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Hasanin AM, Zaki RM, Mostafa M. High spinal block in cesarean section. J Anesth 2024:10.1007/s00540-024-03378-6. [PMID: 39009947 DOI: 10.1007/s00540-024-03378-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2024] [Accepted: 07/04/2024] [Indexed: 07/17/2024]
Affiliation(s)
- Ahmed M Hasanin
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt.
| | - Rana M Zaki
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt
| | - Maha Mostafa
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt
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Tan H, Chen Y, Jiang Y, Sun X, Ye W, Zhu X, Xiong X. Determination of ED90s of Phenylephrine and Norepinephrine Infusion for Prevention of Spinal Anesthesia-Induced Hypotension in Patients with Preeclampsia During Cesarean Delivery. Drug Des Devel Ther 2024; 18:2813-2821. [PMID: 38984209 PMCID: PMC11232882 DOI: 10.2147/dddt.s467072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Accepted: 07/01/2024] [Indexed: 07/11/2024] Open
Abstract
Background Vasopressors remain an important strategy for managing spinal anesthesia-induced hypotension in women with preeclampsia. The aim of this study was to investigate the ED90s and efficacy ratio of phenylephrine and norepinephrine in managing spinal anesthesia-induced hypotension in women with preeclampsia during cesarean delivery. Methods 60 women with preeclampsia, who underwent cesarean delivery, were randomly assigned to receive either a continuous intravenous infusion of phenylephrine or norepinephrine following spinal anesthesia. The initial dosage of phenylephrine or norepinephrine for the first women was 0.5 or 0.05 μg/kg/min, respectively, and subsequent infusion dosages were adjusted based on their efficacy in preventing spinal anesthesia-induced hypotension (defined as a systolic blood pressure less than 80% of the baseline level). The incremental or decremental doses of phenylephrine or norepinephrine were set at 0.1 or 0.01 μg/kg/min. The primary outcomes were the ED90s and efficacy ratio of phenylephrine and norepinephrine infusions for preventing spinal anesthesia-induced hypotension prior to delivery. Results The results obtained from isotonic regression analysis revealed that the ED90 values of the phenylephrine and norepinephrine group for preventing spinal anesthesia-induced hypotension were 0.597 (95% CI: 0.582-0.628) and 0.054 (95% CI: 0.053-0.056) μg/kg/min, respectively, with an efficacy ratio of 11.1:1. The results of Probit regression analysis revealed that the ED90 values were determined to be 0.665 (95% CI: 0.576-1.226) and 0.055 (95% CI: 0.047-0.109) μg/kg/min, respectively, with an efficacy ratio of 12.1:1. Conclusion The administration of 0.6 μg/kg/min phenylephrine and 0.05 μg/kg/min norepinephrine has been found to effectively manage a 90% incidence of spinal anesthesia-induced hypotension in women with preeclampsia.
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Affiliation(s)
- Haijie Tan
- Department of Anesthesiology, The Fifth People's Hospital of Huaian, Huaian, People's Republic of China
| | - Yi Chen
- Department of Anesthesiology and Perioperative Medicine, General Hospital of Ningxia Medical University, Yinchuan, People's Republic of China
| | - Yan Jiang
- Department of Anesthesiology, The Fifth People's Hospital of Huaian, Huaian, People's Republic of China
| | - Xiaojing Sun
- Department of Anesthesiology, The Fifth People's Hospital of Huaian, Huaian, People's Republic of China
| | - Wei Ye
- Department of Anesthesiology, The Fifth People's Hospital of Huaian, Huaian, People's Republic of China
| | - Xuefang Zhu
- Department of Anesthesiology, The Fifth People's Hospital of Huaian, Huaian, People's Republic of China
| | - Xiangsheng Xiong
- Department of Anesthesiology, The Fifth People's Hospital of Huaian, Huaian, People's Republic of China
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Liu S, Luo S, Jiang R, Su S, Zhao M. Left-lateral position versus phenylephrine prophylactic treatment for hypotension following combined spinal epidural anesthesia during elective cesarean section. Heliyon 2024; 10:e30019. [PMID: 38694024 PMCID: PMC11058875 DOI: 10.1016/j.heliyon.2024.e30019] [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: 01/10/2024] [Revised: 04/17/2024] [Accepted: 04/18/2024] [Indexed: 05/03/2024] Open
Abstract
Backgroud Hypotension is one of the most common and dangerous complications following combined spinal epidural anesthesia during elective cesarean delivery. Many methods are used to prevent or treat the hypotension with pharmacological or non-pharmacological measures. Our aim was to assess left-lateral position and phenylephrine prophylactic treatment for the prevention or treatment of maternal hypotension. Methods A total of 127 pregnant women were enrolled to be analyzed. The primary outcome measure was the incidence of maternal hypotension and secondary outcome measures included maternal demographic characteristics, anesthesia-to-incision time interval, birthweight and Apgar scores. Results The incidence of hypotension was 65.4 % in sequential reactive treatment and only 11.3 % achieved complete anesis after left-lateral position, significantly higher than 17.4 % in left-lateral position combined phenylephrine prophylactic treatment (P < 0.001). The increasing in gestational age may decrease the hypotension risk (P < 0.001). There were no significantly differences with maternal age, gravidity, parity, BMI before pregnancy, BMI before cesarean section, anesthesia-to-incision time interval, birthweight and Apgar scores (P > 0.05). The univariate logistic regression analysis revealed a significant association between treatment and hypotension (OR 0.11, 95 % CI 0.05-0.27). After adjusting for confounding variables, the risk of hypotension was decreased in subjects with treatment (OR 0.1, 95 % CI 0.04-0.25; OR 0.15, 95 % CI 0.05-0.43; OR 0.16, 95 % CI 0.05-0.46). The results of stratified and interaction analyses of the association between treatment revealed no interactive role from maternal age, gravidity and BMI before cesarean section (P > 0.05). Conclusions Single use of left-lateral position had limited effective and left-lateral position combined prophylactic phenylephrine used may be much better to prevent or treat hypetension, but larger studies with more robust data are needed to confirm these findings.
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Affiliation(s)
- Songyuan Liu
- Qingdao Medical College, Qingdao University, Qingdao, China
- Department of Anesthesiology, Qingdao Central Hospital, University of Health and Rehabilitation Sciences (Qingdao Central Medical Group), Qingdao, China
| | - Shuzhi Luo
- Department of Anesthesiology, Shandong Province Maternal and Child Health Care Hospital Affiliated to Qingdao University, Jinan, China
| | - Runzhi Jiang
- Department of Anesthesiology, Qingdao Central Hospital, University of Health and Rehabilitation Sciences (Qingdao Central Medical Group), Qingdao, China
| | - Shili Su
- Department of Reproductive Medicine Center, Shandong Province Maternal and Child Health Care Hospital Affiliated to Qingdao University, China
| | - Mingqiang Zhao
- Department of Anesthesiology, Qingdao Central Hospital, University of Health and Rehabilitation Sciences (Qingdao Central Medical Group), Qingdao, China
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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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The use of epinephrine infusion for the prevention of spinal hypotension during Caesarean delivery: A randomized controlled dose-finding trial. Anaesth Crit Care Pain Med 2023; 42:101204. [PMID: 36858257 DOI: 10.1016/j.accpm.2023.101204] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 02/01/2023] [Accepted: 02/20/2023] [Indexed: 03/03/2023]
Abstract
BACKGROUND This study aimed to compare three epinephrine doses for the prevention of spinal hypotension during Caesarean delivery. METHODS This randomized controlled trial included full-term pregnant women undergoing elective Caesarean delivery under spinal anesthesia. The participants received prophylactic epinephrine infusions at rates of 0.01, 0.02, or 0.03 mcg/kg/min. Spinal hypotension (systolic blood pressure <80% of baseline) was managed with a 9-mg ephedrine bolus. The primary outcome was the incidence of spinal hypotension. Secondary outcomes included total ephedrine requirement, the incidence of severe spinal hypotension, excessive tachycardia and hypertension, and neonatal outcomes. RESULTS The final analysis included 271 patients. The incidence of hypotension was lowest in the 0.03 mcg group (11/90 [12%]), followed by the 0.02 mcg (32/91 [35%]) and the 0.01 mcg (55/90 [61%]) groups (p < 0.001). The median ephedrine requirements (quartiles) were also the lowest in the 0.03 mcg group (0 [0-0] mg), followed by the 0.02 mcg (0 [0-9] mg) and the 0.01 mcg (9 [0-18] mg) groups. The incidence of severe hypotension was lower in the 0.03 mcg and 0.02 mcg groups than in the 0.01 mcg group (3/90 [3%], 5/91 [6%], and 15/90 [17%], respectively). The incidences of excessive tachycardia, hypertension, and neonatal outcomes were comparable among the groups. CONCLUSION The use of epinephrine to prevent spinal hypotension during Caesarean delivery is feasible and effective. An initial dose of 0.03 mcg/kg/min produced the lowest incidence of hypotension compared to 0.02 mcg/kg/min and 0.01 mcg/kg/min doses. The three doses were comparable in terms of the incidence of tachycardia, hypertension, and neonatal outcomes. STUDY REGISTRATION ClinicalTrials.gov Identifier: NCT05279703.
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Uerpairojkit K, Thongthaweeporn N, Anusorntanawat R, Pipanmekaporn T, Hinthong T, Bunchungmongkol N, Simarangsan N. A randomized comparison of hemodynamic changes in response to a heart rate‐dependent phenylephrine/ephedrine protocol versus ephedrine‐only for spinal hypotension during elective cesarean section. J Obstet Gynaecol Res 2022; 48:1750-1759. [DOI: 10.1111/jog.15289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Revised: 04/16/2022] [Accepted: 05/03/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Ketchada Uerpairojkit
- Department of Anesthesiology, Faculty of Medicine Chulalongkorn University Bangkok Thailand
| | | | | | | | - Thanoo Hinthong
- Department of Anesthesiology Chiang Mai University Chiang Mai Thailand
| | | | - Nawaporn Simarangsan
- Department of Anesthesiology, Faculty of Medicine Chulalongkorn University Bangkok Thailand
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van Dyk D, Dyer RA, Bishop DG. Spinal hypotension in obstetrics: Context-sensitive prevention and management. Best Pract Res Clin Anaesthesiol 2022; 36:69-82. [PMID: 35659961 DOI: 10.1016/j.bpa.2022.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 03/23/2022] [Accepted: 04/05/2022] [Indexed: 11/15/2022]
Abstract
Spinal hypotension during caesarean section remains a common complication, with important attendant maternal and fetal adverse outcomes. Research elucidating the mechanisms of spinal hypotension has led to the development and refinement of effective management strategies, with a particular emphasis on prophylactic vasopressor administration. This has proved effective in well-resourced settings, with maternal comfort and the elimination of nausea now considered the primary aim of treatment. In resource-limited settings, sophisticated strategies are not feasible due to insufficient equipment, staff, and expertise. Therefore, in these areas spinal hypotension remains an important cause of maternal and fetal morbidity and mortality. Translational, context-sensitive research in resource-limited settings has shown promise in implementing pragmatic strategies based on research from resource-rich environments. We review the current best practice for the prevention and treatment of spinal hypotension, with a special emphasis on effective strategies in resource-limited settings. We further suggest a research agenda to address the knowledge gap in specific contexts.
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Affiliation(s)
- Dominique van Dyk
- D23 Department of Anaesthesia and Perioperative Medicine, University of Cape Town, Groote Schuur Hospital, Anzio Road, Observatory 7925, Cape Town, South Africa.
| | - Robert A Dyer
- D23 Department of Anaesthesia and Perioperative Medicine, University of Cape Town, Groote Schuur Hospital, Anzio Road, Observatory 7925, Cape Town, South Africa.
| | - David G Bishop
- Department of Anaesthesiology and Critical Care, University of KwaZulu-Natal, South Africa; Department of Anaesthesia, Critical Care and Pain Management, University of KwaZulu-Natal, Grey's Hospital, Town Bush Road, Pietermaritzburg, 3201, South Africa.
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Norepinephrine versus phenylephrine infusion for preventing postspinal hypotension during cesarean section for twin pregnancy: a double-blinded randomized controlled clinical trial. BMC Anesthesiol 2022; 22:17. [PMID: 34998371 PMCID: PMC8742356 DOI: 10.1186/s12871-022-01562-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 12/31/2021] [Indexed: 02/08/2023] Open
Abstract
Background Compared with singleton pregnancy, twin gestation is featured by a greater increase in cardiac output. Therefore, norepinephrine might be more suitable than phenylephrine for maintaining blood pressure during cesarean section for twins, as phenylephrine causes reflex bradycardia and a resultant decrease in cardiac output. This study was to determine whether norepinephrine was superior to phenylephrine in maintaining maternal hemodynamics during cesarean section for twins. Methods Informed consent was obtained from all the patients before enrollment. In this double-blinded, randomized clinical trial, 100 parturients with twin gestation undergoing cesarean section with spinal anesthesia were randomized to receive prophylactic norepinephrine (3.2 μg/min) or phenylephrine infusion (40 μg/min). The primary outcome was the change of heart rate and blood pressure during the study period. The secondary outcomes were to compare maternal complications, neonatal outcomes, Apgar scores and umbilical blood acid-base status between the two vasopressors. Results There was no significant difference observed for the change of heart rate between two vasopressors. The mean standardized area under the curve of heart rate was 78 ± 12 with norepinephrine vs. 74 ± 11 beats/min with phenylephrine (mean difference 4.4, 95%CI − 0.1 to 9.0; P = .0567). The mean standardized area under the curve of systolic blood pressure (SBP) was significantly lower in parturients with norepinephrine, as the mean of differences in standardized AUC of SBP was 6 mmHg, with a 95% CI from 2 to 9 mmHg (P = .0013). However, requirements of physician interventions for correcting maternal hemodynamical abnormalities (temporary cessation of vasopressor infusion for reactive hypertension, rescuing vasopressor bolus for hypotension and atropine for heart rate less < 50 beats/min) and neonatal outcomes were also not significantly different between two vasopressors. Conclusion Infusion of norepinephrine was not associated with less overall decrease in heart rate during cesarean section for twins, compared with phenylephrine. Trial registration Chinese Clinical Trial Registry (ChiCTR1900021281).
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Nagarajan S, Chan JJI, Tan CW, Al-Hashim ZGA, Sultana R, Sia ATH, Sng BL. An advanced double intravenous vasopressor automated system to treat hypotension during spinal anaesthesia for caesarean section: A pilot study. Eur J Anaesthesiol 2022; 39:42-49. [PMID: 33831901 DOI: 10.1097/eja.0000000000001496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND During spinal anaesthesia for caesarean section, haemodynamic instability may lead to maternal and foetal complications. We developed a novel advanced double intravenous vasopressor automated system (ADIVA) by using a continuous blood pressure and heart rate monitor. Treatment of hypotension was based on three criteria: the drug (phenylephrine or ephedrine) according to the heart rate; the dose of vasopressor determined by the degree of hypotension; a fast or slow bolus of vasopressor administered depending on whether there was a negative or positive gradient of SBP changes, respectively. OBJECTIVE The aim of this pilot study was to investigate the feasibility of the ADIVA algorithm. DESIGN A prospective pilot study. SETTING Single obstetrics and gynaecology centre in Singapore. PATIENTS Women undergoing elective caesarean delivery under spinal anaesthesia. INTERVENTION Automated administration of ephedrine or phenylephrine based on changes in blood pressure and heart rate (via the ADIVA algorithm) detected on continuous noninvasive haemodynamic monitoring using noninvasive continuous haemodynamic monitor (Nexfin). MAIN OUTCOME MEASURES The primary outcome was the incidence of hypotension, defined as SBP less than 80% of baseline. The secondary outcome measures were reactive hypertension, total vasopressor requirement, maternal and neonatal outcomes and system performance. RESULTS Forty-five women were recruited. Thirty-one women (69.9%) had at least one reading of hypotension. SBP was within ±20% of the baseline in a mean ± SD of 79.7 ± 17.6% of measurements. Forty-four (97.8%) women required phenylephrine before delivery, while 15 (33.3%) required ephedrine. No rescue medications were required. Three women (6.7%) had nausea and two (4.4%) vomiting. All neonates had APGAR scores of 9 at 5 min. CONCLUSION The ADIVA system, with noninvasive continuous haemodynamic monitoring, was able to maintain maternal SBP within ±20% of baseline for the vast majority of the measurements. This system had good maternal and foetal outcomes with minimal intervention from the attending anaesthetist. TRIAL REGISTRATION NCT03620942.
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Affiliation(s)
- Singaraselvan Nagarajan
- From the Department of Women's Anaesthesia, KK Women's and Children's Hospital (SN, JJIC, CWT, ZGAAH, AT, BLS), Duke-NUS Medical School (SN, JJIC, CWT, AT, BLS), and Centre for Quantitative Medicine, Duke-NUS Medical School, Singapore, Singapore (RS)
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Mohta M, Bambode N, Chilkoti GT, Agarwal R, Malhotra RK, Batra P. Neonatal outcomes following phenylephrine or norepinephrine for treatment of spinal anaesthesia-induced hypotension at emergency caesarean section in women with fetal compromise - a randomised controlled study. Int J Obstet Anesth 2021; 49:103247. [PMID: 35012812 DOI: 10.1016/j.ijoa.2021.103247] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 10/24/2021] [Accepted: 12/12/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Norepinephrine is as effective as phenylephrine for management of spinal anaesthesia-induced hypotension. Most of the studies comparing these vasopressors have been conducted in healthy pregnant women undergoing elective caesarean section. In the current study, we tested the null hypothesis that there is no difference in neonatal outcome when phenylephrine or norepinephrine is used to treat spinal anaesthesia-induced hypotension in women undergoing emergency caesarean section for fetal compromise. METHODS Patients undergoing caesarean section for fetal compromise who developed spinal anaesthesia-induced hypotension were randomised to receive phenylephrine 100 μg or norepinephrine 8 μg for treatment of each hypotensive episode, defined as systolic blood pressure <100 mmHg. Umbilical cord arterial and venous blood samples were obtained for blood gas analysis. The primary outcome measure was umbilical artery pH. RESULTS One hundred patients (50 in each group) were studied. There was no significant difference in umbilical artery pH between the two groups (mean difference 0.001; 95% CI -0.032 to 0.034). The number of hypotensive episodes, vasopressor boluses required, the incidence of bradycardia, heart rate and blood pressure trends following vasopressor administration, and the incidence of nausea/vomiting were not significantly different between groups. CONCLUSION Phenylephrine 100 μg and norepinephrine 8 μg were not significantly different in terms of neonatal outcome when administered as intravenous boluses for treatment of spinal anaesthesia-induced hypotension in parturients undergoing emergency caesarean sections for fetal compromise.
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Affiliation(s)
- M Mohta
- Department of Anaesthesiology and Critical Care, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi, India.
| | - N Bambode
- Department of Anaesthesiology and Critical Care, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi, India
| | - G T Chilkoti
- Department of Anaesthesiology and Critical Care, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi, India
| | - R Agarwal
- Department of Obstetrics and Gynaecology, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi, India
| | - R K Malhotra
- Delhi Cancer Registry, Dr. BRA IRCH, All India Institute of Medical Sciences, Delhi, India
| | - P Batra
- Department of Paediatrics, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi, India
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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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Chen Y, Zou L, Li Z, Guo L, Xue W, He L, Ma S, Ni X. Prophylactic norepinephrine infusion for postspinal anesthesia hypotension in patients undergoing cesarean section: A randomized, controlled, dose-finding trial. Pharmacotherapy 2021; 41:370-378. [PMID: 33583066 DOI: 10.1002/phar.2514] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Revised: 01/19/2021] [Accepted: 01/23/2021] [Indexed: 11/10/2022]
Abstract
STUDY OBJECTIVE Prophylactic norepinephrine infusion effectively lowers the incidence of postspinal anesthesia hypotension. The optimal prophylactic dose of norepinephrine remains undefined. The purpose of this study was to investigate the optimal prophylactic dose of norepinephrine to prevent postspinal anesthesia hypotension in patients undergoing cesarean section. DESIGN Prospective, double-blind, randomized, controlled, dose-finding trial. SETTING Operating room from March 2020 to June 2020. PATIENTS Ninety nine primipara or multipara women 18 - 40 years of age, singleton pregnancy ≥ 37 weeks, American Society of Anesthesiologists' physical status 1 or 2, scheduled for elective cesarean section under spinal anesthesia were included in this study. INTERVENTION Patients were randomly assigned into groups to receive normal saline (NS) or one of four different prophylactic doses (0.025 [NE25], 0.05 [NE50], 0.075 [NE75], and 0.1 [NE100] ug/kg/min) of norepinephrine. The primary end point was the incidence of postspinal anesthesia hypotension (systolic blood pressure [SBP] < 80% of baseline) within 15 min after spinal anesthesia. Secondary outcomes included the overall stability of SBP control versus baseline (median performance error [MDPE] and median absolute performance error [MDAPE]), the dose that would be effective in preventing postspinal anesthesia hypotension in 50% (effective dose, ED 50) and 90% (ED90) of patients, other adverse events (bradycardia, nausea, vomiting, hypertension, and the total additional bolus of norepinephrine and atropine), and neonatal outcomes (blood gas values and Apgar scores). MEASUREMENTS AND MAIN RESULTS The incidence of postspinal anesthesia hypotension in NS, NE25, NE50, NE75, and NE100 groups was 68.42% (13/19), 40.00% (8/20), 20.00% (4/20), 15.00% (3/20), and 10.00% (2/20), respectively. With increasing prophylactic doses of norepinephrine, the incidence of postspinal anesthesia hypotension decreased (p < 0.001), SBP was maintained closer to the baseline (MDPE, p < 0.001; MDAPE, p = 0.001), and the total additional bolus of norepinephrine decreased (p < 0.001). The ED50 and ED90 values of norepinephrine were 0.016 (95% CI: -0.014 - 0.033) and 0.088 (95% CI: 0.068 - 0.133) ug/kg/min, respectively. Other adverse effects, neonatal outcomes, and the total additional bolus of atropine did not differ among the five groups. CONCLUSIONS A prophylactic dose of 0.05 or 0.075 μg/kg/min norepinephrine prevents postspinal anesthesia hypotension in patients undergoing cesarean section.
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Affiliation(s)
- Yi Chen
- Department of Anesthesiology, General Hospital of Ningxia Medical University, Yinchuan, Ningxia, China
| | - Lili Zou
- Department of Anesthesiology, General Hospital of Ningxia Medical University, Yinchuan, Ningxia, China
| | - Zhenzhou Li
- Department of Anesthesiology, General Hospital of Ningxia Medical University, Yinchuan, Ningxia, China
| | - Lei Guo
- Department of Anesthesiology, General Hospital of Ningxia Medical University, Yinchuan, Ningxia, China
| | - Wei Xue
- Department of Obstetrics, General Hospital of Ningxia Medical University, Yinchuan, Ningxia, China
| | - Ling He
- Department of Obstetrics, General Hospital of Ningxia Medical University, Yinchuan, Ningxia, China
| | - Shuqin Ma
- Department of Obstetrics, General Hospital of Ningxia Medical University, Yinchuan, Ningxia, China
| | - Xinli Ni
- Department of Anesthesiology, General Hospital of Ningxia Medical University, Yinchuan, Ningxia, China
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Wang Y, Yang Z, Zhang W. Comparison of Continuous Infusion of Epinephrine and Phenylephrine on Hemodynamics During Spinal Anesthesia for Cesarean Delivery: A Randomized Controlled Trial. Clin Ther 2020; 42:2001-2009. [DOI: 10.1016/j.clinthera.2020.08.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 08/06/2020] [Accepted: 08/07/2020] [Indexed: 11/24/2022]
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Norepinephrine or phenylephrine during spinal anaesthesia for Caesarean delivery: a randomised double-blind pragmatic non-inferiority study of neonatal outcome. Br J Anaesth 2020; 125:588-595. [DOI: 10.1016/j.bja.2020.05.057] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 05/19/2020] [Accepted: 05/20/2020] [Indexed: 11/20/2022] Open
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Ferré F, Martin C, Bosch L, Kurrek M, Lairez O, Minville V. Control of Spinal Anesthesia-Induced Hypotension in Adults. Local Reg Anesth 2020; 13:39-46. [PMID: 32581577 PMCID: PMC7276328 DOI: 10.2147/lra.s240753] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 03/27/2020] [Indexed: 12/19/2022] Open
Abstract
Spinal anesthesia-induced hypotension (SAIH) occurs frequently, particularly in the elderly and in patients undergoing caesarean section. SAIH is caused by arterial and venous vasodilatation resulting from the sympathetic block along with a paradoxical activation of cardioinhibitory receptors. Bradycardia after spinal anesthesia (SA) must always be treated as a warning sign of an important hemodynamic compromise. Fluid preloading (before initiation of the SA) with colloids such as hydroxyethyl starch (HES) effectively reduces the incidence and severity of arterial hypotension, whereas crystalloid preloading is not indicated. Co-loading with crystalloid or colloid is as equally effective to HES preloading, provided that the speed of administration is adequate (ie, bolus over 5 to 10 minutes). Ephedrine has traditionally been considered the vasoconstrictor of choice, especially for use during SAIH associated with bradycardia. Phenylephrine, a α1 adrenergic receptor agonist, is increasingly used to treat SAIH and its prophylactic administration (ie, immediately after intrathecal injection of local anesthetics) has been shown to decrease the incidence of arterial hypotension. The role of norepinephrine as a possible alternative to phenylephrine seems promising. Other drugs, such as serotonin receptor antagonists (ondansetron), have been shown to limit the blood pressure drop after SA by inhibiting the Bezold–Jarisch reflex (BJR), but further studies are needed before their widespread use can be recommended.
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Affiliation(s)
- Fabrice Ferré
- Department of Anesthesia and Intensive Care Medicine, CHU Purpan, Toulouse, France
| | - Charlotte Martin
- Department of Anesthesia and Intensive Care Medicine, CHU Purpan, Toulouse, France
| | - Laetitia Bosch
- Department of Anesthesia and Intensive Care Medicine, CHU Purpan, Toulouse, France
| | - Matt Kurrek
- Department of Anesthesia and Intensive Care Medicine, CHU Purpan, Toulouse, France.,Department of Anesthesia, University of Toronto, Toronto, ON M5S 3E2, Canada
| | - Olivier Lairez
- Department of Nuclear Medicine, Toulouse University Hospital, Toulouse Cedex 9 31059, France.,Department of Cardiology, Toulouse University Hospital, Toulouse Cedex 9 31059, France
| | - Vincent Minville
- Department of Anesthesia and Intensive Care Medicine, CHU Purpan, Toulouse, France
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