Prevention Of Spinal-induced Hypotension Research Articles

Norepinephrine or phenylephrine for the prevention of post-spinal hypotension after caesarean section: A double-blinded, randomized, controlled study of fetal heart rate and fetal cardiac output

Study objectiveSpinal anesthesia often causes hypotension, with consequent risk to the fetus. The use of vasopressor agents has been highly recommended for the prevention of spinal anesthesia-induced hypotension during caesarean delivery. Many studies have shown that norepinephrine can provide more stable maternal hemodynamics than phenylephrine. We therefore tested the hypothesis that norepinephrine preserves fetal circulation better than phenylephrine when used to treat maternal hypotension consequent to spinal anesthesia. DesignProspective, randomized, double-blinded study. SettingOperating room. PatientsWe recruited 223 parturients with uncomplicated singleton pregnancies who were scheduled for elective caesarean section under combined spinal-epidural anesthesia. InterventionsThe patients received prophylactic intravenous infusion of either 0.08 μg/kg/min norepinephrine or 0.5 μg/kg/min phenylephrine for prevention of spinal anesthesia-induced hypotension. MeasurementsChanges in fetal heart rate and fetal cardiac output before and after spinal anesthesia were measured using noninvasive Doppler ultrasound. Main results90 subjects who received norepinephrine infusion and 93 subjects who received phenylephrine infusion were ultimately analyzed in the present study. The effects of norepinephrine and phenylephrine on the change of fetal heart rate and fetal cardiac output at 3 and 6 min after spinal block were similar. Although there was a statistically significant decrease in fetal cardiac output at 6 min after subarachnoid block initiation in both the norepinephrine group (mean difference 0.02 L/min; 95% CI, 0–0.04 L/min; P = 0.03) and the phenylephrine group (mean difference 0.02 L/min; 95% CI, 0–0.04 L/min; P = 0.02), it remained within the normal range. ConclusionsProphylactic infusion of comparable doses of phenylephrine or norepinephrine has similar effects on fetal heart rate and cardiac output changes after spinal anesthesia. Neither phenylephrine nor norepinephrine has meaningful detrimental effects on fetal circulation or neonatal outcomes.

Determination of ED90s of Phenylephrine and Norepinephrine Infusion for Prevention of Spinal Anesthesia-Induced Hypotension in Patients with Preeclampsia During Cesarean Delivery.

Vasopressors remain an important strategy for managing spinal anesthesia-induced hypotension in women with preeclampsia. The aim of this study was to investigate the ED90s and efficacy ratio of phenylephrine and norepinephrine in managing spinal anesthesia-induced hypotension in women with preeclampsia during cesarean delivery. 60 women with preeclampsia, who underwent cesarean delivery, were randomly assigned to receive either a continuous intravenous infusion of phenylephrine or norepinephrine following spinal anesthesia. The initial dosage of phenylephrine or norepinephrine for the first women was 0.5 or 0.05 μg/kg/min, respectively, and subsequent infusion dosages were adjusted based on their efficacy in preventing spinal anesthesia-induced hypotension (defined as a systolic blood pressure less than 80% of the baseline level). The incremental or decremental doses of phenylephrine or norepinephrine were set at 0.1 or 0.01 μg/kg/min. The primary outcomes were the ED90s and efficacy ratio of phenylephrine and norepinephrine infusions for preventing spinal anesthesia-induced hypotension prior to delivery. The results obtained from isotonic regression analysis revealed that the ED90 values of the phenylephrine and norepinephrine group for preventing spinal anesthesia-induced hypotension were 0.597 (95% CI: 0.582-0.628) and 0.054 (95% CI: 0.053-0.056) μg/kg/min, respectively, with an efficacy ratio of 11.1:1. The results of Probit regression analysis revealed that the ED90 values were determined to be 0.665 (95% CI: 0.576-1.226) and 0.055 (95% CI: 0.047-0.109) μg/kg/min, respectively, with an efficacy ratio of 12.1:1. The administration of 0.6 μg/kg/min phenylephrine and 0.05 μg/kg/min norepinephrine has been found to effectively manage a 90% incidence of spinal anesthesia-induced hypotension in women with preeclampsia.

Optimal dose of phenylephrine infusion in the prevention of spinal anaesthesia-induced hypotension in elderly patients

Optimal dose of phenylephrine infusion in the prevention of spinal anaesthesia-induced hypotension in elderly patients

The effect of two dose phenylephrin for preventing hypotension during spinal anesthesia for cesarean delivery

Background: Spinal anesthesia-induced hypotension is one of the most complications which can cause many severe maternal and fetal complications. Therefore, the prevention and treatment of spinal anesthesia-induced hypotension in pregnant women undergoing cesarean delivery play an important role. The use of vasopressors is the most effective method of hypotensive prophylaxis and phenylephrine is currently the first-line vasopressor of choice to prevent this complication. The aim of this study is to evaluate the effectiveness and safety of two-dose phenylephrine for prevention of spinal anesthesia-induced hypotension during cesarean delivery. Materials and methods: In a randommized controlled clinical trial, 150 pregnants undregoing cesarean delivery with spinal anesthesia were randomly divided into three groups: Group I: as a control group without phenylephrine prophylaxis (n = 50), Group II: 50µg intravenously bolus phenylephrine (n = 50), and Group III: 75µg intravenously bolus phenylephrine (n = 50) immediately after induction of spinal anesthesia. Hypotension, defined decreasing systolic blood pressure > 20% of baseline. The incidence of hypotension, levels of hypotension, maternal side effects and neonatal APGAR scores at 1 and 5 minutes. Results: The incidence of hypotension was 44%, the incidence of re-hypotension was 16%. Group III: the incidence of hypotension was 28%, the incidence of re-hypotension was 2%. The neonatal APGAR scores of the two groups at both 1 minute and 5 minutes was the same (p > 0.05), all cases had APGAR > 7. Conclusion: Phenylephrine intravenous bolus at doses of 50 µg and 75 µg are both effective for the prevention spinal anesthesia-induced hypotension for cesarean section. However, the 75 µg phenylephrine dose was more effective than the 50 µg dose because of lower rates of hypotension and recurrent hypotension (28% and 2% vs 44% and 16%, p < 0.05). In addition, both groups of prophylactic phenylephrine didn’t cause detrimental adverses for parturients and their babies. Key words: Hypotensive prophylaxis, cesarean section, phenylephrin.

Effect of Palonosetron in the Prevention of Spinal Anaesthesia-induced Hypotension and Bradycardia: A Randomised Controlled Trial

Introduction: Spinal Anaesthesia (SA) is frequently associated with hypotension, which is due to sympathectomy causing vasodilation, leading to relative hypovolemia. This decrease in venous return to the heart causes a decrease in left ventricular filling pressure, leading to the activation of the Bezold-Jarisch Reflex (BJR), which causes bradycardia. This response is mediated by mechanoreceptors and chemoreceptors present on the heart walls. These chemoreceptors are mediated through serotonin (5-HT). Therefore, the activation of 5-HT3 receptors at sensory vagal nerve endings in the heart causes hypotension and bradycardia. Aim: To assess the efficacy of Palonosetron in attenuating spinal anaesthesia-induced hypotension and bradycardia. Materials and Methods: The trial was a parallel-design, randomised, double-blind controlled trial conducted over two years, from February 2021 to August 2022 in the Department of Anaesthesiology, Kalinga Institution of Medical Sciences (KIMS), Bhubaneswar, Odisha, India, among patients undergoing spinal anaesthesia for various surgeries. The patients were divided into two groups based on the type of medication received: Group APalonosetron group and Group B- the saline group. Computergenerated random number generator software was used for randomisation. At a 1:1 ratio, 150 patients were chosen (75 in each group). Baseline assessment of haemodynamic parameters was performed, followed by continuous monitoring. The drug was administered 10 minutes prior to spinal anaesthesia, and the haemodynamic parameters (Heart Rate [HR], Systolic Blood Pressure [SBP], Diastolic Blood Pressure [DBP], and Mean Arterial Pressure [MAP]) were monitored. Continuous variables are expressed as mean±Standard Deviation (SD). The Student’s t-test was used to compare the difference between the two groups, and categorical variables are expressed as frequency and percentage, with comparisons done using the Chi-square test. A p-value of <0.05 was considered statistically significant. Results: The mean age of Group A and Group B was 40.88 and 42.14, respectively. Significant haemodynamic changes (hypotension) were observed following induction in Group B (28 [37.3%]) compared to Group A (9 [12%]). Consumption of vasopressors and intravenous (i.v.) fluids was significantly higher in Group B compared to Group A. The incidence of bradycardia in Group A and Group B was 15 (20%) and 18 (24%), respectively. Postoperative Nausea and Vomiting (PONV) in Group A and Group B were 3 (4%) and 8 (10.7%), respectively. Conclusion: Based on the present study, the prophylactic administration of 0.075 mg Palonosetron 10 minutes before subarachnoid block is effective in attenuating the incidence of spinal anaesthesia-induced hypotension and bradycardia. There is also decreased consumption of vasopressors and a lower incidence of PONV..

The effectiveness of noradrenaline for preventing hypotension during spinal anesthesia for cesarean delivery

Background: Spinal anesthesia-induced hypotension is a common complication which can cause many severe maternal and fetal consequences. Therefore, the prevention and treatment of this complication play an important role. The vasopressor recently suggested to prevent hypotension during spinal anesthesia has been noradrenaline. The aim of this study is to evaluate the efficacy and side effects of noradrenaline intravenous transfusion and bolus for prevention of spinal anesthesia-induced hypotension during cesarean delivery. Methods: In the randomized controlled study, 110 pregnants undergoing cesarean delivery with spinal anesthesia were randomly divided into two groups: Group T: noradrenaline transfusion at a dose of 0.05 μg/kg/min (n = 55), and group B: noradrenaline intravenous injection 6 μg (n = 55). Both groups were recorded the incidence of hypotension, levels of hypotension, maternal side effects and neonatal APGAR scores at 1 and 5 minutes. Results: Four parturients in group B were excluded from the study due to the failure of spinal anesthesia. Maternal hypotension and level of hypotension of 20 - 30% of baseline systolic blood tension were less frequent in group T than in group B. The level of hypotension above 30% of baseline systolic blood tension and maternal side effects in both groups were low and comparable. The neonatal APGAR scores at 1 minute and 5 minutes in both groups were ≥ 8 and ≥ 9 respectively… Conclusion: Noradrenaline prophylactic infusion at dose of 0.05 μg/kg/min was more effective than noradrenaline intravenous bolus of 6 μg for maintaining blood pressure and decreasing the incidence of hypotension, level of hypotension. In addition, both groups of prophylactic noradrenaline didn’t cause detrimental adverses for parturients and their babies. Key words: hypotensive prophylaxis, cesarean delivery, noradrenaline.

Comparative Study between Intramuscular Ephedrine Versus Intravenous Ondansetron Versus Intravenous Dexamethasone for Prevention of Spinal Anaesthesia-Induced Hypotension in Parturients Undergoing Caesarean Section

Comparative Study between Intramuscular Ephedrine Versus Intravenous Ondansetron Versus Intravenous Dexamethasone for Prevention of Spinal Anaesthesia-Induced Hypotension in Parturients Undergoing Caesarean Section

Role of left uterine placement in maternal care bundle for the prevention of spinal anesthesia-induced hypotension in cesarean section

Background Hypotension is the most common serious scenario in patients undergoing cesarean sections under spinal anesthesia. Care bundles have been employed using a set of three to five approaches with the aim to prevent and manage hypotension after spinal anesthesia. This study was conducted to determine the effectiveness of left uterine placement in maternal care bundle for the prevention of spinal anesthesia-induced hypotension in cesarean section.Patients and methods A total of 100 parturients age 25–35 years with American Society of Anesthesia grades I and II, undergoing elective cesarean section under spinal anesthesia, were assigned into two equal groups at random: group A and group B (each group n=50). Both groups were subjected to a bundle of care using 4-mg ondansetron diluted in 10-ml normal saline given slowly intravenous for 5 min before the induction of spinal anesthesia, and spinal anesthesia was initiated using hyperbaric bupivacaine with a constant dose (10 mg), and administration of intravenous ephedrine 9 mg was done after spinal anesthesia had been cited. Group A was subjected to additional parameter in the care bundle, including patient’s suitable position with left displacement of the pregnant uterus. Mean arterial blood pressure (MABP) and heart rate (HR) were recorded every 5 min for 45 min after spinal anesthesia. The total ephedrine and atropine requirements were also determined.Results Both groups showed a nonsignificant difference of the MABP and HR at the baseline measurement values. Follow-up of MABP and HR values every 5 min for 45 min after the onset of spinal anesthesia showed a statistically significant decrease in both groups. Overall consumption of ephedrine and atropine showed statistically significant decrease in group A compared with group B (P<0.001 and 0.01, respectively). By comparing the effect size between both groups using Cohen’s d test regarding MABP, HR measurements, and total dose of ephedrine and atropine, we found that it had a small effect size.Conclusion The application of left uterine placement is an important and effective parameter in a maternal care bundle for decreasing the incidence of postspinal anesthesia hypotension in parturients undergoing elective cesarean section.

A Randomized Controlled Trial of Phenylephrine and Noradrenaline Boluses for Treatment of Postspinal Hypotension During Elective Caesarean Section

(Anaesthesia. 2019;74:850–855) Phenylephrine is the preferred vasopressor for treating spinal-induced hypotension during cesarean delivery due to its rapid onset, short duration of action, and lack of adverse effects on fetal acid-base status. However, norepinephrine is often used in critical care settings, especially in patients with septic shock, and may be less likely than phenylephrine to cause bradycardia. Although several studies have been conducted in recent years on the use of norepinephrine for the treatment and prevention of spinal-induced hypotension during cesarean delivery, there are limited data comparing phenylephrine and norepinephrine in terms of safety, efficacy, neonatal outcomes, and side effects. This study aimed to compare the rate of maternal bradycardia between the 2 drugs when administered as intravenous boluses to treat hypotension during elective cesarean delivery with spinal anesthesia.

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) Hypotension is a common adverse effect of spinal anesthesia for cesarean section. In this setting, phenylephrine is the preferred vasopressor for the treatment of spinal-induced hypotension because it has been associated with a lower rate of fetal acidosis compared with ephedrine. However, this conclusion was based on studies performed in low-risk healthy parturients. Some studies in high-risk parturients undergoing spinal anesthesia for cesarean section, have since been performed. They have not found a difference in umbilical artery pH when ephedrine as compared with phenylephrine was used to treat hypotension. However, the retrospective design of some of these studies is prone to bias. Therefore, the current investigators decided to conduct a meta-analysis of prospective, randomized controlled trials comparing ephedrine versus phenylephrine for the treatment or prevention of spinal-induced hypotension during high-risk cesarean sections.

Effect of leg wrapping technique on prevention of spinal induced hypotension and fetal acidosis during cesarean section: Randomized controlled trial

Background and aim: Hypotension during cesarean section (CS) under spinal anesthesia has been a subject of scientific study for more than 50 years and the search for the most effective strategy to achieve hemodynamic stability remains challenging. Aim: The study was carried out to apply leg wrapping technique for the prevention of spinal-induced hypotension (SIH) during CS.Methods: Randomized Controlled Trial design was utilized at cesarean delivery operating room Mansoura General Hospital in El-Mansoura City during the period from May 2018 to November 2018. A purposive sample of 88 pregnant women, assigned randomly to an intervention group (n = 44) in which their legs wrapped with elastic crepe bandage and control group (n = 44) in which no wrapping was done. Data collected for maternal, neonatal hemodynamic and signs of hypotension, the feasibility of application and cost analysis.Results: There was a statistically significant difference in the incidence of SIH and Ephedrine use among both groups (18.20% in leg wrapping group whereas 75% in control group). In addition, neonatal acidosis and NICU admission were less among leg wrapping group (11.40%, 9.10% respectively). Economically, leg wrapping technique was cost effective compared to the cost of the hospital regimen for treating SIH and admission to (NICU).Conclusion and recommendations: Leg wrapping technique was cost effective and an efficient method for decreasing SIH, neonatal acidosis and Ephedrine administration. It is recommended to apply leg wrapping technique in maternal hospitals' protocol of care for decreasing SIH during CS.

Effect of ondansetron in the prevention of spinal anesthesia-induced hypotension

Background and Aims: Hypotension and bradycardia are the common side effects seen after spinal anesthesia. Multiple strategies are tested to prevent the postspinal anesthesia-induced hypotension. Recently, Ondansetron, a 5-HT3 antagonist commonly used as an antiemetic was found to be effective in preventing spinal anesthesia-induced hypotension. The aim of this study is to evaluate the effect of ondansetron in the prevention of spinal anesthesia-induced hypotension. Materials and Methods: A prospective, randomized, and double-blind study was conducted on 110 elderly patients, aged 50–70 years, of the American Society of Anesthesiologists Grade I or II category, scheduled for various surgeries under spinal anesthesia. The patients were randomly divided into two groups of 55 each to receive either ondansetron 8 mg (Group A) or saline (Group B) before spinal anesthesia. The primary outcome of the study was the incidence of hypotension (systolic blood pressure 20% in the baseline values). Secondary outcomes, such as the requirement of ephedrine, the incidence of bradycardia, nausea, and vomiting were also recorded during the study. Results: Group A and Group B were comparable with respect to age, sex, height, and weight. Thirty-four patients in Group B (60.7%) and 22 patients in Group A developed hypotension (39.3%) (P = 0.0359) [Table 1]. The use of ephedrine was greater in Group B than that of Group A (mean 4.61 ± 1.80 vs. 3.45 ± 1.09, P = 0.0107). Thirteen patients in Group B and four patients in Group A had bradycardia (P = 0.0176). Nine patients in Group B and two patients in Group A had vomiting (P = 0.0261). Conclusion: We conclude that prophylactic administration of ondansetron is effective in reducing the incidence of spinal anesthesia-induced hypotension.

Prevention of Spinal Anesthesia-induced Hypotension During Cesarean Delivery by 5-Hydroxytryptamine-3 Receptor Antagonists: A Systematic Review and Meta-analysis and Meta-regression

(Anesth Analg. 2016;123(4):977–988) Hypotension is a common complication affecting obstetric patients receiving spinal anesthesia, and can lead to nausea and vomiting, altered consciousness, and increased risk of aspiration. As 5-hydroxytryptamine (5-HT3, serotonin) receptors are involved in the mechanism, studies have evaluated 5-HT3 receptor antagonists for their potential to prevent spinal anesthesia-induced hypotension. The authors of the present meta-analysis reviewed the effect of 5-HT3 receptor antagonists on the frequency of hypotension in patients undergoing spinal anesthesia.

Prevention of Spinal Anesthesia-Induced Hypotension During Cesarean Delivery by 5-Hydroxytryptamine-3 Receptor Antagonists

Prevention of Spinal Anesthesia-Induced Hypotension During Cesarean Delivery by 5-Hydroxytryptamine-3 Receptor Antagonists

Treatment and Prevention of Spinal-Induced Hypotension in the Cesarean Section Patient: What Does the Evidence Say?

Most anesthesia providers prefer to do a subarachnoid block (SAB) for cesarean section because of its rapid onset and reliability to provide adequate anesthesia. However an effect of the SAB is that it causes a spinal-induced hypotension (SIH) in up to 85% of the population. There have been multiple studies that assessed fluid administration, vasopressor administration, maternal positioning, or serotonin blockers given prophylactically to attenuate the SIH response. Despite these multiple studies, the method to prevent and treat SIH remains varied from one anesthesia practice to another. The purpose of this chapter is to review the evidence on the various methods used to prevent and treat SIH.

Prevention of Spinal Anesthesia-Induced Hypotension During Cesarean Delivery by 5-Hydroxytryptamine-3 Receptor Antagonists: A Systematic Review and Meta-analysis and Meta-regression.

Hypotension remains a frequent complication of spinal anesthesia, increasing the risk of nausea and vomiting, altered mental status, and aspiration. The aim of this systematic review and meta-analysis was to determine whether 5-hydroxytryptamine3 (5-HT3) receptor antagonists, administered before the initiation of spinal anesthesia, mitigate hypotension. After a systematic literature search in various databases, randomized placebo-controlled double-blind trials studying the preventive effect of 5-HT3 receptor antagonists were included. A random-effects model was applied, risk ratio (RR, binary variables) or weighted mean difference (continuous variables) with 95% confidence intervals (CIs) were calculated. The primary outcome was the incidence of hypotension. Seventeen trials (8 obstetric, 9 non-obstetric) reporting on 1604 patients were identified. Ondansetron in doses from 2 to 12 mg was studied in 12 trials. Prophylactic 5-HT3 administration significantly reduced the risk of hypotension in the combined analysis of 17 trials, RR 0.54 (95% CI 0.36-0.81, I = 79%). In obstetric trials, the RR was 0.52, 95% CI 0.30-0.88, I = 87% (number needed to treat 4). In non-obstetric studies, the 95% CIs were wide and included a clinically relevant reduction in the risk of hypotension (RR 0.50, 95% CI 0.22-1.16; I = 66%). Contour-enhanced funnel plots confirmed publication bias. Meta-regression showed a significant ondansetron dose response in non-obstetric patients (β = -0.355, P = .04). In the combined and in the obstetric-only analysis, the risk of bradycardia was significantly reduced as was the use of phenylephrine equivalents. 5-HT3 antagonists are effective in reducing the incidence of hypotension and bradycardia; the effects are moderate and are only significant in the subgroup of patients undergoing cesarean delivery. The effects in the non-obstetric population are not significant.

Comparison between colloid preload, coload, and no load in the prevention of spinal anesthesia-induced hypotension in patients undergoing inguinal hernia repair

Background and objective The aim of this study was to know whether colloid fluid administration (either preloading or coloading) can decrease the incidence of hypotension secondary to spinal anesthesia in an elderly population undergoing inguinal hernia repair without mesh. Patients and methods After obtaining institutional ethical committee's approval and patients' informed consent, 84 patients (aged 61-89 years) scheduled for elective inguinal hernia repair were enrolled in this prospective, randomized study. We compared the incidence of hypotension and ephedrine requirement after spinal anesthesia between three groups: group P ( n = 28), in which patients were preloaded with 500 ml of 6% hydroxyethyl starch solution (130/0.4), group C ( n = 28), in which patients were coloaded with 6% hydroxyethyl starch solution during spinal anesthesia, and group N ( n = 28), in which patients were not given any fluid. Results The incidence of hypotension and the mean dose of ephedrine were not significantly different between the three groups. Conclusion We concluded that, in elderly patients undergoing inguinal hernia repair, withholding fluid loading (whether preloading or coloading) did not increase the incidence of spinal anesthesia-induced hypotension and did not affect the dose of ephedrine required to correct hypotension, if occurred.

Norepinephrine versus ephedrine for the prevention of spinal anesthesia-induced hypotension in coronary artery disease patients undergoing knee arthroscopy

Background Spinal anesthesia, a popular technique used for lower limb surgery in coronary artery disease patients, could be associated with hypotension, which could be managed with colloids, vasopressor, ephedrine, or norepinephrine (NE). Aim The aim of this study was to assess the efficacy and safety of bolus administration of NE versus ephedrine for the maintenance of systolic blood pressure during spinal anesthesia in coronary artery disease patients undergoing knee arthroscopy. Patients and methods A randomized, controlled, double-blinded study was carried out on 100 ASA II or III coronary artery disease patients undergoing knee arthroscopy. The patients were divided into two groups of 50 patients each: the ephedrine group (group EPH) and the norepinephrine group (group NE). When hypotension occurred, group EPH received 5 mg of ephedrine and group NE received 5 μg of NE. Systolic blood pressure and heart rate were recorded at 0, 5, 10, 15, 30, and 60 min, and side effects of both drugs were also recorded. Results Efficacy was found in 20 (40%) patients of group EPH and in 40 (80%) patients of group NE. The results were highly significant ( P P Conclusion NE is more effective compared with ephedrine in the maintenance of systolic blood pressure with reduction in heart rate, which is useful in coronary artery disease patients undergoing knee arthroscopy under spinal anesthesia in whom tachycardia is undesirable.

A comparative study of infusions of phenylephrine, ephedrine and phenylephrine plus ephedrine on maternal haemodynamics in elective caesarean section

Introduction:This randomized double blind study was started with an objective of management of spinal anaesthesia-induced hypotension in elective caesarean section by combining two commonly used vasopressors – ephedrine and phenylephrine in half of their usual doses with an expectation of reducing their foetomaternal side effects.Methods:One hundred and thirty two patients were randomized into three groups to receive either 100 μg/ml phenylephrine (group-P, n=31) or 3 μg/ml ephedrine (group-E, n=33) or 50 mg phenylephrine plus 1.5 mg ephedrine/ml (group-PE, n=29). Immediately after spinal injection the study solution was started prophylactically in every patient at the rate of 40 ml/h. A predefined algorithm was used to adjust the infusion rate according to the systolic blood pressure (SBP).Results:Mean fall of SBP was significantly more in group-E than group-P (P=0.009) and group-PE (P=0.013). This was not significantly different when compared between group-P and group-PE (P=0.9). Episodes of hypotension and tachycardia were more in group-E than the other two groups. Statistically significant tachycardia was seen in Group-E than that in other two groups. Incidence of bradycardia and hypertension did not differ significantly among the groups. Maternal nausea and Apgar score were also comparable in three groups.Conclusion:Current study claims that prophylactic phenylephrine 100 mg/ml is a better choice than ephedrine (3 mg/ml) or 50 mcg phenylephrine plus 1.5 mg ephedrine/ml in prevention of spinal anaesthesia-induced hypotension in elective caesarean section. Combination of two drugs in half the usual dose has no added advantage over phenylephrine, but this is better than ephedrine alone.

Patients Undergoing Transurethral Resection of the Prostate Should Receive the Same Amount of Intravenous Fluids

In Response: We do not fully agree with the interpretation of our data by Duman and Apiliogullari1 that no firm conclusions can be made regarding the type of fluid and its effects on cardiac output and blood pressure.2 In our discussion, we did point out that the difference in results could have been due to the different volumes of fluid given to the two groups. However, we believe that the more stable hemodynamic status observed after colloid plus saline administration probably relates to the colloid remaining in the intravascular compartment longer than crystalloids alone. Our results are consistent with the findings of Riley et al.3 who compared the efficacy of 500 mL 6% hetastarch plus 1000 mL lactated Ringer’s solution (LR) with an even larger volume of LR (2000 mL) given alone before spinal anesthesia to patients undergoing nonurgent cesarean delivery. They concluded that 6% hetastarch plus LR was more effective in stabilizing hemodynamic status than LR alone. However, this article is also flawed in that different volumes were given in the two groups, albeit less in the colloid group than in the crystalloid group.2 Further studies with many patients should be undertaken to fully elucidate the value of crystalloid and colloid preload in the prevention of spinal anesthesia-induced hypotension. Stefan Suttner, MD, PhD André Riesmeier, MD Joachim Boldt, MD, PhD Department of Anesthesiology and Intensive Care Medicine Klinikum der Stadt Ludwigshafen Ludwigshafen, Germany [email protected]