胎儿手术的麻醉和监测

由于超声诊断等医学技术的发展,已能对患先天性膈疝、肾盂积水、脑积水及先天性心脏病的胎儿及早作出诊断。但若待这些胎儿出生后才手术,往往因病变对肺、肾、脑、心等重要脏器发育的严重影响而仍导致很高的新生儿病死率。例如先天性膈疝的新生儿约有半数于出生后即死亡。自八十年代起,在大量动物实验和临床实践的基础上,Harrison 等已成功地开展了胎儿手     

胎儿手术的麻醉进展

胎儿手术的麻醉既不同于儿科麻醉也有别于产科麻醉。现就胎儿手术的麻醉所需关注的主要问题如麻醉特点及目标、母体的主要麻醉方法、子宫松弛的方法、胎儿麻醉和镇痛、胎儿的安全和监护等及其进展作一综述。     

胎儿手术的麻醉

随着胎儿手术技术的发展，胎儿麻醉的研究不断深入。本文综述了近年有关胎儿麻醉的临床和实验研究新进展。     

胎儿手术麻醉的研究进展

随着医学技术的进步,尤其是产前诊断和影像技术水平的提高,微创技术和外科技术已经突破了先天性和发育异常胎儿的治疗界限,胎儿外科正成为一门迅速发展的新兴学科[1-2].早在1963年,Liley[3]首次报道1例溶血胎儿进行宫内输血治疗并获得成功,随后医学界在动物实验中开展了"胎儿"手术的研究.上世纪80年代,Harris...     

胎儿手术的麻醉

随着胎儿手术技术的发展,胎儿麻醉的研究不断深入。本文综述了近年有关胎儿麻醉的临床和实验研究新进展。     

丙泊酚氯胺酮复合麻醉在剖宫产手术中的应用

本文观察丙泊酚、氯胺酮静脉复合麻醉用于剖宫产术，报告如下。     

腹腔镜手术的麻醉

腹腔镜手术已在临床上广泛应用,手术时CO_2气腹及体位改变等带来的生理影响,给麻醉管理增加了困难。CO_2气腹可使动脉血CO_2升高,腹内压增高还可使肺顺应性降低,同时伴有明显的血动学变化。为此,呼吸道管理是一个重要问题,麻醉可采用吸入或静吸复合,一般不用区域阻滞,因后者不能控制通气和病人术中有不适感以及增加心律失常的发生率。     

Spiral electrode for continuous fetal heart rate monitoring during in-utero myelomeningocele repair

Continuous fetal hemodynamic monitoring during in-utero surgery is desirable, but it is often not feasible without intermittent interruption. We report the use of a fetal spiral electrode for continuous heart rate monitoring during fetal myelomeningocele repair. Fetal echocardiography and a fetal spiral electrode were used to monitor fetal heart rate during in-utero repair at 25 weeks’ gestation. We observed good agreement between echocardiographic and spiral electrode heart rate measurements. Using the Bland-Altman approach, the mean (SD) difference between measurements was 1.8 (3.5) beats per minute with limits of agreement of −5.3 to 8.8 beats per minute. This case illuminates a potential role for a fetal spiral electrode as a real-time adjunct in fetal interventions.     

Minimal-access fetal surgery for twin-to-twin transfusion syndrome

Background: Laser ablation of placental vessels effectively halts severe twin-to-twin transfusion syndrome (TTTS), but fetal surgery remains a dangerous approach. The authors present the technical aspects of endoscopic fetal surgery in their initial clinical experience. Methods: Altogether, 11 women underwent endoscopic fetal surgery for severe TTTS. Access to the recipients sac was obtained by the Seldinger technique via minilaparotomy. A 12-Fr peel-away introducer was used as a cannula to accommodate a custom-curved 9-Fr sheath containing a 1.9-mm semirigid fiber endoscope. Laser ablation was performed on all unpaired vessels crossing the intertwin membrane using a 400-µm neodymium: yttrium-aluminum-garnet (Nd: YAG) fiber. The cannula was removed over a gelatin sponge plug. Results: The median operating time was 65 min (range, 45–105 min). No patient experienced amniotic leak postoperatively. The length of hospital stay was 2.8 ± 1.6 days. Immediate improvement of the TTTS was noted in all but two patients. Pneumonia developed, in one mother leading to premature labor. There were no other major surgical complications. Fetal survival at 2 weeks was 73%. Conclusions: The safety and efficacy of endoscopic fetal surgery for severe TTTS can be optimized with the application of current minimal-access techniques. The superiority of this approach over less invasive means is still being evaluated through prospective studies.     

Anesthesia for fetal surgery

Fetal therapy is an exciting and growing field of medicine. Advances in prenatal imaging and continued innovations in surgical and anesthetic techniques have resulted in a wide range of fetal interventions including minimally invasive, open mid‐gestation, and ex‐utero intrapartum treatment procedures. The potential for maternal morbidity is significant and must be carefully weighed against claimed benefits to the fetus. Appropriate patient selection is critical, and a multidisciplinary team‐based approach is strongly recommended. The anesthetic management should focus on maintaining uteroplacental circulation, achieving profound uterine relaxation, optimizing surgical conditions, monitoring fetal hemodynamics, and minimizing maternal and fetal risk.     

Anesthesia for fetal surgery

Fetal surgery is the antenatal treatment of fetal malformations that cannot be adequately corrected after birth. Anesthesia for fetal surgery involves two patients, and issues of maternal safety, avoidance of fetal asphyxia, adequate fetal anesthesia and monitoring, and uterine relaxation are important. Communication with the surgeon to determine the surgical approach and need for uterine relaxation allows the anesthesiologist the ability to vary the anesthetic technique. Lessons learned from fetal surgery may help other neonates with life-threatening anomalies and may help understand the complex issues related to preterm labor.