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25]

Original Article

Rapid sequence spinal anesthesia versus general

anesthesia: Aprospective randomized study
of anesthesia to delivery time in category1
caesarean section
Susmita Bhattacharya,
Sarmila Ghosh,
Uddalak Chattopadhya,
Dona Saha, Subrata Bisai,
Mrityunjoy Saha
Department of Anaestehsiology,
Burdwan Medical College, Burdwan,
West Bengal, India
Address for correspondence:
Dr.Susmita Bhattacharya,
Burdwan Medical College, Burdwan,
West Bengal, India.
Email:agamoni_bhat@rediffmail.com
ABSTRACT
Background and Aims: Spinal anesthesia is the preferred technique over general anesthesia
in caesarean section. General anesthesia is still used for category1 emergency caesarean
section because of time constraints. We usually follow rapid sequence general anesthesia in
obstetrics to avoid aspiration. However, this technique poses several problems. An approach
of spinal anesthesia termed as rapid sequence spinal anesthesia has been described. The
present study was designed to compare the time intervals(time for anesthesia, time to surgical
readiness, incision to delivery time, emergence time) and Apgar score between rapid sequence
spinal anesthesia and rapid sequence general anesthesia during category1 caesarean section
and to evaluate whether rapid sequence spinal anesthesia is a better option in category1
caesarean section.
Materials and Methods: In this prospective randomized study, 60patients of American Society
of Anesthesiologists physical status(ASAPS) I posted for category1 emergency caesarean
section were randomly allocated into two equal groups and received either of the two techniques.
Demographic data, respective time intervals, and Apgar scores were noted and compared.
Results: The time for anesthesia, surgical readiness, and emergence were significantly
longer(P<0.001) in rapid sequence general anesthesia group as compared to rapid sequence
spinal anesthesia group(144.803.42 vs 131.203.40 s, 178.764.09 vs 169.933.08 s,
512.1334.33 vs 222.1012.80 s). No significant difference was found in incision to delivery
time and Apgar scores between the two groups.
Conclusion: Because anesthesia to delivery time is shorter in rapid sequence spinal
anesthesia, this technique may be equivalent to rapid sequence general anesthesia in
category1 emergency caesarean section.
Key words: Apgar score, category I caesarean section, rapid sequence spinal anesthesia

INTRODUCTION into Perioperative Deaths are: Category 1immediate threat

to life of the woman or fetus, Category 2maternal or fetal

T ermination of pregnancy by caesarean section (CS) is compromise, not immediately lifethreatening, Category
increasing all over the world.[1] The fourpoint classification 3need early delivery but no maternal or fetal compromise,
of urgency of CS used by the National Confidential Enquiry This is an open access article distributed under the terms of the
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Access this article online License, which allows others to remix, tweak, and build upon the
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Cite this article as: Bhattacharya S, Ghosh S, Chattopadhya U, Saha D, Bisai

DOI: S, Saha M. Rapid sequence spinal anesthesia versus general anesthesia: A
10.4103/2249-4472.191597 prospective randomized study of anesthesia to delivery time in category-1
caesarean section. J Obstet Anaesth Crit Care 2016;6:75-80.

2016 Journal of Obstetric Anaesthesia and Critical Care | Published by Wolters Kluwer - Medknow 75
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Bhattacharya, etal.: Rapid sequence spinal anaesthesia is a suitable alternative for category-1 caesarean section-an observational study
Category 4at a time to suit the woman and maternity team.[2]
Spinal anesthesia (SA) has become the standard technique
in category 2, 3, and 4 as it results in less maternal and
neonatal morbidity than general anesthesia (GA) (GradeA
recommendation, NICE).[3] In category1 CS, rapid sequence
general anesthesia (RSGA) is commonly used because this
technique is faster to perform than SA.[4] However, RSGA is
currently being challenged due to risk of hypoxia, aspiration,
and controversies regarding the technique practiced, choice,
and doses of drugs.[5] If SA can be performed faster, it will
become a more acceptable option in category1 CS. Aspecific
approach of spinal anesthesia called rapid sequence spinal
anesthesia (RSSA) for category1 obstetric cases has been
described.[6] The steps of RSSA include the use of a notouch
technique for spinal needle insertion, simplifying the spinal
drug combination, limiting the permitted time available
for attempts, if necessary starting the surgery before full
establishment of the block and be ready to administer general
anesthesia in the event of a spinal failure.[7] In this study, we
followed these steps and compared RSGA and RSSA regarding
anesthesia time, time to surgical readiness, incision to delivery
time, emergence time, and Apgar score, as well as to evaluate
whether RSSA is a better option in category1 caesarean
sections.
MATERIALS AND METHODS
After obtaining institutional ethics committee approval and
informed written consent from patients, this prospective,
randomized study was performed. Sixty patients of American
Society of Anesthesiologists physical status(ASAPS) I selected
for category1 CS were included and randomly allocated into
two equal groups, 30 in each group. Group A received RSGA and
group B received RSSA. Those with known contraindications to
SA such as maternal coagulopathy, hemodynamic instability,
or having anticipated difficult intubation were excluded from
this study. One experienced anesthesiologist performed either
of the two techniques, and another person not involved in
performing the procedures, recorded the Apgar scores and
the following times: patients arrival at operating room, start of
anesthesia(start of preoxygenation in RSGA or back scrubbing
in RSSA), induction time(confirmation of correct endotracheal
tube placement in RSGA or adequate level of block by assessing
loss of cold sensation in RSSA), skin incision, baby delivery,
completion of surgery, and shifting from the operating room to
the ward. The times were recorded according to the operating
room wall clock. The time intervals[Box1] were defined as
time for anesthesia(from start of anesthesia to the completion
of induction), time for surgical readiness (from arrival at
the operating room to incision), incision to delivery time
(from time of incision to delivery of baby), emergence time
76 Journal of Obstetric Anaesthesia and Critical Care / Jul-Dec 2016 / Vol 6 | Issue 2
(from completion of surgery to shifting of patients from the
operating room to ward).
In RSGA(groupA), patients were prepared and draped before
the induction of anesthesia, and in RSSA(groupB), patients
were prepared and draped after the administration of block.
To overcome the problem regarding time calculation, we
considered the time for anesthesia (time from the start of
anesthesia to completion of induction) and time to achieve
surgical readiness(arrival to incision time) instead of the time
for induction(arrival to completion of induction).
After admission, intravenous (IV) cannulation was
done and ringer lactate 10 ml/kg was started. Aspiration
prophylaxis(Ranitidine 50mg IV, Metoclopramide 10mg IV)
was administered. Continuous monitoring of vital parameters
of the fetus and mother was done. As soon as the decision of CS
was made, the anesthetic drug kit and difficult airway cart(either
for GA or SA) was prepared and the anesthesiologist became
ready by wearing sterile gloves and gown for administration
of SA to reduce the time required for anesthesia and surgical
readiness. This preoperative preparation part was designed
similarly for both the study groups.
In RSGA, induction was done with thiopental 5.0 mg/kg
over 1015 s after denitrogenation with 4 vital capacity
breaths. Intubation was performed with succinylcholine
1.0mg/kg. The cricoid pressure was applied as soon as patients
lost consciousness, and it was continued until the correct
position of the endotracheal tube was verified and the cuff was
inflated. Left uterine displacement was performed by putting a
wedge under the right buttock to prevent supine hypotension
syndrome. Time intervals during the technique described
above were calculated. RSSA was established with 26 G pencil
point spinal needle in L3L4 or one space below in a sitting
position with 2.5ml of hyperbaric bupivacaine(0.5%) without
adjuvant after cleaning the skin with a single wipe of 0.5%
chlorhexidine. Drug kit for SA was prepared aseptically, and
the anesthesiologist who performed the procedure was ready
with a sterile gown and gloves before the patients came to the
operating room. The patient was placed in a Trendelenburg
position with a head down tilt of 15 after the procedure. Times
for different components of RSSA were recorded similarly.
After administering spinal anesthesia, draping was done,
and simultaneously the progression of the level of block was
assessed aseptically by loss of cold sensation. When block
height was achieved up to T10, surgeons started the procedure.
Intraoperative heart rate, noninvasive blood pressure,
electrocardiogram, oxygen saturation, and end tracheal carbon
dioxide concentration were monitored. Apgar score[8] was noted
at birth and 5 min after the delivery. Statistical analysis was
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Bhattacharya, etal.: Rapid sequence spinal anaesthesia is a suitable alternative for category-1 caesarean section-an observational study

Box 1: Definitions of time intervals

done with the Statistical Package for the Social Sciences(SPSS) Table1: Demographic data and Apgar score
version 16. (SPSS Inc. Released 2007, SPSS for Windows, Group A Group B P value
Version 16.0, Chicago, SPSS Inc.). The sample size was calculated Age(years) 28.332.35 28.003.28 0.653
by considering the mean difference between two groups as Height(cm) 153.634.64 154.605.47 0.450
7 min (), and according the previous study,[9] the expected Weight(kg) 61.464.38 61.503.93 0.975
difference is 5min(). Considering error as 5% and as error Apgar score 7.031.99 7.401.83 0.461

20%[(Z + Z) 22x 2/2 ]), sample size was calculated to be

30. Numerical data analyzed with unpaired student ttest. Any Table2: Indications of category I caesarean section
Pvalue less than 0.05 was considered to be significant. Results Indications Number of patients Number of patients
were expressed as meanstandard deviation(SD). in RSGA group(n=30) in RSSA group(n=30)
Major hemorrhage 18 3
RESULTS Fetal bradycardia 7 22
Chord prolapse 2 2
Shoulder dystocia 1 2
Both the groups were comparable regarding their age(RSGA: Uterine rupture 2 1
28.332.35vs. RSSA: 28.003.28, P=0.653), height(RSGA:
153.63 4.64 vs. RSSA: 154.60 5.47, P = 0.450), and
weight (RSGA: 61.46 4.38 vs RSSA: 61.50 3.93, Table3: Comparison of time intervals
P=0.975)[Table1]. There was no incidence of block failure Group A Group B P value
(RSGA) (RSSA)
in the RSSA group. Hypotension (MAP 20% of baseline Time for anesthesia 144.803.42 131.203.40 <0.001
value) was observed among 6patients in RSSA group(n=30), Time for surgical readiness 178.764.09 169.933.08 <0.001
which was corrected by intravenous phenylephrine 50 g and Incision to delivery time 181.736.87 178.269.31 0.107
repeated, if required. Bradycardia (HR 60 beats/min) and Emergence time 512.1334.33 222.1012.80 <0.001
high spinal block were not observed in any patients of the RSSA
group. In the present study, indications of category1 CS were The time for surgical readiness was also significantly higher
major hemorrhage, profound and persistent fetal bradycardia, in the RSGA group (178.76 4.09) in comparison to the
prolapsed cord, shoulder dystocia,and uterine rupture[Table2]. RSSA group (169.93 3.08) with P value of < 0.001, which
We achieved adequate block height in all patients of the was statistically significant [Table 3; Figure 2]. The divisions
RSSA group. Time for anesthesia was more in the RSGA of times required for each of the four components of time for
group(144.803.42) than the RSSA group(131.203.40), surgical readinessboth with RSGA and RSSAis shown in
which was statistically significant(P<0.001)[Table3; Figure1]. Figures3 and 4, respectively. Incision to delivery time between

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Bhattacharya, etal.: Rapid sequence spinal anaesthesia is a suitable alternative for category-1 caesarean section-an observational study

both the groups was comparable[Table3; Figure5]. Emergence
time between both the groups was also comparable, which
was significantly higher in the RSGA group(512.1334.33)
than the RSSA group(222.1012.80), with Pvalue of<0.001
[Figure 6]. Apgar score recorded at 5 min after birth was
comparable between both the groups(RSGA: 7.031.99vs.
RSSA: 7.401.83, P=0.461)[Table1]. Fever, tachycardia, neck
rigidity, and altered consciousness were examined to rule out the
incidence of meningitis and arachnoiditis in the postoperative
period. An area of numbness or of pins and needles, weakness
of muscles, paraplegia, and loss of control of bladder and bowel
were also observed to exclude neurological injury. Patients were
followed up for a week in the postoperative period, and no such
complications were noted in any of these patients.
DISCUSSION
The primary goal of anesthesia for caesarean section is to provide
adequate and safe anesthesia both for the mother and baby. The
rapidity of the anesthetic technique is not the sole factor but early
decision making, shorter decision to delivery interval, and proper
neonatal resuscitation are essential during emergency CS. SA is
considered to be safe for parturients undergoing CS.[10] However,
more time is required to perform SA than GA.[11] Hence, this
technique is not preferred in category1 CS. As obstetric patients
are considered to be full stomach patients, rapid sequence
induction and intubation is the traditional approach for CS.
However, this traditional technique is currently being challenged
due to various controversies[12] These controversies include the
choice and dose of drug and the methods of administration,
positive pressure ventilation before tracheal intubation, and
role of cricoid pressure. Report on Confidential Enquiries
into Maternal Deaths(200002) in the UnitedKingdom cited
six deaths attributable to general anesthesia with esophageal
intubation as a cause of mortality.[13] GA is also associated with
shortterm neonatal morbidity of term babies born by category1
CS, despite rapid delivery of the baby.[14]

Figure1: Anesthesia time

Figure2: Time for surgical readiness

Figure3: Components of time(seconds) for surgical readiness in RSGA Figure4: Components of time(seconds) for surgical readiness in RSSA

Figure5: Incision to delivery time Figure6: Emergence time

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Bhattacharya, etal.: Rapid sequence spinal anaesthesia is a suitable alternative for category-1 caesarean section-an observational study
In category1 CS, standard recommendation is to maintain
decision to delivery time within 30min.[15] This time interval
not only depends on the time required for anesthesia and time
for surgical readiness but also depends on the time required
for transfer of the patient to the operating room after decision
of emergency CS and the time gap between skin incision
to baby delivery. A delay in any of these steps will lead to
a prolongation of decision to delivery time irrespective of
the anesthesia technique. Therefore, the present study was
formulated to compare between anesthesia to delivery time
instead of decision to delivery time. Afaster SA procedure will
have greater acceptability as it will avoid the complications of
RSGA even in category1 CS.
The concept of RSSA was introduced by Kinsella etal. for
category1 caesarean section.[6] The steps of RSSA include
the use of notouch technique for spinal needle insertion,
simplify the spinal drug combination, limit the time
available for attempts, if necessary, start the surgery before
full establishment of the block, and be ready to administer
general anesthesia in the event of spinal failure. In this study,
the changes that were carried out were a predesigned spinal
anesthesia kit for quick use; a waiting, masked, gowned,
and gloved anesthesiologist while patients were wheeled
in the OT; and a 15 head down tilt was allowed after
the spinal block to achieve higher level of block rapidly.
Kinsella etal. did not mention the position of the patient
during administration of SA. In their original case series,
among 25 patients, positions used for administration of
spinal block were left lateral, right lateral, and sitting in 17,
7, and 1 patient, respectively. In obese patients, gravity of
the lateral position itself can drag down the pad of the fat
obscuring the midline.[16] Identification of space is easier in
a sitting position. Hence, RSSA was performed in sitting
position. Asepsis was maintained by single wipe of 0.5%
chlorhexidine solution, which was adequate according to
the earlier studies.[17,18] In the present study, blinding was not
possible because of technical differences between the groups.
Both time for anesthesia (144.80 3.42 s with RSGA vs.
131.203.40 s with RSSA; P<0.001) and time to surgical
readiness(178.764.09 s with RSGA vs. 169.933.08 s with
RSSA; P < 0.001) were significantly less with RSSA in the
present study. The time required for performing RSSA was
even shorter than the original finding of Kinsella etal. and
other similar type of studies.[6,7] This is probably because of
the modifications that were made in the RSSA technique in
the present study. Incision to delivery time (181.736.87 s
with RSGA vs. 178.26 9.31 s with RSSA; P = 0.107) was
comparable between both the groups in the present study,
and it is consistent with the finding of others.[19] It indicates
that duration of surgical procedure itself does not depend on
Journal of Obstetric Anaesthesia and Critical Care / Jul-Dec 2016 / Vol 6 | Issue 2 79
the anesthetic technique. The emergence time(512.1334.33
s with RSGA vs. 222.1012.80 s with RSSA, P<0.001) was
much shorter with RSSA, and this was also similar to earlier
studies.[19] Apgar score of the baby at 5min(7.031.99 s with
RSGA vs. 7.401.83 s with RSSA; P=0.461) was comparable
between both the groups, and it was consistent with the finding
of other investigators.[20]
Apgar score recorded at 1min may falsely show a depressed
baby after RSGA as most of the anesthetic drugs are lipid soluble
and readily cross the placental barrier and may influence the
assessment of Apgar score. Hence, we compared the score at
5min after the initial resuscitation done by the pediatrician.
Aretrospective analysis concluded that the 5min Apgar score
remained a valid predictor of neonatal mortality, however,
using it to predict longterm outcome was inappropriate.[21]
Low Apgar scores at 5min are associated with death or cerebral
palsy, and this association increased if both 1 and 5min scores
were low.[22]
There are some limitations of our study. Performance of all
RSSA procedures by the same anesthesiologist may be a
limitation as the same time period may not be reproduced by
other anesthesiologists. Cord blood pH and lactate were not
measured due to lack of facility.
CONCLUSION
In conclusion, anesthesia delivery time (the time interval
between time for anesthesia to delivery of the baby) is shorter
if rapid sequence spinal anesthesia is administered as described
for category 1 CS as compared to rapid sequence general
anesthesia and this technique should be a viable option in
such surgeries.
Financial support and sponsorship
Nil
Conflicts of interest
There are no conflicts of interest.
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