Management of Arterial Hypotension Induced by Spinal Anesthesia during Cesarean Section at the Parakou University Hospital in Benin in 2020: Ephedrine versus Noradrenaline ()
Childbirth is the physical and psychological culmination of pregnancy. This is a way through which it leads to the reality of the childbirth and which is usually done via the downer route that is vaginal. However, in thousands of cases, and for multiple reasons related to either the mother or the newborn, the outcome is via the upper route: it is the caesarean act . Thus, several anesthetic techniques are used to perform the cesarean act safely. Spinal anesthesia (SA) is the technique of choice for Caesarean delivery of parturient classified as ASA 1 and 2. It is an anesthetic technique that exposes the pregnant woman to fewer complications compared with general anesthesia (GA) . By 2014, SA accounted for 60% of anesthetic techniques used for caesarean sections according to the French Society of Anesthesia and Intensive Care (SFAR) . This anesthetic technique has three main effects: sympathetic block, sensory block and motor block. The sympathetic block is the major element that conditions hemodynamic stability and is responsible for low blood pressure, which secondarily leads to a decrease in uteroplacental flow . This finding was made by Cowper et al. who reported that SA leads to maternal hypotension in 50% - 80% of cases . Similarly, other authors have shown that SA-induced hypotension is thought to result from preganglionic sympathetic block and therefore vasodilation  .
Numerous preventive and curative measures have been developed  , including the use of vasoconstrictors  . Two sympathomimetic agents have been widely studied in different protocols. Ephedrine was the first vasopressor used in the management of post SA-induced hypotension, but it is not without consequences and is thought to be responsible for neonatal acidosis  .
Phenylephrine is currently the recommended first-line vasopressor with fewer side effects   . In obstetrics, there are other molecules in common practice that act on cardiac output and blood pressure, the principal one being Noradrenaline (NA). In 2015, Ngan Keeet al., as well as other authors have reported using preventive norepinephrine versus phenylephrine similar effects of the two products    . In Benin, it was assumed that Norepinephrine and Phenylephrine had similar effects and that Phenylephrine was more difficult to access because of its high cost: 3500 FCFA (6.35 US dollars) by ampoule compared to 1200 FCFA (2.18 US dollars) by ampoule for Noradrenaline, it seems appropriate to initiate this study whose aim is to compare the effect of Noradrenaline to that of Ephedrine in the management of SA-induced hypotension during caesarean section.
2. Patients and Method
2.1. Study Framework
The operating rooms of the Gynecology-Obstetrics Department of the University Hospital of Parakou in Benin were used as a study setting. Six (6) obstetrician-gynecologists, 3 anesthesiologists and 18 nurse anesthetists are involved in this sector.
2.2. Study Method
Type and period of study: This was a non-randomized semi-experimental study comparing two intervention strategies with data collection carried out over a period of 5 months from April 15 to August 15, 2020. The protocol was submitted to the Ethics Committee of the Faculty of Medicine and approved according to the number (REF 0318/CLERB-UP/P/SP/R/SA).
Study population:It was made up of parturient who had undergone caesarean section under spinal anesthesia in the operating bloc of the Gynecology-Obstetrics Department of the Parakou University Hospital during the period of the study.
Inclusion criteria: Parturient classified as ASA 1 and 2 who underwent caesarean section under spinal anesthesia during the period of the study and who gave their informed consent or that of a close relative to participate in the study were included.
Exclusion Criteria:Patients who underwent caesarean section under spinal anesthesia and did not receive either of the two vasopressors used in the study were excluded.
Criteria for non-inclusion:Patients with high blood pressure (pre-existing or gestational), pre-eclampsia (regardless of severity) and who had a caesarean section were not included. The variables studied were of two orders.
The dependent variable:the occurrence of hypotension after administration of the local anesthetic (Bupivacaïne).
The independent variables: grouped into sociodemographic data, clinical data, data related to the caesarean section, data related to the anesthesia and evolutionary data under vasopressors.
· Sociodemographic data: age, socio-professional category and marital status.
· Clinical data: patient history, temperature, blood pressure (BP), heart rate (HR), pulsed oxygen saturation (SpO2), respiratory rate (RR), weight, height, body mass index (BMI) and ASA classification.
· Data related to Caesarean section: indication for Caesarean section, type of Caesarean section, time between induction and incision, time between incision and extraction, and duration of the procedure.
· Data related to anesthesia: pre-anesthetic consultation, qualification of the anesthetist, local anesthetic and adjuvants used, site of injection of the local anesthetic, plasma volume expanders and their doses, vasopressors (Ephedrine or Noradrenaline) and the doses used.
· Evolutionary data: vital constants (temperature, BP, RR, SpO2, and HR), time to onset of hypotension after spinal anesthesia and number of hypotension episodes, number of boluses of the vasopressor and total dose used, and side effects observed.
2.3. Method of Data Collection
Collection tools:we used the patients’ medical records, a pre-established survey form and the multipara meter monitor for intraoperative monitoring.
Collection technique:The data of each patient were collected by direct observation using a questionnaire that we filled in after consulting the medical records in preoperative care and follow-up in the operating theatre in intraoperative care.
Sampling procedure:A systematic recruitment of all patients who had a scheduled or emergency caesarean section during the study period and who met our inclusion criteria was carried out.
Collection procedure: On arrival in the operating room, the patients were positioned on the operating table in a lying position with left lateral inclination and the monitoring begun. Basic hemodynamic measurements: TA, HR, SpO2, RR, ETCO2 electrocardiography (ECG) were recorded using a multi parameter monitor. After measurement of the basic hemodynamic variables and complete disinfection of the puncture site, a 25 Gauge (25 G) lumbar puncture needle was inserted via a needle introducer in the interspinous space between L3 - L4 or L4 - L5 and exceptionally between L2 - L2 in the sitting position. After confirmation of the free flow of cerebrospinal fluid, a mixture of 7.5 - 10 mg of 0.5% hyperbaric Bupivacaine and 200 γ of morphine was injected intrathecally, and the patient was returned to a supine position. The quality of the spinal anesthesia was evaluated by three criteria: sympathetic block, level of sensory block, and motor block. The sensory block was sought by the “hot-cold” test, while the motor block was assessed by the BROMAGE score. At the beginning of the intrathecal injection, rapid intravenous therapy with lactated ringer’s solution or saline solution 0.9% was carried out using a large diameter catheter (G18 or G20 catheter). The choice of vasopressor to be administered to each patient and the blood pressure management protocol was recorded on the survey form and made available to the anesthetist. Thus, two groups with equal numbers of parturients were obtained, depending on the type of vasopressor used. The presentation of the two vasopressors and the administration protocol were as follows:
· Noradrenaline tartrate 2 mg/mL (Levophied®, Hospira, Inc., Lake Forest, IL, USA) 1 mg/0.5mL diluted in 10 mL syringes of SS 0.9% to give 10 gamma per mL.
· Ephedrine Sulphate 30 mg/mL (Ephedrine Sulphate®, Akorn, Inc., India), diluted in 10 mL syringes of SS 0.9% to give 3mg/mL Ephedrine.
- Each patient in the NA group (Noradrenaline group) had received an intravenous prophylactic bolus of Noradrenaline 10 γ at during the intrathecal injection of the local anesthetic, plus rescue boluses of Noradrenaline 10 γ whenever maternal systolic blood pressure was less than or equal to 90 mm Hg.
- Each patient in group E (Ephedrine group) received a prophylactic bolus of 10 mg of Ephedrine during the intrathecal injection of the local anesthetic, plus rescue boluses of 10 mg of Ephedrine whenever maternal systolic blood pressure was less than or equal to 90 mm Hg.
The number of boluses of vasopressors used apart from the prophylactic doses was recorded and considered to be the main outcome of the study. Heart Rate (beats/min) and Blood Pressure (mm Hg) were recorded every 2 min after intrathecal injection until delivery of the baby and then every 5 min until the end of the surgery.
The primary endpoint was the delay since vasopressor injection and the hypotension occurrence. Secondary we record the number of hypotension episodes, the tachycardia episodes, the need of vasopressor rescue, and the total doses of the vasopressor.
The side effects as hypertension, bradycardia, nausea, vomiting, headache, vertigo and other were recorded.
2.4. Data Processing and Analysis
All the data were entered twice in the EPI data 3.1 software and the data analyses using the Epi Info v7.2 software from the Center of Disease Control (CDC). Text entry and the creation of tables and graphs were done using Microsoft Office® 2013. The qualitative variables were expressed in terms of frequency, percentage with a 95% confidence interval. The quantitative variables were expressed in terms of mean and standard deviation in the case of normal distribution and in terms of median with interquartile range in the opposite case. The Chi-square test or the Fisher exact test was used to compare the percentages. The Student’s t-test was used to compare averages. For these comparisons the significance threshold will be set at 0.05% or 5%.
During the period of study, 1025 parturients consulted the Gynecology-Obstetrics Department of the University Hospital of Parakou and among them 797 gave birth (77.76%). Three hundred and fourteen deliveries were performed by caesarean section, representing 39.40% of deliveries. According to our inclusion criteria we collected 204 patients (25.60%), divided into 2 groups of 102 patients for Noradrenaline and Ephedrine respectively.
The average age of the study population was 28.37 ± 6.15 years with extremes of 16 and 45 years. The most represented age group was between 26 and 35 years old. Married or cohabiting women accounted for 94.60% of the study population (n = 193). Housewives numbered 90% or 44.17% of the sample. The data on other specific variables were described in the second column in Table 1.
Of the 204 parturients operated on, 159 patients (77.94%) had an ASA 1 score and 45 of them (22.06%) had an ASA 2 score.
Duration of the different phases of the Caesarean section
The average duration of the induction-incision phase (minutes) was 12.58 ± 7.36 with extremes of 2 and 75 minutes. The average duration of the incision-extraction phase (minutes) was 4.44 ± 4.42 with extremes of 1 and 34 minutes. The mean duration of the caesarean section (minutes) was 38.34 ± 18.04 with extremes of 13 and 153 minutes.
Data related to anesthesia
· Pre-anesthetic consultation and qualification of the anesthetist
In our series, 110 parturients (53.92%) got a pre-anesthetic consultation before the caesarean section was performed. The consultation was performed in 99.02% (n = 202) by the anesthetist nurses under cover of the anesthetist and intensive care doctors. On the other hand, 94 (46.08%) got a pre-anesthetic visit before the procedure was carried out.
· Anesthetic drugs and adjuvants used
Table 1. Characteristics of parturient at baseline.
The local anesthetic used in the series was 0.50% hyperbaric Bupivacaine. The average dose administered was 9.95 ± 0.31 milligrams, with extremes of 8 and 10 milligrams. The adjuvant used in our series was morphine at a dose of 200 micrograms.
· Plasma volume expanders
For vascular pre-filling, Ringer Lactate was used in 98.04% (n = 200) and SS 9‰ was used in 1.96% of cases (n = 4). On the other hand, during co-filling, Ringer lactate was used in 97.55% of cases (n = 199) and SS% was used in 2.45% of cases (n = 5).
· Vasopressor doses used
The two vasopressors used in our series were Ephedrine and Noradrenaline. The average dose of Ephedrine (mg) used was 18.73 ± 9.41 with extremes of 10 - 50 mg. The average dose of Noradrenaline (mcg) used was 12.48 ± 4.56 with extremes of 10 - 30 mcg.
Incidence of bradycardia, tachycardia, hypotension and increased blood pressure
Hypotension appeared in 38.24% of cases (n = 78) after the prophylactic doses of vasopressor with an average onset time of 14.62 ± 8.38 minutes and extremes 1 and 46 minutes.
In the series of the study, additional boluses were administered to 20 parturients (19.60%) in the Noradrenaline group and 59 parturients (57.84%) in the Ephedrine group.
When we consider the patients with hypotension (n = 78) the data of each group were compared in Table 2. The parturient in adrenaline group was significantly younger and had a high baseline systolic blood pressure.
The primary endpoint parturient in Noradrenaline group had significantly long delay of hypotension occurrence, low number of hypotension episodes. On the other hand, they had received low doses of vasopressors and less episodes of tachycardia. The side effects were the same in both groups. Those data were summarized in Table 2 and Table 3.
· Hypotension and maternal parameters upon installation
Table 2. Comparison of two groups according to endpoint in patients with hypotension.
Table 3. Comparison of the side effects in two groups.
Table 4. Relationship between hypotension and maternal parameters upon installation.
Table 4 presents the relationship between the occurrence of hypotension and maternal parameters at the time of installation.
· Hypotension and time interval during the operation
There was a link between the onset of hypotension and the delay between induction and incision. Table 5 shows the relationship between hypotension and time interval during the operation.
· Frequency of caesarean section
During the study period, we recorded 797 deliveries, of which 314 were cesarean sections (39.39%). The rate of cesarean delivery in the study is identical to that reported by Mongbo et al. who in a study conducted in 2016 in Cotonou had reported 37.6% of cesarean cases . On the other hand, Atadé et al. in a study carried out in the same hospital in 2004, reported a caesarean section rate of 24.51% . The high rates of cesarean section observed in this study and in
Table 5. Relationship between hypotension and time interval during the operation.
the Mongbo study compared to the Atadé study could be explained by the fact that free cesarean section has become a reality in Benin since 2006.
The average age in our study was 28.37 ± 6.15 years with extremes of 16 and 45 years, and the most represented age group was that of patients aged 26 to 35 years (49.51%). This age range corresponds to the optimal age of fertility and this result was similar to those reported by Ali Elnabtity et al. in Egypt 2018 and Dyer et al. in South Africa in 2010 which were 27.04 ± 4.5 years and 27.1 ± 3.7 years respectively  . On the other hand, in Liege, Belgium, the study conducted by Lecoq et al. in 2010 found a mean age of 39 years justified by the high frequency of late pregnancies often at risk requiring cesarean section for delivery . We did not note any significant differences in age between the parturients of the two groups.
· ASA score
In the present study, 77.94% of parturients (n = 159) had an ASA 1 score. The same finding was made by Dembélé et al. in Mali (53.3%) . In contrast, in France in 2015, Bordes et al. had reported that more than half of their patients had an ASA class greater than or equal to 2 . This difference could be explained by the youth of our study population and young subjects being a prior carrier of less comorbidities.
The average weight of the parturients was 72.30 ± 11.70 kg. This finding was also made by Xian Wang et al. in 2018 in China who had reported in their study a mean weight of 76.5 ± 8.1 kg . In contrast, Lecoq in Liege had reported a mean weight of 65 ± 10 kg . This difference could be explained by the eating habits and lifestyle in each region. However, the excess weight noted in the different studies can easily be explained by hormonal impregnation responsible for water retention and consequently weight gain. This excess weight is confirmed by the average BMI of the parturients in the series, which was 27.33 ± 3.86 kg/m2, and that of Vallejo et al. in a study carried out in the United States (33.6 ± 6.6 kg/m2) .
Data related to cesarean section
· Phases of the cesarean section
The mean time from induction to incision was 12.58 ± 7.36 minutes. There was a significant difference (P < 0.001) between the two groups with 12.82 and 12.34 min for the NA group and the E group, respectively. This difference could be explained by the delay in the onset of sensory block, related to the number of protein receptors (binding to α-1-acid glycoprotein (AGA)) to which Bupivacaine binds for inhibition of nerve impulse transmission along the axonal lipid membrane, a factor that varies from one individual to another and independently of the administration of the vasopressor.
· Time between incision and extraction
The mean time from incision to extraction was 4.44 ± 4.42 minutes. There was a significant difference (P < 0.001) between the two groups with 4.95 and 3.93 for the NA and E groups respectively. This difference could be explained by the ability and experience of the obstetrician to quickly perform the fetal extraction, this being independent of the vasopressor used.
· Duration of the procedure
The average procedure time in the study was 38.34 ± 18.04 minutes. This result differs from that of Ali Elnabtity et al. who reported a mean duration of 50.1 ± 6.25 minutes . This difference could be explained by the fact that Ali Elnabtity’s study only involved scheduled cesarean sections that are performed outside the emergency context.
Data related to anesthesia
· Frequency of spinal anesthesia
Out of 314 cases of cesarean section, 280 were performed under spinal anesthesia, i.e. 89.17%. This high rate of cesarean section under spinal anesthesia is intended to avoid complications related to general anesthesia. Indeed, the pregnant woman in the third trimester being considered as a subject with a full stomach, whether in emergency surgery or in scheduled surgery, is prone to many complications when the technique proposed in case of general anesthesia. Thus, hormonal impregnation and the decrease in pulmonary compliance during pregnancy are responsible for edema and hyper vascularization of the upper aerodigestive tract with a consequent increased incidence of difficult intubation. In contrast to this technique, spinal anesthesia offers the advantage of preserving the freedom of the airways during delivery and also allows the woman to experience this delivery in the same way as a vaginal delivery.
· Frequency of low blood pressure
Like any anesthetic technique, spinal anesthesia is not without consequences. Indeed, it induces three types of blocks: the sympathetic block, the sensory block and the motor block. The sympathetic block is responsible for a pharmacological arterial hypotension. Thus, in the present study, out of 204 patients, 78 showed arterial hypotension, i.e. a rate of 38.24%. Our result is far lower than those observed in the literature where the rate of arterial hypotension induced by spinal anaesthesia is estimated to be between 55% and 90%  . The systematic use of a prophylactic dose of vasopressor in our methodology could be the basis of this result with a low rate of arterial hypotension. The anticipation of management by the anesthesiologists through prophylactic doses of vasopressors is an attitude to be promoted and generalized to all the centers in Benin in order to improve the hemodynamic state of the patients during spinal anesthesia.
Anesthetic drugs and injection site
Hyperbaric Bupivacaine 0.50% was used with every patient at a mean dose of 9.95 ± 0.31 milligrams. Bupivacaine is a local anesthetic that reversibly blocks nerve conduction; moreover, due to its physicochemical properties, it has a duration of action of 3h - 3h 30 minutes, which allows sufficient analgesia during cesarean section, which is generally a medium-length procedure (45 minutes to 1 hour). Also the smaller volume of CSF in pregnant women (<1000 mL) justifies these low doses administered intrathecally .
Time to onset of arterial hypotension
The mean time to onset of hypotension was 14.62 ± 8.38 minutes. We had no significant difference between the two groups (P = 0.513). However, the mean time to hypotension in the E group was higher (8.51 minutes) than in the NA group (4.10 minutes); this may be explained by differences in the pharmacokinetic properties of the 2 vasopressors (short onset and duration of action of norepinephrine compared to ephedrine) .
Filling fluids and quantities
LR was used in 98% of cases for vascular filling in our study. This could be explained not only by its power of volume expansion , but especially the absence of risk of occurrence of hyperchloremic acidosis observed in case of use of SS 0.9% or allergic reactions in case of use of macromolecules.
- Qualification of the anesthetist
In this study, the majority of anesthetic procedures (99.02%) were performed by certified nurse anesthetists (IADE) under the supervision of a MAR. This predominance was also reported by Bonkoungou et al. in Burkina-Faso in 2017, Diango et al. in 2013 in Mali and Chobli et al. in Togo in 2012 with frequencies of 71.60%; 91.90% and 93.71% respectively  . This situation could be explained by the low number of anesthesiologists in sub-Saharan Africa in general and in Benin in particular.
- Maternal data: Bradycardia, tachycardia, arterial hypotension and hypertension
In our series, bradycardia occurred in 2.94% of the cases and would be due either to AR or to a side effect of the vasopressors used. A significant difference was found between the two groups with a P value < 0.001. The mean number of bradycardia was 0.07 and 0.02 in the NA and E groups, respectively. El Shafei et al. in 2015 in a comparative study between Noradrenaline and Ephedrine in patients with coronary artery disease had found that Noradrenaline is more effective than Ephedrine in maintaining BP with reduction in HR, which is beneficial in patients with coronary artery disease. Thus, they found a mean number of 3 in the norepinephrine group versus 0 in the ephedrine group . Ali Elnabtity et al. in 2018 reported a mean number of 1 in the norepinephrine group, with no incidence in the second group . This bradycardia observed in these different studies could be explained on the one hand by the pharmacological effect of Bupivacaine on calcium and potassium channels with effects on contractility and cardiac arrhythmias, and on the other hand by the direct actions of β1-adrenergic stimulation of Noradrenaline that may increase the heart rate, but this is maintained due to an overall neutral state due to reflex bradycardia by α-adrenergic stimulation.
The frequency of tachycardia was 24.51%. A significant difference was found between the two groups with a P value < 0.001. The mean number of tachycardia was 0.25 and 0.64 in the NA and E groups, respectively. This result was close to that of Ali Elnabtity et al., who also reported low incidences of tachycardia. In the E group, the mean number was 1 versus 0 in the NA group . Indeed, Ephedrine is a synthetic sympathicomimetic, acting as an indirect agonist of β1 adrenergic receptors and to a much lesser degree of α-receptors; thus, it leads to the release of endogenous norepinephrine by the postganglionic nerve endings of the orthosympathetic system. This explains why it increases the heart rate .
- Arterial hypotension
The mean number of hypo BP episodes in this study was 0.22 and 0.92 for the NA and E groups respectively; there was a significant difference with a P value < 0.001. El Shafei et al. reported a mean number of 10 in the ephedrine group versus 6 in the norepinephrine group , Ali Elnabtity et al. and Hassani et al. reported a mean of 3 and 1.25 respectively in the ephedrine group versus 1 in the norepinephrine group  . This higher incidence in the E group is explained by the slow onset of action of ephedrine compared to norepinephrine, allowing hypotension to occur more frequently. This shows that NA is more effective. In contrast to our results and those of these authors, Erkinaro et al. did not report a significant difference between the two groups in the maintenance of blood pressure with 10% for the Ephedrine group and 9% for the Phenylephrine group .
- Arterial hypertension
The mean number of occurrences of hypertension found in our series was 0.05 in the NA group and 0.15 in the E group. Ali Elnabtity et al. had reported a mean of high blood pressure: 2 in the Ephedrine group versus 1 in the Noradrenaline group . This increases in blood pressure in the E group can be attributed to a side effect of Ephedrine still referred to as dose-dependent reactive hypertension, and this is when the dose of Ephedrine is greater than or equal to 30 mg . This finding highlights the superiority of the quality of Noradrenaline over Ephedrine.
· Additional Bolus
Additional boli in the study were a function of the onset of arterial hypotension. They were 19.60% in the NA group versus 57.84% in the E group. Thus, we noted a significant difference between the two groups, explained by the α-adrenergic effect and the weak β-adrenergic effect of Noradrenaline to maintain BP. This, once again, demonstrates the superiority of Noradrenaline in terms of consumption. Ali Elnabtity et al. had made the same finding but with a lower frequency, 3.27% and 4.92% for the NA and E groups, respectively .
- Observed side effects
With regard to the side effects observed, nausea was more frequently observed in the NA group (53.57%) than in the E group (46.43%). This finding could be explained pharmacologically by the antiemetic effect of Ephedrine .
Factors associated with arterial hypotension
- Arterial hypotension and systolic blood pressure before induction
In the present series of studies, pre-induction SBP was associated with the occurrence of arterial hypotension (P = 0.008). Indeed, those who had a PAS lower than 125 mm Hg before induction had more episodes of hypotension. This finding was also made by Fakherpour et al. in 2018  and could be explained by the fact that sympatholysis related to spinal anaesthesia would occur in terrain where the capacity to activate a sympathetic system in a very rapid manner could be impaired. These patients would then be at greater risk of arterial hypotension.
- Arterial hypotension and body mass index
A BMI ≥ 30 kg/m2 was a factor associated with the occurrence of arterial hypotension in this study (P = 0.017). This relationship is also found in the literature, but the threshold for which the risk exists varies between 25 kg/m2 and 30 kg/m2  . We can therefore suggest that there is a tendency for obese people to have low blood pressure. Some studies also reveal an association between weight gain during pregnancy and the occurrence of hypotension after spinal anaesthesia. This is the case of the 2018 study by Fakherpour et al., which showed a statistical association for weight gain of 11 to 20 kg . This result on obesity could be due to insufficient dosage of initial vasopressor amines. Indeed, these are not administered according to the patient’s weight. The dosage of amines may be insufficient in obese patients because of a larger volume of distribution, which may increase the incidence of arterial hypotension.
- Arterial Hypotension and Induction-Incision Time
The time between induction of spinal anesthesia and incision appears in the present study to be a factor associated with the occurrence of hypotension. Indeed, a delay of more than 15 minutes increases the risk of occurrence of arterial hypotension (RP = 1.62 95% CI [1.15 - 2.29] (P = 0.015). This makes perfect sense that the longer the delay between induction and incision, the higher the probability of occurrence of arterial hypotension would be. One hypothesis could be that the occurrence of arterial hypotension is frequently at the time of initiation of the sympathetic block, when the patient’s compensatory mechanisms have not yet been brought into play. It would be interesting to promote an effort of rapidity of the intervening parties: obstetrician.
5. Limitations of the Study
Our study has some limitations. On the one hand, the small number of parturients does not allow establishing a good correlation between the results. On the other hand, the execution of the protocol was done by several rotating teams whose practices differ from one team to another, with the exception of the doses of ephedrine and noradrenaline which were imposed on each team.
Spinal anesthesia is an anesthetic technique which has established itself over time as the best anesthesiological management for Caesarean sections. The only disadvantage is the hypotension it induces due to its pharmacological effects. It appears from this study that Noradrenaline is more effective than Ephedrine in the prevention and treatment of spinal anesthesia-induced hypotension during caesarean section with a maintained heart rate. The adoption of this product and the protocol for the prevention and treatment of hypotension is necessary to reduce the serious complications that are often responsible for death.
How to prevent hypotension after spinal anesthesia for cesarean section? ›
Hypotension may be prevented by administering intravenous fluids, giving medications (such as ephedrine, phenylephrine, and ondansetron), by leg compression, or by the mother either lying down or walking around before the spinal anaesthesia.How do you manage hypotension after spinal anesthesia? ›
Phenylephrine, a α1 adrenergic receptor agonist, is increasingly used to treat SAIH and its prophylactic administration (ie, immediately after intrathecal injection of local anesthetics) has been shown to decrease the incidence of arterial hypotension.Which is better for hypotension prophylaxis during cesarean section under spinal anesthesia ephedrine or norepinephrine? ›
The results of the study showed that when compared with ephedrine, norepinephrine maintained maternal blood pressure with lower number of hypotension and hypertension episodes and frequency of tachycardia during cesarean delivery.How much hypotension is associated with spinal anesthesia for cesarean section? ›
Hypotension during caesarean section performed under spinal anaesthesia has been the subject of medical research for more than 50 years (3). The incidence of hypotension during spinal anaesthesia for caesarean section varies in different studies, ranging from 7.4% to 74.1% (1, 4).How do you treat hypotension during a cesarean? ›
Spinal anesthesia is the standard technique for elective cesarean section, but the incidence of maternal hypotension in this setting is reportedly about 80%, without any prophylactic management. Vasopressors are the most reliable method for counteracting the hypotension induced by spinal anesthesia.Which of the following is the best drug for management of hypotension caused by spinal anesthesia? ›
α-agonist drugs are the most appropriate agents to treat or prevent hypotension following spinal anaesthesia. Although those with a small amount of β-agonist activity may have the best profile (noradrenaline (norepinephrine), metaraminol), phenylephrine is currently recommended due to the amount of supporting data.What is the cause of hypotension after spinal anaesthesia? ›
Hypotension is common during spinal anesthesia (SA) and is caused by a decrease in systemic vascular resistance (SVR) and/or cardiac output (CO). The effect of the dose of bupivacaine administered intrathecally on the changes in CO in elderly patients is largely unknown.How long does hypotension last after spinal anesthesia? ›
A fall of blood pressure accompanies each spinal anesthesia. It is the one possible danger associated with this form of anesthesia and may cause death. Its low point is usually ten minutes after the injection, and most fatalities have occurred at that time.What pressors are given during C section? ›
At present, phenylephrine is the vasopressor of choice for preventing and treating SIH at caesarean section. However, its use is often associated with a decreased heart rate and low cardiac output state owing to the lack of β-mimetic activity.Which drug is the first choice vasopressor to restore blood pressure and perfusion in the patient with septic shock? ›
epinephrine, NE vs. early vasopressin), NE remains the first-choice vasopressor in patients with septic shock. Vasopressin and epinephrine represent second-line vasopressor therapies and dopamine should be avoided.
What is the first drug of choice for hypotension? ›
Fludrocortisone is recommended as first-line drug therapy. This is a drug that prevents dehydration by causing the kidneys to retain water. This drug boosts the blood volume, which raises the blood pressure.Which medication should you expect to administer to a patient with hypotension and bradycardia following spinal anesthesia? ›
When nausea, bradycardia or hypotension are evident during spinal anesthesia, additional volume loading, the use of a vasopressor, and prophylactic treatment with atropine should all be considered.What causes hypotension in cesarean section? ›
A common consequence of the sympathetic vasomotor block caused by SA for cesarean section is hypotension, which occurs in up to 80–90% of cases, depending on the definition [24, 25]. SA often leads to a drop in blood pressure and bradycardia by inducing a sympathovagal imbalance toward parasympathetic tone .What meds increase blood pressure after epidural anesthesia? ›
Ephedrine remains the vasopressor of choice for treatment of hypotension during ritodrine infusion and epidural anesthesia. Anesthesiology.What happens if blood pressure drops during C section? ›
Maternal hypotension is the most frequent complication of spinal anaesthesia for caesarean section. It can be associated with nausea or vomiting and may pose serious risks to the mother (unconsciousness, pulmonary aspiration) and baby (hypoxia, acidosis, neurological injury).What is one of the nursing interventions for hypotension management? ›
Instruct the patient to change from a supine/ sitting to a standing position slowly. Orthostatic hypotension occurs when blood pressure drops when standing, decreasing blood supply to the brain. This can increase the risk of falling or fainting and can be avoided by changing positions slowly.Which is an intervention used to treat hypotension? ›
Midodrine. Midodrine activates receptors on the smallest arteries and veins to produce an increase in blood pressure. It is used to help increase standing blood pressure in people with postural hypotension related to nervous system dysfunction.Which type of medication should you expect to give if a patient is hypotensive during sedation? ›
Vasopressor and positive inotropic agents — Vasopressor bolus doses and/or continuous infusions are administered to treat hypotension that does not immediately respond to decreasing anesthetic depth and/or fluid administration (table 1 and table 2) .What drug is used to increase blood pressure during surgery? ›
EPHEDRINE (e FED rin) is used to treat low blood pressure in patients who receive anesthesia during surgery. This medicine may be used for other purposes; ask your health care provider or pharmacist if you have questions.Which vasopressor is useful to control blood pressure during surgery? ›
Norepinephrine is commonly used in patients undergoing cardiac surgery, and its use is increasing in those undergoing noncardiac surgery, including titrated infusion via a peripheral IV catheter [3,84-88].
What are the symptoms of spinal anaesthesia hypotension? ›
Spinal anaesthesia-induced hypotension (SAH) occurs frequently during caesarean section and is primarily caused by sympathetic nerve blockade. SAH has a negative impact on patient wellbeing, and in the awake parturient, it causes nausea, dizziness and vomiting.Which of the following is the most common cause of hypotension in the post anesthesia care unit PACU )? ›
A common cause of postoperative hypotension is blood loss or inadequate fluid replacement. The PACU nurse should be ready to return the patient to the OR if excessive bleeding or hemorrhage occurs.What is the most common post operative complication of spinal anesthesia? ›
The most common are postdural puncture headache and hypotension. Hypotension after spinal anesthesia is a physiological consequence of sympathetic blockade. The diagnoses and management of these sequelae are discussed.What is the most common cause of hypotension in the surgical patient? ›
The authors believe, however, that the most common cause of postoperative hypotension is that group of hematological factors which include transfusion reactions, hemolysis due to distilled water during transurethral resections, and acute or chronic loss of blood.What is the most common complication of cesarean section? ›
A C-section might increase the risk of developing a blood clot inside a deep vein, especially in the legs or pelvis (deep vein thrombosis). If a blood clot travels to the lungs and blocks blood flow (pulmonary embolism), the damage can be life-threatening.
To address both peripheral vasodilation and bradycardia, a vasopressor with both α- and β-adrenergic receptor activity should be selected. Dopamine, norepinephrine, and epinephrine will provide vasoconstriction and increase in heart rate, and are common first-line agents for treatment of neurogenic shock.What is the most common complication after cesarean section that requires the use of anticoagulants? ›
The risk of venous thromboembolism is particularly high during the postpartum period and especially following cesarean delivery. Venous thromboembolism (VTE) is a major cause of maternal morbidity and mortality.Why does BP drop after spinal Anaesthetic? ›
The fall in blood pressure which all observers agree is commonly found accompanying spinal anesthesia has been ascribed in the main to two causes: (1) dilatation of the arterioles in the anesthetized area due to a block of vasoconstrictor fibers in the anesthetized roots1; (2) decreased cardiac output. 1.What causes hypotension during spinal anaesthesia? ›
Hypotension is common during spinal anesthesia (SA) and is caused by a decrease in systemic vascular resistance (SVR) and/or cardiac output (CO). The effect of the dose of bupivacaine administered intrathecally on the changes in CO in elderly patients is largely unknown.What causes low blood pressure after spinal anesthesia? ›
The side effects of spinal anesthesia are well described, but most notably include hypotension (low blood pressure). Spinal hypotension is primarily due to the vasodilatory effects of local anesthetics, and would occur in virtually all women if not prevented or treated.
What happens if your blood pressure drops with epidural? ›
Low blood pressure
It's normal for your blood pressure to fall a little when you have an epidural. Sometimes this can make you feel sick. Your blood pressure will be closely monitored. If necessary, fluids and medicine can be given through a drip to keep your blood pressure normal.
The most common are postdural puncture headache and hypotension. Hypotension after spinal anesthesia is a physiological consequence of sympathetic blockade. The diagnoses and management of these sequelae are discussed.What is the most common reason for hypotension after surgery? ›
The authors believe, however, that the most common cause of postoperative hypotension is that group of hematological factors which include transfusion reactions, hemolysis due to distilled water during transurethral resections, and acute or chronic loss of blood.Why does blood pressure drop during C section? ›
Spinal anesthesia (SA) is often used during childbirth for Cesarean sections (C-sections) or to minimize pain during vaginal delivery. One common side effect of spinal anesthesia is maternal hypotension, or low blood pressure (sometimes this is also referred to as a hypotensive crisis).Why does hypotension occur after epidural? ›
A frequent unwanted side effect of epidural block is hypotension due to the epidurally injected LA blocking the sympathetic nerves and thus the patient's response to hypotension, which is usually due to hypovolemia and/or an unopposed parasympathetic (via the vagus nerve) nervous system.