Spinal Anaesthesia For Caesarean Section Research Articles

Efficacy of ondansetron for spinal anesthesia during cesarean section: a meta-analysis of randomized trials.

ObjectiveTo investigate the efficacy and safety of ondansetron during cesarean section under spinal anesthesia.MethodsWe sought randomized controlled trials (RCTs) on ondansetron during spinal anesthesia for cesarean section in The Cochrane Library, PubMed, MEDLINE, and Web of Science from their inception to September 2016.ResultsAltogether, 21 RCTs were included in this study. Meta-analysis showed that the ondansetron group had a lower incidence of nausea/vomiting and bradycardia than the placebo group during cesarean section under spinal anesthesia [relative risk (RR) = 0.43, 95% confidence interval (CI) (0.36, 0.51) and RR = 0.45, 95% CI (0.26, 0.80), respectively]. There were no significant differences in the incidences of pruritus, hypotension, or shivering during cesarean section under spinal anesthesia [RR = 0.92, 95% CI (0.83, 1.02); RR = 0.72 (0.50, 1.06), 95% CI (0.50, 1.06); and RR = 0.89, 95% CI (0.71, 1.11), respectively].ConclusionOndansetron effectively reduces the incidences of nausea/vomiting and bradycardia under spinal anesthesia during cesarean section.

Techniques for preventing hypotension during spinal anaesthesia for caesarean section.

Techniques for preventing hypotension during spinal anaesthesia for caesarean section.

A Comparison of Crystalloid Preloading and Co-Loading to Prevent Spinal Anaesthesia Induced Hypotension in Caesarean Section

Background: Preloading of crystalloid is a traditional practice to prevent spinal anaesthesia inducedhypotension. But co-loading seems to be more physiological and rational approach as effect was achievedduring the time of spinal anaesthesia. Aims: To compare the efficacy of crystalloid preloading and co-loading for prevention of hypotensionduring spinal anaesthesia in caesarean section. Methods: This study was conducted in Department of Anaesthesia, Analgesia and Critical Care, CombinedMilitary Hospital (CMH), Chittagong. Study was carried out over a period of six months from January toJune 2017. Total 80 patients (40 in each group) were included in this study. Patients with ASA grade 1& 2, aged 18-40 years were included. Patients with complicated pregnancy or failed spinal were excluded.Group-P (Preload group) received 15ml/kg Crystalloid solution (Hartmann’s solution/lactated Ringer’ssolution), 20 min before administration of spinal anaesthesia. Group-C (Co-load group) received bolus of15 ml/kg Crystalloid solution (Hartmann’s solution /lactated Ringer’s solution) at time of administrationof spinal anaesthesia. Blood pressure was recorded at 1, 2, 3, 5 & 10 minutes. Patients received vasopressorswhen mean blood pressure reduced below 20 mm of Hg or systolic blood pressure dropped below 90mmHg. Results: Total study population was 80 patients underwent caesarean section. Mean age of the patientswas 28.36±5.08 years and 28.25±5.06 years in group-P and C, respectively. Overall hypotension was notedin 23 patients (57.5%) of group-P and 19 patients (47.5%) of group-C. The difference between two groupswas statistically insignificant (p=0.241). After induction of spinal anaesthesia at 1 minute hypotensionwas noted in 7 patients (17.5%) of group-P and in 13 patients (32.5%) of group-C, at 2 minutes in 21patients (52.5%) of group-P and in 22 patients (55%) of group-C, at 3 minutes in 23 patients (57.5%) ofgroup-P and in 24 patients (60.0%) of group-C, at 5 minutes in 17 patients (42.5%) of group-P and in 19patients (47.5%) of group-C, at 10 minutes in 13 patients (32.5%) of group-P and in 7 patients (17.5%) ofgroup-C hypotension was developed. Conclusion: Both preloading and co-loading with 15 ml/kg of Crystalloid solution (Hartmann’s solution/lactated Ringer’s solution) when used alone, are ineffective for the prevention of hypotension in caesareansection receiving spinal anaesthesia. We recommend frequent monitoring of maternal blood pressure andprompt treatment of maternal hypotension with vasopressors for better neonatal outcomes. JBSA 2017; 30(2): 83-89

Beneficial effects of the addition of intrathecal fentanyl to bupivacaine for spinal anesthesia in cesarean section

Beneficial effects of the addition of intrathecal fentanyl to bupivacaine for spinal anesthesia in cesarean section

Comparison of the Effects of Intrathecal Meperidine and Morphine on Incidence and Intensity of Shivering After Caesarean Sections Under Spinal Anesthesia: A Randomized Controlled Trial

Background: Shivering is a common unpleasant problem in parturients undergoing cesarean section under spinal anesthesia. Therefore, attempts for solving this problem are rational. Objectives: To evaluate and compare the effect of intrathecal meperidine with morphine on the incidence and intensity of shivering and other side-effects during delivery under spinal anesthesia. Methods: In a double blind randomized controlled trial, 90 parturient women who were scheduled for elective cesarean delivery under spinal anesthesia were selected conveniently and randomly divided in 3 groups at the Besat hospital, which is a tertiary referral hospital in Sanandaj, Iran, from March to October 2013. Spinal anesthesia was applied using 12.5 mg of hyperbaric bupivacaine 0.5% combined with 10 mg meperidine in group P (n = 30), 12.5 mg of hyperbaric bupivacaine 0.5% combined with 0.2 mg morphine in group M (n = 30), and 12.5 mg of hyperbaric bupivacaine 0.5% combined with 0.5 mL saline in group S (n = 30). Results: Incidence of shivering in the meperidine group (6.7%) was significantly lower than the morphine (40%) and control groups (67.7%, P = 0.0001). The intensity of shivering in the meperidine group (0.13) was significantly lower than the morphine (0.73) and control groups (1.43, P = 0.001). There was no clinically significant difference in anesthesia’s side effects between the 3 groups. Conclusions: According to the study results, adding either meperidine or morphine to hyperbaric bupivacaine during spinal anesthesia for cesarean section decreases the incidence and severity of shivering without increasing the side effects. However, intrathechal meperidine is superior for this purpose.

Observation of the pulse oximeter trace to estimate systolic blood pressure during spinal anaesthesia for Caesarean section: the effect of body mass index

Background: The estimation of systolic blood pressure by disappearance and reappearance of the pulse oximeter trace during cuff inflation and deflation was compared with non-invasive blood pressure (NIBP) measurement, across the range of body mass index (BMI), during spinal anaesthesia for Caesarean section.Methods: Seventy-five parturients were recruited, with BMI of 40 kg/m2 ((morbidly obese, Group 3). A non-invasive blood pressure monitor was used with the pulse oximeter probe on the ipsilateral arm. Estimations were done before induction and 5 min after induction of spinal anaesthesia, during cuff inflation and deflation. Bland and Altman analysis was performed and the concordance correlation coefficient (r) estimated.Results: For estimation of systolic blood pressure during cuff inflation under spinal anaesthesia in Groups 1, 2 and 3: r = 0.57, 0.74 and 0.91; bias = –0.4, –2.9 and 0.8 mmHg, and limits of agreement = –27.7 to 26.9, –27.7 to 21.9, and –15.9 to 17....

Effect of General Anesthesia versus Spinal Anesthesia in Cesarean Section on Regain of Gastrointestinal Motility

Background: cesarean section is a common major hospital surgical procedure performed nowadays. One of the most common postoperative complications is postoperative gastrointestinal paralysis (Ileus) that must be minimized due to its possible serious consequences. Objectives: this study aims to compare the time to regain intestinal motility after general anesthesia versus spinal anesthesia for cesarean section. Methods: this prospective controlled study was carried out at Ain Shams University Maternity Hospital during the period from April 2016 to June 2017 after approval of the hospital health ethical committee. It included 150 patients who had C.S and they were subdivided into 2 groups according to a randomization scale (spinal versus general). Results: spinal anesthesia results in a quicker return of bowel activity after cesarean section, decreased hospital stay and less use of post-operative opioids than general anesthesia. Recommendations: we recommend the use of spinal anesthesia for cesarean section especially if there's no contraindication for that.

The use of tenoxicam to prevent symptoms of discomfort induced by vagotonia during uterus manipulation in cesarean sections.

Purpose:Symptoms such as nausea, vomiting, tightness of the chest, bradycardia, and shoulder or abdominal discomfort, caused by vagotonia occurring during uterus manipulation, have concerned healthcare professionals for some time. Patients sometimes report these symptoms when undergoing spinal anesthesia for cesarean sections (CSs). We designed a prospective, double-blind study to investigate the effectiveness of tenoxicam in preventing these symptoms of discomfort.Methods:A total of 105 American Society of Anesthesiologists (ASA) class I-II nulliparous pregnant women, who were scheduled for a CS, were enrolled into this prospective, double-blind study. Spinal anesthesia was conducted to reach a peak dermatome level of no more than T3. The 100 patients were randomly divided into 2 groups having completed study course: Group T (N = 50) received a 20 mg dose of tenoxicam in 5 mL of normal saline (NS) immediately after skin incision and Group N (N = 50) only received 5 mL NS. The incidence and severity of the symptoms experienced by the patients were recorded by a nurse anesthetist who was blinded to the injection regimen the patients were receiving. A chi-square test was used for statistical analysis t test and P < .05 was defined as significant.Results:The incidence and degree of severity of nausea and vomiting were same in both the groups. The incidence and degree of severity of bradycardia, nausea, vomiting, tightness of the chest, shoulder discomfort, and abdominal discomfort were lower in Group T than in Group N.Conclusion:Tenoxicam might theoretically block the parasympathetic vagus pathway and decrease the visceral pain or visceral-specific symptoms, alleviating the symptoms caused by vagotonia. However, the prophylactic effect of tenoxicam in reducing the incidence and severity of nausea and vomiting was not statistically significant. This could be because nausea and vomiting are not solely caused by vagotonia, but also by other mechanisms.

Management of failed spinal anaesthesia for caesarean section.

Failed spinal anaesthesia for caesarean section (CS) may be partial or complete and the subsequent discomfort is the most commonly cited cause of litigation in obstetric anaesthesia. To determine if there is a standardised approach to: (i) testing the level of block of spinal anaesthesia; and (ii) the management of failed spinal anaesthesia for CS. A structured questionnaire to ascertain the current practice of testing the level of block and management of three different scenarios of failed spinal anaesthesia was distributed to 51 government hospitals in KwaZulu-Natal, South Africa (SA). All obstetric anaes-thetic service providers, ranging from interns to specialist anaesthetists, were invited to complete the questionnaire. A total of 375 responses were received from 42 of the 51 hospitals surveyed. Specialist anaesthetists managed failure of spinal anaesthesia significantly differently than other anaesthetic service providers. Specialists were more likely to convert to a general anaesthetic (GA), while others were more likely to repeat spinal anaesthesia or administer intravenous ketamine, midazolam and opioids. Only 212 respondents (56%) tested the level of block and there was no difference between the groups with regard to the method of assessment of height (p=0.15). Non-specialists, however, accepted a significantly lower level of block, using pinprick, than specialists (p=0.027), which could lead to a higher failure rate. More than one-third of non-specialists did not consider themselves competent to perform a GA and &gt;90% of respondents agreed that a 'failed' spinal algorithm would be useful. There is a need for standardised assessment of the adequacy of spinal anaesthesia for CS in SA, as well as a failed spinal algorithm.

A case of acute discitis following spinal anaesthesia: a rarity or a tip of the iceberg?

Acute discitis, an inflammatory process of the intervertebral disc, has been reported as a rare complication of bacterial infection or chemical or mechanical irritation most commonly following spinal surgery. It may extend into the adjacent tissue and lead to grave orthopaedic and neurological consequences. Although it has been reported as an infective complication following spinal anesthesia also, its true incidence in our part of the world is not known. It may be higher than generally thought as the technique is overwhelmingly used. Further, we do not know about its awareness among anesthesia practitioners. Here we report a case of acute discitis in a young lady who presented with severe acute low back pain two weeks after spinal anesthesia for caesarean section; magnetic resonance imaging of lumbosacral spine revealed infective spondilodiscitis and she was treated with antibiotics and analgesics. The true incidence of acute infective discitis following spinal anaesthesia in our part of the world is unknown and it may be higher that thought. It can be prevented by using rigorous aseptic techniques, and anesthesia should be administered by appropriately qualified and trained personnel.

Body height and the spread of spinal anaesthesia for caesarean section: a prospective controlled trial.

No conclusive evidence exists on the effect of patient height on the spread of spinal anaesthesia. Our aim was to measure the ED50 and ED95 values of intrathecal ropivacaine in taller and shorter patients, and thus investigate the hypothesis that the spinal dose requirement in shorter patients is lower than that in taller patients undergoing caesarean section. In this study, 270 pregnant women were assigned to the taller (Group T) or shorter group (Group S) based on their heights. Subjects in both groups were further randomly assigned to one of nine subgroups based on the dosage of intrathecal isobaric ropivacaine to be administered (7, 8, 9, 10, 11, 12, 13, 14 or 15 mg respectively). The ED50 and ED95 values of ropivacaine were 9.24 mg and 13.36 mg in Group S, and 10.11 mg and 14.63 mg in Group T, with no inter-group difference (P = 0.886). There was a significant inter-group difference in the incidence of hypotension and the changes in mean arterial pressure after spinal anaesthesia using 15 mg ropivacaine. The dose of ephedrine administered in Group S was higher than that in Group T when 15 mg ropivacaine was administered (P = 0.031). The taller and shorter patients did not respond differently to modest intrathecal doses of ropivacaine. However, a larger dose of ropivacaine was associated with an increased incidence of hypotension in shorter patients compared to that in taller patients.

Comparison Between Pendant Position and Traditional Sitting Position for Successful Spinal Puncture in Spinal Anesthesia for Cesarean Section.

BackgroundSuccess of spinal anesthesia in pregnant females is strongly influenced by the position of the patient at the time of spinal insertion. Pendant position is a new position introduced to increase the intervertebral spaces. The current study aimed at comparing successful spinal puncture among the patients with pendant position in comparison with the ones with traditional sitting position for the elective caesarean section.MethodsThe current study was a non-blinded, randomized controlled trial (RCT) (registration code: NCT02753660 (ClinicalTrial.gov) on pregnant females undergoing spinal anesthesia. The participants were divided into 2 groups by the random consecutive sampling method; group A (pendant position) and group B (traditional sitting position). The successful placement of spinal needle was determined by the number of attempts, the amount of bone contact, and the time of spinal puncture. The inclusion criteria were pregnant females aged 18 to 45 years, body mass index (BMI) of 18 to 35 kg/m2, and the physical status I to III, based on American society of anesthesiologists classification (ASA).ResultsFollowing the approval of the ethical committee, 308 subjects were enrolled in the study. The rate of successful puncture on the 1st attempt of group A was significantly high (92% vs. 78%, P value = 0.001). Additionally, group A had significantly less total amount of bone contact (185 vs. 421, P value < 0.001) and shorter time for spinal puncture (9 seconds vs. 12 seconds, P value < 0.001).ConclusionsPendant position was significantly better than traditional sitting position to provide successful 1st attempt spinal puncture in pregnant females undergoing cesarean section.

Neonatal effects after vasopressor during spinal anesthesia for cesarean section: a multicenter, randomized controlled trial

BackgroundPlacental transfer of ephedrine causes fetal effects when compared with phenylephrine. This study compared their drug effects on neonatal parameters after cesarean delivery under spinal anesthesia. MethodsThree-hundred-and-fifty-four women undergoing elective cesarean delivery who needed intravenous vasopressor following spinal anesthesia were randomized into two groups. Group E received boluses of ephedrine 6mg, and Group P phenylephrine 100µg, titrated to maintain systolic blood pressure near baseline values. Neonatal heart rates at 10 and 30–45min of age, oxygen saturation and capillary blood glucose at 30min, and capillary blood lactate and urine metamphetamine were recorded. ResultsNeonatal heart rate at 10min was significantly higher (mean difference 4.0, 95%CI 0.6 to 7.3, P=0.02) in Group E versus Group P, but this was not clinically relevant. There was a linear correlation between neonatal heart rate at 10min and ephedrine dose in Group E (r2=0.29, 95%CI 0.22, 0.74, p<0.01). The decremental changes in neonatal heart rate at 10 and 30min were significantly greater in Group E. Urine metamphetamine tests were positive in 19% of 44 neonatal urine samples. Neonatal heart rates at 30min, oxygen saturation, capillary blood glucose and the incidence of tachycardia, respiratory problems or abnormal glucose, were not significantly different. ConclusionsEphedrine, compared to phenylephrine as a vasopressor during cesarean delivery, was associated with higher neonatal heart rate in the early post-birth period, but without a significant difference in clinical outcomes in uncomplicated pregnancies.

The use of vasopressors during spinal anaesthesia for caesarean section.

Hypotension remains one of the most researched subjects in obstetric anaesthesia. The purpose of this study is to review the most recent published articles on the use of vasopressors during spinal anaesthesia for caesarean section. Despite continued research indicating advantages of phenylephrine over ephedrine, practitioners in some countries continue to favour ephedrine. Recent research has continued to compare the two drugs with some work emerging on high-risk patients. Concern about reflexive bradycardia during phenylephrine use has led to consideration of alternatives. Norepinephrine which has mild β-adrenergic activity has been shown to have equivalent pressor activity but with less depressant effect on heart rate and cardiac output versus phenylephrine. Research continues to focus on methods of vasopressor administration. Prophylactic infusions of phenylephrine have been shown to be effective and may require less physician intervention compared with intermittent boluses. Automated computer-controlled systems have been further investigated using multiple agents and continuous noninvasive blood pressure monitoring. Evidence continues to support phenylephrine as the first-line vasopressor in obstetrics. However, recent research is emerging to suggest that low-dose norepinephrine may be a better alternative. Prophylactic infusions are effective and automated systems have potential for the future.

Comparative study between pre-emptive intramuscular ephedrine and intravenous ephedrine to prevent hypotension during spinal anaesthesia in caesarean section

Comparative study between pre-emptive intramuscular ephedrine and intravenous ephedrine to prevent hypotension during spinal anaesthesia in caesarean section

Duration of Motor Block With Intrathecal Ropivacaine Versus Bupivacaine for Cesarean Section: A Meta-analysis

(Int J Obstet Anesth. 2016;27:9–16) Bupivacaine is a local anesthetic commonly used for spinal anesthesia. It provides a quick onset and sustained duration of sensory block but its prolonged duration of motor block is sometimes considered a disadvantage of the drug. Ropivacaine is another local anesthetic that has been used for spinal anesthesia. It is considered to have a shorter duration of motor block. This current meta-analysis was undertaken to examine the difference in duration of motor block as well as several secondary outcomes when ropivacaine was used compared with bupivacaine for spinal anesthesia for cesarean section.

Intravenous dexmedetomidine during spinal anaesthesia for caesarean section: A meta-analysis of randomized trials.

ObjectiveTo evaluate the efficacy and safety of spinal anaesthesia using dexmedetomidine for caesarean section.MethodsPubMed, The Cochrane Library, and CNKI were searched for relevant literature.ResultsThe incidence of nausea and vomiting in the dexmedetomidine group was significantly lower than that in the control group (OR = 0.21, 95% CI: 0.12–0.35, P < 0.00001). No difference was found in the incidence of pruritus between the two groups (OR = 1.21, 95% CI: 0.36–4.09, P = 0.76).The dexmedetomidine group had a higher incidence of bradycardia than did the control group (OR = 2.20, 95% CI: 1.02–4.77, P = 0.05). The incidence of shivering in the dexmedetomidine group was significantly lower than that in the control group (OR = 0.20, 95% CI: 0.13–0.32, P < 0.00001). The incidence of hypotension was not different between the two groups (OR = 0.88, 95% CI: 0.49–1.56, P = 0.65).ConclusionDexmedetomidine can decrease the incidence of nausea, vomiting, bradycardia, and shivering with spinal anaesthesia during caesarean section.

Sequential compression pump effect on hypotension due to spinal anesthesia for cesarean section: A double blind clinical trial.

BackgroundSpinal anesthesia (SA) is a standard technique for cesarean section. Hypotension presents an incident of 80–85% after SA in pregnant women.ObjectiveTo determine the effect of intermittent pneumatic compression of lower limbs on declining spinal anesthesia induced hypotension during cesarean section.MethodsThis double-blind clinical prospective study was conducted on 76 non-laboring parturient patients, aged 18–45 years, with the American Society of Anesthesiologist physical status I or II who were scheduled for elective cesarean section at Razi Hospital, Ahvaz, Iran from December 21, 2015 to January 20, 2016. Patients were divided into treatment mechanical pump (Group M) or control group (Group C) with simple random sampling. Fetal presentation, birth weight, Apgar at 1 and 5 min, time taken for pre-hydration (min), pre-hydration to the administration of spinal anesthesia (min), initiation of spinal to the delivery (min) and total volume of intravenous fluids, total dose of ephedrine and metoclopramide were recorded. Data were analyzed by SPSS version 19, using repeated measures of ANOVA and Chi square test.ResultsHeart rate, MPA, DAP and SAP changes were significantly higher in off-pump group in the baseline and 1st-minute (p<0.05), and in the other times, this change was significantly different with control groups.ConclusionThis research showed the suitability of the use of Sequential Compression Device (SCD) in reducing hypotension after spinal anesthesia for cesarean section, also this method can cause reducing vasopressor dosage for increased blood pressure, but the approval of its effectiveness requires repetition of the study with a larger sample size.Trial registrationThe trial was registered at the Iranian Registry of Clinical Trials (http://www.irct.ir) with the IRCT ID: IRCT2015011217742N3.FundingThe authors received no financial support for the research, authorship, and/or publication of this article.

Pregnant Women Positioning in Spinal Anesthesia for Cesarean Section: Integrative Review

Objective: to analyze the scientific evidence on the positioning of pregnant women in spinal anesthesia for cesarean section.&#x0D; Method: an integrative review of the literature in the Scopus, CINAHL, LILACS and PubMed databases using the descriptors "patient positioning", "spinal anesthesia" and "obstetrics" and their synonyms "patient position" and "spinal anesthetics".&#x0D; Results: the sample of 8 articles showed that the fastest onset of blockade in pregnant women occurs in the lateral horizontal decubitus position and in the sitting position with legs downwards. Lateral decubitus with elevated head presented insufficient blockade. Lateral position was related to greater comfort, and its maintenance for 15 minutes before the supine position, after infiltration with the anesthetic was associated with lower incidence of hypotension.&#x0D; Conclusion: Scientific evidence has shown that positioning influences the effect, potentiation and delay of anesthesia, comfort and the pregnant woman's blood pressure, being relevant to the perioperative and obstetric multidisciplinary practice.

Leg elevation decreases the incidence of post-spinal hypotension in cesarean section: a randomized controlled trial

BackgroundMaternal hypotension is a common complication after spinal anesthesia for cesarean section (CS). In this study we investigated the role of leg elevation (LE) as a method for prevention of post-spinal hypotension (PSH) for cesarean section.MethodsOne hundred and fifty full term parturients scheduled for CS were included in the study. Patients were randomized into two groups: Group LE (leg elevation group, n = 75) and group C (Control group, n = 75). Spinal block was performed in sitting position after administration of 10 mL/Kg Ringer’s lactate as fluid preload. After successful intrathecal injection of local anesthetic, Patients were positioned in the supine position. Leg elevation was performed for LE group directly after spinal anesthesia and maintained till skin incision. Intraoperative hemodynamic parameters (Arterial blood pressure and heart rate), intra-operative ephedrine consumption, incidence of PSH, and incidence of nausea and vomiting were reported.ResultsLE group showed lower incidence of PSH (34.7% Vs 58.7%, P = 0.005) compared to the control group. Arterial blood pressure was higher in the LE group compared to the control group in the first two readings after spinal block. Other readings showed comparable arterial blood pressure and heart rate values between both study groups; however, LE showed less ephedrine consumption (4.9 ± 7.8 mg Vs 10 ± 11 mg, P = 0.001).ConclusionLE performed immediately after spinal block reduced the incidence of PSH in parturients undergoing CS.Trial registrationThe study was registered at Pan African Clinical Trials Registry system on 5/10/2015 with trial number PACTR201510001295348.