椎管内麻醉下剖宫产手术中麻醉相关死亡病例分析

Intraspinal anesthesia-related deaths during cesarean section delivery:six case reports

目的总结椎管内麻醉下剖宫产手术中麻醉相关死亡的原因。方法对2002-2011年间国内文献公开报道和成都地区孕产妇死亡评审病例中因蛛网膜下腔阻滞或(和)硬膜外腔阻滞麻醉引起剖宫产死亡的6例病例进行回顾分析。结果 2例病例缺少年龄报道,其余病例年龄24～35岁。2例为瘢痕子宫。1例蛛网膜下腔阻滞麻醉,4例硬膜外腔阻滞麻醉,1例硬膜外腔与蛛网膜下腔联合阻滞麻醉。麻醉危象出现时间在给予麻醉药后3～55min。2例死亡病例未做尸检,其余4例硬膜外腔阻滞麻醉者均做尸检,其中3例发现硬膜有裂伤,脑脊液外渗;另1例为瘢痕子宫,尸检报告腰段脊髓切面均未见出血,肺泡壁毛细血管有羊水中细胞成分和微血栓,不排除羊水栓塞,未提及检查穿刺点附近硬膜有无破损。结论由于操作为盲式,硬膜外给药可能出现意料之外的硬膜下腔或蛛网膜下腔麻醉,并由此导致孕产妇死亡。因此,在麻醉过程中,务必操作仔细,避免损伤硬膜,必须给予试探剂量,同时密切观察孕产妇生命体征,特别是有瘢痕子宫者更应关注。

Objective To explore the causes of intraspinal anesthesia-related deaths during cesarean section delivery. Methods Six anesthesia-related death cases were analyzed retrospectively who were reported by literature and reviewed by regional department from 2002 to 2011. They were given subarachnoid and/or epidural block anesthesia. Results The age of 4 cases ranged from 24 to 35 years old except 2 cases who had no record on age. Two cases had cicatrix uterus. One case was given subarachnoid block anesthesia, 4 cases were given epidural block anesthesia,and 1 case was given subarachnoid and epidural block anesthesia. The anesthesia crisis occurred 3 to 55 minutes later after administration of anesthetics. Four cases had autopsy and all were received epidural block anesthesia. Three cases were found with split on the dura mater and exudation of cerebro spinal fluid. The left one had cicatrix uterus, no bleeding was found lumbar spinal sections but cells from amniotic fluid and microemboli were found in the capillaries of the pulmonary alveolus, and whether there was rupture near the punctured point on the dura mater was not mentioned in the autopsy report. Conclusions Because of blind operation, Epidural block anesthesia may cause unexpectable responses of subdural or subarachnoid block anesthesia due to damage of the dura mater and induce death in the cesarean section delivery. Hence careful manipulation and surveillance of life signs are necessary, especially in case with cicatrix uterus.