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Hassabelnaby YS, Hasanin AM, Shamardal M, Mostafa M, Zaki RM, Elsherbiny M, Refaat S. Epinephrine vs. phenylephrine infusion for prophylaxis against maternal hypotension after spinal anesthesia for cesarean delivery: a randomized controlled trial. J Anesth 2024; 38:500-507. [PMID: 38789602 DOI: 10.1007/s00540-024-03344-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 05/03/2024] [Indexed: 05/26/2024]
Abstract
BACKGROUND The hemodynamic effects of relatively low-dose epinephrine and phenylephrine infusions during cesarean delivery under spinal anesthesia were compared. METHODS This randomized controlled trial included full-term pregnant women who underwent elective cesarean delivery. After spinal anesthesia, participants received either epinephrine (0.03 mcg/kg/min) or phenylephrine (0.4 mcg/kg/min) infusion that continued until 5 min after delivery. The primary outcome was a composite outcome of the occurrence of any of hypotension, hypertension, bradycardia, and/or tachycardia. Neonatal outcomes, including umbilical artery blood gas and Apgar scores, were assessed. RESULTS In total, 98 patients in each group were analyzed, and the number of patients with the composite outcome was comparable between the epinephrine and phenylephrine groups (30/98 [31%] vs. 31/98 [32%], respectively; P = 0.877). However, the incidence of hypotension was likely lower in the epinephrine group than in the phenylephrine group (P = 0.066), and the number of hypotensive episodes per patient was lower in the epinephrine group than in the phenylephrine group. On the other hand, the incidence of tachycardia was higher in the epinephrine group than that in the phenylephrine group. The incidence of hypertension was comparable between the two groups and none of the participants developed bradycardia. Neonatal outcomes were comparable between the two groups. CONCLUSIONS Epinephrine and phenylephrine infusion produced comparable maternal hemodynamics and neonatal outcomes. Epinephrine was associated with a higher incidence of maternal tachycardia and likely lower incidence of maternal hypotension than phenylephrine. IRB number: MD-245-2022. CLINICAL TRIAL REGISTRATION This study was registered on May 31, 2023 at clinicaltrials.gov registry, NCT05881915, URL: https://classic. CLINICALTRIALS gov/ct2/show/NCT05881915term=NCT05881915&draw=2&rank=1.
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Affiliation(s)
| | - Ahmed M Hasanin
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt.
| | - Mohamed Shamardal
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt
| | - Maha Mostafa
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt
| | - Rana M Zaki
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt
| | - Mona Elsherbiny
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt
| | - Sherin Refaat
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt
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Joachim J, Cartailler J, Vallee F, Lefevre T, Callebert J, Gayat E, Lavielle M. Design of a pharmacokinetic/pharmacodynamic model for administration of low dose peripheral norepinephrine during general anaesthesia. Br J Clin Pharmacol 2024. [PMID: 39039779 DOI: 10.1111/bcp.16180] [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: 03/13/2024] [Revised: 05/24/2024] [Accepted: 06/24/2024] [Indexed: 07/24/2024] Open
Abstract
AIMS Intraoperative hypotension is a risk factor for kidney, heart and cognitive postoperative complications. Literature suggests that the use of low-dose peripheral norepinephrine (NOR) reduces organ dysfunction, yet its administration remains unstandardized. In this work we develop a pharmacokinetic (PK)/pharmacodynamic (PD) model of NOR and its effect on mean arterial pressure (MAP). METHODS From June 2018 to December 2021, we included patients scheduled for elective neurosurgery and requiring vasopressors for intraoperative hypotension management at Lariboisière Hospital, Paris. Low doses of NOR were administered peripherally, and successive arterial blood samples were collected to track its plasmatic concentration. We used a compartmental modelling approach for NOR PK. We developed and compared 2 models for NOR PD on MAP. Model comparison was done using Bayes information criteria. The resulting PK/PD model parameters were fitted over the entire population and linked to age, weight, height and sex. RESULTS We included 29 patients (age 52 [46-64] years, 69% female). NOR median time to peak effect on MAP was 74 [53-94] s. After bolus administration, MAP increased by 24% (15-31%). A 2-comparment model with depot best captured NOR PK. NOR PD effect on MAP was well represented by both Emax and Windkessel models, with better results for the former. We found that age, height and weight as well as history of smoking and hypertension were correlated with model parameters. CONCLUSION We have developed a PK/PD model to accurately track norepinephrine plasma concentration and its effect on MAP over time, which could serve for target-controlled infusion.
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Affiliation(s)
- Jona Joachim
- Université Paris Cité, Paris, France
- Department of Anaesthesiology, Burn and Critical Care, St-Louis-Lariboisière-Fernand Widal University Hospitals, Paris, France
| | - Jérôme Cartailler
- Université Paris Cité, Paris, France
- Department of Anaesthesiology, Burn and Critical Care, St-Louis-Lariboisière-Fernand Widal University Hospitals, Paris, France
| | - Fabrice Vallee
- Université Paris Cité, Paris, France
- Department of Anaesthesiology, Burn and Critical Care, St-Louis-Lariboisière-Fernand Widal University Hospitals, Paris, France
| | - Thomas Lefevre
- Department of Anaesthesiology, Burn and Critical Care, St-Louis-Lariboisière-Fernand Widal University Hospitals, Paris, France
| | - Jacques Callebert
- Université Paris Cité, Paris, France
- Service of Biochemistry and Molecular Biology, St-Louis-Lariboisière-Fernand Widal University Hospitals, Paris, France
| | - Etienne Gayat
- Université Paris Cité, Paris, France
- Department of Anaesthesiology, Burn and Critical Care, St-Louis-Lariboisière-Fernand Widal University Hospitals, Paris, France
| | - Marc Lavielle
- Inria & CMAP, Ecole Polytechnique, CNRS, Institut Polytechnique de Paris, Paris, France
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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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Park HS, Choi WJ. Use of vasopressors to manage spinal anesthesia-induced hypotension during cesarean delivery. Anesth Pain Med (Seoul) 2024; 19:85-93. [PMID: 38725163 PMCID: PMC11089295 DOI: 10.17085/apm.24037] [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: 03/19/2024] [Revised: 04/11/2024] [Accepted: 04/19/2024] [Indexed: 05/15/2024] Open
Abstract
Cesarean sections are commonly performed under spinal anesthesia, which can lead to hypotension, adversely affecting maternal and fetal outcomes. Hypotension following spinal anesthesia is generally defined as a blood pressure of 80-90% below the baseline value. Various strategies have been implemented to reduce the incidence of spinal anesthesia-induced hypotension. The administration of vasopressors is a crucial method for preventing and treating hypotension. In the past decade, phenylephrine, a primarily alpha-adrenergic agonist, has been the preferred vasopressor for cesarean sections. Recently, norepinephrine, a potent alpha-agonist with modest beta-agonist activity, has gained popularity owing to its advantages over phenylephrine. Vasopressors can be administered via a bolus or continuous infusion. Although administering boluses alone is simpler in a clinical setting, continuous prophylactic infusion initiated immediately after spinal anesthesia is more effective in reducing the incidence of hypotension. Tailoring the infusion dose based on the patient's body weight and adjusting the rate in response to blood pressure changes, in addition to using a prophylactic or rescue bolus, helps reduce blood pressure variability during cesarean sections under spinal anesthesia until neonatal delivery.
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Affiliation(s)
- Hee-Sun Park
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Woo-Jong Choi
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Wu W, Zheng Q, Zhou J, Li X, Zhou H. Norepinephrine versus phenylephrine on cerebral tissue oxygen saturation during prophylactic infusion to prevent spinal hypotension for Caesarean birth. Medicine (Baltimore) 2024; 103:e37454. [PMID: 38457564 PMCID: PMC10919502 DOI: 10.1097/md.0000000000037454] [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: 12/05/2023] [Revised: 01/08/2024] [Accepted: 02/09/2024] [Indexed: 03/10/2024] Open
Abstract
BACKGROUND Phenylephrine may cause a reduction in maternal cerebral tissue oxygen saturation (SctO2) during Caesarean birth to prevent spinal hypotension; however, the effect of norepinephrine has not been assessed. We hypothesized that norepinephrine was more effective than phenylephrine in maintaining SctO2 when preventing spinal hypotension during Caesarean birth. METHODS We conducted a randomized, double-blind, controlled study. Sixty patients were randomly assigned to prophylactic norepinephrine or phenylephrine to maintain blood pressure during spinal anesthesia for Caesarean birth. SctO2, systolic blood pressure, and heart rate were recorded. The primary outcome was the incidence of a 10% reduction of intraoperative SctO2 from baseline or more during Caesarean birth. RESULTS The norepinephrine group had a lower incidence of more than 10% reduction of intraoperative SctO2 from baseline than that of the phenylephrine group (13.3% vs 40.0%, P = .02). The change in SctO2 after 5 minutes of norepinephrine infusion was higher than that after phenylephrine infusion (-3.4 ± 4.7 vs -6.2 ± 5.6, P = .04). The change in SctO2 after 10 minutes of norepinephrine infusion was higher than that after phenylephrine infusion (-2.5 ± 4.4 vs -5.4 ± 4.6, P = .006). The norepinephrine group showed greater left- and right-SctO2 values than the phenylephrine group at 5 to 10 minutes. However, the change in systolic blood pressure was comparable between the 2 groups. CONCLUSION Norepinephrine was more effective than phenylephrine in maintaining SctO2 when preventing spinal hypotension during Caesarean birth. However, the changes in clinical outcomes caused by differences in SctO2 between the 2 medications warrant further studies.
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Affiliation(s)
- Weiguo Wu
- Department of Anaesthesiology, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao, P. R. China
| | - Qiang Zheng
- Department of Anaesthesiology, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao, P. R. China
| | - Jinfeng Zhou
- Department of Anaesthesiology, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao, P. R. China
| | - Xiujuan Li
- Department of Anaesthesiology, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao, P. R. China
| | - Haipeng Zhou
- Department of Anaesthesiology, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao, P. R. China
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Pan ZB, Sheng ZM, Zhu M, Mei Z, Shen YP, Liu JP, Qian XW. Randomized Double-Blinded Comparison of Intermittent Boluses Phenylephrine and Norepinephrine for the Treatment of Postspinal Hypotension in Patients with Severe Pre-Eclampsia During Cesarean Section. Drug Des Devel Ther 2024; 18:639-650. [PMID: 38476203 PMCID: PMC10927372 DOI: 10.2147/dddt.s446657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 02/08/2024] [Indexed: 03/14/2024] Open
Abstract
Background Norepinephrine has fewer negative effects on heart rate (HR) and cardiac output (CO) for treating postspinal hypotension (PSH) compared with phenylephrine during cesarean section. However, it remains unclear whether fetuses from patients with severe pre-eclampsia could benefit from the superiority of CO. The objective of this study was to compare the safety and efficacy of intermittent intravenous boluses of phenylephrine and norepinephrine used in equipotent doses for treating postspinal hypotension in patients with severe pre-eclampsia during cesarean section. Methods A total of 80 patients with severe pre-eclampsia who developed PSH predelivery during cesarean section were included. Eligible patients were randomized at a 1:1 ratio to receive either phenylephrine or norepinephrine for treating PSH. The primary outcome was umbilical arterial pH. Secondary outcomes included other umbilical cord blood gas values, Apgar scores at 1 and 5 min, changes in hemodynamic parameters including CO, mean arterial pressure (MAP), HR, stroke volume (SV), and systemic vascular resistance (SVR), the number of vasopressor boluses required, and the incidence of bradycardia, hypertension, nausea, vomiting, and dizziness. Results No significant difference was observed in umbilical arterial pH between the phenylephrine and norepinephrine groups (7.303±0.38 vs 7.303±0.44, respectively; P=0.978). Compared with the phenylephrine group, the overall CO (P=0.009) and HR (P=0.015) were greater in the norepinephrine group. The median [IQR] total number of vasopressor boluses required was comparable between the two groups (2 [1 to 3] and 2 [1 to 3], respectively; P=0.942). No significant difference was found in Apgar scores or the incidence of maternal complications between groups. Conclusion A 60 µg bolus of phenylephrine and a 4.5 µg bolus of norepinephrine showed similar neonatal outcomes assessed by umbilical arterial pH and were equally effective when treating PSH during cesarean section in patients with severe pre-eclampsia. Norepinephrine provided a higher maternal CO and a lower incidence of bradycardia.
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Affiliation(s)
- Zheng-Bin Pan
- Department of Anesthesiology, Women’s Hospital, Zhejiang University School of Medicine, Hangzhou, People’s Republic of China
- Department of Anesthesiology, Shaoxing Maternity and Child Health Care Hospital, Shaoxing, 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
| | - Miao Zhu
- 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
| | - Yan-Ping Shen
- Department of Anesthesiology, Women’s Hospital, Zhejiang University School of Medicine, Hangzhou, People’s Republic of China
| | - Jin-Ping Liu
- 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
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Wang F, Lü Q, Wang M, Xu H, Xie D, Yang Z, Ye Q. Ultrasound-guided caudal anaesthesia combined with epidural anaesthesia for caesarean section: a randomized controlled clinical trial. BMC Pregnancy Childbirth 2024; 24:105. [PMID: 38308257 PMCID: PMC10835986 DOI: 10.1186/s12884-024-06298-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 01/28/2024] [Indexed: 02/04/2024] Open
Abstract
BACKGROUND Although epidural anaesthesia and spinal anaesthesia are currently the general choices for patients undergoing caesarean section, these two neuraxial anaesthesia methods still have drawbacks. Caudal anaesthesia has been considered to be more appropriate for gynaecological surgery. The purpose of this study was to compare epidural anaesthesia combined with caudal anaesthesia, spinal anaesthesia and single-space epidural anaesthesia for caesarean section with respect to postoperative comfort and intraoperative anaesthesia quality. METHODS In this clinical trial, 150 patients undergoing elective caesarean section were recruited and randomized into three groups according to a ratio of 1:1:1to receive epidural anaesthesia only, spinal anaesthesia only or epidural anaesthesia combined with caudal anaesthesia. The primary outcome was postoperative comfort in the three groups. Secondary outcomes included intraoperative anaesthesia quality and the incidences of nausea, vomiting, postdural puncture headache, maternal bradycardia, or hypotension. RESULTS More patients were satisfied with the intraoperative anaesthesia quality in the EAC group than in the EA group (P = 0.001). The obstetrician was more significantly satisfied with the intraoperative anaesthesia quality in the SA and EAC groups than in the EA group (P = 0.004 and 0.020, respectively). The parturients felt more comfortable after surgery in the EA and EAC groups (P = 0.007). The incidence of maternal hypotension during caesarean section was higher in the SA group than in the EA and EAC groups (P = 0.001 and 0.019, respectively). CONCLUSIONS Epidural anaesthesia combined with caudal anaesthesia may be a better choice for elective caesarean section. Compared with epidural anaesthesia and spinal anaesthesia, it has a higher quality of postoperative comfort and intraoperative anaesthesia.
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Affiliation(s)
- Fangjun Wang
- Department of Anesthesiology, Affiliated Hospital, North Sichuan Medical College, No. 63, Cultural Road, Shunqing District, NanchongCity, Sichuan Province, China.
| | - Qi Lü
- Department of Operation Center, Affiliated Hospital, North Sichuan Medical College, Nanchong, 637000, China
| | - Min Wang
- North Sichuan Medical College, Nanchong, 637000, China
| | - Hongchun Xu
- Department of Anesthesiology, Affiliated Hospital, North Sichuan Medical College, No. 63, Cultural Road, Shunqing District, NanchongCity, Sichuan Province, China
| | - Dan Xie
- Department of Anesthesiology, Affiliated Hospital, North Sichuan Medical College, No. 63, Cultural Road, Shunqing District, NanchongCity, Sichuan Province, China
| | - Zheng Yang
- North Sichuan Medical College, Nanchong, 637000, China
| | - Qin Ye
- North Sichuan Medical College, Nanchong, 637000, China
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Fu F, Yang MJ, Xu LL, Chen XZ. A comparison of the effect of phenylephrine and norepinephrine on uteroplacental vascular resistance during the treatment of postspinal hypotension in preeclamptic patients: A randomised controlled study. Eur J Anaesthesiol 2024; 41:150-152. [PMID: 38164096 PMCID: PMC10763705 DOI: 10.1097/eja.0000000000001924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Affiliation(s)
- Feng Fu
- From the Department of Anaesthesia, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, China (FF, MJY, LLX, XZC)
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Amin SM, Hasanin A, Ghanem NT, Mostafa M, Elzayat N, Elsherbiny M, Abdelwahab Y. Comparison of Two Norepinephrine Rescue Bolus Doses for Management of Severe Post-Spinal Hypotension During Elective Caesarean Delivery: A Randomized, Controlled Trial. Int J Gen Med 2024; 17:153-160. [PMID: 38264276 PMCID: PMC10804872 DOI: 10.2147/ijgm.s446021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Accepted: 01/12/2024] [Indexed: 01/25/2024] Open
Abstract
Background Post-spinal hypotension is associated with maternal and neonatal complications; therefore, prompt control maternal blood pressure is necessary. In this study, we aimed to compare the efficacy and safety of two norepinephrine bolus doses in the rescue management of severe maternal hypotension during elective Cesarean delivery. Methods We included full-term pregnant women scheduled for Cesarean delivery under spinal anesthesia. Patients were randomized to receive either 5-mcg norepinephrine (n=79) or 10-mcg norepinephrine (n=79) for treatment of severe postspinal hypotension (systolic blood pressure ≤60% of baseline reading). The management of the hypotensive episode was considered successful if systolic blood pressure was >80% of the baseline within 2 mins of the bolus. The primary outcome was the incidence of successful management of severe post-spinal hypotension. Secondary outcomes included the incidence of reactive bradycardia, reactive hypertension, umbilical blood gases, and neonatal Apgar score at 5-min post-delivery. Results We included 73 patients in the 5-mcg group and 76 patients in the 10-mcg group into the final analysis. The incidence of successful management of severe hypotensive episodes was comparable between the two groups (43/73 [59%] and 46/76 [60%] in the 5-and 10-mcg group, respectively, P=0.917). The incidence of reactive hypertension, bradycardia, and neonatal outcomes were comparable between the two groups. Conclusion In mothers undergoing Cesarean delivery under spinal anesthesia, 10-mcg norepinephrine bolus was not superior to the 5-mcg bolus in the management of severe hypotension. Furthermore, the incidence of reactive bradycardia and hypertension was comparable in the two doses. Clinical Trial Registration NCT05290740, URL: https://clinicaltrials.gov/ct2/show/NCT05290740.
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Affiliation(s)
- Sarah M Amin
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt
| | - Ahmed Hasanin
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt
| | - Nashwa Talaat Ghanem
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt
| | - Maha Mostafa
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt
| | - Nashwa Elzayat
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt
| | - Mona Elsherbiny
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt
| | - Yaser Abdelwahab
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt
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Baytaş V, Karadağ Erkoç S, Özçelik M, Gökmen D, Bermede AO, Selvi Can Ö, Uysalel A. A Randomized, Double-Blind, Graded Dose-Response Study of Norepinephrine Administration for Prevention of Post-Spinal Hypotension during Elective Cesarean Delivery. J Clin Med 2023; 12:6437. [PMID: 37892573 PMCID: PMC10607547 DOI: 10.3390/jcm12206437] [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: 09/12/2023] [Revised: 10/02/2023] [Accepted: 10/09/2023] [Indexed: 10/29/2023] Open
Abstract
Norepinephrine has been recently introduced for prophylaxis against post-spinal hypotension during cesarean delivery; however, no data are available regarding its optimum dosing scheme. The primary objective of this study is to compare three different infusion and bolus dose combinations of norepinephrine for prophylaxis against post-spinal hypotension during cesarean delivery. This randomized, double-blind study was performed between February 2021 and May 2022. The study protocol was registered at Clinicaltrials.gov with the identification number NCT04701190. A total of 192 parturients were enrolled into this study. Patients were assigned to three groups-Zero-Bolus High-Infusion (Group ZBHI, 0 µg/0.1 µg kg-1 min-1, n = 61), Moderate-Bolus Moderate-Infusion (Group MBMI, 5 µg/0.075 µg kg-1 min-1, n = 61) and High-Bolus Low-Infusion (Group HBLI, 10 µg/0.05 µg kg-1 min-1, n = 61)-according to different combinations of norepinephrine infusion and bolus doses. All patients received spinal anesthesia with 10 mg hyperbaric bupivacaine plus 12.5 µg fentanyl. Immediately after cerebrospinal fluid was obtained, patients underwent a norepinephrine protocol corresponding to the randomized group. The primary outcome was the incidence of post-spinal hypotension. Secondary outcomes were post-delivery hypotension, frequency of post-spinal hypertension and bradycardia, and neonatal outcomes. The incidence of post-spinal hypotension was 11.7% in Group HBLI, 6.7% in Group ZBHI and 1.7% in Group MBMI (p = 0.1). The overall incidence of post-delivery hypotension in parturients was 41.1% (p = 0.797). The lowest frequency of post-spinal bradycardia (8.3%) and hypertension (11.7%) was seen in Group HBLI. The neonatal APGAR scores at 1st minute were higher in Group MBMI than in Group ZBHI (8.58 vs. 8.23, p = 0.001). All three infusion and bolus dose combinations of norepinephrine effectively reduced the incidence of post-spinal hypotension. However, high-dose bolus (10 µg) followed by low-dose infusion (0.05 µg kg-1 min-1) of norepinephrine can be preferred due to the reduced frequency of bradycardia and hypertension during cesarean delivery under spinal anesthesia.
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Affiliation(s)
- Volkan Baytaş
- Department of Anaesthesiology and ICM, School of Medicine, Ankara University, 06230 Ankara, Türkiye; (V.B.); (A.O.B.)
| | - Süheyla Karadağ Erkoç
- Department of Anaesthesiology and ICM, School of Medicine, Ankara University, 06230 Ankara, Türkiye; (V.B.); (A.O.B.)
| | - Menekşe Özçelik
- Department of Anaesthesiology and ICM, School of Medicine, Ankara University, 06230 Ankara, Türkiye; (V.B.); (A.O.B.)
| | - Derya Gökmen
- Department of Biostatistics, School of Medicine, Ankara University, 06290 Ankara, Türkiye;
| | - Ahmet Onat Bermede
- Department of Anaesthesiology and ICM, School of Medicine, Ankara University, 06230 Ankara, Türkiye; (V.B.); (A.O.B.)
| | - Özlem Selvi Can
- Department of Anaesthesiology and ICM, School of Medicine, Ankara University, 06230 Ankara, Türkiye; (V.B.); (A.O.B.)
| | - Asuman Uysalel
- Department of Anaesthesiology and ICM, School of Medicine, Ankara University, 06230 Ankara, Türkiye; (V.B.); (A.O.B.)
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12
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Shi M, Zheng Y, Wu Y, Ren Q. Multitask Attention-Based Neural Network for Intraoperative Hypotension Prediction. Bioengineering (Basel) 2023; 10:1026. [PMID: 37760128 PMCID: PMC10525858 DOI: 10.3390/bioengineering10091026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 08/23/2023] [Accepted: 08/29/2023] [Indexed: 09/29/2023] Open
Abstract
Timely detection and response to Intraoperative Hypotension (IOH) during surgery is crucial to avoid severe postoperative complications. Although several methods have been proposed to predict IOH using machine learning, their performance still has space for improvement. In this paper, we propose a ResNet-BiLSTM model based on multitask training and attention mechanism for IOH prediction. We trained and tested our proposed model using bio-signal waveforms obtained from patient monitoring of non-cardiac surgery. We selected three models (WaveNet, CNN, and TCN) that process time-series data for comparison. The experimental results demonstrate that our proposed model has optimal MSE (43.83) and accuracy (0.9224) compared to other models, including WaveNet (51.52, 0.9087), CNN (318.52, 0.5861), and TCN (62.31, 0.9045), which suggests that our proposed model has better regression and classification performance. We conducted ablation experiments on the multitask and attention mechanisms, and the experimental results demonstrated that the multitask and attention mechanisms improved MSE and accuracy. The results demonstrate the effectiveness and superiority of our proposed model in predicting IOH.
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Affiliation(s)
- Meng Shi
- School of Electronics, Peking University, Beijing 100871, China
| | - Yu Zheng
- School of Electronics, Peking University, Beijing 100871, China
| | - Youzhen Wu
- College of Engineering, Peking University, Beijing 100871, China
| | - Quansheng Ren
- School of Electronics, Peking University, Beijing 100871, China
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Lee S, Ju JW, Yoon S, Lee HJ, Ha JH, Hong KY, Jin US, Chang H, Cho YJ. Norepinephrine preserved flap blood flow compared to phenylephrine in free transverse rectus abdominis myocutaneous flap breast reconstruction surgery: A randomized pilot study. J Plast Reconstr Aesthet Surg 2023; 83:438-447. [PMID: 37311286 DOI: 10.1016/j.bjps.2023.04.080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 04/13/2023] [Accepted: 04/26/2023] [Indexed: 06/15/2023]
Abstract
BACKGROUND Vasopressors are used in up to 85% of cases during free flap surgery. However, their use is still debated with concerns of vasoconstriction-related complications, with rates up to 53% in minor cases. We investigated the effects of vasopressors on flap blood flow during free flap breast reconstruction surgery. We hypothesized that norepinephrine may preserve flap perfusion better than phenylephrine during free flap transfer. METHODS A randomized pilot study was performed in patients undergoing free transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction. Patients with peripheral artery disease, allergies to study drugs, previous abdominal operations, left ventricular dysfunction, or uncontrolled arrhythmias were excluded. Twenty patients were randomized to receive either norepinephrine (0.03-0.10 µg/kg/min) or phenylephrine (0.42-1.25 µg/kg/min) (each n = 10) to maintain a mean arterial pressure of 65-80 mmHg. The primary outcome was differences in mean blood flow (MBF) and pulsatility index (PI) of flap vessels after anastomosis measured using transit time flowmetry in the two groups. Secondary outcomes included flap loss, necrosis, thrombosis, wound infection, and reoperation within 7 days postoperatively. RESULTS After anastomosis, MBF showed no significant change in the norepinephrine group (mean difference, -9.4 ± 14.2 mL/min; p = 0.082), whereas it was reduced in the phenylephrine group (-7.9 ± 8.2 mL/min; p = 0.021). PI did not change in either group (0.4 ± 1.0 and 1.3 ± 3.1 in the norepinephrine and phenylephrine groups; p = 0.285 and 0.252, respectively). There were no differences in secondary outcomes between the groups. CONCLUSION During free TRAM flap breast reconstruction, norepinephrine seems to preserve flap perfusion compared to phenylephrine. However, further validation studies are required.
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Affiliation(s)
- Seohee Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Jae-Woo Ju
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Susie Yoon
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Ho-Jin Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Jeong Hyun Ha
- Department of Plastic and Reconstructive Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Ki Yong Hong
- Department of Plastic and Reconstructive Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Ung Sik Jin
- Department of Plastic and Reconstructive Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Hak Chang
- Department of Plastic and Reconstructive Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Youn Joung Cho
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea.
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Pauline A, Arthi K, Parameswari A, Vakamudi M, Manickam A. Prophylactic Fixed-Rate Phenylephrine Versus Norepinephrine Infusion in the Prevention of Post-spinal Anesthesia Hypotension During Cesarean Delivery. Cureus 2023; 15:e41251. [PMID: 37529826 PMCID: PMC10389118 DOI: 10.7759/cureus.41251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/01/2023] [Indexed: 08/03/2023] Open
Abstract
Background Maternal hypotension following spinal anesthesia can be actively countered by the use of vasopressors. Prophylactic infusion of vasopressors with a rescue bolus dosing was observed to be more effective for hemodynamic stability when compared to administering a bolus dose alone. Although phenylephrine is the recommended drug to treat spinal hypotension, many recent studies have focussed on the role of norepinephrine infusions during cesarean section. In this study, we compared prophylactic fixed-rate intravenous infusions of phenylephrine and norepinephrine during cesarean delivery under spinal anesthesia and the requirement of intraoperative provider-administered rescue bolus of phenylephrine needed to overcome post-spinal anesthesia hypotension. Methodology A total of 208 patients undergoing elective cesarean section under spinal anesthesia were randomly assigned to two groups (group P and group N). Group N included 104 patients who received norepinephrine infusion at a rate of 2.5 μg/minute (0.04 μg/kg/minute), and group P included 104 patients who received phenylephrine infusion at a rate of 50 μg/minute (0.8 μg/kg/minute) to treat spinal hypotension. The primary outcome of our study was to compare the reduction in the number and total dose of intraoperative provider-administered rescue bolus of phenylephrine needed to maintain systolic blood pressure. The secondary outcome of our study was to compare the neonatal outcome using umbilical venous blood gas sampling and Apgar score at one and five minutes. Results The total number of phenylephrine rescue bolus required to treat hypotension was significantly lower in group N (p = 0.0005) compared to group P. The neonatal outcome was similar between the two groups. Conclusions Prophylactic norepinephrine infusion when compared to prophylactic phenylephrine infusion is associated with a lesser requirement of rescue phenylephrine boluses.
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Affiliation(s)
- Anisha Pauline
- Anesthesiology, Sri Ramachandra Institute of Higher Education and Research, Chennai, IND
| | - K Arthi
- Anesthesiology, Sri Ramachandra Institute of Higher Education and Research, Chennai, IND
| | - Aruna Parameswari
- Anesthesiology, Sri Ramachandra Institute of Higher Education and Research, Chennai, IND
| | - Mahesh Vakamudi
- Anesthesiology, Sri Ramachandra Institute of Higher Education and Research, Chennai, IND
| | - Akilandeswari Manickam
- Anesthesiology, Sri Ramachandra Institute of Higher Education and Research, Chennai, IND
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de Queiroz DV, Velarde LGC, Alves RL, Verçosa N, Cavalcanti IL. Incidence of bradycardia during noradrenaline or phenylephrine bolus treatment of postspinal hypotension in cesarean delivery: A randomized double-blinded controlled trial. Acta Anaesthesiol Scand 2023; 67:797-803. [PMID: 36866963 DOI: 10.1111/aas.14225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 01/27/2023] [Accepted: 02/15/2023] [Indexed: 03/04/2023]
Abstract
The treatment of choice for spinal anesthesia-induced hypotension during cesarean section is phenylephrine. As this vasopressor can cause reflex bradycardia, noradrenaline is a suggested alternative. This randomized double-blinded controlled trial included 76 parturients undergoing elective cesarean delivery under spinal anesthesia. Women received noradrenaline in bolus doses of 5 mcg or phenylephrine in bolus doses of 100 mcg. These drugs were used intermittently and therapeutically to maintain systolic blood pressure ≥ 90% of its baseline value. The primary study outcome was bradycardia incidence (<60 bpm) with intermittent bolus administration of these drugs. Secondary outcomes included extreme bradycardia (<40 bpm), number of bradycardia episodes, hypertension (systolic blood pressure > 120% of baseline value), and hypotension (systolic blood pressure < 90% of baseline value and requiring vasopressor use). Neonatal outcomes per the Apgar scale and umbilical cord blood gas analysis were also compared. The incidence of bradycardia in both groups (51.4% and 70.3%, respectively; p = 0.16) were not significantly different. No neonates had umbilical vein or artery pH values below 7.20. The noradrenaline group required more boluses than phenylephrine group (8 vs. 5; p = 0.01). There was no significant intergroup difference in any of the other secondary outcomes. When administered in intermittent bolus doses for the treatment of postspinal hypotension in elective cesarean delivery, noradrenaline, and phenylephrine have a similar incidence of bradycardia. When treating hypotension related to spinal anesthesia in obstetric cases, strong vasopressors are commonly administered, thought these can also have side effects. This trial assessed bradycardia after bolus administration of noradrenaline or phenylephrine, and found no difference in risk for clinically meaningful bradycardia.
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Affiliation(s)
- Daniel Vieira de Queiroz
- Department of Anesthesiology, Servidores do Estado Federal Hospital (Hospital Federal dos Servidores do Estado), Rio de Janeiro, Brazil
- Medical Sciences Postgraduate Program, Fluminense Federal University (Universidade Federal Fluminense), Niteroi, Brazil
| | - Luis Guillermo Coca Velarde
- Department of Statistics, Medical Sciences Postgraduate Program, Fluminense Federal University (Universidade Federal Fluminense), Niteroi, Brazil
| | - Rodrigo Leal Alves
- Department of Postgraduate Program in Anesthesiology, Botucatu School of Medicine, São Paulo State University (Universidade Estadual Paulista), São Paulo, Brazil
| | - Nubia Verçosa
- Department of Surgery, Anesthesiology, Surgical Sciences Postgraduate Program, Federal University of Rio de Janeiro (Universidade Federal do Rio de Janeiro), Rio de Janeiro, Brazil
| | - Ismar Lima Cavalcanti
- Medical Sciences Postgraduate Program, Fluminense Federal University (Universidade Federal Fluminense), Niteroi, Brazil
- Department of General and Specialized Surgery, Anesthesiology, Fluminense Federal University (Universidade Federal Fluminense), Niteroi, Brazil
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16
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Guo L, Xu X, Qin R, Shi Y, Xue W, He L, Ma S, Chen Y. Prophylactic Norepinephrine and Phenylephrine Boluses to Prevent Postspinal Anesthesia Hypotension During Cesarean Section: A Randomized Sequential Allocation Dose-Finding Study. Drug Des Devel Ther 2023; 17:1547-1555. [PMID: 37249928 PMCID: PMC10224683 DOI: 10.2147/dddt.s406671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 05/16/2023] [Indexed: 05/31/2023] Open
Abstract
Background Norepinephrine and phenylephrine are widely used for obstetric anesthesia. Our central objective was to determine the ED (effective dose) 90 and potency ratio of prophylactic norepinephrine and phenylephrine boluses for preventing postspinal anesthesia hypotension during cesarean section. Methods Patients scheduled for elective cesarean section (n = 80) were randomly allocated to receive prophylactic norepinephrine (NE) or phenylephrine (PE) boluses immediately after induction of spinal anesthesia. An initial dose of NE (3 μg) and PE (37.5 μg) was given to the first patient, and an up-and-down sequential allocation method was used to determine the next dose level according to the responses (the effectiveness for preventing postspinal anesthesia hypotension [defined as SBP < 80% of baseline value]). Primary outcomes were ED90 and the potency ratio of prophylactic norepinephrine and phenylephrine boluses. Secondary outcomes were the incidence of postspinal anesthesia hypotension, severe postspinal anesthesia hypotension, nausea, vomiting, bradycardia, hypertension, umbilical artery blood gas values, and Apgar scores. Results The ED90 values for prophylactic norepinephrine and phenylephrine boluses were 8.0 μg (95% CI 7.1-11.0 μg) and 90.9 μg (95% CI 82.0-123.9 μg), respectively. The estimated relative potency ratio was 11.4:1. The incidence of bradycardia was lower in the NE group (2.5% vs 20%, P = 0.034). Other outcomes were comparable between the two groups. Conclusion An 8-μg prophylactic bolus of norepinephrine and a 90-μg prophylactic bolus of phenylephrine can effectively prevent postspinal anesthesia hypotension in patients during cesarean section.
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Affiliation(s)
- Lei Guo
- Department of Anesthesiology and Perioperative Medicine, General Hospital of Ningxia Medical University, Yinchuan, People’s Republic of China
| | - Xiangzhao Xu
- Department of Anesthesiology, The People’s Hospital of Nanchuan, Chongqing, People’s Republic of China
| | - Rui Qin
- Department of Anesthesiology and Perioperative Medicine, General Hospital of Ningxia Medical University, Yinchuan, People’s Republic of China
| | - Yongqiang Shi
- Department of Anesthesiology and Perioperative Medicine, General Hospital of Ningxia Medical University, Yinchuan, People’s Republic of China
| | - Wei Xue
- Department of Obstetrics, General Hospital of Ningxia Medical University, Yinchuan, People’s Republic of China
| | - Ling He
- Department of Obstetrics, General Hospital of Ningxia Medical University, Yinchuan, People’s Republic of China
| | - Shuqin Ma
- Department of Obstetrics, General Hospital of Ningxia Medical University, Yinchuan, 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
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Phenylephrine versus noradrenaline for caesarean delivery under spinal anaesthesia: Drugs potency, neonatal and maternal heart rate, and the level of block height. Ugeskr Laeger 2023; 40:70-71. [PMID: 36479996 DOI: 10.1097/eja.0000000000001752] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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18
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Lyu W, Wei P, Tang W, Ma X, Zheng Q, Zhou H, Zhou J, Li J. Preventing Spinal Hypotension During Cesarean Birth With Two Initial Boluses of Norepinephrine in Chinese Parturients: A Randomized, Double-Blind, Controlled Trial. Anesth Analg 2023; 136:94-100. [PMID: 35687059 DOI: 10.1213/ane.0000000000006110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Norepinephrine is effective in preventing spinal hypotension during cesarean birth; however, an optimal regimen has not been determined. We hypothesized that an initial bolus of norepinephrine improves efficacy of spinal hypotension prophylaxis beyond continuous norepinephrine alone. METHODS In this double-blind, controlled study, 120 patients scheduled for cesarean birth under spinal anesthesia were randomly allocated to receive a norepinephrine bolus at 0.05 or 0.10 μg/kg, followed by norepinephrine infusion at a rate of 0.05 μg·kg -1 ·min -1 . The primary outcome was the frequency of spinal hypotension during cesarean birth. The doses of the rescue drug (phenylephrine), frequency of nausea or vomiting, duration of hypotension, frequency of intraoperative hypertension, frequency of bradycardia, and fetal outcomes were also compared. RESULTS One-hundred-fifteen patients were included in the analysis. Compared with the 0.05 μg/kg group, the frequency of spinal hypotension was lower in the 0.10 μg/kg group (20.7% vs 45.6%; odds ratio [OR], 0.31; 95% confidence interval (CI), 0.14-0.71; P = .004). Fewer rescue doses of phenylephrine (0 [0,0] vs 0 [0,80]; 95% CI for the difference, 0 (0-0); P = .006) were required, and the frequency of nausea or vomiting was lower (5.2% vs 17.5%; OR, 0.26; 95% CI, 0.07-0.99; P = .04) in the 0.10 μg/kg group. The duration of hypotension was shorter in the 0.10 μg/kg group than that in the 0.05 μg/kg group (0 [0,0] vs 0 [0,2]; 95% CI for the difference, 0 [0-0]; P = .006). The incidence of intraoperative hypertension, frequency of bradycardia, and fetal outcomes were comparable between the 2 groups. CONCLUSIONS With a fixed-rate norepinephrine infusion of 0.05 μg·kg -1 ·min -1 , the 0.10 μg/kg initial bolus was more effective in reducing the incidence of spinal hypotension compared with the 0.05 μg/kg initial bolus.
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Affiliation(s)
| | | | | | - Xiaotian Ma
- Medicine Experimental Center, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao, China
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Reply to: phenylephrine versus noradrenaline for caesarean delivery under spinal anaesthesia: Drugs potency, neonatal and maternal heart rate, and the level of block height. Eur J Anaesthesiol 2023; 40:71-72. [PMID: 36479997 DOI: 10.1097/eja.0000000000001770] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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20
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Qian J, Zhao YP, Deng JL, Wang LZ, Xiao F, Shen B, Yao HQ. Determination of the Relative Potency of Norepinephrine and Phenylephrine Given as Infusions for Preventing Hypotension During Combined Spinal-Epidural Anesthesia for Cesarean Delivery: A Randomized Up-And-Down Sequential Allocation Study. Front Pharmacol 2022; 13:942005. [PMID: 35910385 PMCID: PMC9330490 DOI: 10.3389/fphar.2022.942005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 06/22/2022] [Indexed: 11/13/2022] Open
Abstract
Purpose: The relative potency of norepinephrine and phenylephrine given as boluses to treat hypotension during spinal anesthesia for cesarean delivery has been reported but few data are available for infusions. This study aimed to determine the relative potency of norepinephrine and phenylephrine when given by infusion for preventing hypotension during combined spinal-epidural anesthesia for cesarean delivery.Methods: This was a prospective, randomized, double-blind, up-and-down sequential allocation study. Patients were randomly allocated to receive a prophylactic infusion of norepinephrine or phenylephrine started immediately after induction of anesthesia. The first patients received either norepinephrine 0.1 μg/kg/min or phenylephrine 0.5 μg/kg/min. An effective infusion rate was defined when no hypotension occurred before delivery. For each subsequent patient, the norepinephrine infusion rate was decreased or increased by 0.01 μg/kg/min or the phenylephrine infusion rate was decreased or increased by 0.05 μg/kg/min according to whether the infusion was effective or ineffective respectively in the previous patient. Values for the infusion rate that was effective in preventing hypotension in 50% of patients (ED50) for norepinephrine and phenylephrine were estimated using up-and-down sequential analysis and relative potency was estimated. Probit regression was used as a backup and sensitivity analysis.Results: The ED50 values for norepinephrine and phenylephrine calculated by the up-and-down method were 0.061 (95% CI 0.054–0.068) μg/kg/min and 0.368 (95% CI 0.343–0.393) μg/kg/min respectively. The estimated relative potency ratio for ED50 for norepinephrine to phenylephrine was 6.03:1 (95% CI 5.26:1 to 6.98:1).Conclusion: Under the conditions of this study, norepinephrine given by infusion was about 6 times more potent than phenylephrine. This information is useful for clinical practice and further comparative studies of norepinephrine versus phenylephrine.Clinical Trial Registration:http://www.chictr.org.cn/showproj.aspx, identifier [ChiCTR2200056237]
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Affiliation(s)
- Jing Qian
- Department of Anesthesia, Jiaxing Women and Children's Hospital of Wenzhou Medical University, Jiaxing, China
- Jiaxing University Affiliated Women and Children Hospital, Jiaxing, China
| | - Yan-Ping Zhao
- Department of Anesthesia, Jiaxing Women and Children's Hospital of Wenzhou Medical University, Jiaxing, China
- Jiaxing University Affiliated Women and Children Hospital, Jiaxing, China
| | - Jia-Li Deng
- Department of Anesthesia, Jiaxing Women and Children's Hospital of Wenzhou Medical University, Jiaxing, China
- Jiaxing University Affiliated Women and Children Hospital, Jiaxing, China
| | - Li-Zhong Wang
- Department of Anesthesia, Jiaxing Women and Children's Hospital of Wenzhou Medical University, Jiaxing, China
- Jiaxing University Affiliated Women and Children Hospital, Jiaxing, China
| | - Fei Xiao
- Department of Anesthesia, Jiaxing Women and Children's Hospital of Wenzhou Medical University, Jiaxing, China
- Jiaxing University Affiliated Women and Children Hospital, Jiaxing, China
| | - Bei Shen
- Department of Anesthesia, Jiaxing Women and Children's Hospital of Wenzhou Medical University, Jiaxing, China
- Jiaxing University Affiliated Women and Children Hospital, Jiaxing, China
| | - Han-Qing Yao
- Department of Anesthesia, Jiaxing Women and Children's Hospital of Wenzhou Medical University, Jiaxing, China
- Jiaxing University Affiliated Women and Children Hospital, Jiaxing, China
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Prediction of intraoperative hypotension from the linear extrapolation of mean arterial pressure. Eur J Anaesthesiol 2022; 39:574-581. [PMID: 35695749 DOI: 10.1097/eja.0000000000001693] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Hypotension prediction index (HPI) software is a proprietary machine learning-based algorithm used to predict intraoperative hypotension (IOH). HPI has shown superiority in predicting IOH when compared to the predictive value of changes in mean arterial pressure (ΔMAP) alone. However, the predictive value of ΔMAP alone, with no reference to the absolute level of MAP, is counterintuitive and poor at predicting IOH. A simple linear extrapolation of mean arterial pressure (LepMAP) is closer to the clinical approach. OBJECTIVES Our primary objective was to investigate whether LepMAP better predicts IOH than ΔMAP alone. DESIGN Retrospective diagnostic accuracy study. SETTING Two tertiary University Hospitals between May 2019 and December 2019. PATIENTS A total of 83 adult patients undergoing high risk non-cardiac surgery. DATA SOURCES Arterial pressure data were automatically extracted from the anaesthesia data collection software (one value per minute). IOH was defined as MAP < 65 mmHg. ANALYSIS Correlations for repeated measurements and the area under the curve (AUC) from receiver operating characteristics (ROC) were determined for the ability of LepMAP and ΔMAP to predict IOH at 1, 2 and 5 min before its occurrence (A-analysis, using the whole dataset). Data were also analysed after exclusion of MAP values between 65 and 75 mmHg (B-analysis). RESULTS A total of 24 318 segments of ten minutes duration were analysed. In the A-analysis, ROC AUCs to predict IOH at 1, 2 and 5 min before its occurrence by LepMAP were 0.87 (95% confidence interval, CI, 0.86 to 0.88), 0.81 (95% CI, 0.79 to 0.83) and 0.69 (95% CI, 0.66 to 0.71) and for ΔMAP alone 0.59 (95% CI, 0.57 to 0.62), 0.61 (95% CI, 0.59 to 0.64), 0.57 (95% CI, 0.54 to 0.69), respectively. In the B analysis for LepMAP these were 0.97 (95% CI, 0.9 to 0.98), 0.93 (95% CI, 0.92 to 0.95) and 0.86 (95% CI, 0.84 to 0.88), respectively, and for ΔMAP alone 0.59 (95% CI, 0.53 to 0.58), 0.56 (95% CI, 0.54 to 0.59), 0.54 (95% CI, 0.51 to 0.57), respectively. LepMAP ROC AUCs were significantly higher than ΔMAP ROC AUCs in all cases. CONCLUSIONS LepMAP provides reliable real-time and continuous prediction of IOH 1 and 2 min before its occurrence. LepMAP offers better discrimination than ΔMAP at 1, 2 and 5 min before its occurrence. Future studies evaluating machine learning algorithms to predict IOH should be compared with LepMAP rather than ΔMAP.
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Uerpairojkit K, Thongthaweeporn N, Anusorntanawat R, Pipanmekaporn T, Hinthong T, Bunchungmongkol N, Simarangsan N. A randomized comparison of hemodynamic changes in response to a heart rate‐dependent phenylephrine/ephedrine protocol versus ephedrine‐only for spinal hypotension during elective cesarean section. J Obstet Gynaecol Res 2022; 48:1750-1759. [DOI: 10.1111/jog.15289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Revised: 04/16/2022] [Accepted: 05/03/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Ketchada Uerpairojkit
- Department of Anesthesiology, Faculty of Medicine Chulalongkorn University Bangkok Thailand
| | | | | | | | - Thanoo Hinthong
- Department of Anesthesiology Chiang Mai University Chiang Mai Thailand
| | | | - Nawaporn Simarangsan
- Department of Anesthesiology, Faculty of Medicine Chulalongkorn University Bangkok Thailand
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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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Zhou Y, Yu Y, Chu M, Zhang Y, Yu X, Chen G. Comparison of Metaraminol, Phenylephrine, and Norepinephrine Infusion for Prevention of Hypotension During Combined Spinal-Epidural Anaesthesia for Elective Caesarean Section: A Three-Arm, Randomized, Double-Blind, Non-Inferiority Trial. Drug Des Devel Ther 2022; 16:117-127. [PMID: 35027821 PMCID: PMC8752065 DOI: 10.2147/dddt.s331177] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 12/15/2021] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND A direct comparison of phenylephrine, metaraminol, and norepinephrine in preventing hypotension during spinal anaesthesia for elective caesarean section has never been made. PATIENTS AND METHODS Seventy-five parturients scheduled for elective caesarean section were randomly assigned into the three groups. After spinal anaesthesia induction, patients received a bonus dose of vasopressor (norepinephrine 4ug, phenylephrine 50ug, or metaraminol 250ug) combined with continuous infusion (norepinephrine 8ug/mL, phenylephrine 100ug/mL, or metaraminol 500ug/mL) at a rate of 30 mL/h to prevent hypotension. The primary outcome was umbilical arterial (UA) pH and other intraoperative data were also recorded. RESULTS The UA pH was 7.32±0.03 for metaraminol, 7.31±0.03 for phenylephrine, and 7.31±0.03 for norepinephrine. The 95% CI of MD was -0.011 to 0.026 comparing metaraminol with norepinephrine and 0.0181 to 0.0182 comparing phenylephrine with norepinephrine. Both lower bounds of the 95% CI of MD were above the predetermined lower boundary of clinical non-inferiority of -0.03, indicating both metaraminol and phenylephrine were non-inferior to norepinephrine. Moreover, the incidence of hypotension was lower in metaraminol compared with norepinephrine (P = 0.01). However, the incidence of hypertension was significantly lower in both phenylephrine and metaraminol compared with norepinephrine. CONCLUSION Both metaraminol and phenylephrine were non-inferior to norepinephrine with respect to neonatal UA pH when used as a bolus and continuous infusion to prevent hypotension during combined spinal-epidural anaesthesia for elective caesarean section.
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Affiliation(s)
- Youfa Zhou
- Department of Anesthesiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China
| | - Yunyun Yu
- Department of Anesthesiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China.,Department of Anesthesiology, Lishui Central Hospital, Lishui, Zhejiang, People's Republic of China
| | - Miaofei Chu
- Department of Anesthesiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China.,Department of Anesthesiology, Zhejiang Greentown Cardiovascular Hospital, Hangzhou, Zhejiang, People's Republic of China
| | - Yanting Zhang
- Department of Anesthesiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China
| | - Xin Yu
- Department of Anesthesiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China
| | - Gang Chen
- Department of Anesthesiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China
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Phenylephrine and norepinephrine for the management of spinal-induced hypotension in preeclamptic patients: Hypothesis-study design mismatch. Eur J Anaesthesiol 2022; 39:291-292. [PMID: 35115462 DOI: 10.1097/eja.0000000000001543] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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26
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Du W, Song Y, Li J, Zhou X, Xu Z, Liu Z. Comparison of Prophylactic Norepinephrine and Phenylephrine Infusions During Spinal Anaesthesia for Primary Caesarean Delivery in Twin Pregnancies: A Randomized Double-Blinded Clinical Study. Drug Des Devel Ther 2022; 16:789-798. [PMID: 35355656 PMCID: PMC8959871 DOI: 10.2147/dddt.s357507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 03/12/2022] [Indexed: 11/23/2022] Open
Abstract
Background Norepinephrine has been associated with improved heart rate (HR) and cardiac output (CO) compared to phenylephrine as a treatment for post-spinal hypotension during caesarean delivery (CD) in singleton pregnancies. Our current study compared the effects of norepinephrine and phenylephrine in maintaining maternal hemodynamics after spinal anaesthesia in twin pregnancies during elective CD. Methods This was a double-blinded, randomized, controlled study. From December 2017 to December 2018, 62 women with healthy twin term pregnancies undergoing elective CD under spinal anaesthesia were studied. Following spinal induction, either norepinephrine (6 μg/mL) or phenylepinephrine (75 μg/mL) was infused at 60 mL/h to maintain systolic blood pressure (SBP) near baseline until delivery. HR, SBP, systemic vascular resistance (SVR), and CO were collected using anaesthesia monitors and continuous-pulse waveform analysis. The primary outcome was maternal CO. Other parameters of maternal hemodynamics, umbilical cord blood gases, and adverse events were also compared. Results Hemodynamic variables (CO, SBP, HR, and SVR) between spinal anaesthesia induction to skin incision were similar between the two groups (P = 0.889, 0.057, 0.977, and 0.416, respectively). The incidence of bradycardia was significantly higher in the phenylephrine group (69%) than in the norepinephrine group (24.2%, P<0.001). Maternal nausea and vomiting, hypotension, reactive hypertension, and neonatal outcomes did not differ between the groups. Conclusion When administered as a prophylactic fixed-rate infusion, phenylephrine and norepinephrine are both capable of maintaining maternal blood pressure following spinal anaesthesia in twin pregnancies. There were no differences in the maternal hemodynamics or foetal outcomes between women receiving norepinephrine and phenylephrine. Previous Presentations Presented at the 51st Society for Obstetric Anesthesia and Perinatology Annual Meeting, Phoenix, Arizona, May 1–5, 2019. Clinical Trial Number and Registry No. ChiCTR-IOR-17013358.
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Affiliation(s)
- Weijia Du
- Department of Anesthesiology, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, 200092, People’s Republic of China
| | - Yujie Song
- Department of Anesthesiology, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, 200092, People’s Republic of China
| | - Jiang Li
- Department of Anesthesiology, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, 200092, People’s Republic of China
| | - Xianjin Zhou
- Department of Anesthesiology, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, 200092, People’s Republic of China
| | - Zhendong Xu
- Department of Anesthesiology, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, 200092, People’s Republic of China
| | - Zhiqiang Liu
- Department of Anesthesiology, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, 200092, People’s Republic of China
- Correspondence: Zhiqiang Liu; Zhendong Xu, Department of Anesthesiology, Shanghai First Maternity and Infant Hospital School of Medicine, Tongji University, No. 2699, West Gaoke Road, Shanghai, People’s Republic of China, Email ;
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Guo L, Qin R, Ren X, Han C, Xue W, He L, Ma L, Pan H, Ma S, Chen Y, Ni X. Prophylactic norepinephrine or phenylephrine infusion for bradycardia and post-spinal anaesthesia hypotension in patients with preeclampsia during Caesarean delivery: a randomised controlled trial. Br J Anaesth 2022; 128:e305-e307. [DOI: 10.1016/j.bja.2022.01.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 01/23/2022] [Accepted: 01/23/2022] [Indexed: 11/28/2022] Open
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Norepinephrine versus phenylephrine infusion for preventing postspinal hypotension during cesarean section for twin pregnancy: a double-blinded randomized controlled clinical trial. BMC Anesthesiol 2022; 22:17. [PMID: 34998371 PMCID: PMC8742356 DOI: 10.1186/s12871-022-01562-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 12/31/2021] [Indexed: 02/08/2023] Open
Abstract
Background Compared with singleton pregnancy, twin gestation is featured by a greater increase in cardiac output. Therefore, norepinephrine might be more suitable than phenylephrine for maintaining blood pressure during cesarean section for twins, as phenylephrine causes reflex bradycardia and a resultant decrease in cardiac output. This study was to determine whether norepinephrine was superior to phenylephrine in maintaining maternal hemodynamics during cesarean section for twins. Methods Informed consent was obtained from all the patients before enrollment. In this double-blinded, randomized clinical trial, 100 parturients with twin gestation undergoing cesarean section with spinal anesthesia were randomized to receive prophylactic norepinephrine (3.2 μg/min) or phenylephrine infusion (40 μg/min). The primary outcome was the change of heart rate and blood pressure during the study period. The secondary outcomes were to compare maternal complications, neonatal outcomes, Apgar scores and umbilical blood acid-base status between the two vasopressors. Results There was no significant difference observed for the change of heart rate between two vasopressors. The mean standardized area under the curve of heart rate was 78 ± 12 with norepinephrine vs. 74 ± 11 beats/min with phenylephrine (mean difference 4.4, 95%CI − 0.1 to 9.0; P = .0567). The mean standardized area under the curve of systolic blood pressure (SBP) was significantly lower in parturients with norepinephrine, as the mean of differences in standardized AUC of SBP was 6 mmHg, with a 95% CI from 2 to 9 mmHg (P = .0013). However, requirements of physician interventions for correcting maternal hemodynamical abnormalities (temporary cessation of vasopressor infusion for reactive hypertension, rescuing vasopressor bolus for hypotension and atropine for heart rate less < 50 beats/min) and neonatal outcomes were also not significantly different between two vasopressors. Conclusion Infusion of norepinephrine was not associated with less overall decrease in heart rate during cesarean section for twins, compared with phenylephrine. Trial registration Chinese Clinical Trial Registry (ChiCTR1900021281).
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Rai AV, Prakash S, Chellani H, Mullick P, Wason R. Comparison of phenylephrine and norepinephrine for treatment of spinal hypotension during elective cesarean delivery- A randomised, double-blind study. J Anaesthesiol Clin Pharmacol 2022; 38:445-452. [PMID: 36505203 PMCID: PMC9728423 DOI: 10.4103/joacp.joacp_499_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 04/14/2021] [Accepted: 05/14/2021] [Indexed: 12/15/2022] Open
Abstract
Background and Aims Hypotension following subarachnoid block for cesarean delivery (CD) is common. We compared the effect of bolus administration of norepinephrine and phenylephrine on umbilical artery pH (primary objective) and their efficacy for the treatment of maternal hypotension (secondary objective) in term parturients undergoing elective CD under spinal anesthesia. Material and Methods In a randomized, double-blinded study, parturients received 1 mL boluses of either phenylephrine 100 μg/mL (group phenylephrine; n = 45) or norepinephrine 7.5 μg/mL (group norepinephrine; n = 45) whenever maternal systolic blood pressure decreased to ≤80% of baseline. Maternal hemodynamic changes, vasopressor, and atropine requirement and neonatal outcome (umbilical cord blood gas analysis, Apgar scores, neonatal neurobehavioral response) were assessed. Results The Apgar scores and umbilical cord blood gas analysis were comparable between groups. The neurobehavioral scale score was significantly higher in group NE compared with that in group PE at 24 h and 48 h; P = 0.007 and 0.002, respectively. The number of vasopressor doses and time to the first vasopressor requirement for maintaining systolic pressure >80% of baseline was comparable in both groups. Incidence of bradycardia (P = 0.009), reactive hypertension (P = 0.003), and dose requirement of atropine (P = 0.005) was higher in group PE compared with group NE. Conclusions In term normotensive parturients who received bolus norepinephrine 7.5 μg or phenylephrine 100 μg for the treatment of post-spinal hypotension during CD, neonatal umbilical cord blood gas analysis and Apgar scores were comparable. Norepinephrine use was associated with a lower incidence of maternal bradycardia and reactive hypertension compared with phenylephrine.
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Affiliation(s)
- Akshatha V. Rai
- Department of Anaesthesia and Intensive Care, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Smita Prakash
- Department of Anaesthesia and Intensive Care, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India,Address for correspondence: Dr. Smita Prakash, C 17 HUDCO Place, New Delhi - 110 049, India. E-mail:
| | - Harish Chellani
- Department of Paediatrics, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Parul Mullick
- Department of Anaesthesia and Intensive Care, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Rama Wason
- Department of Anaesthesia and Intensive Care, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
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Bradford V, Gaiser R. Preservation of Fetal Viability During Noncardiac Surgery. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00030-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Mohta M, Bambode N, Chilkoti GT, Agarwal R, Malhotra RK, Batra P. Neonatal outcomes following phenylephrine or norepinephrine for treatment of spinal anaesthesia-induced hypotension at emergency caesarean section in women with fetal compromise - a randomised controlled study. Int J Obstet Anesth 2021; 49:103247. [PMID: 35012812 DOI: 10.1016/j.ijoa.2021.103247] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 10/24/2021] [Accepted: 12/12/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Norepinephrine is as effective as phenylephrine for management of spinal anaesthesia-induced hypotension. Most of the studies comparing these vasopressors have been conducted in healthy pregnant women undergoing elective caesarean section. In the current study, we tested the null hypothesis that there is no difference in neonatal outcome when phenylephrine or norepinephrine is used to treat spinal anaesthesia-induced hypotension in women undergoing emergency caesarean section for fetal compromise. METHODS Patients undergoing caesarean section for fetal compromise who developed spinal anaesthesia-induced hypotension were randomised to receive phenylephrine 100 μg or norepinephrine 8 μg for treatment of each hypotensive episode, defined as systolic blood pressure <100 mmHg. Umbilical cord arterial and venous blood samples were obtained for blood gas analysis. The primary outcome measure was umbilical artery pH. RESULTS One hundred patients (50 in each group) were studied. There was no significant difference in umbilical artery pH between the two groups (mean difference 0.001; 95% CI -0.032 to 0.034). The number of hypotensive episodes, vasopressor boluses required, the incidence of bradycardia, heart rate and blood pressure trends following vasopressor administration, and the incidence of nausea/vomiting were not significantly different between groups. CONCLUSION Phenylephrine 100 μg and norepinephrine 8 μg were not significantly different in terms of neonatal outcome when administered as intravenous boluses for treatment of spinal anaesthesia-induced hypotension in parturients undergoing emergency caesarean sections for fetal compromise.
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Affiliation(s)
- M Mohta
- Department of Anaesthesiology and Critical Care, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi, India.
| | - N Bambode
- Department of Anaesthesiology and Critical Care, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi, India
| | - G T Chilkoti
- Department of Anaesthesiology and Critical Care, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi, India
| | - R Agarwal
- Department of Obstetrics and Gynaecology, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi, India
| | - R K Malhotra
- Delhi Cancer Registry, Dr. BRA IRCH, All India Institute of Medical Sciences, Delhi, India
| | - P Batra
- Department of Paediatrics, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi, India
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Park SK, Park DN, Kim YW, Yoo S, Kim WH, Lim YJ, Park JS, Jun JK, Kim JT. Colloid coload versus crystalloid coload to prevent maternal hypotension in women receiving prophylactic phenylephrine infusion during caesarean delivery: a randomised controlled trial. Int J Obstet Anesth 2021; 49:103246. [PMID: 35012809 DOI: 10.1016/j.ijoa.2021.103246] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 11/16/2021] [Accepted: 12/12/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND The optimal fluid strategy to prevent maternal hypotension during caesarean delivery remains unclear. This study aim was to compare the incidence of post-spinal anaesthesia hypotension in women receiving either colloid or crystalloid coload in the setting of prophylactic phenylephrine infusion during caesarean delivery. METHODS Healthy mothers undergoing elective caesarean delivery under spinal anaesthesia were randomised to receive a rapid intravenous coload with 6% hydroxyethyl starch 130/0.4 10 mL/kg (colloid group) or balanced crystalloid solution (Plasma Solution A) 10 mL/kg (crystalloid group) during spinal anaesthesia. All women had a prophylactic phenylephrine infusion initiated at 25 μg/min immediately after the subarachnoid block and titrated to systolic blood pressure using a standardised protocol. The primary outcome was the incidence of hypotension (systolic blood pressure <80% of baseline) until delivery. RESULTS The incidence of hypotension was 50% in the colloid group and 62% in the crystalloid group (absolute difference, -12% [95% CI -33% to 9%]; relative risk, 0.8 [95% CI 0.56 to 1.14]; P=0.314). No significant difference between groups was found in the number of hypotensive episodes (median 0.5 [IQR 0 to 1] vs 1 [0 to 2], P=0.132) or phenylephrine dose (675 [IQR 425 to 975] μg vs 750 [625 to 950] μg, P=0.109). The incidence of severe hypotension, symptomatic hypotension, bradycardia, nausea, and the neonatal outcomes were not significantly different. CONCLUSIONS This study found no benefit of colloid coload compared with crystalloid coload for preventing maternal hypotension in the presence of prophylactic phenylephrine infusion during caesarean delivery.
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Affiliation(s)
- S-K Park
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - D-N Park
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Y-W Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - S Yoo
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - W H Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Y-J Lim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - J S Park
- Department of Obstetrics and Gynecology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - J K Jun
- Department of Obstetrics and Gynecology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - J-T Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea.
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Nakamura E, Takahashi S, Matsunaga S, Tanaka H, Furuta M, Sakurai A. Intravenous infusion route in maternal resuscitation: a scoping review. BMC Emerg Med 2021; 21:151. [PMID: 34861839 PMCID: PMC8642880 DOI: 10.1186/s12873-021-00546-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 11/24/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The concept that upper extremities can be used as an infusion route during cardiopulmonary resuscitation in pregnant women is a reasonable recommendation considering the characteristic circulation of pregnant women; however, this method is not based on scientific evidence. OBJECTIVE OF THE REVIEW We conducted a scoping review to determine whether the infusion route should be established above the diaphragm during cardiopulmonary resuscitation in a pregnant woman. DISCUSSION We included randomized controlled trials (RCTs) and non-RCTs on the infusion of fluids in pregnant women after 20 weeks of gestation requiring establishment of an infusion route due to cardiac arrest, massive bleeding, intra-abdominal bleeding, cesarean section, severe infection, or thrombosis. In total, 3150 articles from electronic database were extracted, respectively. After title and abstract review, 265 articles were extracted, and 116 articles were extracted by full-text screening, which were included in the final analysis. The 116 articles included 78 studies on infusion for pregnant women. The location of the intravenous infusion route could be confirmed in only 17 studies, all of which used the upper extremity to secure the venous route. CONCLUSION Pregnant women undergo significant physiological changes that differ from those of normal adults, because of pressure and drainage of the inferior vena cava and pelvic veins by the enlarged uterus. Therefore, despite a lack of evidence, it seems logical to secure the infusion route above the diaphragm when resuscitating a pregnant woman.
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Affiliation(s)
- Eishin Nakamura
- Center for Maternal, Fetal and Neonatal Medicine, Saitama Medical Center, Saitama Medical University, 1981 Kamoda, Kawagoe-shi, Saitama, 350-8550, Japan. .,Japan Resuscitation Council, Maternal group, Tokyo Japan, 2-5-4 Yoyogi, Sibuya-ku, Tokyo, 151-0053, Japan.
| | - Shinji Takahashi
- Japan Resuscitation Council, Maternal group, Tokyo Japan, 2-5-4 Yoyogi, Sibuya-ku, Tokyo, 151-0053, Japan.,Department of Anesthesiology, Juntendo University Urayasu Hospital, 2-1-1 Tomioka, Urayasu-shi, Chiba, 279-0021, Japan
| | - Shigetaka Matsunaga
- Japan Resuscitation Council, Maternal group, Tokyo Japan, 2-5-4 Yoyogi, Sibuya-ku, Tokyo, 151-0053, Japan.,Department of Obstetrics and Gynecology, Saitama Medical Center, Saitama Medical University, 1981 Kamoda, Kawagoe-shi, Saitama, 350-8550, Japan
| | - Hiroaki Tanaka
- Japan Resuscitation Council, Maternal group, Tokyo Japan, 2-5-4 Yoyogi, Sibuya-ku, Tokyo, 151-0053, Japan.,Department of Obstetrics and Gynecology, Mie University School of Medicine, 2-174 Edobashi, Tsu-shi, Mie, 514-8507, Japan
| | - Marie Furuta
- Japan Resuscitation Council, Maternal group, Tokyo Japan, 2-5-4 Yoyogi, Sibuya-ku, Tokyo, 151-0053, Japan.,Department of Human Health Sciences, Graduate School of Medicine, Kyoto University, 53 Kawahara-cho Shogo-in, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Atsushi Sakurai
- Japan Resuscitation Council, Maternal group, Tokyo Japan, 2-5-4 Yoyogi, Sibuya-ku, Tokyo, 151-0053, Japan.,Division of Emergency and Critical Care Medicine, Department of Acute Medicine, Nihon University School of Medicine, 30-1 Oyaguchi Kamimachi, Itabashi-ku, Tokyo, 173-8610, Japan
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Neonatal outcomes following prophylactic administration of phenylephrine or noradrenaline in women undergoing scheduled caesarean delivery: A randomised clinical trial. Eur J Anaesthesiol 2021; 39:269-276. [PMID: 34817421 DOI: 10.1097/eja.0000000000001634] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND There is limited evidence to support the use of noradrenaline over phenylephrine during elective caesarean section with regards to its impact on foetal acidosis. Concerns regarding a deleterious effect of noradrenaline on foetal blood gas analysis because of its β-mimetic activity cannot currently be ruled out by data from randomised controlled trials. OBJECTIVE We hypothesised that noradrenaline would be associated with higher umbilical artery base excess values and less foetal acidosis compared with phenylephrine. This study aimed to observe the effect of prophylactic infusions of phenylephrine or noradrenaline in low-risk elective caesarean delivery on umbilical artery blood gas analysis. DESIGN A prospective, randomised, double-blind trial. SETTING Labour room operating theatre of tertiary care hospital in Northern India from April 2020 to November 2020. PATIENTS Full-term, nonlabouring pregnant women, scheduled for elective caesarean delivery under spinal anaesthesia. INTERVENTION Equipotent prophylactic infusions of either phenylephrine 100 μg min-1 or noradrenaline 5 μg min-1 were administered to maintain maternal SBP between 90 and 110% of baseline using a predefined algorithm. MAIN OUTCOME MEASURE The primary outcome was umbilical artery base excess in noradrenaline versus the phenylephrine group. The incidence of foetal acidosis defined as umbilical artery base excess less than -6 mmol l-1 was also assessed for noradrenaline versus phenylephrine. RESULTS Median [IQR] umbilical artery base excess was significantly higher in the noradrenaline group: -5.4 [-6.6 to -4.03] versus -6.95 [-9.02 to -4.53] in the phenylephrine group (P = 0.014). No significant difference in the incidence of foetal acidosis was observed between noradrenaline and phenylephrine groups: 36 versus 54% (P 0.07); difference 18% (95% CI, -1.4 to 35.6%). CONCLUSION Prophylactic noradrenaline 5 μg min-1 infusion resulted in higher base excess values compared with phenylephrine 100 μg min-1 infusion. A comparable incidence of foetal acidosis was observed in women receiving either noradrenaline or phenylephrine. Maternal bradycardia was more pronounced with phenylephrine while targeting blood pressure goals. CTRI CTRI/2020/03/023986.
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A randomised double-blind comparison of phenylephrine and norepinephrine for the management of postspinal hypotension in pre-eclamptic patients undergoing caesarean section. Eur J Anaesthesiol 2021; 38:1077-1084. [PMID: 34524157 DOI: 10.1097/eja.0000000000001461] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Studies comparing phenylephrine and norepinephrine for the treatment of postspinal hypotension in pre-eclamptic patients are limited. OBJECTIVE To compare bolus doses of phenylephrine and norepinephrine for treating hypotension in pre-eclamptic mothers undergoing caesarean section under spinal anaesthesia. It was hypothesised that norepinephrine and phenylephrine use would be associated with similar neonatal outcome. DESIGN Randomised controlled study. SETTING Single centre, tertiary care, university teaching hospital, from December 2018 to March 2020. PATIENTS A total of 86 women with pre-eclampsia and a singleton pregnancy who developed postspinal hypotension during caesarean section. INTERVENTIONS Patients received intravenous phenylephrine (50 μg) or norepinephrine (4 μg) for treatment of hypotension, defined as a fall in baseline systolic BP by ≥ 20% or an absolute value < 100 mmHg. MAIN OUTCOME MEASURES The primary outcome was umbilical artery pH. Secondary outcomes included Apgar scores, the number of hypotensive episodes, vasopressor requirements, the incidence of tachycardia/bradycardia/arrhythmias/hypertension and maternal complications. RESULTS Umbilical artery pH was not different between the phenylephrine and norepinephrine groups (7.26 ± 0.06 and 7.27 ± 0.06, respectively; P = 0.903). The median [IQR] number of hypotensive episodes was higher in the norepinephrine than the phenylephrine group: 2 [1 to 3] vs 1 [1 to 2], respectively; P = 0.014. Apgar scores, total number of vasopressor boluses required, systolic BP trends and the incidence of maternal complications were comparable in the two groups. Heart rate (HR) values were lower in phenylephrine group (P = 0.026), and one patient in phenylephrine group and none in the norepinephrine group developed bradycardia (HR < 50 bpm), P = 1.000. CONCLUSIONS In women with pre-eclampsia undergoing caesarean section, bolus doses of phenylephrine (50 μg) and norepinephrine (4 μg) used to treat hypotension after spinal anaesthesia are equally effective with similar neonatal and maternal outcomes. TRIAL REGISTRATION CTRI/2018/11/016478.
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Goel K, Luthra N, Goyal N, Grewal A, Taneja A. Comparison of norepinephrine and phenylephrine infusions for maintenance of haemodynamics following subarachnoid block in lower segment caeserean section. Indian J Anaesth 2021; 65:600-605. [PMID: 34584283 PMCID: PMC8445212 DOI: 10.4103/ija.ija_185_21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 03/29/2021] [Accepted: 07/21/2021] [Indexed: 11/05/2022] Open
Abstract
Background and Aims: Phenylephrine is the vasopressor of choice in spinal anaesthesia–induced maternal hypotension. However, it results in reflex bradycardia and decrease in cardiac output (CO), an effect that is perhaps less evident with the use of norepinephrine. We sought to evaluate the effect of phenylephrine and norepinephrine infusion on maternal systolic blood pressure (SBP), heart rate (HR), intraoperative nausea vomiting (IONV) and fatal Apgar scores. Methods: A randomised double-blind study was conducted on 200 American Society of Anesthesiologists (ASA) II–III parturients undergoing caesarean section under subarachnoid block (SAB) who were randomised to two groups A and B to receive variable rate, manually controlled infusions of phenylephrine and norepinephrine targeting maintenance of SBP to 100% of the baseline value. Maternal haemodynamics especially episodes of hypotension, IONV and vasopressor consumption were observed and recorded. Results: A statistically significant trend of lower SBP was observed during the first 6 min following intrathecal injection in group A (P value – 0.000). Though a greater number of parturients experienced ≥1 episode of hypotension in Group A vs Group B (13% vs 9%), the difference was, however, statistically insignificant. The incidence of bradycardia was higher in group A than in group B (16% vs 1%) and was found to be statistically significant (P < 0.05). The episodes of hypertension, IONV, maternal vasopressor consumption and neonatal Apgar score were comparable among both the groups. Conclusion: A dilute solution of norepinephrine infusion is comparably efficacious to the current gold standard vasopressor phenylephrine in maintaining blood pressure following spinal anaesthesia for caesarean delivery, with a significantly lower incidence of bradycardia.
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Affiliation(s)
- Kanika Goel
- Department of Anaesthesia, ESI Hospital, Baddi, Himachal Pradesh, India
| | - Neeru Luthra
- Department of Anaesthesia, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
| | - Namrata Goyal
- Department of Anaesthesia, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
| | - Anju Grewal
- Department of Anaesthesia, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
| | - Ashima Taneja
- Department of Obstetrics and Gynaecology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
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Xu W, Drzymalski DM, Ai L, Yao H, Liu L, Xiao F. The ED 50 and ED 95 of Prophylactic Norepinephrine for Preventing Post-Spinal Hypotension During Cesarean Delivery Under Combined Spinal-Epidural Anesthesia: A Prospective Dose-Finding Study. Front Pharmacol 2021; 12:691809. [PMID: 34322021 PMCID: PMC8312548 DOI: 10.3389/fphar.2021.691809] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 06/28/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Hypotension commonly occurs with spinal anesthesia during cesarean delivery. Norepinephrine is an alternative to phenylephrine which can be used to prevent or treat hypotension, with better maintained cardiac output and less bradycardia. However, an appropriate initial prophylactic infusion dose of norepinephrine remains unclear. The aim of this study was to describe the dose-response relationship of prophylactic norepinephrine infusion during cesarean delivery under combined spinal-epidural anesthesia. Methods: We performed a prospective, randomized, double-blinded dose-finding study. One hundred patients undergoing elective cesarean delivery were randomly assigned to receive an infusion of norepinephrine at 0, 0.025, 0.05, 0.075 or 0.1 μg/kg/min initiated immediately after intrathecal injection of 10 mg bupivacaine combined with 5 µg sufentanil. An effective dose was considered when there was no hypotension (systolic blood pressure < 90 mm Hg or < 80% of baseline) during the time period from injection of intrathecal local anesthetic to delivery of the neonate. The primary aim was to determine the dose-response relationship of norepinephrine to prevent spinal anesthesia-induced hypotension. The median effective dose (ED50) and 95% effective dose (ED95) for norepinephrine were calculated utilizing probit analysis. Results: The proportion of patients with hypotension was 80, 70, 40, 15 and 5% at norepinephrine doses of 0, 0.025, 0.05, 0.075 and 0.1 μg/kg/min, respectively. The ED50 and ED95 were 0.042 (95% CI, 0.025-0.053) µg/kg/min and 0.097 (95% CI, 0.081-0.134) µg/kg/min, respectively. There were no differences in the Apgar scores (p = 0.685) or umbilical arterial pH (p = 0.485) measurements of the newborns among the treatment groups. Conclusion: A norepinephrine infusion of 0.1 μg/kg/min as an initial starting dose was effective for the prevention of spinal-induced hypotension.
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Affiliation(s)
- Wenping Xu
- Department of Anesthesia, Jiaxing University Affiliated Women and Children Hospital, Jiaxing, China
| | - Dan Michael Drzymalski
- Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, Boston, MA, United States
| | - Ling Ai
- Department of Anesthesia, Jiaxing University Affiliated Women and Children Hospital, Jiaxing, China
| | - Hanqing Yao
- Department of Anesthesia, Jiaxing University Affiliated Women and Children Hospital, Jiaxing, China
| | - Lin Liu
- Department of Anesthesia, Jiaxing University Affiliated Women and Children Hospital, Jiaxing, China
| | - Fei Xiao
- Department of Anesthesia, Jiaxing University Affiliated Women and Children Hospital, Jiaxing, China
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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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Comparison of two vasopressor protocols for preventing hypotension post-spinal anesthesia during cesarean section: a randomized controlled trial. Chin Med J (Engl) 2021; 134:792-799. [PMID: 33661141 PMCID: PMC8104294 DOI: 10.1097/cm9.0000000000001404] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Background: Norepinephrine infusion decreases hypotension after spinal anesthesia during cesarean section. This study aimed to compare the efficacy of norepinephrine infusion and ephedrine bolus against post-spinal hypotension in parturients. Methods: In this double-blinded, randomized controlled clinical trial, parturients scheduled for elective cesarean section were randomly allocated to receive norepinephrine infusion (0.05 μg·kg−1·min−1) just before spinal anesthesia continuing for 30 min or ephedrine bolus (0.15 mg/kg) just before spinal anesthesia. A rescue bolus (5 μg norepinephrine for the norepinephrine group, and 5 mg ephedrine for the ephedrine group) was administered whenever hypotension occurred. Our primary outcome was the incidence of hypotension within 30 min of spinal anesthesia administration. Secondary outcomes included maternal and neonatal outcomes 30 min after spinal block, and neonatal cerebral oxygenation 10 min after birth. Results: In total, 190 patients were enrolled; of these patients, 177 were included in the final analysis. Fewer patients suffered hypotension in the norepinephrine group than in the ephedrine group (29.5% vs. 44.9%, odds ratio [OR]: 0.51, 95% confidence interval [CI]: 0.28–0.95, P = 0.034). Moreover, the tachycardia frequency was lower in the norepinephrine group than in the ephedrine group (OR: 0.22, 95% CI: 0.11–0.44, P < 0.001), and patients suffered less nausea and vomiting (OR: 0.28, 95% CI: 0.11–0.70, P = 0.004). There was no difference in Apgar scores and umbilical arterial blood gas analysis between the two groups. However, neonatal cerebral regional saturations were significantly higher after birth in the norepinephrine group than in the ephedrine group (mean difference: 2.0%, 95% CI: 0.55%–3.45%, P = 0.008). Conclusion: In patients undergoing elective cesarean section with spinal anesthesia, norepinephrine infusion compared to ephedrine bolus resulted in less hypotension and tachycardia, and exhibited potential neonatal benefits. Trial Registration: ClinicalTrials.gov, NCT02542748; https://clinicaltrials.gov/ct2/show/record/NCT02542748
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Goradia S, Sardaneh AA, Narayan SW, Penm J, Patanwala AE. Vasopressor dose equivalence: A scoping review and suggested formula. J Crit Care 2021; 61:233-240. [DOI: 10.1016/j.jcrc.2020.11.002] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 10/26/2020] [Accepted: 11/10/2020] [Indexed: 12/20/2022]
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Bolus norepinephrine and phenylephrine for maternal hypotension during elective cesarean section with spinal anesthesia: a randomized, double-blinded study. Chin Med J (Engl) 2020; 133:509-516. [PMID: 31996543 PMCID: PMC7065858 DOI: 10.1097/cm9.0000000000000621] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND In recent years, norepinephrine has attracted increasing attention for the management of maternal hypotension during elective cesarean section with spinal anesthesia. Intermittent bolus is a widely used administration paradigm for vasopressors in obstetric anesthesia in China. Thus, in this randomized, double-blinded study, we compared the efficacy and safety of equivalent bolus norepinephrine and phenylephrine for rescuing maternal post-spinal hypotension. METHODS In a tertiary women's hospital in Nanjing, China, 102 women were allocated with computer derived randomized number to receive prophylactic 8 μg norepinephrine (group N; n = 52) or 100 μg phenylephrine (group P; n = 50) immediately post-spinal anesthesia, followed by an extra bolus of the same dosage until delivery whenever maternal systolic blood pressure became lower than 80% of the baseline. Our primary outcome was standardized maternal cardiac output (CO) reading from spinal anesthesia until delivery analyzed by a two-step method. Other hemodynamic parameters related to vasopressor efficacy and safety were considered as secondary outcomes. Maternal side effects and neonatal outcomes were collected as well. RESULTS Compared to group P, women in group N had a higher CO (standardized CO 5.8 ± 0.9 vs. 5.3 ± 1.0 L/min, t = 2.37, P = 0.02) and stroke volume (SV, standardized SV 73.6 ± 17.2 vs. 60.0 ± 13.3 mL, t = 4.52, P < 0.001), and a lower total peripheral resistance (875 ± 174 vs. 996 ± 182 dyne·s/cm, t = 3.44, P < 0.001). Furthermore, the incidence of bradycardia was lower in group N than in group P (2% vs. 14%, P = 0.023), along with an overall higher standardized heart rate (78.8 ± 11.6 vs. 75.0 ± 7.3 beats/min, P = 0.049). Other hemodynamics, as well as maternal side effects and neonatal outcomes, were similar in two groups (P > 0.05). CONCLUSIONS Compared to equivalent phenylephrine, intermittent bolus norepinephrine provides a greater CO for management of maternal hypotension during elective cesarean section with spinal anesthesia; however, no obvious maternal or neonatal clinical advantages were observed for norepinephrine.
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Hao Q, Hu Y, Zhang L, Ross J, Robishaw S, Noble C, Wu X, Zhang X. A Systematic Review and Meta-analysis of Clinical Trials of Neuraxial, Intravenous, and Inhalational Anesthesia for External Cephalic Version. Anesth Analg 2020; 131:1800-1811. [PMID: 32282385 PMCID: PMC7643798 DOI: 10.1213/ane.0000000000004795] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/02/2020] [Indexed: 01/22/2023]
Abstract
BACKGROUND External cephalic version (ECV) is a frequently performed obstetric procedure for fetal breech presentation to avoid cesarean delivery. Neuraxial, intravenous, and inhalational anesthetic techniques have been studied to reduce maternal discomfort caused by the forceful manipulation. This study compares the effects of these anesthetic techniques on ECV and incidence of cesarean delivery. METHODS We conducted a comprehensive literature search for published randomized controlled trials (RCTs) or well-conducted quasi-randomized trials of ECV performed either without anesthesia or under neuraxial, intravenous, or inhalational anesthesia. Pairwise random-effects meta-analyses and network meta-analyses were performed to compare and rank the perinatal outcomes of the 3 anesthetic interventions and no anesthesia control, including the rate of successful version, cesarean delivery, maternal hypotension, nonreassuring fetal response, and adequacy of maternal pain control/satisfaction. RESULTS Eighteen RCTs and 1 quasi-randomized trial involving a total of 2296 term parturients with a noncephalic presenting singleton fetus were included. ECV under neuraxial anesthesia had significantly higher odds of successful fetal version compared to control (odds ratio [OR] = 2.59; 95% confidence interval [CI], 1.88-3.57), compared to intravenous anesthesia (OR = 2.08; 95% CI, 1.36-3.16), and compared to inhalational anesthesia (OR = 2.30; 95% CI, 1.33-4.00). No association was found between anesthesia interventions and rate of cesarean delivery. Neuraxial anesthesia was associated with higher odds of maternal hypotension (OR = 9.33; 95% CI, 3.14-27.68). Intravenous anesthesia was associated with significantly lower odds of nonreassuring fetal response compared to control (OR = 0.36; 95% CI, 0.16-0.82). Patients received neuraxial anesthesia reported significantly lower visual analog scale (VAS) of procedure-related pain (standardized mean difference [SMD] = -1.61; 95% CI, -1.92 to -1.31). The VAS scores of pain were also significantly lower with intravenous (SMD = -1.61; 95% CI, -1.92 to -1.31) and inhalational (SMD = -1.19; 95% CI, -1.58 to -0.8) anesthesia. The VAS of patient satisfaction was significantly higher with intravenous anesthesia (SMD = 1.53; 95% CI, 0.64-2.43). CONCLUSIONS Compared to control, ECV with neuraxial anesthesia had a significantly higher successful rate; however, the odds of maternal hypotension increased significantly. All anesthesia interventions provided significant reduction of procedure-related pain. Intravenous anesthesia had significantly higher score in patient satisfaction and lower odds of nonreassuring fetal response. No evidence indicated that anesthesia interventions were associated with significant decrease in the incidence of cesarean delivery compared to control.
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Affiliation(s)
- Qingzhong Hao
- From the Division of Anesthesiology, Geisinger Medical Center, Danville, Pennsylvania
| | - Yirui Hu
- Department of Population Health Sciences, Geisinger Medical Center, Danville, Pennsylvania
| | - Li Zhang
- From the Division of Anesthesiology, Geisinger Medical Center, Danville, Pennsylvania
| | - John Ross
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Geisinger Medical Center, Danville, Pennsylvania
| | - Sarah Robishaw
- From the Division of Anesthesiology, Geisinger Medical Center, Danville, Pennsylvania
| | - Christine Noble
- From the Division of Anesthesiology, Geisinger Medical Center, Danville, Pennsylvania
| | - Xianren Wu
- From the Division of Anesthesiology, Geisinger Medical Center, Danville, Pennsylvania
| | - Xiaopeng Zhang
- From the Division of Anesthesiology, Geisinger Medical Center, Danville, Pennsylvania
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Mostafa M, Hasanin A, Mostafa M, Taha MY, Elsayad M, Haggag FA, Taalab O, Rady A, Abdelhamid B. Hemodynamic effects of norepinephrine versus phenylephrine infusion for prophylaxis against spinal anesthesia-induced hypotension in the elderly population undergoing hip fracture surgery: a randomized controlled trial. Korean J Anesthesiol 2020; 74:308-316. [PMID: 33121228 PMCID: PMC8342837 DOI: 10.4097/kja.20519] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 10/29/2020] [Indexed: 11/10/2022] Open
Abstract
Background Elderly population are at increased risk of spinal anesthesia-induced hypotension increasing their risk for postoperative morbidity and mortality. This study aimed to compare the hemodynamic effects of prophylactic infusion of norepinephrine (NE) versus phenylephrine (PE) in elderly patients undergoing hip fracture surgery under spinal anesthesia. Methods Elderly patients scheduled for hip fracture surgery were randomized to receive either NE infusion (8 µg/min) (NE group, n = 31) or PE infusion (100 µg/min) (PE group, n = 31) after spinal anesthesia. Outcomes included mean heart rate, mean blood pressure, cardiac output, incidence of spinal anesthesia-induced hypotension, incidence of bradycardia, and incidence of hypertension. Results Sixty-two patients with a mean age of 71 ± 6 years were included in the final analysis (31 patients in each group). The NE group showed a higher mean heart rate and cardiac output than the PE group. The NE group had a lower incidence of reactive bradycardia (10% vs. 36%, P = 0.031) and hypertension (3% vs. 36%, P = 0.003) than the PE group. No study participant developed hypotension, and the mean blood pressure was comparable between the two groups. Conclusions Both NE and PE infusions effectively prevented spinal anesthesia-induced hypotension in elderly patients undergoing hip fracture surgery. However, NE provided more hemodynamic stability than PE; maintaining the heart rate, higher cardiac output, less reactive bradycardia, and hypertension.
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Affiliation(s)
- Maha Mostafa
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt
| | - Ahmed Hasanin
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt
| | - Mahmoud Mostafa
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt
| | - Mai Y Taha
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt
| | - Mohamed Elsayad
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt
| | | | - Omar Taalab
- Department of Orthopedic Surgery, Cairo University, Cairo, Egypt
| | - Ashraf Rady
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt
| | - Bassant Abdelhamid
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt
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Theodoraki K, Hadzilia S, Valsamidis D, Stamatakis E. Prevention of hypotension during elective cesarean section with a fixed-rate norepinephrine infusion versus a fixed-rate phenylephrine infusion. Α double-blinded randomized controlled trial. Int J Surg 2020; 84:41-49. [PMID: 33080415 DOI: 10.1016/j.ijsu.2020.10.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 09/25/2020] [Accepted: 10/08/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Spinal anesthesia for cesarean section can be complicated by hypotension, with untoward effects for both the mother and fetus. Frequently used phenylephrine can lead to baroreceptor-mediated reflex bradycardia. The aim of the present study was to compare a fixed-rate prophylactic norepinephrine infusion to a fixed-rate prophylactic phenylephrine infusion during elective cesarean section under combined spinal-epidural anesthesia. MATERIALS AND METHODS Eighty-two parturients were randomized to either norepinephrine 4 μg/min or phenylephrine 50 μg/min fixed-rate infusions, starting simultaneously with the administration of the subarachnoid solution. The primary endpoint was the incidence of maternal bradycardia. Maternal hemodynamics at specific timepoints, the incidence of hypotension or hypertension, the requirement for ephedrine or atropine bolus administration as well as the acid-base status and Apgar score of the neonate were recorded. RESULTS The incidence of bradycardia as well as the requirement for atropine administration was lower in the norepinephrine group (4.8% vs. 31.7%, p = 0.004 and 2.4% vs. 24.3%, p = 0.01, respectively). Fetal pH, and fetal blood glucose concentration were higher in the norepinephrine group (p = 0.027 and 0.019, respectively). No difference in the occurrence of hypotension, hypertension, in the requirement for bolus vasoconstrictive medication or in Apgar scores was demonstrated. CONCLUSIONS A fixed-rate infusion of norepinephrine is as effective in the management of hypotension during regional anesthesia for cesarean section as a fixed-rate infusion of phenylephrine, with the avoidance of phenylephrine-induced bradycardia. The more favourable neonatal acid-base profile of noradrenaline might be due to better maintenance of placental blood flow in the noradrenaline group due to its beta action, while the higher fetal glucose concentration in the same group might result from a catecholamine-stimulated glucose metabolism increase and a β-receptor mediated insulin decrease.
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Affiliation(s)
- Kassiani Theodoraki
- 1st Department of Anesthesiology, Aretaieion University Hospital, National and Kapodistrian University of Athens, Greece.
| | - Sofia Hadzilia
- Department of Anesthesiology, Alexandra General Hospital of Athens, Greece
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Zhao C, Li S, Zhang J, Huang Y, Zhang L, Zhao F, Du X, Hou J, Zhang T, Shi C, Wang P, Huo R, Woodman OL, Qin CX, Xu H, Huang L. Current state and future perspective of cardiovascular medicines derived from natural products. Pharmacol Ther 2020; 216:107698. [PMID: 33039419 DOI: 10.1016/j.pharmthera.2020.107698] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 09/25/2020] [Accepted: 09/28/2020] [Indexed: 02/06/2023]
Abstract
The contribution of natural products (NPs) to cardiovascular medicine has been extensively documented, and many have been used for centuries. Cardiovascular disease (CVD) is the leading cause of morbidity and mortality worldwide. Over the past 40 years, approximately 50% of newly developed cardiovascular drugs were based on NPs, suggesting that NPs provide essential skeletal structures for the discovery of novel medicines. After a period of lower productivity since the 1990s, NPs have recently regained scientific and commercial attention, leveraging the wealth of knowledge provided by multi-omics, combinatorial biosynthesis, synthetic biology, integrative pharmacology, analytical and computational technologies. In addition, as a crucial part of complementary and alternative medicine, Traditional Chinese Medicine has increasingly drawn attention as an important source of NPs for cardiovascular drug discovery. Given their structural diversity and biological activity NPs are one of the most valuable sources of drugs and drug leads. In this review, we briefly described the characteristics and classification of NPs in CVDs. Then, we provide an up to date summary on the therapeutic potential and the underlying mechanisms of action of NPs in CVDs, and the current view and future prospect of developing safer and more effective cardiovascular drugs based on NPs.
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Affiliation(s)
- Chunhui Zhao
- Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing 100700, China
| | - Sen Li
- National Resource Center for Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing 100700, China; College of Chinese Medicinal Materials, Jilin Agricultural University, Changchun 130118, China
| | - Junhong Zhang
- Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing 100700, China
| | - Yuanyun Huang
- Biology Department, Cornell University, Ithaca, NY 14850, United States of America
| | - Luoqi Zhang
- National Resource Center for Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing 100700, China; College of Chinese Medicinal Materials, Jilin Agricultural University, Changchun 130118, China
| | - Feng Zhao
- Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing 100700, China
| | - Xia Du
- Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing 100700, China; Shaanxi Academy of Traditional Chinese Medicine, Xi'an 710003, China
| | - Jinli Hou
- Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing 100700, China
| | - Tong Zhang
- Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing 100700, China
| | - Chenjing Shi
- Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing 100700, China
| | - Ping Wang
- Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing 100700, China
| | - Ruili Huo
- China Academy of Chinese Medical Sciences, Beijing 100700, China
| | - Owen L Woodman
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, VIC 3800, Australia
| | - Cheng Xue Qin
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, VIC 3800, Australia; School of Pharmaceutical Science, Shandong University, Shandong 250100, China; Qilu Hospital, Cheeloo College of Medicine, Shandong University, Shandong 250100, China.
| | - Haiyu Xu
- Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing 100700, China.
| | - Luqi Huang
- National Resource Center for Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing 100700, China; China Academy of Chinese Medical Sciences, Beijing 100700, China.
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Norepinephrine or phenylephrine during spinal anaesthesia for Caesarean delivery: a randomised double-blind pragmatic non-inferiority study of neonatal outcome. Br J Anaesth 2020; 125:588-595. [DOI: 10.1016/j.bja.2020.05.057] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 05/19/2020] [Accepted: 05/20/2020] [Indexed: 11/20/2022] Open
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Biricik E, Karacaer F, Ünal İ, Sucu M, Ünlügenç H. [The effect of epinephrine for the treatment of spinal-hypotension: comparison with norepinephrine and phenylephrine, clinical trial]. Rev Bras Anestesiol 2020; 70:500-507. [PMID: 32980142 DOI: 10.1016/j.bjan.2020.04.017] [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: 12/18/2019] [Revised: 04/16/2020] [Accepted: 04/18/2020] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Limited data are present on safety and efficiency of epinephrine for the prophylaxis and treatment of spinal-hypotension. This study was conducted to compare the effect of epinephrine with norepinephrine and phenylephrine on the treatment of spinal-hypotension and ephedrine requirement during cesarean delivery. METHODS One hundred and sixty parturients with uncomplicated pregnancies undergoing elective cesarean delivery under spinal anesthesia were recruited. They were allocated randomly to receive norepinephrine 5 μg.mL-1 (n=40), epinephrine 5 μg.mL-1 (n=40), phenylephrine 100 μg.mL-1 (n=40) or 0.9% saline infusions (n=40) immediately after induction of spinal anesthesia. Whenever systolic blood pressure drops to less than 80% of baseline, 5 mg of iv ephedrine was administered as rescue vasopressor. The incidence of hypotension, total number of hypotension episodes, the number of patients requiring ephedrine, the mean amount of ephedrine consumption and side effects were recorded. RESULTS There was no statistically significant difference in incidence of maternal hypotension between groups. The number of patients requiring ephedrine was significantly greater in group saline than in group phenylephrine (p <0.001). However, it was similar between phenylephrine, norepinephrine, and epinephrine groups. The mean ephedrine consumption was significantly higher in group saline than in norepinephrine, epinephrine, phenylephrine groups (p=0.001). CONCLUSION There is no statistically significant difference in incidence of hypotension and ephedrine consumption during spinal anesthesia for cesarean delivery with the use of epinephrine when compared to norepinephrine or phenylephrine. Epinephrine can be considered as an alternative agent for management of spinal hypotension.
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Affiliation(s)
- Ebru Biricik
- Cukurova University, Faculty of Medicine, Department of Anesthesiology and Reanimation, Adana, Turquia.
| | - Feride Karacaer
- Cukurova University, Faculty of Medicine, Department of Anesthesiology and Reanimation, Adana, Turquia
| | - İlker Ünal
- Çukurova University, Faculty of Medicine, Department of Statistics, Adana, Turquia
| | - Mete Sucu
- Çukurova University, Faculty of Medicine, Department of Obstetrics and Gynecology, Adana, Turquia
| | - Hakkı Ünlügenç
- Cukurova University, Faculty of Medicine, Department of Anesthesiology and Reanimation, Adana, Turquia
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Shah PJ, Agrawal P, Beldar RK. Intravenous norepinephrine and mephentermine for maintenance of blood pressure during spinal anaesthesia for caesarean section: An interventional double-blinded randomised trial. Indian J Anaesth 2020; 64:S235-S241. [PMID: 33311725 PMCID: PMC7714008 DOI: 10.4103/ija.ija_91_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Revised: 04/20/2020] [Accepted: 07/23/2020] [Indexed: 01/18/2023] Open
Abstract
Background and Aims: Spinal anaesthesia induced hypotension (SAIH) and bradycardia may prove deleterious to both parturient and baby, hence vasopressors play a vital role in their management. Recent studies on norepinephrine as rescue vasopressor during subarachnoid block (SAB) enlighten its role for SAIH. This randomised double-blind trial was conducted to compare the effect of intermittent intravenous boluses of norepinephrine and frequently used mephentermine for management of SAIH in caesarean section (CS) to prove whether norepinephrine produces comparable effects or superior to mephentermine. Methods: After approval from Institutional Ethics Committee and registration in Clinical Trials Registry India (CTRI/2019/06/019652), 256 parturients posted for elective CS under SAB were randomly allocated into Group-N and Group-M (n = 84) using chit system, who received boluses of intravenous norepinephrine 8μg and mephentermine 6mg for SAIH, respectively. Systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate (HR), Response%, Apgar score and maternal complications were analysed. Results: The changes in SBP and DBP were comparable in both the groups. It was significantly low after SAB compared to baseline and significantly high compared to 1st hypotensive value in both the groups throughout the study period (<0.0001). HR was comparable for initial 10 min, thereafter it was significantly high in Group-M (<0.0001) till 40 min. Response% after the first bolus was significantly high in Group-N (59.30n ± 29.21 vs 39.78 ± 25.6; P = <0.0001). Conclusion: Intravenous norepinephrine is better than mephentermine with respect to high response% and stable maternal HR although both are equally effective in maintaining blood pressure following SAIH during elective CS.
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Affiliation(s)
- Pratibha Jain Shah
- Department of Anaesthesiology and Critical Care, Pt JNM Medical College, Raipur, Chhattisgarh, India
| | - Pratiksha Agrawal
- Department of Anaesthesiology and Critical Care, Pt JNM Medical College, Raipur, Chhattisgarh, India
| | - Rajesh Kumar Beldar
- Department of Anaesthesiology and Critical Care, Pt JNM Medical College, Raipur, Chhattisgarh, India
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Biricik E, Karacaer F, Ünal İ, Sucu M, Ünlügenç H. The effect of epinephrine for the treatment of spinal-hypotension: comparison with norepinephrine and phenylephrine, clinical trial. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ENGLISH EDITION) 2020. [PMID: 32980142 PMCID: PMC9373668 DOI: 10.1016/j.bjane.2020.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Background and objectives Limited data are present on safety and efficiency of epinephrine for the prophylaxis and treatment of spinal-hypotension. This study was conducted to compare the effect of epinephrine with norepinephrine and phenylephrine on the treatment of spinal-hypotension and ephedrine requirement during cesarean delivery. Methods One hundred and sixty parturients with uncomplicated pregnancies undergoing elective cesarean delivery under spinal anesthesia were recruited. They were allocated randomly to receive norepinephrine 5 μg.mL−1 (n = 40), epinephrine 5 μg.mL−1 (n = 40), phenylephrine 100 μg.mL−1 (n = 40) or 0.9% saline infusions (n = 40) immediately after induction of spinal anesthesia. Whenever systolic blood pressure drops to less than 80% of baseline, 5 mg of intravenous ephedrine was administered as rescue vasopressor. The incidence of hypotension, total number of hypotension episodes, the number of patients requiring ephedrine, the mean amount of ephedrine consumption and side effects were recorded. Results There was no statistically significant difference in incidence of maternal hypotension between groups. The number of patients requiring ephedrine was significantly greater in group saline than in group phenylephrine (p < 0.001). However, it was similar between phenylephrine, norepinephrine, and epinephrine groups. The mean ephedrine consumption was significantly higher in group saline than in norepinephrine, epinephrine, phenylephrine groups (p = 0.001). Conclusion There is no statistically significant difference in incidence of hypotension and ephedrine consumption during spinal anesthesia for cesarean delivery with the use of epinephrine when compared to norepinephrine or phenylephrine. Epinephrine can be considered an alternative agent for management of spinal hypotension.
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Effects of intraoperative hemodynamic management on postoperative acute kidney injury in liver transplantation: An observational cohort study. PLoS One 2020; 15:e0237503. [PMID: 32810154 PMCID: PMC7446917 DOI: 10.1371/journal.pone.0237503] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 07/23/2020] [Indexed: 12/28/2022] Open
Abstract
Background Intraoperative restrictive fluid management strategies might improve postoperative outcomes in liver transplantation. Effects of vasopressors within any hemodynamic management strategy are unclear. Methods We conducted an observational cohort study on adult liver transplant recipients between July 2008 and December 2017. We measured the effect of vasopressors infused at admission in the intensive care unit (ICU) and total intraoperative fluid balance. Our primary outcome was 48-hour acute kidney injury (AKI) and our secondary outcomes were 7-day AKI, need for postoperative renal replacement therapy (RRT), time to extubation in the ICU, time to ICU discharge and survival up to 1 year. We fitted models adjusted for confounders using generalized estimating equations or survival models using robust standard errors. We reported results with 95% confidence intervals. Results We included 532 patients. Vasopressors use was not associated with 48-hour or 7-day AKI but modified the effects of fluid balance on RRT and mortality. A higher fluid balance was associated with a higher need for RRT (OR = 1.52 [1.15, 2.01], p<0.001 for interaction) and lower survival (HR = 1.71 [1.26, 2.34], p<0.01 for interaction) only among patients without vasopressors. In patients with vasopressors, higher doses of vasopressors were associated with a higher mortality (HR = 1.29 [1.13, 1.49] per 10 μg/min of norepinephrine). Conclusion The presence of any vasopressor at the end of surgery was not associated with AKI or RRT. The use of vasopressors might modify the harmful association between fluid balance and other postoperative outcomes. The liberal use of vasopressors to implement a restrictive fluid management strategy deserves further investigation.
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