Zafer DOĞAN, HÜSEYİN YILDIZ, İsmail COŞKUNER, EMİN SİLAY, Gökhan İSPİR, Hafize ÖKSÜZ

Elektif sezaryene yönelik spinal anestezide bos hacminin korunmasının hemodinamik etkileri

Amaç: Spinal anestezi acil ve elektif sezaryen operasyonları sırasında hızlı ve yeterli anestezi sağladığı için sık kullanılmaktadır. Ancak bu girişim sonrasında hastaların %40~S5'inde hipotansiyonla karşılaşılmaktadır, intraabdominal basınç artışı ve subaraknoid boşluğun daralması ile zaten artmış olan subaraknoid basınç, spinal enjeksiyon ile daha da artabilir. Bu çalışmanın amacı sezaryen sırasında subaraknoid boşluğa uygulanan lokal anesteziğin neden olduğu basınç artışının, sabit yolum sağlanması ile engellenerek yapılan spinal anestezinin hemodinami ve seviye üzerine etkisini araştırmaktır. Yöntem: Oluru/ pozisyonda steril boyama ve örtme sonrasında L4-L5 veya L3-L4 aralığından Quincke uçlu 25G spinal iğne ile subaraknoid aralığa girildi. Grup A'da (n- 32) hastaya uygulanması planlanan bupivakaitı heavy (12 mg) hacmi kadar (2,4 ml) hastadan BOS aspire edildi. Grup B'de 0,05). Total uygulanan efedrin miktarı ise her iki grupta benzerdi. Sonuç: Spinal anestezi öncesi uygulanması planlanan lokal anestezik miktarı kadar beyin-omurilik sıvısı alındıktan sonra spinal anestezi yapılması maternal hipotansiyonu geciktirerek bebek çıkmadan önce maternal hipotansiyon oluşma riskini ve efedrin kullanımını azaltarak fetüsün ve bebeğin iyilik haline katkıda bulunabilir.

Hemodynamic effects of constant csf volume during spinal anesthesia for cesarean section

Objective: Spinal anesthesia is commonly used in emergency and elective cesarean section because it provides rapid and adequate anesthesia. However, hypotension occurs in 40-85% patients after this type of anesthesia. Subarachnoid volume can be increased by spinal anesthesia besides increasing intra-abdominal pressure and narrowing subarachnoid space. It was aimed in this study to evaluate the effect of spinal anesthesia with constant subarachnoid volume by aspirating cerebrospinal fluid (CSF) on maternal hemodynamics and fetus during cesarean section. Method: Under sterile condition, subarachnoid space was reached at L4-L5 or L3-L4 intervertebral space with 25G Quinche blade spinal needle. After aspirating 2.4 mL CSF, 12 mg (2.4 mL) bupivacaine heavy was injected into subarachroid space in group A (n=32). In group B (n=33) only 12 mg (2.4 mL) bupivacaine heavy was injected subarachnoid space, without any CSF lost. Results: The time of reaching maximal sensory block was shorter significantly in group B (p<0,05). At the evaluations of blood gases of both uterine artery and uterine venous, mean pH value were lower significantly in group B (p<0,05). Ephedrine usage until birth was lower but not statistically different in group A (p>0,05). Cumulative ephedrine usage is similar in both groups. Conclusion: Taking CSF with the amount of planned administration of local anesthetic before subarachnoid injection decreases both risk of maternal hypotension and ephedrine usage till birth and may contribute the well conditions of fetus and baby.

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1. Kaya S. Karaman H, Erdoğan H, Akyilmaz A, Turhanoglu S. Combined use ol low-dose bupivacaine, colloid preload and wrapping of the legs for preventing hypotension in spinal anaesthesia for eaesarean section. J Int Med Res 2007;35(5):615-25.
2. Sevarino, F. Management of hypotension in obstetric anesthesia: is it time to re-write the textbooks? Curr Opin Anaesthesiol 2003; 16(3):249-51.
3. Dresner. M. Hacmodynamic stability and regional anaesthesia for eaesarean section. Curr Anaesth Crit Care 2004; 15(4 ):262-9.
4. Ko JS. Kim CS. Cho HS. Choi DH. A randomized trial of crystalloid versus colloid solution for prevention of hypotension during spinal or low-dose combined spinal-cpidural anesthesia for elective cesarean delivery, lııt J Obstet Anesth 2007;I6(1):8-12.
5. Avorinde BT. Buczkowski P, Brown J. Shalı J. Buggy DJ. Evaluation of pre-emptive intramuscular phenylephrine and ephedrine for reduction of spinal anaesthesia-induced hypotension during Caesarean section. Br J Anaesth 2001;86(3):372-6.
6. Ngan Kee WD. Lau TK, Khaw KS, Lee BB. Comparison of metaraminol and ephedrine infusions for maintaining arterial pressure during spinal anesthesia for elective cesarean section. Anesthesiology 2001:95(2):307-13.
7. Morgan GE. Mikhail MS. and M. M J., eds. Clinical Anesthesiology. 3rd ed. Obstetric Anesthesia, McGraw-Hill: USA. 828-833.
8. Hawkins JL. Koonin LM. Palmer SK. Gibbs CP. Anesthesia-related deaths during obstetric delivery in the United States, 1979-1990. Anesthesiology 1997:86(2): 277-84.
9. Ben-David B. Miller G, Gavriel R. Gurevitch A. Low-dose bupivacaine-fentanyi spinal anesthesia for cesarean delivery. Reg Anesth Pain Med 2000;25(3):235-9.
10. Rout CC, Rocke DA, Levin J, Gouws E. Reddy D. A reevaluation of the role of crystalloid preload in the prevention of hypotension associated with spinal anesthesia for elective cesarean section. Anesthesiology l993:79(2):262-9.
11. Rees SG, Thurlow JA, Gardner IC, Scrutton MJ. Kinsella SM. Maternal cardiovascular consequences of positioning after spinal anaesthesia for Caesarean section: left 15 degree table tilt vs. lelt lateral. Anaesthesia 2002;57( I): 15-20.
12. Bul AK. Ozttirk E. Giilhaş N. Durmuş M, Doğan Z. Ersoy MÖ. Elektif Sezaryenlerde İntratekal Bupivakaine İlave Edilen Fentanil ve Morfinin Efedrin Gereksinimi ve Fetusa Etkisi. İnönü Üniversitesi Tıp Fakültesi Dergisi 2005:12( l ):5-9.
13. Critchley LA. Stuart JC. Conway F. Short TG. Hypotension during subarachnoid anaesthesia: haemodynainic effects of ephedrine. Br J Anaesth 1995:74(4):373-8.
14. Mercier FJ, Riley ET. Frederickson WL. Roger-Christoph S, Benhamou D, Cohen SE. Phenylephrine added to prophylactic ephedrine infusion during spinal anesthesia for elective cesarean section. Anesthesiology 200l;95(3):668-74.
15. Ngaıı Kee WD. Khaw KS. Lee BB. Lau TK. Gin T. A dose-response study of prophylactic intravenous ephedrine for the prevention of hypotension during spinal anesthesia for cesarean delivery. Anesth Analg 2000:90(6): 1390-5.
16. Vincent RD Jr. Werhan CF. Norman PF. Prophylactic angiotensin II infusion during spinal anesthesia for elective cesarean delivery. Anesthesiology 1998:88(6): 1475-9.
17. Park GE, Haucjh MA, Curlin F. Datta S, Bader AM. The effects of varying volumes of crystalloid administration before cesarean delivery on maternal hemodynamics and colloid osmotic pressure. Anesth Analg l996:83(2):299-303.
18. Siddik-Sayyid SM, Nasr VG. Taha SK. A randomized trial comparing colloid preload to cotoad during spinal anesthesia for elective cesarean delivery. Anesth Analg 2009:109(4): 1219-24.
19. Bancrjee A, Stocche RM. Angle P. Halpern SH. Preload or coload for spinal anesthesia for elective Cesarean delivery: a meta-analysis. Can J Anaesth 2010:57(1):24-31.
20. Ngan Kee WD. Prevention of maternal hypotension after regional anaesthesia for caesarean section. Curr Opin Anaesthesiol 2010: 23(3):304-9.
21. Meııdonca C, Griffiths J. Ateleanu B, Collis RE. Hypoteasion following combined spinal-epidural anaesthesia for Caesarean section. Left lateral position vs. tilted supine position. Anaesthesia 2003;58(5):428-31.
22. Kinsella SM. Whitwam JG, Spencer J A. Aortic compression by the uterus: identification with the Finapres digital arterial pressure instrument. Br J Obstet Gynaecol l990:97(8):700-5.