Comparison between three low dose combined spinal epidural techniques for caesarean delivery in preeclampsia patients

ABSTRACT

Combined spinal epidural is an established technique for caesarean delivery. Various local anesthetics and opioids, either alone or in combination, have been used to induce analgesia intrathecally when combined spinal epidural is used. The aim of this study is to evaluate the quality of anesthesia, hemodynamic changes, the amount of fluids and ephedrine needed and the effects on neonatal outcome of combined spinal epidural anesthesia with three different low intrathecal doses of hyperbaric bupivacaine and fentanyl for caesarean delivery in preeclampsia patients. 60 parturients with preoperative diagnosis of preeclampsia were scheduled for elective caesarean section under combined spinal epidural regional technique. After preloading with 500ml Ringer lactate, patients were randomly classified into three groups. Group I 20 patients who received intrathecal 5mg hyperbaric bupivacaine 0.5% and 20 micro fentanyl, Group II 20 patients who received 7.5mg hyperbaric bupivacaine 0.5% and 20 micro fentanyl, Group III 20 patients who received 10 mg hyperbaric bupivacaine 0.5% and 20 micro fentanyl. The three study groups were compared with respect to sensory level, the onset of epidural supplementation, the severity of hypotension, heart rate, the dose of ephedrine and amount of fluids needed and neonatal Apgar score and umbilical cord arterial pH. Sensory level has reached T4 level in the three study group with subsequent satisfactory surgical conditions. Patients in group I, required supplemental epidural dose after 45 +/- 3 minutes, while group II, after 60 +/- 2 minutes, group III, after 70 +/- 3 minutes. The incidence of systolic hypotension was significantly lesser in group I, 30% +/- 5 than group II, 42% +/- 3 and group III, 51% +/- 4. The incidence of diastolic hypotension was also significantly lesser in group I, 32% +/- 3 than group II, 43% +/- 2 and group III, 51% +/- 3. Bradycardia was significantly lower in group I than group II and III, [20% +/- 4, 29% +/- 2, 39% +/- 3] respectively. The total fluids needed was significantly higher in group III, 1500 +/- 300, than group II, 1250 +/- 250 and lower in group I, 1000 +/- 200. The dose of ephedrine was significantly higher in group III, 35 +/- 10mg, than group II, 25 +/- 10mg and lower in group I, 15 +/- 5mg. There was no significant difference between the three study groups as regard Apgar score after 1 and 5 minutes and umbilical cord arterial blood pH. Low dose combined spinal epidural regional technique can achieve satisfactory surgical conditions. Subsequent supplement with epidural dose may be needed. Reducing the intrathecal dose of local anesthetic provides a better hemodynamic consequences and the need of ephedrine and intraoperative fluids are reduced with consequent better fetal outcome: