A Comparative Study on Low Dose Intrathecal Ropivacaine alone with Ropivacaine and Sufentanil in Labor Analgesia

Prithiviraj, S (2007) A Comparative Study on Low Dose Intrathecal Ropivacaine alone with Ropivacaine and Sufentanil in Labor Analgesia. Masters thesis, Stanley Medical College, Chennai.


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INTRODUCTION: “For all the happiness Mankind can gain is not in pleasure but in rest from pain" - JOHN DRYDEN. Pain derived from the Latin word “poena” which means punishment. In ancient times, Pain was considered as punishment from god. Labor is an extremely painful process. Being a natural process, women have accepted labor pain as a normal one. Traditionally a number of techniques have been employed to provide labor analgesia. Epidural analgesia, either continuous or intermittent boluses, is considered to be the gold standard in labor analgesia due to the long duration of labor. Traditionally only high doses of local anaesthetics were used. Though they provide excellent pain relief, they produce an unacceptable high level of motor blockade which impairs the parturient’s ability to bear down during labor, resulting in prolonged labor. Lower doses of local anaesthetics by themselves are inadequate. The technique of spinal analgesia in labor pain relief was a setback due to the shorter duration of analgesia. The newer technique of combined spinal-epidural analgesia is a major breakthrough in labor analgesia. Current obstetric practice aiming to provide effective pain relief, led Collins and colleagues to popularize the combined spinal-epidural technique for labor analgesia. These techniques involved an initial intrathecal injection of a local anaesthetic with an opioid (Fentanyl) to establish analgesia and subsequent epidural injections to maintain analgesia. The doses of drugs involved were such that ambulation was possible. The discovery of opioid receptors in spinal analgesia provides an interesting option. Opioid agonists selectively block pain impulses but leave the motor system unaffected. The doses for central neuraxial blockade are also very little when compared to parenteral routes and does not result in significant respiratory depression both to the mother and the fetus. Since opioids and local anaesthetics act at different sites, their combination provides a synergistic effect permitting to use lesser concentration of both. When used in such low doses the individual side effects are minimized while maximizing the desired effects. Ropivacaine, a newer local anaesthetics which has been shown to cause less intense motor blockade and less cardiotoxic is rapidly evolving as local anaesthetic of choice in labor analgesia as well as in post operative analgesia. The aim of this study was to compare the analgesic and the motor sparing effect of low dose intrathecal Ropivacaine 3mg with or without sufentanil 10μg as a part of CSE labor analgesia. Efficacy, Duration of analgesia, sensory blockade and fetal effects were studied in detail. AIM: To compare the effect of low dose intrathecal Ropivacaine alone with Ropivacaine and Sufentanil in providing labor analgesia. The parameters that were analysed include: 1. The analgesic and the motor sparing effect of low dose intrathecal Ropivacaine alone and with sufentanil in labor analgesia. 2. Maternal and fetal outcomes. 3. Safety and patient comfort. MATERIALS AND METHODOLOGY: This is a prospective randomized controlled study. Prior approval was obtained from the ethics committee of Stanley Medical College and Hospital & RSRM Lying in Hospital for the study. Forty parturients who were admitted to the labor ward andwho requested pain relief during labor were selected for the study. The procedure was explained to them in detail and written consent was obtained from them. Inclusion Criteria: 1. Patients in early active labor (Cervical dilatation 3-5 cms) 9 2. Patients belonging to ASA I. 3. Only primigravida patients with singleton pregnancy were included in the study. 4. Vertex presentation. Exclusion Criteria: 1. Patients with medical or systemic disorders. 2. Patients with obstetric complications (PIH, GDM, Eclampsia, etc.) 3. Presentation other than vertex 4. Any contraindications for Central Neuraxial Blockade. 5. Patients who have already received parenteral opioids or systemic analgesics. 6. Patients with known allergy to local anaesthetics. RESULTS: The study was conducted in Government RSRM Lying-in Hospital during 2006. Forty patients in active labour (Cervical dilatation 3-5 cms)9 who requested analgesia were chosen and randomly assigned to either of the two groups : R-Group (Ropivacaine) : Recieved intrathecal Ropivacaine 3mg as part of CSE, followed by epidural top-ups with bupivacaine 0.0625% and fentanyl 1.5μg/ml. RS-Group (Ropivacaine with Sufentanil) : Recieved intrathecal Ropivacaine 3mg with Sufentanil 10 μg as part of CSE, followed by epidural top-ups with bupivacaine 0.0625% and fentanyl 1.5μg/ml for standardization. The study commenced at the intrathecal injection and completed with the patients first request for analgesia. The above stated period alone was taken for statistical analysis, using students t-test, Chi-Square tests, fischer tests. Since some of the cases end earlier, the datas were taken for analysis upto 45 mins duration, though all the parameters were monitored till the delivery of the baby. SUMMARY: In my study, parturients in both the groups had effective pain relief and gave more satisfaction because of the earlier onset of analgesia thus Ropivacaine, a useful local anaesthetic in labor analgesia. Motor blockade was nil in both the groups, making Ropivacaine, an effective drug in central neuraxial analgesia, especially in settings where ambulation should be retained, such as analgesia during labor or outpatient anaesthesia. The duration of analgesia was prolonged(mean 93.25 mins in RS-group vs mean 47.6 mins in R-group) when sufentanil is added intrathecally as an additive providing better pain relief, although no statistical difference between the groups in patients satisfaction. Maternal and fetal outcomes were also favourable. Complications were only few, minor and easily manageable with just reassurance. The technique doesnot pose any additional difficulty. CONCLUSION: In my study, I conclude low dose intrathecal Ropivacaine(3 mg as 0.2% solution) provides effective and rapid pain relief ,and doesnot impair the motor function. Thus ambulation is made easy in CSE labour analgesia, without imposing any significant impact on the hemodynamics, mode of delivery, duration of labor or fetal outcome. Hence low dose intrathecal Ropivacaine is a safe drug in CSE labor analgesia. And when combined with sufentanil the quality and duration of intrathecal analgesia is much better (almost twice the duration) with minimal side effects. Low dose intrathecal Ropivacaine with Sufentanil provides safe and satisfactory labor analgesia and can be used in all parturients who request labor pain relief. Providing pain relief to laboring parturients will surely be a gratifying experience for the anaesthesiologists.

Item Type: Thesis (Masters)
Uncontrolled Keywords: Low Dose Intrathecal Ropivacaine ; Ropivacaine ; Sufentanil ; Labor Analgesia ; Comparative Study.
Subjects: MEDICAL > Anaesthesiology
Depositing User: Subramani R
Date Deposited: 22 Apr 2018 15:37
Last Modified: 28 Apr 2018 05:20
URI: http://repository-tnmgrmu.ac.in/id/eprint/7233

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