Comparison of Maternal and Neonatal Effects of Different Inhalational Anaesthetics Used for Cesarean Operations

Öz

Aim: The aim of this study is to evaluate the maternal and fetal effects of frequently used inhalational anaesthetic agents sevoflurane, isoflurane and desflurane in cesarean operations performed under general anaesthesia. Material and Methods: 75 ASA I-II parturients undergoing elective caesarean section were included in the study. Anesthesia induction was performed induction with propofol 2 mg/kg and rocuronium 0.6 mg/kg. In Group S, anesthesia maintenance was done with sevoflurane 1.5 % and N2O 50 % in oxygen inhalation while in Group D and Group I maintainance was done desflurane 3 % and isoflurane 1 % and N2O 50 % in oxygen inhalation respectively. Hemodynamic data were recorded before induction (baseline), at 1, 5, 10, 15, 20, 25 and 30 minutes following intubation. Anesthesia induction-delivery time, anesthesia emergence time and orientation time were recorded. Uterine tonus and blood loss were assessed. Venous blood sample for maternal complete blood count was collected before anaesthesia induction and at 30 minutes postoperatively. Neonatal blood samples for umbilical blood gas analysis were collected after the clamping of cord. A blinded observer to the study protocol evaluated the APGAR score at 1 and 5 minutes after the clamping of the umbilical cord. Same observer also evaluated the NACS at 2nd and 24th hours postoperatively. Results: Maternal demographic data and duration of anesthesia and surgery, anesthesia induction-delivery time, anesthesia emergence and orientation times were similar among groups. The hemodynamic parameters of Group S at 1st minute was higher when compared with the baseline values and Group D at 1st minute was higher when compared with baseline values and Group S and Group I. Estimated blood loss was similar in three groups. There was no difference between the groups in terms of APGAR scores, while the NAC scores at 2nd hour of Group I were lower than the other two Groups. Conclusion: In elective cesarean operations performed with general anaesthesia, sevoflurane and desflurane may be preferred instead of isoflurane in terms of neonatal effects. As desflurane cause a slight increase in maternal hemodynamic parameters, sevoflurane may be the preferred inhalational anaesthetic agent.

Anahtar Kelimeler

• general anaesthesia
• cesarean operation
• inhalational anaesthetics

Sezaryen Operasyonlarında Kullanılan Farklı İnhalasyon Anesteziklerinin Maternal ve Neonatal Etkilerinin Karşılaştırılması

Öz

Amaç: Bu çalışmada amaç, elektif sezaryen girişimlerinde sık kullanılan inhalasyon ajanlarından sevofluran, desfluran ve izofluranın yenidoğan üzerine ve maternal etkilerini karşılaştırmaktır. Gereç ve yöntem: Genel anestezi altında elektif sezaryen ameliyatı planlanan, miadında ASA I-II grubunda 75 gebe çalışmaya dahil edildi. Tüm hastalara intravenöz 2 mg/kg propofol, 0,6 mg/kg roküronyum bromür ile indüksiyon sağlandıktan sonra hastalar rastgele üç gruba ayrılarak idame, %50 N2O-O2 karışımı içerisinde I. grupta % 1.5 sevofluran, II. grupta % 3 desfluran, III.grupta ise %1 izofluran ile sağlandı. Hastaların hemodinamik verileri indüksiyon öncesi, endotrakeal entübasyonu takiben 1, 5,10, 15, 20, 25 ve 30. dk.’larda kaydedildi. Anestezi indüksiyonu- bebek çıkım zamanı, uyanma zamanı, oryantasyon zamanı kaydedildi. Kan kaybı ve uterin tonus değerlendirildi. Yenidoğanın çıkımından hemen sonra umblikal kan gazı için örnek alındı. Tam kan sayımı için maternal venöz kan örnekleri anestezi indüksiyonu öncesi ve ekstübasyondan 30 dk sonra alındı. Neonatal etkiler; uygulanan anestezi yönteminden habersiz ayrı gözlemci tarafından 1 ve 5. dk’da APGAR skoru , 2 ve 24. saat’de nöroadaptif kapasite skoru (NAKS) ile değerlendirildi. Bulgular: Maternal demografik veriler açısından gruplar arasında fark bulunmadı. Anestezi ve cerrahi süresi, anestezi indüksiyonu- bebek çıkım zamanı, anesteziden uyanma ve oryantasyon zamanları gruplar arasında benzerdi. Hemodinamik parametrelerde Grup S’de 1. dakikada başlangıç değerine, Grup D’de ise hem başlangıç değerine, hem de Grup S ve Grup I’ya göre yükselme tesbit edildi. Hesaplanan kan kayıpları üç grupta da benzerdi. APGAR skorları açısından gruplar arasında fark bulunmazken, NAC skorları açısından 2. saatdeki ölçümlerde ısofluran uygulanan Grup I’da daha düşük değerler elde edildi. Sonuç: Genel anestezi altında elektif sezaryen girişimlerinde izoflurana göre, neonatal etkilerinin daha olumlu olması nedeniyle, desfluran ve sevofluran kullanımı tercih edilebilir. Desfluranın da maternal kan basıncında yükselmeye neden olduğu gözönüne alındığı takdirde sevofluran, öncelikle tercih edilebilecek inhalasyon anesteziği olarak değerlendirilebilir.

Anahtar Kelimeler

• genel anestezi
• sezaryen
• inhalasyon anestezikleri

Kaynakça

1. 1. Afolabi BB, Lesi FE, Merah NA. Regional versus general anesthesia for caesearean section. Cochrane Database of Systematic Reviews, 2012; 10: 1465-1858.
2. 2. Sener EB, Guldogus F, Karakaya D, Barıs S, Kocamanoglu S, Tur A: Comparison of Neonatal Effects of Epidural and General Anesthesia for Cesarean section. Gynecol Obstet Invest 2003; 55: 41-45.
3. 3. Abboud LDO, Reyes A, Mosaad P, Zhu J, Mantılla M: Isoflurane or halothane for cesarean section:comparative maternal and neonatal effects. Acta Anaesthesiol Scand 1989: 33: 578-81.
4. 4. Collis RE, Plaat F, Urquhart J . Anaesthesia for caesarean section: general anesthesia. In: Textbook of Obstetric Anaesthesia (Collis R, , eds). London: Greenwich Medical Media Ltd, 2002;113-132.
5. 5. Butwick A, El-Sayed Y, Blumenfeld Y, Osmundson S, Weiniger C. Mode of anaesthesia for preterm Cesarean delivery: secondary analysis from the Maternal-Fetal Medicine Units Network Caesarean Registry. Br J Anaesth 2015;115:267–74.
6. 6. Brown EN, Pavone KJ, Naranjo M. Multimodal General Anesthesia: Theory and Practice. Anesth Analg. 2018 Nov;127(5):1246-1258.
7. 7. Apgar V, Holaday DA, James LS, Princa CE, Wesibrot IM. Comparison of regional and general anesthesia in obstetrics. JAMA 1957;105:2155-21 61.
8. 8. Flood P, Collins MD, Miller RD. Anaesthesia for Obstetrics. Miller’s Anaesthesia 2015: 2328-58.

9. 9. Pintarič T ESRA19-0628 Maternal anaesthesia/analgesia and fetal/neonatal drug uptake. Regional Anesthesia & Pain Medicine 2019;44:A10-A11.
10. 10. Scanlon JW, Brown WU, Weiss JB, Alper MH. Neurobehavioral responses of newborn infants after maternal epidural anesthesia. Anesthesiology 1974;40:121-128.
11. 11. Brazelton TB. Neonatal behavioral assessment scale. Clinics in Developmental Medicine No. 50. Spastics International Medical Publications, London, William Heinemann Medical Books Ltd, 1973.
12. 12. Tison CA, Barrier G, Shnider SM, Levinson G, Hughes SC, Stefani SJ. A new neurologic and adaptive capacity scoring system for evaluating obstetric medications in full-term newborns. Anaesthesiology 1982 56:340-350.
13. 13. Brockhurst NJ, Littleford JA, Halpern SH. The neurologic and adaptive capacity score: A systematic review of its use in obstetric anesthesia research. Anesthesiology. 2000;92:237–46.
14. 14. Hashemi SJ, Jabalameli M and Mokhtary. Effects of different anesthetic techniques on neurologic and adaptation capacity in newborn with elective cesarean section. Adv Biomed Res. 2015; 4:249–254.
15. 15. Gambling DR, Sharma SK, White PF, Beveren TV, Bala SA, Gouldson R. Use of sevoflurane during elective cesarean birth:A comparison with isoflurane and spinal anesthesia. Anesth-Analg 1995;81:90-5.
16. 16. Tatekawa S, Asada A, Nihikawa K et al. Comparison of sevoflurane with isoflurane anesthesia for use in elective cesarean section. (ABST) Anesthesiology 1993; 79:A1018.
17. 17. Abboud LDO, Reyes A, Mosaad P, Zhu J, Mantılla M: Isoflurane or halothane for cesarean section:comparative maternal and neonatal effects. Acta Anaesthesiol Scand 1989: 33: 578-81.
18. 18. Littleford J. Effects on the fetus and newborn of maternal analgesia and anesthesia: a review. Can J Anaesth 2004; 51:586-609.
19. 19. Karaman S, Akercan F, Aldemir O, Terek MC, Yalaz M, Fırat V. The Maternal and Neonatal Effects of the Volatile Anaesthetic Agents Desflurane and Sevoflurane in Caesarean Section: a Prospective, Randomized Clinical Study. The Journal of International Medical Research 2006; 34:183-192.
20. 20. Turner RJ, Lambros M, Kenway L, Gatt SP. The in-vitro effects of sevoflurane and desflurane on the contractility of pregnant human uterine muscle. Int J Obstet Anesth 2002; 11:246-251
21. 21. Stachnik J. Inhaled anesthetic agents. Am J Health Syst Pharm. 2006 Dec 15;63(24):2436.
22. 22. Tercan E, Kotanoğlu MS, Yıldız K, Doğru K, Boyacı A. Comparison of recovery properties of desflurane and sevoflurane according to gender differences. Acta Anaesthesiol Scand 2005; 49 (2):243-7.