The Effect of Gestational Diabetes Mellitus on Sufentanil Consumption After Cesarean Section
The Effect of Gestational Diabetes Mellitus on Sufentanil Consumption After Cesarean Section
Abstract and Introduction
Abstract
Background: Previous research has proven that patients with long-term diabetes require greater opioids after the surgical procedure than patients without diabetes. Gestational diabetes mellitus (GDM) typically only lasts for a short period; nevertheless, its impact on sufentanil intake after the cesarean phase is unknown.
Methods: This prospective cohort study included two groups: a GDM group (n = 32) and a matched non-GDM (NGDM) group (n = 32). All patients underwent routine combined spinal-epidural anesthesia for cesarean delivery. Sufentanil consumption through an intravenous patient-controlled analgesia (PCA) pump, the frequency of PCA requests, and visual analog scale (VAS) score 6 and 24 h after surgery were compared between groups.
Results: Sufentanil consumption (μg) 6 h after surgery was higher in the GDM group than in the NGDM group (24.0 ± 6.6 vs 20.1 ± 5.7, P = 0.023). PCA was used more frequently 6 and 24 h after surgery by the GDM group than by the NGDM group (1[0–2] vs 0[0–1], P = 0.001; 6 [1–5] vs 3 [1,2,6–8], P = 0.001, respectively). The VAS score during activity 24 h after surgery was higher in the GDM group than in the NGDM group (5 [2,3] vs 5 [1,2], respectively, P = 0.03).
Conclusion: Pregnant women with GDM require more opioids during the immediate postoperative period after cesarean section than those without GDM.
Background
Gestational diabetes mellitus (GDM) is defined as high blood glucose caused by impaired glucose tolerance detected and diagnosed during pregnancy. GDM is characterized by elevated fasting blood glucose and impaired glucose tolerance during pregnancy. The reference values used in the oral glucose tolerance test for pregnant women are as follows: fasting, 5.6 mmol/L; 1-h postprandial, 10.3 mmol/L; 2-h postprandial, 8.6 mmol/L; 3-h postprandial, 6.7 mmol/L. GDM is diagnosed when two or more test values reach or exceed the reference values. In most cases, GDM resolves 1 to 2 months after delivery (“transient diabetes“)
GDM is one of the most unusual places where headaches of pregnancy complications, with an occurrence of about three to 7%.
Karci et al. confirmed that the analgesic impact of morphine is negatively affected with excessive blood glucose in patients scheduled for elective total stomach hysterectomy. According to facts on postoperative intravenous patient-managed analgesia (PCA), patients with diabetes require greater opioids than patients without diabetes. Glycated hemoglobin (HbA1c) is an extraordinarily dependable indicator of glycemic control over the preceding eight to twelve weeks. Kim et al. performed a potential observational study and observed that perioperative HbA1c was significantly correlated with postoperative opioid (fentanyl) intake amongst patients with diabetes undergoing open nephrectomy.
A retrospective cohort study performed by Weiner et al., confirmed that general opioid intake all through the 4-month duration following surgical operation turned into accelerated in diabetics with operative ankle fractures. However, the mechanism that underlies this dating is unknown. Chronic excessive blood glucose would possibly affect opioid receptors, thereby changing the pharmacokinetics and pharmacodynamics of opioids.[5] Alternatively, persistent excessive blood glucose would possibly affect a patient’s metabolism or neurotransmitter levels.[10–12]
The sufferers who were previously recognized in research have been recognized with diabetes for at least 60 weeks; however, the direction of gestational diabetes is normally shorter than this, and its affiliation with opioid intake is unclear. Therefore, we performed a potential observational cohort study, have a look wherein we investigated the correlation between gestational diabetes and sufentanil intake throughout the immediate postoperative duration after the cesarean segment. We hypothesized that girls with GDM require greater opioids all through the immediate postoperative duration after cesarean section than those without GDM.
Methods
Participants
The Ethics Committee of the Obstetrics and Gynecology Hospital, Fudan University, accredited this potential, observational cohort study, and it was registered on the Clinical Trials Registry (http://www.chictr.org.cn/, Registration No. ChiCTR1800016014). This study was conducted from June 2018 to October 2018 at the Obstetrics and Gynecology Hospital, Fudan University. Inclusion criterion: pregnant girls, American Society of Anesthesiology (ASA) II with an unmarried fetus scheduled to go through non-obligatory cesarean segment below combined spinal-epidural anesthesia.
Exclusion standards: records of opioid allergies, records of opioid use within the preceding week, contraindications for spinal anesthesia, acknowledged DM or other pregnancy complications (e.g., gestational hypertension, being pregnant complex with hypothyroidism, and preeclampsia). Pregnant girls with GDM who met the above standards had been included in the GDM group. For every pregnant female blanketed withinside the GDM group, a pregnant female without GDM who matched with admire to height ± 2 cm, weight ± 1 kg, and the identical parity became blanketed withinside the non-GDM (NGDM) group (Figure 1). Patients signed a knowledgeable consent record before participation in the study.
Procedure
On the morning of cesarean section, blood was drawn for the size of maternal glucose and HbA1c. Maternal age, height, weight, gestational age, and parity records had been recorded. In addition, the blood glucose control techniques utilized by sufferers withinside the GDM group, which includes weight loss program restrictions, oral medications (and doses), and insulin injections (and doses), had been recorded.
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No remedy was given earlier than the operation. In the running room, an 18-gauge needle was used to puncture a vein in the proper upper arm, and an indwelling catheter was positioned. Blood pressure, electrocardiograms (ECGs), coronary heart rate, and pulse oximetry had been robotically monitored noninvasively. Baseline values had been recorded. At the start of anesthesia, 6% hydroxyethyl starch became infused at 20 mL/min till delivery. The infusion pace was then adjusted by the anesthesiologist consistent with the maternal flow nation till the overall quantity of 500 ml hydroxyethyl starch was infused and changed with Ringer’s lactate solution.
Blended spinal-epidural anesthesia was done on the L3–four or L2–three vertebral interspace with the patient in the left lateral position. An 18-gauge Tuohy needle became positioned within the epidural area and superior till there was lack of resistance to saline; then, a 25-gauge Whitacre spinal needle was inserted via the Tuohy needle till the dura mater became punctured. Next, 8~10 mg bupivacaine became diluted to three ml with cerebrospinal fluid for intrathecal injection, and an epidural catheter (three-four cm) was right now positioned.
The affected person becomes positioned in the supine position, and the working desk is tilted to the left. During the primary 10 min after spinal anesthesia administration, a needle is used to check the sensory block stage every 2 min. The operation started whilst the block stage reached T6. Patients who did not obtain this stage have been excluded from the study, and 1.five% % lidocaine was injected epidurally till anesthesia was achieved. During the operation, the affected person obtained non-stop supplementary oxygen via masks at five L/min. If hypotension passed off (i.e., systolic blood pressure < 90> 20% from baseline), 40 μg of phenylephrine is given intravenously (iv) and repeated as needed; furthermore, the infusion rate of hydroxyethyl starch becomes increased. If sinus bradycardia passes off (coronary heart rate < 50 bpm), 0.2 mg of atropine is given IV, and this is repeated as needed. If an ache passed off after shipping, however, at some point during the operation, it becomes treated with intravenous analgesics.
After the little one becomes added and the umbilical cord has been clamped, 50 mg of flurbiprofen and four mg of ondansetron have been administered intravenously. At the top of the operation, five μg of sufentanil (diluted in saline to five mL) is given through epidural injection, and the epidural catheter is removed. The operative time and blood loss have been recorded.
Procedure
On the morning of cesarean section, the blood was drawn for the size of maternal glucose and HbA1c. Maternal age, height, weight, gestational age, and parity facts have been recorded. In addition, the blood glucose control techniques utilized by sufferers withinside the GDM group, inclusive of eating regimen restrictions, oral medications (and doses), and insulin injections (and doses), have been recorded.
No medicinal drug is given earlier than the operation. In the working room, an 18-gauge needle is used to puncture a vein in the right upper arm, and an indwelling catheter is positioned. Blood pressure, electrocardiograms (ECGs), coronary heart rate, and pulse oximetry have been mechanically monitored noninvasively. Baseline values have been recorded. At the start of anesthesia, 6% hydroxyethyl starch becomes infused at 20 mL/min till shipping. The infusion pace becomes then adjusted through the anesthesiologist consistent with the maternal flow country till the full quantity of 500 ml hydroxyethyl starch has been infused and changed with Ringer’s lactate solution.
Blended spinal-epidural anesthesia was accomplished on the L3–four or L2–three vertebral interspace with the patient in the left lateral position. An 18-gauge Tuohy needle was located within the epidural area and superior till there was lack of resistance to saline; then, a 25-gauge Whitacre spinal needle was inserted via the Tuohy needle till the dura mater was punctured.
Next, 8~10 mg bupivacaine was diluted to a few ml with cerebrospinal fluid for intrathecal injection, and an epidural catheter (three-four cm) was now located. The affected person was located in the supine position, and the running desk was tilted to the left. During the primary 10 min after spinal anesthesia administration, a needle was used to check the sensory block stage each 2 min.
The operation started while the block stage reached T6. Patients who did not gain this stage have been excluded from the study, and 1.five% % lidocaine was injected epidurally till hit anesthesia was achieved. During the operation, the affected person acquired non-stop supplementary oxygen via masks at five L/min. If hypotension came about (i.e., systolic blood pressure < 90> 20% from baseline), 40 μg of phenylephrine was given intravenously (iv) and repeated as needed; furthermore, the infusion rate of hydroxyethyl starch was increased. If sinus bradycardia came about (coronary heart rate < 50 bpm), 0.2 mg of atropine was given IV, and this was repeated as needed. If the ache came about after transport, however, during the operation, it was handled with intravenous analgesics.
After the toddler became brought and the umbilical wire have been clamped, 50 mg of flurbiprofen and four mg of ondansetron had been administered intravenously. At the top of the operation, five μg of sufentanil (diluted in saline to five mL) became given through epidural injection, and the epidural catheter became removed. The operative time and blood loss had been recorded.
After the operation, the affected person was moved to the PACU. When the affected person’s blood pressure and heart rate were regular and the anesthesia stage became T6 or below, an intravenous analgesia pump (Aipeng, Nantong Apon Medical Devices Co., Ltd.) was connected, and the affected person was informed of its right use. The analgesics given through affected person-managed intravenous analgesia (PCIA) protected sufentanil one hundred fifty μg and ondansetron four mg diluted in saline to one hundred fifty mL; the sufentanil concentration became 1 mg/ml. The historical past dose became three mL/h, with a bolus dose of three mL and a lock-out time of 15 min. No different postoperative analgesics had been administered throughout the test period.
The anesthesia nurse, who was inside the room, recorded the usage of the postoperative analgesia pump (sufentanil intake and range of PCA compressions [reflecting maternal need]) in addition to adverse reactions together with nausea, vomiting, and itching. Patients with nausea and vomiting had been given ondansetron (four mg, IV), which was repeated as needed. Moreover, a visible analog scale (VAS, zero cm ~ 10 cm) was used to evaluate all through relaxation and hobby 6 and 24 h after the operation. In addition, the affected person’s pride with the postoperative analgesia became evaluated as 1 (very disappointed), 2 (disappointed), three (neither disappointed nor satisfied), four (satisfied), or five (very satisfied). Patients had been excluded from this take a look at if standard anesthesia or intraoperative intravenous opioids had been used if different medicinal drugs had been administered intraoperatively via the epidural if they underwent hysterectomy because of bleeding or for different reasons if they discontinued the analgesia pump for any reason (e.g., extreme surgical or clinical complications), or if they requested to be withdrawn from the take a look at early.
Statistical Analysis
The number one endpoint became sufentanil intake 6 h after the operation. The secondary endpoints protected sufentanil intake 24 h after the operation, the frequency of PCA press 6 and 24 h after the operation, the VAS score, detrimental reactions all through postoperative analgesia administration, and patient satisfaction with postoperative analgesia.
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