Anaesthesia For Elective Caesarean Section Research Articles

A randomised double-blind trial of phenylephrine and metaraminol infusions for prevention of hypotension during spinal and combined spinal-epidural anaesthesia for elective caesarean section.

Prophylactic vasopressor administration is commonly recommended to reduce maternal hypotension during spinal anaesthesia for caesarean section. Metaraminol has undergone limited investigation in obstetric anaesthesia for this purpose, particularly in comparison with phenylephrine. In this multicentre, randomised, double-blind, non-inferiority study, we compared prophylactic phenylephrine or metaraminol infusions, started immediately after spinal anaesthesia, in 185 women who underwent elective caesarean section. Phenylephrine was initially infused at 50 μg.min-1 , and metaraminol at 250 μg.min-1 . The primary outcome was the difference in umbilical arterial pH between groups; secondary outcomes included other neonatal acid-base measures, and maternal haemodynamic changes. The mean (SD) umbilical arterial pH was 7.28 (0.06) in the phenylephrine group vs. 7.31 (0.04) in the metaraminol group (p = 0.0002). The estimated mean (95%CI) pH difference of 0.03 (0.01-0.04) was above the pre-determined lower boundary of clinical non-inferiority, and also met the criterion for superiority. Umbilical artery lactate concentration was 2.8 (1.2) mmol.l-1 in the phenylephrine group vs. 2.3 (0.7) mmol.l-1 in the metaraminol group (p = 0.0018). Apgar scores did not significantly differ between groups. There was a higher incidence of hypotension, defined as systolic arterial pressure < 90% baseline, in the phenylephrine group; there was a higher incidence of hypertension and severe hypertension (systolic arterial pressure > 110% and > 120% baseline, respectively) in the metaraminol group. There was no significant difference between groups in the incidence of nausea, vomiting or maternal bradycardia. We conclude that, when used as an infusion to prevent hypotension after spinal anaesthesia for elective caesarean section, metaraminol is at least non-inferior to phenylephrine with respect to neonatal acid-base outcomes.

Bolus administration of intravenous lidocaine reduces pain after an elective caesarean section: Findings from a randomised, double-blind, placebo-controlled trial

We conducted a randomised double-blind, placebo-controlled trial to assess whether a bolus dose of lidocaine during the induction of general anaesthesia would reduce postoperative pain over 24 h. Level of satisfaction with pain control at 48 h after surgery and Apgar score were also examined. A total of 100 women aged 20–35 years, who were candidates for elective caesarean section (CS) were randomised to receive either 1.5 mg/kg lidocaine or placebo during the induction of general anaesthesia. Results showed that lidocaine decreased pain intensity over 24 h after surgery (p < .001), and decreased postoperative morphine consumption from median (range) of 3.79 (0–9) mg in the placebo group to 0 (0–12) mg and in the lidocaine group (p <.001). Lidocaine was not associated with postoperative nausea and vomiting or any side effects in women and newborn babies. We conclude that a small bolus dose of lidocaine attenuates postoperative pain, thus reducing the requirement for opioid consumption in the postoperative period.Impact statement• With its anti-inflammatory, anti-hyperalgesic and analgesic properties, intravenous perioperative lidocaine infusion (IVLI) has been used for optimal postoperative care in different surgeries. Limited evidence suggests that IVLI may be a useful adjuvant during general anaesthesia. There is a report of a positive effect on several outcomes after surgery including postoperative pain over 24 h after laparoscopic abdominal surgery or open abdominal surgery. However, there was a paucity of information regarding the efficacy of a bolus dose of lidocaine in patients undergoing caesarean section (CS). In this randomized, placebo-controlled trial the use of a bolus dose of 1.5 mg/kg lidocaine 2%, compared with placebo, during the induction of general anaesthesia for elective CS resulted in a significant decrease in postoperative pain score as well as decreased postoperative morphine consumption over 24 h. Lidocaine use was not associated with any side effect in participants and newborns.• This study provides the first evidence that a bolus dose of lidocaine may be a safe and simple alternative therapeutic intervention for enhanced postoperative recovery in terms of pain and postoperative opioid consumption. Future studies are needed to examine pain reducing effect of perioperative bolus dose of lidocaine after CS under spinal or epidural anesthesia.

To study the efficacy of intravenous dexamethasone in prolonging the duration of spinal anesthesia in elective cesarean section

Background and Aims:Various additives have been evaluated for the purpose of enhancing quality of analgesia and prolonging duration of spinal anesthesia. This randomized, double-blind study was conducted to evaluate the efficacy of intravenous dexamethasone in spinal anesthesia.Methods:A total of sixty patients scheduled for lower segment cesarean section under spinal anesthesia were randomly allocated into two groups, group SD and group SN, including thirty patients each. All the patients received injection bupivacaine 0.5% heavy 10 mg through spinal anesthesia. Group SD received injection dexamethasone 8 mg intravenously, and group SN received injection normal saline (NS) 2 cc immediately after spinal anesthesia. Duration of sensory block, motor block, postoperative analgesia, visual analog pain scale (VAS) score, time of rescue analgesia, total analgesic requirement in the first 24 h, intra- and post-operative hemodynamics, and side effects if any were recorded. Whenever demanded rescue analgesia was given in the form of injection tramadol 100 mg.Results:The mean duration of sensory block (min) in group SD and group SN was 162.50 and 106.17, respectively which was highly significant. Similarly, time to the requirement of first rescue analgesia was prolonged in group SD (8.67 h) as compared to group SN (4.40 h). Significant changes were also seen in VAS score in postoperative period after 1 h of surgery in group SD and group SN. Duration of motor block, intra- and post-operative hemodynamic parameters were comparable in both the groups. No side effects were recorded in both the groups.Conclusion:We concluded that administration of dexamethasone 8 mg intravenously prolongs the duration of postoperative analgesia and sensory block in patients undergoing lower segment cesarean section under spinal anesthesia.

Minimum effective volume of bupivacaine in spinal anesthesia for elective cesarean section. Does it differ with height? A non-randomized parallel study

BackgroundSpinal anesthesia is the preferred anesthetic technique for elective Cesarean deliveries. Hypotension is the most common side-effect and has both maternal and neonatal consequences. This study aims to determine the minimum effective volume of hyperbaric bupivacaine 0.5% with fentanyl in 90% of parturients (MEV90) with different height groups undergoing cesarean section.Patients and MethodsParturients scheduled for elective cesarean section under spinal anesthesia were divided into 3 groups according to their height (ht), group 1 including those with height between 150 and 159 cm, group 2 with ht between 160 and 169 cm and group 3 patients with ht between 170 and 179 cm. The starting volumes were 2.5, 2.6 and 2.7 ml respectively. We identified 3 responses to the injected volume and the volume given to each parturient depends on the response of the previous one. Every patient was assessed for hemodynamics, degree of sensory and motor blocks.ResultsDemographically, all the groups were comparable. The study was completed after recruiting 201 patients. The MEV90 for group 1 was approximately 2.62 ml (95% CI, 2.59–2.65 ml), 2.76 ml for group 2 (95% CI, 2.73–2.77 ml) and 2.80 for group 3 (95% CI, 2.76–2.81 ml). None of the babies had an Apgar score below 7 at 1 and 5 min after birth in the 3 groups.ConclusionThe volumes of hyperbaric 0.5% bupivacaine with fentanyl which produced effective spinal block in 90% of parturients undergoing cesarean deliveries were 2.62, 2.76 and 2.8 ml in the 3 different height groups respectively.

Efficacy of different size Quincke spinal needles in reduction of incidence of Post-Dural Puncture Headache (PDPH) in Caesarean Section (CS). Randomized controlled study

BackgroundRegional analgesia first introduced in clinical practice by the German surgeon Karl August Bier (1898). Spinal, epidural or combined spinal and epidural anaesthesia became the first line of choice in obstetric surgery. PDPH was found to be more frequent after Caesarean Section in young parturients. Also PDPH is related to CSF leakage from the subarachnoid space.ObjectivesThis prospective, double blinded, randomized study compares the frequency of PDPH following spinal anaesthesia for CS and technique difficulty with 22G, 25G and 29G Quincke needles.MethodsOne hundred and eighty ASA I and II full term pregnant females aged 20–40 years, scheduled to receive spinal anaesthesia for elective CS, were randomly divided into three equal groups (n = 60 each). Each group received spinal anaesthesia with 22G (GI), 25G (GII) and 29G (GIII) Quincke needle. Difficulty in localizing the subarachnoid space and time taken to administer spinal anaesthesia were noted. Post-operatively; incidence, onset, site, duration and severity of headache were also studied.ResultsPDPH occurred in 19 patients (31.7%) in GI, 7 patients (11.7%) in GII and 0 patients in GIII. However, the time taken to get CSF from onset of needle insertion was significantly different between the three groups; {13.6(5.2), 28.7(11.1) and 113.5(27.4) sec. mean(SD) in GI, GII and GIII} respectively. The duration of local anaesthetic injection through the spinal needles was significantly different between the three groups; {9.3(0.6), 15.3(1.2) and 37.4(1.7) sec. mean(SD); GI, GII and GIII} respectively. Also time to reach T4 block was significantly longer in GIII when compared with other groups; {5.7(0.8), 5.7(1.1) and 8.0(0.7) min. mean(SD); GI, GII and GIII} respectively. P < 0.05. Conclusion: Spinal anaesthesia with a 29G needle reduced the incidence of PDPH in elective CS to 0%. However, it is significantly more time consuming to give spinal anaesthesia with 29G needle than with the other needles.

Safety and effectiveness of alveolar recruitment maneuvers and positive end-expiratory pressure during general anesthesia for cesarean section: a prospective, randomized trial

IntroductionDuring cesarean section, the supine position reduces functional residual capacity and worsens lung compliance. We tested the hypothesis that alveolar recruitment maneuvers and positive end-expiratory pressure improve lung compliance in women undergoing general anesthesia for cesarean section. MethodsNinety women undergoing cesarean section were randomly assigned to one of two groups in a prospective, double-blind trial. In the alveolar recruitment maneuver group, pressure-control ventilation was used and inspiratory time was increased to 50% after delivery; positive end-expiratory pressure was increased to 20cmH2O and peak airway inspiratory pressure gradually increased to 45–50cmH2O. Volume-control ventilation was then used with low tidal volumes (6mL/kg) and positive end-expiratory pressure was reduced stepwise to 8cmH2O. In the control group, alveolar recruitment maneuvers were not used. Data were collected before and 3, 10 and 20min after the alveolar recruitment maneuver, before extubation and postoperatively at 10 and 20min. ResultsDynamic compliance, peak airway inspiratory pressure, PaO2 and PaO2/FiO2 were significantly different in the alveolar recruitment maneuver group compared to controls at all time points during surgery except at baseline. Oxygen saturation was significantly greater in the alveolar recruitment maneuver group at 10 and 20min and before extubation. Dynamic compliance was 29.7–42.5% higher and peak airway inspiratory pressure 3.6–10.2% lower in the alveolar recruitment maneuver group compared to controls. The PaO2, PaO2/FiO2 and oxygen saturation were higher (9.4–12%, 10.3–11.9% and 0.4–1.3%, respectively) in the alveolar recruitment maneuver group. Postoperatively, PaO2 and oxygen saturation were significantly higher in the alveolar recruitment maneuver group compared to controls (PaO2 9.2% at 10min and 8.4% at 20min, oxygen saturation 0.8% at 10min and 1.1% at 20min). There were no significant differences in hemodynamic stability or adverse events between groups. ConclusionCompared to standard care, the alveolar recruitment maneuver with positive end-expiratory pressure and low tidal volumes appears safe and effective in improving lung compliance and both intraoperative and postoperative oxygenation in women undergoing general anesthesia for elective cesarean section.

The pupillary light reflex for predicting the risk of hypotension after spinal anaesthesia for elective caesarean section

IntroductionThe balance between the sympathetic and parasympathetic systems could be used to predict the onset of hypotension following spinal anaesthesia. The autonomic innervation of the pupil may reflect this balance. The aim of this study was to evaluate the ability of pupillometry to predict the risk of hypotension after spinal anaesthesia for caesarean section. MethodsTwo hundred patients receiving spinal anaesthesia for caesarean section were recruited. Changes in pupillary diameter, pupillary reaction latency, pupil constriction velocity and maximum and minimum pupillary diameters were measured with a pupillometer (Neurolight®, IDMed) prior to induction of spinal anaesthesia with 10mg bupivacaine and fentanyl 30μg. Hypotension was defined as a systolic blood pressure drop of > 20% compared with the baseline value. ResultsA total of 141 patients (70%) presented at least one episode of hypotension. Pupillary reaction latency can poorly predict hypotension and severe hypotension after spinal anaesthesia. The areas under the receiver-operating characteristic curves were 0.654 (95% confidence interval: 0.584–0.720, P=0.0001) and 0.633 (95% confidence interval: 0.562–0.700, P=0.004) for optimal threshold values of 223 and 231ms, respectively. In multivariate analysis, a baseline systolic blood pressure > 130mmHg (odds ratio: 1.98, P=0.04) and a PRL > 223ms (odds ratio: 3.42, P=0.0002) were independently associated with the risk of spinal anaesthesia-related hypotension. ConclusionFollowing spinal anaesthesia in patients undergoing caesarean section, though the predictive capacity pupillary reaction latency for the onset of hypotension and severe hypotension is poor, it is nevertheless the strongest predictor of hypotension identified in our study.

Prophylactic ondansetron for prevention of maternal hypotension following spinal anesthesia in women undergoing cesarean section

Background: Spinal anesthesia induced hypotension is a common problem that occurs in the parturient undergoing elective cesarean section. Prevention of maternal hypotension (MH) could improve safety of spinal anesthesia and satisfaction for both the patient and anesthesia provider. Many techniques have been researched and utilized to reduce the occurrence of hypotension; nevertheless, no single intervention has surfaced to be entirely successful. Ondansetron, a 5-hydroxytryptamine-3 (5-HT3 or serotonin) receptor antagonist, is a commonly used antiemetic medication in obstetric anesthesia for prevention or treatment of nausea and vomiting but its use for prevention of hypotension is still in question. Objective: The objective of this systematic review was to synthesize the best available evidence on the clinical effectiveness of prophylactic ondansetron on diminishing hypotension following spinal anesthesia. Methods: Types of participants Patients irrespective of ethnicity and age undergoing spinal anesthesia for elective cesarean section who received intravenous prophylactic ondansetron or placebo prior to subarachnoid cannulation and anesthetic administration. Types of intervention(s)/phenomena of interest The review included studies that explored the use of ondansetron to a control group and reported frequency of hypotension. Types of outcomes The review considered studies that reported the incidence of hypotension as defined by the researchers and met the hypotension definition detailed in this review: decrease in systolic, diastolic or mean arterial blood pressure more than 20% compared to baseline, or a systolic measurement less than 90 mmHg or diastolic less than 60 mmHg. Search strategy A comprehensive search strategy was utilized to find both published and unpublished studies in the English language, due to resource constraints, from January 1980 through July 2015. A search of PubMed, EMBASE, Cochrane Central Trials Register, Web of Science, Wiley online Library, TRIP, [email protected], and ScienceDirect was carried out. New York Academy of Medicine Grey Literature Report, AHRQ, and ProQuest Dissertations and Theses were utilized for unpublished research. Methodological quality Two independent reviewers utilized the Joanna Briggs Institute Critical Appraisal Checklist for Randomized Controlled Trials. Data extraction Incidence of hypotension for both the ondansetron and placebo groups was extracted from the studies using the Joanna Briggs Institute Data Extraction Form from JBI-MAStARI. Data Synthesis DerSimonian and Laird random and fixed effects model using the CMA software was applied to the extracted quantitative data after it was pooled for meta-analysis. Standard chi-square test was used to assess for heterogeneity. Results: Two common doses (4 mg and 8 mg) of ondansetron surfaced from the nine included studies in this systemic review. Pooling of data from 7 RCTs indicated a statistically significant decrease in hypotension, p = 0.002 and relative risk (RR) of 0.494, (95% CI 0.314 to 0.779) in the parturient that received 4 mg of ondansetron. Data pooled from 4 RCTs indicated no statistically significant decrease in hypotension when 8 mg of ondansetron was administered, p = 0.753 and RR of 0.964 (95% CI 0.767 to 1.212). Discussion/Conclusion: Administration of ondansetron (4 mg) prior to spinal anesthesia can be recommended to help prevent the incidence of hypotension in the pregnant patient undergoing elective cesarean section. Implications for practice Anesthesia professionals utilizing ondansetron (4 mg) will realize a reduction in spinal anesthesia induced hypotension in the parturient for an elective cesarean section. This may impact patient outcomes and current practices by decreasing the adverse events associated with hypotension in this population and satisfaction in both patient and anesthesia provider.

Administration of Vasoconstrictor, But Not Volume Expander Prevents Maternal Hypotension During Spinal-Epidural Anesthesia For Elective Cesarean Section

Administration of Vasoconstrictor, But Not Volume Expander Prevents Maternal Hypotension During Spinal-Epidural Anesthesia For Elective Cesarean Section

Relation between fentanyl dose and patient state index during spinal anesthesia for elective cesarean section

BackgroundIn spinal anesthesia for cesarean section, the addition of fentanyl to the local anesthetic has been reported to improve perioperative analgesia. However, there is only limited knowledge on sedative effects of the added fentanyl. We examined whether the patient state index® (PSI) can detect and present the light sedated level with patients undergoing cesarean section.FindingsWe measured respiratory rate (RR), SpO2, and PSI values. Between child delivery and the completion of the operation, the proportions of time with the PSI values <90 and 80 were calculated. RR <8 breaths/min or SpO2 <95 % was defined as respiratory depression. Respiratory depression was not observed in any patient. At fentanyl doses of 10, 15, and 20 μg, the proportions of time with the PSI <90 were 14.5 ± 20.8, 49.4 ± 35.3, and 71.1 ± 22.9 %, respectively (P < 0.01). There were significant differences between 10 and 15 μg (P < 0.05), and 10 and 20 μg (P < 0.01). Similarly, the proportions of time with the PSI values <80 were 0.5 ± 1.8, 21.1 ± 24.1, and 31.8 ± 32.2 %, respectively (P < 0.05). There was a significant difference between 10 and 20 μg (P < 0.05).ConclusionsThe PSI values decreased in a dose-dependent manner with increasing dose of fentanyl, but no respiratory depression was observed. The PSI values decreased to less than 90, when fentanyl was administered more than 15 μg. Furthermore, the PSI values decreased to less than 80, when fentanyl was administered 20 μg.

Prediction of hypotension during spinal anesthesia for elective cesarean section by altered heart rate variability induced by postural change

BackgroundMaternal hypotension is a common complication during cesarean section performed under spinal anesthesia. Changes in maternal heart rate with postural changes or values of heart rate variability have been reported to predict hypotension. Therefore, we hypothesized that changes in heart rate variability due to postural changes can predict hypotension. MethodsA total of 45 women scheduled to undergo cesarean section under spinal anesthesia were enrolled. A postural change test was performed the day before cesarean section. The ratio of the power of low and high frequency components contributing to heart rate variability was assessed in the order of supine, left lateral, and supine. Patients who exhibited a ⩾two-fold increase in the low-to-high frequency ratio when moving to supine from the lateral position were assigned to the postural change test-positive group. ResultsAccording to the findings of the postural change test, patients were assigned to the positive (n=22) and negative (n=23) groups, respectively. Hypotension occurred in 35/45 patients, of whom 21 (60%) were in the positive group and 14 (40%) were in the negative group. The incidence of hypotension was greater in the positive group (P<0.01). The total dose of ephedrine was greater in the positive group (15±11 vs. 7±7mg, P=0.005). The area under the receiver operating characteristic curve was 0.76 for the postural change test as a predictor of hypotension. ConclusionThe postural change test with heart rate variability analysis may be used to predict the risk of hypotension during spinal anesthesia for cesarean section.

Hyperbaric versus isobaric bupivacaine for spinal anaesthesia for caesarean section.

Bupivacaine is an amide local anaesthetic used in hyperbaric and isobaric forms. These are administered intrathecally into the spine to provide regional anaesthesia for caesarean section. Several trials have compared hyperbaric and isobaric bupivacaine but none have conclusively shown the benefit of either. This review was first published in 2013 and updated in 2016. Our objectives were to:1. Determine the effectiveness of hyperbaric bupivacaine compared to isobaric bupivacaine for spinal anaesthesia in women undergoing caesarean section;2. Determine the safety of hyperbaric bupivacaine compared to isobaric bupivacaine for spinal anaesthesia in women undergoing caesarean section. We originally searched the following databases to January 2011: CENTRAL, MEDLINE and Embase.For this update, we reran our search in the above databases from January 2011 to March 2016; two studies are awaiting a response from authors for assessment and will be dealt with when we next update the review.We imposed no language restriction. We included all randomized controlled trials (RCTs) involving parturients undergoing spinal anaesthesia for elective caesarean section that compared the use of hyperbaric with isobaric bupivacaine. Two authors independently extracted the data. The data that were extracted included the number of events and the sample sizes in both the intervention and control groups. For continuous outcomes, we extracted mean and standard deviation.We reported odds ratios (ORs) and risk ratios (RRs) for binary outcomes, and mean differences (MDs) for continuous outcomes. We included three new RCTs in this update, which now comprises 10 studies with a total of 614 participants. We judged most trials as having uncertain risk of bias regarding randomization. Other than this, the overall risk of bias was low. Most included trials had small sample sizes. All of the trials assessed the primary outcome of conversion to general anaesthesia. Ten trials comparing anaesthesia performed with hyperbaric and isobaric bupivacaine failed to show any difference in need for conversion to general anaesthesia (RR 0.33, 95% CI 0.09 to 1.17, 614 participants, very low quality of evidence). Nine trials also failed to show a difference in the need for supplemental analgesics (RR 0.61, 95% CI 0.26 to 1.41, 554 participants, very low quality of evidence). Four trials comparing requirement for ephedrine did not show any difference (RR 0.89, 95% CI 0.57 to 1.38, 256 participants, very low quality of evidence). Seven trials did not provide convincing evidence of difference in nausea and vomiting (RR 0.99, 95% CI 0.57 to 1.72, 433 participants, low quality of evidence). Three trials failed to show a difference in headache (OR 1.82, 95% CI 0.47 to 6.99, 234 participants, low quality of evidence). Two trials showed that the time until sensory block to the thoracic 4th (T4) spinal level was shorter with hyperbaric bupivacaine (MD -1.06 minutes, 95% CI -1.80 to -0.31, 128 participants, moderate quality of evidence). Six trials showed no difference in the amount of ephedrine used (RR 0.23, 95% CI -1.65 to 2.12, 386 participants, moderate quality of evidence). Three trials failed to show any difference in high block (RR 0.88, 95% CI 0.16 to 4.90, 205 participants). Data are limited for some of the outcomes. Reporting of the included trials is less than optimal. For these reasons the overall quality of evidence is low or very low for most of the outcomes, based on the GRADE method of assessment. This review found that intrathecal hyperbaric bupivacaine had a more rapid onset of sensory blockade at the 4th thoracic vertebra (T4) level than isobaric bupivacaine. Hower, despite incorporating more data in the analysis, we found little evidence that the need for conversion to general anaesthesia and supplemental analgesia differed between the hyperbaric or isobaric bupivacaine groups. This is mainly due to the rarity of these outcomes, variability in the dose, use of adjuvant drugs and differences in the technique used for regional anaesthesia. There were no differences in the adverse effects studied. Any possible advantage of hyperbaric bupivacaine needs to be confirmed in larger randomized trials. In future research, criteria for conversion to general anaesthesia need to be defined objectively and applied uniformly.

Crystalloid Prehydration versus Cohydration for Prevention Of Hypotension during Spinal Anaesthesia For Elective Caesarean Section

Background: Hypotension during spinal anesthesia is a well known problem.Traditionally prehydration before the spinal block is one of the strategies used toprevent hypotension. Recently the efficacy of prehydration has been questioned.Objective: To compare the incidence of hypotension and vasopressor requirementwith crystalloid prehydration and cohydration in women undergoing electivecaesarean section.Methods: The prospective randomized study was carried out in 120 patients undergoing elective lower segment caesarian section under spinal anaesthesia. They were allocated to receive either 20ml/kg of lactated ringer’s solution during 20 minutes prior to induction of spinal anaesthesia (prehydration group) or equivalent volume by rapid infusion immediately after administration of the local anaesthetic intrathecally (cohydration group). Vitals, incidence of hypotension, dose of mephenteramine used and complications were recorded.Results: Hypotension occurred in 19 of 60 patients (31.6%) in prehydration group whereas in 15 of 60 patients (25.0%) in cohydration group, but the difference was not significant (P&gt;0.05). But significantly less patients in the cohydration group (2 of 60 vs 18 of 60) developed hypotension and required vasopressor therapy before delivery of baby (P&lt;0.001). Similarly, parturients in the cohydration group required significantly less dose of mephenteramine for treatment of hypotension.Conclusion: Rapid crystalloid administration after the induction of spinal anaesthesia for elective caesarean section prevents hypotension before delivery and decreases vasopressorrequirement.Health Renaissance 2014;12(3): 190-196

Effect of Glycopyrolate on Nausea, Vomiting and Neonatal Outcome During Spinal Anaesthesia for Elective Caesarean Section

Introduction: Glycopyrrolate has better antisialagogue effect and does not cross placental barrier; thereby when given immediately before subarachnoid block for elective caesarean section might reduce incidence and severity of nausea and vomiting without affecting neonatal outcome. Methods: In a prospective randomized double blind placebo controlled study, sixty ASA PS I and II patients undergoing elective caesarean section at term were assigned to receive 1 ml of Inj Normal Saline IV or 1 ml (0.2 mg) of Inj Glycopyrrolate. After subarachnoid block, nausea score was assessed every 5 min during intraoperative period (before and after cord clamping), every 30 min for initial 4 hour and every 6 hour till 24 hr after surgery. Vomiting was assessed as mild (&lt;2 episodes) and severe (&gt;2 episodes). Apgar scores were recorded 1 min and 5 min after birth. Results:The severity of nausea was less in glycopyrrolate group than in normal saline group during intraoperative period (p value ≤ 0.001) and postoperative period (p value 0.31). During intraoperative and postoperative period, the severity of vomiting was mild in normal saline group where as in glycopyrrolate group there was no vomiting. The incidence of nausea was low in the parturient who received IV glycopyrrolate than those who received normal saline 3.33% vs. 60% (p value &lt;0.001) during intraoperative period particularly after cord clamping 0 vs. 53.33% (p value &lt;0.001). There was also reduced incidence of vomiting 0 vs. 13.33% (p value 0.03) during intraoperative period after cord clamping. All neonates born to the mother participating in the study had satisfactory Apgar score. Conclusions: Injection Glycopyrrolate when given as an IV premedication during spinal anaesthesia for elective caesarean section could reduce both the severity and incidence of nausea and vomiting during intraoperative period particularly after cord clamping without affecting neonatal outcome and causing side effects.

Efficacy of Intravenous Ondansetron Versus Ephedrine as Prophylactic Against Hypotension and Bradycardia Following Spinal Anaesthesia in Elective Caesarean Section - A Comparative Study

Background: The pathophysiological mechanism involved in the occurrence of hypotension and bradycardia following central neuroaxial blockade is peripheral vasodilatation, parasympathetic dominance and increased baroreceptor activity.Current studies correlate these haemodynamic changes with activation of a phenomenon naming Bezold-Jarisch reflex (BJR). 5-Hydroxytryptamine-3 is an important factor associated with inducing BJR and Ondansetron antagonizes the induction of BJR. Objective: To compare the efficacy between ondansetron and ephedrine as prophylactic against spinal anaesthesia induced hypotension and bradycardia. Method: 120 mothers of ASA grade I and II scheduled for elective caesarean section under spinal anaesthesia were selected and randomized into two equal groups naming Group A(n=60) and Group B (n=60). Group A received Ondansetron IV (0.1mg/kg body wt) and group B Ephedrine (0.15 mg/kg body wt) 5 minutes prior spinal anaesthesia. Data were recorded before and just after anaesthesia and at two minutes intervals up to 10th minute followed by five minutes intervals until the end of surgery. Results analyzed using unpaired t-test. A “P” value &lt; 0.05 was considered statistically significant. Result: Group A showed slight but statistically significant higher heart rate than after Group B at 10th min and 15th min (P=0.001). Statistically significant higher values of MAP in Group A found up to the 15th minute of perioperative period. Rescue medications for hypotension were significantly higher in Ephedrine group. Shivering is common for both groups ,whereas nausea and vomiting is significantly less in group A. Conclusion: Ondansetron and Ephedrine has potential role to prevent spinal anaesthesia induced hypotension and bradycardia but Ondansetron shows better efficacy. Ondansetron also plays important role in prevention nausea and vomiting. JBSA 2016; 29(2): 67-74

Transient aphonia following spinal anesthesia in a parturient: A case report

Spinal anesthesia is the preferred technique of administering anesthesia for elective cesarean section (CS). Hypotension, failed spinal anesthesia, postdural-puncture headache, cauda equina syndrome are a few complications that may occur but neurological complications particularly aphonia are quite rare. The use of lipophilic opioids as adjuvants with local anesthetics are considered as culprit but the exact mechanism remains unidentified. We report such presentation in our patient and discuss the likely cause.

Study on the effect of dexmedetomidine in reducing hemodynamic responses to general anesthesia for elective cesarean section in patients with pre-eclampsia

Background Because of the effect of dexmedetomidine (DEX) in hemodynamic stability, it was started as a sedative before and during surgical and other procedures in nonintubated adult and pediatric patients. Since 2009 DEX has been successfully used in laboring parturients. It provides maternal hemodynamic stability, anxiolysis, and stimulation of uterine contractions. Studies have shown that DEX has high placental retention and does not cross the placenta, and there is lower incidence of fetal bradycardia. We hypothesized that dexmedetomidine would be effective in reducing the maternal hemodynamic responses to elective cesarean section in pre-eclamptic patients without adverse neonatal effects. Patients and methods The present study included 40 parturients with pre-eclampsia who were planned for elective cesarean delivery for different indications under general anesthesia. The patients were divided in two groups and they were selected randomly to receive either fentanyl (control group) or 0.4 μg/kg/h intravenous DEX 10 min before induction (n = 20 per group). Changes in maternal heart rate, mean blood pressure, time from induction to delivery, the full anesthesia time, uterine contraction after placental delivery, umbilical blood gas parameters, and sedation scores were recorded. Results The heart rate in the DEX group was lower than that in the fentanyl group. Patients in the dexmedetomidine group had statistically significantly lower change in mean arterial blood pressure, whereas patients taking fentanyl showed much higher mean arterial blood pressure from induction until 5 min after extubation. Further, the dexmedetomidine group showed greater uterine contraction, but there was no difference between the two groups in terms of Apgar score at 1 and 5 min, NACS below 35, and umbilical blood gas analysis. Conclusion It can be concluded that DEX is effective in pre-eclamptic patients undergoing elective cesarean as it stabilizes the maternal hemodynamic parameters with negligible effect on the fetus.

Comparison of spinal anesthesia dosage based on height and weight versus height alone in patients undergoing elective cesarean section.

BackgroundSpinal anesthesia with bupivacaine, typically used for elective and emergency cesarean section, is associated with a significant incidence of hypotension resulting from sympathetic blockade. A variety of dosing regimens have been used to administer spinal anesthesia for cesarean section. The objective of this study was to compare the incidence of hypotension following two different fixed dosing regimens.MethodsThis was a randomized double-blind clinical trial with a two-sided design, 5% significance level and 80% power. After approval of the hospital ethics review committee, 60 patients were divided randomly into two groups. In one group, the local anesthetic dose was adjusted according to height and weight, and in the other, the dose was adjusted according to height only.ResultsSixty women with a singleton pregnancy were included. Of the factors that could affect dose and blood pressure, including age, weight, height, and dose, only height differed between the groups. Mean heart rate was similar between the groups. Hypotension was significantly more frequent with dosage based on height alone than with two-factor dose calculation (56.7% vs. 26.7%; P = 0.018).ConclusionsAdjusting the dose of isobaric bupivacaine to a patient's height and weight provides adequate anesthesia for elective cesarean section and is associated with a decreased incidence and severity of maternal hypotension and less use of ephedrine.

Comparative evaluation of co-loading versus preloading for prevention of post-spinal hypotension in elective caesarean section

Aims and Objectives: The aim of the present study was to study the effectiveness of co-loading of crystalloid over preloading of crystalloid in prevention of maternal hypotension during spinal anaesthesia for elective caesarean section. Material and Methods: Hundred parturients aged 18-35 yrs undergoing elective caesarean section were randomly allocated in two groups of fifty each. Group P received preload of 20ml/kg of ringer’s lactate solution over a period of 20 minutes before spinal anaesthesia, while Group C received co-load of 20ml/Kg of ringer’s lactate solution at the maximal possible rate by pressurized giving set at the time of administration of spinal anaesthesia. Both the groups received spinal anaesthesia using 2ml of 0.5% hyperbaric bupivacaine at L3-4 level with 23G Quinke’s spinal needle. Blood pressure measurements were recorded in both the groups at 2min interval from the start of the regional block for the first 10 min and then at 5min interval till 30min and thereafter every 15min till the end of surgery. Similarly other parameters like heart rate, SPO2, maximum level of sensory block and APGAR scores were also recorded. Statistical Analysis: Chi-square test was used to find the significance of study parameters on categorical scale between groups. Z test was used to find the significance of study parameters on continuous scale between two groups (intergroup analysis) on metric parameters. Significance was assessed at 5 % level of significance. Any p – value less than 0.05 (p

Prophylactic intravenous paracetamol for prevention of shivering after general anesthesia in elective cesarean section

Background: Postoperative shivering is an important common complication after general anesthesia. This may lead to dissatisfaction and a sense of discomfort, especially in parturients undergoing cesarean section. In addition to warming, many drugs have been investigated for prevention of shivering. The aim of this study was to evaluate the efficacy of intravenous paracetamol for prevention of shivering after general anesthesia in cesarean section. Materials and Methods: In this prospective randomized double-blind controlled clinical trial, 110 pregnant women, physical Status I or II, based on the classification of American Society of Anesthesiologists (ASA), aged 18–40 years, who were scheduled for elective cesarean section under general anesthesia were included in the study. They were randomly divided into two groups of 55 each. One group received 100 ml normal saline, and another group received 1 g of paracetamol in 100 ml normal saline intravenously, 15 min after the delivery of the baby. The anesthesia technique was similar in both the groups. Tympanic membrane temperature was measured before and after the induction of anesthesia and every 15 min till the end of recovery from anesthesia. Postanesthetic shivering was graded on a scale of 0 to 4; if the score was more than 2, it was treated with 25 mg pethedine. Vital signs and side effects were recorded during the surgery and recovery period. Results: There were no significant differences between the two groups regarding age, weight, height, and duration of surgery (P > 0.05). Shivering was seen in 5 parturients (9.1%) in paracetamol group (group A) and 28 parturients (50.9%) in the saline group (group N). On a scale of 0 to 4, shivering was of lower intensity in paracetamol group compared to the saline group (P 0.05). There was no difference in the incidence of hypotension, nausea, and vomiting among the two groups (P > 0.05). Conclusion: The prophylactic use of intravenous paracetamol during surgery is effective for the prevention of postoperative shivering.