ORIGINAL ARTICLE
Combined low-dose spinal-epidural anesthesia versus single-shot spinal anesthesia for elective cesarean delivery

https://doi.org/10.1016/j.ijoa.2005.05.009Get rights and content

Summary

Combined spinal-epidural anesthesia balancing low-dose intrathecal bupivacaine/fentanyl and low-dose epidural bupivacaine may be more useful than single-shot spinal anesthesia for cesarean delivery in reducing incidences of adverse effects such as hypotension and nausea and in shortening motor recovery. Combined spinal-epidural anesthesia (n = 50) or spinal anesthesia (n = 50) was randomly performed in 100 parturients. Intrathecal bupivacaine 6 mg added by fentanyl 20 μg followed after 5 min by 10 mL of 0.25% epidural bupivacaine were used for combined spinal-epidural and intrathecal bupivacaine 9 mg with fentanyl 20 μg for spinal anesthesia. The initial sensory block level was higher in the spinal group (P < 0.001), although the maximum levels were the same (T3). Complete surgical anesthesia was achieved and no patient complained of intraoperative pain in either group. Patients in the spinal group had denser motor block in the extremities and a higher incidence of hypotension (P < 0.05) and nausea and vomiting (P < 0.05). Motor recovery was faster in the combined spinal-epidural group (P < 0.001). We concluded that combined spinal-epidural anesthesia using low-dose local anesthetic-opioid spinal anesthesia and routine epidural supplementation before surgery had some potential advantages over single-shot spinal anesthesia in the lower incidences of adverse effects and quicker recovery.

Introduction

Since the advent of fine pencil-point spinal needles, spinal anesthesia has been more popular for cesarean delivery because it offers a rapid-onset, profound, reliable block. However, it is often performed using large doses of bupivacaine (12-15 mg) for fear of inadequate analgesia or visceral pain during surgery. Sometimes large doses generously administered may induce higher sensory block than expected, reaching cervical dermatomes, which might rarely result in swallowing and/or respiratory difficulty, causing extreme distress to the patients.2 Besides, a relatively larger dose of local anesthetic, because of an abruptly extensive sympathetic block, often induces hypotension and its related symptoms such as nausea, vomiting and dizziness.[1], [2], [3] Despite the use of left uterine displacement, fluid preloading with crystalloids or colloids and prophylactic ephedrine, hypotension remains common.[1], [3]

The introduction of both low-dose combinations of local anesthetic with opioid and the combined spinal-epidural (CSE) technique have allowed intrathecal doses of local anesthetic to be greatly reduced, thereby potentially reducing associated complications.[4], [5], [6], [7], [8] Several different versions of the CSE technique have been developed in order to minimize hypotension and other complications.[9], [10], [11], [12], [13]

The aim of this study was to compare a CSE consisting of intrathecal bupivacaine 6 mg with opioid followed by a routine sequential epidural injection of 0.25% bupivacaine 10 mL, with single-shot spinal anesthesia using bupivacaine 9 mg with opioid for cesarean delivery, in terms of feasibility and incidences of side effects such as hypotension and nausea.

Section snippets

Methods

After institutional review board approval and written informed consent, a prospective randomized and double-blinded study was performed in 102 women at term pregnancy (⩾36 weeks) scheduled for elective cesarean delivery. The patients were allocated to receive either CSE (n = 52) or spinal anesthesia (n = 50) using a computer-generated randomization list. Parturients with pregnancy-induced hypertension, multiple pregnancies, placenta previa, cardiac diseases or contraindications to regional

Results

Among 52 patients in the CSE group, there were technical failures in two patients: cerebrospinal fluid could not be aspirated in one patient and intravenous catheterization was noted at the time of epidural injection in another patient. All procedures were successful in the spinal group. There were no significant differences between the groups in patient characteristics such as age, weight and height and duration of surgery. Anesthetic procedure time was longer in the CSE group (P < 0.001) (Table

Discussions

In the present study we found that combined low-dose spinal-epidural anesthesia offered better hemodynamic stability than single-shot spinal anesthesia for cesarean delivery. Moreover, despite the use of routine epidural supplementation of bupivacaine, patients in the CSE group showed faster motor recovery in the postoperative period. Epidural supplementation in the CSE group, however, did not elevate the sensory block levels higher than those of the single-shot spinal group. Complete surgical

References (24)

  • E.T. Riley et al.

    Prevention of hypotension after spinal anesthesia for cesarean section: six percent hetastarch versus lactated Ringer’s solution

    Anesth Analg

    (1995)
  • B. Akerman et al.

    Local anesthetics potentiate spinal morphine antinociception

    Anesth Analg

    (1988)
  • Cited by (43)

    • Headache after neuraxial blocks: A focus on combined spinal-epidural anesthesia

      2021, Treatments, Mechanisms, and Adverse Reactions of Anesthetics and Analgesics
    • Clinical utility of epidural volume extension following reduced intrathecal doses: a randomized controlled trial

      2021, Brazilian Journal of Anesthesiology (English Edition)
      Citation Excerpt :

      This suggests there was no utility of epidural volume extension for sensory block augmentation with either of the two intrathecal doses tested. Earlier studies evaluating various aspects and effects of epidural volume extension have used intrathecal bupivacaine in a range of 2 mg to 15 mg.4–13,23–29 None of these studies has compared its results after applying it to various intrathecal doses under similar conditions.

    • The efficacy of ropivacaine and bupivacaine in the caesarean section and the effect on the vital signs and the hemodynamics of the lying-in women

      2019, Saudi Journal of Biological Sciences
      Citation Excerpt :

      Besides, ropivacaine stabilizes the hemodynamics with little effect on the heart rate and blood pressure and a long time of motor block (Gupta et al., 2013). Relevant studies have shown that ropivacaine has a lower lipid solubility than bupivacaine (Kuusniemi et al., 2000), which suggests that ropivacaine generates less toxic effect on the cardiovascular system and heart; in addition, ropivacaine is more efficient in blocking the sensor and motor that is inferior to the lidocaine but superior to the bupivacaine (Choi et al., 2006). The study has shown that ropivacaine (0.5%) is applicable in the CSEA of caesarean section, with a lower incidence rate of shivering than bupivacaine in an equivalent dose (Cappelleri et al., 2005), while either a low or high dose results in the discomfort for lying-in women (Dyer and Joubert, 2004).

    • Optimal intrathecal hyperbaric bupivacaine dose with opioids for cesarean delivery: a prospective double-blinded randomized trial

      2017, International Journal of Obstetric Anesthesia
      Citation Excerpt :

      The incidence and severity of hypotension is influenced by the dose of intrathecal local anesthetic administered.1–3 Several studies have examined the use of low-dose intrathecal bupivacaine.4–7 However, low-dose bupivacaine may be associated with an inadequate level of anesthesia, so epidural catheterization is often used in conjunction.

    View all citing articles on Scopus

    This article was presented in part at 1st World Congress on Regional Anesthesia and Pain Therapy in Barcelona, Spain (2002). The abstract was published in the IMRAPT 2002;14:A129.

    View full text