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Theodoraki K, Hadzilia S, Valsamidis D, Kalopita K, Stamatakis E. Reply to Akça, B.; Bilotta, F. Time and Type of Administered Fluids during Cesarean Section Might Not Matter for Hemodynamic Outcomes, but There Are Significant Patient Safety Concerns Regarding Colloid Use in Parturients. Comment on "Theodoraki et al. Colloid Preload versus Crystalloid Co-Load in the Setting of Norepinephrine Infusion during Cesarean Section: Time and Type of Administered Fluids Do Not Matter. J. Clin. Med. 2023, 12, 1333 ". J Clin Med 2023; 12:4754. [PMID: 37510868 PMCID: PMC10381518 DOI: 10.3390/jcm12144754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 06/29/2023] [Accepted: 07/07/2023] [Indexed: 07/30/2023] Open
Abstract
We would like to take this opportunity to thank Drs Akça and Bilotta for their interest and their insightful comments [...].
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Affiliation(s)
- Kassiani Theodoraki
- Department of Anesthesiology, Aretaieion University Hospital, National and Kapodistrian University of Athens, 11528 Athens, Greece
| | - Sofia Hadzilia
- Department of Anesthesiology, Alexandra General Hospital of Athens, 11528 Athens, Greece
| | - Dimitrios Valsamidis
- Department of Anesthesiology, Alexandra General Hospital of Athens, 11528 Athens, Greece
| | - Konstantina Kalopita
- Department of Anesthesiology, Alexandra General Hospital of Athens, 11528 Athens, Greece
| | - Emmanouil Stamatakis
- Department of Anesthesiology, Alexandra General Hospital of Athens, 11528 Athens, Greece
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Mercier FJ, Diemunsch P, Ducloy-Bouthors AS, Mignon A, Fischler M, Malinovsky JM, Bolandard F, Aya AG, Raucoules-Aimé M, Chassard D, Keita H, Rigouzzo A, Le Gouez A. 6% Hydroxyethyl starch (130/0.4) vs Ringer's lactate preloading before spinal anaesthesia for Caesarean delivery: the randomized, double-blind, multicentre CAESAR trial. Br J Anaesth 2014; 113:459-67. [PMID: 24970272 DOI: 10.1093/bja/aeu103] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Vasopressor administration is recommended to prevent hypotension during spinal anaesthesia (SA) for elective Caesarean delivery. We aimed to test the superior efficacy and ensure safety of a hydroxyethyl starch (HES) vs a Ringer's lactate (RL) preloading, when combined with a phenylephrine-based prophylaxis. METHODS A total of 167 healthy parturients undergoing elective Caesarean delivery under SA were included in this multicentre, randomized, double-blind study. Patients received 500 ml of 6% HES (130/0.4)+500 ml of RL (HES group) or 1000 ml of RL (RL group) i.v. before SA. After SA, i.v. phenylephrine boluses were titrated when systolic arterial pressure (SAP) was below 95% of baseline. The primary outcome was the incidence of maternal hypotension (SAP <80% of baseline). RESULTS The incidence of both hypotension and symptomatic hypotension (i.e. with dizziness, nausea/vomiting, or both) was significantly lower in the HES group vs the RL group: 36.6% vs 55.3% (one-sided P=0.025) and 3.7% vs 14.1%. There was no significant difference in total phenylephrine requirements [median (range): 350 (50-1800) vs 350 (50-1250) µg]. The decrease in maternal haemoglobin value the day after surgery was similar in the two groups [1.2 (1.0) vs 1.0 (0.9) g dl(-1)]. There was no detectable placental transfer of HES in six umbilical cord blood samples analysed in the HES group. Neonatal outcomes were comparable between the groups. CONCLUSIONS Compared with a pure RL preloading, a mixed HES-RL preloading significantly improved prevention of both hypotension and symptomatic hypotension based on early phenylephrine bolus administration and did not induce adverse effects. CLINICAL TRIAL REGISTRATION NCT00694343 (http://clinicaltrials.gov).
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Affiliation(s)
- F J Mercier
- Département d'Anesthésie-Réanimation, Université Paris-Sud, APHP-Hôpital Antoine Béclère, 157 rue de la Porte de Trivaux, 92141 Clamart, France
| | - P Diemunsch
- Département d'Anesthésie-Réanimation, Hôpital de Hautepierre, 67000 Strasbourg, France
| | - A-S Ducloy-Bouthors
- Département d'Anesthésie-Réanimation, Hôpital Jeanne de Flandre, 59037 Lille, France
| | - A Mignon
- Département d'Anesthésie-Réanimation, APHP- Hôpital Cochin, 75014 Paris, France
| | - M Fischler
- Service d'Anesthésie-Réanimation, Hôpital Foch, 92150 Suresnes, France
| | - J-M Malinovsky
- Département d'Anesthésie-Réanimation, Hôpital Maison Blanche, 51100 Reims, France
| | - F Bolandard
- Département d'Anesthésie-Réanimation, Hôpital Hotel Dieu, 69002 Clermont-Ferrand, France
| | - A G Aya
- Département d'Anesthésie-Réanimation, Hôpital Caremeau, 30000 Nîmes, France
| | - M Raucoules-Aimé
- Département d'Anesthésie-Réanimation, Hôpital de l'Archet, 06200 Nice, France
| | - D Chassard
- Département d'Anesthésie-Réanimation, Hôpital mère-enfant, 69500 Bron, France
| | - H Keita
- Département d'Anesthésie-Réanimation, APHP-Hôpital Louis Mourier, 92701 Colombes, France
| | - A Rigouzzo
- Département d'Anesthésie-Réanimation, APHP-Hôpital Armand-Trousseau, 75012 Paris, France
| | - A Le Gouez
- Département d'Anesthésie-Réanimation, Université Paris-Sud, APHP-Hôpital Antoine Béclère, 157 rue de la Porte de Trivaux, 92141 Clamart, France
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Gogarten W, Struemper D, Gramke HF, Van Aken H, Buerkle H, Durieux M, Marcus MAE. Assessment of volume preload on uteroplacental blood flow during epidural anaesthesia for Caesarean section. Eur J Anaesthesiol 2005; 22:359-62. [PMID: 15918384 DOI: 10.1017/s026502150500061x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND OBJECTIVE Epidural and spinal anaesthesia are the preferred mode of anaesthesia for Caesarean section. Volume preloading is recommended to prevent maternal hypotension and a reduction in uteroplacental blood flow, although positive effects of volume preloading on maternal cardiac output and arterial pressure are debatable. Doppler measurements of the umbilical artery beyond deriving pulsatility indices are not routinely performed. METHODS After Institutional Review Board approval and written informed consent, 14 consecutiVe women with epidural anaesthesia for Caesarean section received either hydroxyethyl starch 500 mL or gelatine 500 mL. Haemodynamic variables monitored were maternal arterial pressure, maximal blood flow velocity and pulsatility indices of the uterine artery derived from Doppler measurements. CONCLUSIONS Maternal arterial pressure and pulsatility indices in both groups did not change from baseline after intravenous colloid infusion. However, uterine blood flow increased significantly in both groups. The effectiveness of volume preloading may therefore be better described by changes in maximum uterine blood flow velocity than by pulsatility indices or maternal arterial pressure.
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Affiliation(s)
- W Gogarten
- Universitätsklinikum Münster, Department of Anaesthesiology and Intensive Care, Münster, Germany
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Erkinaro T, Mäkikallio K, Kavasmaa T, Alahuhta S, Räsänen J. Effects of ephedrine and phenylephrine on uterine and placental circulations and fetal outcome following fetal hypoxaemia and epidural-induced hypotension in a sheep model †. Br J Anaesth 2004; 93:825-32. [PMID: 15465843 DOI: 10.1093/bja/aeh273] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Recent studies support the use of alpha-agonists during regional anaesthesia in uncomplicated term pregnancies. We hypothesized that ephedrine and phenylephrine, administered for maternal hypotension following fetal hypoxaemia, are equal in respect of fetal outcome. METHODS At 117-132 days gestation, chronically instrumented, anaesthetized and mechanically ventilated ewes were randomized to receive boluses of ephedrine (n=9) or phenylephrine (n=8) for maternal epidural-induced hypotension after a period of fetal hypoxaemia. Uterine (QUtA) and placental (QUA) volume blood flows were measured with perivascular transit-time ultrasonic flow probes, and uterine (RUtA) and placental (RUA) vascular resistances were computed from volume blood flows and maternal and fetal mean arterial pressures. Uterine (PIUtA) and umbilical artery (PIUA) pulsatility indices were obtained by Doppler ultrasonography. RESULTS Ephedrine increased QUtA and decreased RUtA and PIUtA from a hypotensive to baseline level and had no significant effect on umbilical circulation. With phenylephrine, QUtA remained lower (P=0.011) and RUtA higher (P=0.043) than at baseline, although PIUtA decreased to baseline level. PIUA increased from baseline with phenylephrine (P=0.007), whereas QUA decreased (P=0.050). Maternal volume expansion with hydroxyethyl starch decreased RUtA significantly irrespective of the vasopressor used. There were no significant differences in fetal blood gas values or lactate concentrations between the ephedrine and phenylephrine groups. CONCLUSIONS Despite the more favourable effects on uterine and placental circulations of ephedrine over phenylephrine, no significant differences in fetal acid-base status or lactate concentrations were observed.
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Affiliation(s)
- T Erkinaro
- Department of Anaesthesiology, University Hospital of Oulu, PO Box 21, FIN-90029 OYS, Finland.
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Gogarten W. Obstetric anaesthesia: are times changing? Curr Opin Anaesthesiol 2004; 17:299-300. [PMID: 17021568 DOI: 10.1097/01.aco.0000137093.60355.69] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
For a long time, epidural anaesthesia has been considered the method of choice for Caesarean delivery. The increased incidence of hypotension by the rapid onset of sympathetic blockade under spinal anaesthesia has been associated with a decline in uteroplacental blood flow and significant fetal acidosis, which may compromise neonatal well-being. Nevertheless, a decrease in fetal pH has not been shown to reduce neonatal Apgar or neurobehavioural assessment scores. Maternal blood pressure can be preserved with little side effects with low doses of vasopressors. On the other hand, spinal anaesthesia conveys significant advantages over epidural anaesthesia such as the simplicity of its use and the speed of onset, which allows neuraxial anaesthesia in urgent Caesarean sections and thus reduces the necessity for general anaesthesia. The small doses of local anaesthetics required to perform spinal anaesthesia reduce the risks of systemic toxicity to zero. Spinal anaesthesia is now considered the method of choice for urgent Caesarean section. The use of intrathecal opioids has profoundly changed the quality of spinal anaesthesia, with improved analgesia, a reduction in local anaesthetic requirements and shorter duration of motor blockade. Preliminary studies indicate that spinal anaesthesia may be safely performed in patients with severe pre-eclampsia, in whom spinal anaesthesia was previously considered contraindicated.
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Affiliation(s)
- Wiebke Gogarten
- Department of Anaesthesiology and Intensive Care, University of Müenster, Albert-Schweitzer-Str. 33, Münster D-48 149, Germany.
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Abramov Y, Fatum M, Abrahamov D, Schenker JG. Hydroxyethylstarch versus human albumin for the treatment of severe ovarian hyperstimulation syndrome: a preliminary report. Fertil Steril 2001; 75:1228-30. [PMID: 11384657 DOI: 10.1016/s0015-0282(01)01784-8] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To compare the efficacy and safety of 6% hydroxyethylstarch and human albumin as colloid solutions for treatment of severe ovarian hyperstimulation syndrome (OHSS). DESIGN Controlled cohort study. SETTING Tertiary medical center. PATIENT(S) Sixteen patients with severe OHSS. INTERVENTION(S) Six percent hydroxyethylstarch (6 patients) and human albumin (10 patients). MAIN OUTCOME MEASURE(S) Urine output, number of abdominal and pleural drainage procedures, complications, duration of hospitalization, and perinatal outcome. RESULT(S) Patients who received 6% hydroxyethylstarch had higher urine output, needed fewer abdominal and pleural paracenteses, and had a shorter hospital stay than those who received human albumin. In each group, no adverse effects or congenital malformations were observed and the rates of miscarriage were similar. CONCLUSION(S) These results suggest that 6% hydroxyethylstarch may be superior to albumin as a colloid solution for the treatment of severe OHSS.
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Affiliation(s)
- Y Abramov
- Department of Obstetrics and Gynecology, Hebrew University Hadassah Medical Center, Jerusalem,
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Strümper D, Gogarten W, Marcus A. Anaesthesia for fetal surgery. Best Pract Res Clin Anaesthesiol 2000. [DOI: 10.1053/bean.2000.0125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Siddik SM, Aouad MT, Kai GE, Sfeir MM, Baraka AS. Hydroxyethylstarch 10% is superior to Ringer's solution for preloading before spinal anesthesia for Cesarean section. Can J Anaesth 2000; 47:616-21. [PMID: 10930199 DOI: 10.1007/bf03018992] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
PURPOSE To compare the preloading effect of 500 ml hydroxyethylstarch (HES) 10% with 1 L Lactated Ringer's solution (LR). METHODS In 40 healthy women undergoing elective Cesarean section HES, 500 ml (n = 20), or LR, IL (n = 20), was administered during 10 min before spinal anesthesia. The incidence of hypotension, (systolic blood pressure < 80% of baseline and < 100 mm Hg), and the amount of ephedrine used to treat it were compared. Also, the incidence of nausea and/or vomiting were recorded. Neonatal outcome was assessed using Apgar scores and umbilical venous and arterial blood gases. RESULTS The incidence of hypotension was higher in the LR than in HES group (80% vs 40%). Mean minimum systolic blood pressure was lower in the LR than in the HES group (86.1 +/- 12.7 mm Hg vs 99.6 +/- 9.7 mm Hg P < 0.05). Systolic blood pressure < 90 mmHg occurred in two of 20 patients (10%) who received HES vs 11 of 20 patients (55%) who received LR (P < 0.05). More doses of ephedrine were required to treat hypotension in the LRthan in the HES group (35.3 +/- 18.4 mg vs 10.6 +/- 8.6 mg; P < 0.05). The incidence of nausea and/or vomiting was lower in the HES than in the crystalloid group. Neonatal outcome was good and similar in both groups. CONCLUSION Preloading patients undergoing elective Cesarean section with 500 ml HES 10%, decreases the incidence and severity of spinal-induced hypotension more than preloading with 1 L of LR solution.
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Affiliation(s)
- S M Siddik
- Department of Anesthesiology, American University of Beirut, Lebanon
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Abstract
The practice of administration of labor analgesia has undergone dramatic changes this decade. This is largely attributable to unparalleled interest in the field by many dedicated and capable investigators around the world. Through their efforts, this decade has witnessed the introduction of new techniques (pencil point needles, CSE, PCEA, ultradilute epidural regimens) that have permitted us to come closer than ever to realizing the goal of complete relief from the pain and suffering of labor while safeguarding the well-being of mother and child and minimizing effects on the labor process. Neuraxial anesthetic techniques and modern multimodal analgesic approaches to postoperative pain relief now minimize the effects of cesarean delivery on maternal satisfaction and participation in the birth process.
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Affiliation(s)
- M G Richardson
- Department of Anesthesiology, University of Rochester Medical Center, New York, USA.
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Vercauteren MP, Coppejans HC, Hoffmann VL, Saldien V, Adriaensen HA. Small-dose hyperbaric versus plain bupivacaine during spinal anesthesia for cesarean section. Anesth Analg 1998; 86:989-93. [PMID: 9585282 DOI: 10.1097/00000539-199805000-00014] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
UNLABELLED In a double-blind, randomized trial, 98 parturients undergoing cesarean section received either hyperbaric or plain bupivacaine 6.6 mg combined with sufentanil 3.3 microg as part of a combined spinal-epidural procedure. To prevent hypotension, 1000 mL of lactated Ringer's solution, 500 mL of hydroxyethyl starch 6%, and ephedrine 5 mg were administered i.v. The height of the block was equal in both groups, but more patients in the plain group had blocks that were either too high or too low (P < 0.01). The number of patients requiring epidural supplementation was equal in both groups. Strict criteria were used to treat hypotension. The overall incidence of systolic blood pressure (<90 mm Hg) was 13%, whereas it was more pronounced in the plain group (21% vs 6% in the hyperbaric group, P < 0.05), which required more ephedrine (P < 0.05) and in which a greater incidence of nausea was noticed (P < 0.05). We conclude that the use of a small dose of intrathecal bupivacaine combined with sufentanil plus our described preloading regimen resulted in a lower incidence of hypotension. Further, we conclude that the use of hyperbaric bupivacaine in this manner provides a more reliable block and a lower incidence of hypotension than plain bupivacaine. IMPLICATIONS A small dose of hyperbaric bupivacaine 0.5% combined with sufentanil used intrathecally during cesarean section offered a more reliable cephalad spread of the spinal block than the glucose-free combination, which was reflected in a lower incidence of hypotension and nausea.
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Affiliation(s)
- M P Vercauteren
- Department of Anesthesiology, University Hospital Antwerp, Edegem, Belgium
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Vercauteren MP, Coppejans HC, Hoffmann VL, Saldien V, Adriaensen HA. Small-Dose Hyperbaric Versus Plain Bupivacaine During Spinal Anesthesia for Cesarean Section. Anesth Analg 1998. [DOI: 10.1213/00000539-199805000-00014] [Citation(s) in RCA: 65] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Heilmann L, von Tempelhoff GF, Berg C. Acute maternal hydration in third-trimester oligohydramnios. Am J Obstet Gynecol 1996; 175:237. [PMID: 8694065 DOI: 10.1016/s0002-9378(96)70295-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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