Spinal Anesthesia For Cesarean Delivery Research Articles

Impact of Arterial Hypotension During Spinal Anesthesia for Cesarean Delivery on the Newborn at Kouba Hospital

Introduction: Spinal anesthesia is commonly used for cesarean deliveries but can lead to maternal hypotension, a frequent complication that may adversely affect the fetus. The objective of this study was to determine the incidence of post-spinal hypotension for cesarean delivery and identify associated risk factors. Methods: This was a prospective descriptive study conducted at Kouba Hospital over one month. Inclusion criteria were patients admitted for scheduled or emergency cesarean under spinal anesthesia after informed consent, without absolute contraindication to spinal anesthesia, baseline blood pressure ≥100 mmHg, and heart rate ≤100 bpm. Patients were excluded if hypotensive, vagotonic, had pre-existing cardiac disease, or received general anesthesia. All patients received 8 mg 0.5% bupivacaine, 2.5 μg sufentanil, and 100 μg intrathecal morphine with standard monitoring and 250 ml fluid preloading. Hypotension was defined as ≥20% decrease from baseline blood pressure. Data collected included demographics, obstetric history, and anesthetic/surgical details. Analysis was done using EPI Info software. Results: 42 parturients were included, mostly ASA II, with mean BMI 26.5±4.1 kg/m2 and gestational age 37.4±2.1 weeks. 50% had a history of hypotension in previous cesareans, and 68% underwent emergency cesarean. Sensory block reached T4 level on average. Hypotension incidence was 80%, with 40% requiring additional fluids and mean 15±10 mg ephedrine. Despite hypotension, most neonates had satisfactory Apgar scores. High BMI, emergency cesarean, and previous hypotension history were significantly associated with increased hypotension risk. Discussion: The high 80% hypotension incidence aligns with literature reports of 70-90%, likely exacerbated by using isobaric/hypobaric rather than hyperbaric bupivacaine. Identified risk factors were consistent with published data. Prompt management likely prevented major neonatal consequences. Conclusion: Intraoperative hypotension is frequent after spinal anesthesia for cesarean delivery. Guidelines recommend a standardized approach with fluid loading, vasopressors, and lateral tilt positioning to prevent maternal and fetal complications. Larger studies are needed to further characterize risk factors.

6248797 Spinal anaesthesia for Caesarean delivery in a patient with severe Factor VII deficiency

6248797 Spinal anaesthesia for Caesarean delivery in a patient with severe Factor VII deficiency

Agreement between three noninvasive temperature monitoring devices during spinal anaesthesia for caesarean delivery: a prospective observational study.

Hypothermia during obstetric spinal anaesthesia is a common and important problem, yet temperature monitoring is often not performed due to the lack of a suitable, cost-effective monitor. This study aimed to compare a noninvasive core temperature monitor with two readily available peripheral temperature monitors during obstetric spinal anaesthesia. We undertook a prospective observational study including elective and emergency caesarean deliveries, to determine the agreement between affordable reusable surface temperature monitors (Welch Allyn SureTemp® Plus oral thermometer and the Braun 3-in-1 No Touch infrared thermometer) and the Dräger T-core© (using dual-sensor heat flux technology), in detecting thermoregulatory changes during obstetric spinal anaesthesia. Predetermined clinically relevant limits of agreement (LOA) were set at ± 0.5°C. We included 166 patients in our analysis. Hypothermia (heat flux temperature < 36°C) occurred in 67% (95% CI 49 to 78%). There was poor agreement between devices. In the Bland-Altman analysis, LOA for the heat flux monitor vs. oral thermometer were 1.8°C (CI 1.7 to 2.0°C; bias 0.5°C), for heat flux monitor vs. infrared thermometer LOA were 2.3°C (CI 2.1 to 2.4°C; bias 0.4°C) and for infrared vs. oral thermometer, LOA were 2.0°C (CI 1.9 to 2.2°C; bias 0.1°C). Error grid analysis highlighted a large amount of clinical disagreement between methods. While monitoring of core temperature during obstetric spinal anaesthesia is clinically important, agreement between monitors was below clinically acceptable limits. Future research with gold-standard temperature monitors and exploration of causes of sensor divergence is needed.

Effect of phenylephrine rescue injection on hypotension after spinal anaesthesia for caesarean delivery when guided by both heart rate and SBP during an early warning window: A randomised controlled trial.

Spinal anaesthesia is now the most common technique for caesarean delivery. However, because of the intermittent nature of noninvasive blood pressure (NIBP) measurements, maternal blood pressure may become hypotensive between the measurements. There is thus an inbuilt delay before the anaesthesiologist can intervene to counteract the hypotension. Based on the principle that changes in blood pressure can induce compensatory changes in the heart rate (HR), combining the NIBP with real-time HR, we designed two warning windows to predict hypotension and hypertension. To evaluate whether phenylephrine administration guided by these warning windows would help maintain haemodynamic stability. A teaching hospital. A randomised controlled trial. One hundred and ten pregnant women scheduled for elective caesarean delivery were enrolled, from which, after exclusions, 86 were eligible for the study. All eligible patients received a continuous intravenous infusion of phenylephrine as soon as spinal anaesthesia was initiated. Thereafter, patients were randomly assigned to two groups. In the test group (Win-Group): rescue phenylephrine administration was triggered by an early warning window of HR above 100 beats per minute (bpm) and SBP 90 to 110 mmHg; pausing the infusion phenylephrine was triggered by a HR lower than 60 bpm and SBP greater than 90 mmHg. In the control group, phenylephrine was guided by BP only when it appeared on the monitor: SBP less than 90 mmHg was the trigger for administering rescue phenylephrine; SBP greater than 110 mmHg was the trigger for pausing the phenylephrine infusion. The primary outcome was incidence of hypotension. Secondary outcomes were the incidence of hypertension and other adverse haemodynamic events. The incidence of hypotension was significantly lower in the Win-Group than in the BP-Group (27.8 vs. 66.7%, P = 0.001). The minimum SBP was significantly higher in Win-Group than in BP-Group (93.9 ± 9.49 vs. 86.7 ± 11.16 mmHg, P  = 0.004). There was no significant difference in the incidence of hypertension between groups. After spinal anaesthesia for caesarean delivery, when phenylephrine infusion is guided by HR along with BP from a warning window it effectively reduces the incidence of hypotension without any significant effect on incidence of hypertension. Chictr.org.cn; Identifier: ChiCTR 2100041812.

Failed spinal anesthesia for cesarean delivery: prevention, identification and management.

There is an increasing awareness of the significance of intraoperative pain during cesarean delivery. Failure of spinal anesthesia for cesarean delivery can occur preoperatively or intraoperatively. Testing of the neuraxial block can identify preoperative failure. Recognition of the risk of high neuraxial block in repeat spinal in case of preoperative failure is important. Knowledge of risk factors for block failure facilitates prevention by selecting the most appropriate neuraxial procedure, adequate intrathecal doses and choice of technique. Intraoperative pain is not uncommon, and neither obstetricians nor anesthesiologists can adequately identify intraoperative pain. Early intraoperative pain should be treated differently from pain towards the end of surgery. Block testing is crucial to identify preoperative failure of spinal anesthesia. Repeat neuraxial is possible but care must be taken with dosing. In this situation, switching to a combined spinal epidural or an epidural technique can be useful. Intraoperative pain must be acknowledged and adequately treated, including offering general anesthesia. Preoperative informed consent should include block failure and its management.

Modelling the incidence and severity of hypothermia during spinal anaesthesia for caesarean delivery: a prospective observational study in a resource-limited setting

Modelling the incidence and severity of hypothermia during spinal anaesthesia for caesarean delivery: a prospective observational study in a resource-limited setting

High Neuraxial Block in Obstetrics: A 2.5-Year Nationwide Surveillance Approach in the Netherlands.

High neuraxial block is a rare but serious adverse event in obstetric anesthesia that can ultimately lead to respiratory insufficiency and cardiac arrest. Previous reports on its incidence are limited to populations in the United Kingdom and the United States. Little is known about the incidence and clinical features of high neuraxial block in the Netherlands, where the presence of anesthesiologists in the labor and delivery unit is comparatively lower. We aimed to assess the incidence and clinical features of high neuraxial block in obstetrics and to formulate ways to improve obstetric anesthesia on a national level. This nationwide, prospective, population-based cohort study was designed to identify cases of high neuraxial block requiring ventilatory support (with supraglottic airway device or tracheal intubation) or cardiopulmonary resuscitation between November 2019 and May 2022. Cases were prospectively collected using the Netherlands Obstetric Surveillance System (NethOSS) in all hospitals with a maternity unit. Complete case file copies were obtained to determine risk factors and clinical course. During the study period, 5 cases of high neuraxial block requiring tracheal intubation were identified. The estimated incidence of high neuraxial block requiring tracheal intubation was 1 in 29,770 neuraxial procedures in labor (95% confidence interval, 1:12,758-1:91,659). Three of 5 identified cases occurred in the operating room after single-shot spinal anesthesia for Cesarean delivery after epidural analgesia in labor. One case developed in the labor ward due to an inadvertent intrathecal or subdural catheter placed for labor analgesia. The fifth case followed single-shot spinal anesthesia for elective Cesarean delivery. All 5 patients were successfully extubated in the operating room after Cesarean delivery, without the need for intensive care admission. There were no cardiac arrests and no neonatal deaths. High neuraxial block requiring tracheal intubation is a rare but impactful complication in obstetric anesthesia, potentially affecting both mother and fetus. Spinal anesthesia after epidural analgesia in labor is a common cause of high neuraxial block. Meticulous follow-up of epidurals in labor facilitates conversion to surgical anesthesia and may therefore reduce the need for spinal anesthesia after epidural analgesia. Large-scale surveillance systems in obstetric anesthesia are needed to identify those at risk, as well as to formulate further strategies to mitigate this burden.

The effect of addition of ultra-low dose of naloxone to fentanyl–bupivacaine mixture on the incidence of pruritis after spinal anesthesia for cesarean delivery: Randomized clinical study

Abstract Background and Aims: The use of intrathecal opioids is associated with high risk of pruritis and this may be decreased by adding a low dose of naloxone. This study evaluated the effect of the addition of 20 μg of naloxone to fentanyl–bupivacaine mixture on the incidence of pruritis in pregnant females scheduled for cesarean section (CS). Material and Methods: Eighty pregnant patients scheduled for CS under spinal anesthesia were randomized to receive either 10 mg of 0.5% hyperbaric bupivacaine (2 ml) plus 25 μg fentanyl (group F) or 10 mg of 0.5% hyperbaric bupivacaine (2 ml) plus 25 μg fentanyl and 20 μg naloxone (group FN). The incidence, onset, duration, site, and severity of pruritis were measured. Furthermore, the postoperative numerical rating scale (NRS) score, the total tramadol rescue analgesia, and the time for the first request of rescue analgesia were recorded. Results: Compared to the F group, the FN group showed a significant decrease in the incidence of pruritis (P = 0.022), prolongation of the onset of pruritis (P = 0.006), shortening of the duration of pruritis (P = 0.029), and decrease in the severity of pruritis (P = 0.039). Furthermore, the postoperative pain score, the rescue analgesic consumption, and the time for the first request of rescue analgesia were comparable between the two groups (P &gt; 0.05). Conclusions: The addition of an ultra-low dose of naloxone (20 μg) to fentanyl–bupivacaine mixture in spinal anesthesia for pregnant females scheduled for CS significantly reduced the incidence of pruritis without having a significant effect on the postoperative analgesia.

A retrospective cohort study of the anesthetic management of postpartum tubal ligation

BackgroundNeuraxial anesthesia with reactivation of a labor epidural catheter is commonly utilized for postpartum tubal ligations (PPTL), although the optimal anesthetic approach is unknown. We assessed institutional anesthesia practices for PPTL, and evaluated the failure rates of reactivation of labor epidural catheters, de novo spinal anesthesia, and spinal anesthesia after failed blocks. MethodsWe conducted a single-center retrospective cohort analysis of 300 consecutive patients who underwent a PPTL and 100 having spinal anesthesia for cesarean delivery. Anesthetic management data (existing labor epidural catheter reactivation, de novo spinal anesthesia or general anesthesia) were collected from electronic medical records. Anesthetic block failure rates were determined for each anesthetic technique. ResultsThe failure rate was 15% for de novo spinal anesthesia and 23% after failed reactivation of a labor epidural catheter or spinal anesthesia. The epidural catheter reactivation failure rate was 35%. The failure rate of spinal anesthesia for cesarean delivery was 4%. Drug dosage, epidural catheter use in labor, time since epidural catheter placement or delivery, labor neuraxial technique (combined spinal-epidural, epidural), supplemental top-up doses during labor, and anesthesiologist experience did not predict neuraxial anesthesia failures. ConclusionsOur analysis revealed an unexpectedly high neuraxial anesthesia failure rate even when de novo spinal anesthesia was used for PPTL. The results are consistent with other institutions' recent findings, and are higher than spinal anesthesia failure rates associated with cesarean delivery. Further studies are required to determine optimal anesthesia dosing strategies, and to understand the mechanisms behind high neuraxial anesthesia failures for PPTL.

A Prospective Randomized Double Blind Comparative Study to Determine the Efficacy of Norepinephrine and Ephedrine to Maintain Arterial Blood Pressure During Spinal Anesthesia for Cesarean Delivery

Background: Spinal Anesthesia Induced Hypotension(SAIH) continues to be the troublesome complication for obstetric patients undergoing cesarean section under subarachnoid block. Vasopressors are emerging as the cornerstone of treating SAIH in cesarean section patients with the evolving evidence of arterial vasodilatation as the primary cause of hypotension. This study was hypothesized to compare the efficacy of norepinephrine and ephedrine boluses to maintain hemodynamics in cesarean section.&#x0D; Methods: After approval from institutional ethics committee and registration in Clinical Trials Registry India(CTRI ) and informed consent, study was conducted in 110 healthy parturients aged 18-40 years, belonging to ASA  physical status I and II, posted for elective cesarean section under spinal anesthesia, were randomly allocated into group N(n=55) and group E(n=55),who received intravenous boluses of norepinephrine  6 g and ephedrine 10mg respectively as prophylaxis(one dose soon after induction) and in treatment of SAIH. The number of vasopressor boluses were recorded as primary objective and hemodynamics, APGAR scores, adverse events were noted.&#x0D; Results: The number of boluses of vasopressor used was 1.9±1.2 for Ephedrine and 4.72±2.9 for Norepinephrine. At 30,40,50 and 60 minutes after anesthesia, there was significant fall in mean arterial pressure in the norepinephrine group compared to ephedrine group. The incidence of tachycardia was more in ephedrine group and incidence of bradycardia was more in norepinephrine group.&#x0D; Conclusion: Both the study drugs, ephedrine and norepinephrine are  comparably effective in preventing SAIH after prophylactic bolus and effective in maintaining blood pressure intraoperatively, more number of boluses of norepinephrine was required compared to ephedrine.

Is crystalloid co-loading necessary to prevent spinal hypotension during elective cesarean delivery? A randomized double-blind trial

BackgroundHypotension is common during spinal anesthesia for cesarean delivery. Preventive strategies include fluid loading and phenylephrine. We hypothesized that if prophylactic phenylephrine infusion is used, omission of fluid loading would be non-inferior to fluid co-loading in maintaining cardiac output. We assumed that if there was a difference, the increase in cardiac output would be greater in the no-loading than in the co-loading group. MethodsTerm pregnant women scheduled for elective cesarean delivery were randomized to receive 1 L crystalloid co-loading or maintenance fluids only. Phenylephrine was titrated to maintain blood pressure. Changes in cardiac output following spinal anesthesia were the primary outcome. The study was powered as a non-inferiority trial, allowing the no-loading arm to have a 50% greater change in cardiac output. Heart rate, dose of phenylephrine, occurrence of nausea and vomiting, Apgar scores and neonatal acid base status were secondary outcomes. ResultsData from 63 women were analyzed. In contrast to our hypothesis, there was 33% less increase in cardiac output with no loading (ratio 0.67, 95% CI 0.15 to 1.36), and 60% greater reduction of cardiac output with no loading (ratio 1.6, 95% CI 1.0 to 2.7). Total dose of phenylephrine was higher in the no-loading group. There may be a less favorable neonatal acid base status without volume loading. ConclusionOmission of crystalloid co-loading leads to a decrease in cardiac output which has a potentially unfavorable impact on neonatal acid base status. We conclude that crystalloid co-loading may be useful in the presence of phenylephrine infusion.

Evaluation of the 'Sip Til Send' regimen before elective caesarean delivery using bedside gastric ultrasound: A paired cohort pragmatic study.

Pre-operative fasting is routinely advocated to avoid pulmonary aspiration. The European Society of Anaesthesiology and Intensive Care (ESAIC) recommends a fasting period of 2 h for liquids before surgery. Liberal drinking policies such as the 'Sip Til Send' are a suggested alternative to maintain hydration before surgery. To compare residual gastric volumes in fully fasted nonlabouring parturients before elective caesarean delivery with the 'Sip Til Send' with water liberal drinking protocol. Our hypothesis was the 'Sip Til Send' would be noninferior to standard fasting at minimising the residual gastric volume immediately before surgery. A paired cohort prospective observational pragmatic study using gastric ultrasound, analysed by an operator blinded to the fasting status of each scan. A tertiary maternity hospital in Dublin, Ireland. The study was conducted between January and June 2023. Pregnant women about to undergo elective caesarean delivery who had followed ESAIC fasting guidelines before admission. Each participant underwent two pairs (semi-recumbent and the semi-recumbent right lateral positions) of standardised ultrasound examinations of the gastric antrum: the order of these scans was randomised. The first pair of scans occurred on admission before the 'Sip Til Send' protocol commenced, the other pair just before spinal anaesthesia for caesarean delivery, after a variable time following the 'Sip Til Send' protocol. The primary outcome was the difference in antral cross-sectional area (CSA) between the fully fasted women on admission and the same women after following the 'Sip Til Send' protocol until just before spinal anaesthesia. Fifty-eight women were randomised for the study: 55 and 54 scans in the semi-recumbent position on admission, and 55 and 54 scans in the right lateral position just before spinal anaesthesia. The mean differences (95% CI) in CSA in the semi-recumbent and RL positions were 0.07 (-0.39 to 0.53) cm 2 and 0.04 (-0.60 to 0.68) cm 2 , respectively. Since the of 95% CIs did not cross the predefined noninferiority margin of 0.88 cm 2 , 'Sip Til Send' was noninferior to fully fasting in in terms of the antral CSA. The 'Sip Til Send' protocol of liberal hydration with water was noninferior to standard fasting prior to elective caesarean delivery. NCT05783427 ClinicalTrials.gov.

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) Spinal anesthesia (SA) can induce maternal hypotension which may compromise uteroplacental and fetal perfusion. Current practices that counteract SA-induced vasodilation employ a phenylephrine or norepinephrine infusion through computer-controlled, fixed-rate, and manual delivery methods. The current study investigated the hemodynamic effects of continuous infusion of norepinephrine compared with phenylephrine in maintaining cardiac index (CI) during cesarean delivery (CD) under SA.

Comparison of intermittent boluses of noradrenaline vs. phenylephrine for spinal anesthesia induced hypotension during cesarean delivery

Background and Objective: Maternal hypotension is a common consequence of spinal anesthesia for cesarean delivery (CD). A vasopressor is recommended in addition to adequate fluid loading to raise mean arterial pressure in pregnant women. Phenylephrine, a pure α–adrenergic receptor agonist, is the first-line agent to manage it. However, phenylephrine is associated with dose-dependent reflex bradycardia and decreased cardiac output. Noradrenaline is suggested as an alternative due to its mild beta-adrenergic effect, which results in a greater heart rate and cardiac output than phenylephrine. We compared the effectiveness and adverse effects of intermittent boluses of noradrenaline with phenylephrine to treat spinal-induced hypotension during CD.&#x0D; Methodology: A randomized controlled trial was conducted at Bach Mai Hospital, Vietnam, from May 2020 to August 2020. There were 120 pregnant women undergoing elective CD under spinal anesthesia enrolled in the study and divided randomly into two groups: the Group N  and the Group P. Group N patients were given noradrenaline 6 µg as an intravenous bolus, and Group P patients were given phenylephrine 100 µg to treat spinal-induced hypotension. The primary outcome was the number of bolus doses of vasopressors needed to treat maternal hypotension. Secondary outcomes were bradycardia, hypertension, nausea, vomiting, umbilical arterial blood gases, and APGAR scores.&#x0D; Results: The number of boluses of vasopressors needed to treat hypotension and maternal hemodynamic changes was equivalent in both groups. The incidence of bradycardia, nausea, and vomiting in the two groups was not significantly different. No pregnant woman suffered from unintended hypertension. APGAR scores were 7 and above at one min and 10 and above at five min for all cases. There were no differences in umbilical arterial pH values between the two groups (7.33 vs. 7.34; P &gt; 0.05).&#x0D; Conclusion: Noradrenaline 6 µg and phenylephrine 100 µg boluses were equally effective in treating spinal-induced hypotension in parturients undergoing cesarean delivery with similar neonatal and maternal outcomes.&#x0D; Abbreviations: CD - Cesarean Delivery; HR - Heart Rate; CO - Cardiac Output; SVR - Systemic Vascular Resistance; SBP - Systolic Blood Pressure; ED 90 - 90 Percent Effective Dose&#x0D; Key words: Anesthesia, Spinal; Hypotension; Cesarean Delivery&#x0D; Citation: Nguyen TT, Nguyen HC, Nguyen ATH, Doan TH, Ngo QS. Comparison of intermittent boluses of noradrenaline vs. phenylephrine for spinal anesthesia induced hypotension during cesarean delivery. Anaesth. pain intensive care 2023;27(5):562−566.&#x0D; DOI: 10.35975/apic.v27i5.2312&#x0D; Received: August 22, 2023; Reviewed: August 23, 2023; Accepted: August 31, 2023

The Effect of Adding 1% Glucose to Crystalloid on Maternal Hemodynamics After Spinal Anesthesia for Cesarean Delivery: A Double-Blind, Randomized Clinical Trial

Background: We aimed to evaluate the effect of glucose-containing crystalloid infusion before anesthesia induction on hemodynamics and postanesthesia complications. Methods: This double-blind, randomized clinical trial was conducted on 60 parturient cases scheduled for elective Cesarean delivery under spinal anesthesia who were referred to the teaching hospitals of Mashhad University of Medical Sciences (Iran). The parturients were randomized into two groups. Both groups received 5 - 7 mL/kg of intravenous bolus serum before spinal anesthesia. The parturients in the glucose-containing normal saline (GcNS) group received 1% glucose solution in normal saline. The normal saline (NS) group received only normal saline. Systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate (HR), blood glucose concentrations, neonatal Apgar scores, postanesthesia complications, and ephedrine and atropine consumption were evaluated. Results: Sixty patients were recruited (30 in each group), with a mean age of 29.14 ± 6.01 and 29.76 ± 6.15 years in the GcNS and NS groups, respectively. There was no significant difference between the two groups in SBP, DBP, or HR after baseline adjustment. The incidence of hypotension was higher in the NS (70.0%) compared to the GcNS group (46.6%), but the difference was not significant. There was no significant difference in Apgar scores. The incidence of nausea, vomiting, pallor, and shivering was higher in the NS group. However, only nausea and vomiting 10 minutes after anesthesia induction were significant. Ephedrine and atropine consumption was higher in the NS group, but not significantly. Conclusions: The present study did not show any clear benefit for adding 1% glucose to normal saline solution preload for hypotension in parturients undergoing Cesarean delivery with spinal anesthesia.

Investigation of the Optimum Baseline Blood Pressure for Spinal Anesthesia to Guide Vasopressor Management for Elective Cesarean Delivery: A Case-Control Design.

Current guidelines recommend prophylactic vasopressor administration during spinal anesthesia for cesarean delivery to maintain intraoperative blood pressure above 90% of the baseline value. We sought to determine the optimum baseline mean arterial pressure (MAP) reading to guide the management of spinal hypotension. We performed a secondary analysis of data collected from normotensive patients presenting for elective cesarean delivery in a tertiary care institution from October 2018 to August 2020. We compared the magnitude of hypotension in patients who reported nausea versus those who did not, using a case-control design. Baseline MAPs at last office visit, morning of surgery, or operating room (pre-spinal) were determined. We calculated the duration and degree of hypotension using the area under the curve (AUC) when the MAP of the respective patient was below 90% of each baseline. The patients who experienced nausea (n=45) had longer and more profound periods of hypotension than those who did not develop nausea (n=240). A comparison of AUC using MAP baseline at the last office visit or on the morning of surgery showed a statistically significant between-group difference, P=0.02, and P=0.005, respectively, and no significant between-group difference when 90% of the MAP baseline in the operating room was used. Patients had the highest preoperative MAP in the operating room and the AUC was similar for those with and without nausea when the pre-spinal MAP baseline was used. Therefore, maintaining higher intraoperative blood pressure using individual pre-spinal MAP as baseline should reduce intraoperative maternal nausea.

Effects of Adding Intrathecal Epinephrine to Spinal Anesthesia on Anesthesia-Related Cesarean Delivery Outcomes: Should We Reconsider Its Use?

Intrathecal epinephrine is used to increase the duration of spinal anesthesia for amenable surgical procedures anticipated to require additional time; however, in the ambulatory setting, it is associated with a prolonged time to post-anesthesia care unit (PACU) discharge. The current study's authors hypothesized that adding intrathecal epinephrine to spinal anesthesia for cesarean delivery would be associated with a dose-dependent prolonged post-anesthesia unit length of stay. A single-center, retrospective study of patients undergoing repeat cesarean delivery under spinal anesthesia from 2011 to 2015 was conducted. Patients received spinal bupivacaine 12 mg, morphine 150 mcg, and fentanyl 15 mcg with no-epinephrine, 100 mcg, or 200 mcg of epinephrine. The primary outcome was recovery room length of stay. Secondary outcomes were surgical duration, intraoperative vasopressor use, perioperative opioids, and antiemetic use. Data were analyzed for 1,362 patients. Median recovery room stay was 123 min (interquartile range, 100 to 150) and was not different among groups. More women receiving epinephrine 200 mcg had ≥2 prior cesarean deliveries compared with no-epinephrine or 100 mcg. No significant differences in surgical duration or intraoperative opioids were identified among the groups. Median intraoperative vasopressor use was increased by 225 mcg of phenylephrine equivalents (99% CI, 25 mcg to 430 mcg) in the 100 mcg group and 250 mcg of phenylephrine equivalents in the 200 mcg group (99% CI, 75 mcg to 500 mcg) compared to no-epinephrine (P<0.001). Recovery room antiemetic and opioid analgesic administration were not different among groups. Based on the results of this study, the addition of intrathecal epinephrine for women undergoing cesarean delivery increases intraoperative vasopressor use but does not prolong PACU length of stay, reduce intraoperative opioids, or increase antiemetic requirements postoperatively. The current study also demonstrated that surgical duration times were not different among the no-epinephrine, 100 mcg, and 200 mcg epinephrine groups.

Comparison of crystalloid and colloid co-load combined with norepinephrine prophylaxis on post-spinal anesthesia hypotension during cesarean delivery: a randomized sequential allocation dose-finding study.

Fluid loading is an essential component of treatment for reducing the incidence of post-spinal anesthesia hypotension and is necessary to maintain intravascular volume, perfuse tissues, and control spinal anesthesia hypotension after sympathetic blockade. We performed a randomized sequential allocation dose-finding study to compare the effects of 10 mL/kg crystalloid and 6% hydroxyethyl starch (130/0.4) co-load on the ED90 of prophylactic norepinephrine infusion for preventing post-spinal anesthesia hypotension during cesarean delivery. Eighty patients were randomly allocated to receive either a 10 mL/kg crystalloid (Crystalloid Group, n = 40) or 6% hydroxyethyl starch (130/0.4) (Colloid Group, n = 40) co-load combined with prophylactic norepinephrine infusion during spinal anesthesia for cesarean delivery. The first patient received an initial prophylactic norepinephrine infusion rate of 0.025 μg/kg/min. Subsequent patients received a 0.005 μg/kg/min gradient dose of prophylactic norepinephrine. This dose was administered as a gradient based on its effectiveness for preventing post-spinal anesthesia hypotension (defined as SBP < 80% of baseline value) and determined by the up-and-down sequential allocation methodology. The primary study outcome was the ED90 of prophylactic norepinephrine infusion. Secondary outcomes included the incidence of post-spinal anesthesia hypotension, bradycardia, hypertension, Apgar scores, and umbilical artery blood gas values were also measured. The ED90 values of prophylactic norepinephrine infusion for preventing post-spinal anesthesia hypotension during cesarean delivery were 0.063 μg (95% CI: 0.050 to 0.064) and 0.062 μg (95% CI: 0.045 to 0.064) using isotonic regression analysis, and 0.068 μg (95% CI: 0.056 to 0.353) and 0.060 μg (95% CI: 0.050 to 3.590) using probit regression analysis in the Crystalloid Group and Colloid Group, respectively. The secondary outcomes were comparable between the two groups. The administration of a 10 mL/kg 6% hydroxyethyl starch (130/0.4) does not provide additional benefits compared to crystalloid co-load in reducing the ED90 of prophylactic norepinephrine infusion for preventing post-spinal anesthesia hypotension during cesarean delivery.

The Effect of Volume Preload versus Ephedrine Infusion for Prevention of Hypotension due to Spinal Anesthesia for Cesarean Section

Abstract Background Spinal anesthesia is the preferred method for elective cesarean sections due to considerable risks regarding airway management associated with physiological changes of pregnancy. We hypothesized that using ephedrine to maintain maternal blood pressure during spinal anesthesia for cesarean delivery provides better hemodynamic stability with subsequent better maternal and neonatal outcomes compared to volume preload. Aim of the Work We compared volume preload and ephedrine infusion to guard against the hypotensive effect of spinal anesthesia during cesarean delivery. Patients and Methods After obtaining approval from the Research Ethical Committee of Faculty of Medicine, Ain Shams University, and written informed consent this study was conducted in the operating theaters of Ain Shams University Hospitals. This study was a randomized Controlled Clinical Trial. Adult parturients undergoing cesarean section under spinal anesthesia randomly assigned into one of the following groups using computer generated codes and opaque sealed envelopes: Group (A) received Volume Preload, group (B) received Ephedrine Infusion. Results The results of the study showed that compared with volume preload, ephedrine maintained maternal blood pressure and uterine artery blood flow. Further, it was associated with lower numbers of hypotension and hypertension episodes and less frequency of bradycardia and tachycardia during cesarean delivery. Conclusion Furthermore, the numbers of boluses of vasopressors used during spinal anesthesia were lower in ephedrine compared with volume preload.

Bilateral Foot Drop After Spinal Anesthesia for Cesarean Section

(Int J Gynaecol Obstet. 2022;158:484–487) Neurological complications after cesarean delivery (CD) under spinal anesthesia are rare. Bilateral foot drops are one such complication and are extremely uncommon. This brief communication aims to report a case of bilateral foot drop that a patient developed after spinal anesthesia for CD.