İbrahim AŞIK, Mehmet ORAL, Sacide DEMİRALP

Doğumda epidural analjezide bupivakain, bupivakain fentanil ve bupivakain klonidin'in karşılaştırılması

Bu çalışmada aktif doğum eylemi başlamış miadında sağlıklı 45 primigravid gebede epidural yoldan verilen bupivakain, bupivakain + fentanil ve bupivakain + klonidin kombinasyonlarının etkileri karşılaştırıldı. Gebelerin çalışmaya alınma kriterleri; primigravite, sefalik prezentasyonda tek fetüs, doğumun aktif fazının başlaması ve servikal dilatasyonun 3-7 cm arasında olmasını içermekteydi. Gebeler rastgele 15'er kişilik üç gruba ayrıldıktan sonra VAS>=7 olan gebelerden L gruba 6 mL %0.25 bupivakain + 6mL NaCl %0.9, II. gruba 6 mL %0.25 bupivakain + 50 µg klonidin (1 mL) + 5 mL NaCl %0.9, III. gruba 6 mL %0.25 bupivakain + 50 µ fentanil (1 mL) + 5 mL NaCl %0.9 uygulandı. Tüm ek dozlar Vizüel Analog Skala 4 ise gebenin isteği ve doğumun seyrine göre %0.25'lik bupivakainden 3 mL şeklinde uygulandı. Maternal veriler; ortalama arter basıncı, kalp atım hızı, analjezik etkinlik, sedasyon, motor blok ve yan etkiler ilk 30 dakikada her 5 dakikada bir, daha sonra doğumun sonuna kadar 20 dakikada bir not edildi. Maternal arteriyel kan gazları; epidural kalelerden bolus doz yapılmadan hemen önce, yapıldıktan 30 dk. sonra ve doğumdan hemen sonra alındı. Uygulanan işlem, anne ve doktor tarafından doğumdan hemen sonra değerlendirildi. Bir neonatalog bebekleri doğumdan hemen sonra Apgar skorlarına göre değerlendirdi. Fentanil grubundaki hastalarda analjezinin başlama süresi ve analjezi kalitesi üstün bulundu (p

Anahtar Kelimeler:

Klonidin, Bupivakain, Anestezikler, lokal, Ağrı ölçümü, Analjezi, epidural, Duyarlılık ve özgüllük, Fentanil

The comparison of bupivacaine, bupivacaine plus fentanyl and bupivacaine plus clonidine for epidural analgesia during labor

This study was designed to compare the effects of bupivacaine, fentanyl + bupivacaine and bupivacaine + clonidine for epidural analgesia during labor. 45 nulliparous women requiring epidural analgesia with an uncomplicated pregnancy and single fetus in cephalic presentation were studied. Parturients were randomly allocated into three groups and the initial doses were given epidurally during active phase of labor when the cervical dilatations were between 3-7 cm. When VAS>=7, the first group (n=15) received 0.25% bupivacaine 6 mL + 0.9% NaCl 6 mL, second group (n=15) received 0.25% bupivacaine 6 mL + 0.9% NaCl 5 mL + 50 µg clonidine and third group (n=15) received 0.25% bupivacaine 6 mL + 0.9% NaCl 5 mL + 50 µg fentanyl. Subsequent doses of 0.25% bupivacaine (3 mL) were given according to patients' comfort and necessity (VAS>4). Maternal variables; mean arterial pressure, heart rate, quality of analgesia, sedation, motor block and side effects were noted every 5 min for 30 min and subsequently at 20 min intervals until the end of labor. Maternal arterial blood gases were taken before the administration of initial bolus doses of study drugs and 30 min. after the bolus doses were given and just after the delivery. Global assessment of the procedure were performed by the mother and the investigator. A neonatalogist evaluated the babies by the Apgar score after birth. Epidural fentanyl was found to be superior in onset and quality of analgesia (p<0.05). Analgesia lasted longer in bupivacaine-fentanyl group after the initial dose (168.6±29.6 min) compared with other groups (p<0.01). Although the duration of labor was longer in fentanyl group (p<0.05), the additional doses required were significantly less than the other groups (p<0.05). Pruritis was observed in one patient in bupivacaine + fentanyl group but required no treatment. Motor blockade was observed in two patients in bupivacaine group and in one patient in bupivacaine + clonidine group. Sedation was marked in the bupivacaine + clonidine group (p<0.05). There were no significant differences between the groups in Apgar scores or umblical cord blood gas analysis. In the present study, the addition of fentanyl resulted in longer duration with quicker onset of analgesia and reduced the total doses of bupivacaine and the frequency of supplementary doses and side effects. Fentanyl also improved the quality of analgesia and its major advantage was to allow the administration of subanesthetic concentrations of bupivacaine.

Keywords:

Clonidine, Bupivacaine, Anesthetics, Local, Pain Measurement, Analgesia, Epidural, Sensitivity and Specificity, Fentanyl,

___

1. Athis FD, Macheboeuf M, Thomas CR, et al. Epidural analgesia with a bupivacaine-fentanyl mixture in obstetrics : comparision of repeated injections and continuous infusion. Can J Anaesth 1988;35:2-8.
2. Celleno D, Capogna G. Epidural fentanyl plus bupivacaine 0.125 percent for labour: analgesic effects. Can J Anaesth 1988; 35: 375-8.
3. Gareth HP. Epidural sufentanil/bupivacaine combinations for analgesia during labor : Effect of varying sufentanil doses. Anesthesiology 1987;67: 835- 8.
4. O'meara ME, Gin T. Comparison of 0.125% bupivacaine with 0.125% bupivacaine and clonidine as extradural analgesia in the first stage of labour. Br J Anaesth 1993;71:651-6.
5. Justins DM, Francis D, Houlton PG, Reynolds F. A controlled trial of extradural fentanyl in labour. Br J Anaesth 1982; 54: 409-15.
6. Wittels B. Does epidural anesthesia affect the course of labor and delivery? Seminars in Perinatology 1991; 15: 358-67.
7. D'Angelo R, Gerancher JC, Eisenach JC, Raphael BL. Epidural fentanyl produces labor analgesia by a spinal mechanism. Anesthesiology 1998; 88:1519-23.
8. Lyons G, Columb M, Hawthorne L, Dresner M. Extradural pain relief in labour: bupivacaine sparing by extradural fentanyl is dose dependent. Br J Anaesth 1997; 78:493-7.
9. Le Polain B, Kock MD, Scholtes JL, Lierde VM. Clonidine combined with sufentanil and bupivacaine with adrenaline for obstetric anesthesia. Br J Anaesth 1993;71:657-60.
10. Cohen SE, Shirley T, George A, Halpern J. Epidural fentanyl/ bupivacaine mixtures for obstetric analgesia. Anesthesiology 1987:67:403-7.
11. Murphy JD, Henderson K, Bowden MI, et al. Bupivacaine versus bupivacaine plus fentanyl for epidural analgesia: effect on maternal satisfaction. BMJ 1991; 30: 564-7.
12. Reynolds F, O'Sullivan G. Epidural fentanyl and perineal pain in labour. Anaesthesia 1989; 44: 341-4.
13. Yau G, Gregory MA, Gin T, Oh TE. Obstetric epidural analgesia with mixtures of bupivacaine, adrenaline and fentanyl. Anaesthesia, 1990; 45:1020-3.
14. Cigarini I, Kaba A, Bonnet F, et al. Epidural clonidine combined with bupivacaine for analgesia in labor. Effects on mother and neonate. Reg Anesth 1995; 20: 113-20.
15. Eisenach JC, Lysak SZ, Viscomi-CM. Epidural clonidine analgesia following surgery: phase I. Anesthesiology 1989; 7: 647-2.
16. Bromage PR. An evaluation of bupivacaine in epidural analgesia for obstetrics. Can Anaesth Soc J 1969;16: 1-4.
17. Carane UA, Milligan KR, Moore J. Extradural clonidine and bupivacaine for postoperative analgesia. Br J Anaesth 1992; 68: 132-5.
18. Greiss FC. A clinical concept of uterine blood flow during pregnancy. Obstet Gynecol 1967; 30: 595-604.
19. Grice SC, Eisenach JC, Dewan DM. Labor analgesia with epidural bupivacaine plus fentanyl: Enhancement with epineph-rine and inhibition with 2-Chloroprocaine. Anesthesiology 1990;72: 623-8.
20. Sullivan AF, Dashwood MR, Dickenspn AH- Alpha-2 adrenoreceptor modulation of nociception in rat spinal cord: location, effects and interactions with morphine. Eur J Pharmacol 1987;13:169-177.
21. Carstens E, Gilly H, Schreiber H, Zimmerman M. Effects of midbrain, stimulation and iontophoretic application of serotonin , noradrenalin, morphine and gaba on electrical thresholds of afferent c-and a- fibre terminals in cat spinal cord. Neuroscience 1987; 21: 395-406.
22. Tyce GM, Yaksh TL. Monoamine release from cat spinal cord by somatic stimuli: An intristic modulatory system. J Physiol 1981, 31: 413-9.
23. Kurashi Y, Hirota N, Sato Y, et al. Noradrenerjic inhibition of the release of substance P from the primary afferents in the rabbit spinal dorsal horn. Brain Res 1988; 35: 177-82:
24. Yaksh TL. Pharmacology of spinal adrenergic systems which modulate spinal nociceptive processing. Pharmacol Biochem Behav 1985; 22: 845 -58.
25. Castro MI, Eisenach JC, Pharmacokinetics and dynamics of intravenous, intrathecal and epidural clonidine in sheep. Anesthesiology 1989; 71:418-25.
26. Gordth T. Epidural clonidine for treatment of postoperative pain after thoracotomy. A double-blind placebo-controlled study. Acta Anaesthesiol Scand 1988; 32:702-9.
27. Siegemurid M, Schneider MC, Hampfl KM, Hosli I. Epidural clonidine for relief from intractable labour pain (letter). Anaesthesia 1995; 50:663-4.
28. Copagna G, Celleno D, Zangrillo A, et al. Additioir'of clonidine to epidural morphine enhances postoperative analgesia after cesarean delivery, Reg Anesth 1995; 20: 57-61.
29. Eisenach JC, D'Angelo R, Taylor C, Hood DD. An isobolographic study of epidural clonidine and fentanyl after cesarean section. Anesth Analg 1994; 79:285-90.
30. Michael JC, Laurence M, Mather E. Intrathecal and epidural administration of opioids. Anesthesiology 1984; 61: 276-310.
31. Shnider SM, Levinson G. Anesthesia for obstetrics. In: ed Miller RD, Anesthesia, New York, Churchill Livingstone 1994: ch 61: 2031-2076.
32. Westmore MD. Epidural opioids in obstetrics. Anaesth Intensive Care 1990; 18: 292-300.
33. Rudd P, Blaschke TF. Antihypertensive agents and the drug therapy of hypertension. In: oilman AG, Goodman LS (eds), The Pharmacological Basis of Therapeutics, New York, Mac Millan Publishing Company 1985;784-805.
34. Eisenach JC, Detweiler D, Hood D. Hemodynamic and analgesic actions of epidurally administered clonidine. Anesthesiology 1993; 78:277-87.
35. Johnson MD, Sevarino FB, Lema MJ, et al. Effect of epidural sufentanil on temperature regulation in the parturient. Anesthesiology 1987; 67 (suppl): A450.
36. Shehabi Y, Gatt S, Buckman T, Isert P. Effect of adrenaline, fentanyl and warming of injectate on shivering following extradural analgesia in labour. Anesth Intensive Care 1990; 18: 31-7.
37. Bonnet F, Boico O, Rostaing S, et al. Postoperative analgesia with extradural clonidine. Br J Anaesth 1989; 63:465-9.
38. Scheinin M. The locus coerulus. Site of hypnotic actions of -2 adrenoreceptor agonists? Anesthesiology 1992; 76: 873-5.