Spinal-epidural Anesthesia For Cesarean Delivery Research Articles

Effect of crystalloidsolution co-loading infusion rate on the dose requirements of prophylactic phenylephrine for preventing hypotension following combined spinal-epidural anesthesia for cesarean delivery.

Intravenous fluid administration and prophylactic vasopressor infusion are the primary methods for preventing spinal anesthesia-induced hypotension during cesarean delivery. However, evidence regarding the impact of different volumes of crystalloid solution on the phenylephrine infusion dosage for preventing this hypotension remains inconclusive. This study aimed to determine the effect of two IV fluid infusion rates (10 or 20 mL/kg/h) on phenylephrine requirement for preventing spinal anesthesia-induced hypotension. Eighty healthy parturients undergoing elective cesarean delivery under combined spinal-epidural anesthesia were enrolled. Participants were randomly assigned to receive either 10 mL/kg/h (group 10) or 20 mL/kg/h (group 20) of lactated Ringer's solution. The first patient in each group received 0.5µg/kg/min of phenylephrine infusion immediately after intrathecal injection. The phenylephrine dose in subsequent patients was adjusted by increments or decrements of 0.05µg/kg/min based on the previous patient's response. The ED50 of phenylephrine infusion for preventing spinal-induced hypotension for cesarean delivery was estimated using a modified up-down sequential analysis, with probit analysis applied as a backup sensitivity analysis. The ED50 values for preventing spinal anesthesia-induced hypotension were 0.30µg/kg/min (95% CI, 0.29-0.32µg/kg/min) for group 10, and 0.19µg/kg/min (95% CI, 0.16-0.22µg/kg/min) for group 20, respectively. The estimated relative potency for phenylephrine in group 10 compared to group 20 was 1.52 (95%CI, 1.24-1.97), showing a significant difference in the ED50 values between the two groups. This study found that a higher crystalloid co-loading rate significantly reduces prophylactic phenylephrine requirement for preventing spinal anesthesia induced hypotension. https://www.chictr.org.cn/showproj.html?proj=125918 (Trial number: ChiCTR2100048002).

Determination of the Relative Potency of Norepinephrine and Phenylephrine Given as Infusions for Preventing Hypotension During Combined Spinal-Epidural Anesthesia for Cesarean Delivery: A Randomized Up-And-Down Sequential Allocation Study.

Purpose: The relative potency of norepinephrine and phenylephrine given as boluses to treat hypotension during spinal anesthesia for cesarean delivery has been reported but few data are available for infusions. This study aimed to determine the relative potency of norepinephrine and phenylephrine when given by infusion for preventing hypotension during combined spinal-epidural anesthesia for cesarean delivery. Methods: This was a prospective, randomized, double-blind, up-and-down sequential allocation study. Patients were randomly allocated to receive a prophylactic infusion of norepinephrine or phenylephrine started immediately after induction of anesthesia. The first patients received either norepinephrine 0.1 μg/kg/min or phenylephrine 0.5 μg/kg/min. An effective infusion rate was defined when no hypotension occurred before delivery. For each subsequent patient, the norepinephrine infusion rate was decreased or increased by 0.01 μg/kg/min or the phenylephrine infusion rate was decreased or increased by 0.05 μg/kg/min according to whether the infusion was effective or ineffective respectively in the previous patient. Values for the infusion rate that was effective in preventing hypotension in 50% of patients (ED50) for norepinephrine and phenylephrine were estimated using up-and-down sequential analysis and relative potency was estimated. Probit regression was used as a backup and sensitivity analysis. Results: The ED50 values for norepinephrine and phenylephrine calculated by the up-and-down method were 0.061 (95% CI 0.054–0.068) μg/kg/min and 0.368 (95% CI 0.343–0.393) μg/kg/min respectively. The estimated relative potency ratio for ED50 for norepinephrine to phenylephrine was 6.03:1 (95% CI 5.26:1 to 6.98:1). Conclusion: Under the conditions of this study, norepinephrine given by infusion was about 6 times more potent than phenylephrine. This information is useful for clinical practice and further comparative studies of norepinephrine versus phenylephrine. Clinical Trial Registration: http://www.chictr.org.cn/showproj.aspx, identifier [ChiCTR2200056237]

The effect of gestational diabetes mellitus on sufentanil consumption after cesarean section: a prospective cohort study

BackgroundPrevious studies have shown that patients with long-term diabetes require more opioids after surgery than patients without diabetes. Gestational diabetes mellitus (GDM) normally only lasts for a brief period; nevertheless, its effect on sufentanil consumption after cesarean section is unknown.MethodsThis prospective cohort study included two groups: a GDM group (n = 32) and a matched non-GDM (NGDM) group (n = 32). All patients underwent routine combined spinal-epidural anesthesia for cesarean delivery. Sufentanil consumption through an intravenous patient-controlled analgesia (PCA) pump, the frequency of PCA requests, and visual analog scale (VAS) scores 6 and 24 h after surgery were compared between groups.ResultsSufentanil consumption (μg) 6 h after surgery was higher in the GDM group than in the NGDM group (24.0 ± 6.6 vs 20.1 ± 5.7, P = 0.023). PCA was used more frequently 6 and 24 h after surgery by the GDM group than by the NGDM group (1[0–2] vs 0[0–1], P = 0.001; 6 [1–5] vs 3 [1, 2, 6–8], P = 0.001, respectively). The VAS score during activity 24 h after surgery was higher in the GDM group than in the NGDM group (5 [2, 3] vs 5 [1, 2], respectively, P = 0.03).ConclusionPregnant women with GDM require more opioids during the immediate postoperative period after cesarean section than those without GDM.Clinical trials registrationNo. ChiCTR1800016014, ChenYang, May 6th 2018.

Comparison between general, spinal, epidural, and combined spinal-epidural anesthesia for cesarean delivery: a network meta-analysis

BackgroundThis study is a network meta-analysis to compare maternal and fetal outcomes associated with four different anesthetic techniques for cesarean delivery. MethodsAn arm-based, random-effects frequentist network meta-analysis was performed. A random effect model was selected considering deviance information criteria. Randomized trials reporting the following outcomes were included: Apgar score at 1- or 5-min; umbilical arterial and venous pH; umbilical arterial pH <7.2; and neonatal score at 2–4 hours. Loop-specific heterogeneity was evaluated by risk of odds ratio and τ2. Quality of evidence was assessed using the GRADE approach. ResultsData from 46 randomized trials including 3689 women contributed to the study. There were significant differences in Apgar score ≤6 at 1 min between spinal versus general anesthesia (odds ratio 0.27, 95% confidence interval [CI] 0.13 to 0.55: moderate quality evidence) and Apgar scores at 1- and 5-min, favoring spinal anesthesia. Umbilical venous pH associated with epidural anesthesia was significantly higher than that with general anesthesia (mean difference 0.010, 95% CI 0.001 to 0.020: moderate quality evidence) or spinal anesthesia. Spinal anesthesia was ranked best for Apgar score ≤6 at 1-min (SUCRA=89.8), Apgar score at 1-min (SUCRA=80.4) and 5-min (SUCRA=90.5). Epidural anesthesia was ranked highest for umbilical venous pH (SUCRA=87.4) and neonatal score (SUCRA=79.3). ConclusionsSpinal and epidural anesthesia were ranked high regarding Apgar scores and epidural anesthesia was ranked high regarding umbilical venous pH, but the results were based on small heterogeneous studies with high or unclear risks of bias.

Does Preprocedural Ultrasound Increase the First-Pass Success Rate of Epidural Catheterization Before Cesarean Delivery? A Randomized Controlled Trial

(Anesth Analg. 2017;124(3):851–856) Studies regarding the use of preprocedural ultrasound for epidural catheterization are largely unblinded and differ greatly in design, expertise of the operator, performance of epidural technique, and primary outcomes. To address this inconsistency, the authors of the present study compared preprocedural ultrasound with conventional palpation for epidural catheterization performed by a single experienced anesthesiologist as a component of double-interspace combined spinal-epidural anesthesia for cesarean delivery.

Evaluation of failed and high blocks associated with spinal anesthesia for Cesarean delivery following inadequate labour epidural: a retrospective cohort study.

The purpose of this retrospective cohort study was to investigate factors associated with failed and high spinal blocks in patients who received spinal anesthesia for Cesarean delivery following a labour epidural that was inadequate for surgical anesthesia. We searched our perioperative database for women with a labour epidural who received spinal or combined spinal-epidural anesthesia for Cesarean delivery due to the inadequacy of the existing epidural. The primary outcome was the occurrence of failed spinal blocks, and the secondary outcome was the occurrence of high blocks following spinal administration. Of the 263 patients in the analysis, there were 29 (11%) failed spinals and nine (3%) high spinals. There was a significant difference between patients with failed spinals and those with successful spinals with regards to receipt of an epidural top-up dose for Cesarean delivery within 30 min of the spinal, type of neuraxial block, body mass index, age, and dose of hyperbaric bupivacaine. In a multivariable analysis, only receipt of an epidural top-up dose was associated with failure (OR, 6.0; 95% CI, 2.1 to 17.0; P < 0.001). As for the risk of a high spinal, patient characteristics and block details were not different amongst patients, except for a younger age in those with a high block. Administration of spinal anesthesia within 30 min of an epidural top-up dose is associated with increased risk of failure. We speculate that this may be due in part to the presence of a large volume of local anesthetic in the epidural space, which may be mistaken for cerebrospinal fluid during spinal placement.

How Long Can Patients Sit Up for Before Lying Down after Combined Spinal-Epidural Anesthesia For Cesarean Delivery? A Randomized Trial

Objective: Sitting patients up for 5 min after spinal anesthesia decreases hypotension and ephedrine requirement. This study aimed at determining how long patients can sit up for after combined spinal-epidural (CSE) anesthesia without requiring epidural supplementation. Methods: Ninety women booked for elective cesarean section under CSE anesthesia were randomized to sit up for 5 min (group 1), 7 min (group 2), or 9 min (group 3) after spinal anesthetic administration before lying down supine with a tilt. Sensory anesthesia level, systolic blood pressure, heart rate, ephedrine requirement, rescue epidural use, and time to achieving a modified Bromage score of two were documented by a blinded observer. Results: The maximum height of sensory anesthesia was [T3 (1) vs. T4 (1) vs. T5 (1) for groups 1-3, respectively, P<0.001]. Group 1 required more ephedrine (16.7% vs. 3.3% vs. 0%, P=0.024). Changes over time in systolic blood pressure (P=0.117) and heart rate (P =0.793), and time to achieving a modified Bromage score of two [112 (17) vs. 110 (16) vs. 100 (28) min, P=0.437] were similar amongest groups. Rescue epidural anesthesia was required in eight (26.7%) patients in group 3 compared to none in the other groups (P<0.001). Conclusion: Sitting the patient up for up to 7 min after CSE anesthesia for cesarean section reduced intraoperative ephedrine requirement without affecting the success of the spinal anesthetic. In contrast, sitting up for 9 min resulted in the need for rescue epidural anesthesia without additional benefit.

Ultrasound Estimates for Midline Epidural Punctures in the Obese Parturient

Spinal ultrasound (US) in the transverse median (TM) plane underestimates the distance to the epidural space in obese pregnant women, most likely because of compression of the subcutaneous tissue during the assessment, often required to compensate for poor visibility. We tested whether scanning in the paramedian sagittal oblique (PSO) plane compared with the TM plane resulted in a more precise estimate of the actual skin-epidural space measurement in this population. We recruited obese (World Health Organization classes I, II, and III) pregnant women at term requesting labor epidural analgesia or combined spinal-epidural anesthesia for cesarean delivery. US imaging was performed with a 5-2 MHz curved array probe to identify the insertion point and to estimate the distance from the skin to the epidural space (US-estimated depth, UD) in the PSO and TM planes. The measurements were performed with the least possible compression of the subcutaneous tissue by the US probe. All punctures were performed via the midline approach. An anesthesiologist performed the epidural/combined spinal-epidural procedure at the predetermined insertion point, and marked the actual needle distance from the skin to the epidural space (needle depth, ND). Bland-Altman analysis was used to determine the differences and 95% limits of agreement between US depth and ND. We studied 60 women. The mean (SD) body mass index was 39.6 (7.9) kg/m(2) (range 30.4-66.2 kg/m(2)). The US estimate in the PSO and TM planes, and the actual ND were 6.5 (1.2) cm, 6.5 (1.1) cm, and 6.6 (1.3) cm, respectively. The Bland-Altman analysis showed a mean difference of 0.05 cm and 95% limits of agreement of ±1 cm. The quality of imaging was rated as good in the PSO and TM planes in 86.7% and 68.3%, respectively (P = 0.028). The estimates of the US-determined distance to the epidural space in the PSO are comparable to those in the TM plane. The ability to use both estimates interchangeably for midline punctures may prove useful in patients presenting with poor visibility in the TM plane.

Does the Baricity of Bupivacaine Influence Intrathecal Spread in the Prolonged Sitting Position Before Elective Cesarean Delivery? A Prospective Randomized Controlled Study

Difficulties in inserting an epidural catheter while performing combined spinal-epidural anesthesia for cesarean delivery may lead to undue delays between the spinal injection of the local anesthetic mixture and the adoption of the supine position with lateral tilt. We hypothesized that this delay may affect the intrathecal distribution of local anesthetic of different baricities such that hypobaric local anesthetic would lead to a higher sensory block level. Healthy parturients with uncomplicated pregnancies undergoing elective cesarean delivery under combined spinal-epidural anesthesia were enrolled in this prospective double-blind randomized controlled trial. The subjects were allocated to receive hyperbaric (hyperbaric group), isobaric (isobaric group), or hypobaric (hypobaric group) spinal bupivacaine 10 mg. After the spinal injection, the subjects remained in the sitting position for 5 minutes (to simulate difficulty in inserting the epidural catheter) before being helped into the supine lateral tilt position. The primary outcome was the sensory block level during the 25 minutes after the spinal injection. Other end points included motor block score, maternal hypotension, and vasopressor requirements. Data from 89 patients were analyzed. Patient characteristics were similar in all groups. The median [interquartile range] (95% confidence interval) sensory levels after spinal injection were significantly higher with decreasing baricity: hyperbaric T10 [T11-8] (T10-9), isobaric T9 [T10-7] (T9-7), and hypobaric T6 [T8-4] (T8-5) (P < 0.001, Cuzick trend). All patients in the hypobaric group reached a sensory block level of T4 at 25 minutes after spinal injection compared with 80% of the patients in both the isobaric and hyperbaric groups (P = 0.04; difference 20%, 95% confidence interval of difference 4%-33%). Significantly more patients in the hypobaric group had complete lower limb motor block (Bromage score = 4) (hyperbaric 43%, isobaric 63%, and hypobaric 90%; P < 0.001). The incidences of maternal hypotension and nausea and vomiting were similar among groups, although the ephedrine requirements were significantly increased in the isobaric and hypobaric groups by factors of 1.83 and 3.0, respectively, compared with the hyperbaric group (P < 0.001, Cuzick trend). We demonstrated that when parturients undergoing cesarean delivery were maintained in the sitting position for 5 minutes after spinal injection of the local anesthetic, hypobaric bupivacaine resulted in sensory block levels that were higher compared with isobaric and hyperbaric bupivacaine, respectively, during the study period.

A Randomized Comparison of Low Doses of Hyperbaric Bupivacaine in Combined Spinal-Epidural Anesthesia for Cesarean Delivery

Obstetric Anesthesia Digest: March 2011 - Volume 31 - Issue 1 - p 56 doi: 10.1097/01.aoa.0000393192.05080.7e

A Randomized Comparison of Low Doses of Hyperbaric Bupivacaine in Combined Spinal-Epidural Anesthesia for Cesarean Delivery

A Randomized Comparison of Low Doses of Hyperbaric Bupivacaine in Combined Spinal-Epidural Anesthesia for Cesarean Delivery

A Randomized Comparison of Low Doses of Hyperbaric Bupivacaine in Combined Spinal-Epidural Anesthesia for Cesarean Delivery

Survey of Anesthesiology: June 2010 - Volume 54 - Issue 3 - p 119-120 doi: 10.1097/01.SA.0000370213.95675.34

Excretion of Ropivacaine in Breast Milk During Patient-controlled Epidural Analgesia After Cesarean Delivery

Background Few studies have been published concerning the excretion of bupivacaine and lidocaine into the breast milk and none concerning ropivacaine. Aim The aim of this study was to determine the levels of ropivacaine in plasma and breast milk after combined spinal-epidural anesthesia for cesarean delivery and postoperative patient-controlled epidural analgesia (PCEA), as well as possible adverse effects from these levels on the neonate. Methods Twenty-five parturients admitted for cesarean delivery under combined spinal-epidural anesthesia participated in the study. The PCEA regimen was prepared as 0.15% ropivacaine and fentanyl 2 microg/mL (basal rate, 6 mL/h; demand dose, 4 mL/20 min). Blood samples were collected before anesthesia and from the umbilical cord immediately after birth, followed by blood and breast milk samples 18 and 24 hrs after initiation of PCEA. The newborns were clinically appraised with the Apgar score at delivery and Neurological and Adaptive Capacity Score 24 hrs later. Local anesthetic side effects were recorded. Ropivacaine levels were determined by high-performance liquid chromatography with a UV detector. Results Ropivacaine excretion into the breast milk produced concentrations that significantly correlated with those in the plasma 18 and 24 hrs after administration, achieving milk-plasma ratios (mean +/- SD) of 0.25 +/- 0.08 and 0.23 +/- 0.07, respectively. Most newborns had maximal Apgar and Neurological and Adaptive Capacity Scores. No adverse effects from ropivacaine were noted in mothers or neonates. Conclusions The milk-plasma concentration ratio of ropivacaine was found to be lower than that reported for other local anesthetics It seems that PCEA with ropivacaine/fentanyl after cesarean delivery is not associated with excessive milk-plasma concentrations of ropivacaine.

A Randomized Comparison of Low Doses of Hyperbaric Bupivacaine in Combined Spinal-Epidural Anesthesia for Cesarean Delivery

The aim of our study was to investigate the block characteristics of intrathecal hyperbaric bupivacaine 7, 8, or 9 mg administered during combined spinal-epidural anesthesia for cesarean delivery and to elucidate the dose that produces adequate sensory blockade for surgery while minimizing the incidence of hypotension, high neuroblockade, and the need for intraoperative epidural supplementation. Sixty women presenting for elective cesarean delivery were randomly assigned to one of the 3 groups. Group 7 received intrathecal hyperbaric bupivacaine 7 mg, Group 8 received 8 mg, and Group 9 received 9 mg. Women in all 3 groups received intrathecal morphine 100 microg and IV hydroxyethyl starch 15 mL/kg at the time of initiation of combined spinal-epidural anesthesia. Surgery began when a sensory level of T4 was achieved. Patients were monitored for block characteristics and side effects by a blinded observer. Our primary outcome was the maximum cephalad sensory block height. There was a difference in the maximum extent of cephalad sensory block among groups (Group 7: median T2 [interquartile range T2-T3]; Group 8: median T2 [T1-T2]; Group 9: median T1 [C8-T2]; P = 0.02). However, the time taken to reach T4 was similar in all 3 groups. The incidence of hypotension requiring vasopressors was different among groups (30% in Group 7, 55% in Group 8, and 70% in Group 9; P = 0.04). No patient had inadequate anesthesia. Neonatal outcomes were similar in all 3 groups. The lowest dose of hyperbaric bupivacaine (7 mg) provided equally rapid onset and effective anesthesia for cesarean delivery while reducing the incidence of hypotension compared with 8 and 9 mg. However, because of its shorter duration of anesthesia, it may be feasible only when the block can be reinforced using a functional epidural catheter.

Excretion of Ropivacaine in Breast Milk During Patient-Controlled Epidural Analgesia After Cesarean Delivery

Few studies have been published concerning the excretion of bupivacaine and lidocaine into the breast milk and none concerning ropivacaine. The aim of this study was to determine the levels of ropivacaine in plasma and breast milk after combined spinal-epidural anesthesia for cesarean delivery and postoperative patient-controlled epidural analgesia (PCEA), as well as possible adverse effects from these levels on the neonate. Twenty-five parturients admitted for cesarean delivery under combined spinal-epidural anesthesia participated in the study. The PCEA regimen was prepared as 0.15% ropivacaine and fentanyl 2 microg/mL (basal rate, 6 mL/h; demand dose, 4 mL/20 min). Blood samples were collected before anesthesia and from the umbilical cord immediately after birth, followed by blood and breast milk samples 18 and 24 hrs after initiation of PCEA. The newborns were clinically appraised with the Apgar score at delivery and Neurological and Adaptive Capacity Score 24 hrs later. Local anesthetic side effects were recorded. Ropivacaine levels were determined by high-performance liquid chromatography with a UV detector. Ropivacaine excretion into the breast milk produced concentrations that significantly correlated with those in the plasma 18 and 24 hrs after administration, achieving milk-plasma ratios (mean +/- SD) of 0.25 +/- 0.08 and 0.23 +/- 0.07, respectively. Most newborns had maximal Apgar and Neurological and Adaptive Capacity Scores. No adverse effects from ropivacaine were noted in mothers or neonates. The milk-plasma concentration ratio of ropivacaine was found to be lower than that reported for other local anesthetics It seems that PCEA with ropivacaine/fentanyl after cesarean delivery is not associated with excessive milk-plasma concentrations of ropivacaine.

The effect of colloid co-hydration on the use of phenylephrine and hemodynamics during low-dose combined spinal-epidural anesthesia for cesarean delivery

Background: Ephedrine has been recommended as the best vasopressor in obstetrics. But, recent clinical evidences show the possibility that phenylephrine has become more pertinent as a primary vasopressor. We think a phenylephrine infusion with colloid co-hydration will be more useful in maintaining baseline blood pressure in combined spinal-epidural anesthesia (CSEA) for cesarean section. Methods: CSEA was performed using 6 mg bupivacaine and 20 μg fentanyl as a spinal and 10 ml of 0.25% levobupivacaine as an epidural in randomized, colloid co-hydration (hydroxyethl starch, HES 500 ml) (group C, n = 34) or no colloid co-hydration (group N, n=34) parturients scheduled to undergo cesarean delivery. After an infusion of 100 μg phenylephrine following the spinal injection, phenylephrine was intermittently infused using a PCA-pump to maintain the baseline blood pressure (BP). Systolic BP and heart rate (HR) were checked and total phenylephrine amount was measured. Nausea and vomiting and fetal umbilical pH/base excess (BE) were also investigated. Results: There was a lower incidence of bradycardia in the C group compared with the N group (5.9% vs. 32.4%, p = 0.014), and total phenylephrine consumption was less in the C group (400 μg vs. 500 μg, p = 0.019). The incidence of reactive hypertension (11.8% vs. 55.9%, p ＜ 0.001), and the hypotension (0% vs. 11.8%, p = 0.114) were lower in the C group, too. The others were comparable in both groups. Conclusions: Colloid co-hydration was effective in reducing the phenylephrine use and the incidences of abnormal hemodynamics such as hypotension, bradycardia and hypertension in low-dose CSEA for cesarean delivery. (Korean J Anesthesiol 2008; 55: 685~90)

370: Hemodynamic effects of preventive administration of ephedrine and phenylephrine during combined spinal-epidural anesthesia for cesarean delivery. A bioimpedance study

370: Hemodynamic effects of preventive administration of ephedrine and phenylephrine during combined spinal-epidural anesthesia for cesarean delivery. A bioimpedance study

Combined Spinal-Epidural Anesthesia for Cesarean Delivery

Survey of Anesthesiology: February 2007 - Volume 51 - Issue 1 - p 18-19 doi: 10.1097/01.sa.0000255115.41526.83

The Sitting Versus Right Lateral Position During Combined Spinal-Epidural Anesthesia for Cesarean Delivery: Block Characteristics and Severity of Hypotension

The Sitting Versus Right Lateral Position During Combined Spinal-Epidural Anesthesia for Cesarean Delivery: Block Characteristics and Severity of Hypotension

The Sitting Versus Right Lateral Position During Combined Spinal-Epidural Anesthesia for Cesarean Delivery

The Sitting Versus Right Lateral Position During Combined Spinal-Epidural Anesthesia for Cesarean Delivery