A comparison between post-operative analgesia after intrathecal nalbuphine with bupivacaine and intrathecal fentanyl with bupivacaine after cesarean section

BackgroundAdding intrathecal opioids to intrathecal local anesthetics to decrease their doses and provide hemodynamic stability are major goals during spinal anesthesia in cesarean section. Different opioids were used to select the one with the longest duration of analgesia and the least side effects. In this study, intrathecal nalbuphine was compared with intrathecal fentanyl as an adjuvant to hyperbaric bupivacaine in cesarean section.Patients and methodsSixty female patients of ASA grades I and II presented for elective cesarean deliveries with spinal anesthesia were randomly allocated to 2 equal groups; Group F: 30 patients received intrathecal injection of 2 ml of 0.5% hyperbaric bupivacaine plus 0.5 ml fentanyl (25 μg); Group N: 30 patients received intrathecal injection of 2 ml of 0.5% hyperbaric bupivacaine plus 0.5 ml nalbuphine (0.8 mg). The onset of sensory and complete motor blockade, time of sensory blockade, duration of analgesia and motor blockade, fetal Apgar score, visual analog scale score, oxygen saturation, adverse effects and hemodynamic parameters were recorded intra-operatively and up to 4 h post-operatively. The effective analgesic time was recorded.ResultsThe onset of complete motor block was significantly more rapid in fentanyl group than in nalbuphine group. The duration of post-operative analgesia was more prolonged in nalbuphine group but the difference was insignificant. No significant difference was found between both groups as regards the duration of sensory block, motor block, duration of analgesia, fetal Apgar score, visual analog scale score, hemodynamic parameters and oxygen saturation. Adverse effects were less common in nalbuphine group but the difference was insignificant.ConclusionEither intrathecal nalbuphine 0.8 mg or intrathecal fentanyl 25 μg combined with 10 mg bupivacaine provides good intra-operative and early post-operative analgesia in cesarean section.     

0.75%重比重布比卡因剖宫产腰硬联合麻醉的应用

目的探讨重比重布比卡因腰硬联合麻醉在剖宫产麻醉中的应用。方法选择120例剖宫产手术的产妇,ASAI-Ⅱ,行L2—3或L3—4间隙穿刺,穿刺成功后注入0.75%布比卡因重比重液1~2mL(7.5~15mg),控制麻醉平面后,测血压、脉搏、呼吸。结果麻醉起效时间为1~3min,注药后(6.3±2.2)min阻滞完善。腰骶部阻滞完善,对产妇血压的影响不超过其基础值的20%,脉搏、呼吸基本无明显影响,术后并发症少,新生儿Apgar评分(18.8±0.7)分。结论腰硬联合麻醉起效快、效果确切、肌松良好、对胎儿循环干扰小、并发症少。     

A new modality for improving the efficacy of intrathecal injection for cesarean section

BackgroundIntrauterine resuscitation (IUR) is to improve O2 delivery to the placenta and umbilical blood flow, for reversal of foetal hypoxia and acidosis. We evaluated whether maintaining a lateral position after an intrathecal injection of a relatively low dose of hyperbaric bupivacaine and high dose of fentanyl improving the efficacy of spinal anaesthesia, IUR and preventing hypotension during cesarean delivery.MethodsOne hundred and seventy two healthy women undergoing elective cesarean delivery were enrolled in a double blind prospective randomized study. Spinal anesthesia was conducted in the right lateral position which maintained for 6 min for all the patients participated in the study, and then the subjects were turned supine. Patients were randomly allocated to two groups: low-dose spinal bupivacaine (LD) group (n = 86) patients received 6 mg of hyperbaric bupivacaine 0.5% and 15 μg of fentanyl, high-dose spinal bupivacaine (HD) group (n = 86) patients received 10 mg of hyperbaric bupivacaine and 15 μg of fentanyl. The incidence of hypotension and nausea, ephedrine requirement, maximal block height, and Apgar score at 1 and 5 min.ResultsThe authors found significant decrease in MAP in the group that was given the high dose of bupivacaine the incidence of hypotension was 80% but the LD spinal bupivacaine group was hemodynamically stable. The lowest blood pressure, boluses of inj. ephedrine used, or nausea were more significant in the HD group than in LD group. Onset of hypotension was more rapid (8 ± 3 vs. 16 ± 6 min, P < 0.001), and the sensory block level was more cephalad in HD group than in LD group (T2 [C8–T5] vs. T4 [T1–T6], P = 0.001). Apgar scores did not differ between the groups.ConclusionMaintaining the lateral position for 6 min after an intrathecal injection of a relatively low dose of hyperbaric bupivacaine and high dose of fentanyl resulted in improving the efficacy of spinal anaesthesia, IUR by more gradual and higher cephalad sensory block, without an increase in the incidence of maternal hypotension.     

布比卡因复合右美托咪定在剖宫产术蛛网膜下腔麻醉中的安全性和有效性

目的探讨布比卡因复合右美托咪定在剖宫产术蛛网膜下腔麻醉(腰麻)的安全性和有效性。方法择期腰麻下行剖宫产术的产妇150例,年龄20～35岁,体重60～85 kg,随机分为三组,B组:0.5%布比卡因9 mg;FB组:0.5%布比卡因7.5 mg+芬太尼20μg;DB组:0.5%布比卡因7.5 mg+右美托咪定5μg。记录产妇感觉和运动阻滞起效时间、持续时间,以及低血压、寒战、恶心呕吐等不良反应发生情况。结果 B组、FB组和DB组感觉阻滞起效时间分别为(14.8±2.9)s、(15.5±2.2)s和(12.3±1.6)s,DB组明显短于B组和FB组,B组明显短于FB组(P0.05)。B组、FB组和DB组感觉阻滞持续时间分别为(122.3±23.5)min、(108.7±21.4)min和(147.3±18.0)min,DB组明显长于B组和FB组,B组明显长于FB组(P0.05)。B组、FB组和DB组运动阻滞起效时间分别为(3.4±1.1)min、(3.2±0.8)min和(2.8±0.7)min,DB组明显短于B组和FB组(P0.05)。B组、FB组和DB组运动阻滞持续时间分别为(162.1±24.5)min、(141.3±21.9)min和(188.5±21.7)min,DB组明显长于B组和FB组,B组明显长于FB组(P0.05)。DB组产妇低血压、寒战、术中及术后恶心呕吐的发生率均明显低于B组(P0.05),且DB组低血压发生率明显低于FB组(P0.05)。结论剖宫产术中布比卡因复合右美托咪定的腰麻效果优于复合芬太尼,且安全性更高。     

Effects of meperidine,pentazocine, bupivacaine and lidocaine in spinal anesthesia for cesarean section

Key words  spinal anesthesia meperidine - pentazocine - bupivacaine - lidocaine - cesarean section     

相同浓度的左旋布比卡因、罗比卡因与布比卡因硬膜外腔给药用于剖宫产术时效性的比较

目的比较左旋布比卡因、罗比卡因和布比卡因用于硬膜外麻醉剖宫产术的阻滞效果、母婴安全和药物不良反应.方法采用随机双盲法,将48例择期剖宫产手术的足月单胎产妇分为三组：0.5%左旋布比卡因组（L组）17例、0.5%罗比卡因组（R组）15例和0.5%布比卡因组（B组）16例.记录硬膜外腔给药后产妇的感觉阻滞和运动阻滞的起效和持续时间、肌松满意程度、麻醉质量评价、恶心和呕吐等不良反应及术中心率、血压、脉搏血氧饱和度和新生儿1 min和5 min Apgar评分.结果产妇的一般情况、新生儿的Apgar评分组间无显著性差异;三组术中低血压及其他不良事件（恶心和呕吐）的发生率无显著性差异;各组的麻醉质量（术中的疼痛评分和肌松满意度）基本一致;感觉阻滞起效和维持时间组间无显著性差异,运动阻滞改良Bromage评分为1分的起效时间和持续时间组间有显著性差异.结论常用量0.5%左旋布比卡因、罗比卡因和布比卡因用于剖宫产手术的硬膜外麻醉时具有相似的麻醉效能和安全性.     

Comparative effect of 6% hydroxyethyl starch (containing 1% dextrose) and lactated Ringer's solution for cesarean section under spinal anesthesia

Purpose. This study aimed to compare low-molecular weight hydroxyethyl starch containing 1% dextrose (HES) infusion and lactated Ringer's solution (LR) in the prevention of hypotension associated with spinal anesthesia for cesarean section. Methods. Sixty-seven patients scheduled for cesarean section under spinal anesthesia were randomly allocated to receive either LR (n= 35) or HES (n= 32) infusion before cesarean delivery. Infusion of the fluid was started immediately after arrival at the operating room, through two fully open i.v. routes of 18 or 16 gauge. The two groups were compared in terms of the incidence of hypotension; ephedrine dose; cord and maternal blood gas, hemoglobin, and glucose; and Apgar scores. Results. Intravenous fluid volume until delivery in the LR group was significantly greater than that in the HES group (1298 ± 503 and 973 ± 339 ml, respectively) in spite of the similar periods of intravenous infusion (18.1 ± 3.9 and 18.2 ± 4.1 min). The incidence of hypotension, and the ephedrine dose, blood gas analyses, and Apgar scores were not significantly different between the groups. The ephedrine dose correlated with the anesthesia level by spinal anesthesia (P < 0.05). Conclusion. This study did not show an advantage of HES compared with LR in the prevention of hypotension or in the reduction of ephedrine dose during cesarean section under spinal anesthesia. The anesthesia level, rather than the choice of intravenous fluid solution, might be related to the ephedrine dose. Received: January 25, 1999 / Accepted: April 7, 2002     

Role of pleth variability index for predicting hypotension after spinal anesthesia for cesarean section

BackgroundHypotension is frequently observed after spinal anesthesia for cesarean section and can be detrimental to both mother and baby. We investigated the role of the pleth variability index for predicting hypotension after spinal anesthesia for cesarean section.MethodsEighty-five parturients undergoing elective cesarean section under spinal anesthesia were enrolled. We recorded pleth variability index and perfusion index before anesthesia, and blood pressure, heart rate and pulse oxygen saturation before and after anesthesia. The association between baseline pleth variability index and perfusion index with hypotension after spinal anesthesia was explored using multivariate analysis.ResultsHypotension occurred in 42 parturients. Baseline pleth variability index was higher in parturients who experienced hypotension than in those who did not (P < 0.05), although there was no difference in baseline perfusion index. The area under the receiver operating characteristic curve was 0.66 for baseline pleth variability index for the prediction of hypotension (P < 0.05). Baseline pleth variability index was significantly related to the incidence of hypotension (P = 0.017), but was not significantly related to the magnitude of the decrease in systolic blood pressure. Baseline perfusion index was not significantly related to the magnitude of the decrease in systolic blood pressure.ConclusionGreater baseline pleth variability index was associated with hypotension after spinal anesthesia for cesarean section, but may not be a clinically useful predictor.     

心率和脉搏灌注变异指数对剖宫产脊麻后低血压的预测作用

目的探讨HR和脉搏灌注变异指数(PVI)对剖宫产脊麻后低血压的预测作用。方法选择择期脊麻下剖宫产的产妇80例,年龄18~40岁,BMI 20~40kg/m2,ASAⅠ或Ⅱ级。在L3-4间隙行硬腰联合麻醉。记录麻醉前后的HR、PVI、BP和MAP。探讨HR和PVI与脊麻后低血压的相关性。结果与未发生低血压的产妇比较,发生低血压的产妇HR基础值明显增快、PVI基础值明显增大(P 0.05)。HR基础值预测低血压的ROC曲线下面积为0.77(P 0.05),最佳阈值为≥84次/分,预测低血压的敏感度和特异度分别为70.7%和81.8%,阳性预测值和阴性预测值分别为91.1%和51.4%。PVI基础值预测低血压的ROC曲线下面积为0.74(P 0.05),最佳阈值为≥21%,预测低血压的敏感度和特异度分别为44.8%和95.5%,阳性预测值和阴性预测值分别为96.3%和39.2%。HR基础值联合PVI基础值预测低血压的ROC曲线下面积为0.86(P 0.05),最佳阈值为≥86次/分(HR)或≥21%(PVI),预测低血压的敏感度和特异度分别为82.8%和86.4%,阳性预测值和阴性预测值分别为92.5%和66.7%。结论脊麻前较大的心率基础值和脉搏灌注变异指数基础值与剖宫产脊麻后低血压相关,联合使用这两个指标可以用于临床预测剖宫产脊麻后低血压。     

生理盐水硬膜外容量扩张对剖宫产蛛网膜下腔阻滞时0.75%罗哌卡因半数有效剂量的影响

目的探讨硬膜外注生理盐水10 ml进行硬膜外容量扩张(EVE)对剖宫产产妇0.75%罗哌卡因蛛网膜下腔阻滞(简称腰麻)半数有效剂量(ED_(50))的影响。方法足月单胎初产妇60例,体重50～80 kg, ASAⅡ级,孕期37周。采用随机数字表法将产妇分为两组:EVE组(E组)和对照组(C组),每组30例。两组均在超声引导下行L_(3-4)间隙腰麻,蛛网膜下腔给予0.75%罗哌卡因后,E组硬膜外推注生理盐水10 ml, C组不给予任何液体。序贯法0.75%罗哌卡因初始剂量为10 mg,根据上一例产妇的镇痛效果,上调或下调下一例产妇所需罗哌卡因剂量,上调或下调的浓度梯度为1 mg。观察腰麻效果,采用Probit回归分析计算罗哌卡因的ED_(50)及ED_(95)。结果 C组0.75%罗哌卡因腰麻的ED_(50)为12.050 mg(95%CI 11.215～12.953 mg),ED_(95)为13.683 mg(95%CI 12.816～15.692 mg);E组0.75%罗哌卡因腰麻的ED_(50)为9.915 mg(95%CI 9.321～10.471 mg),ED_(95)为11.548 mg(95%CI 10.878～13.255 mg)。结论剖宫产产妇0.75%罗哌卡因腰麻的ED_(50)为12.050 mg(95%CI 11.215～12.953 mg),硬膜外生理盐水10 ml容量扩张能使其用量减少约17.7%。     

Evaluation of the analgesic effect of ketamine as an additive to intrathecal bupivacaine in patients undergoing cesarean section

ObjectiveNowadays, conventional analgesic agents, which are widely used for pain relief after cesarean section, provide suboptimal analgesia with occasional serious side effects. We designed a randomized, double-blind, placebo-controlled study to evaluate the analgesic efficacy of intrathecal ketamine added to bupivacaine after cesarean section.MethodsSixty patients scheduled for cesarean section under spinal anesthesia were randomly allocated to one of the two groups to receive either bupivacaine 10 mg combined with 0.1 mg/kg ketamine, or bupivacaine 10 mg combined with 0.5 mL distilled water intrathecally. The time to the first analgesic request, analgesic requirement in the first 24 hours after surgery, onset times of sensory and motor blockades, the durations of sensory and motor blockades, and the incidences of adverse effects such as hypotension, ephedrine requirement, bradycardia, and hypoxemia, were recorded.ResultsPatients who received ketamine had a significantly prolonged duration of anesthesia compared with those who did not in the control group [95% confidence intervals (CI) 195–217; p = 0.001]. The mean time to the first analgesic request was also significantly longer in ketamine group (95% CI 252.5–275; p < 0.001). The total analgesic consumption in the 24 hours following surgery significantly lessened in the ketamine group compared with that of the control group (95% CI 2–2.5; p < 0.001). The two groups did not differ significantly in intraoperative and postoperative side effects.ConclusionIntrathecal ketamine 0.1 mg/kg co-administered with spinal bupivacaine elongated the time to the first analgesic request and lessened the total analgesic consumption in the first 24 postoperative hours in comparison with bupivacaine alone in the control group following elective cesarean delivery.     

Comparison of two fentanyl doses to improve epidural anaesthesia with 0.5% bupivacaine for caesarean section

Ninety women undergoing elective caesarean section under epidural anaesthesia were double blindly randomised into three groups to receive either 2 ml of saline or 50 or 100 μg of fentanyl in 2 ml volume added to 0.5% bupivacaine. Both doses of fentanyl intensified the epidural anaesthesia and reduced patient discomfort during the operation. In both fentanyl groups the epidural blockade more often reached the 5th thoracic segment (P = 0.0258), the patients had significantly less pain (P = 0.0256), needed less intravenous diazepam medication during the operation (P = 0.0005) and the operating conditions were better when compared to the saline group (P = 0.0416). There was no difference between the groups in the condition of the neonates as assessed by the Apgar score and cord blood pH. The postoperative time until treatment for pain was requested by the patients was more than 1 h longer in the fentanyl groups, but there was no difference in the total amount of postoperative analgesics needed during the first 24 h when compared to the saline group. Mild pruritus not requiring treatment was more common in fentanyl groups than in the saline group (P = 0.0187). The results suggest that 50 μg of fentanyl added to 0.5% bupivacaine increases patient comfort and improves the quality of epidural anaesthesia for caesarean section, and that adding 100 μg does not give further advantage.     

Prophylactic infusion of phenylephrine is effective in attenuating the decrease in regional cerebral blood volume and oxygenation during spinal anesthesia for cesarean section

BackgroundHypotension induced by spinal anesthesia for cesarean section causes a decrease in maternal regional cerebral blood volume and oxygenation. We used near-infrared spectroscopy to determine whether prophylactic infusion of phenylephrine attenuates these decreases.MethodsSixty patients undergoing bupivacaine spinal anesthesia for cesarean section were randomly divided into one of three intravenous infusion groups: saline (P0), phenylephrine 25 (P25) or 50 µg/min (P50). Mean arterial pressure, heart rate and near-infrared spectroscopy measurements were made at one-minute intervals for 20 minutes, and oxyhemoglobin, deoxy-hemoglobin and total-hemoglobin concentrations and tissue oxygenation index were determined. Mean changes in the values between baseline and each measurement time after intrathecal injection were compared.ResultsSignificant decreases in mean arterial pressure were seen in group P0 compared to P25 and P50 (P <0.01). Heart rate decreased in a dose-dependent manner during phenylephrine infusion (P0 vs. P25 and P50, P25 vs. P50; P <0.05). Significantly higher total-hemoglobin levels were observed in the phenylephrine groups versus the P0 group (P <0.01). The largest decrease in tissue oxygenation index was found in the P50, followed by P0 and P25 groups (P0 vs. P25 and P50, P25 vs. P50; P <0.05).ConclusionProphylactic infusion of phenylephrine, especially at 25 µg/min, can effectively suppress decreases in regional cerebral blood volume and regional cerebral blood oxygenation after induction of spinal anesthesia for cesarean section.