Publication: Sezaryende Genel ve Epidural Anestezinin Anne Anestezi Konforu ve Yenidoğan Üzerine Etkileri
Abstract
ÖZET Bu çalışma; genel ve epidural anestezinin, sezaryende anne hemodinamiği, oksijen satürasyonu, per ve postoperatif ağn şiddeti, postoperatif analjezik gereksinimi, ilk emzirme süresi, anestezi komplikasyonlan, uterin insizyon- doğum arası süre, bebeğin Apgar ve Nöroadaptif kapasite skorları, umblikal arteriyel kan gazı üzerine etkilerini değerlendirerek karşılaştırmak amacıyla yapıldı. 30 bayan hasta ( ASA I- II ) 15'er kişilik iki gruba ayrıldı. (1. Genel Anestezi Grubu, 2. Epidural Anestezi Grubu). Genel Anestezi Grubu'ndaki hastalara, indüksiyonda 4 mg/kg tiyopental ve 1.5 mg/kg süksinilkolin verilerek entübasyon yapıldı. Bebeğin doğumuna kadar % 50 02, % 50 N20 ve % 0.5 İsofluran verildi. Doğumdan sonra, % 33 02, % 66 N20 ve % 1 konsantrasyonda İsofluran ile anesteziye devam edildi. Epidural Anestezi Grubu'ndaki hastalara, sol yan pozisyonda, L3 - U aralığından 16 no'lu Tuohy iğnesi ile epidural aralığa girilerek, % 0.375'lik 20 mi Bupivakain uygulandı. Blok uygulamasından sonra sırtüstü yatırılıp, duyusal bloğun T4 düzeyine erişmesi beklendi. Operasyon sırasında, bu hastaların ağn şiddetleri ve ek analjezik gereksinimleri değerlendirildi. Tüm olgularda; annenin kalp hızı ( K.A.H. ), sistolik ve diyastolik arter basıncı ( S.A.B. ve D.A.B. ), ortalama arter basıncı ( O.A.B. ), oksijen satürasyonu ( Sa02 ), preoperatif ve postoperatif vizüel analog skala ( V.A.S. ), uterin insizyon - doğum intervali, bebeğini ilk emzirme süresi, ilk analjezik gereksinim süresi, postoperatif analjezik gereksinimleri, anestezi kompiikasyonlannın sıklığı, bebeğin ise; Apgar ve Nöroadaptif kapasite skorları ( N.A.C.S. ), umblikal arteriyel kan gazı değerleri saptanarak, gruplar arası ve grup içi karşılaştırmalar yapıldı. K.A.H. değerleri, Genel Anestezi Grubu'nda insizyon ve operasyon sonunda Epidural Anestezi Grubu'ndan daha yüksekti (p< 0.05 ve p< 0.01). S.A.B. değerleri, insizyon, operasyon sonu ve postoperatif 5. dakikada Genel Anestezi Grubu'nda daha yüksekti (p< 0.01, p< 0.05 ve p< 0.01). D.A.B. değerleri de, insizyon, operasyon sonu ve postoperatif 5. dakikada mGenel Anestezi Grubu'nda daha yüksekti (p< 0.01). O.A.B. değerleri, genel anestezi grubunda insizyon, kordon klemplenmesi, operasyon sonu, postoperatif 5. ve 20. dakikada daha yüksekti (p< 0.01, p< 0.05, p< 0.01, p< 0.001 ve p< 0.05). Sa02 değerleri, Epidural Anestezi Grubu'nda insizyon ve doğumun 15. dakikasında daha düşük bulundu (p< 0.05). V.A.S. değerleri, postoperatif 5., 20. dakika ve 2. saatte Epidural Anestezi Grubu'nda daha düşüktü (p< 0.01, p< 0.001 ve p< 0.05). Grup içinde ise, Epidural Anestezi Grubu'nda, abdominal gerilme ve doğumun 15. dakikası ( uterus eksteriorizasyonu ) safhalarında ağrı şiddeti daha fazlaydı. Uterin insizyon - doğum interval!, her iki grupta benzerdi. Bebeğini ilk emzirme süresi, Epidural Anestezi Grubu'nda daha kısaydı (p< 0.001). Postoperatif ilk analjezik gereksinim süresi, Epidural Anestezi Grubu'nda daha uzun bulundu (p< 0.001). Analjezik gereksinimleri, postoperatif 20. dakika ve 2. saatte Genel Anestezi Grubu'nda daha fazlaydı (p< 0.01). Anestezi komplikasyonlannın görülme sıklığı da, Genel Anestezi Grubu'nda daha fazlaydı. Bebeklerin Apgar skoru değerleri, özellikle 1. dakika skoru Epidural Anestezi Grubu'nda belirgin olarak daha yüksekti (p< 0.001). Bebeklerin N.A.C.S. değerleri, 2. ve 24. saatte Epidural Anestezi Grubu'nda daha yüksek bulundu ( p< 0.001). Bebeklerin kan gazı değerlerinde, umblikal arteriyel pH ve p02 Epidural Anestezi Grubu'nda daha yüksekti (p< 0.05 ve p< 0.001). Sonuç olarak; anne açısından, aspirasyon ve entübasyon güçlüğü riskinin ortadan kalkması, cerrahiye metabolik-endokrin yanıtın kontrolü, hemodinamik stabilitenin sağlanması, anestezi komplikasyonlannın azlığı, postoperatif analjezi, doğum anını yaşamaya bağlı hasta memnuniyeti, bebeğini erken emzirebilmesi gibi konfor ve avantajları ile, yenidoğan açısından ise APGAR, N.A.C.S.'ları ve asid-baz dengesinin daha iyi olması gibi nedenlerden dolayı, elektif sezaryen operasyonlarında, epidural anestezinin genel anesteziye tercih edilebileceği kanısına varıldı. Anahtar sözcükler : Sezaryen, epidural anestezi, genel anestezi IV
ABSTRACT This study was designed to compare the effects of epidural and general anesthesia at cesarean section. For this aim maternal hemodinamic parameters, oxygen saturation, perioperative and postoperative pain intensities, postoperative analgesic requirement, first breastfeeding time, complications of anesthesia, uterine incision-to- delivery interval, APGAR scores and neuroadaptive capacity scores of neonate, umbilical cord blood gases were evaluated. Thirty healty parturients undergoing elective cesarean section ( ASA 1-1 1 ) were divided into two groups ( Groupl: General anesthesia group, Group 2: Epidural anesthesia Group) each included fifteen patients. Anesthesia was induced with thiopental 4 mg/kg, succinylcholine 1.5 mg/kg in the general anesthesia group. After tracheal intubation, anesthesia was maintained 50% 02 + 50% N20 + 0.5% İsoflorane mixture up to the delivery of the fetus. After the delivery anesthesia was maintained by 33% 02 + 66% N20 + 1% İsoflorane. In the lateral decubitis position with a 16 G Tuohy needle, 20 ml bupivacaine was injected to the L3-U epidural space of the patients which were in epidural anesthesia group. After the injection of anesthetic the patient was placed into supine position till to T4 epidural sensory block level achived. The pain intensity and the analgesic requirement of these patients were recorded. Heart rate (HR), systolic and diastolic arterial pressures ( SAP and DAP), mean arterial pressure (MAP), peripheric oxygen saturation ( Sa02 ), preoperative and postoperative Visuel analog scale (VAS), uterine incision-to-delivery interval, first breastfeeding time, first analgesic requirement time, frequency of anesthetic complications of all patients were recorded. APGAR score and neuroadaptive capacity score (NACS) and umbilical cord blood gases of neonates were recorded. The results were compared in groups and into groups by statistical methods.Heart rates at incision and at the end of the operation were high in general anesthesia group than the epidural anesthesia group (p<0.05 and p<0.01 respectively). SAP measurements at incision, at the end of the operation and at the postoperative fifth minute were higher in the general anesthesia group (p<0.01, p<0.05 and p<0.01 respectively). DAP measurements at incision, at the end of the operation and at the postoperative fifth minute were higher in the general anesthesia group (p<0.01). MAP measurements at incision, at the time of umbilical cord clemping, at the end of operation, at the postoperative fifth and twentieth minutes were higher in the general anesthesia group (p<0.01, p<0.05, p<0.01, p<0.001 and p<0.05 respectively). Sa02 values at incision, at fifteenth minute of delivery were lower in the epidural anesthesia group (p<0.05). VAS values at the postoperatif fifth and twentieth minutes and second hour were lower in the epidural anesthesia group (p<0.01, p<0.001, p<0.05 respectively). As for the comparison of in groups, the intensity of pain at traction on the abdominal viscera and fifteenth minute of delivery ( exteriorisation of uterus) was higher in epidural anesthesia group. Uterine incision-to-delivery interval was not significant statistically between groups. First breastfeeding time was shorter in the epidural anesthesia group than the general anesthesia group (p<0.001). Postoperative first analgesic requirement time was longer in the epidural anesthesia group than the general anesthesia group(p<0.001). The amount of analgesic requirements at postoperative twentieth minute and second hour were much in the general anesthesia group (p<0.01). The frequency of anesthetic complications in general anesthesia was higher. APGAR scores of neonates were higher in the epidural anesthesia group particulary at first minutes than the general anesthesia group (p<0.001). NACS at second and twentyfourth hours were higher in the epidural anesthesia group(p<0.001). According to blood gases of umbilical artery, the arterial pH and p02 were higher in the epidural anesthesia group(p<0.05 and p<0.001 respectively). f â VI 'M «s Kî SIn conclusion, we determined that epidural anesthesia was superior to general anesthesia for cesarean section by reducing the risks of aspiration and difficulties in tracheal entubation, controlling the metabolic and endocrine response to surgery, providing hemodynamic stability and postoperative analgesia, reducing anesthesia complications, satisfaction in mother who had been conscious during the birth of child, shorter the time of first breastfeeding. And also epidural anesthesia was superior to general anesthesia because the APGAR and the NACS scores of neonate are better in this group. Key words; Cesarean section, epidural anesthesia, general anesthesia. vn
ABSTRACT This study was designed to compare the effects of epidural and general anesthesia at cesarean section. For this aim maternal hemodinamic parameters, oxygen saturation, perioperative and postoperative pain intensities, postoperative analgesic requirement, first breastfeeding time, complications of anesthesia, uterine incision-to- delivery interval, APGAR scores and neuroadaptive capacity scores of neonate, umbilical cord blood gases were evaluated. Thirty healty parturients undergoing elective cesarean section ( ASA 1-1 1 ) were divided into two groups ( Groupl: General anesthesia group, Group 2: Epidural anesthesia Group) each included fifteen patients. Anesthesia was induced with thiopental 4 mg/kg, succinylcholine 1.5 mg/kg in the general anesthesia group. After tracheal intubation, anesthesia was maintained 50% 02 + 50% N20 + 0.5% İsoflorane mixture up to the delivery of the fetus. After the delivery anesthesia was maintained by 33% 02 + 66% N20 + 1% İsoflorane. In the lateral decubitis position with a 16 G Tuohy needle, 20 ml bupivacaine was injected to the L3-U epidural space of the patients which were in epidural anesthesia group. After the injection of anesthetic the patient was placed into supine position till to T4 epidural sensory block level achived. The pain intensity and the analgesic requirement of these patients were recorded. Heart rate (HR), systolic and diastolic arterial pressures ( SAP and DAP), mean arterial pressure (MAP), peripheric oxygen saturation ( Sa02 ), preoperative and postoperative Visuel analog scale (VAS), uterine incision-to-delivery interval, first breastfeeding time, first analgesic requirement time, frequency of anesthetic complications of all patients were recorded. APGAR score and neuroadaptive capacity score (NACS) and umbilical cord blood gases of neonates were recorded. The results were compared in groups and into groups by statistical methods.Heart rates at incision and at the end of the operation were high in general anesthesia group than the epidural anesthesia group (p<0.05 and p<0.01 respectively). SAP measurements at incision, at the end of the operation and at the postoperative fifth minute were higher in the general anesthesia group (p<0.01, p<0.05 and p<0.01 respectively). DAP measurements at incision, at the end of the operation and at the postoperative fifth minute were higher in the general anesthesia group (p<0.01). MAP measurements at incision, at the time of umbilical cord clemping, at the end of operation, at the postoperative fifth and twentieth minutes were higher in the general anesthesia group (p<0.01, p<0.05, p<0.01, p<0.001 and p<0.05 respectively). Sa02 values at incision, at fifteenth minute of delivery were lower in the epidural anesthesia group (p<0.05). VAS values at the postoperatif fifth and twentieth minutes and second hour were lower in the epidural anesthesia group (p<0.01, p<0.001, p<0.05 respectively). As for the comparison of in groups, the intensity of pain at traction on the abdominal viscera and fifteenth minute of delivery ( exteriorisation of uterus) was higher in epidural anesthesia group. Uterine incision-to-delivery interval was not significant statistically between groups. First breastfeeding time was shorter in the epidural anesthesia group than the general anesthesia group (p<0.001). Postoperative first analgesic requirement time was longer in the epidural anesthesia group than the general anesthesia group(p<0.001). The amount of analgesic requirements at postoperative twentieth minute and second hour were much in the general anesthesia group (p<0.01). The frequency of anesthetic complications in general anesthesia was higher. APGAR scores of neonates were higher in the epidural anesthesia group particulary at first minutes than the general anesthesia group (p<0.001). NACS at second and twentyfourth hours were higher in the epidural anesthesia group(p<0.001). According to blood gases of umbilical artery, the arterial pH and p02 were higher in the epidural anesthesia group(p<0.05 and p<0.001 respectively). f â VI 'M «s Kî SIn conclusion, we determined that epidural anesthesia was superior to general anesthesia for cesarean section by reducing the risks of aspiration and difficulties in tracheal entubation, controlling the metabolic and endocrine response to surgery, providing hemodynamic stability and postoperative analgesia, reducing anesthesia complications, satisfaction in mother who had been conscious during the birth of child, shorter the time of first breastfeeding. And also epidural anesthesia was superior to general anesthesia because the APGAR and the NACS scores of neonate are better in this group. Key words; Cesarean section, epidural anesthesia, general anesthesia. vn
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