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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 4  |  Issue : 4  |  Page : 235-238

Sedation with intrathecal clonidine versus fentanyl with bupivacaine in elective cesarean section in a sample of Egyptian parturients


1 Anesthesia Department, Alexandria Faculty of Medicine, Alexandria, Egypt
2 Anesthesia Department, Magrabi Hospital, Jeddah, Saudi Arabia

Date of Submission16-Dec-2016
Date of Acceptance04-Mar-2017
Date of Web Publication11-Oct-2017

Correspondence Address:
Mohammad Hazem I Ahmad Sabry
Anesthesia Department, Faculty of Medicine, Khartoum Square, Shlalat, Alexandria, 21111
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/roaic.roaic_116_16

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  Abstract 

Background and objective
Regional analgesia has become the preferred technique in obstetrics. Spinal analgesia has many advantages, including being a single injection, being easier to administer, and being faster to take effect.
Patients and methods
This study was carried out on 40 parturients scheduled for cesarean sections with spinal analgesia who were categorized as follows: the fentanyl group − 20 parturients received 2 ml of 0.5% hyperbaric bupivacaine and 25 μg fentanyl; and the clonidine group − 20 parturients received 2 ml of 0.5% hyperbaric bupivacaine and 75 μg clonidine. Hemodynamic measurements, sensory blockade, pain intensity using visual analog scale (VAS) and time to first request for analgesia, motor blockade, perioperative side effects or complications, fetal well-being using Apgar score, and both parturient and surgeon satisfaction were recorded and statistically analyzed.
Results
The parturients who received intrathecal clonidine had a higher level and faster onset of sensory blockade and delayed regression of sensory level compared with those who received intrathecal fentanyl. Regarding the changes in pain intensity measured by VAS, the clonidine group revealed low VAS compared with the fentanyl group immediately after spinal anesthesia and up to 3 h postoperatively with earlier and multiple requests for analgesics in the fentanyl group. On comparing both groups regarding onset of motor block and its regression using the modified Bromage score, we noticed slower onset and regression of motor block in the fentanyl group with longer duration of motor block compared with the clonidine group. Sedation was significantly higher in the clonidine group (25%) than in the fentanyl group. The incidence of nausea and vomiting was significantly higher in parturients who received intrathecal fentanyl (30%) than in those who received intrathecal clonidine (5%) (P<0.05).
Conclusion
Use of intrathecal clonidine for cesarean section results in better sensory blockade and early recovery of motor blockade as compared with the use of intrathecal fentanyl. Intraoperative sedation is significantly better in the clonidine group.

Keywords: cesarean section, clonidine, fentanyl, regional, spinal


How to cite this article:
Ahmad Sabry MI, Aboghanima MA, Sabry AM. Sedation with intrathecal clonidine versus fentanyl with bupivacaine in elective cesarean section in a sample of Egyptian parturients. Res Opin Anesth Intensive Care 2017;4:235-8

How to cite this URL:
Ahmad Sabry MI, Aboghanima MA, Sabry AM. Sedation with intrathecal clonidine versus fentanyl with bupivacaine in elective cesarean section in a sample of Egyptian parturients. Res Opin Anesth Intensive Care [serial online] 2017 [cited 2020 Jun 4];4:235-8. Available from: http://www.roaic.eg.net/text.asp?2017/4/4/235/216448


  Introduction Top


Regional analgesia has become the preferred technique for cesarean delivery because general anesthesia is associated with higher maternal morbidity and mortality. Spinal analgesia has many advantages, including being a single injection, faster effect, easier to administer, need for lower dose of local anesthetics yet producing a denser blocking effect, less neonatal exposure to potentially depressant drugs, decreased risk for maternal pulmonary aspiration, conscious state of the mother to witness the birth of her child, and better early postoperative analgesia. There is increased use of spinal anesthesia in cesarean section [1],[2]. The aim of this study was to evaluate the efficacy of adding intrathecal clonidine versus addition of fentanyl to hyperbaric bupivacaine for cesarean section as regards sensory and motor blockade as the primary outcome, and hemodynamic changes, Apgar score, and parturients’ and surgeons’ satisfaction as secondary outcomes in a sample of Egyptian parturients.


  Patients and methods Top


This study was carried out in El-Shatby Maternity University Hospital on 40 parturients scheduled for elective cesarean delivery under spinal analgesia. After obtaining ethics committee approval and patients’ informed consent, the parturients were randomly categorized into two equal groups (20 parturients each). The sample size was approved by the Department of Statistics, High Institute of Public Health, University of Alexandria.

Group I (the fentanyl group): in this group, 20 parturients received spinal analgesia consisting of 2 ml of 0.5% hyperbaric bupivacaine and 0.5 ml fentanyl (25 μg).

Group II the clonidine group: in this group, 20 parturients received spinal analgesia consisting of 2 ml of 0.5% hyperbaric bupivacaine and 0.5 ml clonidine (75 μg).

All parturients were given intravenous lactated ringer’s solution 10 ml/kg as volume preload. Oxygen was administered through a face mask. Spinal analgesia was performed at the L3–L4 interspace with the patient in the sitting position following the midline approach using a 25-G needle. After intrathecal injection, the parturients were placed supine with left uterine displacement with a wedge beneath the right hip to maintain a pelvic tilt.

Hemodynamic measurements (pulse rate, mean arterial blood pressure, oxygen saturation), sensory blockade using pin prick [time to reach the highest sensory level, segmental level of highest sensory blockade, time to reach T12, pain intensity using the visual analog scale (VAS), and time to first request for analgesia], motor blockade (onset, duration, and regression using the modified Bromage score) [3], perioperative side effects or complications (including sedation using Ramsay sedation score, hypotension, nausea, vomiting, etc.), fetal well-being using Apgar score, and both parturient and surgeon satisfaction were recorded and statistically analyzed.

Statistical analysis

Data were analyzed using SPSS software, version 18.0 (SPSS Inc., Chicago, Illinois, USA). Quantitative data were expressed as range, mean and SD, and qualitative data as frequency and percentage. The χ2-test, Fisher’s exact test, and the Monte Carlo test were applied to compare the two groups. Quantitative data were analyzed using the Student t-test to compare between the two groups and the paired t-test was used to compare between the different periods. P values were assumed to be significant at less than 0.05.


  Results Top


There was no statistically significant difference between the two groups as regards the parturients’ ages (P=0.871), their weights (P=0.318), and the duration of operation (P=0.484).

There was no statistically significant difference between the two groups as regards pulse rate, mean arterial blood pressure, and oxygen saturation (P>0.05).

The results revealed that parturients who received intrathecal clonidine had a higher segmental level of analgesia (P<0.037) ([Figure 1]), faster onset of analgesia (P<0.001), and delayed regression of sensory level with longer duration of analgesia (P<0.001) compared with those who received intrathecal fentanyl ([Figure 2]).
Figure 1 Comparison between the two studied groups as regards the percentage of the segmental level of highest sensory analgesia.

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Figure 2 Comparison between the two studied groups as regards the mean time to onset of sensory analgesia (min).

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Regarding the changes in pain intensity measured by VAS, the clonidine group revealed lower VAS compared with the fentanyl group immediately after spinal anesthesia and up to 3 h postoperatively (postoperative at 1 h, P=0.008; at 2 h, P=0.015; and at 3 h, P=0.004), with earlier and multiple requests for analgesics in the fentanyl group (P<0.001) ([Figure 3]).
Figure 3 Comparison between the two studied groups as regards changes in pain intensity on the visual analog scale (VAS).

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As per the modified Bromage score, the clonidine group showed faster onset of motor block (P<0.001) and motor block regression compared with the fentanyl group, which showed slower onset and regression but longer duration of motor block compared with the clonidine group postoperatively (at 15 min, P=0.005; at 30 min, P=0.001; at 45 min, P<0.001; at 60 min, P<0.001; at 75 min, P<0.001; and at 90 min, P=0.037).

Apgar scores were above 9 in both groups at 1 and 5 min (P>0.05).

Sedation was significant in the clonidine group, although it did not occur in any parturients of the fentanyl group (P=0.047).

There was no incidence of postspinal headache, urinary retention, and respiratory depression in any parturients in either group.

There was no significant difference in the incidence of hypotension and bradycardia between the two studied groups (P>0.05).

Nausea and vomiting were more evident in parturients who received intrathecal fentanyl than in those who received intrathecal clonidine, but with no significant difference (P>0.05).

Itching was significantly higher in parturients who received intrathecal fentanyl than in those who received intrathecal clonidine (P=0.047).

Parturients were more satisfied in the clonidine group than in the fentanyl group (P=0.015).

There were no differences in surgeons’ satisfaction between the two groups (P>0.05).


  Discussion Top


In this study, we have evaluated the use of α2 agonist, clonidine versus fentanyl, when added to hyperbaric bupivacaine 0.5% for elective cesarean section. Filos et al. [4] used intrathecal clonidine 150 mcg as the sole postoperative analgesic after cesarean section with subsequent analgesia with increased sedation and dry mouth. We did not encounter complaints of dry mouth in this study, possibly because of the lower dose that we used in this study (75 mcg). Eisenach et al. [5] evaluated clonidine and fentanyl when used alone or in a mixture as an epidural for postoperative pain and failed to show synergy when both were used. Filos et al. [6] evaluated the use of postoperative intrathecal clonidine in three doses (150, 300, and 450 mcg) after elective cesarean section under general anesthesia, with subsequent increase in analgesic effect but with increased sedation with higher dose; however, Singh et al. [7] did not show side effects . In this study we did not consider mild sedation as a side effect, which could explain the findings of Singh et al. [7]. Benhamou et al. [8] evaluated the use of clonidine with or without fentanyl when used along with hyperbaric bupivacaine in elective cesarean section. They observed subsequent improvement in spinal block and postoperative analgesia when clonidine was used with fentanyl, although with increased sedation and pruritus [8]. Bajwa et al. [9] demonstrated a reduction in the local anesthetic requirement when using clonidine with epidural ropivacaine for elective cesarean section, with increased incidence of dry mouth. Lavand’homme et al. [10] showed an antihyperalgesic effect when adding clonidine to intrathecal bupivacaine and sufentanil mixture in elective cesarean section; however, Bollag et al. [11] failed to show this effect when clonidine was used in TAP block for postoperative analgesia in elective cesarean section despite improved analgesic effect. Sachan et al. [12] showed better analgesia when using sequential clonidine and hyperbaric bupivacaine compared with using a mixture of both. Li et al. [13] used both dexmedetomidine and clonidine with comparable results and no significant side effects.

Carvalho et al. [14] did not find any benefit from adding clonidine to intrathecal morphine and hyperbaric bupivacaine; however, Bragal et al. [15] showed adequate analgesia with the same combination. They showed more perioperative sedation and longer time to motor block recovery when adding clonidine to hyperbaric bupivacaine [16].


  Conclusion Top


Use of intrathecal clonidine for cesarean section results in better sensory blockade and early recovery of motor blockade as compared with intrathecal fentanyl, with significantly more sedation in the clonidine group and fewer requests for supplementary analgesia in the postoperative period. There was a lower incidence of nausea, vomiting, and itching in the clonidine group than in the fentanyl group. Further studies are needed to show the effects of adding both fentanyl and clonidine to hyperbaric bupivacaine 0.5% to improve the efficacy of spinal analgesia and the effects of dose response of intrathecal clonidine and fentanyl.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflict of interest.

 
  References Top

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Bollag L, Richebe P, Siaulys M, Ortner CM, Gofeld M, Landau R. Effect of transversus abdominis plane block with and without clonidine on post-cesarean delivery wound hyperalgesia and pain. Reg Anesth Pain Med 2012; 37:508–514.  Back to cited text no. 11
    
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