Spinal Anesthesia in Caesarian Section

105 Pages·2012·3.09 MB·English

by  Maher Mobarak

Spinal Anesthesia in Caesarian Section: Sitting versus
Lateral position Approach
A Thesis study
Submitted for the fulfillment of the master degree in Anesthesiology, surgical ICU and
Pain Management

Presented by
Mohammad Ahmad Mohammad Yusuf Ollaek
M.B.B.Ch
Faculty of Medicine, Cairo University

Supervised by
Prof.Dr. Manar Mahmoud Elkholy
Professor of Anesthesiology
Faculty of Medicine, Cairo University

Assist.Prof.Dr. Enas Mohamed Samir
Assistant professor of anesthesiology
Faculty of medicine, Cairo University

Dr. Ahmad RagabAbd Elhakim
Lecturer of anesthesiology
Faculty of Medicine, Cairo University

2011
ACKNOWLEDGEMENT 

   Thanks to Allah for giving me the power and strength to carry out 
this work. 
   Words  stand  short  where  they  come  to  express  my  gratitude  to  my 
supervisors.  
    I would like to express my thanks and deepest gratitude to Prof. Dr. 
Manar  Mahmoud  Elkholy,  Professor  of  Anesthesiology,  Faculty  of 
Medicine,  Cairo  University,  for  her  great  support  and  her  continuous 
generous advice.  
    My  deep  gratitude  goes  for  Prof.  Dr.  Enas  Mohamed  Samir, 
Professor of Anesthesiology, Faculty of Medicine, Cairo University, for her 
kind help and great support throughout this work. 
    I  would  like  to  sincerely  thank  Dr.  Ahmed  Ragab  Abd  Elhakim, 
Lecturer of Anesthesiology, Faculty of  Medicine, Cairo University for his 
valuable advice, honest assistance and fruitful suggestions throughout my 
daily work. 
     I would like to express my thanks to all members of my family especially 
my father and my wife for giving me love and care till I have finished this 
work and forever.
DEDICATION 

This  work  is  dedicated  to  the  soul  of  my  mother, 
who stood beside me through my entire life, gave me all 
the support and taught me honesty and sincerity. 

II
Abstract 

Regional anesthesia became of choice in obstetric patients for
its characteristics in providing almost rapid onset of anesthesia,
allowing the mother to immediately interact with her baby; it is
safer for mother than general anesthesia.
After compatison of sitting versus lateral position approach
regarding spinal anesthesia in caesarian section, It proves that
sitting approach produces less hypotension, less cephaled spread
and less post dural puncture headache than lateral approach.

Key Words :  Spinal anesthesia  ‐  Caesarian Section  ‐  Sitting  ‐  Lateral. 

III
Table of Contents

Contents Page

List of abbreviations ……………………………………….………………………….….. II
List of tables …………………………………………………...……………………….….. IV
List of figures …………………………………………...…………………………….…… V
Introduction ……………………………………………………………………….............. 1
Aim of Work......................................................................................................................... 5
Review of Literature:
Chapter (1): Anatomy of Spinal Cord and Vertebral Column…………………………. 6
Chapter (2): Physiologic Changes during Pregnancy…………………………………… 18

Chapter (3): Post Dural Puncture Headache………………...………….………………. 29
Patients and Methods…………………………………….………………………………... 50
Results ………………………...............…………………………………………………… 55
Discussion…………………………………………………………………………………... 64
Conclusion ………………………………………………………………...………….……. 70
Summary ………………………………………………………………...……………….... 71
References ………………………………….………………………………...……….…… 75
Arabic Summary ………………………….………………………………...…………..…
List of Abbreviations

ACTH Adreno-cortico-trophic hormone
AED Antiepileptic drug
ASA American Society of Anesthesiologists
CC Closing Capacity
C.S. Caesarian Section
CT Computed Tomography
CSF Cerebrospinal Fluid
ECG Electrocardiogram
FRC Functional residual capacity
G Gauge
GA General Anesthesia
GABA Gamma-amino butyric acid
GFR Glomerular Filtration Rate
H Hour
Kg Kilogram
L.P Lumber Puncture
PDPH Post dural puncture headache
VC Vertebral Cloumn
ug Microgram
5-HT1D 5 hydroxytryptamine receptor 1D

IV
List of Tables

Table Page
Table (1): Cardiovascular Changes in Pregnancy ……………………………………….. 21
Table (2): Coagulation Factors in Pregnancy ……...……………………………………... 24
Table (3): Values for Renal Function …………………...……...………….………………. 28
Table (4): Estimated rate of spontaneous recovery from post-dural puncture Headache 37
Table (5): Bromage scale……………………………………………………………………. 52
Table (6): Demographic data and Operative time of patients during study…………….. 57
Table (7): Systolic Blood Pressure of patients during study……………………………… 58
Table (8): Systolic Blood Pressure less than 100 mmHg of patients during study………. 59
Table (9): Heart Rate (HR) of patients during study……………………………………... 60
Table (10): O Saturation of patients during study……………………………………….. 60
2
Table (11): Incidence of Nausea and Vomiting of patients during study………………... 61
Table (12): Level of Sensory Block of patients during study……………………………... 62
Table (13): Incidence of PDPH within 48 hours of patients during study……………….. 63

V
List of Figures

Figure Page
Figure (1): Vertebral Column …………………………………………...……………...…. 8
Figure (2): Vertebra ………………………….………………………...………………...…. 9
Figure (3): Ligaments of V.C. …………………................................……...………….…… 11
Figure (4): Sagittal Section of V.C…………………...……...…………………...…….…… 11
Figure (5): Cross Section of spinal cord …………………………....……...………….…… 15
Figure (6): Midline Sagittal view of the lumbar spine……………..……...………….…… 17
Figure (7): Types of Needles …………………...……...……………………………….…… 32
Figure (8): MRI showing diffuse dural enhancement……………………………………... 36
Figure (9): Systolic Blood Pressure of patients during study……………………………... 58
Figure (10): Systolic Blood Pressure less than 100 mmHg of patients during study in
59
T3……………………………………………………………………………….
Figure (11): Incidence of Nausea and Vomiting of patients during study……………….. 61
Figure (12): Level of Sensory Block of patients during study…………………………….. 62
Figure (13): Incidence of PDPH within 48 hours of patients during study……………… 63

VI
Introduction
Introduction

Since, regional anesthesia became of choice in obstetric patients for
its characteristics in providing almost rapid onset of anesthesia, allowing
the mother to immediately interact with her baby; it is safer for mother
than general anesthesia. So, the complications following regional
anesthesia became of great interest either to the anesthesiologist or to the
parturient(1) (2).
Complications of spinal or epidural block are either acute in the form
of pain on injection, high(total) spinal anesthesia and hypotension or
postoperative complications as backache, Post Dural Puncture Headache
(PDPH), urine retention, meningitis and nerve injury(3). Several studies
were done to detect and to role out incidence, pathophysiology and
effective measures to minimize or prevent these complications.
Post Dural Puncture Headache was described since more than 100
years and it presents one of the major complications of spinal and
epidural block annoying to the patients especially parturient with
incidence varies between 0.1 – 36 % in parturient because of sex, young
age and the wide spread application of regional anesthesia(4)(5)(6).
The actual mechanism producing PDPH remains unclear. However,
the widely accepted theory explaining the pathophysiology of PDPH is
based on the assumption of persistent leakage of the CSF through the hole
made by the spinal or epidural needle and decrease in CSF volume or
pressure or both, which leads to shift of intracranial contents and traction
on pain sensitive structures(4). The classic symptoms of PDPH consist of
photophobia, nausea, vomiting, neck stiffness, tinnitus, diplopia and
dizziness in addition to often severe cephalgia(4).
2