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Spinalvolfor LSCS
Spinalvolfor LSCS
In groups 2 and 3, the corresponding bupivacaine two-way ANOVA followed by Tukey’s test for
volumes were 3.6 and 4.0 ml, and 4.0 and 4.4 ml, parametric data, and the chi-square test with Yates’
respectively. All subarachnoid blocks were per- correction, the Kruskall-Wallis followed by the
formed by one anaesthetist and data were collected Mann–Whitney U test for non-parametric data. P
by two registrars who were blinded to the solutions 0.05 was considered statistically significant.
used.
All parturients received ranitidine 10 mg and Results
glycopyrronium 0.2 mg i.m., 1 h before arrival in the
operating room. All patients received an infusion of There were no statistically significant differences in
lactated Ringer’s solution 1000 ml over 10–20 min mean age, weight, height and gestational age between
before induction. They were also given ephedrine the three groups (table 1). In four patients in group
40 mg i.m., approximately 10 min before sub- 1, the spinal was converted to general anaesthesia
arachnoid injection. Subarachnoid injection was 10–15 min after delivery of the neonate because
performed in the right lateral decubitus position surgical anaesthesia was inadequate. These patients
with a 25-gauge Quincke spinal needle, using a were excluded from further analysis of sensory and
midline approach at the L2–3 or L3–4 interspace. motor block.
The predetermined volume of local anaesthetic was Onset and segmental spread of sensory analgesia
injected over 20–30 s without barbotage. After are shown in figure 1. Cephalad spread of sensory
subarachnoid injection, mothers were immediately analgesia was increased significantly with an increase
turned supine with left uterine displacement. The in volume, and the differences between groups 1 and
parturient’s head was rested on a pillow. 3 and between groups 2 and 3 were significant. Onset
The spread of sensory block to pinprick was time of sensory analgesia to T6 was significantly
measured at 2-min intervals during the first 10 min faster in group 3 than in group 1. The mean maximal
and then at 5-min intervals. The degree of motor level of analgesia in group 3 (T2–3) was significantly
block of the lower extremities was also assessed at the higher than that in groups 1 and 2 (T4–5 in each),
same interval, using the modified Bromage scale: 0 and the times to achieve the maximal level were
no paralysis; 1 unable to raise the extended leg; similar, with an average of 10–15 min between the
2 unable to flex knee; 3 unable to flex ankle. three groups. Sensory analgesia at or above T6 was
Maternal arterial pressure and heart rate were obtained in all patients, but sensory analgesia below
recorded every minute until delivery and every
5 min thereafter, using an automated, non-invasive
Table 1 Patient characteristics (mean (SD or range))
device (Sirecust 404, Simens, Germany). If hy-
potension (systolic arterial pressure less than Group 1 Group 2 Group 3
100 mm Hg or a 20 % reduction in systolic arterial (n 20) (n 20) (n 20)
pressure) occurred, it was treated promptly by Age (yr) 30.0 (23–34) 29.9 (25–35) 29.4 (24–36)
increasing uterine displacement and the rate of fluid Height (cm) 159.5 (2.4) 158.8 (2.2) 160.6 (2.7)
administration. If hypotension persisted despite Weight (kg) 65.0 (8.5) 65.6 (5.9) 68.4 (8.5)
these measures, ephedrine 10 mg was given i.v. and Gestation (weeks) 37.8 (0.9) 38.3 (0.8) 37.9 (2.1)
repeated as needed. Oxygen was administered
routinely by face mask at 6 litre min1 until the end
of operation. When sensory block at or above T6 was
established, surgery were commenced. The inci-
dence and frequency of complications were noted.
The efficacy of intraoperative analgesia was as-
sessed by the following four categories: excellent
no discomfort during the procedure; good mild
discomfort but required no systemic analgesia;
fair pain that required additional analgesia; and
poor moderate or severe pain that needed more
than fentanyl 100 g or general anaesthesia.
When the patient complained of pain, fentanyl
50 g was given i.v. and repeated as needed. I.v.
midazolam 2.5 mg was administered if the patient
requested to sleep after the birth of the baby. I.v.
droperidol 0.625 mg was used to treat nausea or
vomiting. The times of bupivacaine injection, start
of surgery, delivery and termination of surgery were
recorded. The condition of the neonates was assessed
by Apgar score at 1 and 5 min after delivery. All
mothers received oxytocin by continuous infusion
after delivery. Return of sensory and motor function
was assessed at 15-min intervals until complete Figure 1 Onset and segmental spread of sensory analgesia after
subarachnoid injection of 0.25 % bupivacaine in 5 % glucose for
recovery from anaesthesia. term parturients in group 1 (3.2–3.6 ml (●)), group 2
All data are expressed as number or mean (SD or (3.6–4.0 ml (■)) and group 3 (4.0–4.4 ml (▲). *P 0.05 vs
range). The results were analysed using one-way and group 1, †P 0.05 vs groups 1 and 2.
Spinal anesthesia for Caesarean section 147
Table 2 Comparison of times of onset and regression of Table 3 Incision direction and surgical times (mean (SD) or
subarachnoid block (mean (SD)). *P 0.05 vs group 1 number). Long/trans Longitudinal/transverse
Excellent 4 10 16
Good 2 5 2
Fair 9 5 2
Poor 5 0 0
comfort at incision from skin to the uterus. Petersen 5. Sheskey MC, Rocco AG, Bizzarri-Schmid M, Francis DM,
and co-workers [12] reported that similar spread of Edstrom H, Covino BG. A dose–response study of bupi-
vacaine for spinal anesthesia. Anesthesia and Analgesia 1983;
sensory block to above T3 developed in patients who 62: 931–935.
received 7.5–10 mg and 10–12.5 mg of 0.5 % hyper- 6. Bengtsson M, Malmqvist L-A, Edstrom HH. Spinal analgesia
baric bupivacaine solution, but the use of a larger with glucose-free bupivacaine: effect of volume and con-
dose of bupivacaine resulted in a lesser frequency of centration. Acta Anaesthesiologica Scandinavica 1984; 28:
583–586.
moderate to severe visceral pain. In our study, the 7. Mukkada TA, Bridenbaugh PO, Singh PM, Edstrom HH.
frequency of visceral pain and requirement for Effects of dose, volume, and concentration of glucose-free
supplementary opioids were significantly less in the bupivacaine in spinal anesthesia. Regional Anesthesia 1986;
3.6–4.0-ml and 4.0–4.4-ml groups than in the 11: 98–101.
3.2–3.6-ml group. 8. Axelsson KH, Edstrom HH, Sundberg AEA, Widman GB.
Spinal anaesthesia with hyperbaric bupivacaine: effects of
A variety of ways have been tried to improve the volume. Acta Anaesthesiologica Scandinavica 1982; 26:
quality of spinal anaesthesia during Caesarean sec- 439–454.
tion. Injecting larger doses of local anaesthetic can 9. Chambers WA, Littlewood DG, Edstrom HH, Scott DB.
improve the quality of sensory block [12, 16]. In Spinal anaesthesia with hyperbaric bupivacaine: effects of
concentration and volume administered. British Journal of
0.25 % hyperbaric bupivacaine solution, increasing Anaesthesia 1982: 54; 75–80.
volume to increase the dose is not recommended 10. Stienstra R, Greene NM. Factors affecting the subarachnoid
because the large volume itself would cause cervical spread of local anesthetic solution. Regional Anesthesia 1991;
spinal block and severe hypotension. The addition of 16: 1–6.
adrenaline [17], morphine [18] or fentanyl [19] to 11. Santos S, Pedersen H, Finster M, Edstrom H. Hyperbaric
bupivacaine for spinal anesthesia in cesarean section. Anes-
hyperbaric bupivacaine solution improved the qual- thesia and Analgesia 1984; 63: 1009–1013.
ity of bupivacaine intraoperative analgesia. In our 12. Pedersen H, Santos AC, Steinberg ES, Schapiro HM.
study with 0.25 % hyperbaric bupivacaine, a larger Harmon TW, Finster M. Incidence of visceral pain during
dose improved the quality of sensory analgesia, but cesarean section: the effect of varying doses of spinal
bupivacaine Anesthesia and Analgesia 1989; 69: 46–49.
the incidence of hypotension and its severity were 13. Van Zundert AA, De Woff AM, Vaes L, Soetens M. High
greater with volumes exceeding 4.0 ml. volume spinal anesthesia with bupivacaine 0.125 % for
cesarean section. Anesthesiology 1988; 69: 998–1003.
14. Russell IF. Spinal anesthesia for cesarean delivery with dilute
solutions of plain bupivacaine: the relationship between
Acknowledgements infused volume and spread. Regional Anesthesia 1991; 16:
This work was supported in part by a grant from Dong-A 130–136.
University, Korea. 15. Vucevic M, Russell IF. Spinal anaesthesia for Caesarean
section: 0.125 % plain bupivacaine 12 ml compared with
0.5 % plain bupivacaine 3 ml. British Journal of Anaesthesia
1992; 68: 590–559.
16. DeSimone CA, Norris MC, Leighton B, Epstein R, Palmer
C, Kaplan S, Goodman D. Spinal anesthesia with hyperbaric
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