الفهرس 
INTRODUCTIONOnly 14 pages are availabe for public view
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Abstract
Spinal anesthesia is the preferred means for cesarean section, being simple to perform, economical and produces rapid onset of anesthesia and complete muscle relaxation. It carries high efficiency, involves less drug doses, minimal neonatal depression, awake mother and lesser incidences of aspiration pneumonitis. However, it also produces a fixed duration of anesthesia, postdural puncture headache, hypotension and lesser control of block height.
Bupivacaine, an amide type of local anesthetic, is the most common local anesthetic used in spinal anesthesia which has high potency, slow onset and long duration of action (1.5–2 hours). For cesarean section intrathecal dose of hyperbaric bupivacaine is 8 to 15 mg. Cesarean delivery requires traction of peritoneum and handling of intraperitoneal organs, resulting in intraoperative visceral pain. With higher doses of hyperbaric bupivacaine, incidence of intraoperative visceral pain associated with higher blocks is reduced but the incidence of complications as hypotension, bradycardia, shivering, respiratory depression, nausea and vomiting are greatly increased with higher blocks.
Different additives have been used as adjuvant with local anesthetics to achieve dense and prolonged block without the need to increase the dose of local anesthetic to avoid high block complications. Opiods have been a choice in regional (intrathecal and epidural routes) anesthesia to improve the antinociceptive effect of local anesthetics, also Benzodiazepine receptors are present throughout the nervous system, including the spinal cord. Midazolam given by intrathecal or epidural injection can also produce an antinociceptive effect, this may be Gamma-Aminobutyric Acid (GABA) mediated which has been shown to have analgesic properties. Ketamine as an N-Methyl-D-Aspartate (NMDA) receptor antagonist is a potent analgesic which modulates pain perception at the dorsal horn of spinal cord, so using these additives to bupivacaine in spinal anesthesia in Cesarean section results in variable effects.
The aim of the work was to compare the haemodynamic effects, onset, level, duration of the intrathecal block and incidence of complications on adding mixture of low-dose ketamine and low-dose midazolam to bupivacaine, and on adding fentanyl to bupivacaine during intrathecal injection for caesarean section.
The present study was carried out in El-Shatby university Hospital on 56 parturients aged between 20 and 40 years of American Society of Anesthiologists (ASA) physical status I undergoing elective lower segment transverse incision CS of singleton pregnancy at >36 gestational weeks by single surgeon under spinal anesthesia.
Exclusion criteria included:
Patients with contraindications for spinal block, history of sensitivity to the used drugs, patients with narcotic addiction or sedative drugs consumption and patients whose heights are <150 cm or >180 cm.
Patients were randomized into two equal groups (28patients) using the sealed-envelope method.