Effects of Adding Midazolam and Sufentanil to Intrathecal Bupivacaine on Analgesia Quality and Postoperative Complications in Elective Cesarean Section

Abstract

Background:Intrathecal adjutants can be used for regional anesthesia (RA) in cesarean section to improve its quality in terms of time and complications. Some previous studies focused on the effects of adding sufentanil and/or midazolam to bupivacaine and compared each with using bupivacaine alone. However, there has been no study to assess the effects of using sufentanil and midazolam in combination with bupivacaine.Objectives:The aim of this study was to evaluate and compare properties (time of achievement/recovery of sensory/motor blocks; and time to request opium), complications (nausea, vomiting, shivering and hypotension), and neonatal first minute Apgar score with and without the addition of midazolam (M) or sufentanil (S) to bupivacaine (B) through intrathecal injection for spinal anesthesia, after the cesarean section.Patients and Methods:In this double blind randomized clinical trial participants were randomly allocated to three equal groups: Group B (2.5 cc of bupivacaine 0.5% + 1 cc normal saline 0.9%), Group BM (2.5 cc of bupivacaine + 0.02 mg/kg midazolam) and Group BS (2.5 cc of bupivacaine 0.5% + 0.7 cc normal saline 0.9% + 1.5 µg of sufentanil, 0.3 cc). We used analysis of variance (ANOVA), post hoc test with Bonferroni adjustment, and chi-square test for statistical analysis; the analyses were performed using the SPSS-16 software. Given a significant level of 0.05, overall and pair-wise comparisons were made.Results:Seventy-five females participated in the study with no significant age difference (mean ± standard deviation (SD): 28.60 ± 6.06, 28.12 ± 5.29 and 28.76 ± 3.97 year; P = 0.9). Except for “time to motor block recovery” (P = 0.057), the overall differences among the three groups was significant in terms of “time to sensory/motor block” (P < 0.001), “time to sensory block recovery” (P < 0.001), and “time to request opium” (P < 0.001). In all pair-wise comparisons there was no significant difference between the BM and BS group, except for “time to request opium”, which was longer in the BS group (P < 0.001). The occurrence of nausea (P = 0.02), postoperative shivering (P = 0.01) and hypotension (P < 0.001) were significantly different between the groups, unlike vomiting, where the difference was not significant (P = 0.2). All neonates had an Apgar score of nine.Conclusions:The findings showed that adding sufentanil or midazolam to bupivacaine shortens the onset of spinal anesthesia and increases the time duration of anesthesia; however it does not change the motor block recovery time. Adding sufentanil delays the first request for narcotic analgesics while adding midazolam leads to a decrease in nausea and hypotension. Adding sufentanil or midazolam does not have any deleterious effect on infants’ Apgar scores. However, increases shivering in patients.

Effect of Intrathecal Lipophilic Opioids on the Incidence of Shivering in Women Undergoing Cesarean Delivery after Spinal Anesthesia: A Systematic Review and Bayesian Network Meta- analysis of Randomized Controlled Trials.

“…Sufentanil: Data on the incidence of shivering with IT sufentanil (5 RCTs, n=156 patients) were available in all the studies. [18][19][20][21][22] The mixed evidence from the network meta-analysis showed that the incidence of the shivering was not signi cantly lower with IT sufentanil when compared to the control group. (IT Sufentanil vs. Control: 23.71% vs. 45.28%; OR: 0.37; 95% CrI: 0.11 to 1.22; P = 0.23).…”

Effect of Intrathecal Lipophilic Opioids on the Incidence of Shivering in Women Undergoing Cesarean Delivery after Spinal Anesthesia: A Systematic Review and Bayesian Network Meta- analysis of Randomized Controlled Trials.

“…Twenty-one potentially relevant articles were identified from 115 citations. Twenty-one studies consisting of 1433 patients (Control group: 590 patients in twenty-one studies; Fentanyl group:199 patients in seven studies [11][12][13][14][15][16][17] ; Sufentanil group: 156 patients in five studies [18][19][20][21][22] ; Meperidine group: 488 patients in ten studies 15,[23][24][25][26][27][28][29][30][31] ) contained data regarding the effect of IT opioids on shivering (Flow chart: Figure 1). Table 1a and 1b summarises the systematic review of the effects of IT fentanyl, sufentanil and meperidine on shivering in women undergoing cesarean delivery.…”

Intrathecal Sufentanil Does Not Reduce Shivering During Neuraxial Anesthesia: A Meta-Analysis

“…An additional 16 papers were excluded on more detailed review for the following reasons: no shivering recorded (n=5), no placebo group (n=10), and added other anti-shivering drugs (n=1). The remaining 8 studies met our selection criteria and were included in the meta-analysis [ 16 – 18 , 24 – 28 ] ( Figure 1 ).…”

“…Intrathecal sufentanil added to bupivacaine, as compared with fentanyl, may prolong duration of analgesia, facilitate the spread of the sensory block, increase mean pulse oximetry levels, and reduce overall adverse effects. De Figueiredo [ 15 ] reported that the addition of sufentanil to hyperbaric bupivacaine and morphine during spinal anesthesia for cesarean section decreased the incidence of shivering during the immediate postoperative period; however, some other studies found that intrathecal sufentanil did not reduce shivering [ 16 – 18 ]. Hoshijima et al [ 19 ] found that remifentanil was associated with an increased incidence of postoperative shivering compared with alfentanil or fentanyl, but no significant difference was seen when compared with sufentanil.…”