The effect of type of anesthesia on intra-and postoperative blood loss at elective cesarean section

Impact of anesthetic agents on the amount of bleeding during dilatation and evacuation: A systematic review and meta-analysis

Purpose

Patients undergo dilatation and evacuation for abortion or miscarriage. However, bleeding is sometimes problematic. Despite reports on the association between volatile anesthetics and increased bleeding during the procedure, firm evidence is lacking. Therefore, we conducted a systematic review and meta-analysis to compare the effects of volatile anesthetics and propofol on the amount of bleeding in patients undergoing dilatation and evacuation.

Methods

We conducted a systematic search of four databases, namely PubMed, Embase, Cochrane Central Register of Controlled Trials databases, and Web of Science (Clarivate Analytics), from their respective inception to April 2021. Moreover, we searched two trial registration sites. The inclusion criterion was randomized controlled trials of patients who underwent dilatation and evacuation under general anesthesia using volatile anesthetics or propofol. The primary outcome was the amount of perioperative bleeding. The mean difference of the bleeding was combined using a random-effects model. The I² statistic was used to assess heterogeneity. We assessed risk of bias with Cochrane domains. We controlled type I and II errors due to sparse data and repetitive testing with Trial Sequential Analysis. We assessed the quality of evidence with GRADE.

Results

Five studies were included in the systematic review. The amount of bleeding was compared in four studies and was higher in the volatile anesthetic group, with a mean difference of 164.7 ml (95% confidence interval, 43.6 to 285.7; p = 0.04). Heterogeneity was considerable, with an I² value of 97%. Two studies evaluated the incidence of significant bleeding, which was significantly higher in the volatile anesthetic group (RR, 2.42; 95% confidence interval, 1.04–5.63; p = 0.04).

Conclusion

Choosing propofol over volatile anesthetics during dilatation and evacuation might reduce bleeding and the incidence of excessive bleeding. However, the quality of the evidence was very low. This necessitates further trials with a low risk of bias.

Trial registration

PROSPERO (CRD42019120873).

The Effect of Different Doses of Intrathecal Hyperbaric Bupivacaine Plus Sufentanil in Spinal Anesthesia for Cesarean Sections

Background

Decreasing side effects and improving the quality of block in caesarean sections by appropriate dosage of local anesthetics and adjuvants could play an important role in the safe management of cesarean section. The present study aimed at comparing the effects of 3 different doses of intrathecal hyperbaric bupivacaine injected with a fixed dose of sufentanil in cesarean sections.

Methods

In a double- blind randomized clinical trial, 105 candidates of elective cesarean section were randomly assigned into 3 groups of 8, 9, and 10 mg of intrathecal bupivacaine plus sufentanil 2.5 µg. The maximum level of sensory block, the intensity of motor block, and vital signs were measured at regular intervals. The incidence of hypotension and bradycardia were also recorded.

Results

No significant difference was found between the maximum level of sensory block and the intensity of motor block in 3 groups. The incidences of hypotension and bradycardia as well as administration of atropine and ephedrine were comparable among the 3 groups (P > 0.05).

Conclusions

According to similar effects of different doses of bupivacaine, administration of lower doses of bupivacaine (8mg) is more reasonable for spinal anesthesia for cesarean section.

Blood loss in elective cesarean section: is there a difference related to the type of anesthesia? A randomized prospective study

OBJECTIVE

We aimed to compare the effect of general and spinal anesthesia on maternal blood loss in elective cesarean section (CS).

MATERIAL AND METHODS

This was a prospective randomized study and included 418 healthy pregnant women with a term uncomplicated singleton pregnancy between 37 and 41 weeks of gestation. The study participants were randomly divided into two groups: the general anesthesia group and spinal anesthesia group. CSs were all performed using the same surgical technique, and within the groups, the same anesthetic procedures were used (either general or spinal). The primary outcome for this study was operative blood loss. Hemoglobin and hematocrit concentrations were compared between the two groups.

RESULTS

The preoperative hemoglobin and hematocrit levels were similar in the both groups (p=0.08 and p=0.239, respectively). Significantly lower operative blood loss was achieved using spinal anesthesia versus general anesthesia during elective CS. The differences between preoperative and postoperative blood values for both the study groups were statistically significant (p<0.001).

CONCLUSION

This study demonstrates that spinal anesthesia is associated with a lower risk of operative blood loss than general anesthesia in low risk patients undergoing elective CS.

Is general anaesthesia for caesarean section associated with postpartum haemorrhage? Systematic review and meta-analysis

BACKGROUND

Postpartum haemorrhage (PPH) remains a leading cause of maternal morbidity and mortality. The odds for PPH were about eight times higher following general anaesthesia compared with neuraxial anaesthesia in a recent retrospective study. We aimed to conduct a systematic review and meta-analysis of the effect of type of anaesthesia (general vs. neuraxial) on estimated blood loss and transfusion requirements after caesarean section.

METHODS

A systematic literature search was performed. The quality of eligible reports was assessed using the Oxford Quality Scale. Data were subjected to meta-analysis using the random effects model.

RESULTS

The search identified 18 articles including 12,330 parturients. Meta-analysis of randomised controlled trials (RCTs) found a significant difference in blood loss, favouring neuraxial anaesthesia (spinal and epidural) when comparing with general anaesthesia {weighted mean difference -106.11 ml [95% confidence interval (CI) -209.80, -2.42 ml], P = 0.04}. In further analyses, we found a significant difference after epidural compared with general anaesthesia but not after spinal compared with general anaesthesia. Based on RCTs, there was no significantly increased risk of blood transfusions with general anaesthesia. Analysis of non-randomised studies found a significantly higher transfusion requirement after general anaesthesia (risk ratio 5.06, 95% CI 2.47-10.36, P < 0.00001). The incidence of hypotension and the amount of fluid given were higher in the neuraxial anaesthesia groups.

CONCLUSION

General anaesthesia is associated with a higher blood loss than neuraxial anaesthesia. However, based on high-quality studies, the need for blood transfusion was not greater. The higher blood loss with general anaesthesia is therefore of uncertain clinical relevance.

Feasibility of radical cystectomy in exclusive spinal and/or epidural anaesthesia

PURPOSE

Muscle invasive bladder cancer can be found predominantly in elderly people with a high likelihood of suffering from concomitant diseases; especially in these patients, the risks associated with general anaesthesia during radical cystectomy can be the limiting factor of performing an otherwise indicated radical operation. To overcome this limitation, we analysed the feasibility of performing radical cystectomy in exclusive spinal and/or epidural anaesthesia.

METHODS

Between March and June 2010, nine patients underwent radical cystectomy in exclusive spinal and/or epidural anaesthesia. These patients were either not willing or unfit to undergo radical cystectomy in general anaesthesia. A continent urinary diversion (ileum neobladder) and an ileum-conduit were performed in five patients and four patients, respectively. The feasibility of radical cystectomy in regional anaesthesia was tested using a variety of parameters.

RESULTS

All nine procedures could be performed under strict regional anaesthesia. Mean operation time was 206 min (range 146-265 min), mean intraoperative blood loss was 622 ml (range 200-1,500 ml), mean postoperative time at intermediate care was 1 day (range 0-3 days) and mean length of hospital stay was 21.8 days (range 17-26 days). Analgesics of the WHO class I, II and III were applied for 5.7, 1.2 and 2.8 days mean, respectively.

CONCLUSION

Performance of radical cystectomy in exclusive spinal and/or epidural anaesthesia is feasible and can be considered particularly in those patients who would be otherwise unfit to undergo radical cystectomy in general anaesthesia. This new operative and anaesthesiological concept could also play an important role in new fast track regimens.