Welcome to Scribd, the world's digital library. Read, publish, and share books and documents. See more
Download
Standard view
Full view
of .
Save to My Library
Look up keyword
Like this
1Activity
0 of .
Results for:
No results containing your search query
P. 1
1

1

Ratings: (0)|Views: 150|Likes:
Published by t3kla

More info:

Published by: t3kla on Apr 25, 2011
Copyright:Attribution Non-commercial

Availability:

Read on Scribd mobile: iPhone, iPad and Android.
download as PDF, TXT or read online from Scribd
See more
See less

08/15/2013

pdf

text

original

 
 Acta Anaesthesiol Scand 2002;
46: 
441–446
Copyright
C
 Acta Anaesthesiol Scand 2002
Printed in Denmark. All rights reserved
ACTA ANAESTHESIOLOGICA SCANDINAVICA
0001-5172
Effect of delayed supine positioning after induction ofspinal anaesthesia for caesarean section
F. K
ØHLER
, J. F. S
ØRENSEN
and H. S. H
ELBO
-H
ANSEN
Department of Anesthesiology and Intensive Care Medicine, Odense University Hospital, Denmark
Background:
The study tested the hypothesis that the inci-dence of hypotension during spinal anaesthesia for caesareansection is less in parturients who remain in the sitting positionfor 3min compared with parturients who are placed in themodified supine position immediately after induction of spinalanesthesia.
Methods:
Spinal anaesthesia was induced with the woman inthe sitting position using 2.8ml hyperbaric bupivacaine 0.5% atthe L
3
ª
4
or L
2
ª
3
interspace. Ninety-eight patients scheduled forelective caesarean section under spinal anaesthesia were ran-domised to assume the supine position on an operating tabletilted 10
æ
to the left (modified supine position) immediately afterspinal injection (group 0, n
52) or to remain in the sitting posi-tion for 3min before they also assumed the modified supineposition (group 3, n
46). Isotonic saline 2–300ml was given in-travenously over 15min before spinal injection followed by 15ml/kg over 15–20min after induction of spinal anaesthesia. Ifthe systolic blood pressure decreased to less than 70% of base-line or to less than 100mmHg or if there was any complaint ofnausea, ephedrine was given in 5mg boluses intravenouslyevery 2min.
Results:
The blood pressure decreased significantly in bothgroups following spinal injection (
P
0.001). Blood pressure
A
RTERIAL
hypotension frequently complicates spinalanaesthesia for elective caesarean section at term.Preventive measures include left uterine displace-ment, special positioning techniques, vasopressor ad-ministration, fluid preloading and techniques thatmechanically compress the venous compartments ofthe legs (1, 2).Hypotension occurs less frequently and is less se-vere with epidural than with spinal anaesthesia (3–5). The slower onset of epidural anaesthesia givingthe body longer to compensate for the occurrence ofsympathetic blockade might explain this, as the de-gree of sympathetic blockade is similar with spinaland epidural anaesthesia (6). It may therefore be poss-ible to reduce the incidence and severity of maternalhypotension by slowing the onset of spinal anaes-thesia.When spinal anaesthesia is performed with a wo-
441
variations over time differed significantly between the twogroups (
P
0.05). However, the incidence of maternal hypoten-sion before delivery was similar in the two groups. The differ-ence was caused by the time to the blood pressure nadir beingsignificantly shorter in group 0 compared with group 3 (9.1
4.5min vs. 11.7
3.7min,
P
0.01). Similar numbers of patients re-ceived rescue with ephedrine before delivery: 35 (67%) in group0 vs. 26 (57%) in group 3 (NS). The mean total dose of ephedrine before delivery was 10.9mg in group 0 vs. 9.2mg in group 3(NS). There were no differences in neonatal outcome betweenthe two groups.
Conclusion:
At elective caesarean section, a 3-min delay be-fore supine positioning does not influence the incidence of mat-ernal hypotension after induction of spinal anaesthesia in thesitting position with 2.8ml of bupivacaine 0.5% with 8% dex-trose.
Received 28 May 2000, accepted for publication 12 October 2001
Key words:
anaesthesia; obstetrical; spinal; bupivacaine.
c
 Acta Anaesthesiologica Scandinavica 46 (2002)
man sitting, a hyperbaric solution will pass caudallyunder the influence of gravity. Once the patient isplaced supine, even in the tilted or wedged supineposition, some degree of vena caval occlusion withconsequent epidural venous plexus engorgement willoccur acutely (7). Gravity and the sudden com-pression of the dural sac forces CSF and the local an-esthetic solution in the cranial direction extending the block to the upper thoracic dermatomes (8–12).Allowing the patient to remain in the sitting positionfor some time after injection of a hyperbaric solutionmay therefore delay the onset of anaesthesia in thethoracic dermatomes and reduce the incidence and se-verity of maternal hypotension. However, when thesitting position is used to site spinal anaesthesia forcaesarean section, it is recommended that the woman be laid supine very quickly (13, 14). We were thereforereluctant to study the effect of longer periods in the
 
F. Køhler et al.
sitting position and chose to study a period of 3min,with which we had gained experience from the com- bined spinal epidural technique.The study tested the hypothesis that the incidenceof maternal hypotension is less in patients, who re-main in the sitting position for 3min compared withpatients who are placed in the modified supine posi-tion immediately after induction of spinal anaesthesiausing 2.8ml of bupivacaine 0.5% with 8.0% dextrose.
Methods
We studied 100 healthy women (American Society ofAnesthesiologists: physical class I or II) consenting tospinal anaesthesia for elective caesarean section. Thelocal Ethics Committee approved the protocol and in-formed consent was obtained from each patient at thepreoperative visit the day before surgery. Patientswith pre-eclampsia, arterial hypertension, gestationalage of less than 38weeks or multiple pregnancy wereexcluded. All women received oral ranitidine 150mgthe night before and on the morning of surgery.Spinal anaesthesia was induced with the patient inthe sitting position with her feet supported on a chair.A 25-gauge pencil-point needle was inserted at theL
2
ª
3
or L
3
ª
4
interspace, with the ejection orifice point-ing cephalad. Bupivacaine 0.5% with 8.0% dextrose(Marcaine
A
Spinal Heavy 0.5%, ASTRA, Sweden) 2.8ml was injected over a 10–20 section. Intrathecalopioids were not given.Two randomization parallel groups were achieved by computer generated codes. Assignments were keptin sealed sequentially numbered opaque envelopes.The envelope was opened immediately after thespinal needle had been withdrawn from the patient.Women in group 0 were placed in the modified supineposition immediately after spinal injection. Women ingroup 3 remained sitting for 3min after induction ofspinal anaesthesia and were then also placed in themodified supine position. From the sitting position,the women were turned in the left lateral position, theoperating table was then tilted 10
æ
to the left and fi-nally the women were turned supine while avoidingstraining. The operating table was kept horizontal inthe longitudinal direction. Using an incline meter con-trolled the degree of tilting. The degree of tilting wasequal for all patients and kept constant until after de-livery, at which time the operating table was placedin neutral position.Before anesthetic induction, 2–300ml of isotonic sa-line was given over 15min. After induction of spinalanaesthesia, an additional 15ml/kg of isotonic salinewas infused over the following 15–20min. Inspired air
442
was supplemented with oxygen 3l/min via a nasalcatheter until delivery. If the systolic blood pressuredecreased to less than 70% of baseline or to less than100mmHg or if there was any complaint of nausea,ephedrine was given in 5mg boluses intravenouslyevery 2min until hypotension was corrected. No ad-ditional fluids were given. Atropine 0.5mg was givenintravenously in case the heart rate decreased to lessthan 60beats/min. Surgery was allowed to begin 15min after induction of spinal anaesthesia. All mothersreceived an intravenous bolus dose of oxytocin 10IUafter delivery of the baby.Systolic arterial pressure (SAP), mean arterial press-ure (MAP) and diastolic arterial pressure (DAP) weremeasured in the left arm at 1-min intervals by anautomated oscillometric technique until 30min afterinduction of spinal anaesthesia and at 5-min intervalsthereafter (Datex AS/3, Helsinki, Finland). Heart rateand oxygen saturation were recorded at 3s intervals.Baseline measurements were recorded after a 5-minperiod of rest in the left lateral recumbent position.All data were recorded on-line on a computer disk(Datex AS/3 PC Data Collection Software Version 2.1,Helsinki, Finland). Haemodynamic data were latertransferred to a database by a person blind to whichgroup the patient had been allocated. Maternal hypo-tension was defined as a decrease in SAP to less than100mmHg or to less than 70% of baseline.Dermatomal level of anaesthesia was assessed usingloss of temperature sensation to an ice cube, startingin the groin and moving cephalad at 10, 15, 20 and 120min after induction and at end of surgery. Intensity ofnausea and pain was evaluated using a four pointcategorical verbal rating scale (0
none, 1
mild, 2
moderate, 4
severe). Patients were asked to rate theirnausea during periods of hypotension, when theyspontaneously complained of nausea and finally be-fore start of surgery. Patients were asked to rate theirpain experience at skin incision, at delivery, duringuterine repair and finally during closure of the abdo-men. The time from intrathecal injection to deliveryand time from uterine incision to delivery were re-corded. Umbilical arterial and venous blood sampleswere obtained from a segment of cord, doubly clamp-ed before the baby’s first breath, for analysis of bloodgas tensions and acid base status (ABL-700, Radi-ometer, Denmark). Apgar scores also assessed thecondition of the neonates at 1 and 5min, and by timefrom delivery to sustained respiration (TSR).The sample size was based on a power calculation,which showed that 50 patients per group were necess-ary to detect a difference in MAP of 10mmHg or areduction of the incidence of maternal hypotension by
 
Delayed supine positioning
50% (
bΩ
0.10,
aΩ
0.05, two-tailed). Results are reportedas mean
SD except where noted otherwise. Re-peated measures analysis of variance (ANOVA) wasused to analyze measurements of blood pressure andheart rate over time and between groups. Where dif-ferences existed,
post hoc
pair-wise comparisons be-tween groups at individual time points were analyzedusing Bonferroni-corrected unpaired Student’s
t
-tests.Nonparametric data were analyzed using chi-squareand Fisher’s exact tests.
P
0.05 was considered statis-tically significant.
Results
Two patients were withdrawn from the study, one be-cause of electrical power failure and one because of
Fig.1. Individual segmental spread of anaesthesia 10, 15, 20 and 120min from time of induction of spinal anaesthesia and at end of surgery.Fig.2. Mean arterial pressure (MAP) from time of induction of spinalanaesthesia. Values are mean
SEM. *P
0.05 between groups at indi-vidual time points.
443
violation of selection criteria. Remaining were 52 pa-tients in group 0 and 46 patients in group 3.Group 0 and group 3 were similar with regard toage (31
5years vs. 31
5years), body weight (85
14kg vs. 82
17kg), height (166
6cm vs. 166
15cm), baseline SAP (131
14mmHg vs. 122
12mmHg), baseline MAP (95
12mmHg vs. 89
11mmHg), and baseline heart rate (84
16/min
ª
1
vs. 80
17/).The dermatomal spread of anaesthesia to cold isshown in Fig.1. The level of anaesthesia spread todermatomal levels higher than T1 in 12 (23%) patientsin group 0 vs. one (2%) patient in group 3 (
P
0.01).All patients had total motor block of the lower limbsat the end of the operation. Before delivery, one pa-tient in group 3 experienced mild pain vs. none ingroup 0. After delivery, three patients from eachgroup experienced mild pain, and two patients fromeach group experienced moderate pain. The patientexperiencing moderate pain received 0.1mg fentanyl.Blood pressures: SAP, MAP and DAP decreased sig-nificantly in both groups following spinal injection(
P
0.001). Mean arterial blood pressures 0–30min fol-lowing spinal injection are shown in Fig.2. A signifi-cant difference with regard to blood pressure vari-ation over time between the two groups was demon-strated (
P
0.05). However, the incidence of maternalhypotension before delivery was similar in the twogroups (Table1): the difference was caused by thetime to the blood pressure nadir being significantlyshorter in group 0 compared with group 3 (9.1
4.5min vs. 11.7
3.7min,
P
0.01). Similar numbers of pa-tients received rescue with ephedrine before delivery:35 (67%) in group 0 vs. 26 (57%) in group 3 (NS). Themean total dose of ephedrine before delivery was 10.9mg in group 0 vs. 9.2mg in group 3 (NS). The ac-cumulated doses of ephedrine in the two groups aredepicted in Fig.3. Heart rate variations were compar-able in the two groups. Atropine 0.5mg was given tofive (10%) women in group 0 vs. seven (15%) in group
Table1
Maternal hypotension (systolic arterial pressure
100mmHg or
70% of baseline) and lowest systolic arterial blood pressure beforedelivery. Values are number (%) of patients. There were no significantdifferences between the groups.Group 0 Group 3(n
52) (n
46)Hypotension 35(67%) 25(54%)SAP
90mmHg 16(31%) 13(28%)SAP
80mmHg 6(12%) 6(13%)SAP
70mmHg 2(4%) 2(4%)
SAP,
systolic arterial pressure.

You're Reading a Free Preview

Download
/*********** DO NOT ALTER ANYTHING BELOW THIS LINE ! ************/ var s_code=s.t();if(s_code)document.write(s_code)//-->