Antihypotensiva bei Kaiserschnittentbindungen: Behandlung der arteriellen Hypotension mit Ephedrin, Phenylephrin und Akrinor® (Cafedrin/Theodrenalin) im Rahmen von Kaiserschnittentbindungen in Spinalanästhesie

Phenylephrine versus cafedrine/theodrenaline (Akrinor) for the treatment of spinal anaesthesia-induced maternal hypotension during caesarean section: a retrospective single-centre cohort study

OBJECTIVE

The main objective of this study was to assess the impact of phenylephrine and cafedrine/theodrenaline on the mother and newborn after spinal anaesthesia for caesarean section.

SETTING

University teaching hospital.

DESIGN

A single-centre retrospective data cohort study.

PATIENTS

All obstetric patients who were scheduled for caesarean section in a 2-year period.

INTERVENTIONS

Administration of either intravenous phenylephrine prophylactically or cafedrine/theodrenaline (Akrinor) reactively to maintain blood pressure after spinal anaesthesia.

MAIN OUTCOME MEASURE

Maternal hypotension, heart rate during caesarean section and after admission to IMC, fetal arterial cord pH and base excess levels, maternal volume resuscitation and the use of rescue medication.

RESULTS

852 data sets could be included: n=440 Akrinor, n=412 in the phenylephrine cohort. During caesarean section blood pressure was slightly higher in the phenylephrine group compared with the Akrinor group, while hypotension <100 mm Hg systolic blood pressure (SBP) occurred significantly more often during arrival at the IMC after surgery when phenylephrine was used. Heart rate was lower and rescue medication was significantly more frequently given in the phenylephrine cohort. Irrespective of the medication used, women with baseline levels of <120 mm Hg SBP had a high risk to develop hypotension <100 mm Hg after spinal anaesthesia for caesarean section. While there was no statistical difference in mean umbilical arterial pH levels, the incidence of acidosis, defined as pH <7.2, was significantly higher with phenylephrine.

CONCLUSION

Phenylephrine was not superior to Akrinor to treat spinal anaesthesia-induced maternal hypotension during caesarean section.

TRIAL REGISTRATION NUMBER

DRKS00025795.

Treatment of spinal anaesthesia-induced hypotension with cafedrine/theodrenaline versus ephedrine during caesarean section: Results from HYPOTENS, a national, multicentre, prospective, noninterventional study

BACKGROUND

In Germany, hypotension induced by spinal anaesthesia is commonly treated with a combination of cafedrine hydrochloride (C, 200 mg) and theodrenaline hydrochloride (T, 10 mg) in 2 ml. We compared the effectiveness of C/T with ephedrine.

OBJECTIVES

The primary objectives were to assess the speed of onset and the ability to restore blood pressure without an increase in heart rate. Secondary objectives were to evaluate maternal/foetal outcomes and the number of required additional boluses or other additional measures.

DESIGN

HYPOTENS was a national, multicentre, prospective, open-label, two-armed, noninterventional study comparing C/T with ephedrine in two prospectively defined cohorts. This study relates to the cohort of patients receiving spinal anaesthesia for caesarean section.

SETTING

German hospitals using either C/T or ephedrine in their routine clinical practice.

PATIENTS

Women aged at least 18 years receiving spinal anaesthesia for caesarean section.

INTERVENTIONS

Bolus administration of C/T or ephedrine at the discretion of the attending anaesthesiologist.

MAIN OUTCOME MEASURES

Endpoints within 15 min after initial administration of C/T or ephedrine were area under the curve between the observed SBP and the minimum target SBP; and incidence of newly occurring heart rate of at least 100 beats min-1.

RESULTS

Although effective blood pressure stabilisation was achieved with both treatments, this effect was faster and more pronounced with C/T (P < 0.0001). The incidence of tachycardia and changes in heart rate were higher with ephedrine (P < 0.01). Fewer additional boluses (P < 0.01) were required with C/T. Although favourable neonatal outcomes were reported in both groups, base deficit and lactate values were greater with ephedrine (P < 0.01). Physician satisfaction was higher with C/T.

CONCLUSIONS

After C/T, tachycardia was not a problem, providing an advantage over ephedrine. Fewer additional boluses were required with C/T, suggesting greater effectiveness. An increased base deficit with ephedrine suggests reduced oxygen supply or increased demands in foetal circulation.

TRIALS REGISTRATION

Clinicaltrials.gov: NCT02893241, German Clinical Trials Register: DRKS00010740.

[Hypotension induced by spinal anesthesia during cesarean section : Current treatment concepts]

Arterial hypotension during cesarean delivery under spinal anesthesia can cause maternal and fetal adverse effects. Therefore, current guidelines recommend the continuous and preferably prophylactic use of vasopressors, emphasizing the use of alpha-agonists, such as phenylephrine. Besides a left lateral uterine displacement either an intravenous colloid preloading or a crystalloid co-loading is recommended. The blood pressure goal is to maintain a systolic arterial blood pressure of at least 90% of the initial baseline value and to avoid a drop to less than 80% of this baseline. To achieve this goal a prophylactic continuous phenylephrine infusion with an adjustable flow rate is recommended. It is advised to start with an initial dose of 25-50 µg/min, initiated immediately following the intrathecal injection of the local anesthetic and titrated according to the vital parameters. Parturients with cardiac diseases should be preoperatively evaluated following individual hemodynamic goals.

[Pregnant patients wirsth major trauma in the resuscitation room : Special (patho)physiological and therapeutic aspects]

BACKGROUND

Severely injured pregnant women are rarely encountered even in major trauma centers; at the same time high expectations are set for the best possible outcome of mother and child.

OBJECTIVE

Summary of the main pathophysiological aspects of pregnancy and essential therapeutic implications for emergency room treatment from the perspective of anesthetists.

METHODOLOGY

Selective literature analysis with a focus on primary physiological literature and the synthesis of pregnancy-adapted recommendations of related guidelines.

RESULTS

The essential physiological adaptations to pregnancy and their implications for acute care are presented.

CONCLUSION

Teamwork, structured decision making as well as airway management and goal-oriented hemodynamic treatment are the foundations for a good outcome of mother and child.

Cross-sectional study on hearing loss and auditory reaction time before and after spinal anesthesia with marcaine 0.5% in patients undergoing elective surgery

Background

Hearing loss is a rarely reported complication of spinal anesthesia. The purpose of this study is to assess the effects of 0.5% Maracine (bupivacaine) on hearing threshold and auditory reaction time before and after spinal anesthesia among patients undergoing elective surgery.

Materials and methods

This is a descriptive cross-sectional study performed on 60 patients undergoing elective surgery with ASA Class II and II anesthesia (0.5% bupivacaine) at Khorramabad Nursing Home. After obtaining consent from the patients, audiometry and tympanometry tests were performed using AZ80 and Madsen otoflex tympanometer and related findings including the presence or absence of hearing loss at various frequencies, before and after the surgery, were noted in a form for each patients along with their demographic data. SPSS 21 was used for statistical analysis and the data were analyzed using descriptive statistics and chi-square inferential tests.

Results

At low frequencies of 250 and 500 Hz, no significant difference in pre- and postoperative hearing threshold in the right ear (P > 0.05) was seen, but at frequencies above 500 Hz, the hearing threshold was significantly decreased after surgery, (P < 0.05). In the left ear at 250, 1000, 3000, and 8000 Hz, there was no significant difference (P > 0.05) between pre- and postoperative hearing threshold. The results of this study showed that the preoperative hearing threshold for men and women did not differ and the auditory threshold and auditory response time after surgery did not differ between the two sexes (P > 0.05). Similarly, the difference was not correlated with the age and the levels of anesthesia (P > 0.05). The results also showed that changes in mean arterial blood pressure (MAP) and heart rate above 30% of baseline were also not correlated with hearing loss (P > 0.05).

Conclusions

The results showed that at certain frequencies, hearing loss was observed in both ears after spinal anesthesia with 5% Marcaine, but this hearing loss was not related to age, sex, and spinal anesthesia level. The results also showed that changes in mean arterial blood pressure (MAP) and heart rate above 30% of baseline did not correlate with hearing loss.

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Hearing loss is a rarely reported complication of spinal anesthesia.

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Hearing loss in both ears is observed after spinal anesthesia with 5% Marcaine.

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Changes in MAP and heart rate greater than 30% of baseline is not associated with the hearing loss.

[Perioperative pharmacological circulatory support in daily clinical routine]

Perioperative phases of hypotension are associated with an increase in postoperative complications and organ damage. Whereas some years ago hemodynamic stabilization was primarily carried out by volume supplementation, in recent years the use and dosing of cardiovascular-active substances has significantly increased. But like intravascular volume therapy, also substances with a cardiovascular effect have therapeutic margins, and thus, potential side effects. This review article discusses indications for each cardiovascular-active agent, weighing up advantages and disadvantages. Special attention is paid to the question how to administrate them: central venous catheter vs. peripheral indwelling venous cannula. The authors come to the conclusion that it is not a question of whether it is principally allowed to apply cardiovascular-active drugs via peripheral veins but more importantly, what should be taken into consideration if a peripheral venous access is used. This article provides concise recommendations.