Indicated delivery delivering a small-forgestational-age infant, HELLPなどのリスク
Rana S, Hacker MR, Modest AM, Salahuddin S, Lim KH, Verlohren S, Perschel FH,
Karumanchi SA.
Circulating angiogenic factors and risk of adverse maternal and perinatal outcomes in twin pregnancies with suspected preeclampsia.
Hypertension. 2012;60:451-8.
Antiangiogenic: soluble fms-like tyrosine kinase-1 (sFlt-1)
高くなる
proangiogenic: placental growth factor (PlGF)
低くなる
従って、sFlt1/PlGF ratioは上記のような合併症発生と関連がある。
sFlt-1/PlGF ratio 85 i以上が 単胎妊婦のpreeclampsia のリスク
Rana S, Powe CE, Salahuddin S, Verlohren S, Perschel FH, Levine RJ, et
al. Angiogenic factors and the risk of adverse outcomes in women with
suspected preeclampsia. Circulation. 2012;125:911–919.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3319742/
2013年1月11日金曜日
2013年1月8日火曜日
130108 産科麻酔のプログラム
1.母体生理
2.胎児、胎盤の生理、病態生理
3.器官形成、催奇形性
4.新生児の生理と新生児蘇生
5.分娩管理（正常、異常）
6.陣痛の痛みとその経路
7.子宮弛緩
8.局所麻酔薬
9.区域麻酔で用いる麻薬
10.区域麻酔のテクニック
11.全身麻酔
12.合併症の麻酔科管理、産科管理
13.内科的疾患と妊娠
14.妊婦の心肺蘇生
15.卵管結紮
16.術後疼痛管理
17.母体への投薬と乳汁移行
18.妊娠中の非産科手術
19.妊婦の研究における倫理的な問題
20.妊娠中の倫理的な問題
21.産科麻酔部門の構築
22.母体死亡
23.医療経済
24.重症妊婦のモニターと搬送
Kuczkowski KM. Running an obstetric anesthesia training program: words of wisdom. Arch Gynecol Obstet. 2009;280:883-8.
2013年1月7日月曜日
130107 産科麻酔 初期研修医教育
産婦人科希望のローテート初期研修医と麻酔研修希望の産婦人科レジデントの研修開始時の気道管理実習。
マネキンを用いて気管挿管とLMAを指導しています。
写真はAWSの指導風景。
マネキンを用いて気管挿管とLMAを指導しています。
写真はAWSの指導風景。
130107 SLEの活動性と妊娠
妊娠時のSLEの活動性が高い場合のリスク
PIH (p=0.0422)
IUGR with PIH(p<0.0001)
premature birth (p<0.0001)
麻酔科医は緊急帝王切開の可能性を考えておく必要がある
Ko HS
Pregnancy outcomes and appropriate timing of pregnancy in 183 pregnancies in
Korean patients with SLE.
Int J Med Sci. 2011;8:577-83.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3198253/
2013年1月6日日曜日
130105 子癇前症の脊麻
子癇前症の帝王切開の脊麻ではの心拍出量低下はわずか
Dyer RA, Piercy JL, Reed AR, Lombard CJ, Schoeman LK, James
MF. Hemodynamic changes associated with spinal anesthesia for
cesarean delivery in severe preeclampsia. Anesthesiology 2008;
108: 802-11.
子癇前症の帝王切開の脊麻でも血圧低下は生じるが、血管収縮薬の投与量は正常妊婦と比較して減るAya AG. Anesth Analg 2003; 97: 867-72.
Aya AG. Anesth Analg 2005; 101: 869-75.
2013年1月4日金曜日
130104 帝王切開の膠質液preload
Fluid and vasopressor management for Cesarean delivery under spinal anesthesia: continuing professional development.
Can J Anaesth. 2012;59:604-19.
http://link.springer.com/article/10.1007%2Fs12630-012-9705-9
膠質液のpreloadは晶質液preloadと比較すると低血圧予防と心拍出量維持には有効である。
Morgan PJ, Halpern SH, Tarshis J. The effects of an increase of central blood volume before spinal anesthesia for cesarean delivery: a qualitative systematic review. Anesth Analg 2001; 92:997-1005.http://www.anesthesia-analgesia.org/content/92/4/997.long
Nishikawa K, Yokoyama N, Saito S, Goto F. Comparison of effects of rapid colloid loading before and after spinal anesthesia on maternal hemodynamics and neonatal outcomes in cesarean
section. J Clin Monit Comput 2007; 21: 125-9.http://link.springer.com/article/10.1007%2Fs10877-006-9066-4
Ngan Kee WD, Khaw KS, Lee BB, Ng FF, Wong MM. Randomized controlled study of colloid preload before spinal anaesthesia for caesarean section. Br J Anaesth 2001; 87: 772-4.http://bja.oxfordjournals.org/content/87/5/772.long
Dahlgren G, Granath F, Pregner K, Rosblad PG, Wessel H, Irestedt L. Colloid vs. crystalloid preloading to prevent maternal hypotension during spinal anesthesia for elective cesarean section. Acta Anaesthesiol Scand 2005; 49: 1200-6.http://onlinelibrary.wiley.com/doi/10.1111/j.1399-6576.2005.00730.x/abstract;jsessionid=1FD01ACA60B158B379231A2C4F916B51.d02t03
Ko JS, Kim CS, Cho HS, Choi DH. A randomized trial of crystalloid versus colloid solution for prevention of hypotension
during spinal or low-dose combined spinal-epidural anesthesia for elective cesarean delivery. Int J Obstet Anesth 2007; 16: 8-12.
500mlのhydroxyethyl starchは1000mlの乳酸リンゲル液と比較して低血圧発現、血管収縮薬投与と嘔気嘔吐の頻度を減少させる。Siddik SM, Aouad MT, Kai GE, Sfeir MM, Baraka AS. Hydroxyethylstarch 10% is superior to Ringer’s solution for preloading before spinal anesthesia for cesarean section. Can J Anesth 2000; 47: 616-21.http://link.springer.com/article/10.1007%2FBF03018992
500ml、1000mlのhydroxyethyl starchと1500mlの晶質液のpreloadをsuprasternal Dopplerで比較した。1000mlHES preloadだけが心拍出量が維持された。Tamilselvan P, Fernando R, Bray J, Sodhi M, Columb M. The effects of crystalloid and colloid preload on cardiac output in the parturient undergoing planned cesarean delivery under spinal anesthesia: a randomized trial. Anesth Analg 2009; 109: 1916-21.http://www.anesthesia-analgesia.org/content/109/6/1916.long
HESは投与後30分間血管内にとどまっているが乳酸リンゲル液は28%しか血管内に存在しない。Ueyama H, He YL, Tanigami H, Mashimo T, Yoshiya I. Effects of crystalloid and colloid preload on blood volume in the parturient undergoing spinal anesthesia for elective cesarean section.
Anesthesiology 1999; 91: 1571-6.http://journals.lww.com/anesthesiology/pages/articleviewer.aspx?year=1999&issue=12000&article=00006&type=abstract
膠質液投与でも臨床的に低血圧は高頻度に生じ、血管収縮薬は時に必要である。
よくまとまってる表はここ。
http://sankamasui.blogspot.jp/2013/01/130103-pre-load.html
Can J Anaesth. 2012;59:604-19.
http://link.springer.com/article/10.1007%2Fs12630-012-9705-9
膠質液のpreloadは晶質液preloadと比較すると低血圧予防と心拍出量維持には有効である。
Morgan PJ, Halpern SH, Tarshis J. The effects of an increase of central blood volume before spinal anesthesia for cesarean delivery: a qualitative systematic review. Anesth Analg 2001; 92:997-1005.http://www.anesthesia-analgesia.org/content/92/4/997.long
Nishikawa K, Yokoyama N, Saito S, Goto F. Comparison of effects of rapid colloid loading before and after spinal anesthesia on maternal hemodynamics and neonatal outcomes in cesarean
section. J Clin Monit Comput 2007; 21: 125-9.http://link.springer.com/article/10.1007%2Fs10877-006-9066-4
Ngan Kee WD, Khaw KS, Lee BB, Ng FF, Wong MM. Randomized controlled study of colloid preload before spinal anaesthesia for caesarean section. Br J Anaesth 2001; 87: 772-4.http://bja.oxfordjournals.org/content/87/5/772.long
Dahlgren G, Granath F, Pregner K, Rosblad PG, Wessel H, Irestedt L. Colloid vs. crystalloid preloading to prevent maternal hypotension during spinal anesthesia for elective cesarean section. Acta Anaesthesiol Scand 2005; 49: 1200-6.http://onlinelibrary.wiley.com/doi/10.1111/j.1399-6576.2005.00730.x/abstract;jsessionid=1FD01ACA60B158B379231A2C4F916B51.d02t03
Ko JS, Kim CS, Cho HS, Choi DH. A randomized trial of crystalloid versus colloid solution for prevention of hypotension
during spinal or low-dose combined spinal-epidural anesthesia for elective cesarean delivery. Int J Obstet Anesth 2007; 16: 8-12.
500mlのhydroxyethyl starchは1000mlの乳酸リンゲル液と比較して低血圧発現、血管収縮薬投与と嘔気嘔吐の頻度を減少させる。Siddik SM, Aouad MT, Kai GE, Sfeir MM, Baraka AS. Hydroxyethylstarch 10% is superior to Ringer’s solution for preloading before spinal anesthesia for cesarean section. Can J Anesth 2000; 47: 616-21.http://link.springer.com/article/10.1007%2FBF03018992
500ml、1000mlのhydroxyethyl starchと1500mlの晶質液のpreloadをsuprasternal Dopplerで比較した。1000mlHES preloadだけが心拍出量が維持された。Tamilselvan P, Fernando R, Bray J, Sodhi M, Columb M. The effects of crystalloid and colloid preload on cardiac output in the parturient undergoing planned cesarean delivery under spinal anesthesia: a randomized trial. Anesth Analg 2009; 109: 1916-21.http://www.anesthesia-analgesia.org/content/109/6/1916.long
HESは投与後30分間血管内にとどまっているが乳酸リンゲル液は28%しか血管内に存在しない。Ueyama H, He YL, Tanigami H, Mashimo T, Yoshiya I. Effects of crystalloid and colloid preload on blood volume in the parturient undergoing spinal anesthesia for elective cesarean section.
Anesthesiology 1999; 91: 1571-6.http://journals.lww.com/anesthesiology/pages/articleviewer.aspx?year=1999&issue=12000&article=00006&type=abstract
膠質液投与でも臨床的に低血圧は高頻度に生じ、血管収縮薬は時に必要である。
よくまとまってる表はここ。
http://sankamasui.blogspot.jp/2013/01/130103-pre-load.html
2013年1月3日木曜日
130103 晶質液pre-load
帝王切開の脊髄クモ膜下麻酔の低血圧予防
よくまとまってる！！
Can J Anaesth. 2012;59:604-19.
Fluid and vasopressor management for Cesarean delivery under spinal anesthesia: continuing professional development.
Loubert C.
http://link.springer.com/article/10.1007%2Fs12630-012-9705-9
(@^^)/~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
(@^^)/~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
20ml/kgの晶質液pre-loadで低血圧の発現に差がなかった(55% vs コントロール71%)
Anesthesiology. 1993;79:262-9.
A reevaluation of the role of crystalloid preload in the prevention of hypotension associated with spinal anesthesia for elective cesarean section.
Rout CC, Rocke DA, Levin J, Gouws E, Reddy D.
30 mLkg-1 までの晶質液pre-load投与では低血圧を予防できず、児の予後にも影響を与えなかった。
Anesth Analg. 1996;83:299-303.
The effects of varying volumes of crystalloid administration before cesarean delivery on maternal hemodynamics and colloid osmotic pressure.
Park GE, Hauch MA, Curlin F, Datta S, Bader AM.
Morgan PJ, Halpern SH, Tarshis J.
The effects of an increase of central blood volume before spinal anesthesia for cesarean delivery: a qualitative systematic review.
Anesth Analg 2001; 92: 997-1005.
現在では晶質液pre-loadは低血圧予防に有効とはいえない。
Mercier FJ. (物静かなイケメン、日本にも来られました)
Fluid loading for cesarean delivery under spinal anesthesia: have we studied all the options?
Anesth Analg 2011; 113: 677-80.
2013年1月2日水曜日
130101 CSの脊麻 Co-load
Meta-analysis 8 研究, 518 例
低血圧発症
Co-load 159/268 (59.3%)
Pre-load 156/250 (62.4%)
差なし
血管収縮薬は必要
Banerjee A. Can J Anesth 2010; 57: 24-31
http://link.springer.com/article/10.1007%2Fs12630-009-9206-7
‘‘Although fluid preloading reduces the frequency of maternal hypotension, initiation of spinal anesthesia should not be delayed to administer a fixed volume of intravenous fluid.’’
American Society of Anesthesiologists Task Force on Obstetric Anesthesia. Practice guidelines for obstetric anesthesia: an updated report by the American Society of Anesthesiologists Task Force on Obstetric Anesthesia.
Anesthesiology 2007; 106: 843
http://journals.lww.com/anesthesiology/Citation/2007/04000/Practice_Guidelines_for_Obstetric_Anesthesia__An.27.aspx
低血圧発症
Co-load 159/268 (59.3%)
Pre-load 156/250 (62.4%)
差なし
血管収縮薬は必要
Banerjee A. Can J Anesth 2010; 57: 24-31
http://link.springer.com/article/10.1007%2Fs12630-009-9206-7
‘‘Although fluid preloading reduces the frequency of maternal hypotension, initiation of spinal anesthesia should not be delayed to administer a fixed volume of intravenous fluid.’’
American Society of Anesthesiologists Task Force on Obstetric Anesthesia. Practice guidelines for obstetric anesthesia: an updated report by the American Society of Anesthesiologists Task Force on Obstetric Anesthesia.
Anesthesiology 2007; 106: 843
http://journals.lww.com/anesthesiology/Citation/2007/04000/Practice_Guidelines_for_Obstetric_Anesthesia__An.27.aspx
2013年1月1日火曜日
130101 子癇前症のCSでレミフェンタニルを使用
子癇前症CSのRSIででレミフェンタニル1 mg kg-21 を使用。
母体の心拍数、血圧、カテコラミン濃度はレミフェンタニルで低い。
APGAR レミフェンタニルで1分値が低く平均6.1 (コントロール 7.5) p=0.03、
新生児のバッグ換気は29%（コントロール5%) p=0.04
British Journal of Anaesthesia 102 (6): 812–19 (2009)
http://bja.oxfordjournals.org/content/102/6/812.long
母体の心拍数、血圧、カテコラミン濃度はレミフェンタニルで低い。
APGAR レミフェンタニルで1分値が低く平均6.1 (コントロール 7.5) p=0.03、
新生児のバッグ換気は29%（コントロール5%) p=0.04
British Journal of Anaesthesia 102 (6): 812–19 (2009)
http://bja.oxfordjournals.org/content/102/6/812.long
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