日本臨床麻酔学会 vol.36

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1 15 症例報告 日臨麻会誌 Vol.36 No.1, 15 19, 2016 脳室腹腔シャント留置中の帝王切開に対する脊髄くも膜下硬膜外併用麻酔の経験 道姓拓也山田新 藤井智子坂本篤紀 伊賀美季子 小坂誠 [ 要旨 ]36 歳の女性. 先天性水頭症に対して 1 歳と 27 歳のときに脳室腹腔 (VP) シャント手術を受けた.VP シャントは機能しており, 頭蓋内圧亢進症状はなかった. 骨盤位妊娠に対して 37 週 6 日で帝王切開の予定となった. 術前の腹部 X 線検査で, 子宮前面に VP シャントの走行を認めた. VP シャントを有する帝王切開の報告は散見するが, 推奨される特定の麻酔方法はない. 神経学的徴候と産科的考慮から選択される. 今回は, 手術開始から児娩出に時間を要すると判断して, 脊髄くも膜下硬膜外併用麻酔を選択した. 脊髄くも膜下麻酔は の高位まで達したが, 母子ともに問題なく分娩を終了した. キーワード : 脳室腹腔シャント, 帝王切開, 脊髄くも膜下硬膜外併用麻酔 はじめに VP 1, 2 VP VP VP combined spinal-epidural anesthesia CSEA VP Ⅰ 症 cm 54.5kg 48.0kg VP VP X VP 例

2 16 Vol.36 No.1/Jan mmhg /min :Th10 :Th10 Th6 Th6 Epi Sp ( 時間 ) 図 1 麻酔記録 CSEA 図 1 Th12/L1 5cm L3/4 25 Quincke mL Th mmHg 4mg VP 図 2 1 5mL Th6 PCA Patient Controlled Analgesia mL/h 3mL 60 PCA 1 VP 8 Ⅱ 考察 VP VA LP Liakos

3 17 図 2 術野写真 5 Landwehr VP 1, 2, 4 ICP 7 MRI 4 VP 1 VP 5 VA VP VP 1, 10 VP cerebrospinal fluid CSF VP mL CSEA Quincke 1 1, 5 VP CSEA VP 1, 10 CSEA needle-through-needle technique L3/4 Th12/ L1 2

4 18 Vol.36 No.1/Jan 結語 CSEA VP Th12/L 参考文献 1) Hirs I, Grbcic P:Cesarean section in spinal anesthesia on a patient with mesencephalic tumor and ventriculoperitoneal drainage -A case report-. Korean J Anesthesiol 63: , ) Goolsby L, Harlass F:Central diabetes insipidus:a complication of ventriculoperitoneal shunt malfunction during pregnancy. Am J Obstet Gynecol 174: , ) Murakami M, Morine M, Iwasa T, et al.:management of maternal hydrocephalus requires replacement of ventriculoperitoneal shunt with ventriculoatrial shunt:a case report. Arch Gynecol Obstet 282: , ) Wisoff JH, Kratzert KJ, Handwerker SM, et al.:pregnancy in patients with cerebrospinal fluid shunts:report of a series and review of the literature. Neurosurgery 29: , ) Liakos AM, Bradley NK, Magram G, et al.:hydrocephalus and the reproductive health of women:the medical implications of maternal shunt dependency in 70 women and 138 pregnancies. Neurol Res 22:69-88, ) Landwehr JB Jr, Isada NB, Pryde PG, et al.:maternal neurosurgical shunts and pregnancy outcome. Obstet Gynecol 83: , ) Ryken TC:Idiopathic intracranial hypertension (Pseudotumor cerebri), hydrocephalus, and ventriculoperitoneal shunts in pregnancy, Neurosurgical Aspects of Pregnancy. Edited by Loftus CM. AANS, Illinois, 1996, ) Barina AR, Virgo KS, Mushi E, et al.:appendectomy for appendicitis in patients with a prior ventriculoperitoneal shunt. J Surg Res 141:40-44, ) Littleford JA, Brockhurst NJ, Bernstein EP, et al.:obstetrical anesthesia for a parturient with a ventriculoperitoneal shunt and third ventriculostomy. Can J Anaesth 46: , )Goulart AP, Moro ET, Rios Rde P, et al.:subarachnoid blockade for cesarean section in a patient with ventriculoperitoneal shunt:case report. Rev Bras Anestesiol 59: , )Abbey P, Singh P, Khandelwal N, et al.:shunt surgery effects on cerebrospinal fluid flow across the aqueduct of Sylvius in patients with communicating hydrocephalus. J Clin Neurosci 16: , 2009

5 19 Combined Spinal-epidural Anesthesia for Cesarean Section in a Patient with Ventriculoperitoneal Shunt Takuya DOUSEI, Tomoko FUJII, Mikiko IGA, Arata YAMADA, Atsunori SAKAMOTO, Makoto KOSAKA Department of Anesthesiology, Showa University Northern Yokohama Hospital A 36-year-old pregnant patient received a ventriculoperitoneal shunt operation for congenital hydrocephalus at 1 year and 27 years of age. The VP shunt functioned normally, and she did not have any intracranial hypertensive symptoms. Elective cesarean section was planned for the breech position of the baby. A review of the literature related to pregnant patients with VP shunt found that both regional and general anesthesia has been used. The choice of anesthesia should be based on neurological status and obstetric advice. The preoperative abdominal X-ray examination indicated that the VP shunt tube was located on the surface of the uterus. The delivery of the baby was expected to take time. We therefore chose CSEA instead of general anesthesia. Spinal anesthesia was performed at the L3/L4 space with a 25-gauge Quincke needle. The drug used was 7.5 mg of 0.5% hyperbaric bupivacaine. Sensory blockade reached the level within 10 minutes. The patient was hemodynamically stable during the anesthesia. The operating procedure was uneventful. The mother and child were discharged from the hospital on the 8th day after birth. Key Words : VP shunt, Cesarean section, Combined spinal-epidural anesthesia(csea) The Journal of Japan Society for Clinical Anesthesia Vol.36 No.1, 2016

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