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Porsche R, Steinhardt F, Knoerlein J, Schick MA. Phenylephrine versus cafedrine/theodrenaline (Akrinor) for the treatment of spinal anaesthesia-induced maternal hypotension during caesarean section: a retrospective single-centre cohort study. BMJ Open 2022; 12:e062512. [PMID: 36385024 PMCID: PMC9670961 DOI: 10.1136/bmjopen-2022-062512] [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] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE The main objective of this study was to assess the impact of phenylephrine and cafedrine/theodrenaline on the mother and newborn after spinal anaesthesia for caesarean section. SETTING University teaching hospital. DESIGN A single-centre retrospective data cohort study. PATIENTS All obstetric patients who were scheduled for caesarean section in a 2-year period. INTERVENTIONS Administration of either intravenous phenylephrine prophylactically or cafedrine/theodrenaline (Akrinor) reactively to maintain blood pressure after spinal anaesthesia. MAIN OUTCOME MEASURE Maternal hypotension, heart rate during caesarean section and after admission to IMC, fetal arterial cord pH and base excess levels, maternal volume resuscitation and the use of rescue medication. RESULTS 852 data sets could be included: n=440 Akrinor, n=412 in the phenylephrine cohort. During caesarean section blood pressure was slightly higher in the phenylephrine group compared with the Akrinor group, while hypotension <100 mm Hg systolic blood pressure (SBP) occurred significantly more often during arrival at the IMC after surgery when phenylephrine was used. Heart rate was lower and rescue medication was significantly more frequently given in the phenylephrine cohort. Irrespective of the medication used, women with baseline levels of <120 mm Hg SBP had a high risk to develop hypotension <100 mm Hg after spinal anaesthesia for caesarean section. While there was no statistical difference in mean umbilical arterial pH levels, the incidence of acidosis, defined as pH <7.2, was significantly higher with phenylephrine. CONCLUSION Phenylephrine was not superior to Akrinor to treat spinal anaesthesia-induced maternal hypotension during caesarean section. TRIAL REGISTRATION NUMBER DRKS00025795.
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Affiliation(s)
- Raphael Porsche
- Department of Anesthesiology and Critical Care, Medical Center-University of Freiburg, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Frederic Steinhardt
- Department of Anesthesiology and Critical Care, Medical Center-University of Freiburg, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Julian Knoerlein
- Department of Anesthesiology and Critical Care, Medical Center-University of Freiburg, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Martin Alexander Schick
- Department of Anesthesiology and Critical Care, Medical Center-University of Freiburg, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Double-blinded, placebo-controlled crossover trial to determine the effects of midodrine on blood pressure during cognitive testing in persons with SCI. Spinal Cord 2020; 58:959-969. [PMID: 32203065 PMCID: PMC7483245 DOI: 10.1038/s41393-020-0448-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 02/19/2020] [Accepted: 02/24/2020] [Indexed: 12/19/2022]
Abstract
Study Design: Clinical trial. Objectives: Individuals with spinal cord injury (SCI) above T6 experience impaired descending cortical control of the autonomic nervous system which predisposes them to hypotension. However, treatment of hypotension is uncommon in the SCI population because there are few safe and effective pharmacological options available. The primary aim of this investigation was to test the efficacy of a single dose of midodrine (10 mg), compared to placebo, to increase and normalize systolic blood pressure (SBP) between 110–120 mmHg during cognitive testing in hypotensive individuals with SCI. Secondary aims were to determine the effects of midodrine on cerebral blood flow velocity (CBFv) and global cognitive function. Setting: United States clinical research laboratory. Methods: Forty-one healthy hypotensive individuals with chronic (≥ 1-year post-injury) SCI participated in this 2-day study. Seated SBP, CBFv, cognitive performance were monitored before and after administration of identical encapsulated tablets, containing either midodrine or placebo. Results: Compared to placebo, midodrine increased SBP (4±13 vs. 18±24 mmHg, respectively; p<0.05); however, responses varied widely with midodrine (−15.7 to +68.6 mmHg). Further, the proportion of SBP recordings within the normotensive range did not improve during cognitive testing with midodrine compared to placebo. Although higher SBP was associated with higher CBFv (p=0.02), global cognitive function was not improved with midodrine. Conclusions: The findings indicate that midodrine increases SBP and may be beneficial in some hypotensive patients with SCI; however, large heterogeneity of responses to midodrine suggest careful monitoring of patients following administration.
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Rüsch D, Arndt C, Eberhart L, Tappert S, Nageldick D, Wulf H. Bispectral index to guide induction of anesthesia: a randomized controlled study. BMC Anesthesiol 2018; 18:66. [PMID: 29902969 PMCID: PMC6003112 DOI: 10.1186/s12871-018-0522-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Accepted: 05/22/2018] [Indexed: 02/07/2023] Open
Abstract
Background It is unknown to what extent hypotension frequently observed following administration of propofol for induction of general anesthesia is caused by overdosing propofol. Unlike clinical signs, electroencephalon-based cerebral monitoring allows to detect and quantify an overdose of hypnotics. Therefore, we tested whether the use of an electroencephalon-based cerebral monitoring will cause less hypotension following induction with propofol. Methods Subjects were randomly assigned to a bispectral index (BIS)-guided (target range 40–60) or to a weight-related (2 mg.kg− 1) manual administration of propofol for induction of general anesthesia. The primary endpoint was the incidence of hypotension following the administration of propofol. Secondary endpoints included the degree of hypotension and correlations between BIS and drop in mean arterial pressure (MAP). Incidences were analyzed with Fisher’s Exact-test. Results Of the 240 patients enrolled into this study, 235 predominantly non-geriatric (median 48 years, 25th – 75th percentile 35–61 years) patients without severe concomitant disease (88% American Society of Anesthesiology physical status 1–2) undergoing ear, nose and throat surgery, ophthalmic surgery, and dermatologic surgery were analyzed. Patients who were manually administered propofol guided by BIS (n = 120) compared to those who were given propofol by weight (n = 115) did not differ concerning the incidence of hypotension (44% vs. 45%; p = 0.87). Study groups were also similar regarding the maximal drop in MAP compared to baseline (33% vs. 30%) and the proportion of hypotensive events related to all measurements (17% vs. 19%). Final propofol induction doses in BIS group and NON-BIS group were similar (1.93 mg/kg vs. 2 mg/kg). There was no linear correlation between BIS and the drop in MAP at all times (r < 0.2 for all) except for a weak one at 6 min (r = 0.221). Conclusion Results of our study suggest that a BIS-guided compared to a weight-adjusted manual administration of propofol for induction of general anesthesia in non-geriatric patients will not lower the incidence and degree of arterial hypotension. Trial registration German Registry of Clinical Trials (DRKS00010544), retrospectively registered on August 4, 2016. Electronic supplementary material The online version of this article (10.1186/s12871-018-0522-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Dirk Rüsch
- Department of Anesthesia and Intensive Care, University Hospital Giessen-Marburg, Marburg Campus, Baldingerstraße, 35033, Marburg, Germany.
| | - Christian Arndt
- Department of Anesthesia and Intensive Care, University Hospital Giessen-Marburg, Marburg Campus, Baldingerstraße, 35033, Marburg, Germany
| | - Leopold Eberhart
- Department of Anesthesia and Intensive Care, University Hospital Giessen-Marburg, Marburg Campus, Baldingerstraße, 35033, Marburg, Germany
| | - Scarlett Tappert
- Department of Anesthesia and Intensive Care, University Hospital Giessen-Marburg, Marburg Campus, Baldingerstraße, 35033, Marburg, Germany
| | - Dennis Nageldick
- Department of Anesthesia and Intensive Care, University Hospital Giessen-Marburg, Marburg Campus, Baldingerstraße, 35033, Marburg, Germany
| | - Hinnerk Wulf
- Department of Anesthesia and Intensive Care, University Hospital Giessen-Marburg, Marburg Campus, Baldingerstraße, 35033, Marburg, Germany
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Nguyen NQ, Toscano L, Lawrence M, Phan VA, Singh R, Bampton P, Fraser RJ, Holloway RH, Schoeman MN. Portable inhaled methoxyflurane is feasible and safe for colonoscopy in subjects with morbid obesity and/or obstructive sleep apnea. Endosc Int Open 2015; 3:E487-93. [PMID: 26528506 PMCID: PMC4612230 DOI: 10.1055/s-0034-1392366] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Accepted: 05/07/2015] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND AND STUDY AIMS Colonoscopy with inhaled methoxyflurane (Penthrox) is well tolerated in unselected subjects and is not associated with respiratory depression. The aim of this prospective study was to compare the feasibility, safety, and post-procedural outcomes of portable methoxyflurane used as an analgesic agent during colonoscopy with those of anesthesia-assisted deep sedation (AADS) in subjects with morbid obesity and/or obstructive sleep apnea (OSA). PATIENTS AND METHODS The outcomes of 140 patients with morbid obesity/OSA who underwent colonoscopy with either Penthrox inhalation (n = 85; 46 men, 39 women; mean age 57.2 ± 1.1 years) or AADS (n = 55; 27 men, 28 women; mean age, 54.9 ± 1.1 years) were prospectively assessed. RESULTS All Penthrox-assisted colonoscopies were successful, without any requirement for additional intravenous sedation. Compared with AADS, Penthrox was associated with a shorter total procedural time (24 ± 1 vs. 52 ± 1 minutes, P < 0.001), a lower incidence of hypotension (3 /85 vs. 23 /55, P < 0.001), and a lower incidence of respiratory desaturation (0 /85 vs. 14 /55, P < 0.001). The patients in the Penthrox group recovered more rapidly and were discharged much earlier than those in the AADS group (27 ± 2 vs. 97 ± 5 minutes, P < 0.0001). Of those who underwent colonoscopy with Penthrox, 90 % were willing to receive Penthrox again for colonoscopy. More importantly, of the patients who underwent colonoscopy with Penthrox and had had AADS for previous colonoscopy, 82 % (28 /34) preferred to receive Penthrox for future colonoscopies. Penthrox-assisted colonoscopy cost significantly less than colonoscopy with AADS ($ 332 vs. $ 725, P < 0.001), with a cost saving of approximately $ 400 for each additional complication avoided. CONCLUSIONS Compared with AADS, Penthrox is highly feasible and safe in patients with morbid obesity/OSA undergoing colonoscopy and is associated with fewer cardiorespiratory complications. Because of the advantages of this approach in regard to procedural time, recovery time, and cost benefit in comparison with AADS, further evaluation in a randomized trial is warranted.
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Affiliation(s)
- Nam Q. Nguyen
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, South Australia, Australia,Corresponding author Nam Q. Nguyen, MD Department of Gastroenterology and HepatologyRoyal Adelaide HospitalNorth TerraceAdelaideSouth Australia, 5000Australia+61-8-8222-5885
| | - Leanne Toscano
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Matthew Lawrence
- Colo-Rectal Surgical Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Vinh-An Phan
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Rajvinder Singh
- Department of Gastroenterology, Lyell McEwin Hospital, Elizabeth Vale, South Australia, Australia
| | - Peter Bampton
- Department of Gastroenterology, Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Robert J. Fraser
- Department of Gastroenterology, Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Richard H. Holloway
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Mark N. Schoeman
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
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Patient-controlled analgesia with inhaled methoxyflurane versus conventional endoscopist-provided sedation for colonoscopy: a randomized multicenter trial. Gastrointest Endosc 2013; 78:892-901. [PMID: 23810328 DOI: 10.1016/j.gie.2013.05.023] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2013] [Accepted: 05/13/2013] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Inhaled methoxyflurane (Penthrox, Medical Device International, Melbourne, Australia) has been used extensively in Australasia (Australia and New Zealand) to manage trauma-related pain. The aim is to evaluate the efficacy, safety, and outcome of Penthrox for colonoscopy. DESIGN Prospective randomized study. SETTING Three tertiary endoscopic centers. PATIENTS Two hundred fifty-one patients were randomized to receive either Penthrox (n = 125, 70 men, 51.4 ± 1.1 years old) or intravenous midazolam and fentanyl (M&F; n = 126, 72 men, 54.9 ± 1.1 years old) during colonoscopy. MAIN OUTCOME MEASUREMENT Discomfort (visual analogue scale [VAS] pain score), anxiety (State-Trait Anxiety Inventory Form Y [STAI-Y] anxiety score), colonoscopy performance, adverse events, and recovery time. RESULTS Precolonoscopy VAS pain and STAI-Y scores were comparable between the 2 groups. There were no differences between groups in (1) pain VAS or STAI Y-1 anxiety scores during or immediately after colonoscopy, (2) procedural success rate (Penthrox: 121/125 vs M&F: 124/126), (3) hypotension during colonoscopy (7/125 vs 8/126), (4) tachycardia (5/125 vs 3/126), (5) cecal arrival time (8 ± 1 vs 8 ± 1 minutes), or (6) polyp detection rate (30/125 vs 43/126). Additional intravenous sedation was required in 10 patients (8%) who received Penthrox. Patients receiving Penthrox alone had no desaturation (oxygen saturation [SaO(2)] < 90%) events (0/115 vs 5/126; P = .03), awoke quicker (3 ± 0 vs 19 ± 1 minutes; P < .001) and were ready for discharge earlier (37 ± 1 vs 66 ± 2 minutes; P < .001) than those receiving intravenous M&F. LIMITATIONS Inhaled Penthrox is not yet available in the United States and Europe. CONCLUSIONS Patient-controlled analgesia with inhaled Penthrox is feasible and as effective as conventional sedation for colonoscopy with shorter recovery time, is not associated with respiratory depression, and does not influence the procedural success and polyp detection.
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Arias J, Lacassie HJ. [Prophylaxis and treatment of arterial hypotension during caesarean with spinal anaesthesia]. ACTA ACUST UNITED AC 2012; 60:511-8. [PMID: 23092743 DOI: 10.1016/j.redar.2012.07.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2012] [Revised: 07/23/2012] [Accepted: 07/29/2012] [Indexed: 11/16/2022]
Abstract
Caesarean section is one of the most common surgical procedures worldwide. Arterial hypotension is the most prevalent adverse effect after spinal anaesthesia. Various methods have been used to prevent or treat hypotension. Since there is no treatment 100% effective by itself, a multimodal management is required to achieve an optimum balance and avoidance of hemodynamic imbalance. Strategies to avoid this side effect are analyzed on the basis of the best evidence available so far, summarized as mechanical factors, anesthetics, fluids and vasopressors. After spinal anaesthesia for caesarean section, the best strategy available for prevention of hypotension appears to be the combination of crystalloids along with an alpha 1 agonist vasopressor.
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Affiliation(s)
- J Arias
- División de Anestesiología, Hospital Dr. José Penna, Bahía Blanca, Provincia de Buenos Aires, Argentina
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Vricella LK, Louis JM, Mercer BM, Bolden N. Epidural-associated hypotension is more common among severely preeclamptic patients in labor. Am J Obstet Gynecol 2012; 207:335.e1-7. [PMID: 23021700 DOI: 10.1016/j.ajog.2012.07.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2012] [Revised: 04/28/2012] [Accepted: 07/18/2012] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To determine whether severe preeclampsia is associated with increased maternal hypotension or fetal heart rate abnormalities after epidural anesthesia placement during labor. STUDY DESIGN Retrospective cohort study of 100 women with severe preeclampsia and 100 normotensive controls who underwent epidural anesthesia during labor from May 2008 to July 2011. Blood pressures during 2-minute time intervals for 20 minutes postepidural were compared with baseline measurements. Fetal heart rate abnormalities and related interventions were evaluated according to study group. RESULTS Severe preeclampsia was associated with a greater percent decrease in blood pressure across all intervals and more episodes of systolic and diastolic hypotension after dosing. Severely preeclamptic women received more intravenous pressor support and developed more Category II fetal heart rate tracings, minimal variability, and late decelerations after dosing. CONCLUSION Severe preeclampsia is associated with more frequent hypotension, need for pressor support, and fetal heart rate abnormalities after epidural anesthesia placement during labor.
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Impact of morbid obesity on epidural anesthesia complications in labor. Am J Obstet Gynecol 2011; 205:370.e1-6. [PMID: 21864821 DOI: 10.1016/j.ajog.2011.06.085] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2011] [Revised: 05/02/2011] [Accepted: 06/22/2011] [Indexed: 11/23/2022]
Abstract
OBJECTIVE We sought to determine whether morbid obesity is associated with increased maternal hypotension or fetal heart rate (FHR) abnormalities after epidural anesthesia placement during labor. STUDY DESIGN This was a retrospective cohort study of women undergoing epidural anesthesia during labor at term from April 2008 through July 2010. RESULTS A total of 125 morbidly obese patients were matched for age and race with 125 normal-weight patients. Morbidly obese patients had more frequent persistent systolic (16% vs 4%, P = .003) and diastolic (49% vs 29%, P = .002) hypotension and more prolonged (16% vs 5%, P = .006) and late (26% vs 14%, P = .03) FHR decelerations. Increasing body mass index was associated with persistent systolic (odds ratio, 1.06; 95% confidence interval, 1.02-1.10) and diastolic (odds ratio, 1.04; 95% confidence interval, 1.01-1.06) hypotension after controlling for epidural bolus dose and hypertensive disorders. CONCLUSION Morbidly obese women have more hypotension and prolonged FHR decelerations following epidural anesthesia during labor at term.
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