The Effect of Gestational Diabetes Mellitus on Sufentanil Consumption After Cesarean Section

Abstract and Introduction

Abstract

Background: Previous research has proven that sufferers with long-time period diabetes require greater opioids after the surgical procedure than sufferers without diabetes. Gestational diabetes mellitus (GDM) typically handiest 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 maximum not unusual place headaches of pregnancy, with an occurrence of about three to 7%.
Karci et al. confirmed that the analgesic impact of morphine is negatively laid low with excessive blood glucose in sufferers scheduled for optional overall stomach hysterectomy. According to facts on postoperative intravenous patient-managed analgesia (PCA), sufferers with diabetes require greater opioids than sufferers without diabetes. Glycated hemoglobin (HbA1c) is an extraordinarily dependable indicator of glycemic manipulate over the preceding eight to twelve weeks. Kim et al. performed a potential observational take a look at and observed that perioperative HbA1c changed into definitely correlated with postoperative opioid (fentanyl) intake amongst sufferers with diabetes present process open nephrectomy.

A retrospective cohort has a look performed through 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.[4] 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[9] or neurotransmitter levels.[10–12]

The sufferers blanketed in preceding research have been recognized with diabetes for at least 60 weeks;[3] 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 have a look wherein we investigated the correlation between gestational diabetes and sufentanil intake all through the on-the-spot postoperative duration after the cesarean segment. We hypothesized that girls with GDM require greater opioids all through the on-the-spot postoperative duration after cesarean segment than the ones without GDM.

Methods

Participants

The Ethics Committee of the Obstetrics and Gynecology Hospital, Fudan University, accredited this potential, observational cohort have a look at, and it turned into registered on the Clinical Trials Registry (http://www.chictr.org.cn/, Registration No. ChiCTR1800016014). This has a look at turned into performed among June 2018 and October 2018 on 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 blended spinal-epidural anesthesia.

Exclusion standards: records of opioid allergies, records of opioid use withinside the preceding week, contraindications for spinal anesthesia, acknowledged DM or different being pregnant complications (e.g., gestational hypertension, being pregnant complex with hypothyroidism, and preeclampsia). Pregnant girls with GDM who met the above standards had been blanketed withinside 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 previous to participation withinside the study.

Procedure

On the morning of cesarean section, blood became 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 became given earlier than the operation. In the running room, an 18-gauge needle became used to puncture a vein withinside the proper higher arm, and an indwelling catheter became 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 became then adjusted via way of means of 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 became done on the L3–four or L2–three vertebral interspace with the affected person withinside the left lateral position. An 18-gauge Tuohy needle became positioned withinside the epidural area and superior till there has been lack of resistance to saline; then, a 25-gauge Whitacre spinal needle became 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) became right now positioned.

The affected person becomes positioned withinside the supine position, and the working desk becomes tilted to the left. During the primary 10 min after spinal anesthesia administration, a needle becomes used to check the sensory block stage each 2 min. The operation started whilst the block stage reached T6. Patients who did now no longer obtain this stage have been excluded from the study, and 1.five% lidocaine become injected epidurally till hit anesthesia become 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), forty μg of phenylephrine become given intravenously (iv) and repeated as needed; furthermore, the infusion price of hydroxyethyl starch becomes increased. If sinus bradycardia passed off (coronary heart price < 50 bpm), 0.2 mg of atropine becomes given iv, and this becomes repeated as needed. If an ache passed off after shipping however at some point of the operation, it becomes dealt with intravenous analgesics.

After the little one becomes added and the umbilical wire 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) become given thru epidural injection, and the epidural catheter becomes removed. The operative time and blood loss have been recorded.
Procedure

On the morning of cesarean section, the blood becomes 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 becomes given earlier than the operation. In the working room, an 18-gauge needle becomes used to puncture a vein withinside the proper higher arm, and an indwelling catheter becomes positioned. Blood pressure, electrocardiograms (ECGs), coronary heart price, 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 turned into accomplished on the L3–four or L2–three vertebral interspace with the affected person withinside the left lateral position. An 18-gauge Tuohy needle turned into located withinside the epidural area and superior till there has been lack of resistance to saline; then, a 25-gauge Whitacre spinal needle turned into inserted via the Tuohy needle till the dura mater turned into punctured.

Next, 8~10 mg bupivacaine turned into diluted to a few ml with cerebrospinal fluid for intrathecal injection, and an epidural catheter (three-four cm) turned into right now located. The affected person turned into located withinside the supine position, and the running desk turned into tilted to the left. During the primary 10 min after spinal anesthesia administration, a needle was turned into used to check the sensory block stage each 2 min.

The operation started while the block stage reached T6. Patients who did now no longer gain this stage have been excluded from the study, and 1.five% lidocaine turned into injected epidurally till hit anesthesia turned into 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), forty μg of phenylephrine turned into given intravenously (iv) and repeated as needed; furthermore, the infusion price of hydroxyethyl starch turned into increased. If sinus bradycardia came about (coronary heart price < 50 bpm), 0.2 mg of atropine turned into given iv, and this turned into repeated as needed. If ache came about after transport however throughout the operation, it turned into 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 became moved to the submitted anesthesia care unit (PACU). When the affected person’s blood strain and coronary heart charge had been regular and the anesthesia stage became T6 or below, an intravenous analgesia pump (Aipeng, Nantong Apon Medical Devices Co., Ltd.) became connected, and the affected person became informed in 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 awareness 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 all through the take a look at period.

 

The anesthesia nurse concerned with inside the take a look at recorded the usage of the postoperative analgesia pump (sufentanil intake and range of PCA compressions [reflecting maternal need]) in addition to detrimental reactions together with nausea, vomiting, and itching. Patients with nausea and vomiting had been given ondansetron (four mg, iv), which became repeated as needed. Moreover, a visible analog scale (VAS, zero cm ~ 10 cm) became used to evaluate ache 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 affected person pride with postoperative analgesia.

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