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Rabkin V, Cohen B, Lavie A, Aptekman B, Greenberger C, Matot I, Weiniger CF. Prophylactic phenylephrine infusion versus treatment with vasopressor bolus as needed during non-urgent cesarean delivery and neonatal acidemia: a retrospective cohort study (2016-2021). Int J Obstet Anesth 2024; 60:104253. [PMID: 39260084 DOI: 10.1016/j.ijoa.2024.104253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Revised: 08/12/2024] [Accepted: 08/19/2024] [Indexed: 09/13/2024]
Abstract
INTRODUCTION Prophylactic vasopressor administration reduces spinal hypotension during cesarean delivery, however the effects of vasopressor administration on neonatal acidemia remain uncertain. We examined the occurrence of neonatal acidemia in the setting of non-urgent cesarean delivery and compared outcomes between cases receiving prophylactic phenylephrine infusion versus cases treated with boluses of phenylephrine. METHODS Retrospective cohort study with ethical approval, comparing non-urgent cesarean delivery cases performed under spinal anesthesia (2016 to 2021), receiving either prophylactic phenylephrine infusion or boluses as needed. Data were collected from anesthesia and labor ward electronic medical records. Records with missing pH or missing blood pressure data were excluded. The independent variable was prophylactic phenylephrine administration, a strategy implemented following international recommendations in 2018. The main outcome was neonatal acidemia, defined as umbilical artery pH < 7.1. The secondary outcome was maternal hypotension, defined as at least one systolic blood pressure (SBP) measurement below 100 mmHg or below 80% baseline. RESULTS A total of 4392 patients were included in the final analysis; 1318 (30.0%) received prophylactic phenylephrine infusion. Neonatal acidemia (umbilical artery pH < 7.1) occurred in 28 (2.1%) cases receiving prophylactic phenylephrine versus 50 (1.6%) treated with boluses as needed (p = 0.188). Prophylactic phenylephrine infusion was not associated with occurrence of neonatal acidemia (aOR 0.83; 95% CI 0.52 to 1.33, p = 0.435). Prophylactic phenylephrine infusion was associated with a reduced spinal hypotension rate when defined as SBP < 100 mmHg (OR 0.47; 95% CI 0.37 to 0.57; p < 0.001), with similar results when hypotension was defined as a drop below 80% or 90% of baseline SBP. CONCLUSION In this pragmatic study, prophylactic phenylephrine infusion was associated with a reduction in maternal spinal hypotension, but not reduced neonatal acidemia.
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Affiliation(s)
- Victor Rabkin
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Tel Aviv Sourasky Medical Center, 6 Weizmann Street, Tel Aviv, Israel; Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Barak Cohen
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Tel Aviv Sourasky Medical Center, 6 Weizmann Street, Tel Aviv, Israel; Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Outcomes Research Consortium, Cleveland Clinic, Cleveland, OH, USA
| | - Anat Lavie
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Obstetrics and Gynecology, Tel Aviv Sourasky Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Boris Aptekman
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Tel Aviv Sourasky Medical Center, 6 Weizmann Street, Tel Aviv, Israel; Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Chaim Greenberger
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Tel Aviv Sourasky Medical Center, 6 Weizmann Street, Tel Aviv, Israel; Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Idit Matot
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Tel Aviv Sourasky Medical Center, 6 Weizmann Street, Tel Aviv, Israel; Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Carolyn F Weiniger
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Tel Aviv Sourasky Medical Center, 6 Weizmann Street, Tel Aviv, Israel; Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
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Li YS, Lin SP, Horng HC, Tsai SW, Chang WK. Risk factors of more severe hypotension after spinal anesthesia for cesarean section. J Chin Med Assoc 2024; 87:442-447. [PMID: 38252496 DOI: 10.1097/jcma.0000000000001056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND The aim of this study was to examine the risk factors associated with the use of vasopressors to prevent hypotension that occurs after spinal anesthesia during cesarean section. Although the prophylactic use of vasopressors is already suggested as routine care in many parts of the world, the occurrence of spinal anesthesia-induced hypotension (SAIH) is still common in parturients. METHODS This retrospective study included parturients receiving elective cesarean deliveries under spinal anesthesia from April 2016 to March 2020. Risk factors related to ephedrine dosage were analyzed using a hurdle model, and risk factors related to SAIH were further analyzed with logistic regression. RESULTS Five risk factors, namely maternal body mass index (BMI, p < 0.001), baseline systolic blood pressure (SBP, p < 0.001), baseline heart rate (HR, p = 0.047), multiparity ( p = 0.003), and large fetal weight ( p = 0.005) were significantly associated with the requirement for ephedrine. Furthermore, a higher ephedrine dosage was significantly associated with maternal BMI ( p < 0.001), baseline SBP ( p < 0.001), baseline HR ( p < 0.001), multiparity ( p = 0.027), large fetal weight ( p = 0.030), maternal age ( p = 0.009), and twin pregnancies ( p < 0.001). Logistic regression analysis also showed that the same five risk factors-maternal BMI ( p = 0.030), baseline SBP ( p < 0.001), baseline HR ( p < 0.001), multiparity ( p < 0.001), and large fetal weight ( p < 0.001)-were significantly associated with SAIH, even in cases where vasopressors were administered. CONCLUSION These findings can be useful for clinicians when deciding the dose of prophylactic ephedrine or phenylephrine to prevent SAIH.
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Affiliation(s)
- Yi-Shiuan Li
- Department of Anesthesiology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Shih-Pin Lin
- Department of Anesthesiology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Huann-Cheng Horng
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Shiang-Wei Tsai
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Department of Obstetrics and Gynecology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, ROC
| | - Wen-Kuei Chang
- Department of Anesthesiology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
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Singh D, Yadav JBS, Singh AK, Rai MK. Comparing the Effect of Phenylephrine Bolus and Phenylephrine Infusion for Maintaining Arterial Blood Pressure During Cesarean Delivery Under Spinal Anesthesia: A Randomized Prospective Study. Cureus 2023; 15:e42713. [PMID: 37654965 PMCID: PMC10466076 DOI: 10.7759/cureus.42713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/29/2023] [Indexed: 09/02/2023] Open
Abstract
INTRODUCTION Maternal hypotension is a common complication of spinal anesthesia in cesarean section and requires immediate intervention. Phenylephrine is most commonly used as a vasopressor agent for the treatment of hypotension due to subarachnoid block. Our aim was to compare the bolus dose of 50 µg of phenylephrine with a fixed infusion at 50 µg.min-1 of phenylephrine for maintaining arterial blood pressure during cesarean delivery. MATERIALS AND METHOD This was a prospective, randomized comparative study. One hundred normotensive pregnant females aged 18-35 years, body mass index 18-29kg.m2, American Society of Anesthesiologists (ASA) physical status classification II scheduled to undergo cesarean section (elective/emergency) under spinal anesthesia were randomly divided into two groups of 50 each. Group PB received a bolus dose of phenylephrine 50 µg after they developed hypotension i.e., a decrease in systolic blood pressure (SBP) ≥ 20% from the baseline. Similarly, patients in Group PI were administered prophylactic infusion using a syringe pump of phenylephrine 50 µg.min-1, started just after the administration of subarachnoid block. The phenylephrine infusion was continued either till the delivery of the baby or when SBP rises >20% above the baseline. Parameters like blood pressure, heart rate, and peripheral oxygen saturation were recorded. After the delivery of the baby, the neonatal APGAR score was assessed at one minute and five minutes. RESULTS Demographic data were comparable in terms of demographic profile, duration of surgery, and ASA physical status classification between the groups. The heart rate was higher in Group PB compared to Group PI throughout the monitoring period (P<0.001). The fall in mean blood pressure was more in Group PB compared to Group PI till 18 minutes of surgery and was statistically significant (P<0.05). After 18 minutes of surgery, mean blood pressure stabilized and was comparable between the groups. Other variables like APGAR score at one minute and five minutes were comparable between the groups. Bradycardia and hypertension were more common in Group PI whereas hypotension, nausea, and vomiting were more common in group PB. CONCLUSION We concluded that during cesarean section under spinal anesthesia, phenylephrine infusion provides better hemodynamic stability and APGAR score during the perioperative period.
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Affiliation(s)
- Dheer Singh
- Anesthesiology, Uttar Pradesh University of Medical Sciences, Saifai, IND
| | | | - Amit K Singh
- Anesthesiology, Uttar Pradesh University of Medical Sciences, Saifai, IND
| | - Mrityunjay K Rai
- Anesthesiology, Uttar Pradesh University of Medical Sciences, Saifai, IND
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Kondo Y, Mihara T, Nakamura E, Noma H, Shimizu S, Goto T. Predictive ability of pulse oximetry-derived indices for hypotension after spinal anaesthesia for caesarean section: protocol for a systematic review and meta-analysis. BMJ Open 2023; 13:e069309. [PMID: 37355260 PMCID: PMC10314498 DOI: 10.1136/bmjopen-2022-069309] [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: 10/18/2022] [Accepted: 06/09/2023] [Indexed: 06/26/2023] Open
Abstract
INTRODUCTION In general, caesarean sections are performed under spinal anaesthesia. Hypotension after spinal anaesthesia adversely affects both the mother and fetus. Although several studies have used pulse oximetry-derived indices, such as pulse perfusion index (PI) and Pleth variability index (PVI), to predict hypotension after spinal anaesthesia, the predictive ability of the PI and PVI remain controversial. METHODS AND ANALYSIS We prepared this protocol following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols guidelines. We will conduct searches of MEDLINE, Embase, Web of Science, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Clinicaltrial.gov, European Union Clinical Trials Register (EU-CTR), WHO International Clinical Trials Registry Platform (ICTRP) and University Hospital Medical Information Network Clinical Trials Registry (UMIN) from inception until 8 October 2022. We will include retrospective and prospective observational studies and randomised controlled trials that evaluated the predictive ability of PI and PVI for hypotension after spinal anaesthesia for caesarean section, published in any language. We will exclude case reports, case series and animal studies. Two authors will independently scan and select eligible studies and perform data extraction and assessment of risk of bias. We will estimate predictive ability of PI and PVI as indices of hypotension after spinal anaesthesia for caesarean section using the Reitsma-type bivariate random-effects synthesis model and the hierarchical summary receiver operating characteristic curve. We will assess the quality of evidence using the Grading of Recommendation Assessment, Development and Evaluation approach. ETHICS AND DISSEMINATION Ethics approval is not required as the systematic review will use existing published data. The results will be submitted for publication in a peer-reviewed journal. PROSPERO REGISTRATION NUMBER CRD42022362596.
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Affiliation(s)
- Yuriko Kondo
- Department of Health Data Science, Yokohama City University, Yokohama, Japan
| | - Takahiro Mihara
- Department of Health Data Science, Yokohama City University, Yokohama, Japan
| | - Eishin Nakamura
- Department of Health Data Science, Yokohama City University, Yokohama, Japan
| | - Hisashi Noma
- Department of Data Science, The Institute of Statistical Mathematics, Tchikawa, Japan
| | - Sayuri Shimizu
- Department of Health Data Science, Yokohama City University, Yokohama, Japan
| | - Takahisa Goto
- Anaesthesiology and Critical Care Medicine, Yokohama City University School of Medicine Graduate School of Medicine, Yokohama, Japan
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Tan Sook Kuan J, Musthafa QA, Abdullah FH, Sayed Masri SNN. Intraoperative phenylephrine infusion to reduce perioperative shivering in lower segment caesarean section: A randomised controlled study. Medicine (Baltimore) 2023; 102:e33721. [PMID: 37171298 PMCID: PMC10174363 DOI: 10.1097/md.0000000000033721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/13/2023] Open
Abstract
BACKGROUND Shivering is described as an involuntary, repetitive activity of the skeletal muscles that can have deleterious effects on anaesthetized patients. This study aimed to evaluate the effectiveness of phenylephrine infusion in preventing perioperative shivering in patients undergoing lower segment cesarean section under spinal anesthesia and to observe the change in the patient's core temperature between the study and control groups. METHODS A total of 118 patients scheduled for elective lower segment cesarean section under spinal anesthesia were recruited for this prospective, double-blind, randomized controlled study. The patients were randomized into 2 groups with 59 patients per group. The phenylephrine Group received phenylephrine infusion at a rate of 0.5 mcg/kg/minutes, while the Control Group received normal saline at an equivalent rate. Systolic and diastolic blood pressure, heart rate, core temperature, and the presence and intensity of shivering were recorded before induction and every 15 minutes intraoperatively and postoperatively. RESULTS The incidence of intraoperative shivering was significantly lower in the Phenylephrine Group compared to control group (29.1% vs 47.5% respectively; P = .044). Postoperatively, the Phenylephrine Group also had a lower incidence of shivering (34.5% vs 42.4%), but the difference was not statistically significant (P value = 0.391). There were no significant differences in the intensity of shivering between the 2 groups perioperatively, as well as in the systolic and diastolic blood pressure and core temperature. The phenylephrine Group showed a significantly lower heart rate at 15, 30, and 45 minutes after spinal block (P value = .005, .000, and .008, respectively), and at 0 and 30 minutes (P value = .004 and .020 respectively) in the recovery room. There were no significant differences in perioperative adverse events such as hypotension, hypertension, and bradycardia. CONCLUSION Phenylephrine infusion reduces the incidence of perioperative shivering in lower segment cesarean sections under spinal anesthesia.
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Affiliation(s)
- Jessica Tan Sook Kuan
- Department of Anesthesiology and Intensive Care, Hospital Sultan Ismail, Johor Bharu, Malaysia
| | - Qurratu Aini Musthafa
- Department of Anesthesiology and Intensive Care, Universiti Kebangsaan Malaysia Medical Centre, Bandar Tun Razak, Cheras, Kuala Lumpur, Malaysia
| | - Farah Hanim Abdullah
- Department of Anesthesiology and Intensive Care, Universiti Kebangsaan Malaysia Medical Centre, Bandar Tun Razak, Cheras, Kuala Lumpur, Malaysia
| | - Syarifah Noor Nazihah Sayed Masri
- Department of Anesthesiology and Intensive Care, Universiti Kebangsaan Malaysia Medical Centre, Bandar Tun Razak, Cheras, Kuala Lumpur, Malaysia
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Muacevic A, Adler JR, Ramani S, Balasubramanian N. A Randomized Controlled Trial Comparing the Effect of Phenylephrine by Intramuscular Route With Intravenous Infusion in Maintaining Haemodynamic Stability During Elective Lower Segment Caesarean Section Under Spinal Anaesthesia. Cureus 2023; 15:e34118. [PMID: 36843684 PMCID: PMC9949751 DOI: 10.7759/cureus.34118] [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: 01/23/2023] [Indexed: 01/25/2023] Open
Abstract
Background Hypotension is a commonly encountered side effect in patients undergoing spinal anaesthesia, particularly in patients undergoing caesarean section. Phenylephrine is a widely used drug to treat spinal-induced hypotension and to maintain hemodynamic stability. Our aim is to evaluate the effectiveness of phenylephrine given through two different routes prophylactically in prevention of post-spinal hypotension in patients undergoing caesarean section. Methods A total of 150 healthy pregnant women undergoing elective caesarean section were randomly allocated into three groups: Group M (prophylactic intramuscular use of 2 mg phenylephrine), group V (prophylactic intravenous infusion of 30 mcg phenylephrine per minute), and group P (no prophylaxis), rescue phenylephrine 30 mcg IV and atropine 0.6 mg IV were used intraoperatively to treat bradycardia and hypotension in all three groups. The primary outcome was maternal hemodynamic changes. Results There was an insignificant difference in demographic data between the groups. Maternal systolic and diastolic blood pressure were more stable in group M compared to group V and group P. Heart rate was significantly lower only in group V. We did not observe any statistical difference between the groups in the APGAR score or the fetal arterial blood gas values. The incidence of nausea and vomiting was more in group P. Conclusion Preventive intramuscular phenylephrine exhibited a more stable maternal hemodynamics when compared with the prophylactic intravenous infusion of phenylephrine and placebo in elective caesarean under spinal anaesthesia.
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Affiliation(s)
- Alexander Muacevic
- Anaesthesiology, SRM Medical College Hospital and Research Centre (MCHRC), Chennai, IND
| | - John R Adler
- Anaesthesiology, SRM Medical College Hospital and Research Centre (MCHRC), Chennai, IND
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Herbosa GAB, Tho NN, Gapay AA, Lorsomradee S, Thang CQ. Consensus on the Southeast Asian management of hypotension using vasopressors and adjunct modalities during cesarean section under spinal anesthesia. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE (ONLINE) 2022; 2:56. [PMID: 37386598 DOI: 10.1186/s44158-022-00084-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 12/08/2022] [Indexed: 07/01/2023]
Abstract
BACKGROUND AND AIMS This consensus statement presents a comprehensive and evidence-based set of guidelines that modify the general European or US guidelines for hypotension management with vasopressors during cesarean delivery. It is tailored to the Southeast Asian context in terms of local human and medical resources, health system capacity, and local values and preferences. METHODS AND RESULTS These guidelines were prepared using a methodological approach. Two principal sources were used to obtain the evidence: scientific evidence and opinion-based evidence. A team of five anesthesia experts from Vietnam, the Philippines, and Thailand came together to define relevant clinical questions; search for literature-based evidence using the MEDLINE, Scopus, Google Scholar, and Cochrane libraries; evaluate existing guidelines; and contextualize recommendations for the Southeast Asian region. Furthermore, a survey was developed and distributed among 183 practitioners in the captioned countries to gather representative opinions of the medical community and identify best practices for the management of hypotension with vasopressors during cesarean section under spinal anesthesia. CONCLUSIONS This consensus statement advocates proactive management of maternal hypotension during cesarean section after spinal anesthesia, which can be detrimental for both the mother and fetus, supports the choice of phenylephrine as a first-line vasopressor and offers a perspective on the use of prefilled syringes in the Southeast Asian region, where factors such as healthcare features, availability, patient safety, and cost should be considered.
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Affiliation(s)
- Grace Anne B Herbosa
- Department of Anesthesiology, University of the Philippines College of Medicine, Manila, Philippines.
| | - Nguyen Ngoc Tho
- Department of Anesthesiology and Intensive Care, Hanoi French Hospital, Hanoi, Vietnam
| | - Angelina A Gapay
- Department of Anesthesiology, Divine Word Hospital, Tacloban, Philippines
| | - Suraphong Lorsomradee
- Department of Anesthesiology, Faculty of Medicine, Chiang Mai University Hospital, Chang Mai, Thailand
| | - Cong Quyet Thang
- Vietnam Society of Anesthesiologists, Head of Department of Anesthesiology and SCIU at HuuNghi Hospital, Hanoi, Vietnam
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Palanisamy S, Rudingwa P, Panneerselvam S, Satyaprakash M, Kuberan A, Amala R. Effect of low dose phenylephrine infusion on shivering and hypothermia in patients undergoing cesarean section under spinal anesthesia: a randomized clinical trial. Int J Obstet Anesth 2022; 50:103542. [DOI: 10.1016/j.ijoa.2022.103542] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 01/16/2022] [Accepted: 03/12/2022] [Indexed: 11/26/2022]
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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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Ali H, ELatief N. Comparison of prophylactic phenylephrine infusion versus intravenous ondansetron on hypotension during spinal anesthesia for cesarean section. Anesth Essays Res 2022; 16:226-230. [DOI: 10.4103/aer.aer_48_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 07/13/2022] [Accepted: 07/28/2022] [Indexed: 11/04/2022] Open
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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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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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Shen YH, Yang F, Jin LD, Qian YJ, Xing L, Huang YL, Lin SF, Xiao F. Prophylactic Phenylephrine Increases the Dose Requirement of Oxytocin to Treat Uterine Atony During Cesarean Delivery: A Double-Blinded, Single-Center, Randomized and Placebo-Controlled Trial. Front Pharmacol 2021; 12:720906. [PMID: 34744714 PMCID: PMC8563700 DOI: 10.3389/fphar.2021.720906] [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: 06/05/2021] [Accepted: 10/04/2021] [Indexed: 11/16/2022] Open
Abstract
Purpose: Studies involving mouse models and human uterine smooth muscle cells have shown that phenylephrine inhibits uterine contractions in non-pregnant mice and human in vitro cell via cyclic adenosine monophosphate (cAMP) signaling. However, there has been no limited exploration to date of the effect of phenylephrine on uterine contractions in clinical practice. This study aimed to compare the dose requirement of oxytocin with or without the infusion of prophylactic phenylephrine to prevent post spinal hypotension during cesarean delivery under combined spinal and epidural anesthesia. Methods: This was a double-blinded, single-center, randomized, control study. One hundred and sixty pregnant patients provided informed consent and were randomly allocated to the phenylephrine (phenylephrine infusion) and control (saline infusion) groups. Patients randomized to the phenylephrine group received an intravenous prophylactic phenylephrine infusion at a fixed rate of 0.5 μg/kg/min. The control group received a saline placebo at the same rate and used the same apparatus for delivery. After neonatal delivery and clamping of the umbilical cord, patients received a standard institutional oxytocin protocol. The primary outcome measure was the total dose of oxytocin administered during CD. Secondary outcomes including the proportion (%) of patients requiring a secondary uterotonic agent and estimated blood loss (EBL) in the first 24 h after surgery. Results: The median oxytocin dose administered was significantly higher in the phenylephrine group than in the control group [6.9 ± 2.5 international standardized units (IU) vs. 5.4 ± 2.4 IU, p = 0.0004]. The number of patients that required a secondary uterotonic agent was significantly higher in the phenylephrine group than in the control group (24.2% vs. 9.1%; p = 0.034). The EBL in the first 24-h postoperatively was similar between the two groups (467 ± 47 ml vs. 392 ± 38 ml; p = 0.22). Conclusions: Prophylactic infusion of phenylephrine used to prevent post-spinal hypotension during CD was associated with a higher dose of oxytocin. This has important clinical implications, as the suboptimal use of oxytocin is associated with an increased risk of postpartum hemorrhage and increased maternal morbidity and mortality. Further studies are now needed to confirm these findings.
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Affiliation(s)
- Yao-Hua Shen
- Department of Anesthesia, Hangzhou City Linping District Maternal and Child Care Hospital, Hangzhou, China
| | - Fan Yang
- Key Laboratory for the Genetics of Developmental and Neuropsychiatric Disorders (Ministry of Education), Bio-X Institutes, Shanghai Jiao Tong University, Shanghai, China
| | - Li-Dan Jin
- Department of Anesthesia, Hangzhou City Linping District Maternal and Child Care Hospital, Hangzhou, China
| | - Yu-Jia Qian
- Department of Anesthesia, Hangzhou City Linping District Maternal and Child Care Hospital, Hangzhou, China
| | - Li Xing
- Department of Anesthesia, Hangzhou City Linping District Maternal and Child Care Hospital, Hangzhou, China
| | - Ya-Li Huang
- Department of Anesthesia, Hangzhou City Linping District Maternal and Child Care Hospital, Hangzhou, China
| | - Su-Feng Lin
- Department of Anesthesia, Hangzhou City Linping District Maternal and Child Care Hospital, Hangzhou, China
| | - Fei Xiao
- Department of Anesthesia, Jiaxing University Affiliated Women and Children Hospital, Jiaxing, China
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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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Gagné MP, Richebé P, Loubert C, Drolet P, Gobert Q, Denault A, Zaphiratos V. Ultrasound evaluation of inferior vena cava compression in tilted and supine term parturients. Can J Anaesth 2021; 68:1507-1513. [PMID: 34212308 DOI: 10.1007/s12630-021-02051-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 05/18/2021] [Accepted: 05/19/2021] [Indexed: 11/26/2022] Open
Abstract
PURPOSE Hypotension is common following spinal anesthesia (SA) during elective Cesarean delivery (CD). Although common practice is to alleviate inferior vena cava (IVC) compression, limited evidence supports a 15° tilt for CD. We measured collapsibility of the IVC in supine and 15° left lateral tilt positions with ultrasound before and after SA and phenylephrine infusion in term parturients. METHODS Twenty term parturients scheduled for CD were recruited for this prospective study. Ultrasound measurements of the IVC were taken 1) supine before SA, 2) tilted 15° before SA, 3) supine after SA, and 4) tilted 15° after SA. A phenylephrine infusion was begun after injection of SA. The primary outcome was to evaluate the impact of position on the IVC collapsibility index (IVCCI): a measure of the difference between the maximum and minimum IVC diameter with respiration. RESULTS The mean (standard deviation) IVCCI (%) before SA was higher in the supine 19.5 (8.0) than in the tilted 15.0 (6.4) position (mean difference, 4.5; 95% confidence interval [CI], 0.1 to 8.9; P = 0.04). After SA, there was no significant difference between IVCCI (%) in the supine 17.8 (8.3) and tilted 14.2 (6.9) position (mean difference, 3.5; 95% CI, -0.9 to 7.9; P = 0.13). There was no correlation between the pre-spinal IVVCI measurements and the quantity of phenylephrine used during the surgery. CONCLUSION The IVCCI was lower in the 15° tilt position than in the supine position, but not after SA with a phenylephrine infusion. Ultrasound imaging can help identify IVC compression. TRIAL REGISTRATION www.clinicaltrials.gov (NCT03410199); registered 18 January 2018.
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Affiliation(s)
- Marie-Pierre Gagné
- Department of Anesthesiology and Pain Medicine, Maisonneuve-Rosemont Hospital, CIUSSS de l'Est de l'Ile de Montreal (CEMTL), University of Montreal, 5415 boul. de l'Assomption, Montreal, QC, H1T 2M4, Canada
| | - Philippe Richebé
- Department of Anesthesiology and Pain Medicine, Maisonneuve-Rosemont Hospital, CIUSSS de l'Est de l'Ile de Montreal (CEMTL), University of Montreal, 5415 boul. de l'Assomption, Montreal, QC, H1T 2M4, Canada
| | - Christian Loubert
- Department of Anesthesiology and Pain Medicine, Maisonneuve-Rosemont Hospital, CIUSSS de l'Est de l'Ile de Montreal (CEMTL), University of Montreal, 5415 boul. de l'Assomption, Montreal, QC, H1T 2M4, Canada
| | - Pierre Drolet
- Department of Anesthesiology and Pain Medicine, Maisonneuve-Rosemont Hospital, CIUSSS de l'Est de l'Ile de Montreal (CEMTL), University of Montreal, 5415 boul. de l'Assomption, Montreal, QC, H1T 2M4, Canada
| | - Quentin Gobert
- Department of Anesthesiology and Pain Medicine, Maisonneuve-Rosemont Hospital, CIUSSS de l'Est de l'Ile de Montreal (CEMTL), University of Montreal, 5415 boul. de l'Assomption, Montreal, QC, H1T 2M4, Canada
| | - André Denault
- Department of Anesthesiology and Critical Care Division, Montreal Heart Institute, University of Montreal, Montreal, QC, Canada
| | - Valerie Zaphiratos
- Department of Anesthesiology and Pain Medicine, Maisonneuve-Rosemont Hospital, CIUSSS de l'Est de l'Ile de Montreal (CEMTL), University of Montreal, 5415 boul. de l'Assomption, Montreal, QC, H1T 2M4, Canada.
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Brebion M, Daccache A, Osse L, El Kazma S, Sabri S, Mercier F, Keita H. Maternal heart rate responses in the supine position and their relationship with hypotension and phenylephrine requirements during elective caesarean delivery using spinal anaesthesia: An observational study. Anaesth Crit Care Pain Med 2021; 40:100904. [PMID: 34147686 DOI: 10.1016/j.accpm.2021.100904] [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: 12/28/2020] [Revised: 03/29/2021] [Accepted: 03/31/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Hypotension is the main side effect of spinal anaesthesia (SA) for elective caesarean delivery (CD). An increased in heart rate in response to inferior vena cava (IVC) compression has been reported to be predictive of hypotension and vasopressor requirements in this setting. The objective of the study was to evaluate the prevalence of an increase in heart rate in response to IVC compression and its potential effect on hypotension and phenylephrine requirements. METHODS Healthy parturients scheduled for elective CD under SA were preoperatively investigated for a positive supine stress test (SST). It was defined as an increase in heart rate (HR) > 10 beats/min after 5 min of supine position. A crystalloid coload and prophylactic phenylephrine infusion were systematically used to maintain systolic arterial pressure (SAP) between 90-100% of baseline. Hypotension was defined as SAP < 80% of baseline. RESULTS Among 100 women, 26% had a positive SST. There was no significant difference in the incidence of hypotension: 38% versus 24.3% (p = 0.17) in women with positive SST or without, respectively. The cumulative dose of phenylephrine (450 µg [325-625] versus 350 µg [250-500], p = 0.09) was not significantly different between the two groups. Incidences of reactive hypertension, bradycardia, nausea or vomiting and neonatal outcomes were comparable. CONCLUSIONS A positive SST to IVC compression was found in a quarter of term women scheduled for elective CD under SA. This condition has no significant impact on hypotension and phenylephrine requirements when using a crystalloid coload and a phenylephrine infusion targeted at maintaining SAP close to baseline.
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Affiliation(s)
- Myriam Brebion
- APHP, Hôpital Necker Enfants Malades, DMU ARME, Service d'Anesthésie-Réanimation Pédiatrique, Paris, France
| | - Antoine Daccache
- APHP, Hôpital Necker Enfants Malades, DMU ARME, Service d'Anesthésie-Réanimation Pédiatrique, Paris, France
| | - Lauranne Osse
- APHP, Hôpital Necker Enfants Malades, DMU ARME, Service d'Anesthésie-Réanimation Pédiatrique, Paris, France
| | - Sylva El Kazma
- APHP, Hôpital Necker Enfants Malades, DMU ARME, Service d'Anesthésie-Réanimation Pédiatrique, Paris, France
| | - Sami Sabri
- APHP, Hôpital Necker Enfants Malades, DMU ARME, Service d'Anesthésie-Réanimation Pédiatrique, Paris, France
| | - Frédéric Mercier
- Département d'Anesthésie, Hôpital Antoine Béclère - APHP, Université Paris Saclay, Clamart, France
| | - Hawa Keita
- APHP, Hôpital Necker Enfants Malades, DMU ARME, Service d'Anesthésie-Réanimation Pédiatrique, Paris, France; Unité de Recherche EA 7323 Pharmacologie et Évaluation des Thérapeutiques Chez l'Enfant et la Femme Enceinte, Université de Paris, Paris, France.
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Kitaguchi M, Ida M, Naito Y, Akasaki Y, Kawaguchi M. Associated factors with umbilical arterial pH after cesarean delivery under spinal anesthesia: a retrospective cohort study. Braz J Anesthesiol 2021; 72:466-471. [PMID: 33932390 PMCID: PMC9373073 DOI: 10.1016/j.bjane.2021.04.022] [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: 08/13/2020] [Revised: 04/01/2021] [Accepted: 04/10/2021] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Maximum decrease of blood pressure and number of minutes of hypotension were independently associated with umbilical arterial pH. However, the impact of hypotension considering the duration of it on umbilical arterial pH is unknown. METHODS Pregnant women aged ≥ 20 years who delivered a baby at full-term via a cesarean delivery under a single-shot spinal anesthesia between January 2017 and March 2019 were included. The main outcome was to predict umbilical arterial pH, based on the value of the time integral of hypotension. Patient demographics, patient comorbidities, and intraoperative data, including the total dose of ephedrine and phenylephrine by fetal delivery and cumulative duration of maternal hypotension, were evaluated. Maternal hypotension was reflected as a decrease in systolic arterial pressure and mean arterial pressure to < 80% of baseline values. The systolic arterial pressure and mean arterial pressure were independently included in a multiple regression analysis along with all other explanatory factors to predict the umbilical arterial pH. RESULTS Of the 416 eligible patients, 381 were enrolled. When including the systolic arterial pressure or mean arterial pressure in the model, emergency cases, the total dose of ephedrine, hypertensive disorders of pregnancy, and systolic arterial pressure or mean arterial pressure values were found to be significant predictive factors of umbilical arterial pH. CONCLUSION Our results suggest that an elevated time integral of maternal hypotension may have a negative impact on umbilical arterial pH. Therefore, to minimize the risk of fetal acidosis, maternal hypotension should be prevented with the consideration of vasopressors selection.
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Affiliation(s)
- Miwa Kitaguchi
- Nara Medical University, Department of Anesthesiology, Kashihara, Japan
| | - Mitsuru Ida
- Nara Medical University, Department of Anesthesiology, Kashihara, Japan.
| | - Yusuke Naito
- Nara Medical University, Department of Anesthesiology, Kashihara, Japan
| | - Yuka Akasaki
- Nara Medical University, Department of Anesthesiology, Kashihara, Japan
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Fantin R, Ortner CM, Klein KU, Putz G, Marhofer D, Jochberger S. [Hypotension induced by spinal anesthesia during cesarean section : Current treatment concepts]. Anaesthesist 2021; 69:254-261. [PMID: 32166396 DOI: 10.1007/s00101-020-00755-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Arterial hypotension during cesarean delivery under spinal anesthesia can cause maternal and fetal adverse effects. Therefore, current guidelines recommend the continuous and preferably prophylactic use of vasopressors, emphasizing the use of alpha-agonists, such as phenylephrine. Besides a left lateral uterine displacement either an intravenous colloid preloading or a crystalloid co-loading is recommended. The blood pressure goal is to maintain a systolic arterial blood pressure of at least 90% of the initial baseline value and to avoid a drop to less than 80% of this baseline. To achieve this goal a prophylactic continuous phenylephrine infusion with an adjustable flow rate is recommended. It is advised to start with an initial dose of 25-50 µg/min, initiated immediately following the intrathecal injection of the local anesthetic and titrated according to the vital parameters. Parturients with cardiac diseases should be preoperatively evaluated following individual hemodynamic goals.
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Affiliation(s)
- R Fantin
- Universitätsklinik für Anästhesie und Intensivmedizin, Medizinische Universität Innsbruck, Anichstraße 35, 6020, Innsbruck, Österreich.
| | - C M Ortner
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford School of Medicine, 94305, Stanford, CA, USA
| | - K U Klein
- Allgemeine Intensivmedizin und Schmerztherapie, Medizinische Universität Wien, Universitätsklinik für Anästhesie, Spitalgasse 23, 1090, Wien, Österreich
| | - G Putz
- Universitätsklinik für Anästhesie und Intensivmedizin, Medizinische Universität Innsbruck, Anichstraße 35, 6020, Innsbruck, Österreich
| | - D Marhofer
- Allgemeine Intensivmedizin und Schmerztherapie, Medizinische Universität Wien, Universitätsklinik für Anästhesie, Spitalgasse 23, 1090, Wien, Österreich
| | - S Jochberger
- Universitätsklinik für Anästhesie und Intensivmedizin, Medizinische Universität Innsbruck, Anichstraße 35, 6020, Innsbruck, Österreich
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Ismail S, Sohaib M, Farrukh F. Management of spinal-induced hypotension for elective caesarean section: A survey of practices among anesthesiologists from a developing country. Afr Health Sci 2020; 20:1918-1926. [PMID: 34394258 PMCID: PMC8351839 DOI: 10.4314/ahs.v20i4.50] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background In developing countries, more than half of the anesthesia-related maternal deaths are related to spinal hypotension. Objective To explore the practices of management of spinal induced hypotension with respect to fluid and vasopressor administration among anesthesiologists from a developing country. Methods After approval from institutional ethics committee, an online questionnaire was sent to anesthesiologists registered with Pakistan Society of Anesthesiologists between July and August 2018 to determine management strategies for prevention and treatment of spinal-induced hypotension. Results The response rate was 36% (156/433), majority from academic institution (62.8%) with equal representation from attending and trainee anesthesiologist. For prophylaxis 39.1% respondents did not use vasopressors, 32.7% used fluid preloading with crystalloids (54.7%) as fluid of choice followed by combination of co-loading and vasopressor(22.4%). Phenylephrine was the vasopressor of choice for both prophylaxis (33.1%) and treatment (57%). Attending anesthesiologist used a combination of fluid co-loading and vasopressors for prophylaxis as compared to trainee anesthesiologists (37.2% vs. 17.9%; P=0.035) and selected vasopressors according to patient's heart rate (33.3% vs. 19.5%; p=0.05). Prophylactic phenylephrine was used more by respondents from the academic institution (p=0.023). Fluid co-loading was used more by respondents with <30 % compared to those with > 30% of clinical responsibility to obstetric anesthesia (P<0.05). Conclusion Phenylephrine as the vasopressor of choice indicates growing awareness of management strategies among anesthesiologists from developing countries but there is a need to increase its use for prophylaxis. Some variation in practice according to the level of anesthesiologist, practice type and responsibilities to obstetric anesthesia are evident.
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Rijs K, Mercier FJ, Lucas DN, Rossaint R, Klimek M, Heesen M. Fluid loading therapy to prevent spinal hypotension in women undergoing elective caesarean section: Network meta-analysis, trial sequential analysis and meta-regression. Eur J Anaesthesiol 2020; 37:1126-1142. [PMID: 33109924 PMCID: PMC7752245 DOI: 10.1097/eja.0000000000001371] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Fluid loading is one of the recognised measures to prevent hypotension due to spinal anaesthesia in women scheduled for a caesarean section. OBJECTIVE We aimed to evaluate the current evidence on fluid loading in the prevention of spinal anaesthesia-induced hypotension. DESIGN Systematic review and network meta-analysis with trial sequential analysis and meta-regression. DATA SOURCES Medline, Epub, Embase.com (Embase and Medline), Cochrane Central, Web of Science and Google Scholar were used. ELIGIBILITY CRITERIA Only randomised controlled trials were used. Patients included women undergoing elective caesarean section who received either crystalloid or colloid fluid therapy as a preload or coload. The comparator was a combination of either a different fluid or time of infusion. RESULTS A total of 49 studies (4317 patients) were included. Network meta-analysis concluded that colloid coload and preload offered the highest chance of success (97 and 67%, respectively). Conventional meta-analysis showed that crystalloid preload is associated with a significantly higher incidence of maternal hypotension than colloid preload: risk ratio 1.48 (95% CI 1.29 to 1.69, P < 0.0001, I = 60%). However, this result was not supported by Trial Sequential Analysis. There was a significant dose-response effect for crystalloid volume preload (regression coefficient = -0.073), which was not present in the analysis of only double-blind studies. There was no dose-response effect for the other fluid regimes. CONCLUSION Unlike previous meta-analysies, we found a lack of data obviating an evidence-based recommendation. In most studies, vasopressors were not given prophylactically as is recommended. Studies on the best fluid regimen in combination with prophylactic vasopressors are needed. Due to official european usage restrictions on the most studied colloid (HES), we recommend crystalloid coload as the most appropriate fluid regimen. TRIAL REGISTRATION CRD42018099347.
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Affiliation(s)
- Koen Rijs
- From the Department of Anaesthesia, Erasmus University Medical Centre, Rotterdam, The Netherlands (KR, MK), the Department of Anaesthesia, Hôpital Antoine Béclère, GHU AP-HP. Université Paris-Saclay, Clamart, France (FJM), the Department of Anaesthesia, Northwick Park Hospital, Harrow, UK (DNL), the Department of Anaesthesia, University Hospital RWTH Aachen, Aachen, Germany (RR), and the Department of Anaesthesia, Kantonsspital Baden, Baden, Switzerland (MH)
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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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A randomised dose-response study of prophylactic Methoxamine infusion for preventing spinal-induced hypotension during Cesarean delivery. BMC Anesthesiol 2020; 20:198. [PMID: 32787783 PMCID: PMC7422554 DOI: 10.1186/s12871-020-01119-2] [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: 11/29/2019] [Accepted: 08/06/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND α-receptor agonists have been reported to be safe and effective for treating or preventing spinal-induced hypotension during cesarean delivery. As a pure α1 adrenergic agonist, methoxamine has potential advantages of reducing myocardial oxygen consumption and protecting the heart in obstetric patients compared to phenylephrine. The aim of this study was to determine the optimal prophylactic methoxamine infusion dose that would be effective for preventing spinal-induced hypotension in 50% (ED50) and 95% (ED95) of parturients. METHODS Eighty parturients with a singleton pregnancy scheduled for elective cesarean delivery were randomly allocated to receive prophylactic methoxamine infusion at one of four different fixed-rates: 1 μg/kg/min (group M1), 2 μg/kg/min (group M2), 3 μg/kg/min (group M3), or 4 μg/kg/min (group M4). An adequate response was defined as absence of hypotension (maternal SBP < 80% of baseline or SBP < 90 mmHg). The values for ED50 and ED95 of prophylactic methoxamine infusion were determined by probit regression model. The outcomes of maternal hemodynamics and fetal status were compared among the groups. RESULTS The calculated ED50 and ED95 (95% confidence interval) of prophylactic methoxamine infusion dose were 2.178 (95% CI 1.564 to 2.680) μg/kg/min and 4.821 (95% CI 3.951 to 7.017) μg/kg/min, respectively. The incidence of hypotension decreased with increasing methoxamine infusion dose (15/20, 11/20, 7/20 and 2/20 in group M1, M2, M3 and M4 respectively, P < 0.001). 1-min Apgar scores and umbilical arterial PaO2 were lower but umbilical arterial PaCO2 was higher in Group M1. No difference was found in the other incidence of adverse effects and neonatal outcomes among groups. CONCLUSIONS Under the conditions of this study, when prophylactic methoxamine infusion was given at a fixed-rate based on body weight for preventing spinal-induced hypotension in obstetric patients, the values for ED50 and ED95 were 2.178 μg/kg/min and 4.821 μg/kg/min respectively. CLINICAL TRIAL REGISTRATION Chinese Clinical Trial Registry (ChiCTR), registry number of clinical trial: ChiCTR-1,800,018,988 , date of registration: October 20, 2018.
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Limratana P, Kiatchai T, Somnuke P, Prapakorn P, Suksompong S. The effect of baricity of intrathecal bupivacaine for elective cesarean delivery on maternal cardiac output: a randomized study. Int J Obstet Anesth 2020; 45:61-66. [PMID: 33121884 DOI: 10.1016/j.ijoa.2020.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 06/30/2020] [Accepted: 07/20/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Hemodynamic instability during spinal anesthesia for cesarean delivery is associated with adverse maternal and fetal outcomes. Plain and hyperbaric bupivacaine are commonly used for cesarean delivery, however, their distinctive pharmacologic properties may affect maternal hemodynamic profiles differently. The aim of this study was to compare hemodynamic profiles using a suprasternal Doppler cardiac output (CO) monitor in healthy term parturients randomized to receive plain or hyperbaric bupivacaine for cesarean delivery. METHODS One hundred-and-sixty-eight healthy parturients scheduled for elective cesarean delivery were randomly assigned to receive 10.9 mg of intrathecal 0.5% plain or hyperbaric bupivacaine, both with 0.2 mg morphine. The primary outcome was CO change after spinal anesthesia. Secondary outcomes were the incidence of hypotension, vasopressor use, and conversion to general anesthesia. RESULTS The mean (±SD) CO at baseline, 1 min and 5 min after spinal anesthesia, and after placental delivery was 4.6 ± 1.2, 5.4 ± 1.3, 5.1 ± 1.4, and 6.4 ± 1.7 L/min in the plain bupivacaine, and 4.5 ± 1.1, 5.2 ± 1.3, 4.9 ± 1.3, and 6.2 ± 1.9 L/min in the hyperbaric bupivacaine group. There were no significant differences in CO, mean arterial pressure, or systemic vascular resistance. Incidences of hypotension, vasopressor and supplemental analgesic use, and conversion to general anesthesia, were not different between groups. CONCLUSIONS Cardiac output changes after plain or hyperbaric bupivacaine were not different in term parturients undergoing spinal anesthesia for cesarean delivery. Further studies comparing block quality and the rate of conversion to general anesthesia are required.
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Affiliation(s)
- P Limratana
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Thailand
| | - T Kiatchai
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Thailand
| | - P Somnuke
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Thailand
| | - P Prapakorn
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Thailand
| | - S Suksompong
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Thailand.
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Nikooseresht M, Seifrabiei MA, Hajian P, Khamooshi S. A Clinical Trial on the Effects of Different Regimens of Phenylephrine on Maternal Hemodynamic After Spinal Anesthesia for Cesarean Section. Anesth Pain Med 2020; 10:e58048. [PMID: 33134140 PMCID: PMC7539049 DOI: 10.5812/aapm.58048] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2017] [Revised: 05/05/2020] [Accepted: 05/28/2020] [Indexed: 11/16/2022] Open
Abstract
Background Phenylephrine is used to prevent and treat hypotension during spinal anesthesia for cesarean delivery. Objectives The present study aims to investigate the effects of different regimens of phenylephrine on blood pressure of candidates for the cesarean section. Methods In this double-blind, randomized clinical trial, a total of 120 candidates of elective cesarean delivery under spinal anesthesia was randomly categorized into three groups. Groups 1, 2, and 3 received bolus and prophylactic saline (control group), prophylactic bolus phenylephrine (100 µg), and prophylactic phenylephrine infusion (50 µg/min), respectively. The incidence of hypotension, maternal hemodynamics, hypertension, rescue phenylephrine dose, nausea, and vomit were compared between the groups. Results In all the three groups, the incidence of nausea and vomit, bradycardia, hypertension, and neonatal Apgar score were not statistically different (P > 0.05). However, the adjuvant phenylephrine dose requirement was remarkably different. Moreover, the mean systolic blood pressure differed significantly in the second and 7th minutes after the spinal block (P < 0.05). 35% in the first group, 15% in the second group, and 2.5% in the third group had hypotension (P = 0.001). Apart from the first measurement after spinal anesthesia, the mean heart rate showed no significant difference between the groups. Conclusions The use of prophylactic phenylephrine infusion is recommended to control the optimal blood pressure in parturients undergoing cesarean section after spinal anesthesia.
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Affiliation(s)
- Mahshid Nikooseresht
- Department of Anesthesiology, Hamadan University of Medical Sciences, Hamadan, Iran
| | | | - Pouran Hajian
- Department of Anesthesiology, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Shadab Khamooshi
- Department of Anesthesiology, Hamadan University of Medical Sciences, Hamadan, Iran
- Corresponding Author: Department of Anesthesiology, Hamadan University of Medical Sciences, Be'sat Hospital, Resalat Sq., Motahari Blvd., Postal Code: 65148-45471, Hamadan, Iran.
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Uterine Exteriorization Compared With In Situ Repair of Hysterotomy After Cesarean Delivery. Obstet Gynecol 2020; 135:1145-1151. [DOI: 10.1097/aog.0000000000003821] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Tan HS, Habib AS. The optimum management of nausea and vomiting during and after cesarean delivery. Best Pract Res Clin Anaesthesiol 2020; 34:735-747. [PMID: 33288123 DOI: 10.1016/j.bpa.2020.04.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 04/17/2020] [Indexed: 12/28/2022]
Abstract
Intraoperative and postoperative nausea and vomiting (IONV and PONV) afflict up to 80% of parturients undergoing cesarean delivery with neuraxial anesthesia. Preventing nausea and emesis is a top priority for women undergoing cesarean delivery and is included in the quality of recovery measures and enhanced recovery after cesarean delivery protocols. The majority of known perioperative emetic triggers can be avoided or mitigated by optimizing anesthetic and surgical management. IONV may arise from spinal anesthesia-induced hypotension, intraoperative pain, and medications such as uterotonics and antibiotics. Furthermore, uterine exteriorization and peritoneal irrigation increase IONV risk. Conversely, preventing PONV mainly focuses on optimizing analgesia through an opioid-sparing, multimodal strategy. In addition, combination prophylactic antiemetic therapy should be instituted in this high-risk population to further reduce the risk of IONV and PONV.
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Affiliation(s)
- Hon Sen Tan
- Department of Anesthesiology, Division of Women's Anesthesia, Duke University Medical Center, Box 3094, Durham, NC, 27710, USA
| | - Ashraf S Habib
- Department of Anesthesiology, Division of Women's Anesthesia, Duke University Medical Center, Box 3094, Durham, NC, 27710, USA.
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Hassabelnaby YS, Hasanin AM, Adly N, Mostafa MMA, Refaat S, Fouad E, Elsonbaty M, Hussein HA, Mahmoud M, Abdelwahab YM, Elsakka A, Amin SM. Comparison of two Norepinephrine rescue bolus for Management of Post-spinal Hypotension during Cesarean Delivery: a randomized controlled trial. BMC Anesthesiol 2020; 20:84. [PMID: 32303180 PMCID: PMC7164145 DOI: 10.1186/s12871-020-01004-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 04/08/2020] [Indexed: 11/10/2022] Open
Abstract
Background Data on the best norepinephrine bolus dose for management of hypotension are limited. The aim of this study was to compare the efficacy and safety of two norepinephrine bolus doses in the rescue management of maternal hypotension during cesarean delivery. Methods This randomized, controlled trial included mothers scheduled for cesarean delivery with spinal anesthesia with a prophylactic norepinephrine infusion. Following spinal anaesthesia administration, a participant was considered hypotensive if systolic blood pressure was ≤80% compared to the baseline reading. Participants were allocated to receive either 6 mcg or 10 mcg norepinephrine bolus for the management of hypotensive episodes. The hemodynamic response after administration of norepinephrine bolus was recorded. The episode was considered successfully managed if systolic blood pressure returned to within 80% from the baseline reading within 2 min after norepinephrine bolus administration, and did not drop again within 6 min after the norepinephrine bolus. The primary outcome was the incidence of successful management of the first hypotensive episode. Other outcomes included systolic blood pressure, heart rate, incidence of maternal bradycardia, and reactive hypertension. Results One hundred and ten mothers developed hypotensive episodes and received norepinephrine boluses for management. The number of successfully managed first hypotensive episodes was 50/57 (88%) in the 6 mcg-treated episodes and 45/53 (85%) in the 10 mcg-treated episodes (p = 0.78). Systolic blood pressure was comparable after administration of either bolus dose. Heart rate was lower after administration of 10 mcg bolus compared to 6 mcg bolus, without significant bradycardia requiring atropine administration. The incidence of reactive hypertension was comparable between both groups. Conclusion In mothers undergoing elective cesarean delivery under prophylactic norepinephrine infusion at 0.05 mcg/kg/min, there was no advantage to the use of 10 mcg norepinephrine bolus over 6 mcg norepinephrine bolus for the rescue management of first hypotensive episode. Neither of the 2 bolus doses reached a 100% success rate. The incidences of bradycardia and reactive hypertension were comparable between both norepinephrine doses. Trial registration At clinicaltrial.gov registry system on January 4, 2019 Clinical trial identifier: NCT03792906.
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Affiliation(s)
- Yasmin S Hassabelnaby
- Department of anesthesia and critical care medicine, 01 elsarayah street, Elmanyal, Cairo, 11559, Egypt.
| | - Ahmed M Hasanin
- Department of anesthesia and critical care medicine, 01 elsarayah street, Elmanyal, Cairo, 11559, Egypt.
| | - Nada Adly
- Department of anesthesia and critical care medicine, 01 elsarayah street, Elmanyal, Cairo, 11559, Egypt
| | - Maha M A Mostafa
- Department of anesthesia and critical care medicine, 01 elsarayah street, Elmanyal, Cairo, 11559, Egypt
| | - Sherin Refaat
- Department of anesthesia and critical care medicine, 01 elsarayah street, Elmanyal, Cairo, 11559, Egypt
| | - Eman Fouad
- Department of anesthesia and critical care medicine, 01 elsarayah street, Elmanyal, Cairo, 11559, Egypt
| | - Mohamed Elsonbaty
- Department of anesthesia and critical care medicine, 01 elsarayah street, Elmanyal, Cairo, 11559, Egypt
| | - Hazem A Hussein
- Department of anesthesia and critical care medicine, Beni-Suef university, Beni-Suef, Egypt
| | - Mohamed Mahmoud
- Department of anesthesia and critical care medicine, 01 elsarayah street, Elmanyal, Cairo, 11559, Egypt
| | - Yaser M Abdelwahab
- Department of anesthesia and critical care medicine, 01 elsarayah street, Elmanyal, Cairo, 11559, Egypt
| | - Ahmed Elsakka
- Department of anesthesia and critical care medicine, 01 elsarayah street, Elmanyal, Cairo, 11559, Egypt
| | - Sarah M Amin
- Department of anesthesia and critical care medicine, 01 elsarayah street, Elmanyal, Cairo, 11559, Egypt
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Vetrugno L, Dogareschi T, Sassanelli R, Orso D, Seremet L, Mattuzzi L, Scapol S, Spasiano A, Cagnacci A, Bove T. Thoracic ultrasound evaluation and B-type natriuretic peptide value in elective cesarean section under spinal anesthesia. Ultrasound J 2020; 12:10. [PMID: 32140875 PMCID: PMC7058737 DOI: 10.1186/s13089-020-00158-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 02/06/2020] [Indexed: 12/14/2022] Open
Abstract
Background Pregnancy-induced changes in cardiovascular status make women more susceptible to pulmonary edema. During cesarean section, to counterbalance the effect of hypotension caused by spinal anesthesia, anesthesiologists must choose between two fundamental approaches to maintain the hemodynamic state—intravenous fluids or vasopressors—and this choice will depend upon their particular opinions and experience. We aim to assess for any correlations between thoracic ultrasound A- and B-line artifacts, brain natriuretic peptide (BNP) levels, and the amount of intraoperative fluids administered. Results From December 2016 to August 2018, at the University-Hospital of Udine, we enrolled 80 consecutive pregnant women undergoing cesarean section. We observed a statistically significant difference in the volume of fluids administered in the first 24 h (p = 0.035) between the patients presenting B-lines in at least one basal area of their thoracic ultrasound and patients with no evident B-lines (AUC 66.4%; IC 0.49–0.83). Dividing the population on whether their BNP levels were higher or less than 20 pg/mL, no statistically significant difference was revealed with regard to fluids administered in the first 24 h (p = 0.537). Conclusions Thoracic ultrasound is a non-invasive and easy-to-use tool for detecting fluid intolerance in pregnant women undergoing cesarean section. BNP levels were slow to rise following the cesarean section and did not show any clear correlation with fluid volumes administered.
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Affiliation(s)
- Luigi Vetrugno
- Anesthesia and Intensive Care Clinic, Department of Medicine, University of Udine, Via Colugna 50, 33100, Udine, Italy. .,University-Hospital of S. M. Misericordia, Udine, Italy, 33100, P.le S. Maria della Misericordia n 15, Udine, Italy.
| | - Teresa Dogareschi
- University-Hospital of S. M. Misericordia, Udine, Italy, 33100, P.le S. Maria della Misericordia n 15, Udine, Italy
| | - Rossella Sassanelli
- Anesthesia and Intensive Care Clinic, Department of Medicine, University of Udine, Via Colugna 50, 33100, Udine, Italy
| | - Daniele Orso
- Anesthesia and Intensive Care Clinic, Department of Medicine, University of Udine, Via Colugna 50, 33100, Udine, Italy
| | - Ludmilla Seremet
- Hospital S. Vito al Tagliamento, Pordenone, Italy, Via della Vecchia Ceramica 1, 33170, Pordenone, Italy
| | - Lisa Mattuzzi
- Anesthesia and Intensive Care Clinic, Department of Medicine, University of Udine, Via Colugna 50, 33100, Udine, Italy
| | - Sara Scapol
- Anesthesia and Intensive Care Clinic, Department of Medicine, University of Udine, Via Colugna 50, 33100, Udine, Italy
| | - Alessandra Spasiano
- University-Hospital of S. M. Misericordia, Udine, Italy, 33100, P.le S. Maria della Misericordia n 15, Udine, Italy
| | - Angelo Cagnacci
- Gynecologic and Obstetric, Department of Medicine, University of Udine, Via Colugna 50, 33100, Udine, Italy
| | - Tiziana Bove
- Anesthesia and Intensive Care Clinic, Department of Medicine, University of Udine, Via Colugna 50, 33100, Udine, Italy.,University-Hospital of S. M. Misericordia, Udine, Italy, 33100, P.le S. Maria della Misericordia n 15, Udine, Italy
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Singh PM, Singh NP, Reschke M, Ngan Kee WD, Palanisamy A, Monks DT. Vasopressor drugs for the prevention and treatment of hypotension during neuraxial anaesthesia for Caesarean delivery: a Bayesian network meta-analysis of fetal and maternal outcomes. Br J Anaesth 2020; 124:e95-e107. [DOI: 10.1016/j.bja.2019.09.045] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 09/27/2019] [Accepted: 09/27/2019] [Indexed: 11/25/2022] Open
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Xiao F, Shen B, Xu WP, Feng Y, Ngan Kee WD, Chen XZ. Dose–Response Study of 4 Weight-Based Phenylephrine Infusion Regimens for Preventing Hypotension During Cesarean Delivery Under Combined Spinal–Epidural Anesthesia. Anesth Analg 2020; 130:187-193. [DOI: 10.1213/ane.0000000000004092] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Buthelezi AS, Bishop DG, Rodseth RN, Dyer RA. Prophylactic phenylephrine and fluid co-administration to reduce spinal hypotension during elective caesarean section in a resource-limited setting: a prospective alternating intervention study. Anaesthesia 2019; 75:487-492. [PMID: 31811659 DOI: 10.1111/anae.14950] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/14/2019] [Indexed: 11/28/2022]
Abstract
Spinal hypotension is a common and clinically important problem during caesarean section. Current consensus recommendations for resource-rich settings suggest the use of a titrated phenylephrine infusion, in combination with fluid coloading, for prevention of maternal hypotension. In resource-limited settings, where syringe drivers are unavailable, these recommendations advise the addition of 500 μg phenylephrine to the first 1 l of intravenous fluid given after initiation of spinal anaesthesia, with additional vasopressor boluses as required. This prospective, alternating intervention study compared the use of a conventional phenylephrine rescue bolus strategy for prevention of hypotension, defined as systolic arterial pressure < 90 mmHg, with a phenylephrine infusion given according to the consensus recommendation. We studied 300 women having elective caesarean section. There were 77 (51%) women who developed hypotension in the bolus group vs. 55 (37%) in the phenylephrine infusion group (p = 0.011). This represented a 29% reduction in hypotension, with a number needed to treat of 6.8. The six highest systolic arterial pressure readings occurred in the phenylephrine infusion group (range 166-188 mmHg), and there were four instances of bradycardia (heart rate < 50 beats.min-1 ) with preserved systolic arterial pressure in each group. There were no adverse clinical sequelae, and no differences in neonatal Apgar scores in either group. The consensus recommendation for phenylephrine and fluid co-administration in resource-limited settings appears effective in preventing maternal hypotension, but at the cost of sporadic systolic hypertension.
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Affiliation(s)
- A S Buthelezi
- Metropolitan Department of Anaesthetics, Critical Care and Pain Management, Pietermaritzburg and School of Clinical Medicine, College of Health Sciences, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - D G Bishop
- Metropolitan Department of Anaesthetics, Critical Care and Pain Management, Pietermaritzburg and School of Clinical Medicine, College of Health Sciences, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - R N Rodseth
- Metropolitan Department of Anaesthetics, Critical Care and Pain Management, Pietermaritzburg and School of Clinical Medicine, College of Health Sciences, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa.,Cleveland Clinic, Cleveland, OH, USA
| | - R A Dyer
- Department of Anaesthesia and Peri-operative Medicine, Groote Schuur Hospital, Faculty of Health Sciences, University of Cape Town, South Africa
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Dux M, Babes A, Manchen J, Sertel-Nakajima J, Vogler B, Schramm J, Messlinger K. High-dose phenylephrine increases meningeal blood flow through TRPV1 receptor activation and release of calcitonin gene-related peptide. Eur J Pain 2019; 24:383-397. [PMID: 31661581 DOI: 10.1002/ejp.1495] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 10/18/2019] [Accepted: 10/21/2019] [Indexed: 01/03/2023]
Abstract
BACKGROUND The α1 -adrenoceptor agonist, phenylephrine, is used at high concentrations as a mydriatic agent and for the treatment of nasal congestion. Among its adverse side-effects transient burning sensations are reported indicating activation of the trigeminal nociceptive system. METHODS Neuropeptide release, calcium imaging and meningeal blood flow recordings were applied in rodent models of meningeal nociception to clarify possible receptor mechanisms underlying these pain phenomena. RESULTS Phenylephrine above 10 mM dose-dependently released calcitonin gene-related peptide (CGRP) from the dura mater and isolated trigeminal ganglia, whereas hyperosmotic mannitol at 90 mM was ineffective. The phenylephrine-evoked release was blocked by the transient receptor potential vanilloid 1 (TRPV1) antagonist BCTC and did not occur in trigeminal ganglia of TRPV1-deficient mice. Phenylephrine at 30 mM caused calcium transients in cultured trigeminal ganglion neurons responding to the TRPV1 agonist capsaicin and in HEK293T cells expressing human TRPV1. Local application of phenylephrine at micromolar concentrations to the exposed rat dura mater reduced meningeal blood flow, whereas concentrations above 10 mM caused increased meningeal blood flow. The flow increase was abolished by pre-application of the CGRP receptor antagonist CGRP8-37 or the TRPV1 antagonist BCTC. CONCLUSIONS Phenylephrine at high millimolar concentrations activates TRPV1 receptor channels of perivascular afferents and, upon calcium inflow, releases CGRP, which increases meningeal blood flow. Activation of TRPV1 receptors may underlie trigeminal nociception leading to cranial pain such as local burning sensations or headaches caused by administration of high doses of phenylephrine. SIGNIFICANCE Phenylephrine is used at high concentrations as a mydriaticum and for treating nasal congestion. As adverse side-effects burning sensations and headaches have been described. Phenylephrine at high concentrations causes calcium transients in trigeminal afferents, CGRP release and increased meningeal blood flow upon activation of TRPV1 receptor channels, which is likely underlying the reported pain phenomena.
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Affiliation(s)
- Mária Dux
- Department of Physiology, University of Szeged, Szeged, Hungary
| | - Alexandru Babes
- Department of Anatomy, Physiology and Biophysics, University of Bucharest, Bucharest, Romania
| | - Jessica Manchen
- Institute of Physiology and Pathophysiology, Friedrich-Alexander-University Erlangen-Nürnberg, Nürnberg, Germany
| | - Julika Sertel-Nakajima
- Institute of Physiology and Pathophysiology, Friedrich-Alexander-University Erlangen-Nürnberg, Nürnberg, Germany
| | - Birgit Vogler
- Institute of Physiology and Pathophysiology, Friedrich-Alexander-University Erlangen-Nürnberg, Nürnberg, Germany
| | - Jana Schramm
- Institute of Physiology and Pathophysiology, Friedrich-Alexander-University Erlangen-Nürnberg, Nürnberg, Germany
| | - Karl Messlinger
- Institute of Physiology and Pathophysiology, Friedrich-Alexander-University Erlangen-Nürnberg, Nürnberg, Germany
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Xu T, Zheng J, An XH, Xu ZF, Wang F. Norepinephrine intravenous prophylactic bolus versus rescue bolus to prevent and treat maternal hypotension after combined spinal and epidural anesthesia during cesarean delivery: a sequential dose-finding study. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:451. [PMID: 31700887 DOI: 10.21037/atm.2019.08.50] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Background As a relatively new drug in obstetrical anesthesia, norepinephrine is less likely to induce bradycardia and decrease cardiac output, which makes it a potential alternative to phenylephrine. The purpose of this study was to determine the optimal norepinephrine bolus dose needed to either prevent or reverse hypotension after the use of combined spinal and epidural (CSE) anesthesia in 90% of women during elective cesarean delivery (CD). Methods Eighty women undergoing elective CD were randomly allocated into either a prophylactic group or a rescue group in this dose finding study. If the women's systolic blood pressure (SBP) was maintained above 80% of their baseline, the next patient had an 8/9th chance of receiving the same dose or a 1/9th chance of receiving a lower dose. If the patient's SBP was not maintained, a higher dose was used for next patient. The primary outcome was the successful use of the norepinephrine bolus dose to maintain SBP above 80% of the baseline until after delivery. Secondary outcomes included nausea, vomiting, breathlessness, dizziness, hypertension, bradycardia due to hypotension and supplemental use of atropine and norepinephrine, upper sensory level of anesthesia, umbilical vein (UV) blood gases, and 1- and 5-minute Apgar scores. The 90% effective dose (ED90) and 95% confidence interval (95% CI) were estimated using isotonic regression methods. Results The estimated ED90 of the norepinephrine prophylactic bolus was 10.85 µg (95% CI, 9.20-11.67 µg) and that of the norepinephrine rescue bolus was 12.3 µg (95% CI, 10.0-12.8 µg) using isotonic regression methods. Conclusions For norepinephrine, either a prophylactic bolus dose of 11 µg or a rescue bolus dose of 12 µg was recommended for clinical practices.
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Affiliation(s)
- Tao Xu
- Department of Anesthesiology, the International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200030, China.,Shanghai Key Laboratory of Embryo Original Diseases, Shanghai 20030, China.,Shanghai Municipal Key Clinical Specialty, Shanghai 20030, China
| | - Jing Zheng
- Department of Anesthesiology, the International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200030, China.,Shanghai Key Laboratory of Embryo Original Diseases, Shanghai 20030, China.,Shanghai Municipal Key Clinical Specialty, Shanghai 20030, China
| | - Xiao-Hu An
- Department of Anesthesiology, the International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200030, China.,Shanghai Key Laboratory of Embryo Original Diseases, Shanghai 20030, China.,Shanghai Municipal Key Clinical Specialty, Shanghai 20030, China
| | - Zi-Feng Xu
- Department of Anesthesiology, the International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200030, China.,Shanghai Key Laboratory of Embryo Original Diseases, Shanghai 20030, China.,Shanghai Municipal Key Clinical Specialty, Shanghai 20030, China
| | - Fang Wang
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, TN, USA
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Raimann FJ, Baldauf HP, Louwen F, Jennewein L, Fischer D, Zacharowski K, Weber CF. Granisetron reduces the need for uterotonics but not sympathomimetics during cesarean delivery. Int J Gynaecol Obstet 2019; 145:361-366. [PMID: 30932170 DOI: 10.1002/ijgo.12819] [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: 07/07/2018] [Revised: 11/04/2018] [Accepted: 03/29/2019] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To assess the effect of a 5-hydroxytryptamine-3 receptor antagonist (granisetron) on the use of sympathomimetic (cafedrine/theodrenaline) and uterotonic (oxytocin) agents after spinal anesthesia during cesarean delivery. METHODS A retrospective observational analysis was conducted using intraoperative records (n=240) created at a single hospital in Germany between November 1, 2016, and July 31, 2017. The granisetron group (n=120) had received 3 mg of granisetron immediately before induction of spinal anesthesia. The control group (n=120) had not received granisetron. The primary endpoints were the intraoperative requirements for sympathomimetic and uterotonic agents. The secondary endpoints were parameters of intraprocedural maternal hemodynamic and clinical states. RESULTS More patients in the granisetron group than in the control group received intraoperative cafedrine/theodrenaline (P=0.045), with the cumulative intraoperative dosage also increased in the granisetron group (P=0.016). By contrast, the cumulative intraoperative dose of oxytocin was lower in the granisetron group than in the control group (P<0.001). Decreases in heart rate and mean arterial blood pressure were lower in the granisetron group versus the control group (P=0.015 and P=0.002, respectively). CONCLUSION Treatment with granisetron immediately before cesarean delivery did not reduce the perioperative requirement for sympathomimetics but did reduce the need for uterotonics. REGISTERED AT CLINICALTRIALS.GOV (NCT03318536).
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Affiliation(s)
- Florian J Raimann
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Henrica P Baldauf
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Frank Louwen
- Department of Obstetrics and Gynecology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Lukas Jennewein
- Department of Obstetrics and Gynecology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Dania Fischer
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Kai Zacharowski
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Christian F Weber
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt am Main, Germany.,Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, Asklepios Hospital Wandsbek, Hamburg, Germany
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Heesen M, Rijs K, Hilber N, Ngan Kee W, Rossaint R, van der Marel C, Klimek M. Ephedrine versus phenylephrine as a vasopressor for spinal anaesthesia-induced hypotension in parturients undergoing high-risk caesarean section: meta-analysis, meta-regression and trial sequential analysis. Int J Obstet Anesth 2019; 37:16-28. [DOI: 10.1016/j.ijoa.2018.10.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2018] [Revised: 10/01/2018] [Accepted: 10/13/2018] [Indexed: 11/28/2022]
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Riley ET, Mangum K, Carvalho B, Butwick AJ. The Crystalloid Co-Load: Clinically as Effective as Colloid Preload for Preventing Hypotension from Spinal Anaesthesia for Caesarean Delivery. Turk J Anaesthesiol Reanim 2019; 47:35-40. [PMID: 31276109 DOI: 10.5152/tjar.2018.76402] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Accepted: 07/12/2018] [Indexed: 11/22/2022] Open
Abstract
Objective Colloid preloading diminishes post-spinal hypotension. However, whether colloid preloading is superior to crystalloid co-loading is uncertain. In this retrospective study, we compared the effects of a colloid preload versus a crystalloid co-load on vasopressor requirements and maternal haemodynamics among women undergoing elective caesarean delivery (CD) with spinal anaesthesia. Methods We extracted data from the medical records of 160 healthy women who underwent elective CD with spinal anaesthesia at an academic obstetric centre before and after an institutional fluid-loading protocol change. Patients received a 500 mL 6% hydroxyethyl starch preload or a 1000 mL crystalloid co-load. The primary outcome was the total phenylephrine dose administered from spinal block placement to delivery. Results Our cohort comprised 79 women in the colloid group and 77 women in the crystalloid group. The mean phenylephrine use was significantly lower in the colloid group than in the crystalloid group (489±403 μg vs. 647±464 μg, respectively, p=0.02). The maximal drop in systolic blood pressure was greater in the colloid group than in the crystalloid group (36±20 mmHg vs. 29±16 mmHg, respectively, p=0.02). There were no clinically significant differences between the groups in heart rate, blood loss, temperature and Apgar scores. Conclusion Vasopressor use was lower in colloid preloading than in crystalloid co-loading. However, differences in all outcome measures were minimal and likely clinically insignificant, suggesting that both fluid-loading techniques are appropriate to use for the prevention of spinal hypotension in women undergoing CD.
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Affiliation(s)
- Edward T Riley
- Stanford University School of Medicine, 300 Pasteur Drive, Stanford, California, USA
| | - Kevin Mangum
- A.T. Still University School of Osteopathic Medicine in Arizona, Meza, Arizona, USA
| | - Brendan Carvalho
- Stanford University School of Medicine, 300 Pasteur Drive, Stanford, California, USA
| | - Alexander J Butwick
- Stanford University School of Medicine, 300 Pasteur Drive, Stanford, California, USA
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Ryu C, Choi GJ, Park YH, Kang H. Vasopressors for the management of maternal hypotension during cesarean section under spinal anesthesia: A Systematic review and network meta-analysis protocol. Medicine (Baltimore) 2019; 98:e13947. [PMID: 30608428 PMCID: PMC6344174 DOI: 10.1097/md.0000000000013947] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Accepted: 12/10/2018] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Spinal anesthesia is the standard technique for elective cesarean section, but the incidence of maternal hypotension in this setting is reportedly about 80%, without any prophylactic management. Vasopressors are the most reliable method for counteracting the hypotension induced by spinal anesthesia. However, studies investigating the effects of vasopressors have yielded inconsistent and debatable results. Therefore, we plan to conduct a systematic review and network meta-analysis to identify the most effective vasopressor to prevent maternal hypotension, and to decrease fetal acidosis in women undergoing spinal anesthesia for elective cesarean section. METHODS A systematic and comprehensive search to detect all the randomized controlled studies on vasopressors for the management of maternal hypotension during cesarean section under spinal anesthesia will be performed using information in the databases, MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), and Google Scholar, beginning from their inception to October 2018. We will conduct a network meta-analysis to combine the direct and indirect comparisons of the vasopressors. We will use the surface under the cumulative ranking curve (SUCRA) values and rankograms to present the hierarchy of vasopressors. A comparison-adjusted funnel plot will be used to assess the presence of small-study effects. The quality of the studies included will be assessed using the risk of bias tool. All statistical analyses will be performed using Stata SE version 15.0. ETHICS AND DISSEMINATION This systematic review and meta-analysis will be published in a peer-reviewed journal. Ethical approval and informed consent are not required, as the study will be a literature review and will not involve direct contact with patients or alterations to patient care. TRIAL REGISTRATION NUMBER The protocol for this review has been registered in the PROSPERO network (registration number: CRD42018111852).
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Kaneko T, Kariya N, Hirose M. Association between intraoperative phenylephrine administration and umbilical artery pH in women with hypertensive disorders of pregnancy: a retrospective cohort study. J Anesth 2018; 32:893-900. [PMID: 30377805 DOI: 10.1007/s00540-018-2572-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Accepted: 10/21/2018] [Indexed: 11/26/2022]
Abstract
PURPOSE In healthy pregnant women undergoing Cesarean section, treatment of post-spinal hypotension (PSH) with phenylephrine is reportedly more efficacious than ephedrine in preventing a decline in umbilical artery pH (UApH), which is an indicator of fetal acidosis. However, phenylephrine has the potential to reduce placental blood flow and consequently decrease UApH in women who develop hypertensive disorders of pregnancy (HDP), due to decreased cardiac function and placental vascular abnormalities. We aimed to verify the association between decreased UApH and phenylephrine administered before delivery to treat PSH in women with HDP. METHODS This single-center retrospective cohort study was conducted between April 2008 and October 2016 by assessing the records of pregnant women with confirmed or suspected HDP who underwent Cesarean section under spinal anesthesia. The association between phenylephrine and the primary endpoint of decreased UApH was investigated using logistic regression analysis and propensity score matching. RESULTS In the original cohort of 107 pregnant women with HDP, neither univariate nor multivariate analysis indicated a significant association between phenylephrine treatment and decreased UApH [crude odds ratio (OR) = 2.26; 95% confidence interval (CI) 0.75-6.77; P = 0.14], (adjusted OR = 1.80; 95% CI 0.55-5.93; P = 0.33). Thirty patients each who were not treated with phenylephrine (control group) and were treated with phenylephrine (phenylephrine group) were matched by propensity score analysis. UApH [median (interquartile range)] was not significantly different between control and phenylephrine groups [7.30 (7.25-7.35) vs. 7.27 (7.25-7.30); P = 0.14]. CONCLUSION Intraoperative phenylephrine administration to treat PSH in women with HDP was not associated with decreased UApH.
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Affiliation(s)
- Takahiko Kaneko
- Department of Anesthesiology and Pain Medicine, Hyogo College of Medicine, Mukogawa-cho 1-1, Nishinomiya, Hyogo, 663-8501, Japan.
| | - Nobutaka Kariya
- Department of Anesthesiology and Pain Medicine, Hyogo College of Medicine, Mukogawa-cho 1-1, Nishinomiya, Hyogo, 663-8501, Japan
| | - Munetaka Hirose
- Department of Anesthesiology and Pain Medicine, Hyogo College of Medicine, Mukogawa-cho 1-1, Nishinomiya, Hyogo, 663-8501, Japan
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Choudhary M, Bajaj JK. Study Comparing Phenylephrine Bolus and Infusion for Maternal Hypotension and Neonatal Outcome during Cesarean Section under Spinal Anesthesia. Anesth Essays Res 2018; 12:446-451. [PMID: 29962614 PMCID: PMC6020566 DOI: 10.4103/aer.aer_23_18] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background Phenylephrine(PE) bolus and infusion have been compared for post spinal hypotension and neonatal effects during cesarean section(CS) under spinal anesthesia(SA). Aim The primary aim of this study was to compare bolus doses of 50μg of PE with a fixed infusion rate of 50 μg/min of the same drug given prophylactically. The secondary aim was to study the neonatal outcome and side effects with the two regimes. Settings and Design This prospective,randomized,comparative study was conducted in the department of Anesthesia in a tertiary care teaching hospital. Materials and Methods This study was conducted on 100 normotensive women undergoing CS under SA. The patients were randomized into two groups of 50 each. Group A received bolus of 50 μg PE after the systolic BP(SBP) fell by 20% from the baseline and Group B received a prophylactic infusion of 50 μg/min PE. The changes in heart rate (HR), BP and side effects were compared till delivery. The neonatal APGAR scores were compared at 1 and 5 minutes and an umbilical artery sample was sent for blood gas analysis. Statistical Analysis Categorical variables were shown in number and percentage. Normally distributed continuous variables were presented as mean ± SD and compared using unpaired t-test. Non normally distributed continuous variables were displayed as median and were compared using Mann-Whitney test. A P value of <0.05 was considered significant. Results In group A, the HR was higher than in group B throughout the monitoring period. (P < 0.001). In group A, SBP trend showed a fall of more than 20% from the base line in 44 patients. The mean fall in SBP was -28.06 ± 5.3 mmHg% in Group A while in group B the mean fall in SBP was only -0.44 ± 4.3mmHg%. Nausea and vomiting was less in group B. There was no difference in APGAR or neonatal acidosis on ABG. Conclusion There was a tighter control of BP in the infusion group vs. the bolus group while the neonatal outcome was similar in both the groups.
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Affiliation(s)
- Manish Choudhary
- Department of Anaesthesia and Intensive Care, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Jeetendra Kumar Bajaj
- Department of Anaesthesia and Intensive Care, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
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Kinsella SM, Carvalho B, Dyer RA, Fernando R, McDonnell N, Mercier FJ, Palanisamy A, Sia ATH, Van de Velde M, Vercueil A. International consensus statement on the management of hypotension with vasopressors during caesarean section under spinal anaesthesia. Anaesthesia 2017; 73:71-92. [DOI: 10.1111/anae.14080] [Citation(s) in RCA: 233] [Impact Index Per Article: 33.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/23/2017] [Indexed: 11/28/2022]
Affiliation(s)
- S. M. Kinsella
- Department of Anaesthesia; St Michael's Hospital; Bristol UK
| | - B. Carvalho
- Department of Anesthesiology; Stanford University School of Medicine; Stanford CA USA
| | - R. A. Dyer
- Department of Anaesthesia and Perioperative Medicine; University of Cape Town; South Africa
| | - R. Fernando
- Department of Anaesthesia; Hamad Women's Hospital; Doha Qatar
| | - N. McDonnell
- Department of Anaesthesia and Pain Medicine; King Edward Memorial Hospital for Women; Subiaco Australia
| | - F. J. Mercier
- Département d'Anesthésie-Réanimation; Hôpital Antoine Béclère; Clamart France
| | - A. Palanisamy
- Department of Anesthesiology; Washington University School of Medicine; St. Louis MO USA
| | - A. T. H. Sia
- Department of Women's Anaesthesia; KK Women's and Children's Hospital; Singapore
| | - M. Van de Velde
- Department of Anesthesiology; UZ Leuven; Leuven Belgium
- Department of Cardiovascular Sciences; KU Leuven; Leuven Belgium
| | - A. Vercueil
- Department of Anaesthesia and Intensive Care Medicine; King's College Hospital NHS Foundation Trust; London UK
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Restrictive or responsive? Outcome classification and unplanned sub-group analyses in meta-analyses. Anaesthesia 2017; 73:279-283. [DOI: 10.1111/anae.14078] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/21/2017] [Indexed: 11/26/2022]
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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.
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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
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Jelting Y, Klein C, Harlander T, Eberhart L, Roewer N, Kranke P. Preventing nausea and vomiting in women undergoing regional anesthesia for cesarean section: challenges and solutions. Local Reg Anesth 2017; 10:83-90. [PMID: 28860857 PMCID: PMC5558589 DOI: 10.2147/lra.s111459] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Intraoperative nausea and vomiting (IONV) or postoperative nausea and vomiting (PONV) affecting women undergoing regional anesthesia for cesarean section is an important clinical problem since these techniques are used widely. There are burdens of literature about IONV/PONV and several in parturient and cesarean. However, it needs more attention. The underlying mechanisms of IONV and PONV in the obstetrical setting mainly include hypotension due to sympathicolysis during neuraxial anesthesia, bradycardia owing to an increased vagal tone, the visceral stimulation via the surgical procedure and intravenously administered opioids. METHODS Given the high and even increasing rate of cesarean sections and the sparse information on the etiology, incidence and severity of nausea and vomiting and the impact of prophylactic measures on the incidence of PONV/IONV, this article aims to review the available information and provide pragmatic suggestions on how to prevent nausea and vomiting in this patient cohort. Current literature and guidelines were identified by electronic database searching (MEDLINE via PubMed and Cochrane database of systematic reviews) up to present, searching through reference lists of included literature and personal contact with experts. DISCUSSION AND CONCLUSION Taking into account the current guidelines and literature as well as everyday clinical experience, the first step for decreasing the incidence of IONV and PONV is a comprehensive management of circulatory parameters. This management includes liberal perioperative fluid administration and the application of vasopressors as the circumstances require. By using low-dose local anesthetics, an additional application of intrathecal or spinal opioids or hyperbaric solutions for a sufficient controllability of neuraxial distribution, maternal hypotension might be reduced. Performing a combined spinal-epidural anesthesia or epidural anesthesia may be considered as an alternative to spinal anesthesia. Antiemetic drugs may be administered restrainedly due to off-label use in pregnant women for IONV or PONV prophylaxis and may be reserved for treatment.
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Affiliation(s)
- Yvonne Jelting
- Department of Anesthesia and Critical Care, University Hospitals of Wuerzburg, Wuerzburg
| | - Christian Klein
- Department of Anesthesia and Critical Care, University Hospitals of Wuerzburg, Wuerzburg
| | - Thomas Harlander
- Department of Anesthesia and Critical Care, University Hospitals of Wuerzburg, Wuerzburg
| | - Leopold Eberhart
- Department of Anesthesiology and Critical Care Medicine, Philipps-University Marburg, Marburg, Germany
| | - Norbert Roewer
- Department of Anesthesia and Critical Care, University Hospitals of Wuerzburg, Wuerzburg
| | - Peter Kranke
- Department of Anesthesia and Critical Care, University Hospitals of Wuerzburg, Wuerzburg
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Uppal V, McKeen DM. Strategies for prevention of spinal-associated hypotension during Cesarean delivery: Are we paying attention? Can J Anaesth 2017; 64:991-996. [PMID: 28702819 DOI: 10.1007/s12630-017-0930-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2017] [Revised: 06/08/2017] [Accepted: 07/05/2017] [Indexed: 11/25/2022] Open
Affiliation(s)
- Vishal Uppal
- Department of Anesthesia, Perioperative Medicine and Pain Management, Dalhousie University, Nova Scotia Health Authority and IWK Health Centre, Halifax, NS, B3H 2Y9, Canada
| | - Dolores M McKeen
- Department of Anesthesia, Perioperative Medicine and Pain Management, Dalhousie University, Nova Scotia Health Authority and IWK Health Centre, Halifax, NS, B3H 2Y9, Canada.
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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
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Heesen M, Klimek M, Hoeks SE, Rossaint R. Prevention of Spinal Anesthesia-Induced Hypotension During Cesarean Delivery by 5-Hydroxytryptamine-3 Receptor Antagonists. Anesth Analg 2016; 123:977-88. [DOI: 10.1213/ane.0000000000001511] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Detweiler BN, Kollmorgen LE, Umberham BA, Hedin RJ, Vassar BM. Risk of bias and methodological appraisal practices in systematic reviews published in anaesthetic journals: a meta-epidemiological study. Anaesthesia 2016; 71:955-68. [DOI: 10.1111/anae.13520] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/08/2016] [Indexed: 11/28/2022]
Affiliation(s)
- B. N. Detweiler
- Institutional Research and Analytics; Oklahoma State University Center for Health Sciences; Tulsa Oklahoma USA
| | - L. E. Kollmorgen
- Institutional Research and Analytics; Oklahoma State University Center for Health Sciences; Tulsa Oklahoma USA
| | - B. A. Umberham
- Institutional Research and Analytics; Oklahoma State University Center for Health Sciences; Tulsa Oklahoma USA
| | - R. J. Hedin
- Institutional Research and Analytics; Oklahoma State University Center for Health Sciences; Tulsa Oklahoma USA
| | - B. M. Vassar
- Institutional Research and Analytics; Oklahoma State University Center for Health Sciences; Tulsa Oklahoma USA
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Arendt KW. The 2015 Gerard W. Ostheimer Lecture: What's New in Labor Analgesia and Cesarean Delivery. Anesth Analg 2016; 122:1524-31. [PMID: 27101497 DOI: 10.1213/ane.0000000000001265] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Every year the Board of Directors of the Society for Obstetric Anesthesia and Perinatology selects an individual to review the literature pertinent to obstetric anesthesiology published the previous calendar year. This individual selects the most notable contributions, creates a syllabus of the articles, and then presents his/her overview in an annual lecture named in honor of the late Gerard W. Ostheimer, a pioneering obstetric anesthesiologist from the Brigham and Women's Hospital. This article reviews the literature published in 2014 focusing on the themes of labor analgesia and cesarean delivery. Its contents were presented as the Gerard W. Ostheimer Lecture at the 47th Annual Meeting of the Society for Obstetric Anesthesia and Perinatology, May 16, 2015, in Colorado Springs, Colorado. The syllabus is available as Supplemental Digital Content (http://links.lww.com/AA/B397).
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Affiliation(s)
- Katherine W Arendt
- From the Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota
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50
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Soxhuku-Isufi A, Shpata V, Sula H. Maternal and Neonatal Effects of Vasopressors Used for Treating Hypotension after Spinal Anesthesia for Caesarean Section: A Randomized Controlled Study. Open Access Maced J Med Sci 2015; 4:54-8. [PMID: 27275330 PMCID: PMC4884253 DOI: 10.3889/oamjms.2016.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Revised: 12/06/2015] [Accepted: 12/05/2015] [Indexed: 11/24/2022] Open
Abstract
AIM: The aim of the study was to examine whether ephedrine and phenylephrine were different in their efficacy for managing maternal hypotension and their effect of adverse maternal and neonatal outcome. METHODS: A double-blind randomized controlled study in healthy pregnant women ASA physical status 2, which underwent elective caesarian delivery under spinal anesthesia. Patients were randomized to receive an intravenous bolus of either phenylephrine (Ph group) or ephedrine (E group) immediately after the episode of hypotension after spinal anesthesia. Maternal and neonatal outcomes were recorded. RESULTS: Two hundred and two (202) pregnant women at term were entered in this study. There were no differences between group E and group Ph regarding the incidence of hypotension after vasopressor therapy, and the incidence of nausea and vomiting. There was no significant difference between groups in the first-minute and the 5th minute Apgar score, none of the neonates had the true fetal acidosis. CONCLUSIONS: Ephedrine and phenylephrine have the same efficacy in treating hypotension after spinal anesthesia for caesarean section. The use of Phenylephrine was associated with better fetal acid-base status, and there were no differences on Apgar score values and on the incidence of maternal bradycardia and hypotension.
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Affiliation(s)
- Alma Soxhuku-Isufi
- University Hospital of Obstetrics and Gynecology "Koço Gliozheni", Tirana, Albania
| | - Vjollca Shpata
- Faculty of Technical Medical Sciences, University of Medicine in Tirana, Tirana, Albania
| | - Hektor Sula
- Faculty Medicine, University of Medicine in Tirana, Tirana, Albania
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