麻醉及麻醉藥對胎兒和新生兒的影響-首都醫(yī)大

麻醉及麻醉藥對胎兒和新生兒的影響

精選課件精選課件胎盤屏障與胎盤血液循環(huán)一、胎盤與胎盤屏障胎盤是哺乳動物妊娠期特有的器官，它連接母體與胎兒，通過子宮和滋養(yǎng)層血管化部分的對合，實現(xiàn)提供內(nèi)分泌激素，選擇性交換可溶性非顆粒物質(zhì)，保證胎兒的正常營養(yǎng)供應(yīng)和廢物排泄。精選課件胎盤屏障與胎盤血液循環(huán)精選課件精選課件圍產(chǎn)期藥理學(xué)圍產(chǎn)期藥理學(xué)：涉及藥物在母親及胎兒兩者體內(nèi)的吸收、分布、生物轉(zhuǎn)化及排泄。圍產(chǎn)期：胎盤藥物轉(zhuǎn)運的決定因素：母體、胎盤、胎兒三方面因素來決定。精選課件圍產(chǎn)期藥理學(xué)母體因素劑量：注射部位：佐劑：藥動學(xué)：精選課件圍產(chǎn)期藥理學(xué)胎盤因素擴散主動運輸大量運輸吞飲作用中斷精選課件圍產(chǎn)期藥理學(xué)胎盤因素一、擴散Fick公式：Q/t=K·A（Cm-Cf）/D精選課件決定通透性的三個方面

分子量

通透性Ｋ脂溶性

離子化｛精選課件麻醉藥分子量蛋白結(jié)合率(%)脂溶性鹽酸利多卡因288.82702.9鹽酸丁卡因300.837680鹽酸布比卡因342.919528鹽酸羅哌卡因328.9394-丙泊酚178.398咪達唑侖362.295嗎啡23-26枸櫞酸芬太尼528.6084舒芬太尼578.6993瑞芬太尼412.9170精選課件圍產(chǎn)期藥理學(xué)胎兒因素一旦藥物透過胎盤，胎兒對藥物的攝取、分布、代謝、排泄決定藥物的清除和生理作用。流向胎盤組織物質(zhì)交換部位的臍血流是影響胎兒藥物攝取的根本因素。胎兒紅細胞和血清蛋白比母體紅細胞和血清蛋白與局麻藥的結(jié)合程度低。胎兒藥物代謝和排泄。精選課件妊娠期麻醉及藥物對胎兒的影響妊娠期間接受外科手術(shù)：0.3%～2.2%未知妊娠接受外科手術(shù)：0.3%1-2%的孕婦在孕期需要接受手術(shù)：

闌尾切除術(shù)（1:1500次妊娠）膽囊切除術(shù)（1:2000-10000次妊娠）

精選課件妊娠期麻醉及藥物對胎兒的影響

妊娠各孕期的孕婦常進行的外科手術(shù)手術(shù)類型第一孕期第二孕期第三孕期１～３月（%）4～6月（%）7～9月（%）CNS耳鼻喉腹部19.930.122.6泌尿生殖-婦科10.623.324.4腹腔鏡檢查矯形外科8.99.313.7內(nèi)鏡檢查3.6118.6皮膚MazzeRL,KallenB:Reproductiveoutcomeafteranesthesiaandoperationduringpregancy.Aregistrystudyof5405case.AmJObstetGynecol161:1178-1185,1989.精選課件精選課件妊娠期麻醉及藥物對胎兒的影響精選課件妊娠期麻醉及藥物對胎兒的影響麻醉醫(yī)師應(yīng)注意以下幾點：①母體安全；②避免應(yīng)用致畸藥物；③避免發(fā)生胎兒宮內(nèi)窘迫；④防止流產(chǎn)和早產(chǎn)。精選課件剖宮產(chǎn)麻醉及藥物對新生兒的影響新生兒狀況的評價指標(biāo):Apgar評分碳酸氫根神經(jīng)和適應(yīng)能力評分（NACS）精選課件剖宮產(chǎn)麻醉及藥物對新生兒的影響ApgarScoringSign0points1point2pointsAActivity

(Muscletone)limplimbsflexedactivemovementPPulse

(heartrate)absent<100/min

>100/minGGrimace

(responsetosmellorfootslap)absentgrimacecoughorsneeze(nose)

cryandwithdrawaloffoot(footslap)AAppearance

(color)bluebodypink

extremitiesbluepinkalloverRRespiration

(breathing)absentirregular

weakcryinggoodstrongcry精選課件FORIMMEDIATERELEASEStampNewsRelease#94-041NEWSTAMPSCORESA"10"ONTHEAPGARSCALE

WASHINGTON,DC(AUGUST15,1994)

A20-centdefinitivestamphonoringDr.ViriginiaApgarwillbeissuedbythePostalServiceonOctober24,1994.AfirstdayofissueceremonyforthenewstampwillbeheldattheAmericanAcademyofPediatricsannualmeetinginDallasonOctober24.MillionsofbabiesaroundtheworldhavealreadybeenblessedwithDr.Apgar'sown"stampofapproval."In1953,shepublishedtheApgarscore,asimpleassessmentmethodthatallowsdoctorsandnursesinthedeliveryroomtomakeanimmediateevaluationofanewbornbaby'sgeneralcondition,aidingidentificationofthoseinfantswhoneedimmediatemedicalattention.Dr.ApgarwasbornonJune7,1909inWestfield,NewJersey.ShegraduatedfromMountHolyokeCollegein1929andwentontoColumbiaforhermedicaldegree,andwasthefirstwomenselectedforafullprofessorshipatColumbiaUniversityCollegeofPhysiciansandSurgeons.Sheaspiredtobeasurgeon,andthenmovedintothethenrelativelynewfieldofanesthesiology,placingspecialemphasisontheeffectsofobstericanesthesiaonnewbornbabies.Dr.ApgarcontinuedhercontributionstomedicinebyservingtheNationalFoundation-MarchofDimes,whereshedirectedprogramsofresearchinthecauses,preventionandtreatmentofbirthdefects.ThePerinatalSectiionoftheAmericanAcademyofPediatricsnameditsannualawardtoher.TheApgarAwardisgivenannuallytothepersonwhohasdonethemosttofurtherthecausetocareofnewbornbabiesandtheirmothers.Inadditiontohermedicalachievements,Dr.Apgarwasknownforhersenseofhumorandempathyforhumanity.Someofherotherinterestsincludedchambermusicandstampcollecting.Asapreludetothestampdedicationceremony,agroupofphysicians/musicianscalledtheApgarStringQuartestwillperformsomeofDr.Apgar'sfavoriteselectionsoninstrumentsshecraftedherself.

Dr.ApgardiedonAugust7,1974.精選課件剖宮產(chǎn)麻醉及藥物對新生兒的影響B(tài)righam婦產(chǎn)醫(yī)院精選課件剖宮產(chǎn)麻醉及藥物對新生兒的影響476/51093.3%34/5106.7%精選課件剖宮產(chǎn)麻醉及藥物對新生兒的影響麻醉劑對孕婦及胎兒的影響（全身麻醉）硫噴妥鈉：氯胺酮：依托咪酯：氧化亞氮：鹵化劑：精選課件剖宮產(chǎn)麻醉及藥物對新生兒的影響

丙泊酚丙泊酚是美國FDA確認的對孕婦及胎兒不良影響比較小的一種麻醉藥物。丙泊酚在產(chǎn)婦全身麻醉中的應(yīng)用以及對母體、胎兒的影響均有研究，認為采用常規(guī)劑量時，對胎兒、新生兒沒有明顯影響。

HeinHAT,PutmanJM.Ispropofolaproperpropositionforreproductiveprocedures.JClinAnesth,1997,9:611-613.宴馥霞.異丙酚在剖宮產(chǎn)全麻中的應(yīng)用.國外醫(yī)學(xué)麻醉學(xué)與復(fù)蘇分冊,1997,18:293-295.

AlcarazAS,QuintanaMB,LaguardaM.Placentaltransferandneonataleffectsofpropofolincaesareansection·JClinPharTherapeut,i1998,3:19-23.精選課件剖宮產(chǎn)麻醉及藥物對新生兒的影響麻醉劑對孕婦及胎兒的影響（全身麻醉）丙泊酚：UV/MA=0.7100ug/Kg/minor2.5mg/Kg

√√150ug/Kg/min精選課件99.45±29.40min3.36±1.87L﹒Kg81.27±18.87min2.66±0.63L/Kg39.32±8.07ml/min/kg29.40±8.72ml/min/kg晏馥霞,李樹人.異丙酚在剖宮產(chǎn)全麻中的應(yīng)用.《國外醫(yī)學(xué)》麻醉學(xué)與復(fù)蘇分冊,1997,18(5):293-295.精選課件剖宮產(chǎn)麻醉及藥物對新生兒的影響瑞芬太尼表瑞芬太尼血液濃度與胎盤轉(zhuǎn)運n瑞芬太尼MA(ug/ml)161.32±0.80UV(ug/ml)150.73±0.27UA(ug/ml)100.20±0.07UV/MA150.88±0.78

0.85±0.18UA/UV100.29±0.07

0.81±0.18MA.母體動脈；UV，臍帶靜脈，UA，臍帶動脈KanRE,HughesSC,RosenC,enMA,etal.Intravenenousremifentanil:Placentaltransfer,maternalandneonataleffects.Anesthesiology1998;88:1467-1474.精選課件剖宮產(chǎn)麻醉及藥物對新生兒的影響肌松藥肌松藥由于其分子量大，蛋白結(jié)合率高，10~25min內(nèi)經(jīng)胎盤轉(zhuǎn)運至胎兒的量很小而并不具有臨床效應(yīng)。IwamaH,KanekoT,TobishimaS,etal.timedependencyoftheratioofumbilicalvein/maternalarteryconcentrationsofvecuroniumincesareansection[J].ActaAnesthsiolScand,1999;43(1):9.精選課件剖宮產(chǎn)麻醉及藥物對新生兒的影響表2兩組新生兒NBNA測定結(jié)果比較(x±s)組別分娩后天數(shù)總評分第2天第14天第28天E組36.82±2.5238.61±1.8539.06±1.4238.16±1.98G組38.17±1.5039.45±1.0239.78±0.48△39.13±1.08△與硬膜外組相比,△P<0.05精選課件剖宮產(chǎn)麻醉及藥物對新生兒的影響表兩組新生兒NBNA比較(分,x±s)組別行為能力被動肌張力主動肌張力原始反射一般狀態(tài)總分G組12·6±0·77·2±0·77·4±0·65·6±0·85·9±0·338·2±1·4E組13·4±0·87·3±0·57·3±0·85·6±0·65·9±0·339·5±1·6李崇華,朱春仙,賀晶.全身麻醉對剖宮產(chǎn)產(chǎn)婦分娩新生兒的影響.中華婦產(chǎn)科雜志,2006,41(3):162-164.

精選課件剖宮產(chǎn)麻醉及藥物對新生兒的影響剖宮產(chǎn)全身麻醉關(guān)鍵點：Ｉ－Ｄ時間：＜10minＵ－Ｄ時間：＜3minKamatSK,ShahMV,ChaudharyLS,etal.Effectofinductiondeliveryanduterine-deliveryonapgarscoringofthenewborn[J],JPostgradMed,1991;37:125.精選課件剖宮產(chǎn)麻醉及藥物對新生兒的影響精選課件剖宮產(chǎn)麻醉及藥物對新生兒的影響精選課件精選課件精選課件術(shù)后鎮(zhèn)痛對新生兒的影響母乳是嬰兒最理想的食品。術(shù)后鎮(zhèn)痛利于泌乳素（PRL）的分泌，利于母乳喂養(yǎng)。水溶性藥物在初乳中濃度高，脂溶性藥物在成熟乳汁中濃度較高。精選課件術(shù)后鎮(zhèn)痛對新生兒的影響不同鎮(zhèn)痛方式對剖宮產(chǎn)術(shù)后哺乳的影響PCEA組：芬太尼0.4mg+氟哌利多2.5mg+0.75%布比卡因25ml+生理鹽水至100ml持續(xù)劑量2ml/h，PCA劑量0·5ml/次。PCIA組：芬太尼1.2mg+氟哌利多2.5mg+生理鹽水至100ml持續(xù)劑量2.5ml/h,PCA劑量1.0ml/次。精選課件術(shù)后鎮(zhèn)痛對新生兒的影響

不同鎮(zhèn)痛方式對剖宮產(chǎn)術(shù)后哺乳的影響表1兩組產(chǎn)婦及新生兒尿液藥物及代謝產(chǎn)物陽性率比較

新生兒尿液陽性率(%)產(chǎn)婦尿液陽性率(%)硬膜外組48·3560·32靜脈組86·8497·18P<0·01<0·01精選課件術(shù)后鎮(zhèn)痛對新生兒的影響

不同鎮(zhèn)痛方式對剖宮產(chǎn)術(shù)后哺乳的影響

表2兩組術(shù)后3小時新生兒呼吸、心率、睜眼時間、尿量比較

呼吸(分/次)心率(分/次)睜眼時間(分鐘)尿量(ml)硬膜外組25.34±2.14150.36±2.49120.37±2.9560.68±2.26靜脈組26.51±1.84153.27±1.92121.36±1.8461.82±1.67t1.611.781.921.54P＞0.05精選課件術(shù)后鎮(zhèn)痛對新生兒的影響

不同鎮(zhèn)痛方式對剖宮產(chǎn)術(shù)后哺乳的影響

表3

兩組產(chǎn)婦術(shù)后1天泌乳量比較