Eley V A, van Zundert A A J, Lipman J, Callaway L K
Anaesthetist, Department of Anaesthesia and Perioperative Medicine, Royal Brisbane and Women's Hospital, School of Medicine, The University of Queensland, Brisbane, Queensland.
Professor, Department of Anaesthesia and Perioperative Medicine, The Royal Brisbane and Women's Hospital, School of Medicine, Professor and Chairman, Discipline of Anaesthesiology, Faculty of Medicine and Biomedical Sciences, The University of Queensland, Brisbane, Queensland.
Anaesth Intensive Care. 2016 Sep;44(5):552-9. doi: 10.1177/0310057X1604400517.
Increasing rates of obesity in western populations present management difficulties for clinicians caring for obese pregnant women. Various governing bodies have published clinical guidelines for the care of obese parturients. These guidelines refer to two components of anaesthetic care: anaesthetic consultation in the antenatal period for women with a body mass index (BMI) ≥ 40 kg/m and the provision of early epidural analgesia in labour. These recommendations are based on the increased incidence of obstetric complications and the predicted risks and difficulties in providing anaesthetic care. The concept behind early epidural analgesia is logical-site the epidural early, use it for surgical anaesthesia and avoid general anaesthesia if surgery is required. Experts support this recommendation, but there is weak supporting evidence. It is known that the management of labour epidurals in obese women is complicated and that women with extreme obesity require higher rates of general anaesthesia. Anecdotally, anaesthetists view and apply the early epidural recommendation inconsistently and the acceptability of early epidural analgesia to pregnant women is variable. In this topic review, we critically appraise these two practice recommendations. The elements required for effective implementation in multidisciplinary maternity care are considered. We identify gaps in the current literature and suggest areas for future research. While prospective cohort studies addressing epidural extension ('top-up') in obese parturients would help inform practice, audit of local practice may better answer the question "is early epidural analgesia beneficial to obese women in my practice?".
西方人群中肥胖率不断上升，给照顾肥胖孕妇的临床医生带来了管理难题。各管理机构已发布了关于肥胖产妇护理的临床指南。这些指南涉及麻醉护理的两个方面：对体重指数（BMI）≥40 kg/m²的女性在产前进行麻醉咨询，以及在分娩时提供早期硬膜外镇痛。这些建议基于产科并发症发生率的增加以及提供麻醉护理时预计的风险和困难。早期硬膜外镇痛背后的理念是合理的——尽早放置硬膜外导管，用于手术麻醉，并在需要手术时避免全身麻醉。专家支持这一建议，但支持证据薄弱。众所周知，肥胖女性分娩时硬膜外麻醉的管理很复杂，极度肥胖的女性需要更高比例的全身麻醉。据传闻，麻醉医生对早期硬膜外镇痛建议的看法和应用并不一致，而且孕妇对早期硬膜外镇痛的接受程度也各不相同。在本专题综述中，我们对这两项实践建议进行了批判性评估。考虑了在多学科产科护理中有效实施所需的要素。我们确定了当前文献中的空白，并提出了未来研究的领域。虽然针对肥胖产妇硬膜外追加麻醉的前瞻性队列研究有助于为实践提供参考，但对当地实践的审核可能更好地回答“在我的实践中，早期硬膜外镇痛对肥胖女性有益吗？”这个问题。
