lunes, 18 de abril de 2016

Raquia en cesarea / Spinal anesthesia in cesarean

Abril 10, 2016. No. 2292

Combinación de sufentanil y bupivacaína versus bupivacaína sola en raquia para cesárea. Meta-análisis de estudios randomizados
Sufentanil and Bupivacaine Combination versus Bupivacaine Alone for Spinal Anesthesia during Cesarean Delivery: A Meta-Analysis of Randomized Trials.
PLoS One. 2016 Mar 31;11(3):e0152605. doi: 10.1371/journal.pone.0152605. eCollection 2016.
OBJECTIVE: The addition of lipophilic opioids to local anesthetics for spinal anesthesia has become a widely used strategy for cesareananesthesia. A meta-analysis to quantify the benefits and risks of combining sufentanil with bupivacaine for patients undergoing cesarean delivery was conducted. METHODS: A comprehensive literature search without language or date limitation was performed to identify clinical trials that compared the addition of sufentanil to bupivacaine with bupivacaine alone for spinal anesthesia in healthy parturients choosing cesarean delivery. The Q and I2 tests were used to assess heterogeneity of the data. Data from each trial were combined using relative ratios (RRs) for dichotomous data or weighted mean differences (WMDs) for continuous data and corresponding 95% confidence intervals (95% CIs) for each trial. Sensitivity analysis was conducted by removing one study a time to assess the quality and consistency of the results. Begg's funnel plots and Egger's linear regression test were used to detect any publication bias. RESULTS: This study included 9 trials containing 578 patients in the final meta-analysis. Sufentanil addition provided a better analgesia quality with less breakthrough pain during surgery than bupivacaine alone (RR = 0.10, 95% CI 0.06 to 0.18, P < 0.001). Sensory block onset time was shorter and first analgesic request time was longer in sufentanil added group compared with the bupivacaine-alone group (WMD = -1.0 min, 95% CI -1.5 to -0.58, P < 0.001 and WMD = 133 min, 95% CI 75 to 213, P < 192, respectively). There was no significant difference in the risk of hypotension and vomiting between these two groups. But pruritus was more frequentely reported in the group with sufentanil added (RR = 7.63, 95% CI 3.85 to 15.12, P < 0.001). CONCLUSION: Bupivacaine and sufentanil combination is superior to that of bupivacaine alone for spinal anesthesia for cesarean delivery in analgesia quality. Women receiving the combined two drugs had less breakthrough pain, shorter sensory block onset time, and longer first analgesic request time. However, the addition of sufentanil to bupivacaine increased the incidence of pruritus.
Efectos de agregar midazolam y sufentanil a bupivacaína intratecal sobre la calidad y complicaciones postoperatorias en cesárea electiva
Effects of Adding Midazolam and Sufentanil to Intrathecal Bupivacaine on Analgesia Quality and Postoperative Complications in Elective Cesarean Section.
Anesth Pain Med. 2015 Aug 22;5(4):e23565. doi: 10.5812/aapm.23565. eCollection 2015.
BACKGROUND: Intrathecal adjutants can be used for regional anesthesia (RA) in cesarean section to improve its quality in terms of time and complications. Some previous studies focused on the effects of adding sufentanil and/or midazolam to bupivacaine and compared each with using bupivacaine alone. However, there has been no study to assess the effects of using sufentanil and midazolam in combination with bupivacaine. OBJECTIVES: The aim of this study was to evaluate and compare properties (time of achievement/recovery of sensory/motor blocks; and time to request opium), complications (nausea, vomiting, shivering and hypotension), and neonatal first minute Apgar score with and without the addition of midazolam (M) or sufentanil (S) to bupivacaine (B) through intrathecal injection for spinal anesthesia, after the cesarean section. PATIENTS AND METHODS:In this double blind randomized clinical trial participants were randomly allocated to three equal groups: Group B (2.5 cc of bupivacaine 0.5% + 1 cc normal saline 0.9%), Group BM (2.5 cc of bupivacaine + 0.02 mg/kg midazolam) and Group BS (2.5 cc of bupivacaine 0.5% + 0.7 cc normal saline 0.9% + 1.5 µg of sufentanil, 0.3 cc). We used analysis of variance (ANOVA), post hoc test with Bonferroni adjustment, and chi-square test for statistical analysis; the analyses were performed using the SPSS-16 software. Given a significant level of 0.05, overall and pair-wise comparisons were made. RESULTS: Seventy-five females participated in the study with no significant age difference (mean ± standard deviation (SD): 28.60 ± 6.06, 28.12 ± 5.29 and 28.76 ± 3.97 year; P = 0.9). Except for "time to motor block recovery" (P = 0.057), the overall differences among the three groups was significant in terms of "time to sensory/motor block" (P < 0.001), "time to sensory block recovery" (P < 0.001), and "time to request opium" (P < 0.001). In all pair-wise comparisons there was no significant difference between the BM and BS group, except for "time to request opium", which was longer in the BS group (P < 0.001). The occurrence of nausea (P = 0.02), postoperative shivering (P = 0.01) and hypotension (P < 0.001) were significantly different between the groups, unlike vomiting, where the difference was not significant (P = 0.2). All neonates had an Apgar score of nine. CONCLUSIONS: The findings showed that adding sufentanil or midazolam to bupivacaine shortens the onset of spinal anesthesia and increases the time duration of anesthesia; however it does not change the motor block recovery time. Adding sufentanil delays the first request for narcotic analgesics while adding midazolam leads to a decrease in nausea and hypotension. Adding sufentanil or midazolam does not have any deleterious effect on infants' Apgar scores. However, increases shivering in patients.
KEYWORDS:Analgesia; Bupivacaine; Cesarean Section; Midazolam; Sufentanil

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