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Bækgaard ES, Madsen BK, Crone V, El-Hallak H, Møller MH, Vester-Andersen M, Krag M. Perioperative hypotension and use of vasoactive agents in non-cardiac surgery: A scoping review. Acta Anaesthesiol Scand 2024. [PMID: 38965670 DOI: 10.1111/aas.14485] [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: 04/26/2024] [Revised: 06/03/2024] [Accepted: 06/13/2024] [Indexed: 07/06/2024]
Abstract
BACKGROUND Perioperative hypotension is common and associated with adverse patient outcomes. Vasoactive agents are often used to manage hypotension, but the ideal drug, dose and duration of treatment has not been established. With this scoping review, we aim to provide an overview of the current body of evidence regarding the vasoactive agents used to treat perioperative hypotension in non-cardiac surgery. METHODS We included all studies describing the use of vasoactive agents for the treatment of perioperative hypotension in non-cardiac surgery. We excluded literature reviews, case studies, and studies on animals and healthy subjects. We posed the following research questions: (1) in which surgical populations have vasoactive agents been studied? (2) which agents have been studied? (3) what doses have been assessed? (4) what is the duration of treatment? and (5) which desirable and undesirable outcomes have been assessed? RESULTS We included 124 studies representing 10 surgical specialties. Eighteen different agents were evaluated, predominantly phenylephrine, ephedrine, and noradrenaline. The agents were administered through six different routes, and numerous comparisons between agents, dosages and routes were included. Then, 88 distinct outcome measures were assessed, of which 54 were judged to be non-patient-centred. CONCLUSIONS We found that studies concerning vasoactive agents for the treatment of perioperative hypotension varied considerably in all aspects. Populations were heterogeneous, interventions and exposures included multiple agents compared against themselves, each other, fluids or placebo, and studies reported primarily non-patient-centred outcomes.
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Affiliation(s)
| | - Bennedikte Kollerup Madsen
- Department of Anaesthesiology and Intensive Care, Holbæk Hospital, Holbæk, Denmark
- Department of Anaesthesiology and Intensive Care, Zealand University Hospital, Køge, Denmark
| | - Vera Crone
- Department of Anaesthesiology and Intensive Care, Holbæk Hospital, Holbæk, Denmark
| | - Hayan El-Hallak
- Department of Anaesthesiology and Intensive Care, Holbæk Hospital, Holbæk, Denmark
- Department of Anaesthesiology, Copenhagen University Hospital-Gentofte, Hellerup, Denmark
| | - Morten Hylander Møller
- Department of Intensive Care, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Morten Vester-Andersen
- Department of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Anaesthesiology and Intensive Care, Copenhagen University Hospital-Herlev-Gentofte, Herlev, Denmark
| | - Mette Krag
- Department of Anaesthesiology and Intensive Care, Holbæk Hospital, Holbæk, Denmark
- Department of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
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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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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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Wang SY, He Y, Zhu HJ, Han B. Dural puncture epidural technique provides better anesthesia quality in repeat cesarean delivery than epidural technique: Randomized controlled study. World J Clin Cases 2022; 10:6890-6899. [PMID: 36051113 PMCID: PMC9297399 DOI: 10.12998/wjcc.v10.i20.6890] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 02/03/2022] [Accepted: 05/17/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Repeat cesarean deliverys involve a longer surgery and more severe visceral traction than primary cesarean deliverys. The dural puncture epidural (DPE) technique provides faster and more effective analgesia for labor, but there is no sufficient evidence to indicate whether it is suitable for parturients undergoing repeat cesarean delivery.
AIM To determine the efficacy and safety of the DPE anesthesia technique in patients undergoing repeat cesarean delivery.
METHODS Patients undergoing repeat cesarean delivery were randomly divided into the DPE and epidural anesthesia (EA) groups. A 25-G spinal needle was used for dural puncture via a 19-G epidural needle. The patients in the two groups were injected with 5 mL of 2% lidocaine followed by 15 mL of a mixture of 1% lidocaine + 0.5% ropivacaine as the epidural dosage. The primary outcome was the onset time of sensory block to the T6 dermatome level and the sensory and motor block degree.
RESULTS A total of 115 women were included (EA: 57, DPE: 58). The mean time to sensory block to the T6 Level was significantly shorter in the DPE group than in the EA group (14.7 min vs 16.6 min; 95% confidence interval, 13.9 to 15.4 vs 15.8 to 17.4; P = 0.001). The cranial sensory block level was significantly higher at 5, 10, and 15 min after the initial dose in the DPE group than in the EA group (P < 0.05). The sacral sensory block level was significantly higher and the modified bromage score was significantly lower in the DPE group at each time point (P < 0.05). Adverse effects and neonatal outcomes were comparable between the two groups (P > 0.05).
CONCLUSION The DPE technique provided higher-quality anesthesia than the EA technique, with a rapid onset of surgical anesthesia, better cranial and sacral sensory block spread and a higher motor block degree, without increasing the incidence of maternal or fetal side effects in patients undergoing repeat cesarean delivery.
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Affiliation(s)
- Sheng-You Wang
- Department of Anesthesiology, Hefei Maternal and Child Health Care Hospital, Hefei 230001, Anhui Province, China
- Department of Anesthesiology, Maternal and Child Health Care Hospital of Anhui Medical University, Hefei 230001, Anhui Province, China
| | - Yan He
- Department of Anesthesiology, Wannan Medical College, Wuhu 241002, Anhui Province, China
| | - Hai-Juan Zhu
- Department of Anesthesiology, Hefei Maternal and Child Health Care Hospital, Hefei 230001, Anhui Province, China
- Department of Anesthesiology, Maternal and Child Health Care Hospital of Anhui Medical University, Hefei 230001, Anhui Province, China
| | - Bo Han
- Department of Anesthesiology, Hefei Maternal and Child Health Care Hospital, Hefei 230001, Anhui Province, China
- Department of Anesthesiology, Maternal and Child Health Care Hospital of Anhui Medical University, Hefei 230001, Anhui Province, China
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