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Kazzi NG, Chen HY, Lee L, Nazeer SA, Brown K, Sibai BM, Chauhan SP. Spinal Hypotension and Time from Spinal-to-Delivery in Scheduled Cesarean Deliveries: Association with Neonatal Acidosis. Am J Perinatol 2024; 41:e3091-e3098. [PMID: 37871639 DOI: 10.1055/a-2196-6660] [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: 10/25/2023]
Abstract
OBJECTIVE This work aimed to study the effect of sustained hypotension after spinal on neonatal acidosis and adverse outcomes in those undergoing scheduled cesarean delivery (CD) with universal prophylactic vasopressor exposure and to examine differences in spinal-to-delivery time by neonatal acidosis status. STUDY DESIGN This retrospective cohort study conducted at a quaternary care center from January 2019 to December 2021 included singleton, term, nonanomalous pregnancies, with scheduled CD under spinal anesthesia. Hypotension was defined as a systolic blood pressure (SYS-BP) < 100 mm Hg (SYS-BP100) or a >20% drop from baseline blood pressure (SYS-BP20). Both the occurrence of hypotension and its magnitude and duration were studied; the latter through the development of a hypotension index. The 90th and 95th percentiles of the hypotension index for SYS-BP20 and SYS-BP100, respectively, were used to define sustained hypotension. The primary outcome was neonatal acidosis (umbilical artery pH ≤ 7.1 or base excess ≤ -12 mmol). Secondary outcomes were composites of neonatal (CNAO) and maternal (CMAO) adverse outcomes. Multivariable Poisson regression models with robust error variance analysis was used to estimate adjusted relative risks (aRRs) and 95% confidence intervals (CIs). RESULTS Our study included 332 individuals who underwent scheduled CD; among them 330 (99.4%) received prophylactic vasopressors. The rate of neonatal acidosis was 4.2%. Sustained hypotension after spinal anesthesia, which occurred in 12.3% of the cohort, was associated with increased risk for neonatal acidosis (aRR 3.96, 95% CI 1.21-12.98), but was not associated with CNAO or CMAO. Time from spinal-to-delivery was not different in those with and without neonatal acidosis. CONCLUSION Despite universal exposure to prophylactic vasopressors, sustained hypotension after spinal anesthesia was still associated with neonatal acidosis, but no other adverse perinatal outcomes. Our findings may provide additional support for the adoption of prophylactic vasopressors to reduce spinal hypotension and downstream effects on the neonate from intraoperative hemodynamic instability. KEY POINTS · Despite prophylactic vasopressors during scheduled CD, neonatal acidosis occurred in 4% of subjects.. · Sustained hypotension after spinal anesthesia was associated with neonatal acidosis, but not adverse neonatal outcomes.. · Spinal-to-delivery time was not associated with neonatal acidosis in scheduled CD..
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Affiliation(s)
- Nayla G Kazzi
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Han-Yang Chen
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Linden Lee
- Division of Obstetrical Anesthesiology, Department of Anesthesiology, Kapiolani Medical Center for Women & Children, Hawaii Pacific Health, Honolulu, Hawaii
| | - Sarah A Nazeer
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Kendra Brown
- Division of Obstetrical Anesthesiology, Department of Anesthesiology, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Baha M Sibai
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Suneet P Chauhan
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas
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Hung KC, Liu CC, Huang YT, Wu JY, Chen JY, Ko CC, Lin CM, Hsing CH, Yew M, Chen IW. Predictive Efficacy of the Perfusion Index for Hypotension following Spinal Anesthesia in Parturient Undergoing Elective Cesarean Section: A Systematic Review and Meta-Analysis. Diagnostics (Basel) 2023; 13:2584. [PMID: 37568947 PMCID: PMC10417716 DOI: 10.3390/diagnostics13152584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 08/01/2023] [Accepted: 08/02/2023] [Indexed: 08/13/2023] Open
Abstract
This meta-analysis assessed the predictive efficacy of perfusion index for hypotension following spinal anesthesia (SA) in parturients undergoing elective cesarean section (CS). Electronic databases, including Google Scholar, EMBASE, Cochrane Library, and MEDLINE, were searched from inception to June 2023. The primary outcome was the diagnostic accuracy of the perfusion index in predicting the probability of perioperative hypotension following SA. The review included 12 studies involving 2009 patients, published between 2017 and 2023. The pooled sensitivity and specificity were 0.81 (95% confidence interval (CI) = 0.72-0.87) and 0.75 (95% CI = 0.67-0.82), respectively. Additionally, the pooled area under the curve (AUC) was calculated as 0.84 (95% CI = 0.81-0.87), suggesting a moderate to good accuracy of the diagnostic test. Using Fagan's nomogram plot, the positive likelihood ratio (LR) and negative LR were found to be 3 and 0.26, respectively. The results demonstrated that the perfusion index exhibited an acceptable level of accuracy in predicting perioperative hypotension after spinal anesthesia in parturients undergoing elective CS. These findings highlight the potential value of incorporating a perfusion index as a useful tool for clinicians to integrate into routine clinical practice, which necessitates further large-scale studies for verification.
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Affiliation(s)
- Kuo-Chuan Hung
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City 71004, Taiwan; (K.-C.H.)
| | - Chien-Cheng Liu
- Department of Anesthesiology, E-Da Hospital, I-Shou University, Kaohsiung City 82456, Taiwan
- Department of Nursing, College of Medicine, I-Shou University, Kaohsiung City 82445, Taiwan
- School of Medicine, I-Shou University, Kaohsiung City 82445, Taiwan
| | - Yen-Ta Huang
- Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan City 70101, Taiwan
| | - Jheng-Yan Wu
- Department of Nutrition, Chi Mei Medical Center, Tainan City 71004, Taiwan
| | - Jen-Yin Chen
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City 71004, Taiwan; (K.-C.H.)
| | - Ching-Chung Ko
- Department of Medical Imaging, Chi Mei Medical Center, Tainan City 71004, Taiwan
- Department of Health and Nutrition, Chia Nan University of Pharmacy and Science, Tainan City 71710, Taiwan
| | - Chien-Ming Lin
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City 71004, Taiwan; (K.-C.H.)
| | - Chung-Hsi Hsing
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City 71004, Taiwan; (K.-C.H.)
- Department of Medical Research, Chi Mei Medical Center, Tainan City 71004, Taiwan
| | - Ming Yew
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City 71004, Taiwan; (K.-C.H.)
| | - I-Wen Chen
- Department of Anesthesiology, Chi Mei Medical Center, Liouying, Tainan City 73657, Taiwan
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Pauline A, Arthi K, Parameswari A, Vakamudi M, Manickam A. Prophylactic Fixed-Rate Phenylephrine Versus Norepinephrine Infusion in the Prevention of Post-spinal Anesthesia Hypotension During Cesarean Delivery. Cureus 2023; 15:e41251. [PMID: 37529826 PMCID: PMC10389118 DOI: 10.7759/cureus.41251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/01/2023] [Indexed: 08/03/2023] Open
Abstract
Background Maternal hypotension following spinal anesthesia can be actively countered by the use of vasopressors. Prophylactic infusion of vasopressors with a rescue bolus dosing was observed to be more effective for hemodynamic stability when compared to administering a bolus dose alone. Although phenylephrine is the recommended drug to treat spinal hypotension, many recent studies have focussed on the role of norepinephrine infusions during cesarean section. In this study, we compared prophylactic fixed-rate intravenous infusions of phenylephrine and norepinephrine during cesarean delivery under spinal anesthesia and the requirement of intraoperative provider-administered rescue bolus of phenylephrine needed to overcome post-spinal anesthesia hypotension. Methodology A total of 208 patients undergoing elective cesarean section under spinal anesthesia were randomly assigned to two groups (group P and group N). Group N included 104 patients who received norepinephrine infusion at a rate of 2.5 μg/minute (0.04 μg/kg/minute), and group P included 104 patients who received phenylephrine infusion at a rate of 50 μg/minute (0.8 μg/kg/minute) to treat spinal hypotension. The primary outcome of our study was to compare the reduction in the number and total dose of intraoperative provider-administered rescue bolus of phenylephrine needed to maintain systolic blood pressure. The secondary outcome of our study was to compare the neonatal outcome using umbilical venous blood gas sampling and Apgar score at one and five minutes. Results The total number of phenylephrine rescue bolus required to treat hypotension was significantly lower in group N (p = 0.0005) compared to group P. The neonatal outcome was similar between the two groups. Conclusions Prophylactic norepinephrine infusion when compared to prophylactic phenylephrine infusion is associated with a lesser requirement of rescue phenylephrine boluses.
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Affiliation(s)
- Anisha Pauline
- Anesthesiology, Sri Ramachandra Institute of Higher Education and Research, Chennai, IND
| | - K Arthi
- Anesthesiology, Sri Ramachandra Institute of Higher Education and Research, Chennai, IND
| | - Aruna Parameswari
- Anesthesiology, Sri Ramachandra Institute of Higher Education and Research, Chennai, IND
| | - Mahesh Vakamudi
- Anesthesiology, Sri Ramachandra Institute of Higher Education and Research, Chennai, IND
| | - Akilandeswari Manickam
- Anesthesiology, Sri Ramachandra Institute of Higher Education and Research, Chennai, IND
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Belin O, Casteres C, Alouini S, Le Pape M, Dupont A, Boulain T. Manually Controlled, Continuous Infusion of Phenylephrine or Norepinephrine for Maintenance of Blood Pressure and Cardiac Output During Spinal Anesthesia for Cesarean Delivery: A Double-Blinded Randomized Study. Anesth Analg 2023; 136:540-550. [PMID: 36279409 DOI: 10.1213/ane.0000000000006244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND To counteract the vasoplegia induced by spinal anesthesia (SA) and maintain blood pressure (BP) during cesarean delivery, phenylephrine is currently recommended, but norepinephrine might offer superior preservation of cardiac output. We aimed to compare the hemodynamic effects of phenylephrine and norepinephrine administered by manually adjusted continuous infusion during elective cesarean delivery. METHODS In this pragmatic, parallel-group, double-blind randomized controlled trial, 124 parturients scheduled for elective cesarean delivery under SA in a tertiary maternity in France, between February 2019 and December 2020, were randomized to receive norepinephrine at a starting rate of 0.05 μg·kg -1 ·min -1 (n = 62) or phenylephrine at a starting rate of 0.5 μg·kg -1 ·min -1 (n = 62). In both groups, the vasopressor infusion rate was then manually adjusted to maintain maternal systolic BP above 90% of the baseline value. The primary outcome, the change in cardiac index (CI) measured by thoracic bioreactance from SA to umbilical cord clamping, was analyzed through repeated measures analysis of variance and post hoc t tests. Secondary outcomes included maternal BP and neonatal outcomes. RESULTS In the norepinephrine group, cardiac index was maintained between 90% and 100% of baseline from SA to umbilical cord clamping, whereas it was maintained at significantly lower values (81%-88%) in the phenylephrine group ( P = .001). The percentage of elapsed time with a mean maternal BP <65 mm Hg and with systolic BP <80% of the baseline value was higher in the phenylephrine group: 2.9% (7.3) vs 0.5% (1.8) (absolute risk difference [ARD], -2.4%; 95% confidence interval, -4.4 to -0.5; P = .012) and 8.5% (16.6) vs 2.3% (5.2) (ARD, -6.2%; 95% confidence interval, -10.6 to -1.8; P = .006). Excluding parturients with gestational diabetes, severe neonatal hypoglycemia was more common in the phenylephrine group at 19.6% (9/46) vs 4.1% (2/49) ( P = .02). The other neonatal outcomes did not differ significantly between the groups. CONCLUSIONS When administered by manually adjusted infusion during SA for cesarean delivery, norepinephrine was associated with a higher CI; both infusions were effective for maintaining BP.
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Affiliation(s)
| | | | | | | | | | - Thierry Boulain
- Medical Intensive Care Unit, Centre Hospitalier Régional d'Orléans, Orléans, France
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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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Liu P, He H, Zhang SS, Liang Y, Gao ZJ, Yuan H, Dong BH. Comparative efficacy and safety of prophylactic norepinephrine and phenylephrine in spinal anesthesia for cesarean section: A systematic review and meta-analysis with trial sequential analysis. Front Pharmacol 2022; 13:1015325. [DOI: 10.3389/fphar.2022.1015325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 11/07/2022] [Indexed: 11/29/2022] Open
Abstract
Background: Phenylephrine is the first-line drug used to maintain blood pressure in cesarean delivery. However, it poses a high risk of bradycardia and depression of cardiac activity in pregnant women. Consequently, norepinephrine has gained popularity over the recent years, as an alternative to Phenylephrine because it is thought that prophylactic use of vasopressors may reduce the incidence of hypotension after spinal anesthesia. This systematic review compared the efficacy of both treatments.Methods: We searched the following databases; CNKI, PubMed, Embase, Web of science, clinicaltrials.gov, Medline and Cochrane Library, for randomized controlled trials comparing the prophylactic efficacy of norepinephrine and phenylephrine on elective cesarean delivery under spinal anesthesia. The search period was from inception to July 2022, and the primary outcome indicator was incidence of bradycardia. Statistical analysis was conducted on Rev manager 5.4, and the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework was used to evaluate the quality of evidence from each main finding.Results: A total of 12 papers were included in the analysis. The incidence of bradycardia (RR = 0.37, 95% CI: 0.28 to 0.49, p < 0.00001) and reactive hypertension (RR = 0.58, 95% CI 0.40 to 0.83, p = 0.003) was significantly lower in the norepinephrine (NE) group compared with the phenylephrine (PE) category. In contrast, there were no statistical differences in the umbilical cord blood gas analysis pH values between the groups (arterial: MD = 0.00, 95% CI −0.00 to 0.01, p = 0.22, vein: MD = 0.01, 95% CI −0.00 to 0.02, p = 0.06). The incidence of hypotension, nausea, and vomiting did not differ significantly between the NE and PE groups (hypotension: 23% vs. 18%; nausea: 14% vs. 18%; vomiting: 5% vs. 7%, respectively).Conclusion: Prophylactic use of norepinephrine is safe and effective in maintaining maternal hemodynamics without causing adverse events to either the pregnant woman or fetus.Systematic Review Registration: website https://www.crd.york.ac.uk/prospero/, identifier CRD42022347095
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Huang Q, Wen G, Hai C, Zheng Z, Li Y, Huang Z, Huang B. A Height-Based Dosing Algorithm of Bupivacaine in Spinal Anesthesia for Decreasing Maternal Hypotension in Cesarean Section Without Prophylactic Fluid Preloading and Vasopressors: A Randomized-Controlled Non-Inferiority Trial. Front Med (Lausanne) 2022; 9:858115. [PMID: 35755061 PMCID: PMC9226673 DOI: 10.3389/fmed.2022.858115] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 05/02/2022] [Indexed: 11/13/2022] Open
Abstract
Background There is a high incidence of maternal hypotension in spinal anesthesia for cesarean section. The aim of the study is to investigate whether there is a height-based dosing algorithm of bupivacaine that provides adequate anesthesia with less maternal hypotension. Methods There were 2 groups of 280 parturients who did not receive prophylactic fluid preloading: Test and Conventional group. In Test group, a height based dosing algorithm was used to confirm the dose of bupivacaine in parturients without prophylactic vasopressors. In the Conventional group, a constant dose of bupivacaine was used. The complications and quality of anesthesia were evaluated. Results In the Conventional group, the shorter participants had higher incidence of hypotension, faster sensory block time, and more participants with complete motor block (p = 0.030, 2.957 × 10-14, and 0.012). In the Test group, the incidence of hypotension, sensory block time, and number of participants with complete motor block did not change with height (p = 0.199, 0.617, and 0.209). The height-based dosing algorithm of bupivacaine decreased the incidence of hypotension (p = 0.004), induced lower sensory block level and less degree of motor block (p = 3.513 × 10-7 and 5.711 × 10-11). The quality of analgesia, quality of muscle relaxation, and degree of intraoperative comfort were similar in both groups (p = 0.065, 0.498, and 0.483). Conclusions The height influences the dose of bupivacaine in spinal anesthesia; without prophylactic fluid pre-loading and vasopressors, the height-based dosing algorithm of bupivacaine is suitable, and meets the cesarean section' requirement with less maternal hypotension. Clinical Trial Registration www.ClinicalTrials.gov, identifier: NCT03497364.
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Affiliation(s)
- Qiang Huang
- Department of Anesthesiology, ShenZhen People's Hospital, Second Clinical Medical College of Jinan University, Shenzhen, China
| | - Gengzhi Wen
- Department of Anesthesiology, Shenzhen Traditional Chinese Medicine Hospital, The Fourth Clinical Medical College of Guangzhou University of Chinese Medicine, Shenzhen, China
| | - Chao Hai
- Department of Anesthesiology, ShenZhen People's Hospital, Second Clinical Medical College of Jinan University, Shenzhen, China
| | - Zihao Zheng
- Department of Anesthesiology, ShenZhen People's Hospital, Second Clinical Medical College of Jinan University, Shenzhen, China
| | - Yali Li
- Department of Anesthesiology, ShenZhen People's Hospital, Second Clinical Medical College of Jinan University, Shenzhen, China
| | - Zengping Huang
- Department of Anesthesiology, Shenzhen Traditional Chinese Medicine Hospital, The Fourth Clinical Medical College of Guangzhou University of Chinese Medicine, Shenzhen, China
| | - Bowan Huang
- Department of Anesthesiology, Shenzhen Traditional Chinese Medicine Hospital, The Fourth Clinical Medical College of Guangzhou University of Chinese Medicine, Shenzhen, China
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Magawa S, Nii M, Sakakura Y, Enomoto N, Takakura S, Maki S, Tanaka H, Kondo E, Ikeda T. Appropriate Method of Administering Vasopressors for Maternal Hypotension Associated with Combined Spinal Epidural Anesthesia in Elective Cesarean Section: Impact on Postnatal Respiratory Support for Newborns. Medicina (B Aires) 2022; 58:medicina58030403. [PMID: 35334579 PMCID: PMC8950217 DOI: 10.3390/medicina58030403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 03/03/2022] [Accepted: 03/04/2022] [Indexed: 11/16/2022] Open
Abstract
Background and Objectives: Vasopressors are used for treating maternal hypotension. However, the appropriate administration method and effects on newborns have not been reported. We evaluated maternal blood pressure fluctuation and neonatal findings in patients who received continuous vasopressor administration during elective cesarean sections and those who received bolus vasopressor administration upon onset of hypotension. Materials and Methods: We retrospectively analyzed the data of 220 patients scheduled for elective cesarean delivery under spinal anesthesia at Mie University Hospital between April 2017 and March 2021. The patients were classified according to the method of vasopressor administration. Maternal information, intraoperative maternal blood pressure fluctuation, and neonatal findings were examined. A multiple regression analysis was performed for the administration of postpartum neonatal respiratory support using maternal background information and other variables related to blood pressure changes as independent variables. Results: The Continuous group and the Bolus group were composed of 98 and 122 patients, respectively. No difference was observed in maternal background information between the groups. Significant changes were noted in several blood pressure parameters between both groups. As for neonatal parameters, newborns of Bolus group patients had lower pO2, 1 min and 5 min Apgar scores, and required more respiratory support than those of Continuous group patients. In the multiple regression analysis, the groups and maternal post-anesthesia diastolic blood pressure variability were considered explanatory variables. Conclusions: Maternal hypotension and the need for neonatal respiratory support associated with anesthesia administration in elective cesarean section may be improved by continuous vasopressor administration upon induction of combined spinal–epidural anesthesia.
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Affiliation(s)
- Shoichi Magawa
- Department of Obstetrics and Gynecology, Faculty of Medicine, Mie University, Tsu 514-8507, Mie, Japan; (M.N.); (N.E.); (S.T.); (S.M.); (H.T.); (E.K.); (T.I.)
- Correspondence:
| | - Masafumi Nii
- Department of Obstetrics and Gynecology, Faculty of Medicine, Mie University, Tsu 514-8507, Mie, Japan; (M.N.); (N.E.); (S.T.); (S.M.); (H.T.); (E.K.); (T.I.)
| | - Yosuke Sakakura
- Department of Clinical Anesthesiology, Faculty of Medicine, Mie University, Tsu 514-8507, Mie, Japan;
| | - Naosuke Enomoto
- Department of Obstetrics and Gynecology, Faculty of Medicine, Mie University, Tsu 514-8507, Mie, Japan; (M.N.); (N.E.); (S.T.); (S.M.); (H.T.); (E.K.); (T.I.)
| | - Sho Takakura
- Department of Obstetrics and Gynecology, Faculty of Medicine, Mie University, Tsu 514-8507, Mie, Japan; (M.N.); (N.E.); (S.T.); (S.M.); (H.T.); (E.K.); (T.I.)
| | - Shintaro Maki
- Department of Obstetrics and Gynecology, Faculty of Medicine, Mie University, Tsu 514-8507, Mie, Japan; (M.N.); (N.E.); (S.T.); (S.M.); (H.T.); (E.K.); (T.I.)
| | - Hiroaki Tanaka
- Department of Obstetrics and Gynecology, Faculty of Medicine, Mie University, Tsu 514-8507, Mie, Japan; (M.N.); (N.E.); (S.T.); (S.M.); (H.T.); (E.K.); (T.I.)
| | - Eiji Kondo
- Department of Obstetrics and Gynecology, Faculty of Medicine, Mie University, Tsu 514-8507, Mie, Japan; (M.N.); (N.E.); (S.T.); (S.M.); (H.T.); (E.K.); (T.I.)
| | - Tomoaki Ikeda
- Department of Obstetrics and Gynecology, Faculty of Medicine, Mie University, Tsu 514-8507, Mie, Japan; (M.N.); (N.E.); (S.T.); (S.M.); (H.T.); (E.K.); (T.I.)
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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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10
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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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Lu A, Ye Y, Hu J, Wei N, Wei J, Lin B, Wang S. Case Series: Video-Assisted Minimally Invasive Cardiac Surgery During Pregnancy. Front Med (Lausanne) 2021; 8:781690. [PMID: 35004748 PMCID: PMC8727488 DOI: 10.3389/fmed.2021.781690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 11/09/2021] [Indexed: 11/16/2022] Open
Abstract
Surgical intervention is expected to improve maternal outcomes in pregnant patients with heart disease once the conservative treatment fails. For pregnant patients with heart disease, the risk of cardiac surgery under cardiopulmonary bypass (CPB) must be balanced due to the high fetal loss. The video-assisted minimally invasive cardiac surgery (MICS) has been progressively applied and shows advantages in non-pregnant patients over the years. We present five cases of pregnant women who underwent a video-assisted minimally invasive surgical approach for cardiac surgery and the management strategies. In conclusion, the video-assisted MICS is feasible and safe to pregnant patients, with good maternal and fetal outcomes under the multidisciplinary assessment and management.
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Affiliation(s)
- Anyi Lu
- Department of Anesthesiology, Guangdong Cardiovascular Institute & Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- College of Medicine, Shantou University, Shantou, China
| | - Yingxian Ye
- Department of Anesthesiology, Guangdong Cardiovascular Institute & Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Jiaqi Hu
- Department of Anesthesiology, Guangdong Cardiovascular Institute & Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Ning Wei
- Department of Anesthesiology, Guangdong Cardiovascular Institute & Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Jinfeng Wei
- Department of Anesthesiology, Guangdong Cardiovascular Institute & Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Bimei Lin
- Department of Operation Room, Guangdong Cardiovascular Institute & Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Sheng Wang
- Department of Anesthesiology, Guangdong Cardiovascular Institute & Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- Department of Anesthesiology, Linzhi People's Hospital, Linzhi, China
- *Correspondence: Sheng Wang
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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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Eskandr AM, Ahmed AM, Bahgat NME. Comparative Study Among Ephedrine, Norepinephrine and Phenylephrine Infusions to Prevent Spinal Hypotension During Cesarean Section. A Randomized Controlled Double-Blind Study. EGYPTIAN JOURNAL OF ANAESTHESIA 2021. [DOI: 10.1080/11101849.2021.1936841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Affiliation(s)
- Ashraf M Eskandr
- Assistant Professor in Anesthesiology and Intensive Care Department, Faculty of Medicine, Menoufia University, Quisna, Egypt
| | - Ali M Ahmed
- Senior Registrar in Anesthesiology, and Intensive Care Department, General Sohag Health Hospital, Sohag, Egypt
| | - Nadia Mohee Eldin Bahgat
- Lecturer in Anesthesiology and Intensive Care Department, Faculty of Medicine, Menoufia University, Shebin El-Kom, Egypt
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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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Biricik E, Ünlügenç H. Vasopressors for the Treatment and Prophylaxis of Spinal Induced Hypotension during Caesarean Section. Turk J Anaesthesiol Reanim 2021; 49:3-10. [PMID: 33718899 PMCID: PMC7932705 DOI: 10.5152/tjar.2020.70] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 12/23/2019] [Indexed: 11/24/2022] Open
Abstract
Vasopressors have currently become the mainstay therapy for the management of spinal-induced hypotension (SIH) as the major mechanism of hypotension after spinal anaesthesia is the loss of arteriolar tone produced by sympathetic block. Vasopressors for the prophylaxis and treatment of SIH have been the subject of a significant amount of research, yet remain an attractive and important clinical problem. This review will highlight controversies and recent research on the use of vasopressors for both prophylaxis and treatment of SIH. For decades, ephedrine was considered to be the best vasopressor for the management of maternal hypotension. However, its use has been reported to be associated with a 5-fold increased risk of foetal acidosis than phenylephrine. At present, phenylephrine is the vasopressor of choice for preventing and treating SIH at caesarean section. However, its use is often associated with a decreased heart rate and low cardiac output state owing to the lack of β-mimetic activity. Norepinephrine has been introduced as an alternative vasopressor for preventing and treating SIH because of its additional β-mimetic activity. However before its routine clinical use, a further series of studies are needed to establish its efficacy and safety for both the mother and foetus.
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Affiliation(s)
- Ebru Biricik
- Department of Anaesthesiology and Reanimation, Çukurova University School of Medicine, Adana, Turkey
| | - Hakkı Ünlügenç
- Department of Anaesthesiology and Reanimation, Çukurova University School of Medicine, Adana, Turkey
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Shang Y, Li H, Ma J, Tan L, Li S, Li P, Sheng B, Wang R. Colloid preloading versus crystalloid preloading to prevent hypotension after spinal anesthesia for cesarean delivery: A protocol for systematic review and meta-analysis. Medicine (Baltimore) 2021; 100:e24607. [PMID: 33607794 PMCID: PMC7899897 DOI: 10.1097/md.0000000000024607] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Accepted: 01/07/2021] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Maternal hypotension is the most frequent complication of spinal anesthesia for cesarean delivery, and intravenous fluid preloading is a preventive measure. We aimed to assess the efficacy of colloids versus crystalloids for preloading to reduce the incidence of spinal anesthesia-induced hypotension and vasopressor requirement in healthy parturients during elective cesarean delivery. METHODS We searched the Cochrane Library, MEDLINE and EMBASE to identify all studies published to June, 2019, through OVID and PubMed. We included randomized controlled trials, comparing colloid preloading with crystalloid preloading in women having spinal anesthesia for cesarean delivery. Primary outcomes were the incidence of hypotension and vasopressor requirement. Secondary outcomes included nausea and/or vomiting, neonatal Apgar score, neonatal umbilical blood pH. We used standardized mean differences for expressing continuous outcomes and risk ratios for dichotomous outcomes. Random-effect model was performed to estimate the pooled risk ratios and standardized mean differences. RESULTS Thirty-three randomized controlled trials contributed data for this meta-analysis. Fewer women experienced hypotension in the colloid group compared with the crystalloid group (risk ratio: 0.72, 95% confidence interval: 0.63-0.82; 2566 women, 32 studies; P < .00001). The total ephedrine dose required was significantly lower with colloid preloading (standardized mean difference: -0.37, 95% CI: -0.64 to -0.09; 1472 women, 19 studies; P = .009). Colloid preloading was also associated with fewer phenylephrine requirement compared with crystalloid preloading (standardized mean difference: -0.54, 95% CI: -0.82 to -0.25; 169 women; P = .0002). The incidence of nausea and/or vomiting was significantly reduced with colloid preloading (risk ratio: 0.72, 95% CI: 0.55-0.95; 1601 women, 20 studies; P = .02). However, the incidence of 1-minute Apgar score < 7, umbilical artery pH < 7.2 and umbilical vein pH < 7.2 were not statistically different between groups. CONCLUSIONS Colloid preloading is superior to crystalloid preloading in reducing the incidence of hypotension induced by spinal anesthesia and vasopressor requirement in the healthy parturients undergoing elective cesarean delivery.The PROSPERO registration number: CRD42018096402.
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Affiliation(s)
- Yuchao Shang
- Department of Anesthesiology, West China Second University Hospital, Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University
| | - Huafeng Li
- Department of Anesthesiology, West China Second University Hospital, Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University
| | - Junmei Ma
- Department of Pediatric Surgery, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital
| | - Ling Tan
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Shuying Li
- Department of Anesthesiology, West China Second University Hospital, Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University
| | - Ping Li
- Department of Anesthesiology, West China Second University Hospital, Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University
| | - Bo Sheng
- Department of Anesthesiology, West China Second University Hospital, Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University
| | - Rurong Wang
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
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Maternal and neonatal outcomes of preeclamptic and normotensive women who underwent cesarean section under spinal anesthesia: A systematic review and meta-analysis. INTERNATIONAL JOURNAL OF SURGERY OPEN 2021. [DOI: 10.1016/j.ijso.2021.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Heesen M, Girard T, Klimek M. Noradrenaline - at best it is not worse. A comparison with phenylephrine in women undergoing spinal anaesthesia for caesarean section. Anaesthesia 2021; 76:743-747. [PMID: 33406274 DOI: 10.1111/anae.15363] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/30/2020] [Indexed: 12/01/2022]
Affiliation(s)
- M Heesen
- Department of Anaesthesia, Kantonsspital Baden, Baden, Switzerland
| | - T Girard
- Department of Anaesthesia, University Hospital Basel, Basel, Switzerland
| | - M Klimek
- Department of Anaesthesiology, Erasmus University Medical Centre, Rotterdam, The Netherlands
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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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Heesen M, Halpern S. Why we need systematic reviews and meta-analyses. Don't miss the forest for the trees. Int J Obstet Anesth 2020; 45:11-13. [PMID: 33309180 DOI: 10.1016/j.ijoa.2020.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 10/08/2020] [Accepted: 11/01/2020] [Indexed: 11/16/2022]
Affiliation(s)
- M Heesen
- Department of Anaesthesia, Kantonsspital Baden, Baden, Switzerland.
| | - S Halpern
- Department of Anesthesiology and Pain Medicine, University of Toronto and Sunnybrook Health Sciences Centre, Toronto, Canada
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Biricik E, Karacaer F, Ünal İ, Sucu M, Ünlügenç H. [The effect of epinephrine for the treatment of spinal-hypotension: comparison with norepinephrine and phenylephrine, clinical trial]. Rev Bras Anestesiol 2020; 70:500-507. [PMID: 32980142 DOI: 10.1016/j.bjan.2020.04.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 04/16/2020] [Accepted: 04/18/2020] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Limited data are present on safety and efficiency of epinephrine for the prophylaxis and treatment of spinal-hypotension. This study was conducted to compare the effect of epinephrine with norepinephrine and phenylephrine on the treatment of spinal-hypotension and ephedrine requirement during cesarean delivery. METHODS One hundred and sixty parturients with uncomplicated pregnancies undergoing elective cesarean delivery under spinal anesthesia were recruited. They were allocated randomly to receive norepinephrine 5 μg.mL-1 (n=40), epinephrine 5 μg.mL-1 (n=40), phenylephrine 100 μg.mL-1 (n=40) or 0.9% saline infusions (n=40) immediately after induction of spinal anesthesia. Whenever systolic blood pressure drops to less than 80% of baseline, 5 mg of iv ephedrine was administered as rescue vasopressor. The incidence of hypotension, total number of hypotension episodes, the number of patients requiring ephedrine, the mean amount of ephedrine consumption and side effects were recorded. RESULTS There was no statistically significant difference in incidence of maternal hypotension between groups. The number of patients requiring ephedrine was significantly greater in group saline than in group phenylephrine (p <0.001). However, it was similar between phenylephrine, norepinephrine, and epinephrine groups. The mean ephedrine consumption was significantly higher in group saline than in norepinephrine, epinephrine, phenylephrine groups (p=0.001). CONCLUSION There is no statistically significant difference in incidence of hypotension and ephedrine consumption during spinal anesthesia for cesarean delivery with the use of epinephrine when compared to norepinephrine or phenylephrine. Epinephrine can be considered as an alternative agent for management of spinal hypotension.
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Affiliation(s)
- Ebru Biricik
- Cukurova University, Faculty of Medicine, Department of Anesthesiology and Reanimation, Adana, Turquia.
| | - Feride Karacaer
- Cukurova University, Faculty of Medicine, Department of Anesthesiology and Reanimation, Adana, Turquia
| | - İlker Ünal
- Çukurova University, Faculty of Medicine, Department of Statistics, Adana, Turquia
| | - Mete Sucu
- Çukurova University, Faculty of Medicine, Department of Obstetrics and Gynecology, Adana, Turquia
| | - Hakkı Ünlügenç
- Cukurova University, Faculty of Medicine, Department of Anesthesiology and Reanimation, Adana, Turquia
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Biricik E, Karacaer F, Ünal İ, Sucu M, Ünlügenç H. The effect of epinephrine for the treatment of spinal-hypotension: comparison with norepinephrine and phenylephrine, clinical trial. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ENGLISH EDITION) 2020. [PMID: 32980142 PMCID: PMC9373668 DOI: 10.1016/j.bjane.2020.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Background and objectives Limited data are present on safety and efficiency of epinephrine for the prophylaxis and treatment of spinal-hypotension. This study was conducted to compare the effect of epinephrine with norepinephrine and phenylephrine on the treatment of spinal-hypotension and ephedrine requirement during cesarean delivery. Methods One hundred and sixty parturients with uncomplicated pregnancies undergoing elective cesarean delivery under spinal anesthesia were recruited. They were allocated randomly to receive norepinephrine 5 μg.mL−1 (n = 40), epinephrine 5 μg.mL−1 (n = 40), phenylephrine 100 μg.mL−1 (n = 40) or 0.9% saline infusions (n = 40) immediately after induction of spinal anesthesia. Whenever systolic blood pressure drops to less than 80% of baseline, 5 mg of intravenous ephedrine was administered as rescue vasopressor. The incidence of hypotension, total number of hypotension episodes, the number of patients requiring ephedrine, the mean amount of ephedrine consumption and side effects were recorded. Results There was no statistically significant difference in incidence of maternal hypotension between groups. The number of patients requiring ephedrine was significantly greater in group saline than in group phenylephrine (p < 0.001). However, it was similar between phenylephrine, norepinephrine, and epinephrine groups. The mean ephedrine consumption was significantly higher in group saline than in norepinephrine, epinephrine, phenylephrine groups (p = 0.001). Conclusion There is no statistically significant difference in incidence of hypotension and ephedrine consumption during spinal anesthesia for cesarean delivery with the use of epinephrine when compared to norepinephrine or phenylephrine. Epinephrine can be considered an alternative agent for management of spinal hypotension.
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Hypotension after spinal anesthesia for cesarean section: how to approach the iatrogenic sympathectomy. Curr Opin Anaesthesiol 2020; 33:291-298. [DOI: 10.1097/aco.0000000000000848] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Hendriks M, Bartolo S, Constans B, Gonzalez M, Tavernier B, Garabedian C, Subtil D. [Factors related to severe neonatal acidosis in planned cesarean section. A case-control study]. ACTA ACUST UNITED AC 2020; 48:784-789. [PMID: 32417399 DOI: 10.1016/j.gofs.2020.05.005] [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: 10/28/2019] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To identify factors related to the occurrence of severe neonatal acidosis in case of planned caesarean section. METHODS Case-control study conducted between 1997 and 2016 among women with planned caesarean delivery at term. Cases were women whose neonates had neonatal arterial pH<7,0. For each case, two planned caesarean sections with neonatal pH≥7,0 were selected as controls. Women whose fetus had a congenital malformation and those whose anesthesia was not spinal anesthesia were excluded. RESULTS Among the 5014 planned cesarean sections of the study period, 38 severe neonatal acidosis were observed (incidence of 0,76% CI95 [0,54-1,04]). Compared to 72 controls, the 36 caesareans with severe neonatal acidosis were associated with more frequent maternal obesity (BMI≥30kg/m2), higher ephedrine doses, longer time from skin incision to infant delivery, and more extraction difficulties. After logistic regression, only maternal obesity remained associated with a significant increase in the risk of severe neonatal acidosis, ORa=3,73, 95%CI (1,11-12,56). CONCLUSIONS In case of planned cesarean section, the main risk factor for severe neonatal acidosis is the existence of maternal obesity.
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Affiliation(s)
- M Hendriks
- Hôpital Jeanne-de-Flandre, pôle Femme-Mère-Nouveau-né, université de Lille, CHU de Lille, 1, rue Eugène-Avinée, 59000 Lille, France.
| | - S Bartolo
- Hôpital Jeanne-de-Flandre, pôle Femme-Mère-Nouveau-né, université de Lille, CHU de Lille, 1, rue Eugène-Avinée, 59000 Lille, France
| | - B Constans
- Département d'anesthésie réanimation, université de Lille, CHU de Lille, 59000 Lille, France
| | - M Gonzalez
- Département d'anesthésie réanimation, université de Lille, CHU de Lille, 59000 Lille, France
| | - B Tavernier
- Département d'anesthésie réanimation, université de Lille, CHU de Lille, 59000 Lille, France
| | - C Garabedian
- Hôpital Jeanne-de-Flandre, pôle Femme-Mère-Nouveau-né, université de Lille, CHU de Lille, 1, rue Eugène-Avinée, 59000 Lille, France; EA 2694 santé publique, épidémiologie et qualité des soins, université de Lille, 59000 Lille, France; Obstetric Department, Catholic Hospitals, Lille Catholic University, 59000 Lille, France
| | - D Subtil
- Hôpital Jeanne-de-Flandre, pôle Femme-Mère-Nouveau-né, université de Lille, CHU de Lille, 1, rue Eugène-Avinée, 59000 Lille, France; EA 2694 santé publique, épidémiologie et qualité des soins, université de Lille, 59000 Lille, France; Obstetric Department, Catholic Hospitals, Lille Catholic University, 59000 Lille, France
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Heesen M, Hilber N, Rijs K, Rossaint R, Girard T, Mercier FJ, Klimek M. A systematic review of phenylephrine vs. noradrenaline for the management of hypotension associated with neuraxial anaesthesia in women undergoing caesarean section. Anaesthesia 2020; 75:800-808. [PMID: 32012226 DOI: 10.1111/anae.14976] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/23/2019] [Indexed: 01/15/2023]
Abstract
Phenylephrine is recommended for the management of hypotension after spinal anaesthesia in women undergoing caesarean section. Noradrenaline, an adrenergic agonist with weak β-adrenergic activity, has been reported to have a more favourable haemodynamic profile than phenylephrine. However, there are concerns that noradrenaline may be associated with a higher risk of fetal acidosis, defined as an umbilical artery pH < 7.20. We performed a systematic review of trials comparing noradrenaline with phenylephrine, concentrating on primary outcomes of fetal acidosis and maternal hypotension. We identified 13 randomised controlled trials including 2002 patients. Heterogeneity among the studies was high, and there were too few data to calculate a pooled effect estimate. Fetal acidosis was assessed in four studies that had a low risk of bias and a low risk of confounding, that is, studies which used a prophylactic vasopressor and where women received the allocated vasopressor only. There were no significant differences between these studies. No significant differences were observed for hypotension. Two trials found a significantly lower incidence of bradycardia when using noradrenaline. Cardiac output was significantly higher after noradrenaline in two of three studies. For other secondary outcomes including nausea, vomiting and Apgar scores at 1 and 5 min, no studies found significant differences. The evidence so far is too limited to support an advantage of noradrenaline over phenylephrine. Concerns of a deleterious effect of noradrenaline on fetal blood gas status cannot currently be assuaged by the available data from randomised controlled studies.
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Affiliation(s)
- M Heesen
- Department of Anaesthesia, Kantonsspital Baden, Baden, Switzerland
| | - N Hilber
- Department of Anaesthesia, Kantonsspital Baden, Baden, Switzerland
| | - K Rijs
- Department of Anaesthesiology, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - R Rossaint
- Department of Anaesthesia, University Hospital RWTH Aachen, Aachen, Germany
| | - T Girard
- Department of Anaesthesia, University Hospital Basel, Basel, Switzerland
| | - F J Mercier
- Department of Anaesthesia, A. Béclère Hospital - APHP & Paris-Saclay University, Clamart, France
| | - M Klimek
- Department of Anaesthesiology, Erasmus University Medical Centre, Rotterdam, the Netherlands
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Abstract
Cesarean section (CS) is a common surgical procedure worldwide. The anesthesiologist is responsible, together with obstetrician and neonatologist, for safe perioperative management. A continuum of risk exists for urgent CS. The decision-to-delivery interval is an important audit tool, to ensure international standards are upheld and good outcomes for mother and neonate are achieved. Urgent CS may be performed under either GA or RA, with benefits and risks attributable to each. Specific clinical scenarios require an individualized approach to anesthesia, including hemorrhage, hypertensive disorders, cardiac disease, the difficult airway and fetal compromise. Ongoing training is integral to the provision of safe anesthesia.
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Affiliation(s)
- Nicole L Fernandes
- Department of Anaesthesia and Perioperative Medicine, University of Cape Town, Groote Schuur Hospital, D23 Groote Schuur Hospital, Anzio Road, Observatory, Cape Town 7925, South Africa
| | - Robert A Dyer
- Department of Anaesthesia and Perioperative Medicine, University of Cape Town, Groote Schuur Hospital, D23 Groote Schuur Hospital, Anzio Road, Observatory, Cape Town 7925, South Africa.
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Norepinephrine versus phenylephrine infusion for prophylaxis against post-spinal anaesthesia hypotension during elective caesarean delivery: A randomised controlled trial. Anaesth Crit Care Pain Med 2019; 38:601-607. [DOI: 10.1016/j.accpm.2019.03.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 03/18/2019] [Accepted: 03/18/2019] [Indexed: 11/18/2022]
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Lee A, Ngan Kee W. Effects of Vasoactive Medications and Maternal Positioning During Cesarean Delivery on Maternal Hemodynamics and Neonatal Acid-Base Status. Clin Perinatol 2019; 46:765-783. [PMID: 31653307 DOI: 10.1016/j.clp.2019.08.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Maternal hemodynamics, positioning, and anesthesia technique for cesarean delivery influence neonatal acid-base balance; direct effects from drugs that cross the placenta also have an influence. Spinal anesthesia limits fetal exposure to depressant drugs and avoids maternal airway instrumentation, but is associated with hypotension. Hypotension may be prevented/treated with vasopressors and intravenous fluids. Current evidence supports phenylephrine as the first-line vasopressor. Fifteen degrees of lateral tilt during cesarean delivery has been advocated to relieve vena caval obstruction, but routine use may be unnecessary in healthy nonobese women having elective cesarean delivery if maternal blood pressure is maintained near baseline.
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Affiliation(s)
- Allison Lee
- Department of Anesthesiology, Columbia University Medical Center, Columbia University, 630 West 168th Street PH-5, New York, NY 10032, USA.
| | - Warwick Ngan Kee
- Department of Anesthesiology, Sidra Medicine, Al Gharrafa Street, Ar-Rayyan, Doha, Qatar
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Žunić M, Krčevski Škvarč N, Kamenik M. The influence of the infusion of ephedrine and phenylephrine on the hemodynamic stability after subarachnoid anesthesia in senior adults - a controlled randomized trial. BMC Anesthesiol 2019; 19:207. [PMID: 31711417 PMCID: PMC6849197 DOI: 10.1186/s12871-019-0878-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 10/24/2019] [Indexed: 12/29/2022] Open
Abstract
Background We studied the influence of ephedrine or phenylephrine infusion administered immediately after spinal anesthesia (SA) on hemodynamics in elderly orthopedic patients. Methods A prospective, randomized, double-blind, placebo-controlled study. After a subarachnoid injection of 15 mg of levobupivacaine, the participants received an infusion of either ephedrine 20 mg (E group), phenylephrine 250 mcg (P group) or saline (C group) within 30 min. We measured blood pressure, cardiac index (CI) and heart rate (HR) from 15 min before to 30 min after SA. Results Seventy patients were included in the final analysis. At the end of measurements, mean arterial pressure (MAP) decreased significantly after SA in comparison to the baseline value in the C group but was maintained in the P and E group, with no significant differences between the groups. CI decreased after SA in the C group, was maintained in the P group, and increased significantly in the E group with significant differences between the C and E group (p = 0.049) also between the P and E (p = 0.01) group at the end of measurements. HR decreased significantly after SA in the C and P group but was maintained in the E group, with significant differences between the P and E group (p = 0.033) at the end of measurements. Conclusions Hemodynamic changes after SA in elderly orthopedic patients can be prevented by an immediate infusion of phenylephrine or ephedrine. In addition to maintaining blood pressure, the ephedrine infusion also maintains HR and increases CI after SA. Trial registration ISRCTN registry with registration number ISRCTN44377602, retrospectively registered on 15 June 2017.
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Affiliation(s)
- Miodrag Žunić
- Department of Anesthesiology, Intensive Care and Pain Management, University Medical Center Maribor, Ljubljanska ulica 5, 2000, Maribor, Slovenia.
| | - Nevenka Krčevski Škvarč
- Department of Anesthesiology, Intensive Care and Pain Management, University Medical Center Maribor, Ljubljanska ulica 5, 2000, Maribor, Slovenia
| | - Mirt Kamenik
- Department of Anesthesiology, Intensive Care and Pain Management, University Medical Center Maribor, Ljubljanska ulica 5, 2000, Maribor, Slovenia
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Dumps C, Umrath V. 58/m mit Sepsis nach Perforation eines Sigmadivertikels. Anaesthesist 2019; 68:284-287. [DOI: 10.1007/s00101-019-00662-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Higgins N, Fitzgerald PC, van Dyk D, Dyer RA, Rodriguez N, McCarthy RJ, Wong CA. The Effect of Prophylactic Phenylephrine and Ephedrine Infusions on Umbilical Artery Blood pH in Women With Preeclampsia Undergoing Cesarean Delivery With Spinal Anesthesia: A Randomized, Double-Blind Trial. Anesth Analg 2019; 126:1999-2006. [PMID: 28953494 DOI: 10.1213/ane.0000000000002524] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Spinal anesthesia for cesarean delivery is associated with a high incidence of hypotension. Phenylephrine results in higher umbilical artery pH than ephedrine when used to prevent or treat hypotension in healthy women. We hypothesized that phenylephrine compared to ephedrine would result in higher umbilical artery pH in women with preeclampsia undergoing cesarean delivery with spinal anesthesia. METHODS This study was a randomized double-blind clinical trial. Nonlaboring women with preeclampsia scheduled for cesarean delivery with spinal anesthesia at Prentice Women's Hospital of Northwestern Medicine were randomized to receive prophylactic infusions of phenylephrine or ephedrine titrated to maintain systolic blood pressure >80% of baseline. Spinal anesthesia consisted of hyperbaric 0.75% bupivacaine 12 mg, fentanyl 15 µg, and morphine 150 µg. The primary outcome was umbilical arterial blood pH and the secondary outcome was umbilical artery base excess. RESULTS One hundred ten women were enrolled in the study and 54 per group were included in the analysis. There were 74 and 72 infants delivered in the ephedrine and phenylephrine groups, respectively. The phenylephrine:ephedrine ratio for umbilical artery pH was 1.002 (95% confidence interval [CI], 0.997-1.007). Mean [standard deviation] umbilical artery pH was not different between the ephedrine 7.20 [0.10] and phenylephrine 7.22 [0.07] groups (mean difference -0.02, 95% CI of the difference -0.06 to 0.07; P = .38). Median (first, third quartiles) umbilical artery base excess was -3.4 mEq/L (-5.7 to -2.0 mEq/L) in the ephedrine group and -2.8 mEq/L (-4.6 to -2.2mEq/L) in the phenylephrine group (difference -0.6 mEq/L, 95% CI of the difference -1.6 to 0.3 mEq/L; P = .10). When adjusted for gestational age and infant gender, umbilical artery pH did not differ between groups. There were also no differences in the umbilical artery pH stratified by magnesium therapy or by the severity of preeclampsia. CONCLUSIONS We were unable to demonstrate a beneficial effect of phenylephrine on umbilical artery pH compared with ephedrine. Our findings suggest that phenylephrine may not have a clinically important advantage compared with ephedrine with regard to improved neonatal acid-base status when used to prevent spinal anesthesia-induced hypotension in women with preeclampsia undergoing cesarean delivery.
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Affiliation(s)
- Nicole Higgins
- From the Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Paul C Fitzgerald
- From the Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Dominique van Dyk
- Department of Anaesthesia and Perioperative Medicine, University of Cape Town, Cape Town, South Africa
| | - Robert A Dyer
- Department of Anaesthesia and Perioperative Medicine, University of Cape Town, Cape Town, South Africa
| | - Natalie Rodriguez
- From the Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Robert J McCarthy
- From the Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Cynthia A Wong
- From the Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Post-spinal anesthesia hypotension during cesarean delivery, a review article. EGYPTIAN JOURNAL OF ANAESTHESIA 2019. [DOI: 10.1016/j.egja.2017.03.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
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Huang B, Huang Q, Hai C, Zheng Z, Li Y, Zhang Z. Height-based dosing algorithm of bupivacaine in spinal anaesthesia for decreasing maternal hypotension in caesarean section without prophylactic fluid preloading and vasopressors: study protocol for a randomised controlled non-inferiority trial. BMJ Open 2019; 9:e024912. [PMID: 31101694 PMCID: PMC6530369 DOI: 10.1136/bmjopen-2018-024912] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Effectively preventing or treating spinal-induced maternal hypotension is considered to be the Holy Grail of obstetric anaesthesia. Prophylactic fluid preloading and vasopressors decrease hypotension but may aggravate heart load, induce fetal acidosis or maternal bradycardia. Using low-dose local anaesthetic decreases hypotension but may cause insufficient anaesthesia. Whether there is a height-based dosing algorithm of local anaesthetic in spinal anaesthesia for caesarean section that can provide sufficient anaesthesia with less hypotension without prophylactic fluid preloading and vasopressors is unclear. This study was designed to investigate a height-based dosing algorithm of bupivacaine in spinal anaesthesia for caesarean section. METHODS AND ANALYSIS This single-centre, double-blinded, prospective, non-inferiority, randomised controlled trial will include 264 parturients (between 18 and 45 years of age) who are scheduled for caesarean section. All participants will not receive prophylactic fluid preloading. The participants will be randomly divided into two groups: the test group or conventional group. For parturients in the test group, 0.5% isobaric bupivacaine (1.15-1.70 mL) will be injected into the subarachnoid space without prophylactic vasopressors. The bupivacaine dose depends on the height of subjects. For parturients in the conventional group, 0.5% bupivacaine (1.8 mL) will be injected into the subarachnoid space along with prophylactic vasopressors. The primary outcome is the incidence of maternal hypotension. The secondary outcomes include the failure rate of spinal anaesthesia, level of sensory block, degree of motor block, other complications in parturients, time of operation, neonatal outcome and quality of anaesthesia. ETHICS AND DISSEMINATION This study was approved by the Ethics Committee of Shenzhen People's Hospital of Jinan University (Permit No. SZY-00251, chairperson Xiaofang Yu) on 8 February 2018The study results will be disseminated through peer-reviewed journals, professional societies and meetings. TRIAL REGISTRATION NUMBER NCT03497364; Pre-results.
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Affiliation(s)
- Bowan Huang
- Department of Anesthesiology, Central People’s Hospital of Zhanjiang, Zhanjiang, China
| | - Qiang Huang
- Department of Anesthesiology, ShenZhen People’s Hospital, 2nd Clinical Medical College of Jinan University, Shenzhen, China
| | - Chao Hai
- Department of Anesthesiology, ShenZhen People’s Hospital, 2nd Clinical Medical College of Jinan University, Shenzhen, China
| | - Zihao Zheng
- Department of Anesthesiology, ShenZhen People’s Hospital, 2nd Clinical Medical College of Jinan University, Shenzhen, China
| | - Yali Li
- Department of Anesthesiology, ShenZhen People’s Hospital, 2nd Clinical Medical College of Jinan University, Shenzhen, China
| | - Zhongjun Zhang
- Department of Anesthesiology, ShenZhen People’s Hospital, 2nd Clinical Medical College of Jinan University, Shenzhen, China
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Antihypotensiva bei Kaiserschnittentbindungen. Anaesthesist 2019; 68:228-238. [DOI: 10.1007/s00101-019-0560-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 02/01/2019] [Accepted: 02/11/2019] [Indexed: 10/27/2022]
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Kim W, Hur M, Park SK, Yoo S, Lim T, Yoon H, Kim JT, Bahk JH. Comparison between general, spinal, epidural, and combined spinal-epidural anesthesia for cesarean delivery: a network meta-analysis. Int J Obstet Anesth 2019; 37:5-15. [DOI: 10.1016/j.ijoa.2018.09.012] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 09/12/2018] [Accepted: 09/21/2018] [Indexed: 12/18/2022]
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36
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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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Chao E, Sun HL, Huang SW, Liao JH, Ma PL, Chen HC. Metaraminol use during spinal anaesthesia for caesarean section: a meta-analysis of randomised controlled trials. Int J Obstet Anesth 2019; 39:42-50. [PMID: 30772119 DOI: 10.1016/j.ijoa.2019.01.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Revised: 01/12/2019] [Accepted: 01/18/2019] [Indexed: 10/27/2022]
Abstract
INTRODUCTION During caesarean section, the use of a vasopressor is often required to achieve haemodynamic stability of the parturient. Metaraminol is a vasopressor used in this context in some countries. However, the differences between metaraminol and other vasopressors remain unclear. METHODS A search of the PubMed, Cochrane Library, and Embase databases was performed to identify randomised controlled trials comparing the use of metaraminol with other vasopressors during spinal anaesthesia at caesarean section. The selected studies were subjected to meta-analysis and risk-of-bias assessment. RESULTS Four randomised, controlled trials met the selection criteria and 409 parturients who underwent an elective caesarean section were included in this meta-analysis. The quality of these trials was good. Metaraminol was associated with higher umbilical arterial pH (standardised mean difference [SMD] 0.82, 95% CI 0.01 to 1.62, P=0.05); a lower incidence of fetal acidosis (RR 0.08, 95% CI 0.01 to 0.63, P=0.02); and a lower incidence of nausea or vomiting (RR 0.16, 95% CI 0.04 to 0.57, P=0.0005) than was ephedrine. Metaraminol resulted in higher umbilical arterial pH (SMD 0.42, 95% CI 0.15 to 0.68, P=0.002) but a higher incidence of reactive hypertension (RR 1.80, 95% CI 1.32 to 2.46, P=0.0002) than did phenylephrine. CONCLUSION The results of this study showed that for spinal anaesthesia at elective caesarean section, metaraminol may be a more suitable vasopressor than ephedrine and its effects are at least not inferior to those of phenylephrine.
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Affiliation(s)
- E Chao
- Department of Anaesthesia, Sijhih Cathay General Hospital, New Taipei City, Taiwan
| | - H-L Sun
- Department of Anaesthesia, Sijhih Cathay General Hospital, New Taipei City, Taiwan; School of Medicine, College of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan
| | - S-W Huang
- Department of Physical Medicine and Rehabilitation, School of Medicine, College of Medicine, Taipei Medical University, Taipei City, Taiwan; Department of Physical Medicine and Rehabilitation, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
| | - J-H Liao
- Department of Anaesthesia, Sijhih Cathay General Hospital, New Taipei City, Taiwan
| | - P-L Ma
- Department of Anaesthesia, Sijhih Cathay General Hospital, New Taipei City, Taiwan
| | - H-C Chen
- Department of Physical Medicine and Rehabilitation, School of Medicine, College of Medicine, Taipei Medical University, Taipei City, Taiwan; Department of Physical Medicine and Rehabilitation, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan; Center for Evidence-Based Health Care, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan.
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Xu C, Liu S, Qian D, Liu A, Liu C, Chen Y, Qi D. Preventive intramuscular phenylephrine in elective cesarean section under spinal anesthesia: A randomized controlled trial. Int J Surg 2019; 62:5-11. [PMID: 30639574 DOI: 10.1016/j.ijsu.2018.12.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 12/02/2018] [Accepted: 12/20/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND Phenylephrine is the first-line vasoactive drug in the cesarean section under spinal anesthesia. The rate of hypotension remains high after intravenous preventive use of phenylephrine. However, few studies have investigated the effect of preventive intramuscular phenylephrine via a longer period of usage on fetal and maternal outcomes. METHODS A total of 99 healthy parturients undergoing elective cesarean delivery were randomly allocated into three groups: M group (preventive intramuscular use of 5 mg phenylephrine), V group (preventive intravenous use of 100 μg phenylephrine), and P group (0.9% normal saline placebo). Rescue phenylephrine, ephedrine and atropine were used intraoperatively to adjust blood pressure and heart rate. The primary outcome was umbilical artery pH. RESULTS Significant differences in umbilical artery pH (M group: 7.32 ± 0.05 versus V group: 7.25 ± 0.04 versus P group: 7.21 ± 0.03, P < 0.05), fetal acidosis (M group: 3% [n = 33] versus V group: 15% [n = 33] versus P group: 30% [n = 33], P = 0.01) and maternal intraoperative hypotension (M group: 12% [33] versus V group: 39% [33] versus P group: 73% [33], P < 0.0001) were identified among the groups. Multiple linear regression analysis demonstrated that treating arms, neonatal birthweight and the interval from the end of anesthesia to baby delivery were associated with umbilical artery pH. CONCLUSION Compared with the preventive intravenous use of phenylephrine and placebo, preventive intramuscular phenylephrine exhibited a better neonatal acid-base status and more stable maternal hemodynamics in elective cesarean under spinal anesthesia.
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Affiliation(s)
- Chao Xu
- Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, 209 Tongshan, Xuzhou, Jangsu, China; Department of Anesthesiology, Affiliated Hospital of Xuzhou Medical, University, No.99 Huaihai West Road, Xuzhou, Jangsu, China
| | - Su Liu
- Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, 209 Tongshan, Xuzhou, Jangsu, China; Department of Anesthesiology, Affiliated Hospital of Xuzhou Medical, University, No.99 Huaihai West Road, Xuzhou, Jangsu, China
| | - Dongchen Qian
- Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, 209 Tongshan, Xuzhou, Jangsu, China; Department of Anesthesiology, Affiliated Hospital of Xuzhou Medical, University, No.99 Huaihai West Road, Xuzhou, Jangsu, China
| | - Aohua Liu
- Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, 209 Tongshan, Xuzhou, Jangsu, China; Department of Anesthesiology, Affiliated Hospital of Xuzhou Medical, University, No.99 Huaihai West Road, Xuzhou, Jangsu, China
| | - Chang Liu
- Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, 209 Tongshan, Xuzhou, Jangsu, China; Department of Anesthesiology, Affiliated Hospital of Xuzhou Medical, University, No.99 Huaihai West Road, Xuzhou, Jangsu, China
| | - Yajie Chen
- Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, 209 Tongshan, Xuzhou, Jangsu, China; Department of Anesthesiology, Affiliated Hospital of Xuzhou Medical, University, No.99 Huaihai West Road, Xuzhou, Jangsu, China
| | - Dunyi Qi
- Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, 209 Tongshan, Xuzhou, Jangsu, China; Department of Anesthesiology, Affiliated Hospital of Xuzhou Medical, University, No.99 Huaihai West Road, Xuzhou, Jangsu, China.
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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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The Efficacy and Safety of Norepinephrine and Its Feasibility as a Replacement for Phenylephrine to Manage Maternal Hypotension during Elective Cesarean Delivery under Spinal Anesthesia. BIOMED RESEARCH INTERNATIONAL 2018; 2018:1869189. [PMID: 30687737 PMCID: PMC6330831 DOI: 10.1155/2018/1869189] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Revised: 11/17/2018] [Accepted: 12/04/2018] [Indexed: 12/12/2022]
Abstract
Maternal hypotension commonly occurs during spinal anesthesia for cesarean delivery, with a decrease of systemic vascular resistance recognized as a significant contributor. Accordingly, counteracting this effect with a vasopressor that constricts arterial vessels is appropriate, and the pure α-adrenergic receptor agonist phenylephrine is the current gold standard for treatment. However, phenylephrine is associated with dose-dependent reflex bradycardia and decreased cardiac output, which can endanger the mother and fetus in certain circumstances. In recent years, the older, traditional vasopressor norepinephrine has attracted increasing attention owing to its mild β-adrenergic effects in addition to its α-adrenergic effects. We search available literature for papers directly related to norepinephrine application in spinal anesthesia for elective cesarean delivery. Nine reports were found for norepinephrine use either alone or compared to phenylephrine. Results show that norepinephrine efficacy in rescuing maternal hypotension is similar to that of phenylephrine without obvious maternal or neonatal adverse outcomes, and with a lower incidence of bradycardia and greater cardiac output. In addition, either computer-controlled closed loop feedback infusion or manually-controlled variable-rate infusion of norepinephrine provides more precise blood pressure management than equipotent phenylephrine infusion or norepinephrine bolus. Thus, based on the limited available literature, norepinephrine appears to be a promising alternative to phenylephrine; however, before routine application begins, more favorable high-quality studies are warranted.
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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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Eberhart L, Geldner G, Huljic S, Marggraf K, Keller T, Koch T, Kranke P. A non-interventional comparative study of the 20:1 combination of cafedrine/theodrenaline versus ephedrine for the treatment of intra-operative arterial hypotension: the 'HYPOTENS' study design and rationale. Curr Med Res Opin 2018; 34:953-961. [PMID: 29415580 DOI: 10.1080/03007995.2018.1438379] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Revised: 01/24/2018] [Accepted: 01/29/2018] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To compare the effectiveness of 20:1 cafedrine/theodrenaline approved for use in Germany to ephedrine in the restoration of arterial blood pressure and on post-operative outcomes in patients with intra-operative arterial hypotension of any origin under standard clinical practice conditions. METHODS AND RESULTS 'HYPOTENS' is a national, multi-center, prospective, open-label, two-armed, non-interventional study. Effectiveness and post-operative outcome following cafedrine/theodrenaline or ephedrine therapy will be evaluated in two cohorts of hypotensive patients. Cohort A includes patients aged ≥50 years with ASA-classification 2-4 undergoing non-emergency surgical procedures under general anesthesia. Cohort B comprises patients undergoing Cesarean section under spinal anesthesia. Participating surgical departments will be assigned to a treatment arm by routinely used anti-hypotensive agent. To minimize bias, matched department pairs will be compared in a stratified selection process. The composite primary end-point is the lower absolute deviation from individually determined target blood pressure (IDTBP) and the incidence of heart rate ≥100 beats/min in the first 15 min. Secondary end-points include incidence and degree of early post-operative delirium (cohort A), severity of fetal acidosis in the newborn (cohort B), upper absolute deviation from IDTBP, percentage increase in systolic blood pressure, and time to IDTBP. CONCLUSION This open-label, non-interventional study design mirrors daily practice in the treatment of patients with intra-operative hypotension and ensures full treatment decision autonomy with respect to each patient's individual condition. Selection of participating sites by a randomization process addresses bias without interfering with the non-interventional nature of the study. First results are expected in 2018. ClinicalTrials.gov identifier: NCT02893241; DRKS identifier: DRKS00010740.
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Affiliation(s)
- Leopold Eberhart
- a Department of Anaesthesiology and Intensive Care , Philipps-Universität Marburg , Marburg , Germany
| | - Götz Geldner
- b Clinic for Intensive Care, Emergency Medicine and Pain Therapy , Klinikum Ludwigsburg , Ludwigsburg , Germany
| | | | | | | | - Tilo Koch
- a Department of Anaesthesiology and Intensive Care , Philipps-Universität Marburg , Marburg , Germany
| | - Peter Kranke
- f Department of Anaesthesia and Critical Care , University Hospital Würzburg , Würzburg , Germany
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Comparison of double intravenous vasopressor automated system using nexfin versus manual vasopressor bolus administration for maintenance of haemodynamic stability during spinal anaesthesia for caesarean delivery. Eur J Anaesthesiol 2018; 35:390-397. [DOI: 10.1097/eja.0000000000000779] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Dyer R, Emmanuel A, Adams S, Lombard C, Arcache M, Vorster A, Wong C, Higgins N, Reed A, James M, Joolay Y, Schulein S, van Dyk D. A randomised comparison of bolus phenylephrine and ephedrine for the management of spinal hypotension in patients with severe preeclampsia and fetal compromise. Int J Obstet Anesth 2018; 33:23-31. [DOI: 10.1016/j.ijoa.2017.08.001] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Revised: 07/23/2017] [Accepted: 08/05/2017] [Indexed: 10/19/2022]
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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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Ge M, Wang S, Dai Z, Li Y, Xie L, Liu X, Yin J. Effect of ephedrine combined with bupivacaine on maternal hemodynamic and spinal nerve block in cesarean delivery. Biomed Rep 2017; 6:295-299. [PMID: 28451389 DOI: 10.3892/br.2017.846] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Accepted: 01/12/2017] [Indexed: 11/06/2022] Open
Abstract
The aim of the study was to investigate the effects of ephedrine intrathecal injection on maternal thermodynamics and spinal nerve block in cesarean section. A total of 107 patients undergoing elective cesarean section under combined spinal epidural anesthesia were randomly divided into two groups: group E: Bupivacaine (6 mg) combined with ephedrine (15 mg) and group C: Bupivacaine (6 mg). Systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate (HR), the incidence of hypotension, hypertension, tachycardia, nausea and vomiting were all recorded. The umbilical vein blood gases and noradrenaline, as well as maternal peripheral venous blood were analyzed. The time of high-quality spinal block was also recorded. Postoperatively, 1 day, 2 days bedside follow-up and 7, 21, 35 days telephone follow-up were carried out to determine any neurological deficit maternal performance. SBP and DBP decreased in group C but not in group E at 3 min after spinal anesthesia and 1 min after delivery (P<0.05). From 3 min post-anesthesia to the end of surgery, the HR levels in the C group were significantly higher than those of the E group (P<0.05). The incidence of hypotension, tachycardia, nausea and vomiting and neonate acidosis was low in group E compared with group C (P<0.05). The time of high-quality spinal block in group E was longer than that of group C (P<0.05). After spinal anesthesia, the concentration of noradrenaline from maternal peripheral venous blood was low in group C but high in group E compared with before spinal anesthesia (P<0.05). Ephedrine combined with low-dose bupivacaine intrathecal injection effectively maintained maternal hemodynamics and prolonged the time of sensory spinal block.
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Affiliation(s)
- Mingyue Ge
- Department of Anesthesiology, First Affiliated Hospital, School of Medicine, Shihezi University, Shihezi, Xinjiang 832002, P.R. China
| | - Sheng Wang
- Department of Anesthesiology, First Affiliated Hospital, School of Medicine, Shihezi University, Shihezi, Xinjiang 832002, P.R. China
| | - Zhigang Dai
- Department of Anesthesiology, First Affiliated Hospital, School of Medicine, Shihezi University, Shihezi, Xinjiang 832002, P.R. China
| | - Yan Li
- Department of Anesthesiology, First Affiliated Hospital, School of Medicine, Shihezi University, Shihezi, Xinjiang 832002, P.R. China
| | - Liping Xie
- Department of Anesthesiology, First Affiliated Hospital, School of Medicine, Shihezi University, Shihezi, Xinjiang 832002, P.R. China
| | - Xuejao Liu
- Department of Anesthesiology, First Affiliated Hospital, School of Medicine, Shihezi University, Shihezi, Xinjiang 832002, P.R. China
| | - Jiangwen Yin
- Department of Anesthesiology, First Affiliated Hospital, School of Medicine, Shihezi University, Shihezi, Xinjiang 832002, P.R. China
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Spinal-induced hypotension: Incidence, mechanisms, prophylaxis, and management: Summarizing 20 years of research. Best Pract Res Clin Anaesthesiol 2017. [DOI: 10.1016/j.bpa.2017.01.001] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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