This study aims to evaluate the efficacy of hyperbaric 5 mg bupivacaine + fentanyl 25 mcg
versus hyperbaric 7.5 mg bupivacaine + fentanyl 25 mcg to lower incidence of hypotension
Cesarean Section
Clinical Trial – Low Dose Hyperbaric Bupivacaine and Dexmedetomidine as an Adjuvant, Caesarean Section
The aim of this study is to evaluate the effectiveness of low dose scheme with
dexmedetomidine as an adjuvant. Taking in consideration optimum intraoperative surgical
conditions, best post-operative pain free experience, and more stable hemodynamic.
Clinical Trial – Dose and Response of Intrathecal Hydromorphone in Patients Undergoing Cesarean Section at Virginia Commonwealth University Health System
In the United States the incidence of cesarean deliveries have increased over the last
several decades and is currently approximately 30% nationwide. The anesthesia and analgesia
for elective c-sections vary between institutions.
Parturients present a unique challenge for the anesthesiologist as the mother has to care not
only for herself, but also for the newborn postpartum. While intrathecal opioids provide
adequate pain relief, they do so at the cost of bothersome side effects for patients, such as
pruritus and nausea/vomiting.
Intrathecal hydromorphone has started to be explored as a new option for intrathecal
analgesia. A study done by Beatty et al. showed in a retrospective review that 40 mcg of
intrathecal dilaudid was safe and effective as compared to intrathecal morphine for analgesia
after cesarean delivery. Additionally they showed no difference in side effect profiles of
the two medications. Mhyre et al. investigated the use of 100 mcg of intrathecal dilaudid
with hyperbaric bupivacaine in varying dosages for labor analgesia. The results were
inconclusive, but the dosage of hydromorphone was reported to be without adverse effects.
Virginia Commonwealth University Health Systems has successfully instituted the use of
intrathecal morphine with superior analgesia but with undesired side effects, most notably
pruritus. Recent drug shortages of duramorph have prompted investigators to seek alternative
options for post cesarean section analgesia. The investigators are interested in determining
the dose, efficacy, and side effect profile of intrathecal hydromorphone. Although our
institution has never utilized intrathecal hydromorphone for our patient population, it has
been studied at various other institutions where it has been found to be safe and efficacious
with an acceptable side effect profile.
Clinical Trial – Two Syringe Spinal Anesthesia Technique for Cesarean Section: A Simple Way to Achieve More Satisfactory Block and Less Hypotension
Background: Poor spinal anaesthesia block is common and is difficult to manage; so a
technique to minimize its incidence is advisable. Hypotension is the commonest problem with
spinal anesthesia. Multiple trials to prevent or combat hypotension using positional changes,
fluid therapy and the use of vasopressors were tried. However, the drug choice and mode of
administration as either bolus or infusion is still a matter of debate.
Objectives: To compare the outcome of spinal injection of hyperbaric bupivacaine and fentanyl
separately to standard injection of mixed fentanyl with hyperbaric bupivacaine.
Design: A randomized, controlled clinical trial.
Setting: Single medical center from 5/2013 to 10/2014.
Patients & Methods: 124 parturient scheduled for elective cesarean section (CS) were randomly
allocated into two groups, each 62 parturient: Group M received spinal anesthesia using 10 mg
bupivacaine 0.5% premixed with 25 µg fentanyl in the same syringe and Group S received 25 µg
fentanyl in one syringe and 10 mg bupivacaine 0.5% without barbotage in a second syringe.
Intravenous fluid co-load with 15 ml/kg warm lactated ringer solution was started as fast
drip during, and continued after spinal anesthesia.
Patients were monitored for hemodynamic parameters, time of sensory onset and height of
maximum sensory block, lower limb motor blockade was scored using modified Bromage scale and
the frequency of side effects.
Clinical Trial – Dexmedetomidine Versus Magnesium Sulphate for Caesarean Delivery
Regional anesthesia has become more popular in cesarean deliveries because most of the
parturients prefer being awake during the birth process. In addition, regional anesthesia may
be a safer method than general. In spinal anesthesia local anesthetics alone may not be
enough for an effective postoperative analgesia and hemodynamic stability of the patient wich
is crucial during cesarean section. So far many adjuvants have been used to augment the
analgesia produced by intrathecal local anesthetics and to reduce their adverse effects .
Various intrathecal adjuvants to local anaesthetics have found to improve the quality and
extend duration of spinal block. Prolongation of duration of spinal block is desirable both
for long procedures and for postoperative pain relief. Efficacy and safty of intrathecal
magnesium as analgesic adjuvant has been tested by several clinical trails in recent
years.Antinociceptive effect of magnesium appears to be relevant for the management of
chronic and post operative pain. These effects are primarily based on regulation of calcium
influx in to the cell. Magnesium blocks calcium influx and non competitively antagonizes NMDA
channels. NMDA receptor signelling plays an impartent in determining the duration of acute
pain3).) addition of magnesium to spinal anaesthesia improved postoperative analgesia in
orthopedic setting. addition of intrathecal magnesium sulfate to 10 mg bupivacaine plus 25µg
fentanyl prolonged spinal anaesthesia in patients undergoing lower extremity surgery.
Dexmedetomidine is a highly selective 2-adrenergic agonist which has been used as
pre-medication and as an adjuvant to general anesthesia.Dexmedetomidine have several
beneficial actions during perioperative period. They decrease sympathetic tone with
attenuation of the neuroendocrine and haemodynamic response to anaesthesia and surgery,
reduce anaesthetic and opiod requirement, cause sedation and analgesia. Dexmedetomidine was
first introduced into clinical practice as a short term intravenous sedative in intensive
care. Like any other adjuvant dexmedetomidine is not free from adverse effects. Use of
dexmedetomidine is often associated with a decrease in heart rate and blood
pressure.Dexmedetomidine was used to enhance the analgesic property of local anaesthetics
like lidocaine bupivacaine and ropivacaine. In vivo and in vitro studies indicated that these
local anaesthetics had significant neurotoxicity. Dexmedetomidine showed protective or growth
promoting properties in tissues, including nerve cells from cortex. Intrathecal
dexmedetomidine has a neuroprotective effect similar to methylprednisolone.
The mechanism by which intrathecal alpha 2-adrenergic agonists prolong the motor and sensory
block of local anesthetics is not clear. It may be an additive or synergistic effect
secondary to the different mechanisms of action of local anesthetic and alpha 2 adrenergic
agonist. The local anesthetics act by blocking sodium channels, whereas the alpha 2
adrenergic agonist acts by binding to pre synapyic C fibre and post synaptic dorsal horn
neurons. Intrathecal alpha 2 adrenergic agonist produce analgesia by depressing the realease
of C fibre transmission by hyperpolarization of post synaptic dorsal horn neurons. Li et al
observed that Glutamate is involved in excitatory neurotransmission nociception and plays an
essential role in relaying noxious stimuli in the spinal cord. Intrathecal injection of alpha
2 adrenergic agonists produces potent antinociceptive effects by altering spinal
neurotransmitter release and effectively treats acute pain.
Clinical Trial – Atropine to Prevent Nausea and Vomiting After Spinal Anesthesia for Caesarean Section
The aim of this study is to assess the efficacy of atropine in preventing nausea and vomiting
after spinal anesthesia with local anesthetic and morphine for elective Caesarean section.
Patients enrolling in the study will be assigned to one of three groups. One will receive a
small dose of intrathecal atropine; another will receive small-dose intravenous atropine; the
third group will receive placebo.