1
|
Monks DT, Singh PM, Palanisamy A. Preventing maternal cardiac arrest: how do we reach the next level of safety in obstetric anaesthesia? Anaesthesia 2024; 79:461-464. [PMID: 38214064 DOI: 10.1111/anae.16230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/12/2023] [Indexed: 01/13/2024]
Affiliation(s)
- D T Monks
- Department of Anesthesiology, Washington University in Saint Louis, St Louis, MO, USA
| | - P M Singh
- Department of Anesthesiology, Washington University in Saint Louis, St Louis, MO, USA
| | - A Palanisamy
- Department of Anesthesiology, Washington University in Saint Louis, St Louis, MO, USA
| |
Collapse
|
2
|
Salhotra R, Tyagi A, Rautela RS, Chauhan J, Dolma L, Sharma A, Batra P, Srivastava H. Efficacy of fixed-dose phenylephrine bolus for treating post-spinal hypotension: Comparison between pre-eclamptics and normotensives. J Anaesthesiol Clin Pharmacol 2023; 39:451-457. [PMID: 38025583 PMCID: PMC10661643 DOI: 10.4103/joacp.joacp_518_21] [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: 10/23/2021] [Accepted: 01/31/2022] [Indexed: 12/01/2023] Open
Abstract
Background and Aims Pre-eclamptic parturients may have an exaggerated response to vasopressors. This study compares the efficacy of a 50 μg fixed bolus of phenylephrine for treatment of post-spinal hypotension in pre-eclamptic versus normotensive parturients. Material and Methods After written informed consent and ethics committee approval, 30 normotensive and 30 pre-eclamptic parturients between 18 and 40 years with singleton term pregnancy about to undergo cesarean section (CS) under spinal anesthesia were included. Post-spinal hypotension was treated with a 50 μg fixed bolus of phenylephrine. The cumulative dose of phenylephrine, the number of boluses, and the median dose required to treat the first hypotensive episode, total number of hypotensive episodes, maternal side effects, neonatal appearance, pulse, grimace, activity, and respiration (APGAR) scores, and umbilical arterial cord blood pH were noted. Statistical analysis was done using Student's t-test, Mann-Whitney U-test, Chi-square test/Fisher's exact test as appropriate. A P <0.05 was considered significant. Results The cumulative dose and number of boluses of phenylephrine required to treat post-spinal hypotension were comparable. The median dose required to treat the first episode of post-spinal hypotension was also similar (p = 0.792). The time to develop the first hypotensive episode was significantly earlier for group N (p = 0.002). The efficacy of a single fixed bolus of 50 μg phenylephrine was similar in both groups (p = 1.000). Neonatal median APGAR scores at 1 min after birth were significantly higher for group N (p = 0.016). Conclusion A fixed-dose bolus of 50 μg phenylephrine is safe and effective in treating post-spinal hypotension in pre-eclampsia. The efficacy of phenylephrine is comparable in pre-eclamptic and normotensive parturients.
Collapse
Affiliation(s)
- Rashmi Salhotra
- Department of Anesthesiology and Critical Care, UCMS and GTB Hospital, Delhi, India
| | - Asha Tyagi
- Department of Anesthesiology and Critical Care, UCMS and GTB Hospital, Delhi, India
| | - Rajesh Singh Rautela
- Department of Anesthesiology and Critical Care, UCMS and GTB Hospital, Delhi, India
| | - Jainendra Chauhan
- Department of Anesthesiology and Critical Care, UCMS and GTB Hospital, Delhi, India
| | - Lhamo Dolma
- Department of Anesthesiology and Critical Care, Sikkim Manipal Institute of Medical Sciences, Central Referral Hospital, Gangtok, Sikkim, India
| | - Ankit Sharma
- Department of Anesthesiology and Critical Care, Department of Onco-Anesthesia and Palliative Medicine, Dr. BRAIRCH, AIIMS, New Delhi, India
| | - Prerna Batra
- Department of Pediatrics, UCMS and GTB Hospital, Delhi, India
| | - Himsweta Srivastava
- Department of Obstetrics and Gynecology, UCMS and GTB Hospital, Delhi, India
| |
Collapse
|
3
|
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.
Collapse
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.
| |
Collapse
|
4
|
|
5
|
Bishop DG, Cairns C, Grobbelaar M, Rodseth RN. Prophylactic Phenylephrine Infusions to Reduce Severe Spinal Anesthesia Hypotension During Cesarean Delivery in a Resource-Constrained Environment. Anesth Analg 2017; 125:904-906. [PMID: 28244952 DOI: 10.1213/ane.0000000000001905] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Phenylephrine infusions are considered as standard management for obstetric spinal hypotension, but there remains reluctance to implement them in resource-limited contexts. This prospective, alternating intervention study of patients undergoing elective or urgent cesarean delivery under spinal anesthesia compared a vasopressor bolus strategy to fixed-rate, low-dose prophylactic phenylephrine infusion with supplemental boluses. The primary outcome was the incidence of severe hypotension (mean arterial pressure <70% baseline or systolic blood pressure <80 mm Hg). Fewer patients receiving prophylactic phenylephrine infusions had severe hypotension (47.4% [n = 120/253] vs 62.1% [n = 157/253], P = .001, estimated relative risk 0.84, 95% confidence interval, 0.69-1.02), with no significant difference in the rate of hypertension (15% [n = 39/253] vs 11% [n = 27/253], P = .11, estimated relative risk 1.39, confidence interval 0.87-2.20). Guidelines for resource-constrained settings should consider a fixed, low-dose phenylephrine infusion in combination with rescue vasopressor bolus therapy.
Collapse
Affiliation(s)
- David G Bishop
- From the *Perioperative Research Group, Metropolitan Department of Anaesthetics, Critical Care and Pain Management, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Pietermaritzburg, South Africa; and †Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio
| | | | | | | |
Collapse
|
6
|
Bishop DG, Rodseth RN, Dyer RA. Context is king - obstetric anaesthesia management strategies in limited resource settings. Int J Obstet Anesth 2017; 31:1-4. [PMID: 28576355 DOI: 10.1016/j.ijoa.2017.04.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Revised: 04/27/2017] [Accepted: 04/30/2017] [Indexed: 10/19/2022]
Affiliation(s)
- D G Bishop
- Perioperative Research Group, Department of Anaesthetics, Critical Care and Pain Management, University of KwaZulu-Natal, Pietermaritzburg, KwaZulu-Natal, South Africa.
| | - R N Rodseth
- Perioperative Research Group, Department of Anaesthetics, Critical Care and Pain, Management, University of KwaZulu-Natal, Pietermaritzburg, KwaZulu-Natal, South Africa; Outcomes Research Consortium, Cleveland Clinic, Cleveland, OH, United States
| | - R A Dyer
- Department of Anaesthesia and Perioperative Medicine, University of Cape Town, Cape Town, Western Cape, South Africa
| |
Collapse
|
7
|
McDonnell NJ, Paech MJ, Muchatuta NA, Hillyard S, Nathan EA. A randomised double-blind trial of phenylephrine and metaraminol infusions for prevention of hypotension during spinal and combined spinal-epidural anaesthesia for elective caesarean section. Anaesthesia 2017; 72:609-617. [DOI: 10.1111/anae.13836] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/19/2017] [Indexed: 11/29/2022]
Affiliation(s)
- N. J. McDonnell
- School of Medicine and Pharmacology; The University of Western Australia; Perth Australia
- School of Women's and Infants Health; The University of Western Australia; Perth Australia
| | - M. J. Paech
- School of Medicine and Pharmacology; The University of Western Australia; Perth Australia
| | | | - S. Hillyard
- Rockingham General Hospital; Rockingham Australia
| | - E. A. Nathan
- Biostatistics and Research Design Unit; Women and Infants Research Foundation; Perth Australia
| |
Collapse
|
8
|
|
9
|
Mohta M, Aggarwal M, Sethi AK, Harisinghani P, Guleria K. Randomized double-blind comparison of ephedrine and phenylephrine for management of post-spinal hypotension in potential fetal compromise. Int J Obstet Anesth 2016; 27:32-40. [PMID: 27020488 DOI: 10.1016/j.ijoa.2016.02.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Revised: 02/05/2016] [Accepted: 02/14/2016] [Indexed: 01/05/2023]
Abstract
BACKGROUND Most studies comparing phenylephrine and ephedrine have been conducted during elective caesarean sections in healthy mothers with no fetal compromise. The effect of vasopressors on fetal outcome may differ between healthy and compromised fetuses. There has been little research into the effect of phenylephrine and ephedrine, when used for management of post-spinal hypotension in the presence of potential fetal compromise. METHODS Healthy women with a singleton pregnancy undergoing emergency caesarean section for fetal compromise under spinal anaesthesia were studied. One-hundred-and-six consecutive subjects, who developed hypotension after spinal anaesthesia, were randomly allocated to two groups of 53 each, to receive either phenylephrine (Group P) or ephedrine (Group E). For every systolic blood pressure reading <100mmHg patients received phenylephrine 100μg or ephedrine 8mg depending on group allocation. Umbilical blood gas parameters and Apgar scores were recorded. RESULTS There was no statistically significant difference in umbilical arterial pH (P=0.79), umbilical venous pH (P=0.98), other blood gas parameters, incidence of fetal acidosis (P=1.00) and Apgar scores. The number of hypotensive episodes, vasopressor doses for treatment of the first hypotensive episode and the total number of doses used during the study period were comparable. The median [IQR] total number of doses of phenylephrine and ephedrine used before delivery were 2 [1-2] and 2 [1-2], respectively (P=0.67). More patients receiving ephedrine (24.5%) developed tachycardia than those receiving phenylephrine (3.8%) (P=0.004). Bradycardia was more common with phenylephrine, with 39.6% of patients in Group P as compared to only 1.9% of patients in Group E developing a heart rate <60beats/min after vasopressor administration (P=0.001). CONCLUSIONS Both phenylephrine 100μg and ephedrine 8mg boluses are equally efficacious when treating post-spinal hypotension in the presence of potential fetal compromise. However, phenylephrine may be a better choice in the presence of maternal tachycardia.
Collapse
Affiliation(s)
- M Mohta
- Department of Anaesthesiology and Critical Care, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi, India.
| | - M Aggarwal
- Department of Anaesthesiology and Critical Care, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi, India
| | - A K Sethi
- Department of Anaesthesiology and Critical Care, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi, India
| | - P Harisinghani
- Department of Anaesthesiology and Critical Care, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi, India
| | - K Guleria
- Department of Obstetrics and Gynaecology, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi, India
| |
Collapse
|
10
|
Odekon L, Landau R, Blouin JL, Brodow D, Wang S, Smiley RM. The Effect of β2-Adrenoceptor Genotype on Phenylephrine Dose Administered During Spinal Anesthesia for Cesarean Delivery. Anesth Analg 2015; 120:1309-16. [DOI: 10.1213/ane.0000000000000675] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
|
11
|
|
12
|
Sachs A, Aaronson J, Smiley R. The role of the anesthesiologist in the care of the parturient with cardiac disease. Semin Perinatol 2014; 38:252-9. [PMID: 25037515 DOI: 10.1053/j.semperi.2014.04.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Women with cardiac disease constitute a growing percentage of parturients, and in many series cardiac disease is the leading cause of maternal mortality. Involvement of anesthesiologists in the planning for and management of delivery in these women can improve the experience and potentially the outcome of these patients. Communication with the anesthesiology team about particularly complex cases is essential to avoid both medical complications and inter-disciplinary disagreements. The specific role and contributions of the anesthesiology team will depend significantly on the nature of the institution and the organization of the (obstetric) anesthesiology service.
Collapse
Affiliation(s)
- Adam Sachs
- Division of Obstetric Anesthesiology, Department of Anesthesiology, Columbia University College of Physicians and Surgeons, 630 West 168th St, New York, NY 10032
| | - Jaime Aaronson
- Division of Obstetric Anesthesiology, Department of Anesthesiology, Columbia University College of Physicians and Surgeons, 630 West 168th St, New York, NY 10032
| | - Richard Smiley
- Division of Obstetric Anesthesiology, Department of Anesthesiology, Columbia University College of Physicians and Surgeons, 630 West 168th St, New York, NY 10032.
| |
Collapse
|
13
|
Butwick AJ, Columb MO, Carvalho B. Preventing spinal hypotension during Caesarean delivery: what is the latest? Br J Anaesth 2014; 114:183-6. [PMID: 25080429 DOI: 10.1093/bja/aeu267] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Affiliation(s)
- A J Butwick
- Department of Anesthesiology (MC:5640), Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA 94305, USA
| | - M O Columb
- Department of Anaesthesia, University Hospital of South Manchester, Wythenshawe, UK
| | - B Carvalho
- Department of Anesthesiology (MC:5640), Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA 94305, USA
| |
Collapse
|
14
|
Mercier FJ, Diemunsch P, Ducloy-Bouthors AS, Mignon A, Fischler M, Malinovsky JM, Bolandard F, Aya AG, Raucoules-Aimé M, Chassard D, Keita H, Rigouzzo A, Le Gouez A. 6% Hydroxyethyl starch (130/0.4) vs Ringer's lactate preloading before spinal anaesthesia for Caesarean delivery: the randomized, double-blind, multicentre CAESAR trial. Br J Anaesth 2014; 113:459-67. [PMID: 24970272 DOI: 10.1093/bja/aeu103] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Vasopressor administration is recommended to prevent hypotension during spinal anaesthesia (SA) for elective Caesarean delivery. We aimed to test the superior efficacy and ensure safety of a hydroxyethyl starch (HES) vs a Ringer's lactate (RL) preloading, when combined with a phenylephrine-based prophylaxis. METHODS A total of 167 healthy parturients undergoing elective Caesarean delivery under SA were included in this multicentre, randomized, double-blind study. Patients received 500 ml of 6% HES (130/0.4)+500 ml of RL (HES group) or 1000 ml of RL (RL group) i.v. before SA. After SA, i.v. phenylephrine boluses were titrated when systolic arterial pressure (SAP) was below 95% of baseline. The primary outcome was the incidence of maternal hypotension (SAP <80% of baseline). RESULTS The incidence of both hypotension and symptomatic hypotension (i.e. with dizziness, nausea/vomiting, or both) was significantly lower in the HES group vs the RL group: 36.6% vs 55.3% (one-sided P=0.025) and 3.7% vs 14.1%. There was no significant difference in total phenylephrine requirements [median (range): 350 (50-1800) vs 350 (50-1250) µg]. The decrease in maternal haemoglobin value the day after surgery was similar in the two groups [1.2 (1.0) vs 1.0 (0.9) g dl(-1)]. There was no detectable placental transfer of HES in six umbilical cord blood samples analysed in the HES group. Neonatal outcomes were comparable between the groups. CONCLUSIONS Compared with a pure RL preloading, a mixed HES-RL preloading significantly improved prevention of both hypotension and symptomatic hypotension based on early phenylephrine bolus administration and did not induce adverse effects. CLINICAL TRIAL REGISTRATION NCT00694343 (http://clinicaltrials.gov).
Collapse
Affiliation(s)
- F J Mercier
- Département d'Anesthésie-Réanimation, Université Paris-Sud, APHP-Hôpital Antoine Béclère, 157 rue de la Porte de Trivaux, 92141 Clamart, France
| | - P Diemunsch
- Département d'Anesthésie-Réanimation, Hôpital de Hautepierre, 67000 Strasbourg, France
| | - A-S Ducloy-Bouthors
- Département d'Anesthésie-Réanimation, Hôpital Jeanne de Flandre, 59037 Lille, France
| | - A Mignon
- Département d'Anesthésie-Réanimation, APHP- Hôpital Cochin, 75014 Paris, France
| | - M Fischler
- Service d'Anesthésie-Réanimation, Hôpital Foch, 92150 Suresnes, France
| | - J-M Malinovsky
- Département d'Anesthésie-Réanimation, Hôpital Maison Blanche, 51100 Reims, France
| | - F Bolandard
- Département d'Anesthésie-Réanimation, Hôpital Hotel Dieu, 69002 Clermont-Ferrand, France
| | - A G Aya
- Département d'Anesthésie-Réanimation, Hôpital Caremeau, 30000 Nîmes, France
| | - M Raucoules-Aimé
- Département d'Anesthésie-Réanimation, Hôpital de l'Archet, 06200 Nice, France
| | - D Chassard
- Département d'Anesthésie-Réanimation, Hôpital mère-enfant, 69500 Bron, France
| | - H Keita
- Département d'Anesthésie-Réanimation, APHP-Hôpital Louis Mourier, 92701 Colombes, France
| | - A Rigouzzo
- Département d'Anesthésie-Réanimation, APHP-Hôpital Armand-Trousseau, 75012 Paris, France
| | - A Le Gouez
- Département d'Anesthésie-Réanimation, Université Paris-Sud, APHP-Hôpital Antoine Béclère, 157 rue de la Porte de Trivaux, 92141 Clamart, France
| | | |
Collapse
|
15
|
Ngan Kee WD. Phenylephrine Infusions for Maintaining Blood Pressure During Spinal Anesthesia for Cesarean Delivery. Anesth Analg 2014; 118:496-8. [DOI: 10.1213/ane.0000000000000111] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
16
|
Arendt KW, Muehlschlegel JD, Tsen LC. Cardiovascular alterations in the parturient undergoing cesarean delivery with neuraxial anesthesia. ACTA ACUST UNITED AC 2014. [DOI: 10.1586/eog.11.79] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
17
|
|
18
|
Maternal Hypotension During Spinal Anesthesia for Cesarean Delivery. CURRENT ANESTHESIOLOGY REPORTS 2013. [DOI: 10.1007/s40140-013-0036-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
|
19
|
Henke VG, Bateman BT, Leffert LR. Focused review: spinal anesthesia in severe preeclampsia. Anesth Analg 2013; 117:686-693. [PMID: 23868886 DOI: 10.1213/ane.0b013e31829eeef5] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Spinal anesthesia is widely regarded as a reasonable anesthetic option for cesarean delivery in severe preeclampsia, provided there is no indwelling epidural catheter or contraindication to neuraxial anesthesia. Compared with healthy parturients, those with severe preeclampsia experience less frequent, less severe spinal-induced hypotension. In severe preeclampsia, spinal anesthesia may cause a higher incidence of hypotension than epidural anesthesia; however, this hypotension is typically easily treated and short lived and has not been linked to clinically significant differences in outcomes. In this review, we describe the advantages and limitations of spinal anesthesia in the setting of severe preeclampsia and the evidence guiding intraoperative hemodynamic management.
Collapse
Affiliation(s)
- Vanessa G Henke
- UCLA Department of Anesthesiology, Ronald Reagan UCLA Medical Center, 757 Westwood Plaza, Suite 3325, Los Angeles, CA 90095-7403.
| | | | | |
Collapse
|
20
|
Ngan Kee W, Lee S, Khaw K, Ng F. Haemodynamic effects of glycopyrrolate pre-treatment before phenylephrine infusion during spinal anaesthesia for caesarean delivery. Int J Obstet Anesth 2013; 22:179-87. [DOI: 10.1016/j.ijoa.2013.03.008] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2012] [Revised: 02/27/2013] [Accepted: 03/11/2013] [Indexed: 11/27/2022]
|
21
|
Cooper D, Mohanram K. Is there potential for heart rate to guide prophylactic phenylephrine administration during spinal anaesthesia for caesarean section? Int J Obstet Anesth 2013; 22:164-5. [PMID: 23474279 DOI: 10.1016/j.ijoa.2013.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2012] [Revised: 01/04/2013] [Accepted: 01/20/2013] [Indexed: 10/27/2022]
|
22
|
Li L, Zhang Y, Tan Y, Xu S. Colloid or crystalloid solution on maternal and neonatal hemodynamics for cesarean section: a meta-analysis of randomized controlled trials. J Obstet Gynaecol Res 2013; 39:932-41. [PMID: 23379937 DOI: 10.1111/jog.12001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2012] [Accepted: 09/29/2012] [Indexed: 11/29/2022]
Abstract
AIM To compare the effect of colloid and crystalloid on maternal and neonatal hemodynamics in cesarean section. MATERIAL AND METHODS We searched MEDLINE (PubMed, 1966-2011), EMBASE (1974-2011), http://www.clinicaltrials.gov, the Cochrane Controlled Clinical Trials Register Database, Biosis Preview, and the Chinese Biomedical Database (1980-2011). Randomized controlled trials involving healthy term patients undergoing scheduled cesarean delivery that compared the effect of colloid and crystalloid on hypotension, need for vasopressors, cardiac output, neonatal outcomes, and other adverse effects were analyzed. RESULTS Ten trials of 853 patients were eligible for analysis. When colloid was used, significantly fewer hypotensive events occurred (odds ratio [OR] 3.21, 95% CI 2.15-4.53, number needed to treat = 4), less demand for vasopressors (standard mean difference [SMD] 0.77, 95% CI 0.34-1.21) and improved cardiac output (SMD -1.08, 95% CI -2.00 - -0.17). In subgroup analysis, the use of colloid reduced hypotensive events and adverse effects in Asian patients. CONCLUSION Colloid hydration should be considered first, especially in Asian patients, focusing on dosage and type of fluids. Preventive or therapeutic vasopressors may be required in a significant proportion of patients.
Collapse
Affiliation(s)
- Le Li
- Department of Anesthesiology, Zhujiang Hospital, Guangzhou, China
| | | | | | | |
Collapse
|
23
|
|
24
|
Ngan Kee W, Khaw K, Ng F, Tam Y. Randomized comparison of closed-loop feedback computer-controlled with manual-controlled infusion of phenylephrine for maintaining arterial pressure during spinal anaesthesia for Caesarean delivery †. Br J Anaesth 2013; 110:59-65. [DOI: 10.1093/bja/aes339] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
|
25
|
DYER RA, BICCARD BM. Ephedrine for spinal hypotension during elective caesarean section: the final nail in the coffin? Acta Anaesthesiol Scand 2012; 56:807-9. [PMID: 22780437 DOI: 10.1111/j.1399-6576.2012.02719.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- R. A. DYER
- Department of Anaesthesia; University of Cape Town and New Groote Schuur Hospital; Cape Town; South Africa
| | - B. M. BICCARD
- Department of Anaesthesia; Nelson R Mandela School of Medicine; University of KwaZulu-Natal; Durban; South Africa
| |
Collapse
|
26
|
Fluid and vasopressor management for Cesarean delivery under spinal anesthesia: continuing professional development. Can J Anaesth 2012; 59:604-19. [PMID: 22528166 DOI: 10.1007/s12630-012-9705-9] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2011] [Accepted: 03/20/2012] [Indexed: 12/11/2022] Open
Abstract
PURPOSE The purpose of this Continuing Professional Development module is to review the physiology of maternal hypotension induced by spinal anesthesia in pregnant women, and the effects of fluids and vasopressors. PRINCIPAL FINDINGS Maternal hypotension induced by spinal anesthesia is caused mainly by peripheral vasodilatation and is not usually associated with a decrease in cardiac output. Although the intravenous administration of fluids helps to increase cardiac output, it does not always prevent maternal hypotension. Three strategies of fluid administrations are equivalent for the prevention of maternal hypotension and a reduced need for vasopressors: (1) colloid preload; (2) colloid coload; and (3) crystalloid coload. Crystalloid preload is not as effective as any of those three strategies. Unlike phenylephrine, ephedrine can cause fetal acidosis. Therefore, phenylephrine is recommended as first line treatment of maternal hypotension. A phenylephrine infusion (25-50 μg x min(-1)) appears to be more effective than phenylephrine boluses to prevent hypotension, and nausea and vomiting. In pre-eclamptic patients, spinal anesthesia produces less hypotension than in normal pregnant women and fluid volumes up to 1,000 mL are usually well tolerated. Therefore mild to moderate intravascular volume loading is recommended, keeping in mind the increased risk for pulmonary edema in this population. In pre-eclamptic patients, hypotension can be treated either with ephedrine or phenylephrine, and phenylephrine infusions are not recommended. CONCLUSION A volume loading regimen other than crystalloid preload should be adopted. A phenylephrine infusion during elective Cesarean delivery is beneficial for the mother and safe for the newborn.
Collapse
|
27
|
Reitman E, Flood P. Anaesthetic considerations for non-obstetric surgery during pregnancy. Br J Anaesth 2012; 107 Suppl 1:i72-8. [PMID: 22156272 DOI: 10.1093/bja/aer343] [Citation(s) in RCA: 146] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Surgery during pregnancy is complicated by the need to balance the requirements of two patients. Under usual circumstances, surgery is only conducted during pregnancy when it is absolutely necessary for the wellbeing of the mother, fetus, or both. Even so, the outcome is generally favourable for both the mother and the fetus. All general anaesthetic drugs cross the placenta and there is no optimal general anaesthetic technique. Neither is there convincing evidence that any particular anaesthetic drug is toxic in humans. There is weak evidence that nitrous oxide should be avoided in early pregnancy due to a potential association with pregnancy loss with high exposure. There is evidence in animal models that many general anaesthetic techniques cause inappropriate neuronal apoptosis and behavioural deficits in later life. It is not known whether these considerations affect the human fetus but studies are underway. Given the general considerations of avoiding fetal exposure to unnecessary medication and potential protection of the maternal airway, regional anaesthesia is usually preferred in pregnancy when it is practical for the medical and surgical condition. When surgery is indicated during pregnancy maintenance of maternal oxygenation, perfusion and homeostasis with the least extensive anaesthetic that is practical will assure the best outcome for the fetus.
Collapse
Affiliation(s)
- E Reitman
- Department of Anesthesiology, Columbia University, New York, NY 10032, USA
| | | |
Collapse
|
28
|
Yoon HJ, Cho HJ, Lee IH, Jee YS, Kim SM. Comparison of hemodynamic changes between phenylephrine and combined phenylephrine and glycopyrrolate groups after spinal anesthesia for cesarean delivery. Korean J Anesthesiol 2012; 62:35-9. [PMID: 22323952 PMCID: PMC3272527 DOI: 10.4097/kjae.2012.62.1.35] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2011] [Revised: 07/07/2011] [Accepted: 07/13/2011] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Hypotension remains a common clinical problem of spinal anesthesia for cesarean delivery and phenylephrine is used as a vasopressor to address this. However, phenylephrine reduces maternal cardiac output (CO) due to reflex bradycardia. Glycopyrrolate is safe for the fetus, and increases heart rate (HR). Using a noninvasive measure of CO, we compared maternal hemodynamic changes between the phenylephrine only group (group P) and the phenylephrine plus glycopyrrolate group (group PG). METHODS In this randomized study, 60 women scheduled for elective cesarean delivery were allocated to group P (n = 30) or group PG (n = 30). In both groups, phenylephrine was infused at 50 µg/min. This infusions stopped if systolic blood pressure (SBP) was higher than the baseline value, and phenylephrine 100 µg was injected if SBP was lower than 80% of the baseline value from spinal anesthesia to delivery. In group PG, glycopyrrolate 0.2 mg was injected intravenously after spinal anesthesia. Hemodynamic parameters, such as SBP, heart rate (HR), stroke volume index (SVI), cardiac index (CI) were measured before and until 15 min after spinal anesthesia. RESULTS There were no significant differences in SBP and SVI compared to the baseline value in each group and between the two groups. HR and CI reduced significantly from 8 min to 15 min in group P compared to the baseline value as well as group PG for each time-point. However, HR and CI were maintained in group PG. CONCLUSIONS The use of glycopyrrolate added to phenylephrine infusion to prevent hypotension by spinal anesthesia for cesarean delivery was effective in maintaining HR and CI.
Collapse
Affiliation(s)
- Hea-Jo Yoon
- Department of Anesthesiology and Pain Medicine, Cheil General Hospital, Kwandong Uiversity Medical School, Seoul, Korea
| | - Hong-Jei Cho
- Department of Anesthesiology and Pain Medicine, Cheil General Hospital, Kwandong Uiversity Medical School, Seoul, Korea
| | - In Ho Lee
- Department of Anesthesiology and Pain Medicine, Cheil General Hospital, Kwandong Uiversity Medical School, Seoul, Korea
| | - Young Seok Jee
- Department of Anesthesiology and Pain Medicine, Cheil General Hospital, Kwandong Uiversity Medical School, Seoul, Korea
| | - Soo Mi Kim
- Department of Anesthesiology and Pain Medicine, Cheil General Hospital, Kwandong Uiversity Medical School, Seoul, Korea
| |
Collapse
|
29
|
Abstract
INTRODUCTION Physiologic changes of pregnancy uniquely influence anesthesia for Cesarean delivery. Included is a review of current obstetrical anesthesia considerations for Cesarean delivery and recent changes improving maternal care and outcome. SOURCES OF DATA A literature review was conducted using Pubmed and the Cochrane database. AREAS OF AGREEMENT AND CONTROVERSY Increased use of neuraxial techniques instead of general anesthesia for Cesarean delivery has improved maternal safety. Recent changes in the prevention of gastric aspiration, hypotension from neuraxial techniques, venous thrombosis and a team approach have improved maternal care. Elective Cesarean deliveries and management of urgent deliveries are areas of discussion. AREAS TIMELY FOR DEVELOPING RESEARCH Obstetric anesthesia advances have improved maternal outcomes. Current areas of needed obstetric anesthesia research include improved obese patient care, the impact of anticoagulation on neuraxial techniques in pregnancy, long-term neurocognitive effects of neonatal exposure to anesthesia and postoperative pain management.
Collapse
Affiliation(s)
- Mark Rollins
- Department of Anesthesia and Perioperative Care, San Francisco, CA 94143-0464, USA.
| | | |
Collapse
|
30
|
McDonald S, Fernando R, Ashpole K, Columb M. Maternal Cardiac Output Changes After Crystalloid or Colloid Coload Following Spinal Anesthesia for Elective Cesarean Delivery. Anesth Analg 2011; 113:803-10. [DOI: 10.1213/ane.0b013e31822c0f08] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
31
|
[Anesthesiological management of Caesarean sections : nationwide survey in Germany]. Anaesthesist 2011; 60:916-28. [PMID: 21833754 DOI: 10.1007/s00101-011-1931-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2011] [Revised: 06/27/2011] [Accepted: 07/07/2011] [Indexed: 10/17/2022]
Abstract
BACKGROUND The rate of Caesarean sections in Germany continues to rise. The change in anesthetic technique of choice from general to spinal anesthesia began later than in other countries and at the last survey in 2002 was not widely established. The literature on the anesthetic management of Caesarean sections contains many controversies, for example fluid preload before performing spinal anesthesia and the vasopressor of choice. Other issues have received relatively little attention, such as the level of experience of anesthesiologists working autonomously on the labour ward or the timing of antibiotic prophylaxis. The aim of the current survey was to provide an updated overview of anesthetic management of Caesarean sections in Germany. MATERIAL AND METHODS A questionnaire was sent out to 709 departments of anesthesiology serving obstetric units in Germany. The questionnaire concerned various aspects of anesthetic management of Caesarean sections. RESULTS A total of 360 questionnaires (50.8%) were returned of which 346 were complete and could be analyzed, accounting for 330,000 births and 90,000 Caesarean sections per year. The predominant anesthetic method used for Caesarean sections was spinal anesthesia (90.8%) using hyperbaric bupivacaine and in approximately one third of the hospitals surveyed without administering intrathecal opioids. Approximately 12% of the departments surveyed used traumatic Quincke needles. In 86.2% the vasopressor of choice was caffedrine/theodrenaline. Nitrous oxide was used in only 19.2% of departments surveyed when general anesthesia is performed. An antibiotic drug was administered in only 11% of hospitals before cord clamping. In 43.1% no neonatologist was available to treat unexpected critically ill newborns. In 32.1% of departments surveyed residents with less than 2 years experience worked autonomously on the labour ward. CONCLUSIONS Currently the predominant anesthetic technique of choice in Germany is spinal anaesthesia and at a much higher rate than in 2002. In addition 12% of departments use traumatic Quincke needles which are associated with a higher incidence of postpuncture headache. Nitrous oxide is no longer frequently used in Germany. Finally, the administration of an antibiotic before cord clamping has been shown to lead to lower rates of endometritis and postoperative wound infection without detrimental effects on the newborn. This is practiced in only a small minority of departments across Germany.
Collapse
|
32
|
Bibliography. Obstetric and gynaecological anesthesia. Current world literature. Curr Opin Anaesthesiol 2011; 24:354-6. [PMID: 21637164 DOI: 10.1097/aco.0b013e328347b491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
33
|
Maternal haemodynamic changes during spinal anaesthesia for caesarean section. Curr Opin Anaesthesiol 2011; 24:242-8. [DOI: 10.1097/aco.0b013e32834588c5] [Citation(s) in RCA: 88] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
34
|
Abstract
The current article covers some of the major themes that emerged in 2009 in the fields of obstetric anesthesiology, obstetrics, and perinatology, with a special emphasis on the implications for the obstetric anesthesiologist.
Collapse
Affiliation(s)
- J M Mhyre
- Department of Anesthesia, Division of Obstetric Anesthesia, Women's Hospital, University of Michigan Health System, Ann Arbor, MI 48109-5278, USA.
| |
Collapse
|
35
|
Osseyran Samper F, Errando CL, Plaza Lloret M, Díaz Cambronero O, García Gregorio N, de Andrés Ibáñez J. [Prophylaxis for hypotension during cesarean section under spinal anesthesia: a randomized trial comparing hydroxyethyl starch 130/0.4 to ephedrine]. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2011; 58:17-24. [PMID: 21348213 DOI: 10.1016/s0034-9356(11)70693-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
BACKGROUND AND OBJECTIVE Spinal anesthesia is the technique of choice for scheduled or emergency cesarean section, but the prevalence of hypotension is high in this setting. Our aim was to compare the efficacy of a colloid (6% hydroxyethyl starch [HES] 130/0.4) to ephedrine for preventing hypotension. PATIENTS AND METHODS Patients undergoing elective or emergency cesarean section (in non-life-threatening situations) were enrolled. Patients were randomized to 3 groups for prophylaxis. The first ephedrine group received 5 mg of ephedrine intravenously (EPHE-5); the second ephedrine group received 10 mg of the drug intravenously (EPHE-10); and the HES group received 500 mL of HES 130/0.4 in rapid infusion n 15 minutes. We recorded systolic and diastolic blood pressures and heart rate after 10 minutes in the operating room and 2, 5, 10, 15, 20, and 30 minutes after injection of the anesthetic. We also assessed the sensory and motor blockades on both sides 2, 5, 10, 15, 20, and 30 minutes after injection. Neonatal status was assessed by Apgar score and umbilical cord blood gas analysis. RESULTS Ninety-six patients, 33 in each ephedrine group and 30 in the HES group, were enrolled. Blood pressure decreased similarly in all 3 groups (36% EPHE-5 group, 36% EPHE-10 group and 40% HES group); no significant between-group differences were observed. Nor were there significant differences in the percentages of patients requiring bolus doses of ephedrine to treat hypotension (23% in the HES group vs 33% in the EPHE-5 group and 27% in the EPHE-10 group) or in the cumulative doses of ephedrine. Neonatal status was also similarly satisfactory in all 3 groups. CONCLUSIONS HES 130/0.4 is as useful for hypotension prophylaxis as 5-mg or 10-mg intravenous doses of ephedrine. HES 130/0.4 might be a substitute for sympathomimetic agents if adverse effects are predicted or contraindications to the use of such drugs are present.
Collapse
Affiliation(s)
- F Osseyran Samper
- Servicio de Anestesiología, Reanimación y Terapia del Dolor, Hospital Universitario La Fe, Valencia.
| | | | | | | | | | | |
Collapse
|
36
|
Stewart A, Fernando R, McDonald S, Hignett R, Jones T, Columb M. The dose-dependent effects of phenylephrine for elective cesarean delivery under spinal anesthesia. Anesth Analg 2010; 111:1230-7. [PMID: 20841418 DOI: 10.1213/ane.0b013e3181f2eae1] [Citation(s) in RCA: 142] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Hypotension is the most common serious side effect of spinal anesthesia for cesarean delivery. There has been a move recently toward the use of phenylephrine as a vasopressor infusion to improve maternal cardiovascular stability and fetal outcome. Although it seems safe in the elective setting, there have been concerns about its propensity for causing an increase in afterload and a baroreceptor-mediated bradycardia in the mother, with a consequent reduction in maternal cardiac output (CO). Using a noninvasive measure of CO, our aim was to investigate whether there were any dose-dependent effects of phenylephrine on maternal cardiovascular stability and, if so, any impact on fetal outcome. METHODS In this randomized, double-blind study, 75 women scheduled for elective cesarean delivery were allocated to receive a phenylephrine infusion at 25 μg/min, 50 μg/min, or 100 μg/min. This infusion was titrated to maintain maternal baseline systolic blood pressure (SBP), from induction of spinal anesthesia until delivery. The maternal cardiovascular variables recorded included heart rate (HR) and SBP. A suprasternal Doppler monitor measured CO and stroke volume, as well as measures of venous return (corrected flow time) and contractility, at baseline, and then every 5 minutes for 20 minutes after initiation of spinal anesthesia. Apgar scores and umbilical cord blood gases were recorded. RESULTS SBP control was satisfactory in all groups; however, the group receiving phenylephrine 100 μg/min required significantly higher doses to achieve arterial blood pressure control compared with the lower infusion rates. There were no significant differences in the number of times SBP decreased below 80% of baseline, or the numbers of boluses of ephedrine or phenylephrine required to maintain SBP above 80% of baseline. There were significant time and dose-dependent reductions in HR and CO with phenylephrine, such that HR and CO were seen to decrease with time in each group, and also with increasing concentrations of phenylephrine. Stroke volume remained stable throughout. Apgar scores and umbilical cord blood gases were similar among groups. CONCLUSION By infusing a higher concentration (100 μg/min), we subject the mother and fetus to a much higher dose of phenylephrine, with significant effects on maternal HR and CO (up to a 20% reduction). Future investigation is required to determine whether this reduction in maternal CO has detrimental effects when providing anesthesia for an emergency cesarean delivery for a compromised fetus.
Collapse
Affiliation(s)
- Adrienne Stewart
- Department of Anesthesia, University College London Hospitals NHS Foundation Trust, London, UK
| | | | | | | | | | | |
Collapse
|
37
|
Prevention of maternal hypotension after regional anaesthesia for caesarean section. Curr Opin Anaesthesiol 2010; 23:304-9. [PMID: 20173633 DOI: 10.1097/aco.0b013e328337ffc6] [Citation(s) in RCA: 103] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
PURPOSE OF REVIEW Hypotension during regional anaesthesia for caesarean section remains a common clinical problem, particularly for spinal anaesthesia. The purpose of this review is to evaluate recent research in this area with a focus on English language papers from the past 1-2 years. RECENT FINDINGS Risk factors for hypotension include increased sympathetic tone, increasing age, obesity, higher blocks and higher birthweight, but not multiple gestation. Methods aimed at countering effects of aortocaval compression do not reliably prevent hypotension. Intravenous crystalloid prehydration has poor efficacy, and focus has changed toward cohydration and use of colloids. Phenylephrine is established as a first-line vasopressor, although there are limited data from high-risk patients. Initial phenylephrine bolus dose requirement may be surprisingly large. Phenylephrine infusions can be conveniently titrated to maintain blood pressure and prevent maternal symptoms. Ephedrine crosses the placenta more than phenylephrine and direct fetal effects of ephedrine may explain associated depression of fetal pH and base excess. CONCLUSION Recent research supports decreased use of crystalloid prehydration and ephedrine and increased use of cohydration, colloids, smaller spinal doses and phenylephrine. Further research is required to investigate these techniques in high-risk patients and to evaluate novel monitoring techniques.
Collapse
|