Jurnal anestesi.docx

8/12/2019 Jurnal anestesi.docx

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Regional versus generalanaesthesia for caesarean section

Writer : Afolabi BB, Lesi FEA, Merah NA

Sumber :Afolabi BB, Lesi FEA, Merah NA. Regional versus general anaesthesia for

caesarean section. Cochrane Database of Systematic Reviews

2006, Issue 4. Art. No.: CD004350. DOI: 10.1002/14651858.CD004350.pub2.

Dipresentasikan oleh :Merie Octavia 11.2012.096

Theresia Puspita Sari 11.2012.146


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Abstract

Background

Regional and general anaesthesia (GA) are

commonly used for caesarean section (CS) and

both have advantages and disadvantages

Objectives

To compare the effects of regional anaesthesia(RA) with those of GA on the outcomes of CS.


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Abstract

Search strategy

We searched the Cochrane Pregnancy and

Childbirth Groups Trials Register (30

December 2005), the Cochrane Central

Register of Controlled Trials (The Cochrane

Library 2005, Issue 1), MEDLINE (1966 to

December 2005), and EMBASE (1980 toDecember 2005)..


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Abstract

Selection criteria

Randomised and quasi-randomised controlled

trials evaluating the use of RA and GA in

women who had CS for any indication

Data collection and analysis

Two authors independently assessed trials forinclusion, data extraction and trial quality.


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Abstract

Main results

Although the operation has become very safe

over the years, it is still associated with

greater maternal mortality and morbidity (4X)

Sixteen studies (1586 women) were included

in this review.


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P L A I N L A N G U A G E S U M M A R Y

There were some differences which favoured

general anaesthesia, for example, less nausea

and vomiting

There were also some differences which

favoured regional anaesthesia, for example,

less blood loss and less shivering.


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Background

General anaesthesia refers to the loss of

ability to perceive pain associated with loss of

consciousness produced by intravenous or

inhalation anaesthetic agents.

The risks include the aspiration of stomach

contents, failed intubations, and respiratory

problems for both mother and baby


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Background

general anaesthesia has also been associated

with a greater risk of maternal blood loss

compared with regional anaesthesia

Spinal and epidural anaesthesia cause a

substantial drop in maternal blood pressure,

which may affect both mother and fetus


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Background

Spinal anaesthesia has a faster onset of action andrequires less of the drug, but causes more

hypotensive episodes than epidural anaesthesia

The advantages of regional anaesthesia include the

reduction of the incidence of general anaesthetic

complications and that of early bonding between the

mother and the newborn, since the mother is awake

during the procedure


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Background

Most of the studies that report no difference

are those done on women who had elective

operations while those done on emergencies

tend to report a positive difference in

neonatal outcome with regional anaesthesia

compared with general.


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C r i t e r i a f o r c o n s i d e r i n g

s t u d i e s f o r t h i s r e v i ew

Types of intervention

Intervention: regional anaesthesia, whether

spinal, epidural or any combination of both.

Control: general anaesthesia using any

combination of anaesthetic drugs and muscle

relaxants.


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Types of outcome measures

Maternal outcomes

Neonatal outcomes


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D E S C R I P T I O N O F S T U D I E S

There are 16 trials (1586 women) in this

review

In 12 of the trials, the indication for caesarean

section was nonurgent and the women were

healthy and stable.

In three of the remaining four trials, the

indication for caesarean was severe

preeclampsia in two, and pre-eclampsia with

non-reassuring heart trace in one.


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R E S U L T S

Maternal outcomes

1. Maternal deaths

No trial reported on deaths.2. Pre and postoperative haematocrit

One study reported a significant difference

which favoured epidural anaesthesia andspinal anaesthesia over general anaesthesia.


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R E S U L T S

3. Maternal blood lossTwo trials each reported on maternal blood loss and

noted that significantly less blood was lost when

using regional than general anesthesia

4. Wound and other infections

No study reported on wound and other infections.

5. Pain.

It reported that the perception of pain during thecaesarean section was less when general anaesthesia

was used when compared to spinal anaesthesia or

epidural anaesthesia


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R E S U L T S

However, postoperative pain is less in patients

with neuraxial techniques, since the time for

the first boost of analgesia is longer .


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R E S U L T S

6. Satisfaction

One study reported on satisfaction using a visualanalogue score and noted that there was no

difference in the level of satisfaction whengeneral anaesthesia is compared with regional.However, when asked which form of analgesiathey would prefer for subsequent procedures,

one study reported that women preferredgeneral over regional

In contrast, 81% preferred neuraxial anesthesia


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RESULTS

7. Adverse events

Nausea and vomiting women were

significantly more frequent in the regional

group than general

Shivering was significantly commoner in

women who received general anaesthesia


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R E S U L T S

8. Other outcomes

The percentage of patients who walked during

the first 24h was higher in neuraxial

anesthesia patients.


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RESULTS

Neonatal outcomes

1. Neonatal deaths

No study reported on neonatal deaths


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RESULTS

2. Umbilical artery pH

when the indications for caesarean sectionwere not urgent (seven out of the eight trials),

there was no difference in the pH in babieswhose mothers had received regionalanaesthesia compared to general anaesthesia

Two studies found the mean umbilical arterypH to be significantly lower in regional whencompared to the general anaesthesia group


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R E S U L T S

3. Umbilical vein pH

The pH was significantly higher in babies

whose mothers had received regional

anaesthesia compared to general anaesthesia


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R E S U L T S

4. Apgar score.

They reported that scores were significantly

lower among babies delivered by general

anaesthesia

the percentage of neonates with Apgar scores

less than 7 at 1min was 25.9% for the general

anesthesia group and 1.1% for the spinal

anesthesia group, however, after 5min, all

neonates had a score over 9.


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R E S U L T S

5. Need for oxygen for resuscitation

no differences in the need for supplementary oxygen

in neonates born with general or epidural anesthesia

C-section.

Another more recent trial did find differences: the

percentage of neonates requiring oxygen or positive

pressure ventilation during neonatal adaptation was

14 % for the general anesthesia group versus 0% for

the spinal anesthesia group


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R E S U L T S

6 Neurological adaptation scores

No differences were found in the neurological

adaptive capacity at 2 and 4h of newborn life

from mother who underwent general or

epidural anesthesia C-section.


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Conclusion

From the results, regional anaesthesia (both

spinal and epidural) appears to be associated

with less blood loss and a higher

postoperative haematocrit than generalanaesthesia


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Conclusion

None of the trials addressed important

outcomes for women like effects on

breastfeeding, effects on the mother-child

relationship and length of time before motherfeels well enough to care for her baby


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Conclusion

Although the preferred anesthetic technique forcesarean section delivery is neuraxial anesthesia, whenthe indication for the procedure is under generalanesthesia, there is no increased risk of maternal death

or unfavorable neonatal clinical outcomes. Mortality may be more linked to the indication for

cesarean section rather than with the anesthetictechnique.

The scale tips in favor of neuraxial anesthesia whenconsidering variables such as post-operative pain,bleeding, and patient satisfaction


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Conclusion

Nausea is more frequent in epidural anesthesia and

in spinal anesthesia, while vomiting is more frequent

only in the spinal anesthesia group of patients, when

compared against general anesthesia. No significant difference was seen in terms of

neonatal Apgar scores of six or less and of four or

less at one and five minutes and need for neonatal

resuscitation with oxygen


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