Neonatal Respiratory Depression and Intrathecal Fentanyl
Objective: To establish the prevalence of neonatal respiratory depression in patients exposed to intrathecal fentanyl during Cesarean section.
Methods: Cross-sectional Analytical Observational Retrospective Study conducted at the Mother and Child Clinic of the Saludcoop Corporation in patients undergoing C-section who received intrathecal fentanyl for regional anesthesia in 2007 and 2008. Primary endpoints: low APGAR score (APGAR<7) and severe APGAR (APGAR<4).
Results: 2165 records of C-sections and intrathecal fentanyl with a mean dose of 19.21mcg (SD=0.206mcg). Prevalence of low APGAR at 1.5 and 10 minutes was 1.77% (SD=0.63%), 0.11% (SD 0.163%), and 0%, respectively. The latter two values were different from the 1-minute value (ANOVA Scheffé Test, p=0.031) and there was no difference between them (minutes 5 and 10) (ANOVA p=0.861). Severely diminished APGAR results were, 0.059% (SD 0.058) 1 minute after birth and 0% at 5 and 10 minutes. There were no statistically significant differences between the three severely diminished values (ANOVA p=0.861).
Conclusions: The prevalence of respiratory depression measured with the APGAR test at birth is low; severely compromised APGAR shows a trend towards 0 in the different minutes of assessment. However, the reliability of the diagnostic tool (APGAR) is questionable, considering discrepancies when the analysis is done with a far more sensitive diagnostic tool (Silverman test).
The importance of this study relates only to the assessment of prevalence and its use as a source of a research hypothesis, and not as an association or prediction study.
2. Littleford J. Effects on the fetus and newborn of maternal analgesia and anesthesia: a review; Obstetrical and Pediatric Anesthesia. Can J Anesth. 2004;51:586-609.
3. Smith CV, Rayburn WF, Allen KV, Bane TM, Livezey GT. Influence of intravenous fentanyl on fetal biophysical parameters during labor. J Matern Fetal Med. 1996;5:89-92.
4. Nikkola EM, Kirjavainen TT, Ekblad UU, Kero PO, Salonen MA. Postnatal adaptation after caesarean section or vaginal delivery, studied with the staticcharge-sensitive bed. Acta Paediatr. 2002;91:927-33.
5. Cowan CM, Kendall JB, Barclay PM, Wilkes RG. Comparison of intratechal fentanyl and diamorphine in addition to bupivacaine for Caesarean section under spinal anesthesia. Br J Anaesth. 2002;89:452-8.
6. Frölich MA, Burchfield DJ, Euliano TY, Caton D. A single dose of fentanyl and midazolam prior to Cesarean section have no adverse neonatal effects. Can J Anesth. 2006;53:79-85.
7. Shende D, Cooper GM, Bowden MI. The influence of intrathecal fentanyl on the characteristics of subarachnoid block for caesarean section. Anaesthesia. 1998;53:702-10.
8. Kelly MC, Carabine UA, Mirakhur RK. Intrathecal for diamorphine for analgesia after caesarean section. Anaesthesia. 1998;53:231-7.
9. Hunt CO, Naulty JS, Bader AM, Hauch MA, Vartikar JV, Datta S, et al. Perioperative analgesia with subarachnoid fentanil-bupivacaine for cesarean delivery. Anesthesiology. 1989;71:535-40.
10. Belzarena SD. Clinical effects of intrathecally administered fentayl in patients undergoing cesarean section. Anesth Analg. 1992;74:653-7.
11. Mardirosoff C, Dumont L, Boulvain M, Tramer MR. Fetal bradycardia due to intrathecal opioids for labour analgesia: a systematic review. BJOG. 2002;109:274-81.
12. American Society of Anesthesiologists Task Force on Neuroaxial Opioids: Terese Horlocker (Chair) et al; Practice Guidelines for the Prevention, Detection, and Management of Respiratory Depression Associated with Neuroaxial Administration. Anesthesiology. 2009;110:218-30.
13. Wong CA, Scavone BM, Peaceman AM, McCarthy RJ, Pharm D, Sullivan JT, et al. The risk of cesarean delivery with neuroaxial analgesia given early versus late in labor. N Engl J Med. 2005;352:655-65.
14. Alvarez S, Perdomo C, Salinas C, Garcia L. Efectos del fentanyl adicionado a Bupivacaína en anestesia peridural para operación cesárea. Rev Colomb Anestesiol. 2002;30: 23-31.