Lesage Sandra
Département d'anesthésiologie, CHU Sainte-Justine and Université de Montréal, 3175 Chemin de la Côte-Sainte-Catherine, Montreal, QC, H3T 1C5, Canada,
Can J Anaesth. 2014 May;61(5):489-503. doi: 10.1007/s12630-014-0125-x. Epub 2014 Apr 4.
Whenever possible, neuraxial anesthesia is the preferred technique for Cesarean delivery; however, under certain circumstances, general anesthesia remains the most appropriate choice. The purpose of this Continuing Professional Development module is to review the key issues regarding general anesthesia for Cesarean delivery.
In developed countries, anesthesia-related maternal mortality and morbidity are both low. Mortality following Cesarean delivery under general anesthesia is attributable chiefly to failed intubation or other induction-related issues. Extubation can also be a danger period. The various methods of preventing difficult intubation and the associated consequences include airway assessment, fasting during obstetric labour, and pharmacological prophylaxis for aspiration. The traditional rapid sequence induction has been slightly modified because of the increased use of propofol and remifentanil. Difficult airway management algorithms specific to the pregnant woman are being developed and tend to recommend the use of supraglottic devices for unanticipated difficult intubation. The prevention of intraoperative awareness is another major consideration. Maintenance with halogenated agents at > 0.7 minimum alveolar concentration (MAC) is recommended; however, propofol maintenance can be an interesting option when uterine atony is present. Multimodal postoperative analgesia is recommended.
A general anesthetic for Cesarean delivery should be based on the following principles: preventing aspiration, anticipating a difficult intubation, maintaining oxygenation, insuring materno-feto-placental perfusion and maintaining a deep level of anesthesia to avoid intraoperative awareness while minimizing neonatal effects.
只要有可能，剖宫产时首选神经轴索麻醉；然而，在某些情况下，全身麻醉仍是最合适的选择。本继续职业发展模块的目的是回顾剖宫产全身麻醉的关键问题。
在发达国家，与麻醉相关的孕产妇死亡率和发病率都很低。全身麻醉下剖宫产术后的死亡主要归因于插管失败或其他诱导相关问题。拔管期也可能存在危险。预防困难插管及其相关后果的各种方法包括气道评估、产科分娩期间禁食以及预防误吸的药物预防。由于丙泊酚和瑞芬太尼的使用增加，传统的快速顺序诱导已略有修改。针对孕妇的困难气道管理算法正在开发中，倾向于推荐在意外困难插管时使用声门上装置。预防术中知晓是另一个主要考虑因素。建议使用最低肺泡浓度（MAC）>0.7的卤化剂维持麻醉；然而，当出现子宫收缩乏力时，丙泊酚维持麻醉可能是一个不错的选择。推荐多模式术后镇痛。
剖宫产全身麻醉应基于以下原则：预防误吸、预测困难插管、维持氧合、确保母胎-胎盘灌注以及维持深度麻醉以避免术中知晓，同时尽量减少对新生儿的影响。
