麻醉及麻醉药对胎儿和新生儿的影响-首都医大

麻醉及麻醉药对胎儿和新生儿的影响首都医科大学北京妇产医院徐铭军胎盘屏障与胎盘血液循环一、胎盘与胎盘屏障胎盘是哺乳动物妊娠期特有的器官，它连接母体与胎儿，通过子宫和滋养层血管化部分的对合，实现提供内分泌激素，选择性交换可溶性非颗粒物质，保证胎儿的正常营养供应和废物排泄。胎盘屏障与胎盘血液循环围产期药理学围产期药理学：涉及药物在母亲及胎儿两者体内的吸收、分布、生物转化及排泄。围产期：胎盘药物转运的决定因素：母体、胎盘、胎儿三方面因素来决定。围产期药理学母体因素剂量：注射部位：佐剂：药动学：围产期药理学胎盘因素扩散主动运输大量运输吞饮作用中断围产期药理学胎盘因素一、扩散Fick公式：Q/t=K·A（Cm-Cf）/D决定通透性的三个方面分子量通透性Ｋ脂溶性离子化麻醉药分子量蛋白结合率(%)脂溶性盐酸利多卡因288.82702.9盐酸丁卡因300.837680盐酸布比卡因342.919528盐酸罗哌卡因328.9394-丙泊酚178.398咪达唑仑362.295吗啡23-26枸橼酸芬太尼528.6084舒芬太尼578.6993瑞芬太尼412.9170围产期药理学胎儿因素一旦药物透过胎盘，胎儿对药物的摄取、分布、代谢、排泄决定药物的清除和生理作用。流向胎盘组织物质交换部位的脐血流是影响胎儿药物摄取的根本因素。胎儿红细胞和血清蛋白比母体红细胞和血清蛋白与局麻药的结合程度低。胎儿药物代谢和排泄。妊娠期麻醉及药物对胎儿的影响妊娠期间接受外科手术：0.3%～2.2%未知妊娠接受外科手术：0.3%1-2%的孕妇在孕期需要接受手术：阑尾切除术（1:1500次妊娠）胆囊切除术（1:2000-10000次妊娠）妊娠期麻醉及药物对胎儿的影响妊娠各孕期的孕妇常进行的外科手术手术类型第一孕期第二孕期第三孕期１～３月（%）4～6月（%）7～9月（%）CNS6.75.45.6耳鼻喉7.66.49.5腹部19.930.122.6泌尿生殖-妇科10.623.324.4腹腔镜检查34.11.55.6矫形外科8.99.313.7内镜检查3.6118.6皮肤3.83.24.1MazzeRL,KallenB:Reproductiveoutcomeafteranesthesiaandoperationduringpregancy.Aregistrystudyof5405case.AmJObstetGynecol161:1178-1185,1989.妊娠期麻醉及药物对胎儿的影响妊娠期麻醉及药物对胎儿的影响麻醉医师应注意以下几点：①母体安全；②避免应用致畸药物；③避免发生胎儿宫内窘迫；④防止流产和早产。剖宫产麻醉及药物对新生儿的影响新生儿状况的评价指标:Apgar评分碳酸氢根神经和适应能力评分（NACS）剖宫产麻醉及药物对新生儿的影响ApgarScoringSign0points1point2pointsAActivity(Muscletone)limplimbsflexedactivemovementPPulse(heartrate)absent100/min100/minGGrimace(responsetosmellorfootslap)absentgrimacecoughorsneeze(nose)cryandwithdrawaloffoot(footslap)AAppearance(color)bluebodypinkextremitiesbluepinkalloverRRespiration(breathing)absentirregularweakcryinggoodstrongcryFORIMMEDIATERELEASEStampNewsRelease#94-041NEWSTAMPSCORESA10ONTHEAPGARSCALEWASHINGTON,DC(AUGUST15,1994)A20-centdefinitivestamphonoringDr.ViriginiaApgarwillbeissuedbythePostalServiceonOctober24,1994.AfirstdayofissueceremonyforthenewstampwillbeheldattheAmericanAcademyofPediatricsannualmeetinginDallasonOctober24.MillionsofbabiesaroundtheworldhavealreadybeenblessedwithDr.Apgar'sownstampofapproval.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.剖宫产麻醉及药物对新生儿的影响Brigham妇产医院剖宫产麻醉及药物对新生儿的影响476/51093.3%34/5106.7%剖宫产麻醉及药物对新生儿的影响麻醉剂对孕妇及胎儿的影响（全身麻醉）硫喷妥钠：氯胺酮：依托咪酯：氧化亞氮：卤化剂：剖宫产麻醉及药物对新生儿的影响丙泊酚丙泊酚是美国FDA确认的对孕妇及胎儿不良影响比较小的一种麻醉药物。丙泊酚在产妇全身麻醉中的应用以及对母体、胎儿的影响均有研究，认为采用常规剂量时，对胎儿、新生儿没有明显影响。HeinHAT,PutmanJM.Ispropofolaproperpropositionforreproductiveprocedures.JClinAnesth,1997,9:611-613.宴馥霞.异丙酚在剖宫产全麻中的应用.国外医学麻醉学与复苏分册,1997,18:293-295.AlcarazAS,QuintanaMB,LaguardaM.Placentaltransferandneonataleffectsofpropofolincaesareansection·JClinPharTherapeut,i1998,3:19-23.剖宫产麻醉及药物对新生儿的影响麻醉剂对孕妇及胎儿的影响（全身麻醉）丙泊酚：UV/MA=0.7100ug/Kg/minor2.5mg/Kg√√150ug/Kg/min99.45±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,李树人.异丙酚在剖宫产全麻中的应用.《国外医学》麻醉学与复苏分册,1997,18(5):293-295.剖宫产麻醉及药物对新生儿的影响瑞芬太尼表瑞芬太尼血液浓度与胎盘转运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±0.780.85±0.18UA/UV100.29±0.070.81±0.18MA.母体动脉；UV，脐带静脉，UA，脐带动脉KanRE,HughesSC,RosenC,enMA,etal.Intravenenousremifentanil:Placentaltransfer,maternalandneonataleffects.Anesthesiology1998;88:1467-1474.剖宫产麻醉及药物对新生儿的影响肌松药肌松药由于其分子量大，蛋白结合率高，10~25min内经胎盘转运至胎儿的量很小而并不具有临床效应。IwamaH,KanekoT,TobishimaS,etal.timedependencyoftheratioofumbilicalvein/maternalarteryconcentrationsofvecuroniumincesareansection[J].ActaAnesthsiolScand,1999;43(1):9.剖宫产麻醉及药物对新生儿的影响表2两组新生儿NBNA测定结果比较(x±s)组别分娩后天数总评分第2天第14天第28天E组36.82±2.5238.61±1.8539.06±1.4238.16±1.98G组38.17±1.5039.45±1.0239.78±0.48△39.13±1.08△与硬膜外组相比,△P0.05剖宫产麻醉及药物对新生儿的影响表两组新生儿NBNA比较(分,x±s)组别行为能力被动肌张力主动肌张力原始反射一般状态总分G组12·6±0·77·2±0·77·4±0·65·6±0·85·9±0·338·2±1·4E组13·4±0·87·3±0·57·3±0·85·6±0·65·9±0·339·5±1·6李崇华,朱春仙,贺晶.全身麻醉对剖宫产产妇分娩新生儿的影响.中华妇产科杂志,2006,41(3):162-164.剖宫产麻醉及药物对新生儿的影响剖宫产全身麻醉关键点：Ｉ－Ｄ时间：＜10minＵ－Ｄ时间：＜3minKamatSK,ShahMV,ChaudharyLS,etal.Effectof