title: Subarachnoid anaesthesia in caesarean delivery: effects on alertness.
abstract: OBJECTIVE
  Subjects in spinal anaesthesia have been reported to show a decrease in the level of alertness, even when they have not received any sedative drugs.
  
  
  OBJECTIVE
  of this study is to verify, in caesarean delivery if the bupivacaine subarachnoid anaesthesia, with or without intrathecal fentanyl dose, produces a sedative effect, to define the entity and to identify the mechanism that most likely causes it.
  
  
  METHODS
  The clinical investigation is divided into Part I (non-randomized trial) and Part II (randomized trial) and is set in the University hospital's delivery-unit. Part I: 45 pregnant women were recruited and enrolled in 3 groups: women having natural delivery (n=15), women receiving caesarean delivery with subarachnoid anaesthesia (n=15) and with general anaesthesia (n=15). Self-rating depression scale (SDS), self-rating anxiety scale (SAS), state anxiety inventory (SAI) and trait anxiety inventory (TAI) psychometric tests were patient-completed for pre-delivery anxiety evaluation. Part II: 23 pregnant women undergoing caesarean delivery were single-blind randomized to receive subarachnoid anaesthesia with single 12.75 mg 0.5% hyperbaric bupivacaine (n=10) or with 12.75 microg 0.5% hyperbaric bupivacaine and 15 mg fentanyl (n=13). Bispectral index (BIS), observer's assessment of alertness/sedation (OAA/S) scale, self-sedation visual analogic scale (VAS) and mean arterial pressure (MAP) were perioperatively monitored.
  
  
  RESULTS
  Part I: it was found, using SAI, a higher level of state anxiety in the pregnant women undergoing caesarean delivery than those having natural delivery (p<0.05). Part II: pregnant women receiving subarachnoid anaesthesia for caesarean delivery had a decrease of the level of alertness from 10 to 70 min after the execution of lumbar puncture (p<0.05), with a sedative peak from 35 to 45 min (p<0.01), as measured by OAA/S scale and self-sedation VAS but not by BIS. Women who received bupivacaine-fentanyl spinal anaesthesia had a more consistent sedative effect from 35 to 70 min (p<0.05).
  
  
  CONCLUSIONS
  Pregnant women undergoing caesarean delivery had a more elevated level of state anxiety, assessed by SAI, as seen in Part I. Subarachnoid anaesthesia in caesarean delivery is associated with a reduction of alertness level. A double mechanism might cause a clinically valuable sedative effect, observed by OAA/S scale and self-sedation VAS: decrease of the afferent spinal inputs and an anxiolytic psychophysiologic effect, induced by good outcome of the birth and mother-baby contact. Intrathecal bupivacaine-fentanyl dose produces a larger alertness decrease than single bupivacaine, because the anaesthetic block density increases. BIS was not a sensitive measure to detect the light sedation occurring in Part II of this study.
authors.affiliation: Operative Unit of Anesthesia and Resuscitation II, Polyclinic Hospital, Bari, Italy. massimo.marucci@tin.it
authors.forename: M
authors.initials: M
authors.lastname: Marucci
authors.forename: C
authors.initials: C
authors.lastname: Diele
authors.forename: F
authors.initials: F
authors.lastname: Bruno
authors.forename: T
authors.initials: T
authors.lastname: Fiore
mesh_terms: D000328:Adult; D000701:Analgesics, Opioid / Q000008:administration & dosage*; D000773:Anesthesia, Obstetrical; D000775:Anesthesia, Spinal; D000779:Anesthetics, Local / Q000008:administration & dosage*; D001007:Anxiety / Q000517:prevention & control; D002045:Bupivacaine / Q000008:administration & dosage*; D002585:Cesarean Section; D016292:Procedural Sedation; D005260:Female; D005283:Fentanyl / Q000008:administration & dosage*; D006801:Humans; D011247:Pregnancy
chemical_list: D000701:Analgesics, Opioid; D000779:Anesthetics, Local; D005283:Fentanyl; D002045:Bupivacaine