疑似伴病理性胎盘附着的前置胎盘剖宫产术的椎管内麻醉：回顾性分析
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Neuraxial Anesthesia During Cesarean Delivery for Placenta Previa With Suspected Morbidly Adherent Placenta: A Retrospective Analysis
背景与目的
方 法
我们对从1997年到2015年疑似伴MAP前置胎盘接受非急诊CD的产妇进行一项单中心、回顾性队列研究。根据患者是否接受GA、NA或术中从NA转为GA，对患者进行分类。主要观察指标为术后敏锐度，定义为需要进入重症监护病房，动脉栓塞，再次手术或持续输注≥3单位的红细胞。我们另外确定变量与子宫切除术中从NA转为GA的概率呈正相关。用逻辑回归模型来控制混杂。
结 果
在疑似伴MAP的前置胎盘患者中，接受非急诊CD的129名患者中，122名（95％）接受NA为主要麻醉方式。大多数患者的体重指数≥40kg / m（9/10，90％），既往CD≥3（18/20，90％），怀疑胎盘增大或过度（2935，83％），Mallampati分级≥3（19中21，90％）。72例NA患者术中需要切除子宫，15例（21％）术中需要转换为GA。转换为GA的患者输注大量红细胞的比率较高（60％vs 25％; P = 0.01），输血量相似（9％比7％; P = 1.0）。此外，患者术后敏锐度的发生率也较高（47％vs 4％; P <.0001），其中包括5例在大容量复苏后需在重症监护室给予呼吸支持管理。校正多个混杂因素后，子宫切除术患者需转为GA的唯一独立预测因子是更长的手术时间（校正比值比1.54,95％CI 1.01.2.42）和≥3次的CD史（校正比值比6.45,95％CI，1.12.45.03）。
结 论
NA可成功用于大多数疑似伴MAP的前置胎盘患者。我们的研究结果支持这类患者在子宫切除术期间可选择性转为GA，重点关注手术较复杂的患者。
原始文献摘要
Markley JC, Farber MK, Perlman NC, Carusi DA.Neuraxial Anesthesia During Cesarean Delivery for Placenta Previa With Suspected Morbidly Adherent Placenta: A Retrospective Analysis.Anesth Analg. 2018 Feb 23.
BACKGROUND: General anesthesia (GA) is often selected for cesarean deliveries (CD) with placenta previa and suspected morbidly adherent placenta (MAP) due to increased risk of hemorrhage and hysterectomy. We reviewed maternal outcomes and risk factors for conversion to GA in a cohort of patients undergoing CD and hysterectomy under neuraxial anesthesia (NA).
METHODS: We performed a single-center, retrospective cohort study of parturients undergoing nonemergent CD for placenta previa with suspected MAP from 1997 to 2015. Patients were classified according to whether they received GA, NA, or intraoperative conversion from NA to GA. The primary outcome measure was postoperative acuity, defined as the need for intensive care unit admission, arterial embolization, reoperation, or ongoing transfusion with ≥3 units packed red blood cells. We additionally identified variables positively associated with intraoperative conversion from NA to GA during hysterectomy. Confounding was controlled with logistic
regression models.
RESULTS: Of 129 patients undergoing nonemergent CD for placenta previa with suspected
MAP, 122 (95%) received NA as the primary anesthetic. NA was selected in the majority of patients with a body mass index ≥40 kg/m2 (9 of 10, 90%), a history of ≥3 prior CDs (18 of
20, 90%), suspected placenta increta or percreta (29 of 35, 83%), and Mallampati classification ≥3 (19 of 21, 90%). Of 72 patients with NA at the time of delivery who required hysterectomy, 15 (21%) required conversion to GA intraoperatively. Converted patients had a higher rate of major packed red blood cell transfusion (60% vs 25%; P = .01), with similar rates of
massive transfusion (9% vs 7%; P = 1.0). Converted patients also had a higher incidence of postoperative acuity (47% vs 4%; P < .0001), including 5 intensive care unit admissions for
airway management after large-volume resuscitation. After adjusting for multiple confounders, the only independent predictors of conversion among hysterectomy patients were longer surgical duration (adjusted odds ratio 1.54, 95% CI, 1.01–2.42) and a history of ≥3 prior CDs (adjusted odds ratio, 6.45; 95% CI, 1.12–45.03).
CONCLUSIONS: NA was applied to and successfully used in the majority of patients with suspected MAP. Our findings support selective conversion to GA during hysterectomy in these patients, focusing on those with the highest levels of surgical complexity.
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