Total Dose Of Ephedrine Research Articles

Combination of Intravenous Ondansetron and Intravenous Glycopyrrolate Versus Intravenous Ondansetron and Intramuscular Glycopyrrolate for Reduction of Post-spinal Hypotension in Cesaraen Section: A Randomized Double-Blinded Study.

In parturients, post-spinal hypotension is common due to loss of sympathetic tone. Compression of the inferior vena cava by the gravid uterus further aggravates it. Various pharmacologic and non-pharmacologic techniques are used to reduce the severity of hypotension. Ondansetron, a selective 5-hydroxytryptamine receptor antagonist, nullifies the Bezold Jarisch reflex response to spinal anaesthesia and glycopyrrolate, an anti-cholinergic, has been used to prevent post-spinal hypotension. We estimated the efficacy of intravenous (IV) glycopyrrolate plus IV ondansetronversusintramuscular (IM) glycopyrrolate plus IV ondansetron to reduce post-spinal hypotension in caesarean section. We compared hypotension episodes and the total ephedrine dose required to treat hypotension among the groups. Ninety parturients undergoing elective and emergency caesarean section under spinal anaesthesia were randomly assigned into three groups of 30 each. Group A received prophylactic IV glycopyrrolate 0.2mg plus IV ondansetron 4mg, Group B received IM glycopyrrolate 0.2mg plus IV ondansetron 4mg and Control Group C received 10ml of normal saline plus IV ondansetron 4mg. The total ephedrine dose required to treat hypotension (primary objective), incidence of hypotension and maternal heart rate variations were analysed. Group B required significantly less vasopressor as compared to Group C (6.4286mg±1.6036 vs 8.7mg±3.6288, p=0.0420). There is no statistically significant difference between Group A and Group C for vasopressor requirement (7.8750mg±2.8723 vs 8.7mg±3.6288, p=0.5425). Maternal heart rate in Group A was higher at the eighth minute compared to Group B and Group C (100.2±21.3 vs 95.3±14.4 vs 86.2±19.0, p=0.015). Incidence of hypotension was same in all the groups (46.7% vs 46.7% vs 51.1%, p=0.491) and complications among groups were comparable. Prophylactic use of IM glycopyrrolate plus IV ondansetron decreases total vasopressor required to treat hypotension but does not decrease the incidence of hypotension. Prophylactic use of IV glycopyrrolate increases maternal heart rate.

Effects of Continuous versus Single Dose Spinal Anesthesia in Octogenarians Undergoing Hip Surgery: Randomized Control Trial

Abstract Background Continuous spinal anesthesia (CSA) is an anesthetic technique that offers several clinical advantages for anesthesia and analgesia in elderly patients. The level of sensory blockade can be titrated to the desired dermatomal level with great precision with intrathecal (IT) catheters, allowing better control of the hemodynamic consequences of sympathetic blockade associated with spinal anesthesia compared to epidural or single shot spinal techniques. Octogenarians are expected to suffer more from hemodynamic instability with spinal anesthesia. Objective The primary outcome is to compare the incidence of hypotension (defined as decrease in mean arterial blood pressure > 20% from the base line) in continuous spinal anesthesia CSA versus single dose spinal anesthesia in octogenarians undergoing hip surgery. The secondary outcome is to determine the total use of vasopressor (Ephedrine) and the incidence of spinal complications as nausea, vomiting and post Dural puncture headache. Methods This is a randomized controlled clinical trial done at Ain-shams University Hospitals, Cairo, Egypt within a period of 6 months from approval of medical ethics committee. Twenty patients in CSA group received increments of (0.5 ml) of plain bupivacaine 0.5% until T10 level blockade is achieved. Twenty patients in SDA group received single shot of (2.5ml) of bupivacaine 0.5%. Results The main finding of this study is that while MAP was significantly lower between 5-35 minutes (<0.001), it was significantly higher between 40-75 minutes in SDA group than CSA group (0.05).Total bupivacaine dose was significantly higher in SDA (12.5±0.8) group than CSA group (7.6±1.3) (p < 0.001). The total ephedrine dose needed was significantly higher in the SDA group (19.5 ±11.3) than in CSA group (4.5±1.7) (p.0.006). Conclusion The main finding of this study is that for octogenarians undergoing hip surgery, while MAP was significantly lower between 5-35 minutes, it was significantly higher between 40-75 minutes in single dose spinal anesthesia group than continuous spinal anesthesia group. Episodes of bradycardia were similar in both groups. The bupivacaine dose as well as total ephedrine dose was significantly higher in SDA group than CSA group. Groups were similar in the incidence of postoperative complications related to the neuraxial blockade. The impact of these changes on the overall cardiovascular status and outcome in octogenarians undergoing hip surgery could not be determined from our study design.

Impact of Sub-Anesthetic Dose of Ketamine on Post Spinal Hypotension in Cesarean Delivery

Abstract Background Spinal anesthesia is the commonest technique used in Cesarean Section (CS) and most frequently associated with maternal hypotension, for whicha lot of techniques have been described to prevent but an effective method is yet to be found. Objectives The aim was to study the effect of using a sub-anesthetic dose of ketamine to prevent post-spinal hypotension in CS delivery. Methods This double-blinded randomized controlled study was conducted on 60 participating parturients who were ASA І, П term pregnant. All the parturients received spinal anesthesia. The parturients were then randomly divided into two equal groups (n = 30 in each); ketamine group received a sub- anesthetic dose of ketamine of 0.5 mg/kg IV bolus in 3 ml saline and control group received the same volume of normal saline IV bolus. Heart Rate (HR) and Mean Arterial blood Pressure (MAP) were recorded at baseline (5 minutes prior to the intrathecal injection), at 5, 10, 15 and 20 minutes after the injection and then every 15 minutes till the end of the operation. Incidences of hypotension and severe hypotension were recorded. The total dose of ephedrine was recorded. Modified Ramsay sedation score was recorded at baseline then 5, 10, 15, 30, 45 minutes after injection and then at the end of the operation. Results The study revealed that ketamine didn’t prevent hypotension, it only delayed it for 10 min compared to control group 5 min. Also, observed that total ephidren dose significantly decreased in ketamine group compared to control group. And sedation scores in the first 30 min were higher in ketamine group. HR wasn’t affected. No changes in APGAR score were noticed between the two groups. No side effects from ketamine except for nystagmus. Conclusion This study concluded that the use of intravenous ketamine in low dose (0.5mg/kg) doesn’t prevent postspinal hypotension but it only decreases ephidren requirements.

Comparison of remimazolam-based and propofol-based total intravenous anesthesia on hemodynamics during anesthesia induction in patients undergoing transcatheter aortic valve replacement: a randomized controlled trial.

This study aimed to compare the hemodynamic effects of remimazolam- and propofol-based total intravenous anesthesia in patients who underwent transcatheter aortic valve replacement. This was a single-center, single-blind, randomized controlled trial set at Nara Medical University, Kashihara, Japan. We included 36 patients aged ≥ 20years scheduled to undergo elective transfemoral transcatheter aortic valve replacement (TAVR) under general anesthesia. The participants were randomly assigned to the remimazolam and propofol groups (n = 18 each). Remimazolam- or propofol-based total intravenous anesthesia was initiated at 12mg/kg/min or 2.5mcg/mL via target-controlled infusion, respectively, along with remifentanil. After confirming the loss of consciousness, the administration rate was adjusted using electroencephalographic monitoring. The primary outcome was the rate of arterial hypotension, defined as a mean arterial pressure < 60mmHg, from anesthesia induction until the beginning of the surgical incision. The total doses of ephedrine and phenylephrine were also assessed. During anesthesia induction, the arterial hypotension rates were 11.9% and 21.6% in the remimazolam and propofol groups, respectively (P = 0.01). The total dose of ephedrine was higher in the propofol group (14.4mg) than in the remimazolam group (1.6mg) (P < 0.001); however, the total dose of phenylephrine was not significantly different between the two groups (propofol 0.31mg vs. remimazolam: 0.17mg, P = 0.10). Remimazolam-based total intravenous anesthesia resulted in a lower hypotension rate than propofol-based total intravenous anesthesia during induction in patients undergoing TAVR. Remimazolam-based total intravenous anesthesia can be used safely during anesthetic induction in patients with severe aortic stenosis.

Efficacy of intravenous ketamine as premedicant for prevention of intraoperative hypotension after spinal anesthesia in parturients posted for elective cesarean section

Background: Hypotension following spinal anesthesia (SA) in lower segment cesarean section can be deleterious to the parturient and to fetus. Ketamine acts by stimulating the cardiovascular system leading to high blood pressure and increase in heart rate (HR) and cardiac output. Aims and Objectives: This study aimed to assess the efficacy of 15 mg of prophylactic intravenous ketamine in elective cesarean section for prevention of hypotension after SA. Materials and Methods: This double-blinded randomized controlled study was conducted on 98 participating parturients who were American Society of Anesthesiologists term pregnant women. The parturients were randomly divided into two groups (n=49 in each). All the parturients received SA. Ketamine group - Group K received 15 mg of ketamine IV bolus in 3 mL saline and control group - Group C received the same volume of normal saline IV bolus. HR and systolic blood pressure (SBP) were recorded at baseline at 5, 10, 15, and 20 min after the injection and then every 15 min till the end of the operation. Incidences of hypotension were recorded. The total number dose of ephedrine used, APGAR score, and Visual Analog Scale scores were recorded. The Ramsay Sedation Score was also recorded at baseline, then 5, 10, 15, 30, and 45 min after injection, and then at the end of the operation. Results: This study showed a statistically significant increase in the incidence of hypotension and higher use of intravenous ephedrine 6 mg boluses in the control group when compared to the ketamine group. Forty-two parturients in the control group developed hypotension compared to 23 parturients in the ketamine group with P&lt;0.001. The total ephedrine dose was significantly lower among the ketamine group. Sedation was observed for the first 15 min intraoperatively in the ketamine group with P=0.001. There was no statistically significant difference in APGAR score between the two groups. Conclusion: There was significantly higher hemodynamic stability in the ketamine group with regard to SBP, diastolic blood pressure, and HR. Hence, low-dose ketamine, when used as a premedicant, is an effective agent that can be used in preventing post-spinal intraoperative hypotension in parturients undergoing cesarean section delivery.

Special maternal care bundle to attenuate post-spinal hypotension in cesarean section: A randomized controlled clinical trial

ABSTRACT Background This study aimed to assess the safety and efficacy of a special maternal care bundle as an alternative technique for the attenuation of hypotension following spinal anesthesia in parturients scheduled for CS. Methods This double-blinded, parallel-group, randomized trial enrolled 138 adult parturients who were scheduled for CS under spinal anesthesia. The patients were randomly allocated to two groups. In the care bundle group, 68 participants received a co-load of lactated Ringer’s solution and ondansetron infusion during administration of spinal anesthesia with a slow rate intrathecal bupivacaine injection and a V-shaped supine position. While in the best practice group, 70 participants received a co-loaded lactated Ringer’s solution during spinal anesthesia with early use of vasopressors and a left uterine tilting position. The primary outcome was the total ephedrine consumption. Secondary outcomes included the mean arterial blood pressure, heart rate, atropine usage, complications such as dizziness, nausea, and vomiting, as well as the baby’s Apgar score. Results Special maternal care bundle significantly reduced the need and the total dose of ephedrine (P = 0.042). The mean arterial blood pressure was significantly less affected by maternal bundle care, but the reduction in heart rate, the need for atropine, the incidence of dizziness, nausea, vomiting, and the Apgar score were comparable in both groups. Conclusion The special maternal care bundle including co-load of lactated ringer, ondansetron 4 mg IV infusion, slow intrathecal injection and v-shaped positions can reduce the incidence of hypotension resulting from spinal anesthesia and ephedrine usage during CS.

EFFECT OF PRELOADING V/S COLOADING OF CRYSTALLOID INFUSION ON MATERNAL HYPOTENSION AFTER SPINAL ANESTHESIA FOR ELECTIVE CESAREAN SECTION: A RANDOMISED COMPARATIVE STUDY

Background: Spinal anesthesia induced hypotension is a major complication in parturient. Intravenous crystalloids administration is a routine practice to prevent and treat maternal hypotension. However, timing of infusion is yet to be determined. We therefore compared preloading with coloading to determine the optimal timing of infusion for prevention of maternal hypotension post spinal anaesthesia. Methods: Seventy parturients were randomized to receive 15ml/kg of crystalloid before (preload group) or after (coload group) intrathecal drug injection for spinal anesthesia. Primary objectives of this study were to look for incidence of intra operative hypotension and total dose of ephedrine used, while secondary objectives were hemodynamic variables, neonatal outcome (apgar scores) and the incidence of maternal nausea and vomiting. Data were expressed as mean (SD) or number (%) as indicated and were compared using chi-square, sher's exact, or student's t test as appropriate. Results: Parturient in preload group (PL) had higher incidence of spinal anesthesia induced hypotension (85.71%) as compare to coload group (CL) (65.71%) but the difference was statistically insignicant(p=0.051). Lower doses of ephedrine were used in coload group median 6 mg (range 0-24mg) then preload group median 12 mg (range0-24mg) p=0.0002. Nausea and vomiting were lower in coload group (14.29%) as compare to preload group (20%) but were statistically insignicant. Apgar score was comparable between both groups. Conclusion: Crystalloid are recommended at the time of block (coload) in parturients undergoing spinal anesthesia to prevent post spinal maternal hypotension and vasopressor requirement.

Crystalloid preload versus crystalloid co-load for hypotension in parturients undergoing caesarean section under spinal anaesthesia

Abstract Though hypotension is a common complication after spinal anaesthesia, preloading with crystalloids may not be able to prevent it. We aimed to compare the efficacy of crystalloid preload and co-load for the prevention of maternal hypotension in parturients undergoing caesarean section under spinal anaesthesia. Seventy parturients, aged 20 to 40 years of American Society of Anaesthesiologist (ASA) physical status 1/II, scheduled for caesarean section under spinal anaesthesia were divided into two groups. Parturients in group P received 15 ml/kg of ringer's lactate as preload over 20 min before the intrathecal drug administration. Parturients in group C received 15 ml/kg of ringer's lactate over 20 min, just after intrathecal drug administration. Incidence of hypotension, systolic blood pressure, diastolic blood pressure, mean arterial pressure, heart rate, the requirement of ephedrine, and any complications was recorded. 25 (71%) parturients in group P and 15 (42%) parturients in group C developed statistically significant hypotension. 21 (59%) parturients developed nausea and vomiting in group P as compared to 9 (25%) parturients in group C which were statistically significant. The mean number of doses of ephedrine required in group P was 1.8±0.6 and 0.9±0.7 in group C which was statistically significant. The total dose of ephedrine used in group P was 9.6±3.4mg and 5.9± 2.1mg in group C which was statistically significant. Co-loading with 15 ml/ kg of crystalloid-like ringer's lactate was more effective than preloading in preventing spinal-induced maternal hypotension, thereby reducing ephedrine requirement and avoiding complications. Keywords: Anaesthesia, Co-load, Hypotension, Preload, Spinal, Caesarean section.

Fluid preloading before beach chair positioning for arthroscopic shoulder procedures: a randomized controlled trial

Background and objectivesThe Beach Chair Position (BCP) has many advantages such as less neurovascular injury and better intra-articular visualization, but it has also negative consequences, including hemodynamic instability. Although maintaining normal Mean Arterial Pressure (MAP) is important, fluid management is also a crucial concept for hemodynamic stability. The main objective of this study is whether preloading before positioning would be effective for less hemodynamic instability. MethodsThis randomized, controlled study was conducted in a single center in the Istanbul University, Istanbul Faculty of Medicine. Forty-nine patients undergoing elective arthroscopic surgery in the BCP were recruited. In the study group, crystalloid fluid at 10...mL.kg-1 of ideal body weight was administered intravenously 30...min before the BCP for preloading. The primary outcome measures were differences of hemodynamic variables as MAP, Stroke Volume (SV), Heart Rate (HR), and Cardiac Output (CO). The secondary outcome measures were Postoperative Nausea and Vomiting (PONV) rates in postoperative first day, surgical satisfaction scale, total ephedrine dose used during surgery, and total amount of fluid. ResultsThe MAP, CO, and SV measurements of the study group were higher than those of the control group in the 5th minute after the BCP (respectively, p...=...0.001, p...=...0.016, p...=...0.01). The total amount of crystalloid and surgical satisfaction scales were higher in the study group (respectively, p...=...0.016, p...=...0.001). Total amount of colloid and ephedrine dose used in the intraoperative period, and PONV rates were lower in the study group (p...=...0.003, p...=...0.018, p...=...0.019, respectively). ConclusionConsequently, preloading can be favorable approach to preserve hemodynamic stability.

Maternal hemodynamic effect of prophylactic glycopyrrolate after spinal anaesthesia for elective caesarean section

Introduction: Hypotension and bradycardia are the most common complications during spinal anesthesia. Bradycardia decreases cardiac output, resulting in hypotension and even cardiac arrest. Glycopyrronium, an anticholinergic drug increases heart rate and prevents bradycardia during spinal anesthesia by blocking the effects of acetylcholine on the sinoatrial node. The study aims to measure the maternal hemodynamic effect of glycopyrrolate after spinal anesthesia for elective caesarean section.&#x0D; Method: An intervention, comparative study was conducted in Patan Hospital after approval from Ethical Committee. Eighty-two pregnant women scheduled for elective caesarean section were randomly assigned in two groups by sealed envelope method; Group I received glycopyrrolate 0.2mg intravenous, Group II did not receive glycopyrrolate. The patient’s heart rate, blood pressure, mean arterial pressure, a total dose of ephedrine, the occurrence of nausea, vomiting, and dry mouth were recorded. Independent-T test, chi-square test were used for statistical analysis.&#x0D; Result: Among 82 elective caesarean sections, 41 in each group, Group II (non-glycopyrrolate) reported increased heart rate compared to Group I (glycopyrrolate), but was statistically not significant. The highest recorded diastolic blood pressure was more in Group I compared to Group II and was statistically significant. The highest recorded Mean Arterial Pressure was high in the glycopyrrolate group and was statistically significant. The total dose of ephedrine was lower in the statistically significant glycopyrrolate group. The incidence of dry mouth was more in the glycopyrrolate group and the difference was statistically significant.&#x0D; Conclusion: Glycopyrrolate reduces the incidence of hypotension but not bradycardia and decreases the need for vasopressor.

Associated factors with umbilical arterial pH after cesarean delivery under spinal anesthesia: a retrospective cohort study

BackgroundMaximum decrease of blood pressure and number of minutes of hypotension were independently associated with umbilical arterial pH. However, the impact of hypotension considering the duration of it on umbilical arterial pH is unknown. MethodsPregnant women aged ≥ 20 years who delivered a baby at full-term via a cesarean delivery under a single-shot spinal anesthesia between January 2017 and March 2019 were included. The main outcome was to predict umbilical arterial pH, based on the value of the time integral of hypotension. Patient demographics, patient comorbidities, and intraoperative data, including the total dose of ephedrine and phenylephrine by fetal delivery and cumulative duration of maternal hypotension, were evaluated. Maternal hypotension was reflected as a decrease in systolic arterial pressure and mean arterial pressure to < 80% of baseline values. The systolic arterial pressure and mean arterial pressure were independently included in a multiple regression analysis along with all other explanatory factors to predict the umbilical arterial pH. ResultsOf the 416 eligible patients, 381 were enrolled. When including the systolic arterial pressure or mean arterial pressure in the model, emergency cases, the total dose of ephedrine, hypertensive disorders of pregnancy, and systolic arterial pressure or mean arterial pressure values were found to be significant predictive factors of umbilical arterial pH. ConclusionOur results suggest that an elevated time integral of maternal hypotension may have a negative impact on umbilical arterial pH. Therefore, to minimize the risk of fetal acidosis, maternal hypotension should be prevented with the consideration of vasopressors selection.

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&lt;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.

Colloid preloading versus crystalloid preloading to prevent hypotension after spinal anesthesia for cesarean delivery: A protocol for systematic review and meta-analysis.

Background:Maternal hypotension is the most frequent complication of spinal anesthesia for cesarean delivery, and intravenous fluid preloading is a preventive measure. We aimed to assess the efficacy of colloids versus crystalloids for preloading to reduce the incidence of spinal anesthesia-induced hypotension and vasopressor requirement in healthy parturients during elective cesarean delivery.Methods:We searched the Cochrane Library, MEDLINE and EMBASE to identify all studies published to June, 2019, through OVID and PubMed. We included randomized controlled trials, comparing colloid preloading with crystalloid preloading in women having spinal anesthesia for cesarean delivery. Primary outcomes were the incidence of hypotension and vasopressor requirement. Secondary outcomes included nausea and/or vomiting, neonatal Apgar score, neonatal umbilical blood pH. We used standardized mean differences for expressing continuous outcomes and risk ratios for dichotomous outcomes. Random-effect model was performed to estimate the pooled risk ratios and standardized mean differences.Results:Thirty-three randomized controlled trials contributed data for this meta-analysis. Fewer women experienced hypotension in the colloid group compared with the crystalloid group (risk ratio: 0.72, 95% confidence interval: 0.63–0.82; 2566 women, 32 studies; P < .00001). The total ephedrine dose required was significantly lower with colloid preloading (standardized mean difference: −0.37, 95% CI: −0.64 to −0.09; 1472 women, 19 studies; P = .009). Colloid preloading was also associated with fewer phenylephrine requirement compared with crystalloid preloading (standardized mean difference: -0.54, 95% CI: -0.82 to -0.25; 169 women; P = .0002). The incidence of nausea and/or vomiting was significantly reduced with colloid preloading (risk ratio: 0.72, 95% CI: 0.55–0.95; 1601 women, 20 studies; P = .02). However, the incidence of 1-minute Apgar score < 7, umbilical artery pH < 7.2 and umbilical vein pH < 7.2 were not statistically different between groups.Conclusions:Colloid preloading is superior to crystalloid preloading in reducing the incidence of hypotension induced by spinal anesthesia and vasopressor requirement in the healthy parturients undergoing elective cesarean delivery.The PROSPERO registration number: CRD42018096402.

Comparison of colloid preloading and continuous infusion of norepinephrine versus crystalloid co-loading and continuous infusion of norepinephrine in the prevention of maternal hypotension

Background and goal of study: Spinal anesthesia for cesarean section can be frequently complicated by hypotension, with untoward effects for both the mother and fetus. Recently, norepinephrine has been shown to be effective in maintaining blood pressure in obstetric patients. Another technique widely used to prevent hypotension is fluid administration. Current evidence suggests that the combination of fluid administration and vasoconstrictive medications should be the main strategy for prevention and management of hypotension. The aim of this randomized study was to investigate the combination of a norepinephrine infusion and colloid preloading versus the combination of a norepinephrine infusion and crystalloid co-loading for the prevention of maternal hypotension during elective cesarean section under combined spinal-epidural anaesthesia Materials and methods: One hundred parturients were randomized to receive either 6% hydroxyethyl starch 130/0.4 5 mL/kg before spinal anesthesia (colloid preload) or Ringer’s Lactate solution 10 mL/kg starting with intrathecal injection (crystalloid co-load). Both groups were also administered norepinephrine 4 μg/min, starting simultaneously with the administration of the subarachnoid solution. The primary outcome was the incidence of maternal hypotension (SBP <80% of baseline). The incidence of severe hypotension (SAP <80 mmHg), total dose of ephedrine administered as well as maternal side-effects and the acid-base status and Apgar score of the neonate were also recorded Results: There were no significant differences in the incidence of hypotension (13.7% vs. 16.3%, P = 0.933 or severe hypotension (0% vs. 4%, P = 0.238) between colloid preload and crystalloid co-load groups, respectively. The median [range] ephedrine dose was 0 [0–15] mg in the colloid preload group and 0 [0–10] mg in the crystalloid co-load group (P = 0.807). There were no significant differences in maternal side-effects or neonatal outcomes between groups Conclusion: The incidence of hypotension during elective cesarean section is low and comparable when a norepinephrine infusion is used in combination with either colloid preload or crystalloid co-load, with perhaps a marginal superiority of colloid preload in the prevention of severe hypotension. It appears that the optimal regimen for prevention of maternal hypotension is a combination of fluids and a prophylactic vasopressor like norepinephrine.

HEMODYNAMIC CHANGES ASSOCIATED WITH SPINAL ANESTHESIA FOR CESAREAN DELIVERY IN SEVERE PREECLAMPSIA

Background: Sever pre-eclampsia is defined as a disorder that occurs in pregnancy which manifests as hypertension and proteinuria with at least one maternal organ dysfunction involvement. Objectives: To determine how pre-eclampsia affects maternal hemodynamics during cesarean delivery after spinal anesthesia. Patients and Methods: This prospective randomized study was carried out on 30 normotensive females and 30 pre-eclamptic females admitted to Hospital for elective cesarean section using spinal anesthesia. The study was conducted in the Obstetrics Department of Al-Azhar University Hospitals, from January 2019 till December 2019. Results: Incidence of hypotension after spinal anesthesia in group A (normotensive) was 66.7% and in group B (preeclampsia) was 30%. The total dose of Ephedrine required to correct hypotension when it happen mean dose ± SD in group A was 9.83 ± 9.30 and in group B was 3.00 ± 5.15. Neonatal outcomes (APGAR score and umbilical artery blood gases) were comparable. There was increased incidence of headache and blurring of vision among severe preeclampsia parturient. Conclusion: Incidence of hypotension after spinal anaesthesiawas less frequent and less severe in preeclampsia patients and required lower dose of ephedrine than normotensive population. There was increased incidence of headache and blurring of vision among severe preeclampsia parturient. No difference in neonatal outcome between normotensive and severe preeclampsia population following spinal anesthesia.

HEMODYNAMIC CHANGES ASSOCIATED WITH SPINAL ANESTHESIA FOR CESAREAN DELIVERY IN SEVERE PREECLAMPSIA

Background: Sever pre-eclampsia is defined as a disorder that occurs in pregnancy which manifests as hypertension and proteinuria with at least one maternal organ dysfunction involvement. Objectives: To determine how pre-eclampsia affects maternal hemodynamics during cesarean delivery after spinal anesthesia. Patients and Methods: This prospective randomized study was carried out on 30 normotensive females and 30 pre-eclamptic females admitted to Hospital for elective cesarean section using spinal anesthesia. The study was conducted in the Obstetrics Department of Al-Azhar University Hospitals, from January 2019 till December 2019. Results: Incidence of hypotension after spinal anesthesia in group A (normotensive) was 66.7% and in group B (preeclampsia) was 30%. The total dose of Ephedrine required to correct hypotension when it happen mean dose ± SD in group A was 9.83 ± 9.30 and in group B was 3.00 ± 5.15. Neonatal outcomes (APGAR score and umbilical artery blood gases) were comparable. There was increased incidence of headache and blurring of vision among severe preeclampsia parturient. Conclusion: Incidence of hypotension after spinal anaesthesiawas less frequent and less severe in preeclampsia patients and required lower dose of ephedrine than normotensive population. There was increased incidence of headache and blurring of vision among severe preeclampsia parturient. No difference in neonatal outcome between normotensive and severe preeclampsia population following spinal anesthesia.

Deep bradycardia after sugammadex: is it due to anaphylaxis or by any other unknown mechanism(s) of sugammadex?

BackgroundSugammadex is a ɣ-cyclodextrin containing 8-thiopropionate side chains, which selectively binds to nondepolarizing aminosteroid neuromuscular blocking agents. Here, we report a case who developed deep bradycardia after administration of sugammadex.Case presentationA 38-year-old-man was scheduled for laparoscopic right hemicolectomy. Besides history of light smoking, he had no other medical/surgical history that included any allergic reactions. At the end of the operation, 200 mg sugammadex was administered to antagonize residual neuromuscular blockade. One minute after the administration of sugammadex, the patient had deep bradycardia (25 beat min−1) and his systolic blood pressure fell below a measurable level. The patient’s blood pressure was restored to 95/55 mmHg and heart rate 110 beats min−1 with the administration of a total dose of ephedrine 10 mg, atropine sulfate 0.5 mg, 0.9% saline 1 L, and 6% hydroxyethylated starch 500 mL over 15 min. Then, he was extubated uneventfully and transferred to the intensive care unit for closer monitoring.ConclusionsAccording to the current literature as well as the case we presented here, we suggest that physicians who use sugammadex especially in endoscopic/laparoscopic procedures using CO2 should be aware of the possibility of sudden bradycardia and/or cardiac arrest.

Risk factors associated with hypotensive bradycardic events during open shoulder surgery in the beach chair position.

BackgroundShoulder surgery in the beach chair position frequently causes hypotensive bradycardic events (HBEs), which are potentially associated with an increased risk of cerebral hypoperfusion. Here, we aimed to investigate the incidence and characteristics of symptomatic HBEs that require pharmacological interventions, and to identify specific risk factors associated with symptomatic HBEs.MethodsWe retrospectively examined the records of all patients aged ≥ 18 years who underwent shoulder arthrotomy in the beach chair position between January 2011 and December 2018 at Samsung Medical Center. For patients who experienced HBEs while in the beach chair position, the minimum heart rate and systolic blood pressure were noted, as was the total dose of ephedrine or atropine.ResultsSymptomatic HBEs occurred in 61.0% of all cases (256/420). Two patients with symptomatic HBEs experienced postoperative neurological complications. Multivariable logistic regression analysis showed that preoperative interscalene brachial plexus block (ISB) and advanced age were risk factors associated with symptomatic HBEs (odds ratio [OR]: 3.240, 95% CI: 2.003, 5.242, P < 0.001; OR: 1.060 for each 1-year increase, 95% CI: 1.044, 1.076, P < 0.001, respectively). Receiver operating curve analysis revealed that a threshold of 62 years of age had a moderate degree of accuracy for predicting symptomatic HBEs (area under curve: 0.764, 95% CI: 0.720, 0.804, P < 0.001).ConclusionsConsidering the increasing risk of neurocognitive complications with aging, proactive hemodynamic management is needed, especially for elderly patients undergoing shoulder surgery in the beach chair position using ISB.

Impact of Sub-Anesthetic Dose of Ketamine on Post Spinal Hypotension in Cesarean Delivery

Background: Spinal anesthesia is the commonest technique used in Cesarean Section (CS) and most frequently associated with maternal hypotension, for which a lot of techniques have been described to prevent but an effective method is yet to be found. Objectives; The aim was to study the effect of using a sub-anesthetic dose of ketamine to prevent post-spinal hypotension in CS delivery. Methods: This double-blinded randomized controlled study was conducted on 80 participating parturients who were ASA І, П term pregnant. All the parturients received spinal anesthesia. The parturients were then randomly divided into two equal groups (n= 40 in each); ketamine group received a sub-anesthetic dose of ketamine of 0.5 mg/kg IV bolus in 3 ml saline and control group received the same volume of normal saline IV bolus. Heart Rate (HR) and Mean Arterial blood Pressure (MAP) were recorded at baseline (5 minutes prior to the intrathecal injection), at 5, 10, 15 and 20 minutes after the injection and then every 15 minutes till the end of the operation. Incidences of hypotension and severe hypotension were recorded. The total dose of ephedrine was recorded. Ramsay sedation score was recorded at baseline then 5, 10, 15, 30, 45 minutes after injection and then at the end of the operation. Results: Compared to the control group, sedation score was significantly higher among ketamine group at 5, 10 and 15 minutes. MAP and HR were significantly higher among ketamine group at 5, 10, 15, and 20 minutes. Total ephedrine dose was significantly lower among the ketamine group. Mild hypotension and severe hypotension were significantly less frequent among the ketamine group, as all the patients in the control group had an attack of mild hypotension and 55% of this group had an attack of severe hypotension. No significant difference between both the groups regarding diplopia, nystagmus, hallucination, nausea and vomiting. Conclusion: It is concluded that ketamine in a sub-anesthetic dose is an effective agent that can be used in preventing post-spinal hypotension in parturients undergoing CS delivery.

A Comparative Study of Fractionated Versus Single Dose Injection for Spinal Anesthesia During Cesarean Section in Patients with Pregnancy-Induced Hypertension.

BackgroundLocal anesthetics for spinal anesthesia in one-single injection are known to induce more severe hypotension than a fractionated dose in healthy obstetric patients. Hypotension in obstetric patients with pregnancy-induced hypertension, including preeclampsia, during spinal anesthesia, could compromise fetal well-being.ObjectivesThis study aimed to compare the mean arterial pressure (MAP), the total dose of ephedrine required, and level of sensory blockade between the fractionated-dose and single-dose spinal anesthesia injection in obstetric patients with pregnancy-induced hypertension who underwent a cesarean section.MethodsThis single-blind randomized clinical trial was conducted from January to April 2018 after being approved by the Research Ethics Committee of Universitas Indonesia (No. 1174/UN2.F1/ETIK/2017) and recorded at ClinicalTrials.gov (NCT03693638). After obtaining informed consent, 42 parturients with hypertension in pregnancy (gestational hypertension or preeclampsia), ASA II-III, aged 18 - 40 years, and BMI of 18.5 - 35 kg/m2 with singleton pregnancy, who were planned for spinal anesthesia for emergency or semi-emergency cesarean section with hyperbaric bupivacaine 0.5% (MarcaineTM, Hospira) and fentanyl, were included in this study. All subjects were randomly divided into two groups including fractionated-dose (FD) and single-dose (SD).ResultsThere was no significant difference between the two groups in MAP in the first 15 minutes after anesthesia (P > 0.05) and median total dose of ephedrine required (10 (0 - 25) mg in the FD group vs. 15 (0 - 30) mg in the SD group, P = 0.30). However, in the FD group, MAP tended to be higher in the first three minutes compared to the SD group. The level of sensory blockade was mostly at T4, which was not significantly different between the groups (52.4% in FD vs. 42.9% in SD, P = 0.59).ConclusionsIn obstetric patients with pregnancy-induced hypertension who underwent a cesarean section, the mean arterial pressure after spinal anesthesia was not significantly different between the fractionated dose of spinal anesthesia injection and single-dose injection. Total ephedrine required and levels of sensory blockade were not significantly different between the groups.