Effects of remifentanil and dexmedetomidine on the mother's awareness and neonatal Apgar scores in caesarean section under general anaesthesia

Anesthetic management for cesarean section in two parturient with ascending aortic aneurysm: a case-based discussion

BACKGROUND

The anesthetic management of parturients with ascending aortic aneurysm for cesarean section can be particularly challenging, primarily because of increased risk for aortic dissection or aneurysm rupture.

CASE PRESENTATION

We present some aspects of the anesthetic management of two parturients with ascending aortic aneurysm for cesarean sections; amongst, the use of remifentanil with its effects on patient and newborn. We emphasize the importance of a cardio-obstetric team in the context of preoperative planning of such patients. Also, we reviewed some literature on the anesthetic management with its effect on peri-operative hemodynamic stability.

CONCLUSION

Maintaining hemodynamic stability is paramount in the prevention of the rupture or dissection of ascending aortic aneurysm during labor of parturient.

Low-Dose Remifentanil in Preterm Cesarean Section with General Anesthesia: A Randomized Controlled Trial

BACKGROUND AND OBJECTIVE

The conventional technique of general anesthesia induction during a Cesarean section involves the use of opioids only after cord clamping. We hypothesized that the use of remifentanil before cord clamping might reduce the use of maternal supplemental anesthetic agents and improve the maternal hemodynamics status and neonatal adaptation of the preterm neonate.

METHODS

A phase III, double-blind, randomized, placebo-controlled, hospital-based trial enrolled parturients undergoing a Cesarean section under general anesthesia before 37 weeks of gestation. Block randomization allocated pregnant women to remifentanil or placebo. The primary outcome was the rate of newborns with Apgar scores < 7 at 5 min. Secondary outcomes were maternal hemodynamic parameters, complications of anesthetic induction, use of adjuvant anesthetic agents, neonatal respiratory distress, umbilical cord pH, and lactate levels.

RESULTS

A total of 52/55 participants were analyzed, comprising 27 women in the remifentanil group and 25 in the placebo group. Nine of 27 (33.3%) neonates had an Apgar score < 7 at 5 min in the remifentanil group versus 11/25 (44.0%) in the placebo group (p = 0.45, odds ratio = 0.66, 95 confidence interval 0.20-2.18). The blood cord gases, cognitive, behavior, sensory, sleeping, and feeding scores at 1 and 2 years of corrected age were not different. For the mothers, hemodynamic parameters, anesthesia duration, and the cumulative treatment dose until cord clamping did not differ between the groups.

CONCLUSIONS

The use of a low dose of remifentanil before cord clamping for a Cesarean section appears to be safe both for the mother and the preterm newborn, but it does not improve maternal or neonatal outcomes.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov: NCT02029898.

The Anesthetic Effect and Safety of Dexmedetomidine in Cesarean Section: A Meta-Analysis

Objective. To evaluate the anesthetic effect and safety of dexmedetomidine in cesarean section. Methods. The Cochrane Library, EMBASE, and PubMed databases (established until September 2020) were searched by computer. Two authors independently screened and extracted literature related to the application of dexmedetomidine in the cesarean section according to inclusion and exclusion criteria. The control group received either subarachnoid block (lumbar anesthesia) or combined lumbar anesthesia and epidural anesthesia (combined lumbar epidural anesthesia) with bupivacaine or combined bupivacaine and fentanyl. The observation group was additionally given dexmedetomidine based on the control group, to analyze the anesthetic effect and safety of dexmedetomidine in cesarean section. Results. A total of 580 cesarean delivery women were included in 8 studies, and the results showed that the peak time of sensory block in the observation group was shorter than that in the control group (standard mean $\text{difference}=-0.28$ ; 95% confidence interval: -0.48, -0.08; $P=0.006$ ), sensory block lasted longer than that in the control group (standard mean $\text{difference}=1.49$ ; 95% confidence interval: 1.21, 1.78; $P<0.00001$ ), the sedation rate was higher than that in the control group, the onset of the first postoperative pain was significantly delayed compared with that in the control group, and the incidence of postoperative pain, nausea and vomiting, postoperative chills, and fever was lower than that in the control group ( $P<0.05$ ). Conclusion. Dexmedetomidine combined with lumbar anesthesia or combined lumbar epidural anesthesia for women in cesarean section has more clinical benefits and better safety.

Effect of intravenous dexmedetomidine and remifentanil on neonatal outcomes after caesarean section under general anaesthesia: A systematic review and meta-analysis

BACKGROUND

Various strategies have been used to mitigate haemodynamic instability during general anaesthesia for caesarean section. However, the safety of these strategies for neonates remains controversial.

OBJECTIVE

To investigate the effects of intravenous dexmedetomidine and remifentanil on neonatal outcomes during caesarean section under general anaesthesia.

DESIGN

Systematic review and meta-analysis of randomised controlled trials.

DATA SOURCES

Databases of PubMed, EMBASE and CENTRAL were searched until March 2020 and updated in February 2021.

ELIGIBILITY CRITERIA

Randomised controlled trials were included if they compared dexmedetomidine and remifentanil infusion on neonatal outcomes after elective caesarean section under general anaesthesia. Primary outcomes were 1 and 5 min Apgar scores. Secondary outcomes were the incidence of neonatal mask ventilation or endotracheal intubation, and pH of the umbilical artery and vein. Studies that did not report primary outcomes were excluded.

RESULTS

Five studies with 258 patients in total were included. The Apgar score at 1 min in the remifentanil group was lower than that in the dexmedetomidine group for both quantitative [weighted mean difference (WMD): 0.75; 95% CI, 0.44 to 1.07; τ2 = 0.00] and categorical outcomes (≥Apgar 7 vs.

CONCLUSION

In our study, Apgar score at 1 min reported using both quantitative and categorical variables were lower in the remifentanil group than in the dexmedetomidine group but TSA showed that these differences were inconclusive for categorical variables. Data for other outcomes were scarce and did not allow any conclusions to be drawn. Thus, further studies with larger numbers of parturients and with neonatal outcomes as a primary endpoint are warranted to clarify the effects of intravenous dexmedetomidine and remifentanil.

TRIAL REGISTRATION

The protocol of this study has been registered in PROSPERO (CRD42019141102).

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MESH Headings

• Anesthesia, General/adverse effects
• Cesarean Section
• Dexmedetomidine/adverse effects
• Female
• Humans
• Infant, Newborn
• Piperidines/adverse effects
• Pregnancy
• Remifentanil

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Affiliation(s)

Myeongjong Lee From the Department of Anesthesiology and Pain Medicine (ML), Research Institute of Medical Science, Konkuk University School of Medicine, Chungju (ML), Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Songpa-gu, Seoul (HK), Department of Anesthesiology and Pain Medicine, Wonkwang University School of Medicine, Muwang-ro, Iksan (CL) and Department of Anesthesiology and Pain Medicine, Chung-Ang University College of Medicine, Heukseok-ro, Dongjak-gu, Seoul, Republic of Korea (HK)
Hyungtae Kim
Cheol Lee
Hyun Kang

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Effects of dexmedetomidine versus remifentanil on mothers and neonates during cesarean section under general anesthesia

BACKGROUND AND AIMS

Dexmedetomidine and remifentanil use in obstetric general anesthesia is controversial. This study aimed to compare the effects of remifentanil and dexmedetomidine on mothers and neonates during cesarean section under general anesthesia.

METHODS

A total of 120 patients scheduled for elective cesarean section under general anesthesia were randomly allocated to dexmedetomidine (D), remifentanil (R), and control (C) groups. Anesthesia was induced with propofol and muscle relaxants in all groups. Anesthesia in groups D and R was induced with dexmedetomidine (induction, 0.5 µg/kg; maintenance, 0.5 µg/kg.h) and remifentanil (induction, 0.5 µg/kg; maintenance, 2 µg/kg.h), respectively, until birth. Group C received equivalent volumes of normal saline. Mean arterial blood pressure (MAP), heart rate (HR), plasma catecholamine, visual analog pain score (VAS), and total tramadol consumption at 1, 2, and 3 hours after extubation were recorded. Neonatal effects were assessed by Apgar scores and umbilical blood gas analysis.

RESULTS

Post induction, MAP was significantly higher in group D compared to groups C and R, and significantly lower in group R than in group C. At intubation/skin incision and delivery, MAP, HR, and plasma epinephrine and norepinephrine concentrations were significantly lower in groups D and R than in group C. Compared to group R, MAP was significantly higher, and HR, plasma epinephrine, and norepinephrine concentrations were significantly lower in group D. Compared with groups C and D, the percentage of neonates with Apgar score < 7 was higher in group R at 1 min after delivery. Compared with groups C and R, the VAS was significantly lower in group D at 1 and 2 h postoperatively. Total tramadol consumption was significantly lower in group D at 3 hours postoperatively.

CONCLUSION

During general anesthesia for cesarean section, remifentanil demonstrated better control of hemodynamic stability, while dexmedetomidine demonstrated better neonatal Apgar scores, postoperative analgesia, and decreased catecholamine release.

TRIAL REGISTRATION

Chinese Clinical Trial Register (ChiCTR) - ChiCTR1800017125.

Effectiveness and safety of intravenous application of dexmedetomidine for cesarean section under general anesthesia: a meta-analysis of randomized trials

Objective

The meta-analysis was conducted to assess the effectiveness and safety of intravenous administration of dexmedetomidine for cesarean section under general anesthesia, as well as neonatal outcomes.

Materials and methods

We searched PubMed, Embase, Cochrane Central Register of Controlled Trials and the China National Knowledge Infrastructure database for relevant randomized controlled trials (RCTs) about the application of intravenous dexmedetomidine under general anesthesia for cesarean section. RevMan 5.3 was used to conduct the meta-analysis of the outcomes of interest.

Results

Eight RCTs involved 376 participants were included in this study. The meta-analysis showed that the mean blood pressure at the time of intubation (weighted mean difference [WMD]: -15.67, 95% CI: -21.21, -10.13, P<0.00001), skin incision (WMD: -12.83, 95% CI -20.53, -5.14, P=0.001), and delivery (WMD: -11.65, 95% CI -17.18, -6.13, P<0.0001) in dexmedetomidine group were significantly lower than that in the control group. The heart rate (HR) at the time of intubation (WMD: -31.41, 95% CI -35.01, -27.81, P<0.00001), skin incision (WMD: -22.32, 95% CI -34.55, -10.10, P=0.0003), and delivery (WMD: -19.07, 95% CI -22.09, -16.04, P<0.00001) were also lower than that in control group. For neonatal parameters, no differences existed in umbilical blood gases at delivery, and Apgar scores at 1 minute (WMD: -0.12, 95% CI -0.37, 0.12, P=0.33) and 5 minutes (WMD: -0.17, 95% CI -0.13, 0.46, P=0.27) among two groups.

Conclusion

Intravenous administration of dexmedetomidine could efficiently attenuate the maternal cardiovascular response during cesarean section, without affecting Apgar score of the neonate.