產(chǎn)科麻醉在病理性肥胖中演繹課件

ObstetricObesity:AnesthesiaImplicationsandManagementYunhongZhang,MD,PhDAnesthesiaAssociatesofSt.LouisJune,2015ObstetricObesity:Anesthesia1產(chǎn)科麻醉在病理性肥胖中演繹課件2產(chǎn)科麻醉在病理性肥胖中演繹課件3OutlineDefinitionandprevalencePhysiologicalchangesonthetopofpregnancyPregnancycomplicationsMaternalcomplicationsFetalcomplicationsAnesthesiaproblemsandmanagementOutlineDefinitionandprevalen4DefinitionBMI=kg/m2Normal:18.5-24.9Overweight:25-29.9Obesity:>30TherevisedpregnancyweightgainguidelinebyIOM2009NOTdifferentiatebwClassI30-34.99ClassII35-39.99ClassIIIormorbidlyobese>40Obesityinpregnancy,ACOG,2013DefinitionBMI=kg/m25產(chǎn)科麻醉在病理性肥胖中演繹課件6NodatainChinayetNodatainChinayet7Whatwillhappenwhenpeoplegetbig?Whatwillhappenwhenpeopleg8產(chǎn)科麻醉在病理性肥胖中演繹課件9產(chǎn)科麻醉在病理性肥胖中演繹課件10產(chǎn)科麻醉在病理性肥胖中演繹課件11PhysiologicalchangesofobesityonpregnancyPhysiologicalchangesofobesi12產(chǎn)科麻醉在病理性肥胖中演繹課件13Airway

Pregnancy&obesity,riskfactorsfordifficultairwayInpregnancy:Breastenlargement,Adiposetissuedeposition,MucosaengorgementFailedintubationis8timesmoreAirwayPregnancy&obesity,ri14AirwayDifficultairwayinobesityDifficultintubation15.5%vs.2.2%(BMI>35vs.Leanpeople)(Juvinetal)6/17(total117morbidlyobesepregnantwomen)difficultintubationinobeseparturientsforc/s(HoodandDewan)Implication:pre-laboranesthesiaconsultationAirwayDifficultairwayinobes15RespirationDecreasedRV,ERV,FRCinpregnancyReducedpulmonaryandchestwallcomplianceinobesityIncreasedoxygenconsumptionandCO2productionFRCcanfallbelowclosingcapacity(earlyairwayclosureandshuntingImportanceofpreoxygenationRespirationDecreasedRV,ERV,16產(chǎn)科麻醉在病理性肥胖中演繹課件17OSARiskofOSAdoublesinoverweightparturientsIncreasedriskforHTN,DM,pretermlaborandoperativeinterventionandadversefetaloutcomes.EarlydiagnosisandtreatmentcanimprovematernalandfetaloutcomesOSARiskofOSAdoublesinover18CardiovascularInPregnancy:CO,50%higherafter2ndtrimesterFirststage25%morethantheprelabor2ndstage40%morePostpartum,75%abovetheprelaborCardiovascularInPregnancy:19CardiovascularObesity:30-50ml/min/100gincreaseinCO60%obeseptsmayhavemildtomodHTNObeseparturients:exacerbatedincreaseinbloodvolume,impairedafterloadreductionb/oincreasedPVRNeuroendocrineactivation,renalsodiumretentionandincreasedsystemicoxidativestressduetocomorbiditiesinobesityleadtocardiacremodelingandmyocardialdysfunction.SupineHypotensiveSyndromeisexacerbatedCardiovascularObesity:20GIPregnancyleadstoGERD:hormonalandmechanicalmechanismGERDsymptomsexacerbatedinobeseparturients“Fullstomach”precautious,RSI,“TripleRx”:SodiumBicitrate,Metoclopramide,famotidineGIPregnancyleadstoGERD:hor21PregnancycomplicationsPregnancycomplications22MaternalComplicationsGestationalDMGestationalHTNPreeclampsiaFetalmacrosomiaOSAAsthmaMaternalComplicationsGestatio23產(chǎn)科麻醉在病理性肥胖中演繹課件24FetalcomplicationsPrematurityStill-birthCongenitalabnormalitiesMacrosomiaChildhoodandadolescentobesityFetalcomplicationsPrematurity25MCVallejo,SOAP,2013MCVallejo,SOAP,201326IntrapartumComplicationsBigbaby,uterineatonyShoulderdystociaIncreasedC-sectionrateIncreasedinstrumentaldeliveryIntrapartumComplicationsBigb27MaternalRisksHypertensivedisorders,includingpreEGestationaldiabetesAsthmaOSAMaternalRisksHypertensivedis28L.Ellinas,,2013L.Ellinas,29L.Ellinas,,2013L.Ellinas,30產(chǎn)科麻醉在病理性肥胖中演繹課件31AnesthesiaconsiderationsAnesthesiaconsiderations32產(chǎn)科麻醉在病理性肥胖中演繹課件33產(chǎn)科麻醉在病理性肥胖中演繹課件34產(chǎn)科麻醉在病理性肥胖中演繹課件35Pre-anesthesiaConsiderationsPre-admissionconsultationispreferredEarlythoroughphysicalexaminationGoodanesthesiaplanIVmaybedifficultEquipment:BPcuff,operatingtable,videoscopeEvaluateabilitytoliesupineForOSApatients,whereistheCPAPmachinePre-anesthesiaConsiderationsP36LaborAnalgesiaWillbedifficultPrefertoplaceearlyMakesureitworksDoanythingpossibletopreventfailureofconversiontoC-sectionepiduralLaborAnalgesiaWillbedifficu37LaborAnalgesiaCatheterplacementPositionLocationTechniqueLaborAnalgesiaCatheterplacem38Whatpredictsdifficult?CouldNOTfeelanythingwhentouchCouldNOTsitstillScoliosisPreviouslowerbacksurgeryWhatpredictsdifficult?Could39DepthtospaceDepthtospace40FailurerateUnilateralblockFailurefromthebeginningLaterfailureEverybackcanmakethecatheterinandout4cmintheepiduralspaceinobesepatientsFailurerateUnilateralblock41TechniquesDirectinsertionNeedlemappingUltrasoundTechniquesDirectinsertion42UltrasoundtechniqueforepiduralplacementUltrasoundtechniqueforepidu43產(chǎn)科麻醉在病理性肥胖中演繹課件445basicplanesKJChin,ISURA,20125basicplanesKJChin,ISURA,45產(chǎn)科麻醉在病理性肥胖中演繹課件46產(chǎn)科麻醉在病理性肥胖中演繹課件47產(chǎn)科麻醉在病理性肥胖中演繹課件48產(chǎn)科麻醉在病理性肥胖中演繹課件49產(chǎn)科麻醉在病理性肥胖中演繹課件50CesareanDeliveryAnesthesiaCesareanDeliveryAnesthesia51ConversionLaborEpiduraltoC/DanesthesiaWithexistingworkingepiduralcatheterDosethroughthecatheter2%lidocainewithepinephrine15-25mlSodiumBicarbonate1in10ml3%2-chloroprocaine15-25ml0.5%bupivacaine15-30Fentanyl50-100mcgthroughepiduralPreservative-freemorphine3mgafterumbilicalcordisclampedLevel:T4ConversionLaborEpiduraltoC52WithoutAnEpiduralSpinalCSE(combinedspinalandepidural)Hyperbaricbupivacaine12-15mgFentanyl10-15mcgEpinephrine100-200mcgPreservative-freemorphine100mcgWithoutAnEpiduralSpinal53GETATheanesthesiaofchoiceforrealOBemergencyPre-meds:sodiumbitrate,famotidine,metoclopramidePosition,alignmentoftheaxisRSIVideoscope,FOI,LMAGETATheanesthesiaofchoicef54HEShobary,MEJAnesth2011187KG,BMI70,OSA,DMIIHEShobary,MEJAnesth201118755MCVallejo,SOAP,2013MCVallejo,SOAP,201356InductiondrugsPropofol2.5mg/kgMethohexital(Brevital),1-2mg/kg,or50-120mgKetamine1mg/kgupto100mgEtomidate0.3mg/kgFentanyl50-100mcgSuccinylcholine1-2mg/kg,oktouserocurroniuminstead,butbecautiousinobesepatientsHalfMACofgas+50/50nitrousoxideVentilatetonormo-carbia,DONOTOVERVENTILATEInductiondrugsPropofol2.5mg57EmergenceMichiganseries1985-2003,7anesthesiacontributingmaternaldeathNoneduringinductionofGAFiveresultedfromhypoventilationorairwayobstructionduringemergence,extubation,orrecoveryFullywakeupObesityincreasestherisksignificantlyJMMhyre,Anesthesiology,2007EmergenceMichiganseries1985-58SummaryOBanesthesiaisNOTjustpaincontrolObesityputpatientsonvariousrisksAvoidGAifpossibleStartearlyPreparefortheworstTeachyourpatientstoloseweightwheneverisappropriateSummaryOBanesthesiaisNOTju59The2016SOAPAnnualMeetingMay18-22,2016SeaportHotelBoston,MAEtherdome!The2016SOAPAnnualMeetingEt60THANKYOU!THANKYOU!61ObstetricObesity:AnesthesiaImplicationsandManagementYunhongZhang,MD,PhDAnesthesiaAssociatesofSt.LouisJune,2015ObstetricObesity:Anesthesia62產(chǎn)科麻醉在病理性肥胖中演繹課件63產(chǎn)科麻醉在病理性肥胖中演繹課件64OutlineDefinitionandprevalencePhysiologicalchangesonthetopofpregnancyPregnancycomplicationsMaternalcomplicationsFetalcomplicationsAnesthesiaproblemsandmanagementOutlineDefinitionandprevalen65DefinitionBMI=kg/m2Normal:18.5-24.9Overweight:25-29.9Obesity:>30TherevisedpregnancyweightgainguidelinebyIOM2009NOTdifferentiatebwClassI30-34.99ClassII35-39.99ClassIIIormorbidlyobese>40Obesityinpregnancy,ACOG,2013DefinitionBMI=kg/m266產(chǎn)科麻醉在病理性肥胖中演繹課件67NodatainChinayetNodatainChinayet68Whatwillhappenwhenpeoplegetbig?Whatwillhappenwhenpeopleg69產(chǎn)科麻醉在病理性肥胖中演繹課件70產(chǎn)科麻醉在病理性肥胖中演繹課件71產(chǎn)科麻醉在病理性肥胖中演繹課件72PhysiologicalchangesofobesityonpregnancyPhysiologicalchangesofobesi73產(chǎn)科麻醉在病理性肥胖中演繹課件74Airway

Pregnancy&obesity,riskfactorsfordifficultairwayInpregnancy:Breastenlargement,Adiposetissuedeposition,MucosaengorgementFailedintubationis8timesmoreAirwayPregnancy&obesity,ri75AirwayDifficultairwayinobesityDifficultintubation15.5%vs.2.2%(BMI>35vs.Leanpeople)(Juvinetal)6/17(total117morbidlyobesepregnantwomen)difficultintubationinobeseparturientsforc/s(HoodandDewan)Implication:pre-laboranesthesiaconsultationAirwayDifficultairwayinobes76RespirationDecreasedRV,ERV,FRCinpregnancyReducedpulmonaryandchestwallcomplianceinobesityIncreasedoxygenconsumptionandCO2productionFRCcanfallbelowclosingcapacity(earlyairwayclosureandshuntingImportanceofpreoxygenationRespirationDecreasedRV,ERV,77產(chǎn)科麻醉在病理性肥胖中演繹課件78OSARiskofOSAdoublesinoverweightparturientsIncreasedriskforHTN,DM,pretermlaborandoperativeinterventionandadversefetaloutcomes.EarlydiagnosisandtreatmentcanimprovematernalandfetaloutcomesOSARiskofOSAdoublesinover79CardiovascularInPregnancy:CO,50%higherafter2ndtrimesterFirststage25%morethantheprelabor2ndstage40%morePostpartum,75%abovetheprelaborCardiovascularInPregnancy:80CardiovascularObesity:30-50ml/min/100gincreaseinCO60%obeseptsmayhavemildtomodHTNObeseparturients:exacerbatedincreaseinbloodvolume,impairedafterloadreductionb/oincreasedPVRNeuroendocrineactivation,renalsodiumretentionandincreasedsystemicoxidativestressduetocomorbiditiesinobesityleadtocardiacremodelingandmyocardialdysfunction.SupineHypotensiveSyndromeisexacerbatedCardiovascularObesity:81GIPregnancyleadstoGERD:hormonalandmechanicalmechanismGERDsymptomsexacerbatedinobeseparturients“Fullstomach”precautious,RSI,“TripleRx”:SodiumBicitrate,Metoclopramide,famotidineGIPregnancyleadstoGERD:hor82PregnancycomplicationsPregnancycomplications83MaternalComplicationsGestationalDMGestationalHTNPreeclampsiaFetalmacrosomiaOSAAsthmaMaternalComplicationsGestatio84產(chǎn)科麻醉在病理性肥胖中演繹課件85FetalcomplicationsPrematurityStill-birthCongenitalabnormalitiesMacrosomiaChildhoodandadolescentobesityFetalcomplicationsPrematurity86MCVallejo,SOAP,2013MCVallejo,SOAP,201387IntrapartumComplicationsBigbaby,uterineatonyShoulderdystociaIncreasedC-sectionrateIncreasedinstrumentaldeliveryIntrapartumComplicationsBigb88MaternalRisksHypertensivedisorders,includingpreEGestationaldiabetesAsthmaOSAMaternalRisksHypertensivedis89L.Ellinas,,2013L.Ellinas,90L.Ellinas,,2013L.Ellinas,91產(chǎn)科麻醉在病理性肥胖中演繹課件92AnesthesiaconsiderationsAnesthesiaconsiderations93產(chǎn)科麻醉在病理性肥胖中演繹課件94產(chǎn)科麻醉在病理性肥胖中演繹課件95產(chǎn)科麻醉在病理性肥胖中演繹課件96Pre-anesthesiaConsiderationsPre-admissionconsultationispreferredEarlythoroughphysicalexaminationGoodanesthesiaplanIVmaybedifficultEquipment:BPcuff,operatingtable,videoscopeEvaluateabilitytoliesupineForOSApatients,whereistheCPAPmachinePre-anesthesiaConsiderationsP97LaborAnalgesiaWillbedifficultPrefertoplaceearlyMakesureitworksDoanythingpossibletopreventfailureofconversiontoC-sectionepiduralLaborAnalgesiaWillbedifficu98LaborAnalgesiaCatheterplacementPositionLocationTechniqueLaborAnalgesiaCatheterplacem99Whatpredictsdifficult?CouldNOTfeelanythingwhentouchCouldNOTsitstillScoliosisPreviouslowerbacksurgeryWhatpredictsdifficult?Could100DepthtospaceDepthtospace101FailurerateUnilateralblockFailurefromthebeginningLaterfailureEverybackcanmakethecatheterinandout4cmintheepiduralspaceinobesepatientsFailurerateUnilateralblock102TechniquesDirectinsertionNeedlemappingUltrasoundTechniquesDirectinsertion103UltrasoundtechniqueforepiduralplacementUltrasoundtechniqueforepidu104產(chǎn)科麻醉在病理性肥胖中演繹課件1055basicplanesKJChin,ISURA,20125basicplanesKJChin,ISURA,106產(chǎn)科麻醉在病理性肥胖中演繹課件107產(chǎn)科麻醉在病理性肥胖中演繹課件108產(chǎn)科麻醉在病理性肥胖中演繹課件109產(chǎn)科麻醉在病理性肥胖中演繹課件110產(chǎn)科麻醉在病理性肥胖中演繹課件111CesareanDeliveryAnesthesiaCesareanDeliveryAnesthesia112ConversionLaborEpiduraltoC/DanesthesiaWithexistingworkingepiduralcatheterDosethroughthecatheter2%lidocainewithepinephrine15-25mlSodiumBicarbonate1in10ml3%2-chloroprocaine15-25ml0.5%bupivacaine15-30Fentanyl50-100mcgthroughepiduralPreservative-freemorphine3mgafterumbilicalcordisclampedLevel:T4ConversionLaborEpiduraltoC113WithoutAnEpiduralSpinalCSE(combinedspinalandepidural)Hyperbaricbupivacaine12-15mgFentanyl10-15mcgEpinephrine100-200mcgPreservative-freemorphin