Περιοχική αναισθησία ταχείας διακίνησης στην καισαρική τομή
Authors: Διαμαντής Μόρφης 
Published: July 2014

Introduction: Nowadays, regional anaesthesia has replaced general anaesthesia forelective caesarean sections. The aim of this randomized study was to compare thecombined subarachnoid-epidural technique with the epidural technique.Materials and methods: One hundred and eight parturients scheduled for electivecaesarean section were randomly chosen to receive combined subarachnoid-epiduralanaesthesia (n = 54) or epidural anaesthesia (n = 54). Through the epidural catheter, 15ml of ropivacaine 0.75% in increments was given to the epidural group, whereas thecombined group received 2 ml of ropivacaine 0.75%. After the operation, the methods ofchoice for analgesia were the systematic epidural administration of 0.2% ropivacaine andthe application of a PCA pump with morphine.Time required for the sensory block to reach T10, Σ7 and T4 dermatomes, thelevel of motor block when sensory block was at T7 dermatome, the supplementary dosesand the rescue doses of ropivacaine needed intraoperatively were recorded, as well as theincision time and the duration of surgery, the time of entrance and discharge from thePACU, and the duration of PACU stay. Regression of the block below T4 dermatome andup to T6 dermatome, were registered. Finally, the time of full recovery of motor blockwas recorded, as well as the level of the sensory block at that moment.Two, 4, 8 and 24 hours after the operation, the analgesic requirements formorphine, as well as the VAS scores at rest and cough were recorded. Ambulation ability8 hours after the operation, satisfaction using the verbal score scale 0-10, as well as theincidence of headache, nausea and vomiting, in the first 24 hours postoperatively wererecorded.Results: Time required for the sensory block to reach T7 and T10 was 13.1 ± 3.8 minand 17.79 ± 5.35 min for epidural anaesthesia and 5 ± 2.7 min and 6.5 ± 2.3 min forcombined anaesthesia respectively (p< 0.001). Sensory block reached T4 dermatomeafter 28 ± 10 min in the epidural group and after 9 ± 4 min in the combined group (p<0.001) and regressed to T6 dermatome after 200 (98-439) min in the epidural group and125.5 (70-332) min in the combined group (p< 0.001). At the time sensory block was atT7, there was a better motor response in the epidural group compared to the combinedgroup. Eleven out of 53 parturients needed supplementary dose from the epidural group,102whereas no parturient needed supplementary dose in the combined group (p< 0.001).There was no significant difference in the number of parturients requiring rescue dosebetween the two groups (p= 0.72). The incision time was significantly higher in theepidural (34.81 ± 9.05) than in the combined anaesthesia group (16.77 ± 4.2) (p< 0.001).The duration of surgery was significantly higher in the epidural (84.88 ± 14.42 min) thanin the combined group (68.48 ± 14.2 min) (p< 0.001). In addition, there was a significantdifference in time of entrance and exit from the PACU between the epidural group (93.14± 14.9 and 233.3 ± 86.02 min, respectively) and the combined group (76.23 ± 14.2 and154.65 ± 61.8 min, respectively) (p< 0.001). The median time to full motor recovery wassignificantly higher in the epidural (120 (78-399) min) than in the combined group (101(69-258) min) (p= 0.003). At the time of full motor recovery, the median sensory blockwas at a higher level in the epidural than in the combined group (p= 0.001). Women inthe group of epidural stayed in the PACU 140 ± 86 min whereas women in the combinedgroup stayed 78 ± 60 min (p< 0.001).Morphine consumption 2 hours after the operation was 1.78 ± 2.45 mg in theepidural versus 7.30 ± 4.69 mg in the combined group (p< 0.001). Morphineconsumption 4 hours postoperatively was 3.27 ± 3.81 mg and 9.04 ± 5.7 mg in theepidural and combined group respectively (p< 0.001). Cumulative morphine consumptionafter 24 hours was 40.71 ± 16.05 mg in the epidural group versus 42.71 ± 17.2 mg in thecombined group (p= 0.38). The two groups did not differ regarding VAS score, at rest(p= 0.56) or cough (p= 0.35), satisfaction (p= 0.61) and incidence of headache (p= 1.0),nausea and/or vomiting (p= 0.78) at any time point of measurement. During the first 30min after the sensory block had reached T4 dermatome there was no difference betweenthe two groups regarding systolic (p= 0.482) and diastolic (p= 0.108) blood pressures orheart rate (p= 0.939). Total ephedrine consumption was lower in the epidural (8 ± 7 mg)than in the combined (11 ± 7 mg) group (p= 0.02).Conclusion: Combined subarachnoid-epidural anaesthesia with 0.75% ropivacaine forcaesarean section is more cost effective regarding the fast-tracking of patients, comparingto the epidural anaesthesia. The analgesic needs and the adverse effects did not differbetween the two techniques