Shekhar Shivam, Rautela Rajesh S, Chaudhary Sujata, Sony Sony
Anesthesiology, All India Institute of Medical Sciences, Rishikesh, Rishikesh, IND.
Anesthesiology, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi, IND.
Cureus. 2023 Jun 17;15(6):e40558. doi: 10.7759/cureus.40558. eCollection 2023 Jun.
Obstetric analgesia and anesthesia is a challenge in itself. It requires an understanding of the physiological changes during pregnancy and labor and the effect of anesthetic agents on the fetus and newborn. Because neuraxial techniques provide superior analgesia and materno-fetal benefits, their use have increased significantly over the past three decades or so. A combination of local anesthetics like ropivacaine with opioids like nalbuphine has been shown to have additive beneficial effects in subarachnoid block (SAB) in lower segment cesarean section (LSCS). However, the optimal dose combination of ropivacaine and nalbuphine to maximize their benefits and minimize side effects remains to be established. Our study has compared the clinical efficacy and safety of 0.75% isobaric ropivacaine (15 mg) with two different doses of nalbuphine (0.4 mg and 0.6 mg) when given intrathecally for LSCS in terms of quality of sensory and motor blocks, hemodynamic parameters, duration of effective analgesia, Apgar score in newborn, and associated side effects.
In this prospective, randomized, double-blind study, a total of 69 parturients between the age of 20-45 years, belonging to American Society of Anesthesiologists (ASA) grade I and II, undergoing cesarean section under SAB were evaluated. Patients were randomly allocated into three groups of 23 each by using the draw-of-lots technique. The patient and the observer were kept blinded as to which dose of drug (intrathecal) was being given to the patient. Patients in Group A received 0.75% isobaric ropivacaine 15 mg (2 ml) + 0.3 ml normal saline; patients in Group B received 0.75% isobaric ropivacaine 15 mg (2 ml) + 0.4 mg of nalbuphine (0.2 ml) + 0.1 ml normal saline; patients in Group C received 0.75% isobaric ropivacaine 15 mg (2 ml) + 0.6 mg of nalbuphine (0.3 ml). The total volume of drug solution in all three groups was 2.3 ml.
We found that the time to onset of sensory block was shortest in Group A (5.87±1.290 minutes) followed by Group C (6.00±1.087 minutes) and Group B (6.17±1.696 minutes); time to two-segment regression of sensory block was longest in Group C (101.74±8.996 minutes) followed by Group B (85.87±15.348 minutes) and Group A (65.00±7.071 minutes); duration of effective analgesia was longest in Group C (206.09±18.766 minutes) followed by Group B (183.91±15.880 minutes) and Group A (121.74±11.833 minutes); and time from SAB to complete regression of motor block was longest in Group C (216.52±15.553 minutes) followed by Group B (203.48±20.138 minutes) and Group A (174.78±14.731 minutes). Side effects were comparable among all three groups.
The optimal dose combination in SAB for cesarean section was 15 mg of 0.75% isobaric ropivacaine + 0.6 mg nalbuphine, with minimal side effects.
产科镇痛与麻醉本身就是一项挑战。这需要了解孕期和分娩期间的生理变化以及麻醉药物对胎儿和新生儿的影响。由于神经轴技术能提供卓越的镇痛效果且对母婴有益，在过去三十年左右的时间里，其使用显著增加。已证明，在低位剖宫产（LSCS）的蛛网膜下腔阻滞（SAB）中，罗哌卡因等局部麻醉药与纳布啡等阿片类药物联合使用具有相加的有益效果。然而，罗哌卡因和纳布啡的最佳剂量组合，以实现其益处最大化和副作用最小化，仍有待确定。我们的研究比较了在腰麻下行低位剖宫产时，0.75%等比重罗哌卡因（15毫克）与两种不同剂量纳布啡（0.4毫克和0.6毫克）鞘内给药的临床疗效和安全性，包括感觉和运动阻滞质量、血流动力学参数、有效镇痛持续时间、新生儿阿氏评分以及相关副作用。
在这项前瞻性、随机、双盲研究中，共评估了69例年龄在20 - 45岁之间、属于美国麻醉医师协会（ASA）I级和II级、在蛛网膜下腔阻滞下行剖宫产的产妇。采用抽签技术将患者随机分为三组，每组23例。患者和观察者均不知患者接受的是哪种剂量的鞘内药物。A组患者接受0.75%等比重罗哌卡因15毫克（2毫升）+ 0.3毫升生理盐水；B组患者接受0.75%等比重罗哌卡因15毫克（2毫升）+ 0.4毫克纳布啡（0.2毫升）+ 0.1毫升生理盐水；C组患者接受0.75%等比重罗哌卡因15毫克（2毫升）+ 0.6毫克纳布啡（0.3毫升）。三组药物溶液的总体积均为2.3毫升。
我们发现，感觉阻滞起效时间A组最短（5.87±1.290分钟），其次是C组（6.00±1.087分钟）和B组（6.17±1.696分钟）；感觉阻滞消退至两个节段的时间C组最长（101.74±8.996分钟），其次是B组（85.87±15.348分钟）和A组（65.00±7.071分钟）；有效镇痛持续时间C组最长（206.09±18.766分钟），其次是B组（183.91±15.880分钟）和A组（121.74±11.833分钟）；从蛛网膜下腔阻滞到运动阻滞完全消退的时间C组最长（216.52±15.553分钟），其次是B组（203.48±20.138分钟）和A组（174.78±14.731分钟）。三组的副作用相当。
剖宫产蛛网膜下腔阻滞的最佳剂量组合是15毫克0.75%等比重罗哌卡因 + 0.6毫克纳布啡，副作用最小。
