Mushambi Mary C, Jaladi Sahana
Department of Anaesthesia, University Hospitals of Leicester, United Kingdom.
Curr Opin Anaesthesiol. 2016 Jun;29(3):261-7. doi: 10.1097/ACO.0000000000000309.
Airway management and failed intubation in the pregnant woman requires unique considerations, which differ from the nonpregnant patient. Factors that influence airway management in this setting include anatomical and physiological changes in pregnancy, environmental factors as well as training matters. In addition, surgery is often being performed with extreme urgency, which requires rapid decision-making process that takes into account safe outcome of mother and baby. The purpose of this review is to focus on recent developments that address these exceptional airway challenges in obstetrics.
The first national UK obstetric difficult airway guidelines that have been recently published, are based around algorithms that deal with induction of general anaesthesia, failed intubation and front-of-the-neck access. As well as emphasising good practice in planning, preparation, and rapid sequence induction (RSI) technique, they outline how to make a provisional plan prior to the induction of general anaesthesia, on whether to awaken or continue general anaesthesia, should failed intubation occur. Current recommendations aim to move away from the traditional and outdated obstetric RSI technique to introduce changes, which are in keeping with anaesthetic practice in the nonpregnant patients. Such changes include the choice of induction agent and muscle relaxant, preoxygenation techniques, and mask ventilation during RSI; and the early release of cricoid pressure should failed intubation occur.
Recent advances and recommendations in the management of the obstetric airway should help to bring consistency of clinical practice, reduce adverse events, and standardize teaching by providing a structure for teaching and training on failed tracheal intubation in obstetrics. Opportunities during elective caesarean sections and simulation should be used as teaching tools to improve anaesthetists' and team performance during a crisis.
孕妇的气道管理和插管失败需要特殊考虑，这与非孕妇患者不同。在此情况下影响气道管理的因素包括孕期的解剖和生理变化、环境因素以及培训问题。此外，手术通常非常紧急，这需要快速决策过程，同时要考虑母婴的安全结局。本综述的目的是关注近期应对产科这些特殊气道挑战的进展。
英国最近发布了首个全国性产科困难气道指南，该指南基于处理全身麻醉诱导、插管失败和颈部前方通路的算法。除了强调在计划、准备和快速顺序诱导（RSI）技术方面的良好做法外，它们还概述了在全身麻醉诱导前如何制定临时计划，即如果插管失败，是唤醒患者还是继续全身麻醉。当前的建议旨在摒弃传统且过时的产科RSI技术，引入与非孕妇麻醉实践相符的变化。这些变化包括诱导剂和肌肉松弛剂的选择、预充氧技术以及RSI期间的面罩通气；如果插管失败，应尽早解除环状软骨压迫。
产科气道管理的最新进展和建议应有助于使临床实践保持一致，减少不良事件，并通过提供产科气管插管失败教学和培训的框架来规范教学。择期剖宫产和模拟期间的机会应用作教学工具，以提高麻醉医生和团队在危机期间的表现。
