British Journal of Anaesthesia 1996; 77: 145–149
Spinal anaesthesia with 0.25 % hyperbaric bupivacaine for
Caesarean section: effects of volume
C. J. CHUNG, S. H. BAE, K. Y. CHAE AND Y. J. CHIN
Summary
To investigate the safety and efficacy of 0.25 %
hyperbaric bupivacaine for spinal anaesthesia in
Caesarean section, we studied 60 parturients allocated randomly to one of three groups. According
to the patient’s height, groups 1, 2 and 3 received
3.2–3.6 ml (8–9 mg), 3.6–4.0 ml (9–10 mg) and
4.0–4.4 ml (10–11 mg) of 0.25 % bupivacaine in
5 % glucose, respectively. Subarachnoid injection
was performed in the right lateral decubitus position, and parturients were then turned immediately
supine with left uterine displacement. Mean spread
of sensory analgesia was significantly higher in
group 3 (T2–3) than in groups 1 and 2 (T4–5 in
each group). Duration of sensory analgesia was
significantly longer in groups 2 and 3 than in group
1. Complete motor block of the lower extremities
occurred in all patients but in only one in group 1.
Onset time and duration of motor block were not
significantly different between the three groups.
The incidence of hypotension was significantly
higher in group 3 (75 %) than in groups 1 and 2
(40 % in each group). The efficacy of intraoperative
analgesia was significantly greater in groups 2 and
3 than in group 1. The incidence of patients
requiring analgesics during operation was significantly lower in groups 2 (25 %) and 3 (10 %) than in
group 1 (70 %). There was no difference in neonatal
condition between the three groups. Spinal anaesthesia with 3.6–4.0 ml of 0.25 % bupivacaine in
5 % glucose was satisfactory for Caesarean section.
(Br. J. Anaesth. 1996; 77: 145–149)
Key words
Anaesthetics local, bupivacaine. Anaesthetic techniques, subarachnoid. Anaesthesia, obstetric.
Amylocaine is a drug used frequently for spinal
anaesthesia in Caesarean section. However, this
agent often fails to provide good maternal sensory
block [1, 2]. Recently, bupivacaine has gained popularity in obstetric anaesthesia but 0.5 % plain
bupivacaine has been shown to be unreliable and
produced occasional high block [3, 4]. Therefore,
hyperbaric bupivacaine has been used more often
than plain bupivacaine for spinal anaesthesia in
Caesarean section.
The total dose of bupivacaine is more important
than volume or concentration of anaesthetic solution
in determining spread of anaesthetic solution in the
CSF [5–7]. However, the effect of volume of
hyperbaric spinal anaesthetic solution injected may
be additive to the effects of gravity, position and dose
[8–10]. Almost all parturients given 0.5 % hyperbaric
bupivacaine 7.5–10 mg for spinal anaesthesia in
Caesarean section required supplementary analgesia
because of visceral pain during surgery [11, 12].
When hyperbaric bupivacaine 10–15 mg was used
for spinal anaesthesia in Caesarean section, good
sensory block developed and the incidence of
supplementary analgesia was decreased [2, 12]. However, the volume exceeded 3 ml in those cases. When
0.25 % hyperbaric bupivacaine solution 10–15 mg is
used for spinal anaesthesia in Caesarean section, the
volume reaches 4–6 ml, which may influence spinal
anaesthesia because of easily cephalad spread of local
anaesthetic solution in CSF.
The aim of this investigation was to assess the
safety and efficacy of 0.25 % bupivacaine in 5 %
glucose for spinal anaesthesia in Caesarean section.
Sensory and motor block, haemodynamic changes,
quality of intraoperative analgesia and complications
were compared.
Patients and methods
We studied 60 term parturients, ASA I or II, chosen
to have spinal anaesthesia for elective Caesarean
section. The study was approved by the Hospital
Ethics Committee and written informed consent was
obtained from all patients at the preoperative visit.
Parturients who had obstetric complications or
evidence of fetal compromise were excluded. Hyperbaric bupivacaine solution 0.25 % was made with
the same volume of 0.5 % bupivacaine hydrochloride
(Marcaine, Astra, Sweden) and 10 % glucose monohydrate (Daehan Pharmaceutical Co., Seoul, Korea).
The specific gravity of 0.25 % bupivacaine in 5 %
glucose was 1.022 at 23 ⬚C. Patients were allocated
randomly to one of three groups. Each group had 10
mothers who were 156–160 cm tall and 10 mothers
161–165 cm tall. Group 1 mothers (156–160 cm tall)
were given 3.2 ml of 0.25 % bupivacaine in 5 %
glucose, and those 161–165 cm received 3.6 ml.
CHAN JONG CHUNG*, MD, SEUNG HWAN BAE, MD, KI YOUNG
CHAE, MD, YOUNG JHOON CHIN, MD, Department of Anesthesiology, College of Medicine, Dong-A University, Pusan,
Korea. Accepted for publication: March 13, 1996.
* Address for correspondence: Department of Anaesthesiology,
Dong-A Medical Centre, 1-3 ga Tongdaesin-dong, Seo-gu,
Pusan, 602-103, Korea.
146
In groups 2 and 3, the corresponding bupivacaine
volumes were 3.6 and 4.0 ml, and 4.0 and 4.4 ml,
respectively. All subarachnoid blocks were performed by one anaesthetist and data were collected
by two registrars who were blinded to the solutions
used.
All parturients received ranitidine 10 mg and
glycopyrronium 0.2 mg i.m., 1 h before arrival in the
operating room. All patients received an infusion of
lactated Ringer’s solution 1000 ml over 10–20 min
before induction. They were also given ephedrine
40 mg i.m., approximately 10 min before subarachnoid injection. Subarachnoid injection was
performed in the right lateral decubitus position
with a 25-gauge Quincke spinal needle, using a
midline approach at the L2–3 or L3–4 interspace.
The predetermined volume of local anaesthetic was
injected over 20–30 s without barbotage. After
subarachnoid injection, mothers were immediately
turned supine with left uterine displacement. The
parturient’s head was rested on a pillow.
The spread of sensory block to pinprick was
measured at 2-min intervals during the first 10 min
and then at 5-min intervals. The degree of motor
block of the lower extremities was also assessed at the
same interval, using the modified Bromage scale: 0
no paralysis; 1 unable to raise the extended leg;
2 unable to flex knee; 3 unable to flex ankle.
Maternal arterial pressure and heart rate were
recorded every minute until delivery and every
5 min thereafter, using an automated, non-invasive
device (Sirecust 404, Simens, Germany). If hypotension (systolic arterial pressure less than
100 mm Hg or a 20 % reduction in systolic arterial
pressure) occurred, it was treated promptly by
increasing uterine displacement and the rate of fluid
administration. If hypotension persisted despite
these measures, ephedrine 10 mg was given i.v. and
repeated as needed. Oxygen was administered
routinely by face mask at 6 litre min1 until the end
of operation. When sensory block at or above T6 was
established, surgery were commenced. The incidence and frequency of complications were noted.
The efficacy of intraoperative analgesia was assessed by the following four categories: excellent
no discomfort during the procedure; good mild
discomfort but required no systemic analgesia;
fair pain that required additional analgesia; and
poor moderate or severe pain that needed more
than fentanyl 100 ␮g or general anaesthesia.
When the patient complained of pain, fentanyl
50 ␮g was given i.v. and repeated as needed. I.v.
midazolam 2.5 mg was administered if the patient
requested to sleep after the birth of the baby. I.v.
droperidol 0.625 mg was used to treat nausea or
vomiting. The times of bupivacaine injection, start
of surgery, delivery and termination of surgery were
recorded. The condition of the neonates was assessed
by Apgar score at 1 and 5 min after delivery. All
mothers received oxytocin by continuous infusion
after delivery. Return of sensory and motor function
was assessed at 15-min intervals until complete
recovery from anaesthesia.
All data are expressed as number or mean (SD or
range). The results were analysed using one-way and
British Journal of Anaesthesia
two-way ANOVA followed by Tukey’s test for
parametric data, and the chi-square test with Yates’
correction, the Kruskall-Wallis followed by the
Mann–Whitney U test for non-parametric data. P 0.05 was considered statistically significant.
Results
There were no statistically significant differences in
mean age, weight, height and gestational age between
the three groups (table 1). In four patients in group
1, the spinal was converted to general anaesthesia
10–15 min after delivery of the neonate because
surgical anaesthesia was inadequate. These patients
were excluded from further analysis of sensory and
motor block.
Onset and segmental spread of sensory analgesia
are shown in figure 1. Cephalad spread of sensory
analgesia was increased significantly with an increase
in volume, and the differences between groups 1 and
3 and between groups 2 and 3 were significant. Onset
time of sensory analgesia to T6 was significantly
faster in group 3 than in group 1. The mean maximal
level of analgesia in group 3 (T2–3) was significantly
higher than that in groups 1 and 2 (T4–5 in each),
and the times to achieve the maximal level were
similar, with an average of 10–15 min between the
three groups. Sensory analgesia at or above T6 was
obtained in all patients, but sensory analgesia below
Table 1 Patient characteristics (mean (SD or range))
Group 1
(n 20)
Age (yr)
Height (cm)
Weight (kg)
Gestation (weeks)
Group 2
(n 20)
Group 3
(n 20)
30.0 (23–34) 29.9 (25–35)
29.4 (24–36)
159.5 (2.4)
158.8 (2.2)
160.6 (2.7)
65.0 (8.5)
65.6 (5.9)
68.4 (8.5)
37.8 (0.9)
38.3 (0.8)
37.9 (2.1)
Figure 1 Onset and segmental spread of sensory analgesia after
subarachnoid injection of 0.25 % bupivacaine in 5 % glucose for
term parturients in group 1 (3.2–3.6 ml (●)), group 2
(3.6–4.0 ml (■)) and group 3 (4.0–4.4 ml (▲). *P 0.05 vs
group 1, †P 0.05 vs groups 1 and 2.
Spinal anesthesia for Caesarean section
147
Table 2 Comparison of times of onset and regression of
subarachnoid block (mean (SD)). *P 0.05 vs group 1
Group 1
(n 16)
Sensory block (min)
Time to T6
Time to
maximal level
Regression time
to T10
Regression time
to L5
Motor block (min)
Time to
complete block
Time to
complete
regression
Group 2
(n 20)
7.7 (2.4)
6.9 (1.8)
13.8 (3.2)
12.7 (2.7)
Group 3
(n 20)
5.5 (2.4)*
11.9 (3.0)
85.0 (15.3) 103.0 (14.3)* 108.5 (20.8)*
164.0 (20.3) 185.5 (20.9)* 198.0 (26.8)*
11.6 (3.7)
12.1 (3.2)
122.0 (25.9) 137.3 (24.5)
Table 3 Incision direction and surgical times (mean (SD) or
number). Long/trans Longitudinal/transverse
10.7 (3.7)
Incision direction
Long/trans
Induction to operative
start time (min)
Induction to operative end
time (min)
Uterine incision to
delivery time (s)
T4 was obtained significantly more in group 1 (70 %)
Figure 3 Changes in maternal heart rate during the first
30 min after subarachnoid injection of 0.25 % bupivacaine in
5 % glucose for term parturients in group 1 (3.2–3.6 ml (●)),
group 2 (3.6–4.0 ml (■)) and group 3 (4.0–4.4 ml (▲)).
C Control.
than in groups 2 and 3 (30 % and 10 %, respectively).
Two patients in group 3 had a block up to C6 and
C7, respectively. Total time for regression of sensory
analgesia to T10 and L5 was significantly longer in
groups 2 and 3 than in group 1 (table 2).
Complete motor block of the lower extremities
was obtained in all patients at an average time of
Group 2
(n 20)
Group 3
(n 20)
6/14
7/13
6/14
16.6 (4.5)
16.5 (3.2)
15.9 (3.5)
82.3 (9.3)
84.6 (10.3) 83.2 (8.1)
91.6 (23.2) 78.3 (33.0) 82.5 (26.7)
Table 4 Efficacy of sensory block during surgery (number).
*P 0.05 vs group 1
142.2 (33.3)
Figure 2 Changes in maternal systolic arterial pressure (SAP)
during the first 30 min after subarachnoid injection of 0.25 %
bupivacaine in 5 % glucose for term parturients in group 1
(3.2–3.6 ml (●)), group 2 (3.6–4.0 ml (■)) and group 3
(4.0–4.4 ml (▲)). C Control. *P 0.05 compared with
control value in each group.
Group 1
(n 20)
Category
Group 1
(n 20)
Group 2*
(n 20)
Group 3*
(n 20)
Excellent
Good
Fair
Poor
4
2
9
5
10
5
5
0
16
2
2
0
10–13 min, except for one patient in group 1
(Bromage scale 2). Duration of complete motor block
was longer with an increase in volume, but this was
not statistically significant (table 2).
There were no significant differences in systolic
arterial pressure and heart rate during the first
30 min between the three groups (figs 2, 3). Compared with control preanaesthetic values, systolic
arterial pressure was significantly decreased at 4 min
in groups 1 and 2, and at 4 and 6 min in group 3. The
percentage maximal decreases in systolic arterial
pressure were 16.1 (9.9) %, 17.8 (10.1) % and 25.7
(13.2) % in groups 1, 2 and 3, respectively, recorded
4–6 min after induction of spinal anaesthesia. Hypotension developed in eight of 20 patients in group 1
(40 %), and six required i.v. ephedrine, compared
with eight of 20 patients in group 2 (40 %), and seven
required i.v. ephedrine and 15 of 20 patients in
group 3 (75 %), and 14 required i.v. ephedrine. The
incidence of hypotension and need for ephedrine
were significantly greater in group 3 than in groups
1 and 2.
The various time intervals from induction of
anaesthesia to end of surgery are shown in table 3.
There were no significant differences in these times
between the groups.
No patient in any group complained of discomfort
at incision from skin to the uterus. The efficacy of
intraoperative analgesia was significantly greater in
groups 2 and 3 than in group 1 (table 4). In group 1,
only four patients (20 %) were totally painless; 14
patients (70 %) required supplementary analgesia
40–50 min after induction, four of whom required
general anaesthesia about 10–15 min after delivery.
Five patients in group 2 (25 %) and two in group 3
(10 %) required supplementary analgesia 50–60 min
after induction of spinal anaesthesia.
Neonatal weight and Apgar scores at 1 and 5 min
were similar between the three groups (table 5). The
condition of the neonates was good. Two infants in
group 3 had an Apgar score of 5 and 6, but more than
8 at 5 min.
148
British Journal of Anaesthesia
Table 5 Neonatal status (mean (SD))
Neonatal weight (kg)
Apgar score
1 min
5 min
Group 1
(n 20)
Group 2
(n 20)
Group 3
(n 20)
3.3 (0.3)
3.2 (0.2)
3.4 (0.3)
8.3 (0.5)
9.5 (0.4)
8.4 (0.5)
9.6 (0.3)
8.2 (0.8)
9.4 (0.7)
Table 6 Intraoperative complications (number). † Patients in
whom droperidol was used. *P 0.05 vs groups 1 and 2
Hypotension
Bradycardia
Nausea/vomiting †
Dyspnoea
Transient headache
Group 1
(n 20)
Group 2
(n 20)
Group 3
(n 20)
8
4
2
1
0
8
5
3
2
0
15*
7
6
4
2
The incidences of complications after spinal
anaesthesia are shown in table 6. Complications
occurred more in group 3 than in groups 1 and 2, but
this was not significant.
Discussion
Our data indicated that 0.25 % bupivacaine in 5 %
glucose could be used safely and effectively for spinal
anaesthesia in Caesarean section. Lignocaine, amylocaine and bupivacaine can be used for spinal
anaesthesia in Caesarean section but some mothers
who received amylocaine spinal anaesthesia needed
supplementary analgesia because of intraoperative
visceral pain [1, 2]. Recently, bupivacaine has gained
popularity in obstetric anaesthesia for extradural and
also spinal anaesthesia. Hyperbaric bupivacaine
provided better intraoperative analgesia and produced shorter duration of motor block than hyperbaric amylocaine [2].
Within the range of 7.5–12 mg of 0.5 % hyperbaric
bupivacaine, similar levels of sensory block to T3
occurred, despite the varying doses of drug injected,
but the duration of sensory block was longer with the
large than the small dose. Increasing the dose
increased the intensity of motor block, but the
duration of motor block was similar [11, 12]. In our
study, increasing the dose increased the level and
duration of sensory block, but the intensity and
duration of motor block were similar between the
three groups.
Several reports [5–7] have suggested that the total
dose of bupivacaine is more important than volume
or concentration of anaesthetic solution in determining spread of anaesthetic solution in the CSF.
The relationship between volume of anaesthetic
injected for spinal anaesthesia and final level of block
have not been defined clearly. Baricity determines
primarily the spread of subarachnoid local anaesthetic in the CSF. In recent studies of plain spinal
infusion in pregnancy, final levels of block were
similar with volumes and concentrations ranging
from 3 ml of 0.5 % to 18 ml of 0.083 % plain
bupivacaine [13–15]. However, increasing the vol-
ume administered into the subarachnoid space,
especially in a hyperbaric solution, resulted in
significantly greater cephalad spread [8–10]. The
effect of volume of hyperbaric spinal anaesthetic
solution injected may be additive to the effects of
gravity, position and dose. High volumes of hyperbaric local anaesthetic solution may influence the
spread of local anaesthetic in CSF and final block. In
the clinical dose range (10–15 mg) of 0.5 % or
0.75 % hyperbaric bupivacaine, the volume does not
exceed 3 ml. When 0.25 % hyperbaric bupivacaine
solution is used, the dose of 10–15 mg reaches
3.0–6.0 ml. The large volume itself may influence
the spread of local anaesthetic in CSF and final
block, especially in the narrow subarachnoid space of
term parturients. In our preliminary study with
5–6 ml of 0.25 % bupivacaine in 5 % glucose, sensory
block occurred at the cervical level of dermatome in
a few minutes after subarachnoid injection in all
parturients. Severe hypotension developed and
nausea or vomiting, dyspnoea, and transient headache occurred in all patients.
The one cause limiting the choice of spinal
anaesthesia for Caesarean section is the possibility of
neonatal depression because of severe hypotension
after spinal anaesthesia. Petersen and co-workers
[12] reported incidences of hypotension in patients
given 7.5–10 mg and 10–12.5 mg of 0.5 % hyperbaric
bupivacaine solution of 24 % and 26 %, respectively.
In our study, despite adequate hydration and i.m.
ephedrine before induction of spinal anaesthesia, the
incidence of hypotension in the 4.0–4.4-ml group
(75 %) was significantly greater than in the 3.2–3.6ml and 3.6–4.0-ml groups (40 % in each group). The
percentage maximal decrease in systolic arterial
pressure and the incidence of patients requiring
supplementary ephedrine were significantly greater
in the 4.0–4.4-ml group than in the two other
groups. The condition of the neonates, assessed by
Apgar score, was good and similar in the three
groups. Two neonates in the 4.0–4.4-ml group had
an Apgar score of 5 and 6 at 1 min, respectively, but
the scores at 5 min were more than 8. In these two
neonates, maternal systolic arterial pressure decreased transiently to 70 and 75 mm Hg a few minutes
after induction of spinal anaesthesia. A large volume
of 0.25 % hyperbaric bupivacaine solution could
easily spread in a cephalad direction in CSF and
influence sensory block and also sympathetic block.
Therefore, simply increasing the volume of 0.25 %
hyperbaric bupivacaine solution to increase the
dose must be considered for spinal anaesthesia for
Caesarean section.
It is generally accepted that sensory analgesia to at
least the fourth thoracic dermatome is necessary for
Caesarean section. However, despite seemingly adequate levels of sensory block regardless of the local
anaesthetic used, many parturients required supplementary analgesia during exteriorization of the
uterus and traction on the abdominal viscera [11,
12]. In our study, all parturients experienced a block
at or above T6 in sensory analgesia. Sensory block
above T4 was obtained significantly more often in
the 3.6–4.0-ml and 4.0–4.4-ml groups than in the
3.2–3.6-ml group. No patient complained of dis-
Spinal anesthesia for Caesarean section
comfort at incision from skin to the uterus. Petersen
and co-workers [12] reported that similar spread of
sensory block to above T3 developed in patients who
received 7.5–10 mg and 10–12.5 mg of 0.5 % hyperbaric bupivacaine solution, but the use of a larger
dose of bupivacaine resulted in a lesser frequency of
moderate to severe visceral pain. In our study, the
frequency of visceral pain and requirement for
supplementary opioids were significantly less in the
3.6–4.0-ml and 4.0–4.4-ml groups than in the
3.2–3.6-ml group.
A variety of ways have been tried to improve the
quality of spinal anaesthesia during Caesarean section. Injecting larger doses of local anaesthetic can
improve the quality of sensory block [12, 16]. In
0.25 % hyperbaric bupivacaine solution, increasing
volume to increase the dose is not recommended
because the large volume itself would cause cervical
spinal block and severe hypotension. The addition of
adrenaline [17], morphine [18] or fentanyl [19] to
hyperbaric bupivacaine solution improved the quality of bupivacaine intraoperative analgesia. In our
study with 0.25 % hyperbaric bupivacaine, a larger
dose improved the quality of sensory analgesia, but
the incidence of hypotension and its severity were
greater with volumes exceeding 4.0 ml.
Acknowledgements
This work was supported in part by a grant from Dong-A
University, Korea.
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