Comparison of intrathecal isobaric bupivacaine-morphine and ropivacaine-morphine for CS delivery

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• Comparison of intrathecal isobaric
  bupivacaine-morphine and ropivacaine-morphine for
  CS delivery
• Department of Anaesthesiology and Intensive Care
  and Department of OBGYN, Facultry of
  medicine,Selcuk University,Konya,Turkey.
• BJA 90(5)659-64(2003)

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BACKGROUND

• Ropivacaine
• A new long acting
• Amide
• A high pKa and low lipid solubility
• Block sensory N.gt motor N.
• Less cardiotoxic than bupivacaine in vitro
• Higher threshold for CNS toxicity than racemic
  bupivacaine

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BACKGROUND

• In previous study
• Intrathecal hyperbaric ropivacaine - non OB Sx.
  Or labour analgesia combined with sufentanyl or
  fentanyl (Chung and colleagues)
• A dose-response study with isobaric ropivacaine
  in C/S (Khaw and colleagues)

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OBJECTIVES

• Prospective, double-blind, randomized study
• Compare the analgesia and spinal block
  characteristics of 0.5 isobaric
  ropivacainemorphine and 0.5 isobaric
  bupivacainemorphine in C/S

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MATERIALS AND METHODS

• ??????? 50 ASA I or II elective CS of
  single babies at term
• Exclusion -cardiac disease , haematological
  dis., DM, eclampsia, bleeding or coagulopathy,
  fetal distress or known fetal anomalies
• Premed. - sodium citrate 30 ml 30 min before
• Fluid loading - 6 hydroxyethystarch 10 ml/kg

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MATERIALS AND METHODS

• A computer-generated randomization table group RM
  ( n25 ) and group BM ( n25 )
• RM (n25 ) 0.5 isobaric R. 15 mg MO
  150 ug
• BM (n25 ) 0.5 isobaric B. 15 mg MO
  150 ug
• Anaesthetist not involved the data
• The investigator were blinded

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MATERIALS AND METHODS

• Monitors - HR, MAP, SpO2, RR,
• IV MT- LRS 10 ml/kg/hr during surgery
• Spinal anaesthesia
• Sitting position
• Quincke needle NO.25
• L3-4 or L4-5
• Study solution 3.7 ml administered 30 s(0.12
  ml/sec)
• Confirmed by aspiration and re-injection of
  0.2-0.3 ml CSF before and after
• Turned to supine with left uterine displacement
  position

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MATERIALS AND METHODS

• After the spinal block- HR,RR,SpO2 and MAP q 1
  min until delivery and then q 2 min.
• Hypotension 20 of baseline MAP
• Rx. Hypotension with ephredine 5-10 mg and total
  ephredine were recorded
• Supplement O2 with facemask

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MATERIALS AND METHODS

• Sensory block loss of pin-prick sens.
  (20 G hypodermic needle) at MCL q 5 min until
  reached T5 dermatome the q 10 min
• Motor block Bromage scale(0no motor
  block,3complete block of lower ext) q 1 min
  until complete block q 30 min
• The motor block when the sensory level reached T5
  were recorded

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MATERIALS AND METHODS

• The time from skin incision to delivery
• After delivery,umbilical blood gas
• APGAR scores at 1 and 5 min
• Side effect and sedation or GA
• Maternal sedation scores
• 48 hrs. After surgery - prutitus,headache,backach
  e,resp.distress,N/V
• The quality of anaesthesia (by anaesthetists),the
  quality of MR (by surgeon)

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STATISTICAL ANALYSIS

• SD of time to recovery from motor block and time
  to regression of two segment wiht ropivacaine
  power analysis
• 30-min difference in mean duration of motor block
  or a 10- min difference in mean duration two
  segment regression between 2 groups
  two-side alpha of 5 and beta of 20
• Group size of 16-17 was necessary
• One-way and two-way ANOVA repeated
  measures

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STATISTICAL ANALYSIS

• Unpaired and paired t-tests for quantitative
• X2 test for categorical data
• P lt 0.05 was significant

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RESULTS

• As table

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Table 1. Patient charactersistics
BM (n25) RM ( n25)
Height (cm) 160.5(5.7) 160.6(6.0)
Weight (kg) 77.4(10.2) 76.1(16.5)
Age (years) 29.1(19-43) 29.4(21-38)
No.of preg 2.4(1.7) 2.1(0.8)
No.of CS 0.3(0.5) 0.6(0.6)
GA 39.7(2.1) 38.4(1.3)
Operation time 27.3(11.5) 19.0(13.3)
Delivery time 3.5(1.9) 4.1(2.0)
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Table 2 Characteristics of SPB and PO analgesia
times
BM(n25) RM(n25) p
Sensory block ns
Motor block -time to complete -complete at T5 -time to complete recovery 4.0(2.0) 24(96) 220.0(32.4) 5.9(3.3) 22(88) 200.2(34.9) lt0.05 ns lt0.05
Sympathetic block -ephredine require -ephredine dose 10 19.7(8.6) 10 4.0(5.2) ns lt0.05
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Table 3 Haemodynamic,respiratory data And
sedation scores.
BM(n25) RM(n25) p
Baseline - HR,MAP,SpO2,RR,sedation score ns
1 min after block MAP 76.8(19.7) 88.7(14.9) lt0.05
After incision
10 min after incision
20 min after incision
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Table 4 Side effects.(ns)
BM (n25) RM (n25)
Bradycradia 0(0) 0(0)
Hypotension 10(40) 10(40)
Nausea 6(24) 3(12)
Vomiting 2(8) 0(0)
Shivering 0(0) 0(0)
Sedation 11(44) 9(36)
Resp.distress 0(0) 0(0)
Pruritus 16(64) 18(72)
Backache 0(0) 0(0)
Headache 2(8) 1(4)
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DISCUSSION

• Similar sensory block and PO analgesia,shorter
  duration of motor block,less ephredine
  requirement,similar APGAR scores and umbilical pH
  and similar SE
• An equal dose of R. And B. (15 mg) and
  ropivacaine dose ED50(Khaw and coll.)
• Prolong PO analgesia after CS RM
  is considered to be less potent than BM But
  similar two-segment regression(Chung and coll.)

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DISCUSSION

• The equipotent ratio between B. And R. Is 32 or
  21 R. Expected to lead to less
  cephalad spread than similar B. Dose( Parlow and
  coll. demon.that adding opioid alter the density
  and spread in CSF)
• Pharmacodynamic studies not know why RMBM
  Further studies

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DISCUSSION

• Previous study-Motor block of BM gt RM but dose
  is 32 but in this study dose is 11
• PO neurological symptoms
• Hypotension

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• THANK YOU
• FOR YOUR ATTENTION
• 
  P.Chatchawarat,MD

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