A Randomized Controlled Comparison Between Combined Spinal-Epidural and Single-Shot Spinal Techniques in Morbidly Obese Parturients Undergoing Cesarean Delivery

ArticleinAnesthesia and analgesia 118(1):168-72 · October 2014with22 Reads
DOI: 10.1213/ANE.0000000000000022 · Source: PubMed
There is no current consensus on the optimal technique for subarachnoid anesthesia in morbidly obese parturients even though some providers prefer the combined spinal-epidural (CSE) over single-shot spinal (SSS) technique. In this randomized controlled study, we compared the time required for initiation of subarachnoid anesthesia between SSS and CSE techniques in morbidly obese parturients undergoing elective cesarean delivery. Morbidly obese parturients presenting for elective cesarean delivery were randomized to receive subarachnoid anesthesia performed either with a SSS or a CSE technique. The spinal procedure in the sitting position was attempted by an experienced resident for up to 10 minutes, and if unsuccessful, the attending obstetric anesthesiologist assumed control of the procedure. The primary outcome was the time it took from the insertion of the introducer needle (SSS group) or insertion of the epidural needle (CSE group) to the end of intrathecal injection of drugs (procedure time). Forty-four patients were enrolled and completed the study. Three were excluded due to protocol violations. Of the remaining, 21 patients were in the SSS group and 20 in the CSE group. Demographic variables and mean (SD) body mass index (48.7 ± 7.6 kg/m for SSS; 49.9 ± 8.6 kg/m for CSE) were not different between groups. The median [interquartile range] for procedure time was 210 [116-692] seconds and 180 [75-450] seconds for SSS and CSE groups, respectively (P = 0.36), while the 95% confidence interval (CI) of the difference was -80 to +180 seconds. The first operator completed the procedure in <10 minutes in 71% of subjects in the SSS group and 95% of those in the CSE group (P = 0.09) and the 95% CI of the difference was -2% to +45%. There were more attempts to successful completion of the procedure in the SSS group (P = 0.007) with its 95% CI of the difference being +1 to +6. Our results suggest that the CSE technique is noninferior to the SS technique in morbidly obese parturients for time of initiation of subarachnoid anesthesia and may be accomplished with fewer attempts than the SSS technique with experienced residents.
  • [Show abstract] [Hide abstract] ABSTRACT: La prise en charge opératoire des patients atteints d’obésité est de plus en plus fréquente dans nos blocs opératoires. L’anesthésiste doit tenir compte des spécificités liées à l’obésité et ses répercussions, notamment cardiorespiratoires. Certains risques particuliers pouvant survenir au cours de l’anesthésie générale peuvent être directement en rapport avec l’obésité. Les techniques d’anesthésie et/ou d’analgésie locorégionale, en évitant le recours à l’anesthésie générale, offrent un certain nombre d’avantages dans ce contexte. Cependant, elles nécessitent une connaissance parfaite et présentent également plusieurs points à risque directement en rapport avec l’obésité. L’objectif de cette revue est de discuter les points clés de l’anesthésie locorégionale réalisée pour la prise en charge périopératoire du patient obèse. Abstract The number of procedures schedules for obese patients increases regularly. The anesthesiologist has to take into account the obese-related characteristics, first of all the cardiorespiratory ones. Some specific risks that occurred during general anesthesia may be directly in relation with obesity. By avoiding general anesthesia, most of regional anesthesia/analgesia techniques present some advantages in this context. However, skill and experience are key point to avoid some complications. The goal of this review is to discuss specific points of regional anesthesia performed in obese patient.
    Article · Jan 2014
  • [Show abstract] [Hide abstract] ABSTRACT: Background: In 1993, Hood and Dewan published the results of a trial comparing obstetric and anesthetic outcomes of 117 morbidly obese parturients with matched controls. The authors demonstrated a higher initial epidural anesthesia failure rate, a higher cesarean delivery rate and an increased risk of obstetric complications. We replicated the previous study to provide updated information on outcomes in the morbidly obese pregnant population. We hypothesized that morbidly obese women would still have higher complication and failure rates compared to matched controls and that general anesthesia would be less commonly used than in the previous study. Methods: The medical records of 230 patients weighing >136 kg (300 pounds) were compared to matched controls: the next patient delivered by the same obstetrician with a weight <113 kg (250 pounds). Results: The mean body mass index of the morbidly obese group was 53.4 ± 6.6 kg/m² [corrected] compared to 31.1±5.4 kg/m2 in the control group. Fifty percent of morbidly obese women required cesarean delivery compared to 32% of controls (P < 0.01). Morbidly obese patients had a longer first stage of labor (P < 0.01), larger neonates (P < 0.01), and were more likely to have a failed initial neuraxial technique for labor analgesia (P < 0.01). The need for a replacement procedure for labor was 17%, significantly less than 20 years ago when 42% of catheters in morbidly obese women failed (P < 0.01). Failure rates of neuraxial anesthesia for cesarean delivery were similar between groups. Neuraxial procedure times were greater in morbidly obese parturients (P < 0.01). Morbidly obese women were less likely to receive general anesthesia compared to 20 years ago (3% vs. 24%, P < 0.01). Conclusions: Morbidly obese parturients are still at increased risk for antenatal comorbidities, failed labor analgesia, longer first stage of labor and operative delivery. Replacement labor epidural catheters and general anesthesia for cesarean delivery are less commonly required anesthetic techniques compared to the original study.
    Article · Nov 2014
  • [Show abstract] [Hide abstract] ABSTRACT: The purpose of this national survey was to determine current anesthesia practices for cesarean delivery in the Czech Republic. In November 2011, we invited all departments of obstetric anesthesia in the Czech Republic to participate in a prospective study to monitor consecutive peripartum obstetric anesthesia procedures. Data were recorded online in the TrialDB database (Yale University, New Haven, CT). The response rate was 51% (49 of 97 departments); participating centers represented 60% of all births in the country during the study period. There were 1943 cases of peripartum anesthesia care, of which 1166 cases (60%) were anesthesia for cesarean delivery. Estimates were weighted based on population distribution of cesarean delivery among types of participating centers. Neuraxial anesthesia was used in 55.6% (95% confidence interval [CI], 52.8%-58.5%); the distribution of anesthesia techniques differed among type of participating center. The rate of neuraxial anesthesia in university hospitals was 55.6% (95% CI, 51.5%-59.6%), 32.4% (95% CI, 26.4%-39.0%) in regional hospitals, and 60.7% (95% CI, 55.2%-66.0%) in local hospitals. The reasons for cesarean delivery under general anesthesia were emergency procedure (67%), refusal of neuraxial blockade by parturient (30%), failure of neuraxial anesthesia (6%), and preoperative administration of low-molecular-weight heparin (3%). Postcesarean analgesia was primarily provided by systemic opioid (66%) and nonopioid analgesics (61%), solely or in combination. Epidural postoperative analgesia was used in 14% of cases. Compared with national neuraxial anesthesia rate data published in the 1990s (6.7% in 1993), there has been an upward trend in the use of neuraxial anesthesia for cesarean delivery during the 21st century (40.5% in 2000) in the Czech Republic. The rate of neuraxial anesthesia use for cesarean delivery has increased in the Czech Republic in the last 2 decades. However, the current rate of general anesthesia is high compared with other Western countries.
    Full-text · Article · Dec 2014
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