engleski

An different approach to CSE-EVE for reducing hypothension during Caesarean section under spinal anaesthesia

Background and Objectives: Spinal anaesthesia is the most preferred anaesthetic technique for elective as well as for unplanned Caesarean section. Spinal-induced hypotension remains the most important side effect with a reported incidence between 20% and 100%. It can cause maternal discomfort (nausea and vomiting) and impaired utero-placental perfusion. The present study was designed to examine the influence of epidural volume effect on the spread and duration of low dose hyperbaric levobupivacaine. The aim of this study was to evaluate the influence of epidural restriction (injection of saline) on the distribution of anaesthesia as well as the incidence of hypotension during the spinal anaesthesia. Methods: After the approval by Ethics Committee, 60 full term parturient women (ASA I or II) with uncomplicated pregnancies were prospectively randomized into two groups: SA group (single shot spinal anaesthesia) included 37 patients and CSE-EVR (combined spinal-epidural anaesthesia) included 39 patients were we induced the restriction of the spinal space by epidural volume compression. The blocks were performed at L2/3 or L3/4 level in sitting position, in CSE-EVR group using the needle through-needle technique. The initial dose for CSE-EVR was exactly half of the SA dose (0, 5 mg per 10 cm height of hyperbaric levobupivacaine and 20microg fentanyl). After spinal injection, an epidural catheter was located in the CSE- EVR and injected a volume of 20 ml saline solution. After injection women, were turned supine with a left uterine displacement. Surgery was allowed when a sensory block at or above T8 dermatome was established. We evaluated the height of the block by the pinprick method and the motor block by Bromage scale, 10 minutes after spinal injection, during the operation time and at the end of surgery. Hemodynamic monitoring (NIBP, HR) was assessed every 2 minutes until the childbirth, then every 5 minutes during operative time. Anaesthetic efficacy was evaluated for breakthrough pain by visual analogue pain score (VAPS), Apgar score at birth, umbilical artery- pH, and epinephrine consumption. Results: The level of anaesthesia 10 minutes after the induction was significantly higher in spinal group (SA) than in CSE-EVR T5 (T4-T7) vs.T7(T6-T8).The SA group experienced complete motor block during the time of anaesthesia, while the CSE-EVR group demonstrated significantly faster motor recovery. The incidence of hypotension and ephedrine supplementation was significantly lower in the CSE-EVR group (19 patients vs.35) than in the SA group (p<0.05).The neonatal outcome and umbilical artery-pH was higher in the CSE-EVR group. Both groups were comparable in demographic data, VAS scores, preloading and infusion volume, atropine or ephedrine use, and adverse effects as nausea or skin pruritus. Conclusions: We demonstrated a possible restriction of the spread of spinal anaesthesia by using epidural volume restriction with 20 ml saline as part of a combined spinal epidural technique. The study shows that CSE with EVR with only 50% of the levobupivacaine dose provided adequate anaesthesia for elective caesarean delivery, as well as better maternal hemodynamic stability.

combined spinal-epidural anaesthesia ; epidural volume expansion ; levobupivacaine ; hemodynamic ; caesarean section

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