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(Neuroanesthesia for the Pregnant Woman)

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Title: (Neuroanesthesia for the Pregnant Woman)

1

???? ???? ??? ?? ??? ???
(Neuroanesthesia for the
Pregnant Woman)
ANESTHESIA ANAGESIA Vol 107, No 1, July 2008
????? ???????
R3 ???

2
? Review Article?

Evidence-based recommendation???
? Intracranial vascular leisions(?)SAH, ICH)
? AVM(arteriovenous malformation)? Sinus
thrombosis
? Ischemic stroke
? Symptomatic intracranial tumor
? Cerebral abscess
? Spinal cord tumors? leisions
? ?? ???? ??? ??? ???? ????? ??? ???? ?????
?? ???? 67?? ?? ? ????
?? ???? ????.
???, ?? ????
???? ?? ????? ???? ??? ?? ??? ?? ??? ? ???,
? Review article? ?????.

3
1.??? ???? ??? ??? ???

Brain Tumors
? ?? 10? ? ? 1? ?? CNS? ??? ??? ????,
?? ? ???? ? ????? ???.
? Vascularity? ??? ?? edema?
Pregnancy-related immunotolerance? ??
tumor? ??? ??
? Sx? ????? ????.
? ?? ? ??? ????? Meningioma? ?? ???
Estrogen? Progesterone receptors? ???? ???
? ?? ? ?? ?? ???.
? ?? ? suprasellar? cerebellopontine angle
tumors? ??? ???? ???
??? ? ??
ICH
? ICH? ?? ?? ? Aneurysm rupture (35)
? AVM? ?? (65)
? ??
? ???? ??? 10? ? ? 1050? ????,
? ?? ? ?? ??? ? 7? ????.
? ??? ?? ? ????, ? ?? ?????? 20? ???.

4
??? NS??? ??? ???

? ??? AVM? ?? ??? ?? ???? ?????? ???
Rebleeding? ??? ??? ??? 35?? ??
?? ??? 2.5?
??.
? Rebleeding? ?? ??? ??? ? Hematoma? ????
craniotomy?
? AVM ???? ????.
? SAH? ??? ???? 3? ?? ?? ???? ?? 1???.
? ?? ? SAH? ??? ? ???, 35? ??? ?? ?? ????
25? ?? ? ????.
? ???? SAH? Intracranial aneurysm? rupture? ??
????.
(??, ??? 10? ? ? 20? ?? ????)
? ?? ? Aneurysm rupture? ??? ???? ????
? ?? ??? ??
? Cardiac output? ??
? ?????? ??? ???? Hormone? ?? ?? ??? ??
? ?? ? Aneurysm rupture? ??? ??
?????? ??? ?? ????? ??? ??

5
??? NS??? ??? ???

Traumatic Brain Injury
? ???? Traumatic brain injury?
? Brain ??? ??? Trauma? ??? ??? ????? ???
? ??? ?? ??? ???? ??? ??? ???? ?????.
? ????? ????? ??? ????
? Thiopental?? Propofol? Succinylcholine? ??
? Rapid sequence intubation? ???? ??.
? ?? 20? ????
? Vena cava? ??? ?? ???? ?? Lt. Lateral
position? ???
? ??? ?? ??? rotation?? ?? ???? ?? ? ??? ??
??? ??.
? Difficult intubation? ??? 300?? 1? ?? ????.
? ??? ??? ??? ???, C-Spine injury? ?? ??
? Fiberoptic technique? ???? ??,
? ??? ??? ?? ????,
??? ??? ???? Direct Laryngoscopy? ??? ??
??.

6
??? NS??? ??? ???

Spinal Procedures
?? Cauda equina syndrome??
? ???? ??? ?? ? ? ?? ??? ???
? ?? Spinal surgery? ??? ?? ??.
? Hormone? ??? ?? Spinal tumors? Sx.? ??? ??
??.
? Spinal tumor? bleeding? evacuation? ???
hematoma ?? ?? ??? ??
? Decompression? ??? Vertebral vascular
malformations? ?? ??? ??.
? ?? ? Sx.? ???? Lumbar disk displacement? ????
?? 1? ? ? 1? ???.
? Lumbar spinal surgery? ?? Prone position? ??
23?? ???? ??,
? Fetal monitoring? ?? C/SEC? ??? ???? ?? ??
???,
? Placental perfusion? ??? ??????,
? ???? ??????? ?? ? Spinal surgery ??? ????
??.

7
2. ?? ?? ??? ?? ???? ? ??

? Maternal hypotension ? Uterine artery
vasoconstriction
? Maternal hypoxemia ? Acid-base changes ?,
? ? Uteroplacental perfusion? ??????
? Fetal gas exchange? ?????
??? Maternal physiology? ???? ??? ??? ? ? ??.
???? ?? ????? ???? ??? ?? ???? ????
( ?)?? ? ???? ????)
??? ??? ??? ?? ?? ??? ????.
( ?)??? ??? ???? ?? 08?? Anticonvulsant?
???? ?)
???? ?? ?? ??? ?? ???? 1 rem??
?? ???? 0.5 rem??.
? ??? ?? ??? ?? ??? ????? ???? ????,
? ?? 08? ??? ??? ??? ???? ??? ???? ??,
? ? ? ??? ??? ??? ??? ? ? ? Growth
restriction
?Microcephaly
?Childhood cancer? ?? ?? ??.
Intracranial aneurysm? endovascular closure???
???? ??,
???? ?? ? ??? ??? ??? ??,
0.3 rem? ???? ???? ????? ???? 0.1rem? ????
??.

8
???? ??? ?? ???? ? ??

FHR monitoring? ?? ???
???? ???? ???? ??? ???? ??? ??? ?? ??? ????.
FHR? Monitoring? ?? 16? ???? ?????,
? Severe bradycardia? tachycardia? ??
baseline? change?
? ??24? ??? ??? ???? ???? ??? ? ?? ???
???
? ??? ??? FHR baseline? ??? ?? ? ????
? 24? ??? ???? FHR monitoring ?? ?? ??
?? ??? ???? ?? ??? ????.
FHR? ??? ?? 26? ???? ??? ??? ? ? ??,
??? ?? ???? FHR? ?? ??? ??? ??? ? ??.
???? ?? ?? Severe fetal bradycardia? ??? ??,
? Uteroplacental flow? fetal oxygenation?
?????? ??,
? Maternal arterial blood pressure? ????
? ??? Lt. lateral? ???
? Normoventilation? ?????.

9
3. ??? ??? ??

?? 24? ??? Early pregnancy ???
Neurosurgical intervention? ?? ?? ????
? Fetal management? ??? ??? ??? ????? ??? ?
??.
??, ???? Neurosurgery? ??? ???? ??? ??? ?????,
? ?? ? ??? ?? ? ? ??, ??? 3?? ? ? ??? ??? ??.
? ????? ????,
? ?? ?? ??? ? ???? NS??? ????,
? ???? NS???? ?? ???? ???? ??
? ??? ?? ??? ? ??
NS?? ? ??? ?? ??? ???? ??? ????
C/SEC? ??? ??? ?? ??.
? NS??? ?? C/SEC? ? ????
? ?? ???? NS???? ?? ?? ? ??? ??.
? C/SEC? ?? ?? NS ??? ?? ????.

10
??? ??? ??

NS??? ??? ???? ?? ? ???? ????
? ?????? ? ?? ? ???? ???? ???
? ?? ? ?? ?? Risk? ?? ???
??? ??
? ??? ??? NS?? ? ???? ??, ?? ??? ??
??? ??? ?? ?? ??? ????.
? ??? ?????, NS???, ?????? ???, ???? ???, ???
??? ??? ??? ????.
? ?? ?, Anticonvulsant therapy? ???? ????? ?????
? ?? ???,
?? ??? ????, ??? ?? ???? ?? ?? ? ?? ????
????? ?? ??? ????? ????? ???? ??? ??.
? ??? ???? ??? ??? ?? ?????
? Aspiration? ???? ??? ????
? ????? ?? ??
Ranitidine 150300 mg? ?? 1?? ? ?? ?????
?? ??? ????? ?, Ranitidine 50 mg? IV?? ??
???? ??,
Induction 30? ??? 0.3M sodium citrate 30 mL?
??? ??? ? ??.
? ?? ? ?????? ????,
????? ???? ?? ?? ??? ??? ??? ?? ????.
?) FRC? ??? ????? ???? ???? ??? ?????? ?????,
(? ????? ???????? ½? ???? ???)

11
?? ? ?? ? ???? ????

? ?? ?? ? ??? ???? ???? ??.
? ?? ??,
?? ??? ???? ?? ???? Intubation? ??? ??? ??
???,
? Intubation??, ??? ?? ?? ??? ?????
? Difficult intubation? ???? ?? manage ? ? ??
??? ???? ??? ??.
( ?) fiberoptic intubation, LMA )
? ??? 2nd trimester??
Aspiration? risk? ??? ?? Rapid sequence
intubation? ????.
? ?? 20? ??? ????,
hip wedge? side-tilting table? ???? 15o ??
??? ???? ????
? Aortocaval compression? ??? ? ? ??.

12
4. NS??? ???? ???

????? ??
? ????? ??? ??? ???? ??? ? ???,
? Intraarterial BP monitoring? ????.
? Cerebral? Uteroplacental perfusion? ???? ??
? ???? ???? ???? ?? ????, ?? ????
? ??? ??? ??
? Aortocaval compression? ??
? Vasopressor drugs? ??? ?? ?? ??
? ???? monitoring? ????.
? ???? ??? ?? ?? ? ? ??? ???? ??? ??? ????? ??.
? ?? ?????, ? ??? ? ?? ? ???? Lateral
position? ??? ??.
? NS??? ????? ??? ? ???? Large bore IV access?
??? ?? ??.
? Central venous access? ? Vasoactive drug?
??
?
CVP monitoring
?
Air emboli? ??? ???? ???.
? Phenylephrine? a-receptor agonist?? ?????
? Maternal cardiovascular stability?
Neonatal acid-base status? ???? ??.

13
NS??? ???? ???

? ???
? Baseline values? ???? ???? ?? ?????
? Mild preeclampsia(140/90)? Severe
preeclampsia(160/110)???
? ?? 140/90 mmHg ???? ??? ??? ??? ??.
? ICP? ???? ?? ?? NS????? BP? ??? ?? ?? ??.
? ???? Cerebral aneurysm? ???? ??? BP???
????
? ?? ??? ?? ??.
(????? ?????? SBP lt 150 mmHg? ???? ??)
???? ??
? ???? ???? ???? ?? ???, ?? PaCO2? 3032
mmHg??.
? Controlled hyperventilation?
? ICP? ???? ??? ??? ??? ? ? ???,
? PaCO2 lt 25 mmHg ? Severe
hyperventilation?
? Uterine artery vasoconstriction? ????
Maternal oxyhemoglobin dissociation
curve? ????? ??? ? ??
? Head injury ? ?? ??? ??? ??? ?? ???
????
Prophylactic hyperventilation? ?????
??
? ??, ???? Maternal PaCO2 25 30 mmHg? ???? ??

14
NS??? ???? ???

???? ??
? ??? ?? ??? ??? ?? ? ??? ????? ??? ??.
? ?? ??? ?? ?? ? ?????? ?? ??? ?? ??
? ???? ?????
???? ?? ??.
? ??? ??? ?? ????? BIS?
? ??
???? ???? ??? ???? ?? ??
???? ??
? Neuronal preservation? ?? ?? ??? ??? ? ??
???? ??? ???,
? ???? ???? ??? ???? ???? ????
? ICP????? morbidity ??? ???? ??? ??? ??? ??.
? NS?? ?
? ???? ??? ???? ???? ??
? ?????(Forced air warmer)? ??? ? ??,
? ?? ??? ?? ???? ??? temperature probe? ? ??
??.

15
NS??? ???? ???

Mannitol? IV ???? ??
? ICP? ???? ??
? Head-up position? ?? ??? ?
? ????? ????? ???? Low tidal volumes? ??? ??
?
? ???? ?? ? ??? ????? ?
? Mannitol?
? ????? ??? ??? ???? ???
? Fetal lung fluid production? ??
? Urinary blood flow? ??
? Plasma sodium concentration? ??
?? Physiological changes? ?? ? ? ?? Fetal
hyperosmolality? ?? ? ??
? ??????? ???? ????? ?????? ??
Fetal dehydration? ?????.
? ???, 0.250.5 mg/kg ????? ???? ??? ?????
????? ??
? Furosamide?
? Hourly Urine Output? ????? ???? ??? ?????
??.
? Cerebral ?? Spinal neurosurgery??
Cerebral edema? hyperglycemia? ??? ???? ?
??
Isonatremic, isotonic, glucose-free
solution??.

16
NS??? ???? ???

Steroid treatment ??
? ????? ??? ?? ??? ?? ????
Dexamethasone? Single dose???
??? Teratogenic ?? Carcinogenic effect? ????
???.
? Dexamethasone 1? 4? 4mg IM?? IV ???
Surfactant? ??? ???? Fetal lung maturity?
??????,
? Betamethasone? ??? ????? ?? ?? Neonatal
outcome? ????
Antiemetic treatment ??
? ???? Antiemetic drugs? ?? ? ?????,
? Metoclopramide, ? Antihistamines, ?
Droperidol,
? Serotonin3 receptor(5-HT3) antagonists ??
?? ???? ??.
? ? Intubation-induced hypertensive response?
? Anesthesia-induced hypotension?? ??
ICP? Cerebral blood flow? ??? ??? ??
? Laryngoscopy???? ?? ??? ??? ? ? ?? ??? ???
????.

17
NS??? ???? ???

??
? ??????? ??? Propofol? ??? ???? ?? ???,
? ?? ? ??????? Thiopental? ??? ?? ?? ??? ??.
? Propofol? Thiopental? ? ?,
? Hypertensive response, ICP, Cerebral
metabolism? ???????
? Cerebral autoregulation? ?????, ????? ??? ?
? ??? ????,
? Laryngoscopy? Intubation? ?? ????? ???
Propofol? ? ?????.
? ?? ? NS??? ?? ???(1418??)? ?? ?
Propofol? IV? ??? ??? ??,
? 1011??? ??? ? ??? Mild metabolic acidosis?
?????,
? ??? ???? ??? ????? Propofol? ??? ?? ??
?????.
? ?? ? NS??? ?? Volatile anesthetics? ??,
? Isoflurane? Sevoflurane? ????,
? ?? ?? ??? ?????? ? Cerebral metabolic rate?
?????,
? ICP? ?? ????? ??
? Cerebral protection? ???? ????.

18
NS??? ???? ???

? MAC?? ?? Volatile anesthetics?? ? ??? ??
25 ?? ?????,
? Initial end-tidal Isoflurane
concentration? 1.0
Sevoflurane
concentration? 1.5 ??? ????.
? ? ??? ??? ?? ??? ?????? ??? ??? ?????,
Cerebral autoregulation? ???? ? ? ??
???? ????.
? NS ?? ? ??? ?? ??? ???? ??? ?? ?? ???? ????
? Nifedipine, NSAIDs ?? ??.
? NS? ? ??? ??? ??? ???? ? ? ???,
?? ????,
NS?? ? ????????(tocodynamometer)? ?? ??? ????
??.

19
5. ??NS??? C/SEC? ?? ?? ?? ??? ????

Intracranial aneurysm rupture? Cauda equina
syndrome? ??
? ?? ?????? ??NS??? ????
? ??? ????? ????.
3rd trimester gestations? ????,
? ?? C/SEC? ?? NS??? ?? ?? ????,
NS?? ? Uterine atony? ?? Postpartum
hemorrhage? ??? ? ? ??.
? Oxytocic drug? ???? ????,
? ?? ???? C/SEC??? ????? ??? ??? ??
???? ????? IV????
????? ???
????? ???? ???? ???,
? ???? ???? ? ?? ?? ?????? ??? ?? ???? ??.

20
6. ???? ?? ??? ???

???? ??? ???? ? Propofol ? ? ??? TIVA?
? IV ???
?????? ??? ? ? ???? ??.
C/SEC?
Propofol? Induction? Maintenance ??? ???? ??
??? ?? ???,
? ?? TIVA? Thiopental? ????? ???? ??
Neonatal Neurobehavioral Performance? ?????
?? ???? ?? ????.
??? Thiopental (45 mg/kg)?? Propofol (22.5
mg/kg)?
Succinylcholine (11.5 mg/kg) ? ?????
? ?????? ?? ?? ?? ???? ICP? ??? ?? ? ??.
????? ????? ??? ???? ??? ?? ???
? ???? ?? Difficult intubation? ??? ?? ????.
? ???, SAH? ?? ??? ??,
? ? ??? Neurological damage? ??? ?? ??
? Cerebral function? ???? ?? ?? ??? ?????,
? Laryngoscopy? ??? Intubation? ???? ????
?????
? Moderate dose fentanyl(25 µg/kg)?
? Intermediate-acting neuromuscular
blocking drug? ????.

21
???? ????

SAH? ?? ???? C/SEC Induction? Opioid? ?????
? Short-acting opioid? Remifentanil? Induction
1? ?? 1 µg/kg ???? Target-controlled propofol
infusion? ????? ????? ???,
? Neonatal chest wall rigidity? ?? Apnea ???
? Neonatal Resuscitation? ? ? ?? ??? ??? ???
??.
? ???, Alfentanil? ????? ??? ??? ???? ???,
? ? ??? Neonatal Care? Resuscitation? ? ? ??
??? ??? ??? ??,
Neonatal naloxone? ??? ??
??.
Eclampsia? SAH? ?? ??? Induction???
Magnesium sulfate 3060 mg/kg IV? ?????.
Esmolol 0.51.0 mg/kg? Fetal bradycardia? ?? ? ?
??.
Lidocaine 1 mg/kg? Remifentanil ?? ? ?????.
Nitrous Oxide? NS?? ? ????.
? ? ICP? Cerebral blood flow, Cerebral oxygen
metabolic rate? ?????
? Autoregulation? ?????
? Air bubbles? ?????
? ?? ? Nausea Vomiting? ??? ? ????

22
???? ????

Oxytocic drugs
? ICP? Cerebral blood flow? ?? ??? ?? ???? ??
???,
Intracranial tumors ???? ??? ?? Oxytocin?
????? ?? ??? ??.
? ???? ???? ???? ? ?? ???? ????? ?????.
Ergometrine
? ??? venoconstrictor??,
? Blood-Brain Barrier? ??? ???? ICP? ?? ???
????? ????,
? Autoregulation? ???.
? ???, Cerebral venous constriction? ????
Intracranial blood volume? ?????? ?? ???
? Intracranial hypertension? ??? ???? ??.
? ?? ? ???? ??? ?? ??? Ergometrine? ????? ??
????
NS team? ?? ??? ?? ??.

23
7. Interventional Neuroradiology? ??

??? SAH? ??? ??? ????? ????.
Open craniotomy? surgical clipping? ??? ??? ???
??
Interventional Neuroradiology? ??? ??? ???
???? ??.
Interventional Neuroradiology? ?? ?? ??
? Cerebral Aneurysms? Endovascular Coiling ?
? AVM? Preoperative Embolization ?
???? ?? Interventional Neuroradiology ? ??? ??
? ???? Intervention??? ????? Invasive BP
monitoring? ??? ??
??? ??? ??? ?? ??? Minimal sedation? ??? ?
??.
? ?? ??? ???? Intervention ? ??? ??? (?)
Intracranial artery? occlusion? ?? test?? ?) ??
??? ??? ? ?? ??.
? ??? ??? Sedation? ?? ? ? ??.
? Interventional Neuroradiology?
? ??? ??? ??? ??? ???? ??? ????? ???? ????,
? ???, Neuroradiology ? ??? ? ???? ?? ?? ???
??? Case? ??? ??? ? ??.
? ??? ?? ?? ?? ?? ??? ????,
? Arterial cannulation?
? Uterine artery? ?? Endovascular closure? ?
??? ?? ??? ??.