Department of Anaesthesia, University Hospitals of Leicester, Leicester, UK.
Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
Anaesthesia. 2020 Jul;75(7):945-961. doi: 10.1111/anae.15007. Epub 2020 Mar 6.
We reviewed the literature on management of general and regional anaesthesia in pregnant women with anticipated airway difficulty. We identified 138 publications comprising 158 cases; these either described equipment or techniques for the provision of general anaesthesia, or the management of women with regional analgesia or anaesthesia, with the aim of avoiding general anaesthesia. Most of the former group described women requiring caesarean section alone, or in combination with other surgery, which was sometimes airway-related. Management techniques were largely similar to those in non-obstetric patients requiring surgery who have airway difficulties, although suggested differences related to physiological changes of pregnancy and avoidance of nasal intubation. In the reports discussing regional anaesthesia, consideration was often given to the possible requirement for urgent out-of-hours anaesthetic intervention, and the predicted difficulty of management of general anaesthesia should it be required. In a number of reported cases, multidisciplinary planning led to the conclusion that elective caesarean section should be performed in order to avoid emergency airway management. Based on this literature review, we advise antenatal planning that includes: assessment of the patient's clinical characteristics; consideration of the equipment and personnel available to provide safe airway management out-of-hours; and elective caesarean section should these be lacking. If general anaesthesia is required, a risk assessment must be made as to the probability of safe airway management after the induction of anaesthesia, and awake tracheal intubation should be used if this cannot be assured. Decision aids are provided to illustrate these points. Online appendices include a comprehensive compendium of case reports on the management of a number of rare syndromes and airway conditions.
我们回顾了有关预期有气道困难的孕妇全身麻醉和区域麻醉管理的文献。我们共确定了 138 篇文献，其中包含 158 例病例；这些文献或是描述了用于全身麻醉的设备或技术，或是描述了有区域镇痛或麻醉的孕妇的管理方法，旨在避免全身麻醉。这些文献中，大多数关于需要单独或联合其他手术（有时与气道相关）的剖宫产孕妇的描述，其管理技术与那些有气道困难但需要手术的非产科患者的管理技术基本相似，尽管有一些与妊娠生理变化和避免鼻插管相关的差异。在讨论区域麻醉的文献中，通常会考虑到紧急情况下麻醉干预的可能需求，以及如果需要全身麻醉时，预计其管理的难度。在一些报道的病例中，多学科规划得出结论，为避免紧急气道管理，应择期行剖宫产术。基于这项文献综述，我们建议进行产前规划，包括：评估患者的临床特征；考虑提供安全气道管理的设备和人员是否可在非工作时间使用；如果缺乏这些条件，应选择择期剖宫产术。如果需要全身麻醉，则必须评估在麻醉诱导后安全气道管理的可能性，如果不能保证，则应使用清醒气管插管。为了说明这些要点，我们提供了决策辅助工具。在线附录包括了一些罕见综合征和气道状况管理的大量病例报告的综合汇编。
