Spinal anesthesia is often administered in sectio caesarea. It is an easier and faster anesthetic technique to block the nervous system. Giving spinal anesthesia during sectio caesarea (cesarean section) produces analgesic, anesthetic and motor block effects depending on the volume, concentration and dose of the drug used [1]. Several factors such as the onset and duration of analgesia, the level of sensory block to the level of motor block and cardiovascular toxicity should be considered when selecting drugs for spinal anesthesia. Bupivacaine is the most common drug for spinal anesthesia in patients undergoing cesarean section [2]. Levobupivacaine is an enantiomer of bupivacaine. It is reported that this agent has less cardiotoxic and neurotoxic effects and a shorter duration of the motor block than bupivacaine [3,4]. 

The addition of low-dose opioids to spinal anesthesia in patients undergoing cesarean section can reduce the side effects of spinal anesthesia and improve the quality of intra- and post-operative analgesia by reducing the dose of local anesthetic administered [5].

Fentanyl can be combined with local anesthetics for spinal anesthesia. Fentanyl is known to prolong the duration and spread of sensory blockade well and has been combined with bupivacaine in lower extremity operations, inguanalis hernia and cesarean section [6,7]. 

This study aims to compare the effectiveness of intrathecal Bupivacaine-Fentanyl and Levobupivacaine-Fentanyl in patients undergoing sectio caesarea. The analgesic duration was recorded. Vital signs including blood pressure and pulse, neonatal side effects and patient side effects were recorded.

After obtaining approval from the Research Ethics Committee at the Muhammadiyah Babat Hospital, the researcher recruited 32 patients as the research subjects. This research involved 18-40-year-old patients who underwent elective sectio caesarea and cito with a gestational age of more than 37 weeks and the condition of the American Society of Anesthesiologists (ASA) class I and II. The exclusion criteria were patients who had contraindications to spinal anesthesia, weighed more than 100 kg and were 150 cm tall, had systemic disease and had fetal anomalies, placenta previa and placental abruption.

The research subjects were divided into two groups, namely the Bupivacaine-Fentanyl (BF) group and the Levobupivacaine-Fentanyl (LF) group. Each group consisted of 16 patients who were selected by purposive sampling. BF group received bupivacaine 12.5 mg (2.5 mL) with fentanyl 25 mcg (0.5 mL) and LF group received levobupivacaine 12.5 mg (2.5 mL) with fentanyl 25 mcg (0.5 mL) administered intrathecally.

Prior to spinal anesthesia, a monitor (blood pressure measurement, ECG and pulse oximetry) was installed and an intravenous infusion with an 18 needle was placed. He was given a rapid infusion of 15 cc/kg RL fluid. The patient was in the sitting position. The skin was disinfected. A lumbar puncture was performed at the L3-L4 intervertebral space with a G27 spinal needle. After spinal anesthesia, the patient was changed to the supine position and given oxygen at 4l pm with a facemask. The degree of analgesia was determined by dermatome with a 22G needle prick. Motor block assessment was performed using the Bromage criteria. The onset of motor block was at a Bromage score of 3 and the loss of motor block was at a Bromage score of 2. The neonates were assessed by the APGAR score. The analgesic duration was recorded. Vital signs including blood pressure and pulse, neonatal side effects and patient side effects were recorded.

Prior to analysis, data were entered, edited and tabulated using SPSS version 24. The statistical analysis in this study used unpaired numerical comparative hypothesis tests in 2 groups. Unpaired t-test was used when the data distribution was normal. If the data distribution is not normal, the Mann-Whitney test is used. The normality test of this study used the Shapiro-Wilk test.

After the statistical test was conducted, the p-value of age, height, weight and surgery duration variables was greater than 0.05 (Table 1), so there was no statistically significant difference. 

Table 2 shows that the BF group had a mean analgesic duration of M±SD: 173.75±5.89 minutes. This result was clinically higher than that of the LF group, which was 163.50±19.31 minutes. However, it was found that the p-value was 0.051, indicating no statistically significant difference.

In Table 3, the BF group had a lower mean MAP than the LF group at each measurement time. The lowest mean MAP in the BF group at 10 minutes after spinal anesthesia was M±SD: 72.16±20.76. Meanwhile, the LF group had the lowest mean MAP at 20 minutes (M±SD: 78.76±6.52). Table 3 shows that the MAP value decreases over time and the mean value begins to increase at 20 minutes (BF group) and 40 minutes (LF group).

Table 4 shows that hypotension and bradycardia were more common side effects in the BF group than in the LF group. Other side effects such as headache, back pain, nausea, vomiting and shivering were found to be almost the same in both groups.

Table 1: Characteristics of the Research Population

Expressed as Mean±Standard Deviation

Table 2: Analgesic Duration Between 2 Groups

Expressed as Mean±Standard Deviation

Table 3: Hemodynamic Parameters Between 2 Groups

Data are Expressed as Mean±Standard Deviation

Table 4: Side Effects

Data are Expressed in the Number of Patients (%)

Table 5: Neonatal Effect

Data are Expressed as Mean±Standard Deviation

In Table 5, the effect of neonates in the BF group has the first minute mean APGAR score of 7.75±0.44 and the fifth minute APGAR score of 9.62±0.50. This outcome was clinically higher than that of the LF group (first-minute APGAR score: 7.56±0.51 and fifth-minute: 9.43±0.51). However, both had a p-value of >0.05, so it can be concluded that there is no statistically significant difference.

Spinal anesthesia is often administered in sectio caesarea. Spinal anesthesia has been enhanced by the addition of opioid drugs. Several studies state that the administration of local anesthetic drugs alone in cesarean section surgery with spinal anesthesia is not sufficient to prevent the incidence of nausea and visceral pain during surgery [8]. The addition of morphine as an adjuvant has been reported to significantly prolong the postoperative analgesic effect of 18 to 24 hours. Meanwhile, the more lipophilic opioids, such as fentanyl, enhance and prolong the intraoperative analgesic effect and decrease the need and dose of local anesthetic due to dermatomal spread and the need for a sufficient intensity of blockade for cesarean section. By reducing the intensity and duration of motor blockade, the patient is expected to mobilize more quickly [9]. 

Currently, hyperbaric bupivacaine is the most used drug for spinal anesthesia in cesarean section. However, it has been reported that the use of levobupivacaine as a pure S enantiomer of bupivacaine has lower cardiovascular side effects and central nervous system toxicity [4]. 

Our study compared two groups namely Bupivacaine-Fentanyl (BF group) and Levobupivacaine-Fentanyl (LF group). In accordance with the statistical results on the population characteristics, there was no significant difference in the variables of age, height, weight and surgery duration (p-value >0.05) between the groups.

Our study found that the mean duration of analgesics in the BF group was clinically higher than in the LF group, but there was no statistically significant difference between the groups. Another study reported that intrathecal 0.5% levobupivacaine had a weaker motor block potential than intrathecal 0.5% bupivacaine in cases of elective cesarean section with the Combined Spinal-Epidural (CSE) technique [10]. Meanwhile, Guler et al. compared 2 mL and Subasi et al. compared 1.5 mL of the drug combinations. They found that motor blockade was faster and lasted longer with hyperbaric bupivacaine [11, 12].

The administration of low-dose bupivacaine can also reduce the incidence of hypotension, but it was found that the level of patient satisfaction is less [13]. Levobupivacaine, when compared to bupivacaine, has fewer bradycardia and hypotensive effects [11]. This is in line with our study that hemodynamic stability is better in the LF group than in the BF group. We found that the BF group had a lower mean MAP than the LF group at each measurement time.

Intrathecal administration of opioids has side effects such as nausea, vomiting, itching, respiratory depression and urinary retention [14]. In our study, hypotension and bradycardia were more common side effects in the BF group than in the LF group. The study by Turkmen et al. shows that bupivacaine and levobupivacaine have similar side effects, but both have different hemodynamic effects [15]. 

In our study, there was no significant difference in the APGAR mean scores in both groups. Another study found that the addition of fentanyl and morphine to intrathecal bupivacaine did not have a significant effect on APGAR scores and blood gas analysis scores in newborns at cesarean section [16]. 

The weaknesses in this study include the limited time of sample measurement and the size of the sample. Our relatively small sample size may have influenced the statistical differences in study results. It is recommended that future researchers use a larger sample size coverage, assess other anesthetic parameters and use a more complete level of motor and sensory blockade. This research can be continued with different drug variants or doses.

The combination of levobupivacaine 12.5 mg and fentanyl 25 mcg intrathecally can be a good alternative to the combination of bupivacaine 12.5 mg and fentanyl 25 mcg in sectio caesarea. Both are combinations for spinal anesthesia in sectio caesarea which are effective and have no side effects on neonates.

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