Spinal Anesthesia in Caesarian Section: Sitting versus Lateral position Approach A Thesis study Submitted for the fulfillment of the master degree in Anesthesiology, surgical ICU and Pain Management Presented by Mohammad Ahmad Mohammad Yusuf Ollaek M.B.B.Ch Faculty of Medicine, Cairo University Supervised by Prof.Dr. Manar Mahmoud Elkholy Professor of Anesthesiology Faculty of Medicine, Cairo University Assist.Prof.Dr. Enas Mohamed Samir Assistant professor of anesthesiology Faculty of medicine, Cairo University Dr. Ahmad RagabAbd Elhakim Lecturer of anesthesiology Faculty of Medicine, Cairo University 2011
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Spinal Anesthesia in Caesarian Section: Sitting versus Lateral position Approach
A Thesis study
Submitted for the fulfillment of the master degree in Anesthesiology, surgical ICU and Pain Management
Presented by
Mohammad Ahmad Mohammad Yusuf Ollaek
M.B.B.Ch
Faculty of Medicine, Cairo University
Supervised by
Prof.Dr. Manar Mahmoud Elkholy Professor of Anesthesiology
Faculty of Medicine, Cairo University
Assist.Prof.Dr. Enas Mohamed Samir Assistant professor of anesthesiology
Faculty of medicine, Cairo University
Dr. Ahmad RagabAbd Elhakim Lecturer of anesthesiology
Faculty of Medicine, Cairo University
2011
ACKNOWLEDGEMENT
Thanks to Allah for giving me the power and strength to carry out
this work.
Words stand short where they come to express my gratitude to my
supervisors.
I would like to express my thanks and deepest gratitude to Prof. Dr.
Manar Mahmoud Elkholy, Professor of Anesthesiology, Faculty of
Medicine, Cairo University, for her great support and her continuous
generous advice.
My deep gratitude goes for Prof. Dr. Enas Mohamed Samir,
Professor of Anesthesiology, Faculty of Medicine, Cairo University, for her
kind help and great support throughout this work.
I would like to sincerely thank Dr. Ahmed Ragab Abd Elhakim,
Lecturer of Anesthesiology, Faculty of Medicine, Cairo University for his
valuable advice, honest assistance and fruitful suggestions throughout my
daily work.
I would like to express my thanks to all members of my family especially
my father and my wife for giving me love and care till I have finished this
work and forever.
II
DEDICATION
This work is dedicated to the soul of my mother,
who stood beside me through my entire life, gave me all
the support and taught me honesty and sincerity.
III
Abstract
Regional anesthesia became of choice in obstetric patients for
its characteristics in providing almost rapid onset of anesthesia,
allowing the mother to immediately interact with her baby; it is
safer for mother than general anesthesia.
After compatison of sitting versus lateral position approach
regarding spinal anesthesia in caesarian section, It proves that
sitting approach produces less hypotension, less cephaled spread
and less post dural puncture headache than lateral approach.
venous thrombosis (76) (77), migraine, chemical or infective meningitis (78)
and non-specific headache. It has been estimated that 39% of parturient
report symptoms of a headache unrelated to dural puncture following
delivery (79).
Duration
The largest follow-up of post-dural puncture headache is still that of
Vandam and Dripps in 1956 (63). They reported that 72% of headaches
resolved within 7 days, and 87% had resolved in 6 months (Table 4). In a
minority of patients the headache can persist (69).Indeed, case reports have
described the persistence of headache for as long as 1–8 yr after dural
puncture (80).
It is interesting to note that even post-dural puncture headaches of this
duration have been successfully treated with an epidural blood patch (67).
Table 4: Estimated rate of spontaneous recovery from post-dural
puncture Headache (81).
Duration Percentage recovery %
1±2 days 24 3±4 days 29 5±7 days 19 8±14 days 8 3±6 weeks 5 3±6 months 2 7±12 months 4
Review of Literature
38
Prevention And Treatment Of PDPH
The aim of management of post-dural puncture headache is to:
(I)Replace the lost CSF.
(II) Seal the puncture site.
(III) Control the cerebral vasodilatation.
Overview
The literature regarding the treatment of post dural puncture headache
often involves small numbers of patients, or uses inappropriate statistical
analysis. Studies observing the effects of treatments in post-dural puncture
headache often fail to recognize that, with no treatment, over 85% of post-
dural puncture headaches will resolve within 6 weeks (Table 4) (81).
A- Psychological
Patients who develop post-dural puncture headache may reveal a wide
range of emotional responses from misery and tears to anger and panic. It is
important both from a clinical and medico-legal point of view, to discuss
the possibility of headache before a procedure is undertaken that has a risk
of this complication. Obstetric patients are particularly unfortunate should
they develop this complication, as they expect to feel well and happy and to
be able to look after their new baby. It is important to give the mother a
thorough explanation of the reason for the headache, the expected time
course, and the therapeutic options available (69).
Review of Literature
39
B- Simple
Spriggs DA et al. found that bed rest has been shown to be of no benefit (82). Supportive therapy such as rehydration, acetaminophen, non-steroidal
anti-inflammatory drugs, opioids, and anti-emetics may control the
symptoms and so reduce the need for more aggressive therapy (83)but do
not provide complete relief (84).
C- Posture
If a patient develops a headache, they should be encouraged to lie in a
comfortable position. The patient will often have identified this, without
the intervention of an anesthetist. The prone position has been advocated,
but it is not a comfortable position for the post-partum patient. The prone
position according to Handler CE et al. raises the intra-abdominal pressure,
which is transmitted to the epidural space and may alleviate the headache.
A clinical trial of the prone position following dural puncture failed to
demonstrate a reduction in post-dural puncture headache (85).
D- Abdominal Binder
A tight abdominal binder raises the intra-abdominal pressure. The
elevated intra-abdominal pressure is transmitted to the epidural space and
may relieve the headache (85).
Review of Literature
40
E- Haydration : There is no evidence supporting the use of increased fluids to prevent
post-LP headache (86). The only prospective study of this intervention
involved oral hydration. Dieterich and Brandt performed a prospective
study of 100 age-matched, randomly allocated neurologic patients and
found no correlation between the incidence of post lumber puncture
headache and the amount of fluid intake (87).
F- Pharmacological Treatment
A number of therapeutic agents have been suggested for the management
of post-dural puncture headache.
The main problem in choosing the most appropriate one is the lack of
large, randomized, controlled clinical trials.
a) Desmopressin Acetate And Adrenocortico trophic Hormone
Regarding desmopressin acetate, intramuscular administration before
lumbar puncture was not shown to reduce the incidence of post-dural
puncture headache (88). ACTH (adreno-cortico-trophic-hormone) has been
administered as an infusion (1.5 µg/kg),but inadequate statistical analysis
prevents assessment of the value of ACTH (89).
b) Caffeine
Caffeine is a central nervous system stimulant that amongst other
properties produces cerebral vasoconstriction. It is available in an oral and
I.V. form. The oral form is well absorbed with peak levels reached in
Review of Literature
41
30 min. Caffeine crosses the blood–brain barrier and the long half-life of 3–
7.5 h allows for infrequent dosing schedules.
Dose
The dose now recommended for the treatment of post-dural puncture
headache is 300–500 mg of oral or I.V. caffeine once or twice daily (90).
One cup of coffee contains about 50–100 mg of caffeine and soft drinks
contain 35–50 mg.
Mode Of Action
It is assumed that caffeine acts through vasoconstriction of dilated
cerebral vessels (53). If cerebral vasodilatation were the source of the pain,
cerebral vasoconstriction might limit the pain experienced. Indeed, it has
been demonstrated that caffeine causes a reduction in cerebral blood flow, (91)but this effect is not sustained. However, the effects of caffeine on post-
dural puncture headache seem, at best, temporary (90). In addition, caffeine
is not a therapy without complications(92)and does not restore normal CSF
dynamics, thus leaving the patient at risk from the serious complications
associated with low CSF pressure(92).
c) Sumatriptan
The treatment for migranous headaches has focused on modification of
cerebral vascular tone. Sumatriptan is a 5-HT1D receptor agonist that
promotes cerebral vasoconstriction, in a similar way to caffeine (93).
Sumatriptan is advocated for the management of migraine and for post-
dural puncture headache.
Review of Literature
42
However, a controlled trial found no evidence of benefit from Sumatriptan
for the conservative management of post-dural puncture headache (94).
d) Gabapentin
Gabapentin is an antiepileptic drug (AED) with analgesic properties. The
mechanism by which gabapentin exerts its analgesic action is unknown.
Gabapentin is structurally related to the neurotransmitter GABA (gamma-
aminobutyric acid) but it does not modify GABA (A) or GABA (B) radio-
ligand binding, it is not converted metabolically into GABA or a GABA
agonist, and it is not an inhibitor of GABA uptake or degradation.
Advantages And Disadvantages:
Potential advantages of gabapentin include lack of cardiovascular or
respiratory adverse effects, very good tolerability, lack of hepatic
metabolism, lack of liver and enzyme-inducing or –inhibiting effects, less
monitoring of laboratory tests. Gabapentin may have an advantage in
patients taking medications (e.g., antiretroviral agents for HIV infection)
that may result in clinically important interactions when taken concurrently
with enzyme-inducing or –inhibiting drugs. In addition, acute oral
overdoses of gabapentin tend to produce non–life-threatening symptoms
(e.g., ataxia, diarrhea, diplopia, drowsiness, lethargy, and slurred speech).
A potential drawback to gabapentin is a delay in response due to need for
dosage titration. Dosage adjustment is required in patients with renal
impairment (95).
Review of Literature
43
Gabapentin has been reported to be effective in prophylaxis and treatment
of PDPH. After treatment with gabapentin 400 mg three times daily, PDPH
was relieved remarkably in 24 hr(96).
G- Epidural Blood Patch
History
After the observation that ‘bloody taps’ were associated with a reduced
headache rate the concept of the epidural blood patch has developed. The
theory is that the blood, once introduced into the epidural space, will clot
and occlude the perforation, preventing further CSF leak. The high success
rateand the low incidence of complications have established the epidural
blood patch as the standard against which to evaluate alternative methods
to treat post-dural puncture headache (97).
The Mechanism of Action
Using either radiolabelled red cells (98) or an MRI scan (99)several studies
have reported the degree of spread of the epidural blood patch. After
injection, blood is distributed caudally and cephalad regardless of the
direction of the bevel of the Tuohy needle. The blood also passes
circumferentially around to the anterior epidural space. In addition, the
blood passes out of the intervertebral foramina and into the paravertebral
space. The mean spread of 14 ml of blood is six spinal segments cephalad
and three segments caudal. Compression of the thecal space for the first 3
h, and a presumed elevation of subarachnoid pressure, may explain the
Review of Literature
44
rapid resolution of the headache. Compression of the thecal sac is not,
however, sustained and maintenance of the therapeutic effect is likely to be
attributable to the presence of the clot eliminating the CSF leak. It has been
observed that CSF acts as a procoagulant, accelerating the clotting process (98). At 7–13 h, there is clot resolution leaving a thick layer of mature clot
over the dorsal part of the thecal sac. Animal studies have demonstrated
that 7 days after the administration of an epidural blood patch, there is
widespread fibroblastic activity and collagen formation. Fortunately, the
presence of blood does not initiate an inflammatory process and there is no
evidence of axonal edema, necrosis or demyelination (100)(101).
Technique
The presences of fever, infection on the back, coagulopathy, or patient
refusal are contraindications to the performance of an epidural blood patch
(102). As a precautionary measure, a sample of the subject’s blood should
be sent to microbiology for culture (103). With the patient in the lateral
position, the epidural space is located with a Tuohy needle at the level of
the supposed dural puncture or an intervertebral space lower. The operator
should be prepared for the presence of CSF within the epidural space. Up
to 30 ml of blood is then taken from the patient’s arm and injecting slowly
through the Tuohy needle. There is no consensus as to the precise volume
of blood required. Most practitioners now recognize that the 2–3 ml of
blood originally described by Gormley is inadequate, and that 20–30 ml of
blood is more likely to guarantee success (103). Larger volumes, up to
60 ml, (104) have been used successfully in cases of spontaneous intracranial
hypotension. At the conclusion of the procedure, the patient is asked to lie
still for one (102) or, preferably, 2 h (105) and is then allowed to walk.
Review of Literature
45
Outcome
The technique has a success rate of 70–98% if carried out more than 24 h
after the dural puncture. If an epidural blood patch fails to resolve the
headache, repeating the blood patch has a similar success rate. Failure of
the second patch and repeating the patch for a third or fourth time has been
reported. However, in the presence of persistent severe headache, an
alternative cause should be considered (106).
Complications
Immediate exacerbation of symptoms and radicular pain has been
described (107). These symptoms do not persist and resolve with the
administration of simple pain killers. Long-term complications of epidural
blood patch are rare. A single case report of an inadvertent subdural
epidural blood patch described non-postural, persistent headache and lower
extremity discomfort (108).
Prophylactic Epidural Blood Patch
Where the known incidence of post-dural puncture headache is high, such
as in the parturient, the use of a prophylactic epidural blood patch after
accidental dural puncture, that is blood patching before the onset of
symptoms, is an attractive option. Prophylactic patching has generally been
dismissed as ineffective, but the evidence is conflicting. A controlled trial
in post-myelogram headaches (109) and one after spinal anesthesia and after
unintentional dural puncture with an epidural needle (110) have confirmed
the benefit of prophylactic patching. Those studies that have not supported
Review of Literature
46
the use of prophylactic patching may have used insufficient blood for the
patch (110).
The pressure gradient between the thecal and epidural space may be high
immediately after dural puncture and lead to patch separation from the site
of the perforation. Blood patching at that time may therefore need a greater
volume of blood to produce a successful patch compared with a late patch,
where the CSF pressure may be lower (111).
H- Epidural saline
Concerns have been expressed about the potential danger of an
autologous epidural blood patch for the treatment of post-dural puncture
headache. The immediate resolution of the headache with a blood patch is
attributable to thecal compression raising the CSF pressure. An epidural
injection of saline would, in theory, produce the same mass effect, and
restore normal CSF dynamics. As saline is a relatively inert and sterile
solution, epidural saline bolus or infusion appears to be an attractive
alternative. Regimens that have been advocated include:
(i) 1.0–1.5 liter of epidural Hartmanns solution over 24 h, starting
on the first day after dural puncture (112).
(ii) Up to 35 ml/h of epidural saline or Hartmanns solution for 24–
48 h, or after development of the headache (113).
(iii) A single 30 ml bolus of epidural saline after development of
headache (114).
(iv) 10–120 ml of saline injected as a bolus via the caudal epidural
space (115).
Review of Literature
47
Advocates of an epidural saline bolus or infusion maintain that the
lumbar injection of saline raises epidural and intra-thecal pressure.
Reduction in the leak would allow the dura to repair.
However, observations of the pressures produced in the subarachnoid
and epidural space show that, despite a large rise in epidural pressure, the
consequent rise in subarachnoid pressure maintains the differential pressure
across the dura. The pressure rise is also not sustained and is dissipated
within 10 min (116). The saline may induce an inflammatory reaction within
the epidural space, promoting closure of the dural perforation.
I- Epidural Dextran
Despite the paucity of evidence to support epidural saline, some
observers have considered the epidural administration of Dextran 40 (117).
Those studies that recommend Dextran 40, either as an infusion or as a
bolus, conclude that the high molecular weight and viscosity of Dextran 40
slows its removal from the epidural space. The sustained tamponade around
the dural perforation allows spontaneous closure. However, it is unlikely
that Dextran 40 will act any differently to saline in the epidural space. Any
pressure rise within the subarachnoid space would, like saline, be only
transient. Histological inspection of the epidural space after administration
of Dextran 40 (100), does not demonstrate any inflammatory response that
would promote the healing process. The evidence for the administration of
epidural Dextran to treat post-dural puncture headache is not proven and
the theoretical argument to justify its use is poor.
Review of Literature
48
J- Epidural, Intrathecal And Parenteral Opioids
A number of authors have advocated the use of epidural (118), intra-
thecal (119) or parenteral morphine (120) the majority of these reports are
either case reports or inadequately controlled trials.
Some of the studies used epidural morphine after the onset of headache;
others used epidural or intra-thecal morphine as prophylaxis or in
combination with an intra-thecal catheter (119). A controlled trial of intra-
thecal fentanyl as prophylaxis found no evidence of a reduction in the
incidence of post-spinal headache after dural puncture with a 25-gauge
spinal needle (121).
K- Fibrin Glue
Alternative agents to blood, such as fibrinous glue, have been proposed
to repair spinal dural perforations (122). Cranial dural perforations are
frequently repaired successfully with it. In the case of lumbar dural
perforation, the fibrin glue may be placed blindly or using CT-guided
percutaneous injection (123). There is, however, a risk of the development of
aseptic meningitis with this procedure (124).
L- Intrathecal Catheters
After accidental dural perforation with a Tuohy needle, it has been
suggested that placement of a spinal catheter through the perforation may
provoke an inflammatory reaction that will seal the hole. Evidence to
support this claim is conflicting (125). The mean age of the patients in some
Review of Literature
49
of the trials has been >50 yr, where the rate of post-dural puncture
headache is low. Some trials have used spinal microcatheters, 26G–32G;
others have placed 20G epidural catheters through an 18G Tuohy needle (126).
Histopathological studies in animals and humans with long-term intra-
thecal catheters confirm the presence of an inflammatory reaction at the site
of the catheter. Comparison between the effects of a catheter left in situ for
24 h and for several days or weeks would seem inappropriate (127).
If, after accidental dural puncture with a Tuohy needle, the insertion of an
intra-thecal catheter reduced the post-dural puncture headache rate, then it
would be worth considering. However, neurological complications, such as
cauda equina syndrome and infection, should preclude the use of intra-
thecal catheters (128).
M- Surgery
There are case reports of persistent CSF leaks that are unresponsive to
other therapies, being treated successfully by surgical closure of the dural
perforation(129). This is clearly a last resort treatment.
Patients and Methods
Patients and Methods
51
After approval by the Ethical Committee and written informed patient
consent, 40 adult ASA physical status I parturients at full-term gestation
and presenting for elective cesarean delivery were enrolled in this
prospective, randomized study. Women suffering from preeclampsia,
hypertension, diabetes, obesity, or ante-partum hemorrhage were excluded.
On arrival to the operating room basic monitoring was applied for each
patient in the form of electrocardiogram (ECG), pulse oximetry and blood
pressure. Two wide bore cannulae (18G) were inserted after application of
EMLA® cream at site of cannulation.
Before initiation the of the block, each patient received 500 mL of
Ringer Acetate solution within 10-15 minute and placed in the supine
position with a 15° left lateral tilt then patients were randomized into one of
two groups. Group (A) in the sitting position (n=20) and group (B) in the
right lateral decubitus position (n=20).
After obtaining baseline recordings (Time 1) (T 1) for Blood pressure
(Systolic, Diastolic, Mean arterial blood pressure (MAP)), Heart rate (HR)
and O2 saturation anesthesia was given in the sitting position (Group A)
where a stool can be provided as a footrest and a pillow placed in the lap.
The assistant then maintains the patient in a vertical plane while flexing the
patient’s neck and arms over the pillow to open up the lumbar vertebral
space. While in the right lateral position(Group B) the patients were placed
with their back parallel to the edge of the operating table nearest the
anesthesiologist, their thighs flexed on their abdomen, and their neck flexed
to allow the forehead to bias close as possible to the knees.
Patients and Methods
52
After sterilization of patient back with povidone-iodine (Betadine), the
L3-4 or L4-5 interspace is identified and using 25G Quincke`s spinal
needle inserted in the defined space. After obtaining clear cerebrospinal
fluid, 2 ml of hyperbaric bupivacaine (Bucain 0.5% Hyperbar®) + 25 mcg
Fentanyl were slowly injected. After removal of spinal needle, patients
were placed in the supine position with a 15° left lateral tilt. The height of
sensory block measured with alcohol swabs and the degree of motor
impairment using the Bromage scale were evaluated every 2 min which
described on Table (5) (130 ). Surgery was allowed to start when at least the
T4 dermatome was anesthetized.
Table (5): Bromage scale (130)
Grade Criteria Degree of block
I Free movement of legs and feet Nil (0%)
II Just able to flex knees with free movement of feet Partial (33%)
III Unable to flex knees, but with free movement of
feet
Almost complete
(66%)
IV Unable to move legs or feet Complete (100%)
Intra-operative blood pressure, heart rate and O2 saturation were
monitored every 5 min and systolic blood pressure, HR, O2 saturation were
recorded before induction of anesthesia as mentioned before (T 1), after
induction (T 2), after stabilization of the sensory level ( T 3) and by the end
of operation (T 4) . Ephedrine in increments of 5 mg was given IV to treat
hypotension, defined in this study as a maternal systolic blood pressure
Patients and Methods
53
below 70-80% of baseline recordings and/or an absolute value of < 90 -
100mmHg. In addition, bradycardia with heart rate less than 60 beats/min.
was treated was atropine 0.5 mg. Other side effects such as nausea or
vomiting were recorded throughout the intraoperative period and treated
accordingly.
Follow up of PDPH within 48 hours of the end of operation and all
participants informed to lie flat in bed after the procedure, to have adequate
hydration and in case of developing headache to have Paracetamol 500 mg
+ Caffeine 50 mg(Panadol Extra®) /6 hours.
Patients and Methods
54
Statistical Analysis:
Continuous variables were analyzed statistically using analysis of variance
and Scheffé’spost hoc test or unpaired Student’s t-testing whenever
appropriate. Categorical data were analyzed using the Fisher’s exact test
and χ2 analysis. A P value < 0.05 was considered statistically significant.
RESULTS
Results
56
There were no differences in patient demographics with respect to age,
weight, height and the operative time (Table 6). Baseline systolic blood
pressures (Time 1)(T1) were almost similar in both groups (120.05 ± 6.84
mm Hg versus 117.70 ± 7.45 mm Hg in the sitting and lateral group,
respectively; (P =0.376)( Table 7).
In the lateral group, 3 (15%) patients became hypotensive as compared
with 1 (5%) in the sitting group in the reading after induction (T2). This
difference did not achieve statistical significance (P = 0.292) (Table 8).
Hypotension was also noticed later after stabilization of sensory level (T3)
in the lateral group, 11 (55%) more than in the sitting group, 4 (20%). This
difference achieve statistical significance (P = 0.022) (Table 8). There was
no difference in HR, O2 Saturation (Table 9) (Table 10) respectively. There
was increased incidence of nausea/vomiting in lateral group; 8 (40%)
versus 2 (10%) in sitting group, (P =0.028) (Table 11).
All patients had a sensory block reaching at least T4, but the maximal
spread of the sensory block was more cephalad with the lateral position and
this group also had more sensory blocks that reached higher than the T3
dermatome (80% versus 35%, P = 0.004) (Table 12). Regarding PDPH; In
the lateral group, 11 (55%) patients developed PDPH within 48 hours post-
operative versus 2 (10%) patients in the sitting group ;( P = 0.002) (Table
13).
Results
57
Table (6) Demographic data and Operative time of patients during study
Data are expressed as number, mean and standard deviation.
Sitting(n=20) Lateral(n=20) P-value
Age (years)
24.55±2.65 25.05±2.54 0.546
Weight (kg)
75.00±6.28 74.75±6.1 0.900
Height (cm)
162.25 ± 3.02 160.5 ± 3.94 0.123
Operative Time (min.)
65.25 ± 6.78 65.25 ± 6.78 1.000
Results
58
Table 7: Systolic Blood Pressure of patients during study
Data are expressed as number, mean and standard deviation.
Sitting(n=20) Lateral(n=20) P-value
T1
120.05 ± 6.84 117.70 ± 7.45 0.376
T2
111.75 ± 8.93 104.40 ± 5.46 0.003*
T3
102.00 ± 5.54 96.75 ± 5.44 0.004*
T4
115.50 ± 7.42 111.30 ± 6.08 0.054
*= statistically significant. (P-value of statistical significance ≤ 0.05)
Figure (9): Systolic Blood Pressure of patients during study
Results
59
Table 8: Systolic Blood Pressure less than 100 mmHg of patients during study
Data are expressed as number and percentage.
Sitting (n=20) Lateral (n=20) P-value
T2
1 (5%) 3 (15%) 0.292
T3
4 (20%) 11 (55%) 0.022*
*= statistically significant. (P-value of statistical significance ≤ 0.05)
Figure (10): Systolic Blood Pressure less than 100 mmHg of patients during study in T3
Results
60
Table 9: Heart Rate (HR) of patients during study
Data are expressed as number, mean and standard deviation.
Sitting(n=20) Lateral(n=20) P-value
T 1
92.40±9.56 91.65±9.52 0.805
T 2
92.55±9.57 96.85±10.30 0.180
T 3
91.15±8.61 96.20±11.54 0.125
T 4
91.50±8.60 92.25±8.87 0.788
Table 10: O2 Saturation of patients during study
Data are expressed as number, mean and standard deviation.
Sitting(n=20) Lateral(n=20) P-value
T 1
99.00±0.56 98.75±0.96 0.32
T 2
99.05±0.51 98.80±0.83 0.26
T 3
99.20±0.61 99.05±0.05 0.58
T 4
99.45±0.51 99.25±0.78 0.35
Results
61
Table 11: Incidence of Nausea and Vomiting of patients during study
Data are expressed as number and percentage within group.
Sitting(n=20) Lateral(n=20) P-value N&V
2 (10%) 8 (40%) 0.028*
*= statistically significant. (P-value of statistical significance ≤ 0.05)
Figure (11): Incidence of Nausea and Vomiting of patients during study
Results
62
Table 12: Level of Sensory Block of patients during study
Data are expressed as number and percentage within group
Sitting(n=20) Lateral(n=20) P-value
T4
13 (65%) 4 (20%) 0.004*
T2
7 (35%) 16 (80%) 0.004*
*= statistically significant.
Figure (12): Level of Sensory Block of patients during study
Results
63
Table 13: Incidence of PDPH within 48 hours of patients during study
Data are expressed as number and percentage within group
Sitting(n=20) Lateral(n=20) P-value
PDPH
2 (10%) 11 (55%) 0.002*
*= statistically significant.
Figure (13): Incidence of PDPH within 48 hours of patients during study
Discussion
Discussion
65
Since, regional anesthesia became of choice in obstetric patients for its
characteristics in providing almost rapid onset of anesthesia, allowing the
mother to immediately interact with her baby; it is safer for mother than
general anesthesia. So, the complications following regional anesthesia
became of great interest either to the anesthesiologist or to the parturient
(1) (2).Complications of spinal or epidural block are either acute in the form
of pain on injection, high (total) spinal anesthesia and hypotension or
postoperative complications as backache, Post Dural Puncture Headache
(PDPH), urine retention, meningitis and nerve injury(3).
During pregnancy, Maternal physiologic changes occur as a result of
hormonal alterations, mechanical effects of the gravid uterus, increased
metabolic and oxygen requirements, metabolic demands of the feto-
placental unit, and hemodynamic alterations associated with the placental
circulation. Such changes become more significant as pregnancy
progresses, and they have major implications for anesthetic management,
especially in high-risk parturient (20).
PDPH presents one of the major complications of spinal and epidural
block annoying to the patients especially parturient(4)(5)(6). The incidence
of post-dural puncture headache was 66% in 1998 (62). Ninety per cent of
headaches will occur within 3 days of the procedure (66), 66% start within
the first 48 h (67) and rarely, the headache develops between 5 and 14 days
after the procedure. The headache is described as severe, searing and
spreading like hot metal (69). The common distribution is over the frontal
and occipital areas radiating to the neck and shoulders. The pain is
exacerbated by head movement, and adoption of the upright posture, and
relieved by lying down. The largest follow-up of post-dural puncture
Discussion
66
headache is still that of Vandam and Dripps in 1956 (63). They reported
that 72% of headaches resolved within 7 days.
Many studies implementing incidence of PDPH following different
techniques like median and para-median approach or usage of different
sizes and types of spinal needles. The outcome of these studies revealed
increased incidence with para-median technique in young patients and
decrease incidence while using smaller sizes spinal needles(7)(8).
In our study we studied the effect of placing parturient either in sitting
position or right lateral position during induction of spinal anesthesia on
severity of hypotension, level of sensory block, incidence of nausea and
vomiting and development of PDPH within 48 hours post-operative.
Twenty patients in each group were assessed. The right lateral group
showed more hypotension and more cephaled spread than in the sitting
group.
In our study there were no statistically significant differences in patient
demographics with respect to age, weight, height and the operative time.
Baseline systolic blood pressures (T1) were almost similar in both groups
(120.05 ± 6.84 mm Hg versus 117.70 ± 7.45 mm Hg in the sitting and
lateral group, respectively; P = 0.376). In the lateral group, 3 (15%)
patients became hypotensive as compared with 1 (5%) in the sitting group
in the reading after induction (T2). This difference did not achieve
statistical significance (P = 0.292). Hypotension was also noticed later
after stabilization of sensory level (T3) in the lateral group, 11 (55%)
more than in the sitting group, 4 (20%). This difference achieve statistical
significance (P = 0.022). There was no difference in HR, O2 Sat. There
was increased incidence of nausea/vomiting in lateral group; 8 (40%)
versus 2 (10%) in sitting group, (P =0.028).
Discussion
67
All patients had a sensory block reaching at least T4, but the maximal
spread of the sensory block was more cephalad with the lateral position
and this group also had more sensory blocks that reached higher than the
T3 dermatome (80% versus 35%, P = 0.004).
Regarding PDPH; in the lateral group, 11 (55%) patients developed
PDPH within 48 hours post-operative versus 2 (10%) patients in the
sitting group; (P = 0.002).
Studies comparing the left and right lateral position were unable to find
a final preference. The first investigators evaluating the sitting versus the
lateral position during induction of spinal anesthesia placed patients back
in the supine position immediately after a single-dose intra-thecal
injection (131)(132). Because of the extremely short interval between
injection and resuming the supine position, it is not surprising that the
block characteristics did not differ significantly but Inglis A et al. found
that there was a faster onset of sensory block to a higher level in right
lateral group and in turn required more ephedrine in the first 10 m after
siting the spinal (132). These results are on the side of more hypotension
that developed with lateral group in our study which in turn required
ephedrine supplementation early post induction but in our study we found
even after stabilization of sensory level there was characteristic difference
in level of sensory block between sitting and right lateral group.
Similar to our study Hilde C. Coppejans et al.(11)evaluated whether
the sitting position during initiation of small-dose combined spinal-
epidural anesthesia (CSE) would induce less hypotension as compared
with the lateral position , their findings are in accordance with our result
as respect more severe hypotension , more cephaled spread and increase
incidence of nausea and vomiting with right lateral group more than with
Discussion
68
the sitting group in spite of they used combined spinal epidural technique
using small dose of local anesthetic and in turn they needed epidural
supplementation more in sitting group.
Patel et al. found that the slower and more limited cephalad spread of
sensory block may explain the reduced incidence and/or severity of
hypotension (133) and these results are consistent with our results as seen in
the sitting position versus in the right lateral position which showed more
cephaled spread.
Rucklidge MW et al. made a comparison of the lateral, oxford and
sitting positions for performing combined spinal-epidural anesthesia for
elective caesarean section(134) and there result are in accordance with our
results as regarding higher dermatomal level in the lateral group more
than in the sitting group.
Studies reporting incidence of PDPH used different techniques like
median and para-median approach or usage of different sizes and types of
spinal needles (7) (8) other than implementing incidence after using
different positions for induction of regional anesthesia are not as plenty as
we mentioned regarding severity of hypotension or level of sensory block
and in turn incidence of nausea and vomiting and ephedrine
supplementation.
Siamak Afshin Majd et al. evaluated the occurrence of post lumbar
puncture headache in 125 patients undergoing lumbar puncture with a21
gauge Quincke`s needle(135), divided randomly into sitting and lateral
decubitus groups in the following five days and they found lumbar
puncture in sitting position could produce more post lumbar puncture
headache in comparison with lateral decubitus position. this was in
Discussion
69
contrast to our study as we found that incidence of PDPH was more in
lateral group but we must take in consideration that we use 25 gauge
Quincke`s needle and the mean of the patients’ age in their study was
50.96 ± 13.15 while in our study was 24.55±2.65 and 25.05±2.54 in
sitting and lateral group respectively.
Another study implemented by R. J. Chilvers et al. noted the frequent
incidence of Post dural puncture headache (PDPH), particularly with the
25- gauge Quincke`s needle(136 ) which used in our study but also they
found that even for the 25-gauge Whitacre needle the PDPH rate was
more than 3% which may assume that type of needle may not present an
actual predictor for development of PDPH.
Hans Lybecker et al. reported that age was significant predictors of
PDPH (53) as he evaluated a wide range of age in his study and this is not
in accordance with our study as age was insignificant between right
lateral group and sitting group as regarding females in child bearing
period.
In the current study incidence of PDPH was higher in the right lateral
group than in the sitting group. There are no studies reported why
incidence of PDPH may be high in right lateral position and if there is a
relation between high sensory level block and more severe hypotension
that develop with right lateral position and incidence of PDPH. Incidence
of PDPH in current study being high in lateral position may be
misestimated due to small number of cases in the study so, it is important
in to implement similar studies on larger number of patient to be more
efficient and conclusive. Also, it should be taken into consideration to
make more studies regarding this aspect in different age groups for good
estimation of the results.
Conclusion
70
Conclusion
Performing spinal anesthesia in caesarian section in the sitting position
is more technically easier and induces less severe hypotension, less
cephaled spread and less post dural puncture headache than in the right
lateral group.
Summary
Summary
72
Internationally, obstetric anesthesia guidelines recommend spinal and
epidural over general anesthesia (GA) for most caesarean sections.
The primary reason for recommending regional blocks is the risk of
failed endotracheal intubation and aspiration of gastric contents in pregnant
women who undergo general anesthesia (GA), while there is evidence that
GA is associated with an increased need for neonatal resuscitation.
The anesthetic plan for cesarean delivery should take into account the
well-being of two patients: the mother and the fetus. Regional anesthesia is
the most common method of anesthesia for delivery because it allows the
mother to be awake and immediately interact with her baby. It is also safer
for the mother than general anesthesia.
Regional anesthesia is used for 95% of planned cesarean deliveries in the
United States. The use of spinal anesthesia for cesarean delivery was
facilitated by the popularization of pencil-point needles, which dramatically
reduced the incidence of post dural puncture headache.
The question posed regarding the effect of sitting versus lateral position
approach for spinal anesthesia on severity of hypotension, block
characteristics, incidence of nausea and vomiting and incidence of PDPH is
an interesting one. This subject has been studied by many investigators
over the years. Most of theses studies found there were more hypotension,
more cephaled spread and increased incidence of nausea and vomiting with
lateral group. Regarding PDPH, incidence of its occurrence was evaluated
in a lot of studies either following different techniques like median and
para-median approach or usage of different sizes and types of spinal
needles also as regarding position of patient either in sitting or lateral
approach.
Summary
73
A total of 40 consecutive women with uncomplicated singleton
pregnancies at term and scheduled to undergo elective CS participated in
this prospective study .The women were divided into 2 groups of equal
size (each 20) , Sitting group (A) and right lateral group (B).
Women who had uncomplicated pregnancies were delivered electively
by Caesarean section at Kasr El-Aini hospital.
Measured variable
‐ Vital Signs recordings every 5 minutes (Blood Pressure, oxygen saturation and pulse)
‐ Incidence of nausea and vomiting ‐ Level of Sensory Block ‐ Development of PDPH within 48 hours
There was statistically significant differences between the 2 groups as
regarding severity of hypotension , where with right lateral group there was
more hypotension after induction if spinal anesthesia and after stabilization
of sensory level than with sitting group.
There was a statistically significant difference between the 2 groups as
regarding level of sensory block and incidence of nausea and vomiting,
where with right lateral group there was more cepaled spread following
spinal anesthesia than with sitting group and also increased incidence of
nausea and vomiting with lateral group.
Patients in right lateral group developed more PDPH compared to
patients in sitting group.
Summary
74
There was no statistical difference of medical importance between the 2
groups as regarding demographic data, operative time, HR and O2
saturation.
Conclusion:
Performing spinal anesthesia in caesarian section in the sitting position is
more technically easier and induce less severe hypotension, less cephaled
spread and less post dural puncture headache than in the right lateral group.
.
References
References
76
1- Ranasinghe JS. Steadmann J. Toyama T. Lai M. Combined spinal
epidural anesthesia is better than spinal or epidural alone for