الفهرس 
Introduction & Aim of WorkOnly 14 pages are availabe for public view
 |  | from | 127 |  |  |
| | | from | 127 | | |
Abstract
Background: Epidural anesthesia is a safe and inexpensive technique with the advantage of providing surgical anesthesia and prolonged postoperative pain relief. Epidural analgesia is the most commonly used regional technique for normal vaginal delivery, due to its simplicity of execution, relatively fast onset and predictable effects However, in high doses; epidural local anesthetics may produce high levels of sensory and motor block and hypotension. It is particularly important for parturients undergoing normal vaginal delivery, as maternal hypotension causes decreasing maternal cardiac output and uteroplacental blood flow.
The addition of various additives may allow the dose of local anesthetic to be reduced, producing a synergistic effect that enhances analgesia and prolongs the duration of the sensory block without intensifying motor block.
Levobupivacaine produce a sensory and motor block different from that produced by bupivacaine, which is the most popular local anesthetic in parturients undergoing normal vaginal delivery. The aim of this study was to investigate the block characteristics, the clinical efficacy and hemodynamic effects of using different concentrations of levobupivacaine and studying the pharmacokinetic profile of each concentration.
Methods: After approval of College Ethical Committee, 60 parturient with American Society of Anesthesiologists I-II undergoing normal vaginal delivery were enrolled for study with their informed consent. They were randomly divided equally to three Groups each parturient received epidural bolus of 15ML then 10ML/h OF 3 different concentrations of levobupivacaine plus 2mg fentanyl per ML as follow:
• group 1(n = 20): received epidural levobupivacaine 0.25%
• group 2(n = 20) : received epidural levobupivacaine 0.125%
• group 3(n = 20): received epidural levobupivacaine 0.0625%
Sensory and motor block characteristics of the groups were assessed with pinprick, cold swab, VAS score and Bromage scale; observed hemodynamic changes and side-effects were recorded. Blood sampling for pharmacokinetic study. Effects on the neonate were observed by APGAR score at 1 and 5 min.
Results: the time to onset of sensory block was rapid in all groups but was more rapid in group 1 and 2 than group 3 and the duration of analgesia (VAS score ≤ 3) was longer in group 1 of median (115 min) than group 2 of median (105 min) than group 3 of median (95 min). Requirement of postoperative rescue analgesics was less in group1 and 2 than group 3. the VAS score decreased gradually in all groups compared to the baseline score in the first 60 min., but was lower in group 1 than group 2 than group 3, then started to increase gradually till delivery but still lower in group 1 than group 2 than group 3 and lower in group 1 and 2 than their corresponding baseline score, this finding was supported by our finding of peak plasma concentration level of levobupivacaine being higher in group 1 than group 2 than group 3.
The sensory level was nearly the same in the three groups at T10 with slightly higher in group 1 to T9.
There was no motor affection in group 2 and 3 while motor affection occurred in group 1 in the form of bromage 1 recorded in 7 cases(≈ 39%) , three of them delivered by Caesarean section and the other cases of the same group delivered spontaneously.
No hemodynamic side effects were recorded.Neonatal Apgar scores did not differ among the study groups.
Conclusion All regimes were effective in improving the sensory blockade staring from concentration 0.0625%, 0.125% and 0.25%, while we found that the concentration 0.125% is superior to the other two concentrations being better for labour analgesia without motor affection or side effects on the mother or the baby
Adding the fentanyl to the levobupivacaine offered an advantage of rapid onset of sensory block and prolonged duration of sensory block and postoperative analgesia, thus decreasing the doses of rescue analgesia in the postoperative period.
Levobupivacaine pharmacokinetic parameters were dose independent and it seems that levobupivacaine faster clearance and larger distribution volume observed in this study is understandable in the light of pregnancy-induced alterations in human physiology. However, more studies are needed to confirm this.