The Effect of Spinal versus General Anesthesia on Quality of Life in Women Undergoing Cesarean Delivery on Maternal Request

Improving safety: Neuraxial blockade guided by thromboelastography for patients with uncertain coagulation profile

ABSTRACT

Neuraxial blockade procedures are essential for anesthesia and pain management but pose risks in patients with uncertain coagulation profiles. Traditional coagulation tests often fail to predict bleeding risks associated with neuraxial blockade. Thromboelastography (TEG) offers real-time insights into coagulation status, potentially improving safety outcomes. In this case series, six patients underwent neuraxial blockade guided by TEG analysis. An individualized anesthetic plan was formulated based on TEG findings to mitigate bleeding risks while ensuring pain management. Tailoring anesthetic techniques to real-time TEG data improved safety outcomes with minimized bleeding complications and satisfactory pain control. In conclusion, neuraxial blockade guided by TEG enhances safety in patients with uncertain coagulation profiles. Further studies are needed to validate benefits in broader clinical settings.

Incidence of post-dural lumbar puncture headache (PDLPH) in comparison between emergency and elective lower segment cesarean section (LSCS) with 26G Quincke-Babcock cutting-beveled spinal needle

Background

C-section is usually performed under spinal anesthesia also known as a subarachnoid block (SAB) over general anesthesia. Because of the lesser amount of dose used, there is a lower risk of local anesthetic toxicity and minimal transfer of drugs to the fetus. Obstetric patients have a higher risk of having post-dural puncture headache (PDPH). PDPH occurs due to leakage of the cerebrospinal fluid (CSF) through the hole created by a spinal needle. There are many elements affecting the frequency of PDPH, these elements can also consist of age, female sex, needle size, and types, pregnancy, preceding records of PDPH, median-paramedian distinction in approach, a puncture level. PDPH is commonly in the form of a frontal, occipital, or retro-orbital headache that starts in 12-72 h after the dural puncture and will increase when standing and decrease when lying down or resting. We aimed to learn about headache frequency between elective and emergency lower segment cesarean section using 26-G Quincke spinal needle in full-term pregnant patients.

Objectives

To study the incidence of PDPH using the 26G Quincke spinal needle. To analyze the causal factors/determinants such as adequate preloading of fluids, size of spinal needle, number of pricks, and technique of lumbar puncture effects on the incidence of PDPH.

Methodology

This study is a prospective questionnaire-based comparative observational study using the convenience sampling method. The patients were interviewed with a structured questionnaire at the Symbiosis University Hospital and Research Centre, Lavale, Pune. The patients observed for the study were between 20 and 40 of age group, posted for emergency or elective lower segment cesarean section, with body mass index (BMI) less than 14.5 to 24.9 and with ASA I and II grades. Patients with any comorbidities, recurrent headaches, obesity, and spine deformity were excluded. According to the review of the literature and with the help of a formula, the sample size was calculated as 20; 10 patients for elective LSCS, and 10 patients for emergency LSCS.

Results

Out of 20 patients, 10 patients were posted for elective LSCS, and the rest 10 patients were for emergency LSCS under spinal anesthesia. The incidence of PDPH was found only in 2 out of 10 emergency LSCS patients, and no patients from elective LSCS cases showed up with the incidence of PDPH.

A 74-Year-Old Man with Severe Comorbidities and Successful Abdominal Aortic Aneurysm Repair with Thoracic Segmental Spinal Anesthesia: A Case Report

BACKGROUND Elderly patients with severe or multiple comorbidities can be at high risk for complications of general anesthesia. This report is of a 74-year-old man with severe comorbidities, including ischemic heart disease (IHD) and chronic obstructive pulmonary disease (COPD), and successful abdominal aortic aneurysm repair with thoracic segmental spinal anesthesia. CASE REPORT The patient, aged 74, had previously been diagnosed with severe COPD and IHD. He was classified as American Society of Anesthesiology (ASA) grade IV, diagnosed with an abdominal aortic aneurysm (AAA) measuring 6 cm in diameter, and had to undergo surgical repair of the aneurysm with the insertion of a synthetic graft. Due to a shortage of beds in the ICU and the desire to avoid the complications associated with general anesthesia, the decision was made to proceed with thoracic spinal regional anesthesia, which is not a customary choice for this type of surgery. Spinal anesthesia was administered at the Th10-11 level, utilizing 8.5 mg of Bupivacaine, 50 mcg of Fentanyl, and 4 mg of Dexason. An epidural catheter was placed at the same level. The surgical procedure lasted 145 min and was successfully completed under regional anesthesia. CONCLUSIONS This report has highlighted that developments in spinal thoracic anesthesia mean that this can be a successful alternative to general anesthesia in high-risk patients, even for major emergency surgery.

Functional recovery after cesarean delivery: a prospective cohort study in rural Rwanda

INTRODUCTION

Women who deliver via cesarean section (c-section) experience short- and long-term disability that may affect their physical health and their ability to function normally. While clinical complications are assessed, postpartum functional outcomes are not well understood from a patient's perspective or well-characterized by previous studies. In Rwanda, 11% of rural women deliver via c-section. This study explores the functional recovery of rural Rwandan women after c-section and assesses factors that predict poor functionality at postoperative day (POD) 30.

METHODS

Data were collected prospectively on POD 3, 11, and 30 from women delivering at Kirehe District Hospital between October 2019 and March 2020. Functionality was measured by self-reported overall health, energy level, mobility, self-care ability, and ability to perform usual activities; and each domain was rated on a 4-point likert scale, lower scores reflecting higher level of difficulties. Using the four functionality domains, we computed composite mean scores with a maximum score of 4.0 and we defined poor functionality as composite score of ≤ 2.0. We assessed functionality with descriptive statistics and logistic regression.

RESULTS

Of 617 patients, 54.0%, 25.9%, and 26.8% reported poor functional status at POD3, POD11, and POD30, respectively. At POD30, the most self-reported poor functionality dimensions were poor or very poor overall health (48.1%), and inability to perform usual activities (15.6%). In the adjusted model, women whose surgery lasted 30-45 min had higher odds of poor functionality (aOR = 1.85, p = 0.01), as did women who experienced intraoperative complications (aOR = 4.12, 95% CI (1.09, 25.57), p = 0.037). High income patients had incrementally lower significant odds of poor physical functionality (aOR = 0.62 for every US$1 increase in monthly income, 95% CI (0.40, 0.96) p = 0.04).

CONCLUSION

We found a high proportion of poor physical functionality 30 days post-c-section in this Rwandan cohort. Surgery lasting > 30 min and intra-operative complications were associated with poor functionality, whereas a reported higher income status was associated with lower odds of poor functionality. Functional status assessments, monitoring and support should be included in post-partum care for women who delivered via c-section. Effective risk mitigating intervention should be implemented to recover functionality after c-section, particularly among low-income women and those undergoing longer surgical procedures or those with intraoperative complications.

The Prevalence of Acceptance Between General Anesthesia and Spinal Anesthesia Among Pregnant Women Undergoing Elective Caesarean Sections in Saudi Arabia

Background The choice of anesthesia for an elective cesarean section should be based on an individual benefit-risk assessment, considering the pregnant woman's preferences, concerns, and the available medical expertise. This study aimed to determine the preferences for general and spinal anesthesia among women undergoing elective cesarean sections and the factors affecting their choice. Methods The study design is a cross-sectional study, and it was conducted on pregnant women to measure the acceptance of general anesthesia and spinal anesthesia in patients with elective cesarean sections in Saudi Arabia. Random pregnant women were invited to participate in this study across Saudi Arabia after fulfilling the inclusion criteria. A digital questionnaire was distributed across Saudi Arabia to be filled out by female residents. A Microsoft Excel (Microsoft Corporation, Redmond, Washington, USA) sheet was used for data entry, while IBM SPSS software version 27.0.1 (IBM Corp., Armonk, New York, USA) was used for statistical analysis. Results The study included 813 participants; most (28%) of them were 25-30 years old. Of the study participants, 54% had chosen spinal anesthesia before, 22% had chosen general anesthesia, and 24% had chosen neither. Reasons to choose general anesthesia were reported as follows: 21.6% feared pain during surgery, 24.2% feared watching the surgical procedures on their bodies, 16.6% feared back pain, 12.8% feared being paralyzed, and 15.1% feared needles used to administer anesthesia in the lower back. Reasons for choosing spinal anesthesia were reported as follows: 26.3% had back pain concerns; 13% feared prolonged unconsciousness; 9.6% feared having a headache after surgery; 17% had post-surgery pain concerns; 30.1% wanted to be alert at the time of the birth of the baby; 10.6% feared the chances of experiencing nausea and vomiting; and 7.4% feared not being able to breastfeed. Conclusion Spinal anesthesia was chosen by more participants than general anesthesia. There was a statistically significant association between choosing spinal anesthesia and the number of previous pregnancies, parity, history of preterm labor, and recommendation to undergo general or spinal anesthesia by non-medical staff. It was also significant with the older age and higher educational level of participants. This decision may be influenced by a number of variables, the most significant of which are prior experience with general anesthesia or spinal anesthesia, educational attainment, and non-medical advice.

Patient Satisfaction With General Anesthesia Compared to Spinal Anesthesia for Cesarean Section: A Multicenter Observational Study

Background Satisfaction in patients undergoing cesarean section (CS) is of great importance in every hospital. There are big differences between spinal and general anesthesia for CS in terms of outcome, recovery times, and quality of service. Methods This multicenter observational study included 1443 patients who had elective (n=622) or emergency (n=821) CS in five medical centers over the period of 16 months. Bauer questionnaire was used for measuring patient satisfaction after CS. The questionnaire contained 15 questions about anesthesia-related discomfort and satisfaction with anesthesia care. Results During the study period, 1161 (80%) patients underwent CS under general anesthesia (GA) and 282 of them (20%) received spinal anesthesia (SA) for CS. The most frequently reported anesthesia-related discomfort was pain at the surgical site (>70%), drowsiness (68%), and thirst (60%). The data on patient satisfaction showed high satisfaction that exceeded 90%. Anesthesia side effects were less frequent and the general satisfaction rate was higher in the SA group compared to the GA group (P < .001). Conclusion SA for CS had less frequent side effects and a better satisfaction rate compared to GA for CS. Hospitals need to make room for improvement of postoperative acute pain control and introduction to Enhanced Recovery After Surgery (ERAS) protocols for elective CS.

Effect of Carbetocin on Uterine Tone during Cesarean Section: A Comparison between Subarachnoid Block and General Anesthesia

Background

Postpartum hemorrhage remains a challenge in obstetric practice in developing climes and contributes immensely to the horrendous figures of maternal mortality worldwide.

Aim

The aim was to compare the effect of intravenous (IV) carbetocin on uterine tone under different anesthetic techniques for elective cesarean section.

Methods

Four hundred and seventy-eight consecutive women scheduled for elective cesarean section were recruited into two groups by convenience. While 445 parturients received subarachnoid block (SAB), 33 had general anesthesia (GA). At delivery, IV carbetocin was administered. The uterine tone was assessed manually and blood loss from intraoperative period to the 24th h was determined. Other variables such as hemodynamic profiles and Apgar scores were determined and recorded.

Results

The bio-characteristics between the two groups were essentially the same in terms of age, weight, height, body mass index, preoperative hemoglobin, and gestational age. While the response to the administered carbetocin was slower in the GA group, there was no need for additional dose. The mean estimated intraoperative blood loss under SAB was 250.44 ± 50.59 ml and that under GA was 470.89 ± 35.70 ml, P = 0.000000. The ephedrine consumption was 6.25 ± 2.05 mg in the SAB group while it was 11.25 ± 2.49 mg, P = 0.000000. There was no further maternal blood loss observed after the intraoperative period until the end of 24-h period. The hemodynamic profiles were significantly different in terms of mean systolic blood pressure, mean diastolic blood pressure, and mean arterial blood pressure, P = 0.006, P = 0.002, and P = 0.003, respectively. However, the difference in the mean heart rate was not statistically significant, P = 0.304. While the Apgar scores between groups were not statistically significant, the mean umbilical pH was 7.34 ± 0.09 in the SAB group, it was 7.35 ± 0.02 in the GA group, P = 0.071.

Conclusion

Intraoperative maternal blood loss was more among the parturients who received GA than subarachnoid blood. This could probably be due to the effect of the halogenated vapor used for the GA on the uterine tone. There was no further blood loss after the intraoperative period. The hemodynamic profile was better under SAB as evidenced by the total ephedrine consumption.

Role of Internal Jugular Vein Collapsibility Index in Predicting Post-spinal Hypotension in Pregnant Women Undergoing Cesarean Section: A Prospective Observational Study

Introduction Post-spinal hypotension (PSH) frequently occurs in women undergoing cesarean section. In recent studies, Ultrasound-guided measurements of the internal jugular vein (IJV) have been reported to predict fluid responsiveness. We planned to evaluate the correlation between the internal jugular vein collapsibility index (IJVCI) and PSH in cesarean section patients. Methods Ninety-one parturients who underwent elective lower segment cesarean section with a singleton pregnancy were recruited. Preoperatively, patients were placed in a supine position with a 15-degree left lateral tilt. Maximum (at the end of expiration) and minimum (at the end of inspiration) IJV diameters (mm) and IJVCI were assessed using M-mode imaging during spontaneous and deep breathing. Spinal anaesthesia was performed at the L3-4 or L4-5 level. Systolic blood pressure, diastolic blood pressure, mean arterial pressure, heart rate, respiratory rate, and SpO2 were recorded from baseline till the delivery of the baby. Results Among 91 patients, 40 (45.5%) patients had at least one episode of hypotension. Demographic variables and baseline vitals were comparable between the hypotensive and normotensive groups (p>0.05). In spontaneous and deep breathing, IJV diameter at the end-expiration (IJVdmax), end-inspiration (IJVdmin), and IJVCI amongst both hypotensive and non-hypotensive pregnant women were statistically similar. Receiver Operating Characteristic (ROC) curve analysis showed that during spontaneous breathing, using a cut-off point of 29.5%, IJVCI had a sensitivity and specificity of 70% and 23%, respectively, for predicting PSH; whereas during deep breathing, IJVCI had a sensitivity and specificity of 77% and 27%, respectively, for predicting the same using a cut-off value of 37.5%. Conclusion We conclude that internal jugular vein parameters such as maximum diameter, minimum diameter, and IJVCI during spontaneous and deep breathing cannot be used as reliable predictors of post-spinal hypotension in pregnant patients undergoing elective cesarean section.

Evaluation of the Effect of Intravenous Dexamethasone on the Duration of Spinal Anaesthesia in Parturients Undergoing Lower Segment Caesarean Section

Introduction Dexamethasone is shown to prolong the duration of nerve blocks when administered perineurally as well as intravenously. The effect of intravenous dexamethasone on the duration of hyperbaric bupivacaine spinal anesthesia is lesser known. We conducted a randomized control trial to determine the effect of intravenous dexamethasone on the duration of spinal anesthesia in parturients undergoing lower-segment cesarean section (LSCS). Methods Eighty parturients planned for LSCS under spinal anesthesia were randomly allocated to two groups. Patients in group A were administered dexamethasone intravenously, and group B received normal saline intravenously before spinal anesthesia. The primary objective was to determine the effect of intravenous dexamethasone on the duration of sensory and motor block after spinal anesthesia. The secondary objective was to determine the duration of analgesia and complications in both groups. Result The total duration of the sensory and motor blocks in group A was 118.38 ± 19.88 minutes and 95.63 ± 19.91 minutes, respectively. The entire sensory and motor blockade duration in group B was 116.88 ± 13.48 minutes and 97.63 ± 15.15 minutes, respectively. The difference between the groups was found to be statistically insignificant. Conclusion Intravenous 8 mg dexamethasone in patients planned for LSCS under hyperbaric spinal anesthesia does not prolong the sensory or motor block duration compared to placebo.

Health-Related Quality-of-Life among Pregnant Women after First, Second, and Multiple Cesarean Sections in the Perinatal Period: A Short-Term Longitudinal Study

The primary objective of this study was to compare assessments of health-related quality-of-life (HRQoL) in women who had a medical qualification for cesarean section (CS), depending on the number of CSs in their medical history. A short longitudinal study was conducted among 115 women on the day before a planned cesarean section (CS)-T1, and on the third day after CS-T2. They were divided into three groups. G1: no CS (n = 17); G2: one CS (n = 34); G3: two or more CSs (n  =  64). Participants completed a set of questionnaires concerning sociodemographic aspects and psychological outcomes: the HRQoL questionnaire (EQ-5D-3L). A chi-square test, McNemar's test, and repeated measures ANOVA were used to compare the three groups in T1 and T2. Regardless of the number of CSs, before a CS, women mainly experience health problems with pain and anxiety/depression, and after a CS, mostly problems with pain, usual activity, and mobility. All participants experienced an increase in the amount of health problems with mobility and pain after a CS. Women who have had two or more CSs also had problems with self-care and usual activities. Women who have had one or two CSs experienced a decrease in the general assessment of the HRQoL, which is not observed in the group of women with multiple CSs. However, the HRQoL of women in the group with multiple CSs was lower before the CS than in the other groups. The results indicated the significance of the number of CSs, not only in postoperative, but also in preoperative HRQoL.

Comparison between 10 and 12 mg doses of intrathecal hyperbaric (0.5%) bupivacaine on sensory block level after first spinal failure in cesarean section: A double-blind, randomized clinical trial

Background

Reducing adverse effects during cesarean delivery and improving the quality of sensory blocks with appropriate doses of intrathecal hyperbaric bupivacaine can play an important role in the safe management of cesarean delivery. The aim of this study was to compare the doses of 10 and 12 mg of intrathecal hyperbaric bupivacaine 0.5% on sensory block level after first spinal failure in cesarean section (CS).

Methods

In this double-blind, randomized clinical trial, 40 candidates of CS after first spinal failure with class I-II based on American Society of Anesthesiologists (ASA) were randomly assigned into two equal groups (n = 20). Group A and B received the spinal anesthesia with 10 mg and 12 mg of hyperbaric bupivacaine (0.5%), respectively. Maximum levels of sensory block, motor block quality, and vital signs were measured in two groups by 60 min after SPA. Incidence of SPA complications during surgery were also recorded. Data were analyzed by SPSS ver.21 software using repeated measures analysis of variance at 95% confidence interval (CI) level.

Results

Excellent quality of sensory blocks and complete quality of motor blocks were achieved in all participants (100%). However, the mean time to onset of anesthesia (4.47 ± 0.69 vs. 3.38 ± 0.47, P < 0.001) and time to reach T10 level (60.73 ± 11.92 vs. 79.00 ± 19.21, P < 0.001) in the Group A, were significantly shorter than in the patients of Group B. The incidence of hypotension (P = 0.001), nausea/vomiting (P = 0.007) and bradycardia (P = 0.012) as well as administration of ephedrine and atropine were significantly higher in Group B compared to Group A.

Conclusion

Spinal anesthesia can be safely repeated with a 10 mg of hyperbaric bupivacaine 0.5% in a caesarean section after the initial spinal failure.

Clinical trial registration

[https://en.irct.ir/trial/40714], identifier [IRCT20120915010841N20].

Evaluation Effect of Aspiration of 0.2 ml of Cerebrospinal Fluid After Completion of Injection 0.5% Bupivacaine and Reinjection Into Subarachnoid Space on Sensory and Motor Block in Cesarean Section: A Randomized Clinical Trial

Background

Spinal anesthesia (SPA) is the most common type of anesthesia administered for cesarean section. The main aim of this study was to evaluate the effect of aspiration of CSF (0.2 mL) immediately after SPA with hyperbaric 0.5% bupivacaine on the extent of sensory and motor block.

Methods

In this clinical trial, 60 women at ≥37 weeks of gestation and aged between 18 and 46 years, candidate for cesarean delivery under spinal anesthesia were randomly allocated into two equal groups (n = 30). Group A (CSF-aspiration group) received the spinal anesthesia with 10 mg of hyperbaric 0.5% bupivacaine with aspiration of 0.2 ml of CSF. Group B (no-CSF-aspiration group) received only 10 mg of 0.5% hyperbaric bupivacaine. Pin-prick analgesia and motor block were tested during the induction.

Results

The mean maximum level of analgesia was T6 in each group. Although the mean time to reach the maximum level of anesthesia (4.43 ± 5.14 vs. 2.76 ± 2.04, P = 0.107) and to reach T10 level (50.56 ± 11.51 vs. 49.10 ± 13.68, P = 0.665) in the CSF-aspiration group is longer than the non-CSF-aspiration group, but this differences were not significant. There were no significant between-group differences regarding sensory and motor block quality (P = 0.389) or failed SPA (four cases in CSF-aspiration group vs. two cases in no-CSF-aspiration group, P = 0.389). The incidence of bradycardia, hypotension, headache, vomiting and nausea were similar in both groups (P > 0.05). In addition, the difference in hemodynamic parameters between the two groups over times was not statistically significant.

Conclusion

Our finding indicated that the aspiration of 0.2 ml of CSF after injection of spinal anesthesia with hyperbaric 0.5% bupivacaine does not seem to affect the extent of sensory and motor block, success rate, or outcome after SPA in cesarean section.

Clinical Trial Registration

[https://www.irct.ir/search/result?query=IRCT20120915010841N25], identifier [IRCT20120915010841N25].

Anesthesia and breastfeeding

The importance of breastfeeding with its positive impact on the wellbeing of the mother-infant pair is well established. Anesthesiologists should encourage the promotion of lactation by being willing to give reassurance during the preoperative period and preparing a plan that does not interfere with safe breastfeeding. There is concern regarding the transfer of drugs into breast milk, which may lead to inconsistent advice from many health professionals and to early discontinuation. However, evidence shows that most anesthetic drugs are safe in terms of transfer into breast milk, and hence, compatible with breastfeeding, which should be resumed after anesthesia as soon as the mother is alert and feels well enough to hold her infant, without the need to “pump and dump”. This review provides pharmacokinetic information on commonly used anesthesia drugs and their passage into breast milk, to help practitioners discuss risks and benefits with the mother, emphasizing that anesthesia should not interfere with the benefits of breastfeeding. Four practical clinical scenarios are presented: pregnant women concerned about the effect of epidural analgesia on subsequent breastfeeding, spinal anesthesia for c-section and lactation, patients who will receive general anesthesia during cesarean section, and finally women who are breastfeeding and require anesthesia for elective or urgent surgery. Neuraxial anesthesia allows for better pain control and immediate skin-to-skin contact at the time of childbirth. Also, it interferes the least with the woman’s ability to care for her infant. Regional techniques, opioid-sparing techniques and outpatient surgery are preferred. Drugs such as opioids and longer-acting benzodiazepines should be administered cautiously, particularly in repeat doses.

Comparing the Effects of Low Dose of Ketamine, Tramadol, and Ondansetron in Prevention of Post Spinal Anesthesia Shivering in Cesarean Section

Background

Shivering frequently occurs in cesarean section (CS) under spinal anesthesia (SA), resulting in several complications. To date, pethidine has been considered as the gold standard for post-SA shivering control, but it is contraindicated in breastfeeding women.

Methods

This randomized, double-blind study was conducted at Alzahra hospital in Guilan, Iran, From January 2019 to November 2020. A total of 508 eligible term parturient women were enrolled and randomly divided into four groups of low dose ketamine (K), tramadol (T), ondansetron (O), and placebo (P). The incidence and severity of shivering and patients' complications were recorded and compared among the groups.

Results

The patients were homogenous in terms of demographic variables. Shivering was witnessed in 68 (53.5%), 26 (20.5%), 75 (59.1%), and 82 (64.6%) patients in K, T, O, and P groups, respectively (P = 0.0001). Regarding shivering severity, there was a significant difference among the four groups (P = 0.0001). In addition, a significant difference was seen regarding Apgar scores at the first minute, but not at the fifth minute (P = 0.168).

Conclusions

Considering the high incidence of shivering in placebo group, prophylactic intervention in CS under SA seems to be necessary. Among the studied drugs, tramadol was the most effective one, followed by a low dose of ketamine and ondansetron.

Correlation Between Anthropometric Measurements and Sensory Block Level of Spinal Anesthesia for Cesarean Section

Background

When performing spinal anesthesia for cesarean section, it is important to determine the appropriate anesthetic dose as well as to predict the level of spinal anesthesia. In this study, it was hypothesized that some anthropometric measurements may be related to maximum sensory block and hemodynamic changes.

Objectives

The aim of this study are to find maternal anthropometric values that are correlate with the level of spinal anesthesia.

Methods

Maternal anthropometric measurements, including height, weight, supine and standing abdominal circumference (AC), and hip circumference, were recorded before spinal anesthesia for cesarean section. Spinal anesthesia was induced by administering 8 mg of 0.5% hyperbaric bupivacaine and 20 μg of fentanyl at the L3-L4 interspace. The level of sensory block was determined using pin-prick at 1, 5, 10, and 15 minutes after spinal anesthesia. The sensory block level and hemodynamic adverse events were analyzed in relationship to anthropometric measurements.

Results

The supine AC/height ratios significantly correlate with the maximal sensory block level at 5, 10, and 15 minutes after the injection of spinal anesthetic (P = 0.001, P < 0.001 and P < 0.001, respectively). Further, there were significant correlations between body mass index (BMI) and sensory block level at every assessment (P = 0.041, P = 0.002, P = 0.001 and P < 0.001, respectively). When comparing the groups with and without hypotension, BMI, weight, and supine AC/height ratio were found to be significantly higher in the group with hypotension (P = 0.002, P = 0.004 and P = 0.006, respectively).

Conclusions

We conclude that BMI and AC/height ratio correlate with the sensory block level of spinal anesthesia for cesarean section.

The Current Role of General Anesthesia for Cesarean Delivery

Purpose of the Review

The use of general anesthesia for cesarean delivery has declined in the last decades due to the widespread utilization of neuraxial techniques and the understanding that neuraxial anesthesia can be provided even in urgent circumstances. In fact, the role of general anesthesia for cesarean delivery has been revisited, because despite recent devices facilitating endotracheal intubation and clinical algorithms, guiding anesthesiologists facing challenging scenarios, risks, and complications of general anesthesia at the time of delivery for both mother and neonate(s) remain significant. In this review, we will discuss clinical scenarios and risk factors associated with general anesthesia for cesarean delivery and address reasons why anesthesiologists should apply strategies to minimize its use.

Recent Findings

Unnecessary general anesthesia for cesarean delivery is associated with maternal complications, including serious anesthesia-related complications, surgical site infection, and venous thromboembolic events. Racial and socioeconomic disparities and low-resource settings are major contributing factors in the use of general anesthesia for cesarean delivery, with both maternal and perinatal mortality increasing when general anesthesia is provided. In addition, more significant maternal pain and higher rates of postpartum depression requiring hospitalization are associated with general anesthesia for cesarean delivery.

Summary

Rates of general anesthesia for cesarean delivery have overall decreased, and while general anesthesia no longer is a contributing factor to anesthesia-related maternal deaths, further opportunities to reduce its use should be emphasized. Raising awareness in identifying situations and patients at risk to help avoid unnecessary general anesthesia remains crucial.

Anesthesia for Cesarean Section: Retrospective Comparative Study

Background

Cesarean section is a widely performed surgery.

Objective

To compare anesthetic types regarding feto-maternal outcomes.

Materials and Methods

Retrospective comparative study of 3599 cesarean sections (emergency and elective categories).

Results

Mean APGAR score was statistically higher in the spinal than general anesthesia among the emergency category, P = 0.000 and 0.026, respectively, with no significant difference in the elective category. Estimated blood loss among the elective category was statistically significantly higher in the spinal than general anesthesia, P = 0.001. However, among the emergency category, it was significantly higher in the general than in spinal or epidural anesthesia, P = 0.000. Diclofenac sodium was used more after spinal than general anesthesia (P = 0.000), with no significant difference between epidural and general or between epidural and spinal anesthesia. Pethidine hydrochloride (HCL) was used more after general than after spinal anesthesia (P = 0.000). However, pethidine HCL use was not statistically significantly different between spinal and epidural anesthesia. In the elective category, paracetamol was requested more after spinal than epidural or general anesthesia, P = 0.000. No significant difference was seen between epidural and general anesthesia, P = 1.000. No statistically significant difference was found among the anesthetic types in both categories regarding tramadol HCL. Length of hospital stay, operative time and neonatal intensive care unit admission were not statistically different between anesthetic modes. In the emergency category, significantly higher percentage of patients were satisfied with and would recommend epidural anesthesia.

Conclusion

There was no statistically significant difference among the three types of anesthesia regarding neonatal intensive care admission and length of hospital stay for emergency and elective categories. APGAR score was higher with spinal than with general anesthesia in the emergency category with no significant difference in the elective category. More diclofenac sodium and paracetamol and less opioids were used after regional than after general anesthesia. Satisfaction was higher with epidural anesthesia.

Limitations

Retrospective and single centered.

The efficacy and safety of intrathecal dexmedetomidine for parturients undergoing cesarean section: a double-blind randomized controlled trial

BACKGROUND

The efficacy and safety of spinal anesthesia by intrathecal dexmedetomidine (DEX) for parturients undergoing cesarean section are still lack of evidence. This aim of our study was to evaluate the efficacy and safety of intrathecal DEX for parturients undergoing cesarean section to provide more data evidence for intrathecal applications.

METHODS

Three hundred parturients undergoing cesarean section under spinal anesthesia were randomly assigned into three groups: group B: 9.0 mg (1.2 ml) of 0.75% bupivacaine with saline (1 ml); group FB: 9.0 mg (1.2 ml) of 0.75% bupivacaine with 20 μg of fentanyl (1 ml); group DB: 9.0 mg (1.2 ml) of 0.75% bupivacaine with 5 μg of DEX (1 ml). Intraoperative block characteristics, parturients' postoperative quality of recovery, maternal and neonatal outcomes and the plasma concentration of DEX were measured. All parturients were followed up for 30 days to determine whether nerve injury occurred.

RESULTS

Compared with group B, the duration of sensory block in group FB and group DB were significantly prolonged (108.4 min [95% Confidence Interval (CI) = 104.6-112.3] in group B, and 122.0 min [95% CI = 116.8-127.3] in group FB, 148.2 min [95% CI = 145.3-151.1] in group DB). The overall score of quality recovery in group DB (71.6 [95% CI = 71.0-72.2]) was significantly higher than that in group FB (61.5 [95% CI = 60.8-62.2]) and group B (61.7 [95% CI = 61.0-62.4]). There was no statistically significant difference among the three groups for PH, PaO₂, and PaCO₂ of newborn. The plasma concentration of DEX in umbilical artery and umbilical vein was low and cannot be detected. The 30-days follow-up of parturients did not show any new onset of back, buttock or leg pain or paresthesia.

CONCLUSIONS

DEX is a potential local anesthetic adjuvant that the intrathecal combination of 5 μg DEX can safely exhibit a facilitatory block effect and improve parturients' recovery quality.

TRIAL REGISTRATION

Chinese Clinical Trial Registry (Registration number # ChiCTR1900022019 ; Date of Registration on March 20th, 2019).

Evaluation of changes in anesthetic methods for cesarean delivery: an analysis for 5 years using the big data of the Korean Health Insurance Review and Assessment Service

Background

As an anesthesia induced during cesarean section, spinal anesthesia is preferred over general and epidural anesthesia. This study aimed to review the trend of anesthetic methods for cesarean section based on data obtained from the Korean Health Insurance Review and Assessment Service from 2013 to 2018.

Methods

The anesthetic methods were analyzed in 753,285 parturients who underwent a cesarean section in Korea from 2013 to 2018. We determined the association between each anesthetic method and hospital type and maternal and fetal factors. We also evaluated whether the anesthetic method was associated with the parturients’ length of hospital stay.

Results

General anesthesia, spinal anesthesia, and epidural anesthesia were induced in 28.8%, 47.7%, and 23.6% of parturients from 2013 to 2018, respectively. Trend analyses showed that spinal anesthesia increased from 40.0% in 2013 to 53.7% in 2018. The opposite trend applied to general anesthesia, decreasing from 37.1% in 2013 to 22.2% in 2018. The factors that were significantly associated with the anesthetic method were parturient’s parity, emergency condition, gestational age, and fetal weight. The type of hospital, parturient’s age, and multiple birth were also associated with the anesthetic methods. There was a strong association between general anesthesia and hospital stay longer than 7 days.

Conclusions

Spinal anesthesia is currently the main anesthetic method used for cesarean delivery, and the rate of spinal anesthesia is gradually increasing in Korea.

Incidence and Causes of Failed Spinal Anesthesia

Introduction: Spinal anesthesia (SA) is one of the most frequently applied anesthesia procedures today. However, SA failure rate varies between 1 and 17%. The age of the patient, the position at which the procedure is performed, or the characteristics of the technical operation can affect success. In this study, we aimed to compare the most frequent SA failures according to the types of surgery and causes of failure. The results of SA procedures performed in a university hospital were compare to those published in the current literature. Materials and Methods: After obtaining ethics committee ­approval for our study, the hospital archives were examined retrospectively for 1 year with respect to SA procedures. SA application and failure rates were examined. Three or more SA attempts, failed dural puncture, or unsuccessful injection, and anesthesia applications that did not provide sufficient sensory block for surgery despite successful drug treatment were defined as failure. Results: Of all anesthesia procedures, SA was applied at a rate of 23.5%. Our SA failure rate was calculated as 16.6%. Considering a single surgical procedure, obstetric anesthesia was the most common surgery with failed SA (28.7%). The most common cause of failure was insufficient analgesia (32.9%). Discussion: SA failure rates were observed to be in a variable distribution range in the literature, and in some studies, SA failure was defined as a block that did not occur despite a full dose and successful injection, and this rate was found to be 3.9%. The high rate in our study group may be explained by differences in the definition of SA: blocks performed with several trials and any block that could not be applied were also recorded as SA failure. The reasons for failing to apply this procedure is an issue that is worth examining also in terms of patient satisfaction and safety, which is an important issue. Conclusion: Although the definition of unsuccessful SA is confusing, SA failure rates are worth examining and improving for each hospital.

Review of evidences for management of rapid sequence spinal anesthesia for category one cesarean section, in resource limiting setting

BACKGROUND

Globally obstetric anesthesia is being done under spinal and epidural than general anesthesia (GA) for most caesarean sections (CSs). This is because GA is associated with failed endotracheal intubation and aspiration of gastric contents. Eventhough general anesthesia is the fastest method for anesthetizing a category 1 cesarean section, it is associated with increased maternal mortality and morbidity. Spinal anesthesia is the preferred regional technique for cesarean section but failure sometimes occurs. To minimize the time factor of spinal anesthesia as well as to avoid the side effects of general anesthesia 'rapid sequence spinal '(RSS) has developed as a novel approach in cases of category one cesarean sections.

METHODS

The study was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol. Search engines like PubMed through HINARI, Cochrane database and Google Scholars were used to find high-level evidences that help to draw appropriate conclusions.

DISCUSSION

Neuraxial anesthetic techniques have several advantages which include low risk of aspiration and failed intubation, avoidance of central nervous system (CNS) and respiratory depressant drugs, the ability to maintain a wakeful state of mother enjoying the experience of delivery of baby and also lower incidence of blood loss. 'Rapid sequence spinal' described to minimize anesthetic time. This consists of a no-touch spinal technique, consideration of omission of the spinal opioid, limiting spinal attempts, allowing the start of surgery before full establishment of the spinal block, and being prepared for conversion to general anesthesia if there are delays or problems. To do rapid sequence spinal anesthesia safely and timely, cooperative work is mandatory with good team relation for those simultaneous and necessary tasks.

CONCLUSION

The choice of anesthetic in Cesarean section has long been recognized as one of prime importance, because there are two lives to safeguard instead of one. A balance must be struck between the anesthetic dictated by the general condition of the mother and that suited to the needs of the fetal respiratory system.