maternal airway（全麻的减少，和更多气道替代设备的熟练操作）. 2) a growing acceptance of neuraxial technique use in parturients with significant comorbidities (e.g. obesity, severe preeclampsia, hematologic and cardiac disease)（对合并有 包括肥胖，严重子痫前期，凝血功能障碍及心脏病产妇使用椎 管内麻醉的接受程度）,Is there a Preferred Anesthetic Technique?,The combined spinal epidural (CSE) technique may offer the most flexibility（腰硬联合提供更多的灵活度） in terms of reducing the initial drug dose (通过减少初始剂 量），allowing for potentially less hypotension and faster recovery（更少的低血压发生率和更快的恢复）, as well as prolonging the blockade should operative complications （减少手术并发症） or postoperative pain management （术后镇痛管理） issues occur.,Should Newer Local Anesthetics be used（新型局麻药的使用）?,Potentially reduced recovery times and toxicity profiles have fostered an interest in the newer local anesthetics为了 减少恢复时间和毒性反应，促使了新型局麻药的发展）, ropivacaine and levobupivacaine（罗哌卡因和左布比卡因）. Although established to be safe and acceptable for elective cesarean deliveries（虽然被证实剖腹产时更安全） ,these two local anesthetics may not be significantly less cardiotoxic than bupivacaine（并没有比布比卡因明显减少心 脏毒性） Moreover, because the toxicity of bupivacaine does not appear to be enhanced in pregnancy（因为布比卡因的毒性 在怀孕期并没有增加）,cardiac toxicity should only occur with unintentional large intravascular doses（心脏毒性只在 血管内意外大量注射后发生）.,Should Newer Local Anesthetics be used?,With the common and more forgiving use of chloroprocaine 3% and lidocaine 2% for conversion of epidural labor analgesia to cesarean Anesthesia（随着 普鲁卡因和利多卡因作为剖腹产硬膜外麻醉的药物, coupled with proper drug administration practices (e.g. attention to incremental dosing practices, total dose guidelines, and toxicity symptoms，如果掌握正确的给药 方式（例如注意追加剂量、总剂量的给药方法、掌握判断 毒性反应的方法), toxic intravascular levels should be a rare（血管内毒性水平可以降到很低）.,Should Lower Doses of Bupivacaine be used（低剂量布比卡因的使用）?,The dose of local anesthetics has been reduced as a method to potentially obtain less hypotension, faster motor recovery and discharge times, and improved maternal satisfaction（减少局麻 药用量可以作为预防低血压，改善恢复时间和产妇满意度的方法） Such dose reductions may be achieved by using spinal versus epidural anesthesia（通过使用腰麻）, as well as less total local anesthetic