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Tan H, Chen Y, Jiang Y, Sun X, Ye W, Zhu X, Xiong X. Determination of ED90s of Phenylephrine and Norepinephrine Infusion for Prevention of Spinal Anesthesia-Induced Hypotension in Patients with Preeclampsia During Cesarean Delivery. Drug Des Devel Ther 2024; 18:2813-2821. [PMID: 38984209 PMCID: PMC11232882 DOI: 10.2147/dddt.s467072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Accepted: 07/01/2024] [Indexed: 07/11/2024] Open
Abstract
Background Vasopressors remain an important strategy for managing spinal anesthesia-induced hypotension in women with preeclampsia. The aim of this study was to investigate the ED90s and efficacy ratio of phenylephrine and norepinephrine in managing spinal anesthesia-induced hypotension in women with preeclampsia during cesarean delivery. Methods 60 women with preeclampsia, who underwent cesarean delivery, were randomly assigned to receive either a continuous intravenous infusion of phenylephrine or norepinephrine following spinal anesthesia. The initial dosage of phenylephrine or norepinephrine for the first women was 0.5 or 0.05 μg/kg/min, respectively, and subsequent infusion dosages were adjusted based on their efficacy in preventing spinal anesthesia-induced hypotension (defined as a systolic blood pressure less than 80% of the baseline level). The incremental or decremental doses of phenylephrine or norepinephrine were set at 0.1 or 0.01 μg/kg/min. The primary outcomes were the ED90s and efficacy ratio of phenylephrine and norepinephrine infusions for preventing spinal anesthesia-induced hypotension prior to delivery. Results The results obtained from isotonic regression analysis revealed that the ED90 values of the phenylephrine and norepinephrine group for preventing spinal anesthesia-induced hypotension were 0.597 (95% CI: 0.582-0.628) and 0.054 (95% CI: 0.053-0.056) μg/kg/min, respectively, with an efficacy ratio of 11.1:1. The results of Probit regression analysis revealed that the ED90 values were determined to be 0.665 (95% CI: 0.576-1.226) and 0.055 (95% CI: 0.047-0.109) μg/kg/min, respectively, with an efficacy ratio of 12.1:1. Conclusion The administration of 0.6 μg/kg/min phenylephrine and 0.05 μg/kg/min norepinephrine has been found to effectively manage a 90% incidence of spinal anesthesia-induced hypotension in women with preeclampsia.
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Affiliation(s)
- Haijie Tan
- Department of Anesthesiology, The Fifth People's Hospital of Huaian, Huaian, People's Republic of China
| | - Yi Chen
- Department of Anesthesiology and Perioperative Medicine, General Hospital of Ningxia Medical University, Yinchuan, People's Republic of China
| | - Yan Jiang
- Department of Anesthesiology, The Fifth People's Hospital of Huaian, Huaian, People's Republic of China
| | - Xiaojing Sun
- Department of Anesthesiology, The Fifth People's Hospital of Huaian, Huaian, People's Republic of China
| | - Wei Ye
- Department of Anesthesiology, The Fifth People's Hospital of Huaian, Huaian, People's Republic of China
| | - Xuefang Zhu
- Department of Anesthesiology, The Fifth People's Hospital of Huaian, Huaian, People's Republic of China
| | - Xiangsheng Xiong
- Department of Anesthesiology, The Fifth People's Hospital of Huaian, Huaian, People's Republic of China
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Chen Y, Guo L, Qin R, Xi N, Wang S, Ma Y, Ni X. Dose-Response Study of Norepinephrine Infusion for Maternal Hypotension in Preeclamptic Patients Undergoing Cesarean Delivery Under Spinal Anesthesia. Clin Pharmacokinet 2024; 63:847-856. [PMID: 38869701 DOI: 10.1007/s40262-024-01381-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/07/2024] [Indexed: 06/14/2024]
Abstract
BACKGROUND AND OBJECTIVE Spinal anesthesia remains the preferred mode of anesthesia for preeclamptic patients during cesarean delivery. We investigated the incidence of maternal hypotension under spinal anesthesia during cesarean delivery, by comparing different prophylactic infusion rates of norepinephrine with normal saline. METHODS We randomly allocated 180 preeclamptic patients (45 in each groups) aged 18-45 scheduled for cesarean delivery to receive one of four prophylactic norepinephrine infusions at doses of 0 (normal saline group), 0.025 (0.025 group), 0.05 (0.05 group), or 0.075 (0.075 group) µg/kg/min following spinal anesthesia. The primary endpoint was the incidence of maternal hypotension (systolic blood pressure < 80% of baseline). RESULTS The incidence of maternal hypotension was reduced with different prophylactic infusion rates of norepinephrine (26.7%, 15.6%, and 6.7%) compared with normal saline (37.8%) with a significant decreasing trend (p = 0.002). As the infusion doses of norepinephrine increased, there is a significant decreasing trend in deviation of systolic blood pressure control (median performance error; median absolute performance error) from baseline (p < 0.001; p < 0.001) and need for rescue norepinephrine boluses (p = 0.020). The effective dose 50 and effective dose 90 of prophylactic norepinephrine infusion were - 0.018 (95% confidence interval - 0.074, 0.002) µg/kg/min and 0.065 (95% confidence interval 0.048, 0.108) µg/kg/min, respectively. CONCLUSIONS Prophylactic infusion of norepinephrine, as compared to no preventive measures, can effectively reduce the incidence of maternal hypotension in preeclamptic patients under spinal anesthesia during cesarean delivery, without increasing other adverse events for either the mother or neonate. REGISTRATION Clinical trials.gov identifier number NCT04556370.
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Affiliation(s)
- Yi Chen
- Department of Anesthesiology and Perioperative Medicine, General Hospital of Ningxia Medical University, 804S Shengli Street, Yinchuan, Ningxia 750004, China
| | - Lei Guo
- Department of Anesthesiology and Perioperative Medicine, General Hospital of Ningxia Medical University, 804S Shengli Street, Yinchuan, Ningxia 750004, China
| | - Rui Qin
- Department of Anesthesiology and Perioperative Medicine, General Hospital of Ningxia Medical University, 804S Shengli Street, Yinchuan, Ningxia 750004, China
| | - Nan Xi
- Department of Anesthesiology and Perioperative Medicine, General Hospital of Ningxia Medical University, 804S Shengli Street, Yinchuan, Ningxia 750004, China
| | - Shengfu Wang
- Department of Anesthesiology and Perioperative Medicine, General Hospital of Ningxia Medical University, 804S Shengli Street, Yinchuan, Ningxia 750004, China
| | - Yujie Ma
- Department of Anesthesiology and Perioperative Medicine, General Hospital of Ningxia Medical University, 804S Shengli Street, Yinchuan, Ningxia 750004, China
| | - Xinli Ni
- Department of Anesthesiology and Perioperative Medicine, General Hospital of Ningxia Medical University, 804S Shengli Street, Yinchuan, Ningxia 750004, China.
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Buddeberg BS, Seeberger E, Bläsi C, Dutilh G, Steiner LA, Bandschapp O, Palanisamy A, Girard T. Is crystalloid co-loading necessary to prevent spinal hypotension during elective cesarean delivery? A randomized double-blind trial. Int J Obstet Anesth 2024; 58:103968. [PMID: 38485584 DOI: 10.1016/j.ijoa.2023.103968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 11/23/2023] [Accepted: 11/30/2023] [Indexed: 05/07/2024]
Abstract
BACKGROUND Hypotension is common during spinal anesthesia for cesarean delivery. Preventive strategies include fluid loading and phenylephrine. We hypothesized that if prophylactic phenylephrine infusion is used, omission of fluid loading would be non-inferior to fluid co-loading in maintaining cardiac output. We assumed that if there was a difference, the increase in cardiac output would be greater in the no-loading than in the co-loading group. METHODS Term pregnant women scheduled for elective cesarean delivery were randomized to receive 1 L crystalloid co-loading or maintenance fluids only. Phenylephrine was titrated to maintain blood pressure. Changes in cardiac output following spinal anesthesia were the primary outcome. The study was powered as a non-inferiority trial, allowing the no-loading arm to have a 50% greater change in cardiac output. Heart rate, dose of phenylephrine, occurrence of nausea and vomiting, Apgar scores and neonatal acid base status were secondary outcomes. RESULTS Data from 63 women were analyzed. In contrast to our hypothesis, there was 33% less increase in cardiac output with no loading (ratio 0.67, 95% CI 0.15 to 1.36), and 60% greater reduction of cardiac output with no loading (ratio 1.6, 95% CI 1.0 to 2.7). Total dose of phenylephrine was higher in the no-loading group. There may be a less favorable neonatal acid base status without volume loading. CONCLUSION Omission of crystalloid co-loading leads to a decrease in cardiac output which has a potentially unfavorable impact on neonatal acid base status. We conclude that crystalloid co-loading may be useful in the presence of phenylephrine infusion.
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Affiliation(s)
- B S Buddeberg
- Clinic for Anaesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Switzerland; Department of Clinical Research, University of Basel, Switzerland.
| | - E Seeberger
- Clinic for Anaesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Switzerland
| | - C Bläsi
- Clinic for Anaesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Switzerland
| | - G Dutilh
- Department of Clinical Research, University of Basel, Switzerland
| | - L A Steiner
- Clinic for Anaesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Switzerland; Department of Clinical Research, University of Basel, Switzerland
| | - O Bandschapp
- Clinic for Anaesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Switzerland; Department of Clinical Research, University of Basel, Switzerland
| | - A Palanisamy
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - T Girard
- Clinic for Anaesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Switzerland; Department of Clinical Research, University of Basel, Switzerland
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Gurrieri C, Sharpe EE, Connolly HM, Rose CH, Arendt KW. Peripartum anesthetic management in patients with Ebstein anomaly: a case series. Proc AMIA Symp 2023; 36:346-350. [PMID: 37091760 PMCID: PMC10120540 DOI: 10.1080/08998280.2023.2169561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023] Open
Abstract
Ebstein anomaly is a rare congenital cardiac condition associated with displacement and incompetence of the tricuspid valve. Peripartum anesthetic management can be particularly challenging since these patients are at high risk of cardiac failure and tachyarrhythmias. Risk stratification is important since it helps to identify high-risk patients who should deliver at a tertiary care center where a multidisciplinary team (obstetrics, cardiology, anesthesiology, and neonatology) is immediately available. We describe the peripartum anesthetic management of 9 patients with Ebstein anomaly who underwent 12 deliveries at our institution. All patients tolerated neuraxial anesthesia and analgesia well. No maternal or fetal deaths occurred.
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Affiliation(s)
- Carmelina Gurrieri
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Emily E. Sharpe
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Heidi M. Connolly
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Carl H. Rose
- Division of Maternal and Fetal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Katherine W. Arendt
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
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5
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Liu P, He H, Zhang SS, Liang Y, Gao ZJ, Yuan H, Dong BH. Comparative efficacy and safety of prophylactic norepinephrine and phenylephrine in spinal anesthesia for cesarean section: A systematic review and meta-analysis with trial sequential analysis. Front Pharmacol 2022; 13:1015325. [DOI: 10.3389/fphar.2022.1015325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 11/07/2022] [Indexed: 11/29/2022] Open
Abstract
Background: Phenylephrine is the first-line drug used to maintain blood pressure in cesarean delivery. However, it poses a high risk of bradycardia and depression of cardiac activity in pregnant women. Consequently, norepinephrine has gained popularity over the recent years, as an alternative to Phenylephrine because it is thought that prophylactic use of vasopressors may reduce the incidence of hypotension after spinal anesthesia. This systematic review compared the efficacy of both treatments.Methods: We searched the following databases; CNKI, PubMed, Embase, Web of science, clinicaltrials.gov, Medline and Cochrane Library, for randomized controlled trials comparing the prophylactic efficacy of norepinephrine and phenylephrine on elective cesarean delivery under spinal anesthesia. The search period was from inception to July 2022, and the primary outcome indicator was incidence of bradycardia. Statistical analysis was conducted on Rev manager 5.4, and the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework was used to evaluate the quality of evidence from each main finding.Results: A total of 12 papers were included in the analysis. The incidence of bradycardia (RR = 0.37, 95% CI: 0.28 to 0.49, p < 0.00001) and reactive hypertension (RR = 0.58, 95% CI 0.40 to 0.83, p = 0.003) was significantly lower in the norepinephrine (NE) group compared with the phenylephrine (PE) category. In contrast, there were no statistical differences in the umbilical cord blood gas analysis pH values between the groups (arterial: MD = 0.00, 95% CI −0.00 to 0.01, p = 0.22, vein: MD = 0.01, 95% CI −0.00 to 0.02, p = 0.06). The incidence of hypotension, nausea, and vomiting did not differ significantly between the NE and PE groups (hypotension: 23% vs. 18%; nausea: 14% vs. 18%; vomiting: 5% vs. 7%, respectively).Conclusion: Prophylactic use of norepinephrine is safe and effective in maintaining maternal hemodynamics without causing adverse events to either the pregnant woman or fetus.Systematic Review Registration: website https://www.crd.york.ac.uk/prospero/, identifier CRD42022347095
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Hu LJ, Mei Z, Shen YP, Sun HT, Sheng ZM, Chen XZ, Qian XW. Comparative Dose-Response Study of Phenylephrine Bolus for the Treatment of the First Episode of Spinal Anesthesia-Induced Hypotension for Cesarean Delivery in Severe Preeclamptic versus Normotensive Parturients. Drug Des Devel Ther 2022; 16:2189-2198. [PMID: 35837022 PMCID: PMC9275428 DOI: 10.2147/dddt.s368480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 06/28/2022] [Indexed: 11/23/2022] Open
Affiliation(s)
- Li-Juan Hu
- Department of Anesthesiology, Women’s Hospital, Zhejiang University School of Medicine, Hangzhou, People’s Republic of China
| | - Zhong Mei
- Department of Anesthesiology, Women’s Hospital, Zhejiang University School of Medicine, Hangzhou, People’s Republic of China
- Department of Anesthesiology, Affiliated Xiaoshan Hospital, Hangzhou Normal University, Hangzhou, People’s Republic of China
| | - Yan-Ping Shen
- Department of Anesthesiology, Women’s Hospital, Zhejiang University School of Medicine, Hangzhou, People’s Republic of China
| | - Hao-Tian Sun
- Department of Anesthesiology, Women’s Hospital, Zhejiang University School of Medicine, Hangzhou, People’s Republic of China
| | - Zhi-Min Sheng
- Department of Anesthesiology, Women’s Hospital, Zhejiang University School of Medicine, Hangzhou, People’s Republic of China
| | - Xin-Zhong Chen
- Department of Anesthesiology, Women’s Hospital, Zhejiang University School of Medicine, Hangzhou, People’s Republic of China
| | - Xiao-Wei Qian
- Department of Anesthesiology, Women’s Hospital, Zhejiang University School of Medicine, Hangzhou, People’s Republic of China
- Correspondence: Xiao-Wei Qian, Department of Anesthesiology, Women’s Hospital, Zhejiang University School of Medicine, Xueshi Road 1, Hangzhou, 310006, People’s Republic of China, Tel +86-571-87061501, Fax +86 571 87061878, Email
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7
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van Dyk D, Dyer RA, Bishop DG. Spinal hypotension in obstetrics: Context-sensitive prevention and management. Best Pract Res Clin Anaesthesiol 2022; 36:69-82. [PMID: 35659961 DOI: 10.1016/j.bpa.2022.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 03/23/2022] [Accepted: 04/05/2022] [Indexed: 11/15/2022]
Abstract
Spinal hypotension during caesarean section remains a common complication, with important attendant maternal and fetal adverse outcomes. Research elucidating the mechanisms of spinal hypotension has led to the development and refinement of effective management strategies, with a particular emphasis on prophylactic vasopressor administration. This has proved effective in well-resourced settings, with maternal comfort and the elimination of nausea now considered the primary aim of treatment. In resource-limited settings, sophisticated strategies are not feasible due to insufficient equipment, staff, and expertise. Therefore, in these areas spinal hypotension remains an important cause of maternal and fetal morbidity and mortality. Translational, context-sensitive research in resource-limited settings has shown promise in implementing pragmatic strategies based on research from resource-rich environments. We review the current best practice for the prevention and treatment of spinal hypotension, with a special emphasis on effective strategies in resource-limited settings. We further suggest a research agenda to address the knowledge gap in specific contexts.
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Affiliation(s)
- Dominique van Dyk
- D23 Department of Anaesthesia and Perioperative Medicine, University of Cape Town, Groote Schuur Hospital, Anzio Road, Observatory 7925, Cape Town, South Africa.
| | - Robert A Dyer
- D23 Department of Anaesthesia and Perioperative Medicine, University of Cape Town, Groote Schuur Hospital, Anzio Road, Observatory 7925, Cape Town, South Africa.
| | - David G Bishop
- Department of Anaesthesiology and Critical Care, University of KwaZulu-Natal, South Africa; Department of Anaesthesia, Critical Care and Pain Management, University of KwaZulu-Natal, Grey's Hospital, Town Bush Road, Pietermaritzburg, 3201, South Africa.
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8
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van Dyk D, Dyer RA, Fernandes NL. Preeclampsia in 2021-a Perioperative Medical Challenge for the Anesthesiologist. Anesthesiol Clin 2021; 39:711-725. [PMID: 34776105 DOI: 10.1016/j.anclin.2021.08.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The authors provide a review of recent advances in the understanding of pathophysiology and perioperative management of preeclampsia and eclampsia, from the perspective of the anesthesiologist. This review includes aspects of assessment of severity of disease, hemodynamic monitoring, peripartum anesthesia care, and postpartum management. The perioperative management of patients with eclampsia is also discussed.
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Affiliation(s)
- Dominique van Dyk
- Department of Anaesthesia and Perioperative Medicine, University of Cape Town, D23 Department of Anaesthesia and Perioperative Medicine, Groote Schuur Hospital, Anzio Road, Observatory, 7925, Cape Town, South Africa.
| | - Robert A Dyer
- Department of Anaesthesia and Perioperative Medicine, University of Cape Town, D23 Department of Anaesthesia and Perioperative Medicine, Groote Schuur Hospital, Anzio Road, Observatory, 7925, Cape Town, South Africa
| | - Nicole L Fernandes
- Department of Anaesthesia and Perioperative Medicine, University of Cape Town, D23 Department of Anaesthesia and Perioperative Medicine, Groote Schuur Hospital, Anzio Road, Observatory, 7925, Cape Town, South Africa
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9
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Biricik E, Ünlügenç H. Vasopressors for the Treatment and Prophylaxis of Spinal Induced Hypotension during Caesarean Section. Turk J Anaesthesiol Reanim 2021; 49:3-10. [PMID: 33718899 PMCID: PMC7932705 DOI: 10.5152/tjar.2020.70] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 12/23/2019] [Indexed: 11/24/2022] Open
Abstract
Vasopressors have currently become the mainstay therapy for the management of spinal-induced hypotension (SIH) as the major mechanism of hypotension after spinal anaesthesia is the loss of arteriolar tone produced by sympathetic block. Vasopressors for the prophylaxis and treatment of SIH have been the subject of a significant amount of research, yet remain an attractive and important clinical problem. This review will highlight controversies and recent research on the use of vasopressors for both prophylaxis and treatment of SIH. For decades, ephedrine was considered to be the best vasopressor for the management of maternal hypotension. However, its use has been reported to be associated with a 5-fold increased risk of foetal acidosis than phenylephrine. At present, phenylephrine is the vasopressor of choice for preventing and treating SIH at caesarean section. However, its use is often associated with a decreased heart rate and low cardiac output state owing to the lack of β-mimetic activity. Norepinephrine has been introduced as an alternative vasopressor for preventing and treating SIH because of its additional β-mimetic activity. However before its routine clinical use, a further series of studies are needed to establish its efficacy and safety for both the mother and foetus.
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Affiliation(s)
- Ebru Biricik
- Department of Anaesthesiology and Reanimation, Çukurova University School of Medicine, Adana, Turkey
| | - Hakkı Ünlügenç
- Department of Anaesthesiology and Reanimation, Çukurova University School of Medicine, Adana, Turkey
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Heesen M, Girard T, Klimek M. Noradrenaline - at best it is not worse. A comparison with phenylephrine in women undergoing spinal anaesthesia for caesarean section. Anaesthesia 2021; 76:743-747. [PMID: 33406274 DOI: 10.1111/anae.15363] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/30/2020] [Indexed: 12/01/2022]
Affiliation(s)
- M Heesen
- Department of Anaesthesia, Kantonsspital Baden, Baden, Switzerland
| | - T Girard
- Department of Anaesthesia, University Hospital Basel, Basel, Switzerland
| | - M Klimek
- Department of Anaesthesiology, Erasmus University Medical Centre, Rotterdam, The Netherlands
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Heesen M, Halpern S. Why we need systematic reviews and meta-analyses. Don't miss the forest for the trees. Int J Obstet Anesth 2020; 45:11-13. [PMID: 33309180 DOI: 10.1016/j.ijoa.2020.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 10/08/2020] [Accepted: 11/01/2020] [Indexed: 11/16/2022]
Affiliation(s)
- M Heesen
- Department of Anaesthesia, Kantonsspital Baden, Baden, Switzerland.
| | - S Halpern
- Department of Anesthesiology and Pain Medicine, University of Toronto and Sunnybrook Health Sciences Centre, Toronto, Canada
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12
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Columb MO, Cochrane NE, Thompson EL. Forest plots and deforestation: time to save the trees! Int J Obstet Anesth 2020; 45:14-16. [PMID: 33358636 DOI: 10.1016/j.ijoa.2020.11.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 10/20/2020] [Accepted: 11/01/2020] [Indexed: 01/17/2023]
Affiliation(s)
- M O Columb
- Department of Anaesthesia and Intensive Care Medicine Manchester University Foundation NHS Trust Wythenshawe Hospital, Manchester, UK.
| | - N E Cochrane
- Department of Intensive Care Medicine and Anaesthesia, NIHR Academic Clinical Fellow in Intensive Care Medicine, Manchester University Foundation NHS Trust Wythenshawe Hospital, UK
| | - E L Thompson
- Department of Anaesthesia, Manchester University Foundation NHS Trust, Wythenshawe Hospital, Manchester, UK
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El Sherbiny D, Wahba MEK. Studying the effect of vasopressors on therapeutic drug monitoring of two local anesthetics using hybrid micelle liquid chromatography as an analysis tool. J Chromatogr B Analyt Technol Biomed Life Sci 2020; 1154:122277. [PMID: 32866937 DOI: 10.1016/j.jchromb.2020.122277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 07/06/2020] [Accepted: 07/19/2020] [Indexed: 11/17/2022]
Abstract
A hybrid micelle based mobile phase was used to develop and validate a liquid chromatographic method for the separation and quantification of two local anesthetics namely; lidocaine hydrochloride (LID), and bupivacaine hydrochloride (BPV) in presence of the frequently co administered vasopressors phenyl ephrine (PHR) and ephedrine (EPH). Optimization of chromatographic separation conditions was performed applying experimental one factor at a time tool, and design of experiment, where the retention behavior of all analytes using both optimization protocols was in accordance. Chromatographic separation was carried on a C8 column operating at 40 °C at a flow rate of 1.5 mL/min. using a mobile phase consisting of 0.18 M sodium dodecyl sulphate, 10% acetonitrile, containing 0.3% triethyl amine and adjusted to pH 7 using 2 M ortho phosphoric acid, adopting UV detection at 230 nm. The proposed method was fully validated and applied to both in vitro and in vivo analysis of rat blood samples. The pharmacokinetics of both LID and BPV was followed when they were solitary injected or when co administered with either PHR or EPH. Moreover, the in vitro spiked experiment was also subjected to documented bio-analytical validation procedures.
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Affiliation(s)
- Dina El Sherbiny
- Department of Pharmaceutical Chemistry, Faculty of Pharmacy, Delta University for Science and Technology, 35712 Gamasa, Egypt; Department of Medicinal Chemistry, Faculty of Pharmacy, Mansoura University, Mansoura 35516, Egypt
| | - Mary E K Wahba
- Department of Pharmaceutical Chemistry, Faculty of Pharmacy, Delta University for Science and Technology, 35712 Gamasa, Egypt; Department of Pharmaceutical Analytical Chemistry, Faculty of Pharmacy, Mansoura University, Mansoura 35516, Egypt.
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Abstract
PURPOSE OF REVIEW Preeclampsia remains an important cause of maternal and neonatal morbidity and mortality. Recent interest in angiogenic biomarkers as a prognostic indicator is reviewed, together with analgesic, anaesthetic and critical-care management of the preeclamptic patient. RECENT FINDINGS There has been recent interest in the angiogenic biomarkers placental growth factor and soluble fms-like tyrosine kinase-1 in establishing the diagnosis of preeclampsia and guiding its management. Neuraxial blocks are recommended for both labour and operative delivery if not contraindicated by thrombocytopenia or coagulopathy, although a safe lower limit for platelet numbers has not been established. For spinal hypotension phenylephrine is noninferior to ephedrine in preeclamptic parturients and may offer some benefits. When general anaesthesia is required, efforts must be made to blunt the hypertensive response to laryngoscopy and intubation. Transthoracic echocardiography has emerged as useful technique to monitor maternal haemodynamics in preeclampsia. SUMMARY Improvements in the diagnosis of preeclampsia may lead to better outcomes for mothers and babies. Peripartum care requires a multidisciplinary team approach with many preeclamptic women receiving neuraxial analgesia or anaesthesia. Women with severe preeclampsia may require critical-care support and this should meet the same standards afforded to other acutely unwell patients.
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15
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Singh PM, Singh NP, Reschke M, Ngan Kee WD, Palanisamy A, Monks DT. Vasopressor drugs for the prevention and treatment of hypotension during neuraxial anaesthesia for Caesarean delivery: a Bayesian network meta-analysis of fetal and maternal outcomes. Br J Anaesth 2020; 124:e95-e107. [DOI: 10.1016/j.bja.2019.09.045] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 09/27/2019] [Accepted: 09/27/2019] [Indexed: 11/25/2022] Open
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Lee A, Ngan Kee W. Effects of Vasoactive Medications and Maternal Positioning During Cesarean Delivery on Maternal Hemodynamics and Neonatal Acid-Base Status. Clin Perinatol 2019; 46:765-783. [PMID: 31653307 DOI: 10.1016/j.clp.2019.08.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Maternal hemodynamics, positioning, and anesthesia technique for cesarean delivery influence neonatal acid-base balance; direct effects from drugs that cross the placenta also have an influence. Spinal anesthesia limits fetal exposure to depressant drugs and avoids maternal airway instrumentation, but is associated with hypotension. Hypotension may be prevented/treated with vasopressors and intravenous fluids. Current evidence supports phenylephrine as the first-line vasopressor. Fifteen degrees of lateral tilt during cesarean delivery has been advocated to relieve vena caval obstruction, but routine use may be unnecessary in healthy nonobese women having elective cesarean delivery if maternal blood pressure is maintained near baseline.
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Affiliation(s)
- Allison Lee
- Department of Anesthesiology, Columbia University Medical Center, Columbia University, 630 West 168th Street PH-5, New York, NY 10032, USA.
| | - Warwick Ngan Kee
- Department of Anesthesiology, Sidra Medicine, Al Gharrafa Street, Ar-Rayyan, Doha, Qatar
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Shapiro J, Ginosar Y, Gielchinsky Y, Elchalal U, Bromberg Z, Corchia-Nachmanson N, Abramovitch R. BOLD-MRI demonstrates acute placental and fetal organ hypoperfusion with fetal brain sparing in response to phenylephrine but not ephedrine. Placenta 2019; 90:52-57. [PMID: 32056552 DOI: 10.1016/j.placenta.2019.11.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 11/15/2019] [Accepted: 11/28/2019] [Indexed: 11/24/2022]
Abstract
INTRODUCTION We previously reported blood oxygen level dependent MRI (BOLD-MRI) for monitoring placental and fetal hemodynamic changes in mice following maternal hypercapnia. Here we use BOLD-MRI to compare the placental and fetal hemodynamic effects of different maternal vasopressors in mice. METHODS Pregnant ICR mice (n = 16; E17.5) anesthetized with pentobarbital (80 mg/kg i.p.) were placed supine in a 4.7-T Bruker Biospec MRI. Following baseline images, equipotential doses of ephedrine (10 mg/kg) or phenylephrine (10mcg/kg) were administered intravenously. Changes in placental and fetal signal were analyzed from T2*-weighted gradient echo MR images (TR/TE = 147/10 ms). Different regions of interest (placenta, fetal heart, fetal liver and fetal brain) were identified. Percentage change of BOLD-MRI signal intensity (SI) were presented as time curves. RESULTS Ephedrine and phenylephrine elicited markedly different effects. Phenylephrine caused an approximate 50% reduction in placental, fetal heart and fetal liver BOLD-MRI-SI, but fetal brain BOLD-MRI-SI was unchanged (statistically different from placenta and other fetal organs; p < 0.001), and the fetal brain/liver BOLD-MRI-SI ratio was markedly increased versus baseline (p < 0.001). Following ephedrine, placental BOLD-MRI-SI increased 30% and fetal heart BOLD-MRI-SI was reduced 26%; other fetal organs were unchanged. Blood gases were unchanged. DISCUSSION Phenylephrine induced BOLD-MRI-SI changes suggestive of placental and fetal hypoperfusion with brain sparing. Ephedrine induced BOLD-MRI-SI changes suggestive of increased cardiac output; we speculate that reduced fetal heart BOLD-MRI-SI may be due to increased fetal myocardial oxygen extraction or metabolic acidosis. The result demonstrates the potential of BOLD-MRI as a non-invasive hemodynamic tool for assessing pharmacodynamics effects in the placental and fetus.
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Affiliation(s)
- Joel Shapiro
- Department of Anesthesiology and Critical Care Medicine, Hadassah Hebrew University Medical Center, Ein Karem, Jerusalem, Israel
| | - Yehuda Ginosar
- Department of Anesthesiology and Critical Care Medicine, Hadassah Hebrew University Medical Center, Ein Karem, Jerusalem, Israel; Department of Anesthesiology, Washington University School of Medicine, St Louis, MO, USA; Wohl Institute of Translational Medicine, Hadassah Hebrew University Medical Center, Jerusalem, Israel.
| | - Yuval Gielchinsky
- Department of Obstetrics and Gynecology, Hadassah Hebrew University Medical Center, Ein Karem, Jerusalem, Israel
| | - Uriel Elchalal
- Department of Obstetrics and Gynecology, Hadassah Hebrew University Medical Center, Ein Karem, Jerusalem, Israel
| | - Zohar Bromberg
- The Goldyne Savad Institute of Gene Therapy and MRI Laboratory, Hadassah Hebrew University Medical Center, Ein Karem, Jerusalem, Israel
| | - Nathalie Corchia-Nachmanson
- Wohl Institute of Translational Medicine, Hadassah Hebrew University Medical Center, Jerusalem, Israel; The Goldyne Savad Institute of Gene Therapy and MRI Laboratory, Hadassah Hebrew University Medical Center, Ein Karem, Jerusalem, Israel
| | - Rinat Abramovitch
- Wohl Institute of Translational Medicine, Hadassah Hebrew University Medical Center, Jerusalem, Israel; The Goldyne Savad Institute of Gene Therapy and MRI Laboratory, Hadassah Hebrew University Medical Center, Ein Karem, Jerusalem, Israel
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Heesen M, Hilber N, Rijs K, van der Marel C, Rossaint R, Schäffer L, Klimek M. Intrathecal catheterisation after observed accidental dural puncture in labouring women: update of a meta-analysis and a trial-sequential analysis. Int J Obstet Anesth 2019; 41:71-82. [PMID: 31522933 DOI: 10.1016/j.ijoa.2019.08.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 07/11/2019] [Accepted: 08/05/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND Our meta-analysis from 2013 showed that inserting a catheter intrathecally after an observed accidental dural puncture can reduce the need for epidural blood patch in labouring women requesting epidural analgesia. We updated our conventional meta-analysis and added a trial-sequential analysis (TSA). METHODS A systematic literature search was conducted to identify studies that compared inserting the catheter intrathecally with an epidural catheter re-site or with no intervention. The extracted data were pooled and the risk ratio (RR) and 95% confidence interval (95%CI) for the incidence of post-dural puncture headache (PDPH) was calculated, using the random effects model. A contour-enhanced funnel plot was constructed. A TSA was performed and the cumulative Z score, monitoring and futility boundaries were constructed. RESULTS Our search identified 13 studies, reporting on 1653 patients, with a low risk of bias. The RR for the incidence of PDPH was 0.82 (95%CI 0.71 to 0.95) and the RR for the need for epidural blood patch was 0.62 (95%CI 0.49 to 0.79); heterogeneity of both analyses was high. The TSA showed that the monitoring or futility boundaries were not crossed, indicating insufficient data to exclude a type I error of statistical analysis. Contour-enhanced funnel plots were symmetric, suggesting no publication bias. CONCLUSIONS Conventional meta-analyses showed for the first time that intrathecal catheterisation can reduce the incidence of PDPH. However, TSA did not corroborate this finding. Despite increasing use in clinical practice there is no firm evidence on which to base a definite conclusion.
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Affiliation(s)
- M Heesen
- Department of Anaesthesia, Kantonsspital Baden, Baden, Switzerland.
| | - N Hilber
- Department of Anaesthesia, Kantonsspital Baden, Baden, Switzerland
| | - K Rijs
- Department of Anaesthesiology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - C van der Marel
- Department of Anaesthesiology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - R Rossaint
- Department of Anaesthesiology, University Hospital RWTH Aachen, Aachen, Germany
| | - L Schäffer
- Department of Obstetrics, Kantonsspital Baden, Baden, Switzerland
| | - M Klimek
- Department of Anaesthesiology, Erasmus University Medical Centre, Rotterdam, The Netherlands
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