ED50and ED95of Intrathecal Bupivacaine in Morbidly Obese Patients Undergoing Cesarean Delivery

Carvalho, Brendan; Collins, Jeremy; Drover, David R.; Ralls, Lindsey Atkinson; Riley, Edward T.

doi:10.1097/aln.0b013e318209a92d

Cited by 83 publications

(37 citation statements)

References 37 publications

(33 reference statements)

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“…In a study estimating the dose requirements for bupivacaine in obese and nonobese parturients, Lee et al87 reported that the 95% effective dose (ED95) was similar in the two groups. Carvalho et al also found no difference in the ED50 and ED95 of hyperbaric spinal bupivacaine for cesarean delivery in morbidly obese parturients as compared with those estimated in a previous study using the same methodology in nonobese parturients 93,94. Therefore, current data do not support a reduction in the spinal dose of hyperbaric bupivacaine in the obese parturient.…”

Section: Technical Considerationscontrasting

confidence: 65%

Managing anesthesia  for cesarean section in obese patients: current perspectives

Lamon¹,

Habib²

2016

LRA

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Obesity is a worldwide epidemic. It is associated with increased comorbidities and increased maternal, fetal, and neonatal complications. The risk of cesarean delivery is also increased in obese parturients. Anesthetic management of the obese parturient is challenging and requires adequate planning. Therefore, those patients should be referred to antenatal anesthetic consultation. Anesthesia-related complications and maternal mortality are increased in this patient population. The risk of difficult intubation is increased in obese patients. Neuraxial techniques are the preferred anesthetic techniques for cesarean delivery in obese parturients but can be technically challenging. An existing labor epidural catheter can be topped up for cesarean delivery. In patients who do not have a well-functioning labor epidural, a combined spinal epidural technique might be preferred over a single-shot spinal technique since it is technically easier in obese parturients and allows for extending the duration of the block as required. A continuous spinal technique can also be considered. Studies suggest that there is no need to reduce the dose of spinal bupivacaine in the obese parturient, but there is little data about spinal dosing in super obese parturients. Intraoperatively, patients should be placed in a ramped position, with close monitoring of ventilation and hemodynamic status. Adequate postoperative analgesia is crucial to allow for early mobilization. This can be achieved using a multimodal regimen incorporating neuraxial morphine (with appropriate observations) with scheduled nonsteroidal anti-inflammatory drugs and acetaminophen. Thromboprophylaxis is also important in this patient population due to the increased risk of thromboembolic complications. These patients should be monitored carefully in the postoperative period, since there is increased risk of postoperative complications in the morbidly obese parturients.

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Section: Technical Considerationscontrasting

confidence: 65%

Managing anesthesia  for cesarean section in obese patients: current perspectives

Lamon¹,

Habib²

2016

LRA

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“…Obese women have reduced lumbar cerebrospinal fluid (CSF) volume which can be inversely related to cephalad spread of local anesthetics. 14 Carvalho et al 7 and Lee et al 15 found no association with BMI and the height of spinal anesthesia for obese women undergoing a CD. However, the study sizes are small and use methods that assume large sample properties.…”

mentioning

confidence: 96%

“…6 Both pregnancy and obesity have profound effects on the mother’s physiology, which may alter the cardiovascular response to both spinal anesthetics 7–9 and vasopressor therapy. 9, 10 Pregnancy is associated with a significant increase in both cardiac output and blood volume, which are further increased by obesity.…”

mentioning

confidence: 99%

A randomized trial of phenylephrine infusion versus bolus dosing for nausea and vomiting during Cesarean delivery in obese women

George

McKeen

Dominguez

et al. 2017

Can J Anesth/J Can Anesth

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Purpose Hypotension is common after spinal anesthesia for cesarean delivery. It is associated with nausea, vomiting and fetal acidosis. Previous research on phenylephrine excluded obese subjects. We compared the incidence of intraoperative nausea and vomiting (IONV) in obese patients who received a prophylactic phenylephrine infusion versus those who received phenylephrine boluses for the treatment of spinal-induced hypotension. Methods In this multi-centre, double-blinded randomized controlled trial, 160 obese women undergoing elective cesarean delivery under spinal anesthesia were randomized to receive a prophylactic phenylephrine infusion initiated at 50 μg/min and titrated according to a predefined algorithm or 100 μg phenylephrine boluses to treat hypotension. Maternal systolic blood pressure was maintained within 20% of baseline. The primary study outcome was the incidence of IONV. Results IONV was significantly reduced in the infusion group compared to the bolus group, 46% vs 75%; relative risk 0.61 (95% CI 0.47 to 0.80); P < 0.001. This was associated with significantly reduced need for intraoperative rescue antiemetics, 26% vs 42%; relative risk 0.62 (95% CI 0.40 to 0.97); P = 0.04, but no difference in the incidence of vomiting. Postoperative vomiting at 2h was reduced in the infusion group, 11% vs 25%; relative risk 0.44 (95% CI 0.21 to 0.90); P = 0.02, however there were no differences in the incidence or severity of postoperative nausea, need for rescue antiemetics at 2h and 24h or the incidence of postoperative vomiting at 24h. The infusion group had a significantly lower incidence of hypotension but greater incidence of reactive hypertension. Conclusion In obese women undergoing cesarean delivery with spinal anesthesia, prophylactic phenylephrine infusion was associated with less intraoperative nausea, less need for rescue antiemetics and reduced early postoperative vomiting. Trial Registry Number NCT01481740 https://clinicaltrials.gov/ct2/show/NCT01481740?term=NCT01481740&rank=1

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“…However, it has been demonstrated that height, weight, and bodymass index did not influence the spread of sensory blockade after subarachnoidal injection of bupivacaine [13, 14]. The obese and nonobese parturients also had a similar effective dose of intrathecal bupivacaine for cesarean delivery [15]. Of course, a carefully designed randomized controlled trial would eliminate these possible confounding factors.…”

Section: Discussionmentioning

confidence: 99%

Comparison of Spinal Block Levels between Laboring and Nonlaboring Parturients Using Combined Spinal Epidural Technique with Intrathecal Plain Bupivacaine

Tang

Zhou

Ren³

et al. 2012

Anesthesiology Research and Practice

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Background. It was suggested that labor may influence the spread of intrathecal bupivacaine using combined spinal epidural (CSE) technique. However, no previous studies investigated this proposition. We designed this study to investigate the spinal block characteristics of plain bupivacaine between nonlaboring and laboring parturients using CSE technique. Methods. Twenty-five nonlaboring (Group NL) and twenty-five laboring parturients (Group L) undergoing cesarean delivery were enrolled. Following identification of the epidural space at the L3-4 interspace, plain bupivacaine 10 mg was administered intrathecally using CSE technique. The level of sensory block, degree of motor block, and hemodynamic changes were assessed. Results. The baseline systolic blood pressure (SBP) and the maximal decrease of SBP in Group L were significantly higher than those in Group NL (P = 0.002 and P = 0.03, resp.). The median sensory level tested by cold stimulation was T6 for Group NL and T5 for Group L (P = 0.46). The median sensory level tested by pinprick was T7 for both groups (P = 0.35). The degree of motor block was comparable between the two groups (P = 0.85). Conclusion. We did not detect significant differences in the sensory block levels between laboring and nonlaboring parturients using CSE technique with intrathecal plain bupivacaine.

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ED50and ED95of Intrathecal Bupivacaine in Morbidly Obese Patients Undergoing Cesarean Delivery

Cited by 83 publications

References 37 publications

Managing anesthesia  for cesarean section in obese patients: current perspectives

Managing anesthesia  for cesarean section in obese patients: current perspectives

A randomized trial of phenylephrine infusion versus bolus dosing for nausea and vomiting during Cesarean delivery in obese women

Comparison of Spinal Block Levels between Laboring and Nonlaboring Parturients Using Combined Spinal Epidural Technique with Intrathecal Plain Bupivacaine

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ED50and ED95of Intrathecal Bupivacaine in Morbidly Obese Patients Undergoing Cesarean Delivery

Cited by 83 publications

References 37 publications

Managing anesthesia &nbsp;for cesarean section in obese patients: current perspectives

Managing anesthesia &nbsp;for cesarean section in obese patients: current perspectives

A randomized trial of phenylephrine infusion versus bolus dosing for nausea and vomiting during Cesarean delivery in obese women

Comparison of Spinal Block Levels between Laboring and Nonlaboring Parturients Using Combined Spinal Epidural Technique with Intrathecal Plain Bupivacaine

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Managing anesthesia for cesarean section in obese patients: current perspectives

Managing anesthesia for cesarean section in obese patients: current perspectives