From the Department of Anesthesiology, Pain, and Perioperative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York.
Department of Anesthesiology, Medical University of South Carolina, Charleston, South Carolina.
Anesth Analg. 2018 Jul;127(1):171-178. doi: 10.1213/ANE.0000000000002542.
Spinal anesthesia has become the most common type of anesthetic for cesarean delivery. The major limitation to spinal anesthesia is that the duration of the anesthetic may not be adequate in the event of a prolonged surgery. Some practitioners add epinephrine to hyperbaric bupivacaine to increase the duration, although its effect has not been fully studied. We therefore aimed to evaluate whether adding epinephrine to the spinal medication prolongs the duration of action of the resultant block in women presenting for repeat cesarean delivery.
Sixty-eight patients were randomized to receive no epinephrine (NE group), epinephrine 100 µg (low-dose [LD] group), or epinephrine 200 µg (high-dose [HD] group) with a standardized spinal mixture (1.5 mL 0.75% hyperbaric bupivacaine with 0.25 mg morphine). Sixty-five patients were included for primary analysis. Our primary outcome was time to intraoperative activation of the epidural catheter or postoperative regression of sensory blockade to T-10 dermatome level as measured by pinprick sensation; motor recovery was a secondary outcome, and graded via a Modified Bromage scale.
Block onset time, vital sign changes, and the incidence of hypotension; nausea, and vomiting were similar among groups. Median difference in time to T-10 regression was greatest in the HD group compared to the NE group (median difference [min] [95% confidence interval]: 40 [15-60]; P = .007), followed by the HD group to the LD group (30 [15-45]; P = .007). Comparisons of LD to NE were not significant, but trended to an increase in T-10 regression time (10 [-15 to 30]; P = .76). Median difference in time to knee extension (Bromage 3) was also greatest in the HD group when compared to both the LD and NE group (median difference [min] [95% confidence interval]: 30 [0-60]; P = .034, 60 [0-93]; P = .007). Median difference time to knee extension (min) between the LD and NE group was also significant (37.5 [15-60]; P = .001]. Pain scores during the procedure were higher in the NE group (median [interquartile range] HD: 0 [0-0], LD: 0 [0-0], NE: 0 [0-3]; P = .02) during uterine closure and were otherwise not significantly different from the other groups.
In this single center, prospective, double-blind, randomized control trial, the addition of epinephrine 200 µg to hyperbaric bupivacaine and preservative-free morphine for repeat cesarean delivery prolonged the duration of the sensory blockade. Motor blockade was similarly prolonged and block quality may have been enhanced.
椎管内麻醉已成为剖宫产最常用的麻醉方式。椎管内麻醉的主要局限性在于，如果手术时间延长，麻醉持续时间可能不足。一些医生在布比卡因中加入肾上腺素以延长麻醉时间，但其效果尚未得到充分研究。因此，我们旨在评估在接受重复剖宫产的女性中，向椎管内药物中加入肾上腺素是否可以延长阻滞作用的持续时间。
68 名患者被随机分为不加入肾上腺素组（NE 组）、加入肾上腺素 100µg（低剂量[LD]组）或 200µg（高剂量[HD]组），使用标准化的脊髓混合物（1.5mL0.75%布比卡因加 0.25mg 吗啡）。65 名患者纳入主要分析。我们的主要结局是术中硬膜外导管激活或术后感觉阻滞至 T-10 皮节水平的时间，通过刺痛感来衡量；运动恢复是次要结局，通过改良 Bromage 量表进行分级。
各组的阻滞起效时间、生命体征变化以及低血压、恶心和呕吐的发生率相似。与 NE 组相比，HD 组 T-10 消退时间的中位数差异最大（中位数差值[min] [95%置信区间]：40 [15-60]；P =.007），其次是 HD 组与 LD 组（30 [15-45]；P =.007）。LD 与 NE 之间的比较没有统计学意义，但趋势是 T-10 消退时间延长（10 [-15-30]；P =.76）。与 LD 和 NE 组相比，HD 组的膝关节伸展（Bromage 3）时间中位数差异也最大（中位数差值[min] [95%置信区间]：30 [0-60]；P =.034，60 [0-93]；P =.007）。LD 与 NE 组之间的膝关节伸展（min）中位数差异时间也有统计学意义（37.5 [15-60]；P =.001）。在子宫关闭期间，NE 组的术中疼痛评分更高（中位数[四分位间距]HD：0 [0-0]，LD：0 [0-0]，NE：0 [0-3]；P =.02），其他方面与其他组无显著差异。
在这项单中心、前瞻性、双盲、随机对照试验中，在布比卡因和无防腐剂吗啡中加入肾上腺素 200µg 可延长感觉阻滞的持续时间。运动阻滞时间也同样延长，且阻滞质量可能得到改善。
