Neonatal effect of remifentanil in general anaesthesia for caesarean section: a randomized trial

Pavlina Noskova, Jan Blaha, Hana Bakhouche, Jana Kubatova, Jitka Ulrichova, Patricia Marusicova, Jan Smisek, Antonin Parizek, Ondrej Slanar, Pavel Michalek, Pavlina Noskova, Jan Blaha, Hana Bakhouche, Jana Kubatova, Jitka Ulrichova, Patricia Marusicova, Jan Smisek, Antonin Parizek, Ondrej Slanar, Pavel Michalek

Abstract

Background: Remifentanil has been suggested for its short duration of action to replace standard opioids for induction of general anaesthesia in caesarean section. While the stabilizing effect of remifentanil on maternal circulation has been confirmed, its effect on postnatal adaptation remains unclear, as currently published studies are not powered sufficiently to detect any clinical effect of remifentanil on the newborn.

Methods: Using a double-blinded randomized design, a total of 151 parturients undergoing caesarean delivery under general anaesthesia were randomized into two groups--76 patients received a bolus of remifentanil prior to induction, while 75 patients were assigned to the control group. Remifentanil 1 μg/kg was administered 30 seconds before the standard induction of general anaesthesia. The primary outcome measure was an assessment of neonatal adaptation using the Apgar score, while secondary outcomes included the need for respiratory support after delivery and differences in umbilical blood gas analysis (Astrup).

Results: The incidence of lower Apgar scores between 0 and 7 was significantly higher in the remifentanil group at one minute (25% vs. 9.3% of newborns, p = 0.017); whilst at five minutes and later no Apgar score differences were observed. There was no difference in the need for moderate (nasal CPAP) or intensive (intubation) respiratory support, but significantly more neonates in the remifentanil group required tactile stimulation for breathing support (21% vs. 7% of newborns, p = 0.017). There was no difference in the parameters from umbilical cord blood gas analysis between the groups.

Conclusion: At a dose of 1 μg/kg, remifentanil prior to induction of general anaesthesia increases the risk of neonatal respiratory depression during first minutes after caesarean delivery but duration of clinical symptoms is short.

Trial registration: ClinicalTrials.gov: NCT01550640.

Keywords: Caesarean delivery; General anaesthesia; Neonatal effect; Remifentanil.

Figures

Figure 1
Figure 1
Assessment, randomization, and follow-up of the study patients.
Figure 2
Figure 2
Bar graph showing the need for management of newborn respiratory depression. The bar graph plots the percentage of newborns requiring each level of respiratory stimulation or support (n = 76 in the remifentanil group and n = 75 in standard group). The black column represents the remifentanil group; the cross-hatched column the control group. *P = 0.017. CPAP = continuous positive airway pressure ventilation.

References

    1. Morishima HO, Pedersen H, Finster M. The influence of maternal psychological stress on the fetus. Am J Obstet Gynecol. 1978;131(3):286–290. doi: 10.1016/0002-9378(78)90602-6.
    1. Vogl SE, Worda C, Egarter C, Bieglmayer C, Szekeres T, Huber J, et al. Mode of delivery is associated with maternal and fetal endocrine stress response. BJOG. 2006;113(4):441–445. doi: 10.1111/j.1471-0528.2006.00865.x.
    1. Tsen L. Anesthesia for cesarean delivery. In: Chestnut D, Polley L, Tsen L, Wong C, editors. Obstetric anesthesia. 4. Philadelphia, PA: Mosby-Elsevier; 2009. pp. 521–574.
    1. Lyons G, Akerman N. Problems with general anaesthesia for caesarean section. Minerva Anestesiol. 2005;71(1–2):27–38.
    1. Bedard JM, Richardson MG, Wissler RN. General anesthesia with remifentanil for cesarean section in a parturient with an acoustic neuroma. Can J Anaesth. 1999;46(6):576–580. doi: 10.1007/BF03013550.
    1. Johannsen EK, Munro AJ. Remifentanil in emergency caesarean section in pre-eclampsia complicated by thrombocytopenia and abnormal liver function. Anaesth Intensive Care. 1999;27(5):527–529.
    1. Johnston AJ, Hall JM, Levy DM. Anaesthesia with remifentanil and rocuronium for caesarean section in a patient with long-QT syndrome and an automatic implantable cardioverter-defibrillator. Int J Obstet Anesth. 2000;9(2):133–136. doi: 10.1054/ijoa.1999.0362.
    1. Manullang TR, Chun K, Egan TD. The use of remifentanil for cesarean section in a parturient with recurrent aortic coarctation. Can J Anaesth. 2000;47(5):454–459. doi: 10.1007/BF03018976.
    1. McCarroll CP, Paxton LD, Elliott P, Wilson DB. Use of remifentanil in a patient with peripartum cardiomyopathy requiring caesarean section. Br J Anaesth. 2001;86(1):135–138. doi: 10.1093/bja/86.1.135.
    1. Orme RM, Grange CS, Ainsworth QP, Grebenik CR. General anaesthesia using remifentanil for caesarean section in parturients with critical aortic stenosis: a series of four cases. Int J Obstet Anesth. 2004;13(3):183–187. doi: 10.1016/j.ijoa.2003.12.008.
    1. Scott H, Bateman C, Price M. The use of remifentanil in general anaesthesia for caesarean section in a patient with mitral valve disease. Anaesthesia. 1998;53(7):695–697. doi: 10.1046/j.1365-2044.1998.490-az0564.x.
    1. Ltd. GG. ULTIVA 1 MG. SPC - Summary of product characteristics. : SUKL. State Institute for Drug Control; 2011.
    1. Egan TD. Pharmacokinetics and pharmacodynamics of remifentanil: an update in the year 2000. Curr Opin Anaesthesiol. 2000;13(4):449–455. doi: 10.1097/00001503-200008000-00009.
    1. Kan RE, Hughes SC, Rosen MA, Kessin C, Preston PG, Lobo EP. Intravenous remifentanil: placental transfer, maternal and neonatal effects. Anesthesiology. 1998;88(6):1467–1474. doi: 10.1097/00000542-199806000-00008.
    1. Ngan Kee WD, Khaw KS, Ma KC, Wong AS, Lee BB, Ng FF. Maternal and neonatal effects of remifentanil at induction of general anesthesia for cesarean delivery: a randomized, double-blind, controlled trial. Anesthesiology. 2006;104(1):14–20. doi: 10.1097/00000542-200601000-00004.
    1. Stourac P, Suchomelova H, Stodulkova M, Huser M, Krikava I, Janku P, et al. Comparison of parturient - controlled remifentanil with epidural bupivacain and sufentanil for labour analgesia: randomised controlled trial. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub. 2014;158(2):227–232.
    1. Heesen M, Klohr S, Hofmann T, Rossaint R, Devroe S, Straube S, et al. Maternal and foetal effects of remifentanil for general anaesthesia in parturients undergoing caesarean section: a systematic review and meta-analysis. Acta Anaesthesiol Scand. 2013;57(1):29–36. doi: 10.1111/j.1399-6576.2012.02723.x.
    1. Yoo KY, Jeong CW, Park BY, Kim SJ, Jeong ST, Shin MH, et al. Effects of remifentanil on cardiovascular and bispectral index responses to endotracheal intubation in severe pre-eclamptic patients undergoing caesarean delivery under general anaesthesia. Br J Anaesth. 2009;102(6):812–819. doi: 10.1093/bja/aep099.
    1. Bouattour L, Ben Amar H, Bouali Y, Kolsi K, Gargouri A, Khemakhem K, et al. Maternal and neonatal effects of remifentanil for general anaesthesia for caesarean delivery. Ann Fr Anesth Reanim. 2007;26(4):299–304. doi: 10.1016/j.annfar.2007.01.005.
    1. Draisci G, Valente A, Suppa E, Frassanito L, Pinto R, Meo F, et al. Remifentanil for cesarean section under general anesthesia: effects on maternal stress hormone secretion and neonatal well-being: a randomized trial. Int J Obstet Anesth. 2008;17(2):130–136. doi: 10.1016/j.ijoa.2008.01.002.
    1. Pechandova K, Buzkova H, Slanar O, Perlik F. Polymorphisms of the MDR1 gene in the Czech population. Folia Biol. 2006;52(6):184–189.
    1. Smith HS. Variations in opioid responsiveness. Pain Physician. 2008;11(2):237–248.
    1. Rossouw JN, Hall D, Harvey J. Time between skin incision and delivery during cesarean. Int J Gynaecol Obstet. 2013;121(1):82–85. doi: 10.1016/j.ijgo.2012.11.008.
    1. Yoo KY, Kang DH, Jeong H, Jeong CW, Choi YY, Lee J. A dose–response study of remifentanil for attenuation of the hypertensive response to laryngoscopy and tracheal intubation in severely preeclamptic women undergoing caesarean delivery under general anaesthesia. Int J Obstet Anesth. 2013;22(1):10–18. doi: 10.1016/j.ijoa.2012.09.010.
    1. Bader AM, Datta S, Arthur GR, Benvenuti E, Courtney M, Hauch M. Maternal and fetal catecholamines and uterine incision-to-delivery interval during elective cesarean. Obstet Gynecol. 1990;75(4):600–603.
    1. Luthra G, Gawade P, Starikov R, Markenson G. Uterine incision-to-delivery interval and perinatal outcomes in transverse versus vertical incisions in preterm cesarean deliveries. J Matern Fetal Neonatal Med. 2013;26(18):1788–1791. doi: 10.3109/14767058.2013.811226.
    1. Doherty DA, Magann EF, Chauhan SP, O’Boyle AL, Busch JM, Morrison JC. Factors affecting caesarean operative time and the effect of operative time on pregnancy outcomes. Aust N Z J Obstet Gynaecol. 2008;48(3):286–291. doi: 10.1111/j.1479-828X.2008.00862.x.
    1. Malin GL, Morris RK, Khan KS. Strength of association between umbilical cord pH and perinatal and long term outcomes: systematic review and meta-analysis. BMJ. 2010;340:c1471. doi: 10.1136/bmj.c1471.
    1. Chin KJ, Yeo SW. A BIS-guided study of sevoflurane requirements for adequate depth of anaesthesia in Caesarean section. Anaesthesia. 2004;59(11):1064–1068. doi: 10.1111/j.1365-2044.2004.03944.x.
    1. Yeo SN, Lo WK. Bispectral index in assessment of adequacy of general anaesthesia for lower segment caesarean section. Anaesth Intensive Care. 2002;30(1):36–40.
    1. Dyer RA. Update on general anaesthesia for caesarean section. South Afr J Anaesth Analg. 2011;17(1):110–112.

Source: PubMed

Sponsorer och medarbetare

Medicinska tillstånd

Läkemedelsinterventioner

3
Prenumerera