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Anesthesia for Cesarean Delivery Utilizing Spinal Anesthesia Tetracaine Versus Tetracaine and Procaine
Abstract
: Twenty-one parturients undergoing elective cesarean delivery were studied in a randomized double-blind fashion. Ten received a mixture of tetracaine 1% diluted with an equal volume of dextrose 10% in water, and 11 received tetracaine 1% diluted with an equal volume of procaine 10%. Significantly higher sensory anesthesia levels occurred in the parturients who received tetracaine and procaine. The quality of sensory anesthesia was also improved in the latter group as demonstrated by the significantly lower use of intraoperative narcotic supplementation. There were no differences in the duration of motor or sensory block, the incidence of hypotension, Apgar scores, or blood gases between the groups.
(C)1984 American Society of Regional Anesthesia and Pain Medicine
... At present, procaine is primarily used for infiltration anaesthesia and diagnostic differential spinal blocks. Recently, a combination of procaine and amethocaine has been used for spinal anaesthesia in obstetric patients (Chantigian et al., 1984). ...
Chemical compounds that demonstrate local anesthetic activity usually possess the following chemical arrangement: Aromatic portion — Intermediate chain — Amine Portion
... Some authors do not seem to have this problem with their obstetric patients (Brownridge, 1981). Others, presumably because of the low incidence, do not mention it (Chantigian et al., 1984). Why there is such variation in the incidence of headaches is not clear, but it is possible that the use of a 26-gauge needle may result in a lower incidence of post-spinal headaches (Carrie, personal communication). ...
Thirty-five women scheduled for elective Caesarean section were randomly assigned to have subarachnoid analgesia induced in
either the right or left lateral position. They were then turned supine with a wedge under the right hip. No patient in the
right-sided group required further analgesia. Five patients in the left-sided group required postural manipulation to encourage
the spread of analgesia and two required supplementary analgesia (P < 0.01).
Evaluation of the geriatric patient for orthopedic operations is similar to patient evaluation for any other procedure. Concomitant diseases must be diagnosed and treated to bring the patient to an optimal physical status. The evaluation can only be thorough when the anesthesiologist has a good understanding of indications for the procedure, the pathophysiology involved and knowledge about the operative procedure.
Communication at all levels of the medical care system must continue to be developed to maintain a high level of patient care in face of increasing pressures from various cost containment programs. Premedication must be individualized and big doses require surveillance.
Orthopedic operations performed in geriatric patients frequently lend themselves to regional anesthesia but anesthesiologists' skill may be a limitation. It continues to be controversial whether regional anesthesia reduces morbidity and mortality over general anesthesia. General anesthesia is indicated if this is the technique with which the anesthesiologist is most familiar and if it is what the informed patient requests.
Many medications are available to the parturient to ease the pain associated with labor and delivery. These include barbiturates and tranquilizers that work by decreasing maternal anxiety and that may make the pain more manageable even though they have no intrinsic analgesic or pain-relieving properties. Parenteral analgesics (i.e., narcotics) are given by the intravenous or the intramuscular route and inhalation analgesics (i.e., nitrous oxide or enflurane) are given by inhalation for pain relief. General anesthesia is used not only to remove pain (analgesia) but also to remove all other perceptions as well, i.e., produce a loss of consciousness. Pain relief can be produced in specific parts of the body by the use of local anesthetics.
Neuraxial blockade (spinal and epidural anesthesia) has become the primary means of administering anesthesia for cesarean delivery in the United States. These techniques, when properly administered, allow the production of nearly ideal operating conditions, excellent maintenance of both maternal and fetal homeostasis, and offer the advantages of an awake, cooperative, and participating patient during the birth process. These advantages over general anesthesia are considerable, and with proper attention to the details of management, as elucidated previously, safe and effective anesthesia can be provided with these techniques. However, the apparent safety of these techniques require even more vigilance by the anesthesiologist to detect as early as possible the occasionally disastrous complications that may arise, and the practitioner of these techniques must be ready to treat at any time the oftentimes unbelievably rapid development of life-threatening complications.
This chapter describes the local anesthetics used during various treatments. Local anesthetics exert a wide array of local, regional, systemic and focal effects, whether adverse or desirable, a full understanding of which is needed if local anesthesia is to be a safe alternative to general anesthesia. Headache is the commonest complication of spinal anesthesia. Using thin needles reduces the occurrence of post-spinal headache but hydration exerts no clear protection. Neurological complications, for example, anterior spinal artery syndrome and cauda equina syndrome, can occur with chloroprocaine though they are uncommon. True allergic reactions only account for a very small percentage of adverse reactions due to local anesthetics. A combination of spinal bupivacaine and morphine exerts no deleterious effect on respiratory function. The use of bupivacaine for intravenous regional anesthesia remains controversial. Systemic adverse reactions, although rare, may be fatal; in such cases, cardiorespiratory and neurotoxic symptoms are most common.
Local anesthetics are the most common and importantly used drugs in obstetric anesthesia; hence an adequate knowledge of these
chemical agents is absolutely essential.
Hyperbaric solutions of 0.75% bupivacaine (8.25% dextrose), and 1% tetracaine mixed with an equal volume of 10% procaine were compared in a double-blind study of 22 parturients undergoing elective cesarean delivery and spinal anesthesia. The onset of sensory anesthesia and motor block was similar in the two groups. The maximal level of sensory anesthesia to pinprick was significantly higher after the use of the tetracaine-procaine mixture. The adequacy of anesthesia was similar in both groups as indicated by the lack of differences with regard to anesthetic supplementation between the groups. However, a significantly shorter duration of sensory anesthesia and motor blockade occurred in the group in which bupivacaine was employed. The incidence of hypotension was higher in those patients receiving the tetracaine-procaine mixture as indicated by the use of significantly higher total doses of ephedrine to maintain baseline blood pressure in this group. No differences in Apgar scores or blood gases were noted between the two groups of patients. This study suggests that hyperbaric 0.75% bupivacaine offers certain advantages over hyperbaric tetracaine-procaine when used in equal volumes for spinal anesthesia cesarean delivery.
Venous air embolism (VAE) is a potential but rare complication of cesarean delivery that can be associated with morbidity and death. Uterine sinuses are susceptible to the entrance of air during cesarean delivery. To define the incidence of VAE and its relation to arterial oxygen saturation (SaO2) and consequent electrocardiographic (ECG) changes, a prospective study was undertaken in which precordial Doppler monitoring was conducted during cesarean delivery. Concomitant, SaO2 and ECG were recorded in 78 patients. Fifty-one of 78 (65%) of the subjects had Doppler changes consistent with VAE. Of these, 37 patients (72%) showed a decreased SaO2, (average decline 5.2%). The remainder of the patients with Doppler changes showed no SaO2 change. Twenty of the patients with Doppler changes and decreased SaO2 complained of chest pain and dyspnea. Three of these patients exhibited ECG changes including ST segment depression. Although all ECG changes resolved spontaneously without sequelae, the potential clearly existed for life threatening embolic events. Thus, precordial Doppler monitoring of cesarean delivery patients demonstrated a surprisingly high incidence of Doppler changes consistent with VAE. Some episodes were associated with a significant reduction in SaO2 and rarely with ECG changes.
Lidocaine, tetracaine, and bupivacaine are the local anesthetic agents most commonly employed for spinal anesthesia in the U.S. Lidocaine provides a short duration of anesthesia and is primarily useful for surgical and obstetrical procedures lasting less than one hour. Tetracaine and bupivacaine are used for procedures lasting 2 to 5 hours. Tetracaine appears to provide a somewhat longer duration of anesthesia and a more profound degree of motor block than does bupivacaine. On the other hand, compared with tetracaine, bupivacaine has been demonstrated to be associated with a decreased incidence of hypotension. In addition, bupivacaine may be better than tetracaine for use in orthopedic surgical procedures since it appears to be associated with a lower incidence of tourniquet pain. Vasoconstrictors can prolong the duration of spinal anesthesia of all three agents. However, the greatest duration is seen when vasoconstrictors are added to tetracaine solutions. Lidocaine and bupivacaine do not appear to benefit as much from the addition of vasoconstrictors. In general, the local anesthetic agents that are currently available for spinal anesthesia provide significant versatility. By carefully considering the planned surgical procedure, the surgeon's requirements, and the patient's characteristics (e.g., age, height, gravidity), and by understanding the factors that influence spinal anesthesia, the anesthesiologist can select a local anesthetic agent that will assure adequate and satisfying spinal anesthesia.
Die Spinalanästhesie hat sich im Konstanzer Klinikum als Standardmethode zur Kaiserschnitt-Narkose bewährt. Der folgende Erfahrungsbericht gibt eine Übersicht über die Vorteile der Methode gegenüber anderen rückenmarknahen Verfahren und schildert detailliert das in Konstanz geübte Vorgehen. Es wird in Seitenlage durch paramedianen Zugang eine Spinalanästhesie mit hyperbarem Bupivacain in einer Dosierung von 10 - 12,5 mg angelegt, dem zur postoperativen Analgesie 1 µg/kg KG Morphin zugesetzt sind. Es werden 27-gg-Pencilpoint-Kanülen mit Introducer verwendet. Zur Behandlung von Hypotonien wird Cafedrin eingesetzt.
Spinal Anaesthesia for Caesarean Section.
In the community hospital of Konstanz, spinal block is the standard method of anaesthesia for caesarean section. The report below gives a review about the advantages of the method compared to other central blocks and describes the procedure in detail. The block is performed in the lateral decubitus position by paramedian approach, using 0,5 % hyperbaric bupivacaine in doses of 10 - 12,5 mg. For postoperative analgesia, morphine 1 µg/kg BW is added. The spinal puncture is carried out with 27-gg-pencilpoint needle which is inserted through an introducer. If necessary, cafedrine is employed for support of blood pressure.
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