N.A.C.S. In Assessment of
Neonatal Status Following Caesarian-Section Under Anaesthesia: Pipecuronium
Bromide
Dhruv
V.K.1, Sahu A.2, Bansal A.K.3, Shashi Kala
Dhruv (Thakur) 4, Baghel B.2, Viswanadham K. K.2
and Bithika Nel Kumar5,
Dept. of Anaesthesia1, Paediatrics2, Community Medicine3,
Pathology4 and Pharmacology5, Govt. Medical College,
Jagdalpur (BASTAR) -494001 –INDIA.
ABSTRACT:
Background: For Caesrian section to
provide optimal anaesthesia, causing less transpass in to the existing
patho-physiology of the mother and child, needs the use of such technique and
drugs which have minimal side effects. Research question: Use of Pipe
curonium Bromide as an anaesthetic agent, has any bearing, on neonates using
Neurological Adaptive Capacity Score. Material and Methods: New Bornes
of 85 mothers who have under gone elective and emergency L.S.C.S. were included
in the study. Observations: 85%of newborns had an average N.A.C.S. score
of 35.37 at 15 minutes, 38.46 to 39.90 at 2 hours and 24 hours intervals, there
by depiciting a vigorous neonate with no evidence of cardio respiratory
depression or residual effects of neuromuscular blocks drugs. Conclusion: Pipecuronium
Bromide is a good muscle relaxant as evaluated by N.A.C.S. System.
KEYWORDS: Muscle Relaxant, New borne
INTRODUCTION:
Recently more sophisticated analytical techniques have
been applied in attempts to define deviations from normally in the newborn.
These have developed from early investigations concerned with neonatal
neurological and behaviour patterns of the newborn infants. As Apgar score fails to distinguish fine differences
in response to drugs reaching the infant in relatively low concentration across
placenta, a more critical yet easily accomplished test is required, Thus the
assessment of new born by neurobehavioural function tests has been introduced
to reveal the residual effects of anaesthetic drugs. A study by Hollmen A.I. et
al (2) also recommended neurobehavioural assessment as a sensitive test of
overall infant condition. These neurobehavioural assessment defect subtle
neurobehavioural changes in the neonate. Indeed many babies with normal Apgar
score have demonstrable neurobehavioural changes within the first few hrs. of
life (Scalon,et al 1974).A variety of examinations Neurological and adaptive
capacity score (N.A.C.S.) Amiel - Tison et al (3) are currently available for
evaluating the neurobehaviour of the newborn. (NACS) is the most widely used
test for evaluating effect or obstetric medication on the newborn.
As very few reports of clinical study of this drug is
available and in 1957 a study group of World Health Organization has expressed
the view that in order to get a comprehensive picture of disease (drug used)
more and more studies have to be carried out, Garg Narendra K.(1). This
prompted the authors to undertake this study to assess the effects of
Pipecuronium in balanced anesthesia on neonatal outcome..
MATERIAL
AND METHODS:
This study was undertaken in the Medical College
Hospital, Rewa (M.P.) In the year 1994 -97 in the Dept. of Anaesthesiology. A
total of eighty five mothers included in the study who have undergone elective
and emergency L.S.C.S. Neonate outcome were assessed by the use of N. A.C.S.
test. The NACS is based on 20 criteria, each of which is given a score of 0, 1,
or 2. NACS at 15 minutes, 2 hours and 24 hours as item of primary reflex,
general assessment, passive tone, active tone, adaptive capacity scoring were
assessed. The observations were tabulated and analyzed.
These criteria assess five
general areas:-
1. Primary reflex.
2. General assessment.
3. Passive tone.
4. Active tone.
5. Adaptive capacity score.
Thus each criterion is given a score of 0, 1
or 2 based on whether the response to testing is absent or grossly abnormal –
0, slightly abnormal – 1, normal. Therefore the maximum possible score is
40.Although the 20 items in the NACS can be performed in any order .The
examiner determines the neonate’s best performance; if the neonates score 1 or
0 an item should be retested later in the examination to confirm the low score.
1.
primary reflex :
- Moro
Reflex
- Sucking
- Automatic
waking.
2.
General Neurological assessment:
- Motor
activity
- Alertness
- Crying.
3.
Passive tone :
- Scarf
sign
- Recoil
of Elbow
- Poplital
angle.
- Recoil
of lower limbs
4.
Active tone:
- Active
contraction of the neck flexors.
- Active
contraction of neck extensors
- Palmer
grasps.
- Response
to traction.
- Supporting
reaction.
5
Adaptive capacity Score:
- Response
to sound.
- Habituation
to sound.
- Response
to light.
- Habituation
to light.
- Consolability.
OBSERVATIONS:
(Table -1) reveal that 14.21 + 4.46 in study
group was comparable with control group i.e. 14.21 +4.31 which was on
statistical analysis found insignificant (P < 0.01). N.A.C.S. of 35 TO 40
was considered to be vigorous new borne. At 15 minutes interval N.A.C.S. was
82% in study group and 92% in control group. At 2 hour interval N.A.C.S. was
91.66%in study group and 100% in control group and at 24 hours 100%in both
group.
Table –II Showed that on comparison the
N.A.C.S. of infants of study group at 15 minutes, 2 and 24 hours of delivery
found 1999, 2236 and 2231 respectively in comparison to their counter parts
control group 25, 974 and 996 having P value of < 0.01 which is significant.
Table –III Revealed that N.A.C.S. indices at
different time interval s of both groups, N.A.C.S component each having a score
of marks against each primary reflex -6, General assessment -6, passive tone-8,
Active tone-10 and adaptive capacity scoting -10. The sub components of primary
reflex requires assessment of moro reflex
2 mark, sucking reflex 2 mark, Automatic walking -2 mark. General
assessment total 6, 2 for motor activity, 2 for alertness and 2 for crying
Passive tone has 4 point of evaluation each of 2 mark such as scarf sign, recoil
of elbow, poplitial angle, recoil of lower limbs. Active tone is of 10 marks
with 5 items is to be evaluated, each having 2 mark such as active contraction
of the neck flexors, active contraction of the neck extensors, Palmar grasp,
response to traction, supporting reaction, adaptive capacity score has total of
10 marks 2 each for response to sound habituation to sound and response to
light habituation to light and consol-ability.
DISCUSSIONS:
No significant affect on neonatal outcome could be
correlated. Thus the presentation of the foetus did not alter the neonatal out
come in our study which is in accordance with the studies of Crewford et al (1982).
The following table reveals the percentage of NACS
after caesarean-section using pancuronium, vecuronium, atracurium and present
study drug pipecuronium.
|
S. N. |
Authors |
Year |
Drug Studied |
NACS (35-40) |
||
|
at 15 min. |
at 2 hrs. |
at 24 hrs. |
||||
|
1. |
Dailey et. al. |
1984 |
Pancuronium |
29% |
57% |
100% |
|
2. |
Dailey et. al. |
1984 |
Vecuronium |
73% |
73% |
100% |
|
3. |
Hwakins et. al. |
1990 |
Vecuronium |
--- |
50% |
70% |
|
4. |
Perzeault et. al. |
1991 |
Atracurium |
55% |
90% |
100% |
|
5. |
Present study |
1996 |
Pipecuronium |
80% |
91. 66% |
100% |
In conclusion pipecuronium bromide for caesarean
section is a good muscle relaxant because of its longest duration of action, no
histamine release, a good cardiovascular stability and better neonatal status
as evaluated by the NACS System.
Table No. – I: Mean birth weight,
NACS at 15 minute, at 2 hours and 24 hours in both group.
|
S. No. |
Data |
Study Group |
Control Group |
|
1 |
Mean birth weight |
2.83 ± .56 |
2.66 ± 2.31 |
|
2 |
Baby’s crying
time (in sec. ± mean S.D.) |
14.21 ± 4.46 |
14.12 ± 4.31 |
|
5 |
NACS (35-40) |
|
|
|
|
at 15 min. |
80% |
92% |
|
|
at 2 hours |
91.66% |
100% |
|
|
at 24 hours |
100% |
100% |
Table No. – II: Compares the
NACS of infants into both group at 15 min, 2 hours & 24 hours after
delivery
|
S. N. |
Items |
Study Group |
Control Group |
||||
|
15 min. |
2 hrs. |
24hrs. |
15 min. |
2 hrs. |
24hrs. |
||
|
1 |
Primary reflex |
360/299 |
330 |
352 |
150/131 |
144 |
149 |
|
2 |
General
assessment |
360/337 |
354 |
359 |
150/149 |
150 |
150 |
|
3 |
Passive tone |
480/449 |
465 |
473 |
200/197 |
198 |
199 |
|
4 |
Active tone |
600/441 |
527 |
576 |
250/211 |
235 |
248 |
|
5 |
Adaptive capacity
score |
600/482 |
570 |
591 |
250/237 |
249 |
250 |
|
|
Total |
2400/1999 |
2236 |
2361 |
1000/925 |
974 |
996 |
Table No. –III: Compares the
NACS indices at different time intervals of both study and control.
|
S. N. |
Item |
Criteria |
Study group |
Control Group |
||||
|
15min. |
2 hrs. |
24 hrs. |
15 min. |
2 hrs. |
24 hrs. |
|||
|
1. |
Primary reflex |
1.M.R. 2.S.K.
3.A.W. |
86% 90% 35% |
95% 96% 63% |
98% 98% 90% |
100% 100% 32% |
100% 100% 68% |
100% 100% 100% |
|
2. |
General
assessment |
1.M.A. 2.A.L.
3.C.R. |
90% 88% 93% |
96% 98% 98% |
96% 98% 98% |
100% 96% 100% |
100% 100% 100% |
96% 100% 100% |
|
3. |
Passive tone |
1. S.S. 2.R.E.
3.P.A. 4.R.L. |
93% 93% 91% 88% |
93% 98% 95% 95% |
95% 100% 98% 100% |
96% 96% 96% 100% |
96% 100% 96% 100% |
100% 100% 92%
100% |
|
4. |
Active tone |
1. A.C.N.F. 2.
A.C.N.E. 3.P.G. 4.R.T. 5.S. R. |
65% 51% 43% 76% 46% |
83% 68% 63% 91% 71% |
95% 91% 90% 98% 96% |
92% 84% 8% 92% 72% |
96% 96% 92% 100% 88% |
100% 100% 100% 100% 100% |
|
5. |
Adaptive capacity
score |
1. R.S. 2.S.H.
3.R.L. 4.H.L. 5.Conso. |
86% 41% 76% 38%
88% |
98% 81% 93% 80%
98% |
100% 96% 98% 90%
100% |
100% 88% 96% 6%
100% |
100% 100% 100%
96% 100% |
100% 100% 100%
100% 100% |
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Received on 20.04.2011
Accepted on 18.05.2011
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Research J. Pharmacology and
Pharmacodynamics. 3(4): July –August, 2011, 207-209