LOW DOSE SPINAL ANETHESIA

FOR ERACS

Isngadi
Dept. Anesthesiology & Intensive Care
Faculty of Medicine Brawijaya University
Dr Saiful Anwar Hospital
Malang 2022
ANESTHESIA CHOICES FOR CESAREAN
DELIVERY

General, epidural, spinal or combined

spinal epidural (CSE) anesthesia

J Anesth Clin Res 2016, 7:11

 SPINAL ANESTHESIA IS THE PREFERRED
METHOD IN CESAREAN SECTION AS GENERAL
ANESTHESIA

Spinal anesthesia was associated

with higher incidence of hypotension

Int J Obstet Anesth. 2010;19(2):209-12.

 HYPOTENSION IS A VERY COMMON
CONSEQUENCE OF THE SYMPATHETIC
VASOMOTOR BLOCK CAUSED BY SPINAL
ANAESTHESIA FOR CAESAREAN SECTION

maternal and neonatal outcome

Anaesthesia 2018, 73, 71–92 ; British Journal of Anaesthesia 107 (3): 308–18 (2011)
 ERACS

Prevent and treat

spinal anesthesia induced hypotension
 ENHANCED RECOVERY AFTER CESAREAN SURGERY
(ERACS)
• Pre-Operative ERACS Elements
- Limit fasting interval • Solids up to 6-8 hrs prior to cesarean delivery
• Clear fluids up to 2 hrs prior to cesarean delivery
- Non-particulate liquid carbohydrate loading :
• Non-particulate carbohydrate drink up to 2 hrs prior to
cesarean delivery (non-diabetic women only)
• 45 grams carbohydrate is recommended ( Apple juice 475 ml (56 g
carbohydrate).
• Intra-Operative ERACS Elements
- Intravenous fluid optimization
- Prevent and treat spinal anesthesia induced hypotension
• Goal is to prevent intraoperative nausea/vomiting after spinal
anesthesia and maintain uteroplacental perfusion
 ENHANCED RECOVERY AFTER CESAREAN SURGERY
(ERACS)
• Intra-Operative ERACS Elements :
• Maintain normothermia
• Optimal uterotonic administration
• Intra- and Postoperative nausea and vomiting (IONV/PONV) prophylaxis and treatment
• Initiate multimodal analgesia (Neuraxial long-acting opioid : • IT morphine 50-150 mcg)
• Postoperative ERACS Elements:
• Early oral intake
• Early mobilization
• Promotion of resting periods
• Promotion of return of bowel function
• Multimodal analgesia
 HOW TO PREVENT
SPINAL INDUCES HYPOTENSION ?

➢ Preloading/Colloading fluids
➢Uterine displacement
➢Vasoconstrictor
➢Low-dose Local Anestetic

Sao Paulo Med J. 2015; 133(3):227-34; J SOC OBSTET GYNAECOL CAN 1998;20(8):754.61
 THE INCIDENCE OF HYPOTENSION IN WOMEN WHO
RECEIVE SPINAL ANAESTHESIA FOR CAESAREAN
DELIVERY : 69-80%.

?
Low
Prevention of spinal hypotension dose
Spinal

Fetal-maternal adverse outcome

BritishJournalof Anaesthesia114(2): 183–6(2015); Anaesthesia 2018, 73, 71–92

 THE INCIDENCE OF SPINAL ANESTHESIA
INDUCED HYPOTENSION
IS LOCAL ANESTHETIC DOSE DEPENDENT

(Anesth Analg 2013;117:686–93)

 CESAREAN DELIVERY
Traction of peritoneum Local anesthetics
• intraoperative visceral • Higher dose
pain. higher blocks

• intraoperative visceral
pain is reduced
Adverse effect +++

BMC Anesthesiology 2005, 5:5

 CESAREAN DELIVERY
Local Anesthetic
low dose + Opioids

Opioids are able to reduce the dose of Local Anesthetic

Adverse effect - - - Hemodynamic Stability

BMC Anesthesiology 2005, 5:5

 + OPIOID

ERACS

Synergistic
analgesic effect
Inadequate anesthesia
 LOW DOSE SPINAL ANETHESIA FOR ERACS

• Intra-Operative ERACS Elements:

- Prevent spinal anesthesia induced hypotension
- Initiate multimodal analgesia
• Postoperative ERACS Elements:
- Early mobilization
- Multimodal analgesia
- Promotion of return of bowel function

Prevent nausea / vomiting after spinal anesthesia and maintain

uteroplacental perfusion
 LOW DOSE LOCAL ANESTHETICS + OPIOID

➢maternal hemodynamic is ➢duration of adequate

stable surgical block is limited
➢equally efficacious
anesthesia

Still enough for obstetrician in Malang

Acta Anæsthesiologica Belgica, 2006, 57, 383-386.
INTRATHECAL BUPIVACAINE 5 AND 7 MG ARE
SUFICIENT TO PROVIDE SUFICIENT
ANAESTHESIA FOR A CAESAREAN SECTION

Roofthooft E, Van de Velde M. Low-dose spinal anaesthesia for Caesarean

section to preventspinal-induced hypotension. Curr Opin Anaesthesiol
2008;21:259–62.
Low-dose bupivacaine can limit the distribution of spinal
block to reduce adverse haemodynamic effects.

Intrathecal opioids can enhance analgesia in combination

with subtherapeutic doses of local anaesthetics

British Journal of Anaesthesia 103 (5): 750–4 (2009)

 SINCE THE DISCOVERY OF OPIATE RECEPTORS IN THE BRAIN
AND SPINAL CORD, THE USE OF INTRATHECAL OPIOIDS HAS
BECOME COMMON PRACTICE AS ON EFFECTIVE METHOD OF
ANALGESIA

Fentanyl is the most commonly used spinal lipophilic opioids. The

combination therefore, has, the advantage of a prompt onset of
analgesia and a long action, and has been used for spinal
anesthesia in obstetric

AĞRI 2011;23(2):57-63
 INTRATHECAL FENTANYL DOSES
(6.25 ug – 50 ug)
➢to improve intraoperative analgesia in doses ≥6.25 µg

➢No additional benefit was found by increasing the

intrathecal fentanyl dose > 50 ug

➢Recommend using 20-30 ug suplement bupivacain IT

Anesthesiology 1989;71(4):535-40, AĞRI 2011;23(2):57-63

 POSTOPERATIVE ANALGESIA INCREASED IN
DURATION WITH INCREASING FENTANYL DOSES,
WHILE SPINAL ANESTHETIC MOTOR AND
SENSORY RECOVERY TIMES WERE NOT
PROLONGED

Reg Anesth Pain Med 1999;24(3):255-63

 Lovering the dose
improves maternal haemodinamic stability
 ADDITION OF FENTANYL INTRATHECAL

1. Reduse baricity
2. Reduce the supplementary analgesia requirement
3. Produces satisfactory level of anaesthesia
4. Extent of sensory & motor block
5. Hemodinamic stability

J Pak Med Assoc . Vol. 62, No. 8, August 2012

THE USE OF A LOWER DOSE SPINAL ANAESTHESIA
• Decreases maternal side effect :
• Hypotension
• Nausea
• Vomiting
• Reduce the time to discharge
• Improve maternal satisfaction

✓ compromise the adequacy of anaesthesia Low dose Spinal

✓ supplementary analgesia +
✓ conversion to general anaesthesia Epidural

British Journal of Anaesthesia 107 (3): 308–18 (2011)

OPIOIDS AS ADJUVANTS TO NEURAXIAL ANAESTHESIA
IMPROVE THE QUALITY OF THE BLOCK WITHOUT
PRODUCING A HIGHER LEVEL OF ANALGESIA TO
PINPRICK

Low-dose spinal anaesthesia may not

be the optimal technique for all
patients and institutions
British Journal of Anaesthesia 107 (3): 308–18 (2011 )
MULTI MODAL ANALGESIA
 USE OF LEVOBUPIVACAINE

The indications for levobupivacaine include epidural,

intrathecal, peripheral nerve block, peribulbar
administration and local infiltration for surgical
anaesthesia in adults. Levobupivacaine is also indicated for
epidural use for the management of pain, including
labour and postoperative pain in adults. In children,
levobupivacaine is indicated for ilioinguinal/iliohypogastric
nerve block.

Foster RH, Markham A. Levobupivacaine: A review of its pharmacology and use as a local anaesthetic Drugs 2000;59:551-79
Comparative study of isobaric levobupivacaine and hyperbaric
bupivacaine for subarachnoid block in elective cesarean sections
Dinesh Govinda Rao1, Shalini A.2* , Nayaz Pasha3

Objectives:
To evaluate the clinical efficacy of intrathecal 0.5% isobaric levobupivacaine compared to 0.5%
hyperbaric bupivacaine with fentanyl 25 μg for elective LSCS.

Methods:
❑ Each group received either 8 mg of 0.5% isobaric levobupivacaine + 25 μg fentanyl (Group-L) or
8 mg of 0.5% hyperbaric bupivacaine + 25 μg fentanyl (Group-B).
❑ Sensory and motor block characteristics of both groups were assessed with pinprick and Bromage
scale; neonatal APGAR scores, hemodynamic changes and side effects, if any, were recorded.
 Comparative study of isobaric levobupivacaine and hyperbaric
bupivacaine for subarachnoid block in elective cesarean sections
Dinesh Govinda Rao1, Shalini A.2*, Nayaz Pasha3

Thus isobaric levobupivacaine produces motor block of shorter duration yet sufficient for cesarean
sections and favors early postoperative ambulation, preventing postoperative
complications like DVT and thromboembolic phenomena.
 J Obstet Anaesth Crit Care 2015;5:78-83.
OBJECTIVE : to compare the quality of sensory and motor block and side effects if any, following intrathecal levobupivacaine and hyperbaric bupivacaine,
in parturients undergoing elective cesarean section.
METODE : 60 patients ASA I and II parturients for the elective cesarean section . Subarachnoid block was performed with 2 ml of 0.5% isobaric
levobupivacaine in Group L (n=30) and 2 ml of 0.5% hyperbaric bupivacaine in Group B (n=30)

• Duggal, R et. Al, A Comparison of intrathecal levobupivacaine with hyperbaric bupivacaine for elective cesarean section: A prospective randomized double-blind study. Journal of Obstetric Anaesthesia and
Critical Care. 2015
Intrathecal 7.5 mg hyperbaric levobupivacaine
and 25 mcg fentanyl combination is good
alternative to 7.5 mg bupivacaine - 25 mcg
fentanyl combination in cesarean surgery as it is
less effective in motor block, but it maintains
hemodynamic stability at higher sensorial block
levels.
Conclusions
Our study demonstrated that the addition of sufentanil and fentanyl
to intrathecal levobupivacaine during caesarean section surgery is
more effective than the administration of levobupivacaine alone. The
addition of sufentanil to levobupivacaine allowed rapid onset time for
sensory and motor block levels. It also extended the duration of
postoperative analgesia, and led to a decrease in total analgesic
requirement.
 SUMMARY
1) Hypotension is a very common consequence of spinal anaesthesia for
caesarean section.

2) Prevent and treat spinal anesthesia induced hypotension are Intra-

Operative ERAC Elements

3) Low dose of local anesthetic + Opioid (IT) could be minimized

hypotension of spinal anesthesia but not be the optimal technique for
all patients and institutions

4) Intrathecal opioids can enhance analgesia in combination with

subtherapeutic doses of local anaesthetics