幾乎失誤的剖腹產麻醉－－病例報告

Near Miss in Anesthesia for Cesarean Delivery

本文報告剖腹產手術後發生大出血的一例。31歲健康的初產婦，G1PO，懷孕41週接受選擇性剖腹產手術，麻醉的術前訪視並無異常現象。在脊椎穿刺半身麻醉下，剖腹產順利的進行，並產下一健康女嬰。開始縫合腹壁時，估算失血約500 ml，點滴給予生理食鹽水1500 ml。當我們要結束手術時，產婦突然發生躁動不安，臉色蒼白。此時病人血壓5分鐘內由正常120/70 mmHg下降為66/40 mmHg，脈搏跳動由86/min增加到140/min。婦產科醫師立刻被告知可能有大量快速失血。在充滿疑惑之下，確定腹部傷口內外均已充分止血，婦產科醫師只得快速把傷口縫合，並且給予病人大量血液及點滴急救。當整個手術完全完成後，翻開無菌手術布單時，發現在病人兩腿間約有近2000ml血液流失。此時確定發生了產後大出血，而最可能的原因為宮縮無力。經過所有積極努力的治療，包括藥物，輸液／血，陰道及子宮內壓力等，仍持續冒出血來。於是只好施予全身麻醉，重新打開傷口作完全子宮切除術，才控制住病情。產婦在術後三天完全康復。從這個病例，我們發現，即使在一般的常規手術，也可能有意外發生。所幸迅速處理，否則發生悲劇在所難免。

A case of massive bleeding following cesarean section and its management is presented. A 31-year-old para 0, gravida 1, artificial abortion 1, otherwise healthy woman at 41-wk uncomplicated gestation presented to the operating room for elective cesarean section. Pre-operative visits did not reveal anything unusual. Following the spinal anesthesia, the cesarean section was successfully done and a healthy female infant was delivered. At the wound closure, an estimated total blood loss was 500 mL and the total normal saline intake was 1500 mL. As we were about to finish the case, the patient began restless and pale. We discovered that her blood pressure dropped from 120/70 mmHg to 66/40 mmHg and the pulse rate increased from 86/mim to 140/min in 5 minutes. The surgeon was notified that a rapid blood loss was occurring somewhere and fast. The surgeon was mystified and ascertained that the wound was dry from inside out. The surgeon was asked to quickly finish the case while aggressive blood/fluid resuscitation continued. On undraping the patient from the sterile sheets when the procedure was done, an estimated fresh blood loss of 2000 mL between the legs was discovered.Massive postpartum hemorrhage has occurred, most likely from uterine atony. In spite of vigorous management, the active vaginal bleeding continued.Under general anesthesia and continued resuscitation,the wound was re-opened and total hysterectomy was performed. This patient uneventfully recovered 3 days later.From this excruciating experience,we remind ourselves that even in routine case,dangerous situation may happen. An anesthesiologist should be prepared to deal with sudden encounters.