Publication: Elektif sezeryanameliyatlarında anne ve yenidoğan üzerine etkileri açısından optimal anestezi yöntemi: genel, spinal veya epidural
Abstract
Çalışmamızın amacı; elektif sezeryan ameliyatlarında genel, epidural ve spinal anestezinin anne ve yenidoğan üzerine etkilerinin karşılaştırılmasıdır. Elektif sezeryan operasyonu geçirecek,gebelik haftası 38 hafta olan, ASA 1-2 grubuna giren 75 hasta randomize olarak genel anestezi grubu (GA), epidural anestezi grubu (EA) ve spinal anestezi grubu (SA) olarak üç gruba (n= 25) ayrıldı. Genel anestezi (GA)grubunda anestezi indüksiyonu tiyopental sodyum 5 mg/ kg, roküronyum 0,6 mg/ kg ile sağlandı. Endotrakeal entübasyonsonrasıanestezi idamesinde % 30 O2, % 70 N2O ve % 1-2 sevofluran kullanıldı. Tidal volüm 8 ml/ kg, solunum frekansı 8 atım/ dk olarak ayarlanarak mekanik ventilasyon uygulandı. Epidural anestezi (GrupEA) grubundaL4-L5 intervertebral aralıktanepidural aralığa girilerek, %0,5 bupivakain 16 ml+morfin 3 mg uygulandı. Epidural aralıkta 5 cm kalacak şekilde kateter yerleştirildi. Spinal anestezi (Grup SA)L4-L5 intervertebral aralıktan subaraknoid aralığa girilerek 3 ml % 0,5 bupivakain+200 µg morfin uygulandı. Her üç grupta da sistolik arter basıncı (SAB), diyastolik arter basıncı (DAB), ortalama arter basıncı (OAB), kalp atım hızı (KAH) ve SpO2 değerleri anestezi indüksiyonu öncesi, sonrası, cerrahi insizyonun 1, 5,10, 20 ve 40. dakikalarında kaydedildi. Peroperatif kanama miktarı, preoperatif ve postoperatif hemoglobin, hematokrit değerleri, cilt-uterus insizyonu, uterus insizyonu-bebek çıkış zamanı, operasyon süresi, sıvı veefedrin ihtiyacı, postoperatif dönemdeanneninilk analjezik gereksinim, ilk emzirme, ilk defekasyon, ilk idrar, mobilizasyon ve taburculuk zamanı kaydedildi.Yenidoğan çıkımında umbilikal venöz kandankan gazı analizi yapıldı. YenidoğanınSAB, DAB, KTA ve SpO2 değerleri, 1, 5ve 10. dakika Apgar skorları kaydedildi. Postoperatif dönemdeilk emme, ilk idrar yapma, ilk defekasyon zamanı, kilosu, fototerapiihtiyacı,24. ve 48. saat bilirübin değerleri, 24.ve 48. saat postnatal tartı kaybı,doğumda serbest O₂, pozitif basınçlı ventilasyon (PBV),göğüs kompresyonu, entübasyon ve yoğunbakım ihtiyacı kaydedildi. Postoperatif dönemde NRS3 olduğu anilk analjezik gereksinim zamanı olarak kaydedildi, genel ve spinal anestezi grubunda 4 x1 mg/ kg meperidin iv, 3x1 g parasetamol iv, epidural anestezi grubunda ise epidural kateterden 3 mg morfin+15 mg bupivakain 9 cc de uygulandı. Annenin SAB,DAB, OAB, KAHve kanama miktarı GAgrubunda anlamlı olarak yüksek saptandı(p0.05). Annenin SpO2, postoperatifhb-hct değeri, bebeğin Apgar skoru, SpO2 değeri GA grubundaanlamlı olarak düşük saptandı(p0.05). GA grubunda 6 bebekte serbest oksijen ve PBV desteği gerekti (p0.05). ilkidrar zamanı anlamlı olarak en erken GA grubunda saptandı. Annede peroperatif efedrin ve sıvı ihtiyacıSA grubunda EA grubundan anlamlı olarak yüksekti (p0.05). Mobilizasyon zamanı SA grubunda belirginkısa saptandı. EA grubunda ilk analjezik zamanı belirgin uzun, ilk defekasyon zamanı kısa olarak bulundu (p0.05). Genel anestezinin anne ve bebek üzerinde olumsuz etkileri olduğu ve spinal anestezideki hemodinamik instabilite morbiditeyi artırabileceği için, epidural anestezinin elektif sezeryanda tercih edilmesi gerektiği kanısınavarıldı.
The aim of this study isto compare the maternal and neonatal effects of spinal, general and epidural anesthesia for elective cesarean section. 75 patients, ASA I-II, undergoing elective cesarean section at 38th weekwere divided into three groups (n=25) randomly as general anesthesia(GA), epidural anesthesia (EA) and spinal anesthesia(SA).In GA group, anesthesia was induced with thiopental sodium 5 mg/ kg and rocuronium 0.6 mg/ kg iv and after endotracheal intubation,was maintained with 30% O2, 70% N2O and 1-2% sevoflurane. Mechanical ventilation was performed witha tidal volume of 8 mL/ kg and a respiratory rate of 8 beats/ min. In EA group, 16 ml of 0.5% bupivacaine+morphine 3 mg was injected epidurally from L4-L5 intervertebral space. Acatheter was inserted 5 cm in theepidural space. InSA group, 3 ml0.5% bupivacaine+ 200 µg morphine was injected intrathecally from L4-L5 intervertebral space.In all patients, systolic(SAP), diastolic (DAP) andmean arterial pressure (MAP),heart rate (HR),SpO2 values were recordedbefore anesthesia induction, after surgical incision, at 1, 5, 10, 20 and 40. min. Peroperative bleeding, preoperative and postoperative hemoglobin, hematocritvalues, skin-uterine incision, uterine incision-baby out time, duration of surgery, fluid andephedrine requirement, postoperatively first analgesic requirement, defecation, lactation, micturition,mobilization and discharge times were recorded.Umbilical venous blood samples were taken after umbilical cord clamping.Newborn SAP, DAP, HR, SpO2 andApgar scores at1, 5, and 10.minutes were recorded.Postoperatively, the first intake, urination, defecation time,weight, need for phototherapy,bilirubin valuesandpostnatal weight loss at 24. and 48. hours, the requirement of free oxygen, positive pressure ventilation (PPV), chest compression,intubation and intensive care were recorded.Postoperatively when VAS3, in GA and SA group, 4 x1 mg/ kg meperidine and 3x1 gparacetamol iv, in EAgroup, 3 mg morphine+15 mg bupivacain in 9 ml was administered epidurally. Maternal SAP, DAP, OAP and the amount of bleeding were significantly higher and maternal SpO2, postoperative hb-hct values, newborn Apgar score and SpO2 weresignificantly lower inGA group(p0.05). Six babies in GA group required free oxygen andPBV support at birth (p0.05).Ephedrine and fluid requirementswas significantly higher inSA groupthan those of EA group (p0.05).Mobilization time was found significantly shorterin the SA group.The first analgesic requirement and defecation time were significantly shorter inEAgroup (p0.05). We concluded that as general anesthesia has negative maternal and neonatal effects and hemodynamic instability during spinal anestesia may cause increased morbidity, epidural anesthesia can be preferred duringelective cesarean section.
The aim of this study isto compare the maternal and neonatal effects of spinal, general and epidural anesthesia for elective cesarean section. 75 patients, ASA I-II, undergoing elective cesarean section at 38th weekwere divided into three groups (n=25) randomly as general anesthesia(GA), epidural anesthesia (EA) and spinal anesthesia(SA).In GA group, anesthesia was induced with thiopental sodium 5 mg/ kg and rocuronium 0.6 mg/ kg iv and after endotracheal intubation,was maintained with 30% O2, 70% N2O and 1-2% sevoflurane. Mechanical ventilation was performed witha tidal volume of 8 mL/ kg and a respiratory rate of 8 beats/ min. In EA group, 16 ml of 0.5% bupivacaine+morphine 3 mg was injected epidurally from L4-L5 intervertebral space. Acatheter was inserted 5 cm in theepidural space. InSA group, 3 ml0.5% bupivacaine+ 200 µg morphine was injected intrathecally from L4-L5 intervertebral space.In all patients, systolic(SAP), diastolic (DAP) andmean arterial pressure (MAP),heart rate (HR),SpO2 values were recordedbefore anesthesia induction, after surgical incision, at 1, 5, 10, 20 and 40. min. Peroperative bleeding, preoperative and postoperative hemoglobin, hematocritvalues, skin-uterine incision, uterine incision-baby out time, duration of surgery, fluid andephedrine requirement, postoperatively first analgesic requirement, defecation, lactation, micturition,mobilization and discharge times were recorded.Umbilical venous blood samples were taken after umbilical cord clamping.Newborn SAP, DAP, HR, SpO2 andApgar scores at1, 5, and 10.minutes were recorded.Postoperatively, the first intake, urination, defecation time,weight, need for phototherapy,bilirubin valuesandpostnatal weight loss at 24. and 48. hours, the requirement of free oxygen, positive pressure ventilation (PPV), chest compression,intubation and intensive care were recorded.Postoperatively when VAS3, in GA and SA group, 4 x1 mg/ kg meperidine and 3x1 gparacetamol iv, in EAgroup, 3 mg morphine+15 mg bupivacain in 9 ml was administered epidurally. Maternal SAP, DAP, OAP and the amount of bleeding were significantly higher and maternal SpO2, postoperative hb-hct values, newborn Apgar score and SpO2 weresignificantly lower inGA group(p0.05). Six babies in GA group required free oxygen andPBV support at birth (p0.05).Ephedrine and fluid requirementswas significantly higher inSA groupthan those of EA group (p0.05).Mobilization time was found significantly shorterin the SA group.The first analgesic requirement and defecation time were significantly shorter inEAgroup (p0.05). We concluded that as general anesthesia has negative maternal and neonatal effects and hemodynamic instability during spinal anestesia may cause increased morbidity, epidural anesthesia can be preferred duringelective cesarean section.