الفهرس 
INTRODUCTIONOnly 14 pages are availabe for public view
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Abstract
For most of the morbidly obese parturients, the risk–benefit profiles of regional anaesthesia and general anaesthesia strongly favour the use of regional anaesthesia when feasible. Important factors to consider are the risks of clinically significant maternal haemodynamic derangements, difficult airway management and adverse neonatal outcomes. in morbidly obese patients , spinal anaesthesia–induced side effects are typically easily treated, and there is no evidence that neonatal outcomes are compromised. In contrast, potential complications of general anaesthesia, such as aspiration, difficult airway management and fetal sedation, are leading causes of morbidity and mortality. More over, the use of combined spinal epidural anaesthesia allows rapid and satisfactory anaesthesia with prolonged duration when using the higher doses of bupivacaine and the epidural catheter allows intraoperative and postoperative topup analgesia with minimal side effects unlike intravenous analgesia in morbidly obese parturients.
The aim of this study was to compare multiple doses of hyperbaric bupivacaine low dose (8 mg) and higher doses (10 mg and 11 mg) in combined spinal epidural anaesthesia in morbidly obese parturients undergoing elective caesarean section as regards sensory and motor blockade, haemodynamic changes, Apgar score and parturient and surgeons’ satisfaction.
This study was carried out in El-Shatby Maternity University Hospital, on thirty morbidly obese parturients scheduled for elective caesarean delivery under combined spinal epidural analgesia.
Patients were randomized into 3 groups, 10 patients in each group:
group VIII: Patients received hyperbaric bupivacaine 8 mg with fentanyl 25 μg intrathecally.
group X: Patients received hyperbaric bupivacaine 10mg with fentanyl 25 μg intrathecally.
group XI: Patients received hyperbaric bupivacaine 11mg with fentanyl 25 μg intrathecally.
All parturients were given intravenous lactated Ringer’s solution 10 ml/kg as volume preload. Oxygen was administered through a face mask. The combined spinal epidural analgesia was performed while the patient was in the sitting position by the needle through needle technique using long needles. After intrathecal injection, parturients were placed supine with left uterine displacement with a wedge beneath the right hip to maintain a pelvic tilt.
Haemodynamic measurements (pulse rate, mean arterial blood pressure,oxygen saturation), sensory blockade (time to reach the highest sensory level, segmental level of highest sensory blockade, time to reach T12, pain intensity and time for first request for analgesia), motor blockade (onset, duration and regression using the modified Bromage score), perioperative side effects or complications (including hypotension, nausea, vomiting...etc.), fetal well-being using Apgar score, both parturient and surgeon satisfaction were all recorded and statistically analyzed.
There was no significant difference between the three groups regarding age, weights and duration of the operation.
There was no statistically significant difference also between the three groups regarding pulse rate, arterial blood pressure and oxygen saturation.
The results revealed that parturients in the group XI had faster sensory and motor onsets with longer duration block than those in the group X and the group VIII. Patients in group XI had significantly longer sensory and motor durations than those in groups X and VIII.
Regarding intraoperative rescue analgesia, epidural activation was done in 100% in group VIII, 20% in group X and no activation of epidural was in group XI. Regarding postoperative rescue analgesia, 10% of group VIII and 10% of group X needed ketorolac 30 mg.
Apgar scores were within the normal range in the three groups at one and five minutes.
Regarding side effects (hypotension, bradycardia, nausea, vomiting and itching), there was no significant difference between the three groups.
Regarding satisfaction, there was more satisfaction in parturients in the group XI than group VIII but no significant difference between the three groups as regard the surgeons’ satisfaction.
from this study we conclude that low dose of hyperbaric bupivacaine (8 mg) was not effective to yield the target sensory and motor block in morbidly obese parturients but better sensory and motor block was obtained by higher dose (10 mg) (20% of the parturients needed epidural activation), while the dose of (11mg) hyperbaric bupivacaine produced the target sensory and motor block without any block failure nor high spinal block. BMI was a minor factor in the distribution of hyperbaric bupivacaine in the intrathecal block.