Combination of Small Doses of Subarachnoid Bupivacaine/Fentanyl and Epidural Bupivacaine in Combined Spinal-Epidural Anesthesia for Cesarean Section / 대한마취과학회지

BACKGROUND: An intrathecal injection of a small-dose local anesthetic and an opioid using combined spinal-epidural anesthesia (CSEA) technique is a new trend in regional anesthesia for cesarean section. Prophylactic epidural injection may be useful to complete the new regimen. METHODS: Spinal anesthesia via the CSEA technique was performed with 6 mg 0.5% hyperbaric bupivacaine plus 20ng fentanyl in 75 parturients undergoing cesarean section. group S (study, n = 38) received an epidural injection of 10 ml of 0.25% bupivacaine 5 min after intrathecal injection, and was compared with group C (control, n = 37) in sensory levels and Bromage scores, incidences of side effects such as hypotentsion, pain and discomfort, nausea and vomiting, dizziness, pruritus and shivering. Recovery times from sensory and motor block and the duration of postoperative analgesia were assessed between the groups. RESULTS: Sensory block levels were higher (but remained

Comparison of Intrathecal Isobaric and Hyperbaric Bupivacaine during Combined Spinal Epidural Anesthesia for Cesarean Section / 대한마취과학회지

BACKGROUND: We aimed to compare the clinical effects of 7 mg of intrathecal isobaric and hyperbaric 0.5% bupivacaine during combined spinal epidural (CSE) anesthesia for a cesarean section. METHODS: Thirty patients scheduled for an elective cesarean section under the CSE technique were randomly divided into two groups. 0.5% hyperbaric bupivacaine (Hyperbaric group, n = 15) or 0.5% isobaric bupivacaine (Isobaric group, n = 15) was separately injected into the subarachnoid space through a 26 G Quincke needle. Immediately after fixing the epidural catheter, 2% lidocaine 4 ml and fentanyl 50 microgram were injected through the epidural catheter. We measured the level and time of maximal sensory block, hemodynamic variables and many other clinical effects according to times. RESULTS: The level of maximal sensory block and duration of sensory block were not significantly different between the two groups. The time to maximal sensory block was significantly shorter in group I. Five of group H and two of group I needed an additional injection of epidural lidocaine and two of group H and four of group I needed IV fentanyl. However, all patients had the operation in comfort. CONCLUSIONS: An intrathecal injection of 7 mg of isobaric or hyperbaric 0.5% bupivacaine both with an epidural dose of 2% lidocaine 4 ml and fentanyl 50 microgram during CSE anesthesia is suitable for an elective cesarean section.

The Effect of Prior Dural Puncture with a 27G Spinal Needle on Epidural Anesthesia for Cesarean Section / 대한마취과학회지

BACKGROUND: If started with segmental block, epidural anesthesia appears to have an inadequate sacral block in the early part of cesarean deliveries. A dural puncture using the combined spinal-epidural technique making an early sacral blockade might be a solution. METHODS: A prospective, randomized, double-blinded study was performed on forty patients who were divided into two groups (C, DP; n = 20, each). An epidural infusion of 25 ml of 2% lidocaine with epinephrine was given to the group C. A dural puncture with a 27G Whitacre needle was done before the epidural infusion in the group DP. Two-way sensory levels were checked for 15 min, just before the operation. The side effects and recovery variables were also compared between the groups. RESULTS: Initial wider cephalic block (P = 0.038, 0 min) followed by more caudal block (P = 0.023, 0.013; 5, 10 min after the completion of the epidural infusion, respectively) occurred in the DP group. After 10 min, there were no differences in both block levels. The number of dermatomes blocked was bigger in the DP group at 10 min after. Fewer patients in the DP group had nausea and/or vomiting (P = 0.044). CONCLUSIONS: Early spread of the sensory blockade, initial cephalic and then caudal, was due to the dural puncture by a 27G needle. This fast onset could make the parturients more comfortable in the early part of cesarean sections.

The Effects of Epidural "Top-up" on Spinal Block during Combined Spinal Epidural Anesthesia for Cesarean Section / 대한마취과학회지

BACKGROUND: Epidural "top-up" has been known to enhance spinal anesthesia in combined spinal-epidural anesthesia. Saline and local anesthetics were reported to have a volume effect when infused as epidural "top-up". In cesarean deliveries where high sensory block has been achieved using a combined spinal-epidural technique, we evaluated the effects of epidural "top-up" on the underlying spinal block. METHODS: Sixty-six parturients were allocated randomly into group C (control, n = 21), S (saline, n = 21), or B (bupivacaine, n = 24). Ten minutes after they received 8 mg of 0.5% hyperbaric bupivacaine intrathecally, nothing, 10 ml saline, or 10 ml of 0.25% bupivacaine were infused, respectively. The sensory level at 10 min, the maximal level and the time to reach it, and degrees of motor block and muscle relaxation were compared. We also investigated intraoperative side effects and postoperative findings in the PACU. RESULTS: There were significant changes in sensory level after epidural top-ups in the group S and B, but no differences in maximal height of sensory block and degree of muscle relaxation among the groups. Intraoperative pain was complained in fewer patients in the group B. Times to sensory and motor recovery were longer in patients of the group B. CONCLUSIONS: Eight milligrams of hyperbaric bupivacaine using a combined spinal-epidural technique was not sufficient for cesarean section. Epidural saline top-up showed volume effect, which didn't improve the spinal block. Epidural "top-up" of 0.25% 10 ml bupivacaine enhanced the spinal block and sustained the block postoperatively.

Comparison of Epidural Buprenorphine and Morphine for Postoperative Pain Control in Combined Spinal Epidural Anesthesia for Cesarean Section / 대한마취과학회지

BACKGROUND: Combined spinal epidural anesthesia has become the technique of anesthesia for cesarean section because of the reliability of spinal block with the flexibility of epidural block. Buprenorphine, a new synthetic thebaine derivative is a partial agonist of the opioid micro-receptor with high receptor affinity, great lipid solubility, and slow rate of opiate receptor association and dissociation. Continous epidural infusion of opioid can possibly produced undesirable effects, such as respiratory depression, pruritus, etc. METHODS: The present study was undertaken to compare the analgesic properties and side effects of continous epidural infusion of buprenorphine and morphine combined with bupivacaine in 60 patients following elective cesarean section in combined spinal epidural anesthesia. At the clothing of peritoneum, the initial bolus doses were 3 mg morphine (M group), 0.15 mg buprenorphine (0.15B group), 0.3 mg buprenorphine (0.3B Group) combined with 0.15% bupivacaine 10 ml and subsequent continous infusion doses were 6 mg morphine plus 0.125% bupivacaine 100 ml (M Group) and 0.6 mg buprenorphine plus 0.125% bupivacaine 100 ml (0.15B, 0.3B Group) during 48 hours. The assessment of analgesic efficacy and side effects were made at arrival of recovery room,postoperative 1, 4, 8, 24, 36, and 48 hours. RESULTS: The pain score during 48 hours was significantly higher in the 0.15B group than in the M group and 0.3B group except the pain score of recovery room. (p<0.05) and the number of patients requiring additional analgesics was higher in 0.15B group than in the M group and 0.3B group but, it was not significant. The incidence of pruritus and urinary retention was significantly higher in M group than in the 0.15B and 0.3B group, and the incidence of sedation, nausea and vomiting was similar in three group. The subjective rating of satisfaction was better in the 0.3B group and M group than in the 0.15B group. CONCLUSION: The above results suggest that continous epidural infusion of 0.6 mg buprenorphine after 0.3 mg buprenorphine initial bolus dose combined with low dose bupivacaine is an advisable method of postoperative pain control in combined spinal epidural anesthesia for cesarean section.

Comparison of Epidural Buprenorphine and Morphine for Postoperative Pain Control in Combined Spinal Epidural Anesthesia for Cesarean Section / 대한마취과학회지

BACKGROUND: Combined spinal epidural anesthesia has become the technique of anesthesia for cesarean section because of the reliability of spinal block with the flexibility of epidural block. Buprenorphine, a new synthetic thebaine derivative is a partial agonist of the opioid micro-receptor with high receptor affinity, great lipid solubility, and slow rate of opiate receptor association and dissociation. Continous epidural infusion of opioid can possibly produced undesirable effects, such as respiratory depression, pruritus, etc. METHODS: The present study was undertaken to compare the analgesic properties and side effects of continous epidural infusion of buprenorphine and morphine combined with bupivacaine in 60 patients following elective cesarean section in combined spinal epidural anesthesia. At the clothing of peritoneum, the initial bolus doses were 3 mg morphine (M group), 0.15 mg buprenorphine (0.15B group), 0.3 mg buprenorphine (0.3B Group) combined with 0.15% bupivacaine 10 ml and subsequent continous infusion doses were 6 mg morphine plus 0.125% bupivacaine 100 ml (M Group) and 0.6 mg buprenorphine plus 0.125% bupivacaine 100 ml (0.15B, 0.3B Group) during 48 hours. The assessment of analgesic efficacy and side effects were made at arrival of recovery room,postoperative 1, 4, 8, 24, 36, and 48 hours. RESULTS: The pain score during 48 hours was significantly higher in the 0.15B group than in the M group and 0.3B group except the pain score of recovery room. (p<0.05) and the number of patients requiring additional analgesics was higher in 0.15B group than in the M group and 0.3B group but, it was not significant. The incidence of pruritus and urinary retention was significantly higher in M group than in the 0.15B and 0.3B group, and the incidence of sedation, nausea and vomiting was similar in three group. The subjective rating of satisfaction was better in the 0.3B group and M group than in the 0.15B group. CONCLUSION: The above results suggest that continous epidural infusion of 0.6 mg buprenorphine after 0.3 mg buprenorphine initial bolus dose combined with low dose bupivacaine is an advisable method of postoperative pain control in combined spinal epidural anesthesia for cesarean section.

The Effects of Subarachnoid Fentanyl in Combined Spinal-Epidural Anesthesia for Cesarean Section / 대한마취과학회지

BACKGROUND: Combined spinal-epidural anesthesia (CSEA) for cesarean section has gained an increasing interest as it combines a reliability of spinal anesthesia and the flexibility of epidural anesthesia. The aim of this study is to compare the surgical analgesia and the frequency of side effects for cesarean section produced by CSEA using subarachnoid fentanyl or placbo. METHODS: The study was performed in a randomized, double-blined fashion in 40 (20 per group) healthy, full-term parturients presenting for elective cesarean section. We compared the effects of intrathecal fentanyl (20 microgram), and placebo when administered together with 0.5% hyperbaric bupivacaine 7 mg in combined spinal-epidural anesthesia (CSEA) for cesarean section. Patients' anesthetic levels, vital signs and intraoperative pain were recorded. If anesthetic level achieved by intrathecal injection was not sufficient for cesarean section (T4), additional 2% lidocaine 2 ml per segment was administered epidurally. Patients were asked to rate their severity of pain on a visual analog scale (VAS) score intraoperatively and intravenous fentanyl was administered if the patient experienced intraoperative discomfort. The quality and side effects of anesthsia and neonatal Apgar scores were compared between two groups. RESULTS: The number (percent) of patients achieved sensory block level above T4 by subarachnoid injection alone was significantly higher in the fentanyl group (17/18, 94.4%) than the control grop (10/16, 62.5%). The dose of epidural lidocaine was significantly less in the fentanyl group (p<0.05). The frequency of intraoperative pain was significantly less in the fentanyl group (17%) than in the control group (50%). CONCLUSION: We conclude that adding fentanyl into subarachnoid injection in CSEA for cesarean section significantly decreases the additional epidural local anesthetics and intraoperative pain.

Comparison of Combined Spinal Epidural Anesthesia and Epidural Anesthesia for Cesarean Section / 대한마취과학회지

BACKGROUND: Epidural anesthesia (EA) has become most popular for cesarean section, but has some drawbacks such as incomplete block, inadequate muscle relaxation and delayed onset. Combined spinal epidural anesthesia (CSEA) has gained an increasing interest as it combines a reliability of the spinal block and the flexibility of an epidural block. We investigated the efficacy of CSEA which combines main spinal and supporting epidural anesthesia, comparing with pH adjusted EA, for cesarean section. METHODS: Sixty four pregnant women at full term were divided into two groups. Group 1 (n=32) received CSEA with 1.5~1.6 ml of 0.5% hyperbaric bupivacaine intrathecally, followed 10 minutes after by 10 ml of 0.25% plain bupivacaine through the epidural catheter. Group 2 (n=32) received EA with 20~25 ml of 2% lidocaine which was added 0.1 ml of 0.1% epinephrine, 100 microgram of fentanyl and 1.5 ml of 8.4% sodium bicarbonate. The quality and side effects of surgical anesthesia, neonatal state and postoperative course were compared between two groups. RESULTS: While 22% (7 cases) of Group 2 complained of intraoperative pain but none of Group 1 did (p=0.011). Muscle relaxation and motor block were much better in group 1 (p<0.001 and p=0.011 each). Significantly more women in group 2 had shivering (p=0.001) and they also had nausea and vomiting more, though that difference is not significant. Not only time to T4 (9.7 vs. 8.3 min., mean, p<0.001), but also stay at PACU, recovery of sensory and motor block and start of postoperative pain were all significantly shorter in Group 1. None of both groups had post-dural puncture headache (PDPH). CONCLUSIONS: We can conclude that CSEA, when combining main spinal and supporting epidural anesthesia, has greater efficacy and less side effects for cesarean section than pH adjusted EA.