The effects of remifentanil used during cesarean section on oxidative stress markers in correlation with maternal hemodynamics and neonatal outcome: a randomized controlled trial

Kutlesic, Marija S.; Kocic, Gordana; Kutlesic, Ranko M.

doi:10.1016/j.bjane.2019.05.004

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Scientific Articles • Rev. Bras. Anestesiol. 69 (6) • Nov-Dec 2019 • https://doi.org/10.1016/j.bjane.2019.05.004 copy

The effects of remifentanil used during cesarean section on oxidative stress markers in correlation with maternal hemodynamics and neonatal outcome: a randomized controlled trial^☆ ☆ The study was carried out at Clinic of Obstetrics and Gynaecology Department of Anaesthesiology, University Clinical Centre Niš, Serbia.

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Background and objective:

Remifentanil is used to attenuate maternal hemodynamic response to intubation and surgical stress during Induction-Delivery period of cesarean section. The goal was to compare the effects of two remifentanil dosing regimens on oxidative stress level, in correlation with its hemodynamic and neonatal effects.

Methods:

Fifty-one patients, 17 per group, enrolled for elective cesarean section were randomly divided by computer-generated codes into three parallel groups: (A) patients received a 1 µg.kg^-1 remifentanil bolus immediately before induction, followed by 0.15 µg.kg^-1.min^-1 infusion, that was stopped after skin incision; (B) patients received a 1 µg.kg^-1 remifentanil bolus immediately before induction; (C) (control), patients did not receive remifentanil until delivery. Maternal venous blood samples were taken at basal time, at extraction and 30 minutes after the end of operation for spectrophotometrical determination of malondialdehyde and advanced oxidation protein products concentration. The same was conducted for umbilical venous sample.

Results:

Systolic blood pressure and heart rate remained significantly lower in group A compared to B and C during entire Induction-Delivery period (p < 0.001, p = 0.02 after intubation; p = 0.006, p = 0.03 after skin incision; p = 0.029, p = 0.04 after extraction; respectively). Malondialdehyde concentration was lower at time of extraction in maternal blood in group A compared to B and C (p = 0.026). All neonatal Apgar scores were ≥ 8 and umbilical acid-base values within normal range.

Conclusions:

The remifentanil dosing regimen applied in group A significantly attenuated lipid peroxidation and maternal hemodynamic response during entire I-D period, without compromising neonatal outcome.

KEYWORDS
Anesthesia; Obstetrics; Remifentanil; Malondialdechyde; Advanced oxidation protein products

	n	Group A	n	Group B	n	Group C	p ^a a ANOVA. I-D, Induction-Delivery Interval; U-D, Uterine Incision-Delivery.
		Mean ± SD		Mean ± SD		Mean ± SD
Age (years)	17	32.18 ± 4.86	17	30.76 ± 5.54	17	31.18 ± 3.32	0.571
Gestation (weeks)	17	38.94 ± 0.83	17	39.0 ± 1.12	17	39.47 ± 0.94	0.131
Weight (kg)	17	78.59 ± 11.67	17	77.76 ± 9.67	17	73.53 ± 11.3	0.242
I-D interval (min)	17	11.23 ± 1.52	17	10.18 ± 1.67	17	10.35 ± 1.8	0.353
U-D interval (s)	17	58.0 ± 17.28	17	59.47 ± 15.2	17	58.0 ± 21.1	0.871

	Group A		Group B		Group C		p ^a a ANOVA.	Post hoc
	n	Mean ± SD	n	Mean ± SD	n	Mean ± SD
SAP T0	17	131.71 ± 15.25	17	129.59 ± 10.33	17	135.53 ± 9.49	0.781
SAP T1	17	109.76 ± 13.67	17	108.29 ± 13.98	17	116.87 ± 9.61	0.221
SAP T2	17	119.06 ± 16.31	17	122.59 ± 15.94	17	149.13 ± 15.85	<0.001	^c c A vs. C. p < 0.001
SAP T2	17	119.06 ± 16.31	17	122.59 ± 15.94	17	149.13 ± 15.85	<0.001	^d d B vs. C. p < 0.001
SAP T3	17	118.88 ± 15.98	17	124.88 ± 13.68	17	131.33 ± 7.91	0.006	^c c A vs. C. p = 0.006
SAP T4	17	117.0 ± 14.15	17	126.41 ± 9.43	17	125.60 ± 5.11	0.02	^b b A vs. B. p = 0.029
SAP T5	17	128.47 ± 8.35	17	123.47 ± 8.47	17	126.82 ± 6.85	0.355	^c c A vs. C. p = 0.016

	Group A		Group B		Group C		p ^a a ANOVA.	Post hoc
	n	Mean ± SD	n	Mean ± SD	n	Mean ± SD
HR T0	17	101.12 ± 15.0	17	100.06 ± 13.29	17	98.18 ± 14.9	0.699
HR T1	17	96.47 ± 10.19	17	96.29 ± 9.82	17	102.87 ± 11.05	0.367
HR T2	17	101.53 ± 8.49	17	100.88 ± 8.51	17	108.20 ± 9.70	0.02	^c c A vs. C. p = 0.027
HR T2	17	101.53 ± 8.49	17	100.88 ± 8.51	17	108.20 ± 9.70	0.02	^d d B vs. C. p = 0.017
HR T3	17	99.06 ± 15.19	17	103.82 ± 12.53	17	109.33 ± 12.79	0.03	^c c A vs. C. p = 0.031
HR T4	17	92.24 ± 13.85	17	100.32 ± 16.34	17	101.67 ± 12.21	0.04	^b b A vs. B. p = 0.040
HR T5	17	81.06 ± 11.7	17	76.82 ± 9.22	17	80.88 ± 8.92	0.455	^c c A vs. C. p = 0.032

	Group A		Group B		Group C		p
	n	Mean ± SD	n	Mean ± SD	n	Mean ± SD
Ap¹	17	8.71 ± 0.47	17	8.76 ± 0.41	17	8.59 ± 0.51	0.493^b b χKW2, Kruskal-Wallis test. Ap1, Apgar score in 1st minute; Ap5, Apgar score in 5th minute; PCO2, CO2 partial pressure; PO2, O2 partial pressure; BD, base deficit.
Ap⁵	17	8.94 ± 0.24	17	8.88 ± 0.33	17	8.88 ± 0.33	0.706^b b χKW2, Kruskal-Wallis test. Ap1, Apgar score in 1st minute; Ap5, Apgar score in 5th minute; PCO2, CO2 partial pressure; PO2, O2 partial pressure; BD, base deficit.
Venous pH	17	7.30 ± 0.02	17	7.32 ± 0.03	17	7.32 ± 0.03	0.144^b b χKW2, Kruskal-Wallis test. Ap1, Apgar score in 1st minute; Ap5, Apgar score in 5th minute; PCO2, CO2 partial pressure; PO2, O2 partial pressure; BD, base deficit.
Venous PCO₂ (mmHg)	17	39.46 ± 3.49	17	38.29 ± 5.21	17	37.0 ± 4.03	0.068^b b χKW2, Kruskal-Wallis test. Ap1, Apgar score in 1st minute; Ap5, Apgar score in 5th minute; PCO2, CO2 partial pressure; PO2, O2 partial pressure; BD, base deficit.
Venous PO₂ (mmHg)	17	35.01 ± 7.43	17	36.12 ± 9.59	17	31.49 ± 5.99	0.317^a a ANOVA.
Venous BD (mmoL.L^-1)	17	4.49 ± 1.25	17	4.49 ± 1.65	17	4.88 ± 1.33	0.616^a a ANOVA.
Venous lactate (mmoL.L^-1)	17	1.33 ± 0.18	17	1.35 ± 0.25	17	1.22 ± 0.18	0.338^a a ANOVA.
Arterial pH	17	7.27 ± 0.02	17	7.28 ± 0.03	17	7.28 ± 0.03	0.312^b b χKW2, Kruskal-Wallis test. Ap1, Apgar score in 1st minute; Ap5, Apgar score in 5th minute; PCO2, CO2 partial pressure; PO2, O2 partial pressure; BD, base deficit.
Arterial PCO₂ (mmHg)	17	48.58 ± 5.16	17	50.61 ± 6.08	17	48.26 ± 4.31	0.455^a a ANOVA.
Arterial PO₂ (mmHg)	17	19.04 ± 2.86	17	19.12 ± 2.64	17	19.38 ± 1.59	0.658^a a ANOVA.
Arterial BD (mmoL.L^-1)	17	4.29 ± 1.55	17	4.22 ± 1.70	17	4.07 ± 0.94	0.762^a a ANOVA.
Arterial lactate (mmoL.L^-1)	17	1.35 ± 0.35	17	1.35 ± 0.34	17	1.39 ± 0.24	0.788^a a ANOVA.

Sample	Malondialdechide (µmoL.L^-1)
	n	Group A	n	Group B	n	Group C	p ^a a ANOVA.
		Mean ± SD		Mean ± SD		Mean ± SD
First	17	1.65 ± 0.86	17	1.91 ± 0.83	17	1.64 ± 0.73	0.762
Second	17	1.30 ± 0.57	17	2.11 ± 0.81	17	2.07 ± 0.85	0.026
Third	17	1.63 ± 0.78	17	1.98 ± 0.96	17	1.59 ± 0.91	0.671
Fourth	17	1.46 ± 0.77	17	1.80 ± 0.53	17	2.58 ± 1.44	0.054

Sample	Advanced oxidation protein products (µmoL.L^-1)						p ^a a χKW2, Kruskal-Wallis test.
	n	Group A	n	Group B	n	Group C
		Mean ± SD		Mean ± SD		Mean ± SD
First	17	58.64 ± 26.22	17	59.34 ± 41.3	17	67.57 ± 49.83	0.318
Second	17	47.02 ± 27.69	17	47.98 ± 26.42	17	71.94 ± 55.53	0.103
Third	17	46.50 ± 30.06	17	40.54 ± 32.13	17	54.13 ± 26.88	0.296
Fourth	17	44.94 ± 28.84	17	51.19 ± 46.19	17	60.20 ± 47.16	0.564

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[1] * Corresponding author. E-mail:mkutlesic5@gmail.com (M.S. Kutlesic).