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Sequential CSE versus standard CSE in the morbidly obese parturient presenting for elective cesarean delivery
Abstract Number: F-19
Abstract Type: Original Research
Introduction:Concern exists regarding the appropriate dose and choice of neuraxial technique for spinal anesthesia in morbidly obese parturients undergoing cesarean delivery (CD). Although the ED95 for spinal bupivacaine has been demonstrated to be equivalent in obese and nonobese parturients(1), the consequences of inadvertent high spinal blockade in the morbidly obese patient undergoing elective CD are best avoided. The sequential combined spinal epidural (CSE) technique is a catheter based neuraxial technique, which allows for a slow, controlled induction of neuraxial anesthesia for CD. Direct comparison of sequential CSE versus standard CSE in the morbidly obese parturient may reveal the superiority of one technique over the other in this high-risk population.
Methods:Ours is a prospective, randomized, controlled, double blinded trial comparing sequential CSE to standard CSE technique in class III obese parturients presenting for elective CD. Each patient was randomly assigned to receive either 7.5 mg or 12 mg of 0.75% hyperbaric bupivacaine administered with fentanyl 10 mcg and morphine 150 mcg intrathecally. The primary endpoint was the number of epidural catheters requiring test dose administration. Secondary endpoints included spinal blockade level as determined by pinprick at five specific intervals, degree of hypotension from baseline, nausea and or vomiting, amount of epidural local anesthetic administered, dose of vasopressor given, and incidence of high spinal or block failure.
Results:Mean BMI was 47.3 ± 5.55 in the sequential CSE group (n=17) and 43.4 ± 2.53 in the standard CSE group (n=13). Median spinal blockade level at 15 minutes was T2 in the sequential CSE group and T1 in the standard CSE group. 47% of patients in the sequential CSE group and 15% in the standard CSE group required dosing of the epidural catheter (p=0.12) at an average of 55 and 91 minutes from the spinal dosing respectively (p=0.04). No difference in nausea and vomiting, hypotension from baseline, or vasopressor use was demonstrated between the two groups. There were no high spinals or block failures in either group.
Discussion: Although the sequential CSE technique has been shown to offer less hypotension during induction of neuraxial anesthesia, we have not been able to demonstrate this finding by reductions in hypotension from baseline, nausea, vomiting, or vasopressor use. We cannot recommend a decreased intrathecal dose of hyperbaric bupivacaine for CD in the morbidly obese parturient as part of a single shot spinal technique; further, our findings argue that class III obese patients should receive a catheter based technique for CD, as 15% of those receiving the standard CSE also required epidural supplementation, which seems to be related to the prolonged surgical time in the morbidly obese parturient. Data collection is ongoing.
1.Curr Opin Anaesthesiol. 2009,22:341-46.