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Randomized Controlled Trial Comparative Study
Hyperbaric prilocaine vs. hyperbaric bupivacaine for spinal anaesthesia in women undergoing elective caesarean section: a comparative randomised double-blind study.
For women undergoing elective caesarean section, intrathecal hyperbaric prilocaine results in significantly shorter motor block than hyperbaric bupivacaine, with no difference in maternal hypotension, pain or satisfaction.
pearl- K Chapron, J-C Sleth, X Capdevila, S Bringuier, and C Dadure.
- Department of Paediatric and Gynaecology Anaesthesia, Lapeyronie University Hospital, CHU Montpellier, University of Montpellier, Montpellier, France.
- Anaesthesia. 2021 Jun 1; 76 (6): 777-784.
AbstractHyperbaric bupivacaine spinal anaesthesia remains the gold standard for elective caesarean section, but the resultant clinical effects can be unpredictable. Hyperbaric prilocaine induces shorter motor block but has not previously been studied in the obstetric spinal anaesthesia setting. We aimed to compare duration of motor block after spinal anaesthesia with prilocaine or bupivacaine during elective caesarean section. In this prospective randomised, double-blind study, women with uncomplicated pregnancy undergoing elective caesarean section were eligible for inclusion. Exclusion criteria included: patients aged < 18 years; height < 155 cm or > 175 cm; a desire to breastfeed; or a contra-indication to spinal anaesthesia. Patients were randomly allocated to two groups: the prilocaine group underwent spinal anaesthesia with 60 mg intrathecal prilocaine; and the bupivacaine group received 12.5 mg intrathecal heavy bupivacaine. Both 2.5 µg sufentanil and 100 µg morphine were added to the local anaesthetic agent in both groups. The primary outcome was duration of motor block, which was assessed every 15 min after arriving in the post-anaesthetic care unit. Maternal haemodynamics, APGAR scores, pain scores, patient satisfaction and side-effects were recorded. Fifty patients were included, with 25 randomly allocated to each group. Median (IQR [range]) motor block duration was significantly shorter in the prilocaine group, 158 (125-188 [95-249]) vs. 220 (189-250 [89-302]) min, p < 0.001. Median length of stay in the post-anaesthetic care unit was significantly shorter in the prilocaine group, 135 (120-180 [120-230]) vs. 180 (150-195 [120-240]) min, p = 0.009. There was no difference between groups for: maternal intra-operative hypotension; APGAR score; umbilical cord blood pH; maternal postoperative pain; and patients' or obstetricians' satisfaction. We conclude that hyperbaric prilocaine induces a shorter and more reliable motor block than hyperbaric bupivacaine for women with uncomplicated pregnancy undergoing elective caesarean section.© 2021 Association of Anaesthetists.
Notes
Although interesting and perhaps relevant to settings which require motor block resolution before discharge from PACU (or when there are bupivacaine shortages), the practical relevance of this study is questionable.
Notable in this French study is the extended duration of PACU stay after caesarean section: more than 2 hours in the prilocaine group, and 3 hours in the bupivcaine group! It is unclear whether this is routine post-CS care, or specific to the study design to allow for motor block assessment.
Also of note, the caesarean sections were "...performed using Misgav-Ladach technique with externalisation of the uterus" which may again make this study less relevant in settings where it is routinely accepted that avoiding uterine externalisation makes for better patient experience.
Daniel Jolley
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