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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? ?
    ??? ?? ??? ??.

24
Interventional Neuroradiology? ??
  • Femoral artery cannulation? ?? ???
  • ? ???? ?? ??? ?? ???? ??? ?? ???? ??? ??,
  • ? ???? 20? ??? ???? ????
  • ?? ??(Uterine displacement)?? ?? ??? ????
    ??? ??.
  • Interventional Neuroradiology? ?? ???? Heparin?
    ????? ???,
  • ? ?? C/SEC?? ? ???? ??? ????? Reversal? ???
    ?? ??.
  • Fetal compromise? ??? ???
  • ? ??? ??? ??? Neuroradiologic Procedure? ????
    ? ?? ???,
  • ? ?, ? Intracranial catheter(s)? ????
  • ? Femoral artery sheath(s)? ???
    ????,
  • ? heparin? reverse ? ? ??.
  • Fetal monitoring? Fetal mortality? morbidity? ???
    ?? ??? ?????,
  • Doppler monitoring? ???? ???? ??.
  • ???, Radiology suites ??? ??? ??? ???? ??? ??.
  • SAH? Coiling?? ?? ?? ?? ???
  • ?? ?? ?????? ???? ?????? ??? ??? ???? ??.

25
8. NS?? ?? C/SEC? ?? ??? ??
  • Late 2nd ? 3rd Trimesters??,
  • ???? Neurosurgery? ?? ? ??? ??? ??? ????
  • ??? ???? ??.
  • ???? Neurosurgery? ?? ?, C/SEC? ??? ?? ??? ???? ?
    ??
  • 9. ICP? ????? ????.
  • 9. ICP? Regional anesthesia
  • ???? Alert??, ?????? ICP? ??? ????
  • ???? ??? ? ???? ??????, Regional anesthesia?
    ?? ????.
  • ICP? ?? ???? Spinal anesthesia? ?? Dural puncture
    ??
  • ? CSF ??? ??? ?????
  • ? Herniation?? Intracranial hemorrhage? ?? ?
    ? ?? ??? ??? ???.
  • ?) Epidural anesthesia ?? Intracranial
    Subdural Hematoma? ??? ???
  • Spinal anesthesia ?? SAH? ?? ??? ??? ????
    ??.
  • ???, ? ?? ? CSF? ?? ??????
  • ? Transnasal Pituitary surgery??
    CSF rhinorrhea? ????
  • ? Facial trauma? ?? ???? ICP? ???
    ?? ??.

26
  • Epidural injection?
  • ? Dural sac? ???? ICP? ??? ??? ? ???
  • ? ?????? ?? ??? ??.
  • ? ???, ??? ??? ???? ?? ?????.
  • ? ?????(Paraplegia)? ???
  • ? ?? ???(Autonomic hyperreflexia)? ???
  • ? Cervical AVM? ???
  • ? Ventriculoperitoneal shunt? ?? ????
    C/SEC???
  • ? Regional anesthesia(Spinal?? Combined
    spinal-Epidural)? ????.
  • ? ?? ???(Pseudotumor cerebri)? ?? ???
  • ? Lumbar-peritoneal shunt? ?? ???? C/SEC???
  • ? Epidural anesthesia? ????.

27
10. ?? ? ??
  • ????
  • ? ????? Intracranial ? extracranial surgery?? ?
    ???,
  • ? Craniotomy pain? ??? 50 ???? Moderate to
    Severe?? ????.
  • ? ? ???? ???? ??? ? ?? ??? ??,
  • ? ?????? ???? ????? ? ??? ? ? ?? ??? ????.
  • ? Analgesia? ?????? ??, Scalp blocks, Opioids?
    Pracetamol? ?? ?
  • ??? ??? ?? ???? ?? ?????.
  • ? Morphine, Codeine, Tramadol? Postcraniotomy
    pain? ?? ?? ?????
  • ? Morphine? ?? ????? ??
  • ???? ?? ??? ????.
  • ? Tramadol? Respiratory depression? ???,
  • Seizure threshold? ???
    ??? ????? ???? ??.
  • ? Extracranial surgery ???, ???? ????? ????,
  • Patient-controlled IV opioid ( fentanyl ??
    morphine )? ??? ? ??.
  • ? Spinal surgery ??? Neuraxial opioids?
    Epidural analgesia? ?????.

28
?? ? ??
  • ? Cyclooxygenase1? Cyclooxygenase2 inhibitor,
    NSAIDs? ????.
  • ? ? Intracranial surgery?? ??? ??? ?????,
  • ? Renal failure, Necrotizing
    enterocolitis, ?? Fetal circulation? ?? ?
  • ??? ?? ???? ??? ? ?? ????.(??, ??32?
    ???)
  • ? Celecoxib, Parecoxib, Valdecoxib? ??
    Cyclooxygenase2 inhibitor?
  • ???? ?? ??? ???
  • ?? ? ???? ?? ??? ?? ???? ??? ????
  • Deep Vein Thrombosis? ??
  • ? ??? hypercoagulable state?? ???,
  • ? ?? ? Thromboembolism? Risk? ????.
  • ? ? Antithromboembolic TED stockings,
  • ? Calf stimulation
  • ? Calf compressors
  • ? Pedal pumps ?? ? ???? ?? ??? ??? ?????
    ??.
  • ? Neurosurgery? ??? ???? Risk? ????? ????,
  • Heparin? ?????? ??? ?? NS???? ???? ??

29
?? ? ??
  • Cerebral Vasospasm
  • ? SAH? ?? ? 36? ? Cerebral vasospasm? ??? ?
    ??.
  • ? Triple H-therapy (Hypertensive, Hypervolemic,
    Hemodilution)?
  • ??? ?? ?? ? ???? ??? ??.
  • ? ???? ??? ???? ???? ? ???? ???,
  • ? ????? ?? Hypervolemic ??? hemodiluted ? ???
    ???? ???,
  • ? ??? ????? SAH ?? Cerebral Vasospasm? ?????
    ??? ??.
  • ? Preeclampsia?? ??? ??? Eclampsia? Risk? ??? ?
    ??

  • ?? Cerebral comlications? ?? ? ? ??.
  • ? Magnesium sulfate? SAH? Vasospasm? ????? ???
    ??? ???
  • ? Cerebral vasospasm? ??? Eclampsia? ??? ???
    ??? ??.
  • ? ?????? Vasospasm? ??????
  • Trans-cranial flow velocity? ??? ????, ??
    ?????
  • ???? ??? ????? Papaverine?? Verapamil?
    ????.
  • ? ???, ????? ??? ??? ??? ???? ??? ??? ?? ??,
  • ? ?? ?? ? ???? ?? ??? ???? ?? ????.
  • ? Nimodipine? Intracranial vasospasm? ?????? ??
    ??? ??.
  • ??????? ??? ??? ???? ???
    ??? ???,
  • ????? ?? ? ????? ??? ???
    ?? ??
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