Magnesium Therapy in Pre-eclampsia Prolongs Analgesia Following Spinal Anaesthesia with Fentanyl and Bupivacaine: An Observational Study

Abstract

Background: Magnesium has anti-nociceptive effects and potentiates opioid analgesia following its systemic and neuraxial administration. However, there is no study evaluating the effects of intravenous (IV) magnesium sulphate (MgSO4) therapy on spinal anaesthesia characteristics in severely pre-eclamptic patients. Aims: The aim of this study was to compare spinal anaesthesia characteristics in severely pre-eclamptic parturients treated with MgSO4 and healthy preterm parturients undergoing caesarean section. Thus, our primary outcome was regarded as the time to first analgesic request following spinal anaesthesia. Study Design: Case-control Study. Methods: Following approval of Institutional Clinical Research Ethics Committee and informed consent of the patients, 44 parturients undergoing caesarean section with spinal anaesthesia were enrolled in the study in two groups: Healthy preterm parturients (Group C) and severely pre-eclamptic parturients with IV MgSO4 therapy (Group Mg). Following blood and cerebrospinal fluid (CSF) sampling, spinal anaesthesia was induced with 9 mg hyperbaric bupivacaine and 20 µg fentanyl. Serum and CSF magnesium levels, onset of sensory block at T4 level, highest sensory block level, motor block characteristics, time to first analgesic request, maternal haemodynamics as well as side effects were evaluated. Results: Blood and CSF magnesium levels were higher in Group Mg. Sensory block onset at T4 were 257.1±77.5 and 194.5±80.1 sec in Group C and Mg respectively (p=0.015). Time to first postoperative analgesic request was significantly prolonged in Group Mg than in Group C (246.1±52.8 and 137.4±30.5 min, respectively, p<0.001; with a mean difference of 108.6 min and 95% CI between 81.6 and 135.7). Side effects were similar in both groups. Group C required significantly more fluids. Conclusion: Treatment with IV MgSO4 in severe pre-eclamptic parturients significantly prolonged the time to first analgesic request compared to healthy preterm parturients, which might be attributed to the opioid potentiation of magnesium.

Keywords

• Caesarean section, magnesium sulphate, pre-eclampsia, spinal anaesthesia

Magnesium Therapy in Pre-eclampsia Prolongs Analgesia Following Spinal Anaesthesia with Fentanyl and Bupivacaine: An Observational Study

Öz

Kaynakça

1. Mebazaa MS, Ouerghi S, Frikha N, Moncer K, Mestiri T, James MF, et al. Is magnesium sulfate by the intrathecal route efficient and safe? Ann Fr Anesth Reanim 2011;30:47-50. [CrossRef]
2. Albrecht E, Kirkham KR, Liu SS, Brull R. Peri-operative intravenous administration of magnesium sulphate and postoperative pain: a meta- analysis. Anaesthesia 2013;68:79-90. [CrossRef]
3. Apan A, Buyukkocak U, Ozcan S, Sari E, Basar H. Postoperative mag- nesium sulphate infusion reduces analgesic requirements in spinal an- aesthesia. Eur J Anaesthesiol 2004;21:766-9. [CrossRef]
4. Dabbagh A, Elyasi H, Razavi SS, Fathi M, Rajaei S. Intravenous magne- sium sulfate for post-operative pain in patients undergoing lower limb or- thopedic surgery. Acta Anaesthesiol Scand 2009;53:1088-91. [CrossRef]
5. Hwang JY, Na HS, Jeon YT, Ro YJ, Kim CS, Do SH. I.V. infusion of magnesium sulphate during spinal anaesthesia improves postoperative analgesia. Br J Anaesth 2010;104:89-93. [CrossRef]
6. Gupta SD, Mitra K, Mukherjee M, Roy S, Sarkar A, Kundu S, et al. Effect of magnesium infusion on thoracic epidural analgesia. Saudi J Anaesth 2011;5:55-61. [CrossRef]
7. Ko SH, Lim HR, Kim DC, Han YJ, Choe H, Song HS. Magnesium sul- fate does not reduce postoperative analgesic requirements. Anesthesiol- ogy 2001;95:640-6. [CrossRef]
8. Amburgey O, Chapman AC, May V, Bernstein IM, Cipolla MJ. Plasma from preeclamptic women increases blood-brain barrier permeabil- ity: role of vascular endothelial growth factor signaling. Hypertension 2010;56:1003-8. [CrossRef]

9. Thurnau GR, Kemp DB, Jarvis A. Cerebrospinal fluid levels of mag- nesium in patients with preeclampsia after treatment with intrave- nous magnesium sulfate: a preliminary report. Am J Obstet Gynecol 1987;157:1435-8. [CrossRef]
10. Fong J, Gurewitsch ED, Volpe L, Wagner WE, Gomillion MC, August P. Baseline serum and cerebrospinal fluid magnesium levels in normal preg- nancy and preeclampsia. Obstet Gynecol 1995;85:444-8. [CrossRef]
11. Apostol A, Apostol R, Ali E, Choi A, Ehsuni N, Hu B, et al. Cerebral spinal fluid and serum ionized magnesium and calcium levels in pre- eclamptic women during administration of magnesium sulfate. Fertil Steril 2010;94:276-82. [CrossRef]
12. Gogarten W. Preeclampsia and anaesthesia. Curr Opin Anaesthesiol 2009;22:347-51. [CrossRef]
13. Lockwood C, Wendel G. ACOG Committee on Practice Bulletins- Obstetrics. ACOG practice bulletin. Diagnosis and management of pre- eclampsia and eclampsia. Number 33, January 2002. Obstet Gynecol 2002;99:159-67.
14. McKee JA, Brewer RP, Macy GE, Borel CO, Reynolds JD, Warner DS. Magnesium neuroprotection is limited in humans with acute brain in- jury. Neurocrit Care 2005;2:342-51. [CrossRef]
15. Unlugenc H, Ozalevli M, Gunduz M, Gunasti S, Urunsak IF, Guler T, et al. Comparison of intrathecal magnesium, fentanyl, or placebo com- bined with bupivacaine 0.5% for parturients undergoing elective cesar- ean delivery. Acta Anaesthesiol Scand 2009;53:346-53. [CrossRef]
16. Yousef AA, Amr YM. The effect of adding magnesium sulphate to epidural bupivacaine and fentanyl in elective caesarean section using combined spinal-epidural anaesthesia: a prospective double blind ran- domised study. Int J Obstet Anesth 2010;19:401-4. [CrossRef]
17. Malleeswaran S, Panda N, Mathew P, Bagga R. A randomised study of magnesium sulphate as an adjuvant to intrathecal bupivacaine in patients with mild preeclampsia undergoing caesarean section. Int J Obstet Anes- th 2010;19:161-6. [CrossRef]
18. Herroeder S, Schönherr ME, De Hert SG, Hollmann MW. Magnesium--es- sentials for anesthesiologists. Anesthesiology 2011;114:971-93. [CrossRef]
19. Mercieri M, De Blasi RA, Palmisani S, Forte S, Cardelli P, Romano R, et al. Changes in cerebrospinal fluid magnesium levels in patients undergo- ing spinal anaesthesia for hip arthroplasty: does intravenous infusion of magnesium sulphate make any difference? A prospective, randomized, controlled study. Br J Anaesth 2012;109:208-15. [CrossRef]
20. Ghrab BE, Maatoug M, Kallel N, Khemakhem K, Chaari M, Kolsi K, et al. [Does combination of intrathecal magnesium sulfate and morphine improve postcaesarean section analgesia?]. Ann Fr Anesth Reanim 2009;28:454-9. [CrossRef]
21. Ozalevli M, Cetin TO, Unlugenc H, Guler T, Isik G. The effect of adding intrathecal magnesium sulphate to bupivacaine-fentanyl spinal anaes- thesia. Acta Anaesthesiol Scand 2005;49:1514-9. [CrossRef]
22. Aya AGM, Vialles N, Tanoubi I, Mangin R, Ferrer JM, Robert C, et al. Spinal anesthesia-induced hypotension: a risk comparison between pa- tients with severe preeclampsia and healthy women undergoing preterm cesarean delivery. Anesth Analg 2005;101:869-75. [CrossRef]
23. Hoenig JM, Heisey DM. The abuse of power: the pervasive fallacy of power calculations for data analysis. Am Stat 2001;55:19-24. [CrossRef]
24. National Institute for Health and Clinical Excellence. Hypertension in pregnancy. The management of hypertensive disorders during preg- nancy. NICE clinical guideline (serial online) 107. Issued: August 2010, last modified: January 2011. Available from: http://www.nice.org.uk/ nicemedia/live/13098/50418/50418.pdf
25. Girard B, Beucher G, Muris C, Simonet T, Dreyfus M. [Magnesium sul- phate and severe preeclampsia: its use in current practice]. J Gynecol Obstet Biol Reprod 2005;34:17-22. [CrossRef]
26. Belfort MA, Clark SL, Sibai B. Cerebral hemodynamics in preeclamp- sia: cerebral perfusion and the rationale for an alternative to magnesium sulfate. Obstet Gynecol Surv 2006;61:655-65. [CrossRef]