Randomized Double-blinded Comparison of Norepinephrine and Phenylephrine for Maintenance of Blood Pressure during Spinal Anesthesia for Cesarean Delivery

2015 ◽  
Vol 122 (4) ◽  
pp. 736-745 ◽  
Author(s):  
Warwick D. Ngan Kee ◽  
Shara W. Y. Lee ◽  
Floria F. Ng ◽  
Perpetua E. Tan ◽  
Kim S. Khaw
Keyword(s):  
Blood Pressure ◽  
Heart Rate ◽  
Cardiac Output ◽  
Systolic Blood Pressure ◽  
Spinal Anesthesia ◽  
Cesarean Delivery ◽  
Adrenergic Receptor ◽  
Neonatal Outcome ◽  
Computer Controlled ◽  
Double Blinded

Abstract Background: During spinal anesthesia for cesarean delivery, phenylephrine can cause reflexive decreases in maternal heart rate and cardiac output. Norepinephrine has weak β-adrenergic receptor agonist activity in addition to potent α-adrenergic receptor activity and therefore may be suitable for maintaining blood pressure with less negative effects on heart rate and cardiac output compared with phenylephrine. Methods: In a randomized, double-blinded study, 104 healthy patients having cesarean delivery under spinal anesthesia were randomized to have systolic blood pressure maintained with a computer-controlled infusion of norepinephrine 5 μg/ml or phenylephrine 100 μg/ml. The primary outcome compared was cardiac output. Blood pressure heart rate and neonatal outcome were also compared. Results: Normalized cardiac output 5 min after induction was greater in the norepinephrine group versus the phenylephrine group (median 102.7% [interquartile range, 94.3 to 116.7%] versus 93.8% [85.0 to 103.1%], P = 0.004, median difference 9.8%, 95% CI of difference between medians 2.8 to 16.1%). From induction until uterine incision, for norepinephrine versus phenylephrine, systolic blood pressure and stroke volume were similar, heart rate and cardiac output were greater, systemic vascular resistance was lower, and the incidence of bradycardia was smaller. Neonatal outcome was similar between groups. Conclusions: When given by computer-controlled infusion during spinal anesthesia for cesarean delivery, norepinephrine was effective for maintaining blood pressure and was associated with greater heart rate and cardiac output compared with phenylephrine. Further work would be of interest to confirm the safety and efficacy of norepinephrine as a vasopressor in obstetric patients.

Prophylactic Angiotensin II Infusion during Spinal Anesthesia for Elective Cesarean Delivery 

1998 ◽  
Vol 88 (6) ◽  
pp. 1475-1479 ◽  
Author(s):  
Robert D. Vincent ◽  
Carol F. Werhan ◽  
Patricia F. Norman ◽  
Grace H. Shih ◽  
David H. Chestnut ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Heart Rate ◽  
Angiotensin Ii ◽  
Systolic Blood Pressure ◽  
Spinal Anesthesia ◽  
Cesarean Delivery ◽  
Elective Cesarean Section ◽  
Elective Cesarean Delivery ◽  
Maternal Heart Rate ◽  
Elective Cesarean

Background Angiotensin II may prove useful in treating regional anesthesia-induced hypotension in obstetric patients, because it causes less uterine vasoconstriction than do other vasoconstrictor drugs (such as phenylephrine). This study compared (1) maternal blood pressure and heart rate and (2) fetal status at delivery in parturients given either prophylactic angiotensin II or ephedrine infusion during spinal anesthesia for elective cesarean delivery. Methods Fifty-four women were randomized to receive either angiotensin II or ephedrine infusion intravenously during spinal anesthesia for elective cesarean section delivery. Simultaneous with subarachnoid injection, infusion of angiotensin II (2.5 microg/ml) or ephedrine (5 mg/ml) was initiated at 10 ng x kg(-1) x min(-1) and 50 microg x kg(-1) x min(-1), respectively. The rate of each infusion was adjusted to maintain maternal systolic blood pressure at 90-100% of baseline. Results Cumulative vasopressor doses (mean+/-SD) through 10, 20, and 30 min were 150+/-100, 310+/-180, and 500+/-320 ng/kg in the angiotensin group and 480+/-210, 660+/-390, and 790+/-640 microg/kg in the ephedrine group. Maternal heart rate was significantly higher (P < 0.001) during vasopressor infusion in the ephedrine group than in the angiotensin group. Umbilical arterial and venous blood pH and base excess were all significantly higher (P < 0.05) in the angiotensin group than in the ephedrine group. Conclusions Angiotensin II infusion maintained maternal systolic blood pressure during spinal anesthesia without increasing maternal heart rate or causing fetal acidosis.

scholarly journals Continuous Invasive Blood Pressure and Cardiac Output Monitoring during Cesarean Delivery

2008 ◽  
Vol 109 (5) ◽  
pp. 856-863 ◽  
Author(s):  
Eldrid Langesæter ◽  
Leiv Arne Rosseland ◽  
Audun Stubhaug
Keyword(s):  
Blood Pressure ◽  
Cardiac Output ◽  
Systolic Blood Pressure ◽  
Spinal Anesthesia ◽  
Cesarean Delivery ◽  
Systemic Vascular Resistance ◽  
Vascular Resistance ◽  
Low Dose ◽  
Dose Infusion ◽  
Phenylephrine Infusion

Background Prevention of hemodynamic instability during cesarean delivery during spinal anesthesia has been the aim of several studies. Noninvasive monitoring has been used in all previous studies. This is the first study in healthy pregnant women with continuous invasive recording of arterial blood pressure, cardiac output, and systemic vascular resistance. The aim of this randomized trial was to compare the effects of two different intrathecal doses of bupivacaine, with or without intravenous phenylephrine infusion, on cardiac output and systolic blood pressure. Methods In this double-blinded study, 80 healthy women scheduled to undergo elective cesarean delivery were randomly assigned to one of four different groups receiving 7 mg spinal bupivacaine with or without a concomitant low-dose infusion of phenylephrine (0.25 microg . kg(-1) . min(-1)) or 10 mg spinal bupivacaine with or without phenylephrine infusion. All patients had 4 microg sufentanil added to the spinal solution and had cohydration with 750 ml saline, 0.9%. Results The low-dose spinal bupivacaine group with intravenous phenylephrine infusion was the most stable group regarding all hemodynamic variables. The authors found significant differences between this group and the group that was given the high dose of bupivacaine with intravenous placebo infusion regarding cardiac output (P = 0.005), systemic vascular resistance (P < 0.0001), and systolic blood pressure (P = 0.012). Conclusions This study shows that low-dose bupivacaine (with sufentanil), combined with a low-dose infusion of phenylephrine and moderate cohydration, gives the best hemodynamic stability during spinal anesthesia for cesarean delivery.

Treatment of Hypotension after Hyperbaric Tetracaine Spinal Anesthesia 

1997 ◽  
Vol 86 (4) ◽  
pp. 797-805 ◽  
Author(s):  
Robert F. Brooker ◽  
John F. IV Butterworth ◽  
Dalane W. Kitzman ◽  
Jeffrey M. Berman ◽  
Hillel I. Kashtan ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Heart Rate ◽  
Cardiac Output ◽  
Stroke Volume ◽  
Systolic Blood Pressure ◽  
Spinal Anesthesia ◽  
Adrenergic Agonist ◽  
Induced Hypotension ◽  
Alpha Adrenergic Agonist ◽  
Hyperbaric Tetracaine

Background Despite many advantages, spinal anesthesia often is followed by undesirable decreases in blood pressure, for which the ideal treatment remains controversial. Because spinal anesthesia-induced sympathectomy and management with a pure alpha-adrenergic agonist can separately lead to bradycardia, the authors hypothesized that epinephrine, a mixed alpha- and beta-adrenergic agonist, would more effectively restore arterial blood pressure and cardiac output after spinal anesthesia than phenylephrine, a pure alpha-adrenergic agonist. Methods Using a prospective, double-blind, randomized, cross-over study design, 13 patients received sequential infusions of epinephrine and phenylephrine to manage hypotension after hyperbaric tetracaine (10 mg) spinal anesthesia. Blood pressure, heart rate, and stroke volume (measured by Doppler echocardiography using the transmitral time-velocity integral) were recorded at baseline, 5 min after injection of tetracaine, and before and after management of hypotension with epinephrine and phenylephrine. Cardiac output was calculated by multiplying stroke volume x heart rate. Results Five min after placement of a hyperbaric tetracaine spinal anesthesia, significant decrease in systolic (from 143 +/- 6 mmHg to 125 +/- 5 mmHg; P < 0.001), diastolic (from 81 +/- 3 to 71 +/- 3; P < 0.001), and mean (from 102 +/- 4 to 89 +/- 3; P < 0.001) arterial pressures occurred. Heart rate (75 +/- 4 beats/min to 76 +/- 4 beat/min; P = 0.9), stroke volume (115 +/- 17 to 113 +/- 13; P = 0.9), and cardiac output (8.0 +/- 1 l/m to 8.0 +/- 1l/m; P = 0.8) did not change significantly after spinal anesthesia. Phenylephrine was effective at restoring systolic blood pressure after spinal anesthesia (120 +/- 6 mmHg to 144 +/- 5 mmHg; P < 0.001) but was associated with a decrease in heart rate from 80 +/- 5 beats/min to 60 +/- 4 beats/min (P < 0.001) and in cardiac output from 8.6 +/- 0.7 l/m to 6.2 +/- 0.7 l/m (P < 0.003). Epinephrine was effective at restoring systolic blood pressure after spinal anesthesia (119 +/- 5 mmHg to 139 +/- 6 mmHg; P < 0.001) and was associated with an increase in stroke volume from 114 +/- 12 ml to 142 +/- 17 (P < 0.001) and cardiac output from 7.8 +/- 0.6 l/m to 10.8 +/- 1.1 l/m (P < 0.001). Conclusions Epinephrine management of tetracaine spinal-induced hypotension increases heart rate and cardiac output and restores systolic arterial pressure but does not restore mean and diastolic blood pressure. Phenylephrine management of tetracaine spinal-induced hypotension decreases heart rate and cardiac output while restoring systolic, mean, and diastolic blood pressure.

scholarly journals Norepinephrine versus phenylephrine for maintenance of blood pressure during spinal anaesthesia for caesarean delivery - A randomized double blind controlled study

2021 ◽  
Vol 8 (3) ◽  
pp. 460-464
Author(s):  
Devyani Desai ◽  
Bhoomika Kalarthi
Keyword(s):  
Blood Pressure ◽  
Heart Rate ◽  
Cardiac Output ◽  
Systolic Blood Pressure ◽  
Spinal Anesthesia ◽  
Spinal Anaesthesia ◽  
Caesarean Delivery ◽  
Controlled Study ◽  
Double Blind ◽  
Significant Difference

: Currently phenylephrine is a preferred 1 line vasopressor for maintenance of blood pressure during spinal anaesthesia, may be associated with reflex bradycardia and decreased cardiac output, posing risk to mother or foetus. Norepinephrine may be an useful alternative as being potent alpha with weak beta adrenergic agonist activity. : This study compared the effectiveness of prophylactic and treatment boluses of norepinephrine and phenylephrine to maintain systolic blood pressure at or above 80% of baseline value during spinal anesthesia for cesarean delivery with the primary aim to compare cardiac output. Secondary aims were total doses of study drug required, neonatal outcome and perioperative complications.: Total 100, term pregnant women with ASA status II undergoing caesarean delivery under spinal anaesthesia were enrolled in this prospective, double blind controlled study. Patients were randomized to receive prophylactic bolus dose of norepinephrine (6 µg) or phenylephrine (100 µg) immediately after spinal anaesthesia. Systolic blood pressure, cardiac output and heart rate were monitored. Intermittent bolus doses were repeated whenever required. Student ‘t’ test and chi square test were used for analysing the data. : Both the drugs were able to maintain the systolic blood pressure ≥ 80% of baseline (p=0.356). Significant difference observed in cardiac output while comparing both the groups from 3 to 15 minutes after spinal anesthesia (p=0.014). The incidence of bradycardia was lower in norepinephrine group as compared to phenylephrine group (P=0.018). : Norepinephrine is as effective as phenylephrine for maintenance of blood pressure after spinal anaesthesia for caesarean delivery with stable heart rate and cardiac output.

scholarly journals Norepinephrine Infusion for Preventing Postspinal Anesthesia Hypotension during Cesarean Delivery

2019 ◽  
Vol 130 (1) ◽  
pp. 55-62 ◽  
Author(s):  
Ahmed M. Hasanin ◽  
Sarah M. Amin ◽  
Nora A. Agiza ◽  
Mohamed K. Elsayed ◽  
Sherin Refaat ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Heart Rate ◽  
Systolic Blood Pressure ◽  
Cesarean Delivery ◽  
Odds Ratio ◽  
Dose Group ◽  
Primary Outcome ◽  
Norepinephrine Infusion ◽  
Double Blinded ◽  
Intraoperative Hypertension

Abstract EDITOR’S PERSPECTIVE What We Already Know about This Topic Hypotension after spinal anesthesia for cesarean delivery is common, usually treated with phenylephrine or ephedrine Norepinephrine was recently introduced in obstetric anesthesia but the optimal dose is unknown What This Article Tells Us That Is New This randomized, double-blinded trial compared prophylactic norepinephrine infusions of 0.025, 0.050, or 0.075 μg · kg-1 · min-1, started after bupivacaine spinal anesthesia, in full-term parturients having elective cesarean delivery The primary outcome, maternal hypotension (systolic blood pressure less than 80% of baseline), occurred less frequently after both 0.050 and 0.075 μg · kg-1 · min-1 compared 0.025 μg · kg-1 · min-1 norepinephrine Background Norepinephrine has been recently introduced for prophylaxis against postspinal hypotension during cesarean delivery; however, no data are available regarding its optimum dose. The objective of this study is to compare three infusion rates of norepinephrine for prophylaxis against postspinal hypotension during cesarean delivery. Methods The authors conducted a double-blinded, randomized, controlled study including full-term pregnant women scheduled for cesarean delivery. Norepinephrine infusion was commenced after subarachnoid block. Patients were randomized into three groups, which received norepinephrine with starting infusion rates of 0.025 μg · kg-1 · min-1, 0.050 μg · kg-1 · min-1, and 0.075 μg · kg-1 · min-1. Infusion was stopped when intraoperative hypertension occurred. The primary outcome was the frequency of postspinal hypotension (defined as decreased systolic blood pressure less than 80% of the baseline reading). The three groups were compared according to the following: systolic blood pressure, heart rate, frequency of intraoperative hypertension, frequency of bradycardia, and neonatal outcomes. Results Two hundred eighty-four mothers were included in the analysis. The frequency of postspinal hypotension was lower for both the 0.050-μg · kg-1 · min-1 dose group (23/93 [24.7%], odds ratio: 0.45 [95% CI: 0.24 to 0.82], P = 0.014) and the 0.075-μg · kg-1 · min-1 dose group (25/96 [26.0%], odds ratio: 0.48 [95% CI:0.26 to 0.89], P = 0.022) compared with the 0.025-μg · kg-1 · min-1 dose group (40/95 [42.1%]). The two higher-dose groups (the 0.050-μg · kg-1 · min-1 group and the 0.075-μg · kg-1 · min-1 group) had higher systolic blood pressure and lower heart rate compared with the 0.025 μg · kg-1 · min-1 group. The three groups were comparable in the frequency of intraoperative hypertension, incidence of bradycardia, and neonatal outcomes. Conclusions Both the 0.050-μg · kg-1 · min-1 and 0.075-μg · kg-1 · min-1 norepinephrine infusion rates effectively reduced postspinal hypotension during cesarean delivery compared with the 0.025-μg · kg-1 · min-1 infusion rate.

scholarly journals Variable versus fixed-rate infusion of phenylephrine during cesarean delivery: a randomized controlled trial

2019 ◽  
Vol 19 (1) ◽  
Author(s):  
Ahmed Hasanin ◽  
Sara Habib ◽  
Yaser Abdelwahab ◽  
Mohamed Elsayad ◽  
Maha Mostafa ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Heart Rate ◽  
Systolic Blood Pressure ◽  
Cesarean Delivery ◽  
Controlled Trial ◽  
Controlled Study ◽  
Lower Systolic Blood Pressure ◽  
Randomized Controlled ◽  
Phenylephrine Infusion ◽  
Infusion Regimen

Abstract Background Phenylephrine is the most commonly used vasopressor for prophylaxis against maternal hypotension during cesarean delivery; however, the best regimen for its administration is not well established. Although variable infusion protocols had been suggested for phenylephrine infusion, evidence-based evaluation of variable infusion regimens are lacking. The aim of this work is to compare variable infusion, fixed on-and-off infusion, and intermittent boluses of phenylephrine for prophylaxis against maternal hypotension during cesarean delivery. Methods A randomized controlled study was conducted, including full-term pregnant women scheduled for elective cesarean delivery. Participants were divided into three groups which received phenylephrine by either intermittent boluses (1.5 mcg/Kg phenylephrine), fixed on-and-off infusion (with a dose of 0.75 mcg/Kg/min), or variable infusion (with a starting dose of 0.75 mcg/Kg/min). The three groups were compared with regard to frequency of: maternal hypotension (primary outcome), second episode hypotension, reactive hypertension, and bradycardia. Other outcomes included heart rate, systolic blood pressure, physician interventions, and neonatal outcomes. Results Two-hundred and seventeen mothers were available for final analysis. The 2 infusion groups showed less incidence of maternal hypotension {26/70 (37%), 22/71 (31%), and (51/76 (67%)} and higher incidence of reactive hypertension compared to the intermittent boluses group without significant differences between the two former groups. The number of physician interventions was highest in the variable infusion group compared to the other two groups. The intermittent boluses group showed lower systolic blood pressure and higher heart rate compared to the two infusion groups; whilst the two later groups were comparable. Conclusion Both phenylephrine infusion regimens equally prevented maternal hypotension during cesarean delivery compared to intermittent boluses regimen. Due to higher number of physician interventions in the variable infusion regimen, the current recommendations which favor this regimen over fixed infusion regimen might need re-evaluation.

scholarly journals Hemodynamic Changes Associated with Spinal Anesthesia for Cesarean Delivery in Severe Preeclampsia

2008 ◽  
Vol 108 (5) ◽  
pp. 802-811 ◽  
Author(s):  
Robert A. Dyer ◽  
Jenna L. Piercy ◽  
Anthony R. Reed ◽  
Carl J. Lombard ◽  
Leann K. Schoeman ◽  
...  
Keyword(s):  
Heart Rate ◽  
Cardiac Output ◽  
Mean Arterial Pressure ◽  
Arterial Pressure ◽  
Stroke Volume ◽  
Spinal Anesthesia ◽  
Cesarean Delivery ◽  
Systemic Vascular Resistance ◽  
Vascular Resistance ◽  
Severe Preeclampsia

Background Hemodynamic responses to spinal anesthesia (SA) for cesarean delivery in patients with severe preeclampsia are poorly understood. This study used a beat-by-beat monitor of cardiac output (CO) to characterize the response to SA. The hypothesis was that CO would decrease from baseline values by less than 20%. Methods Fifteen patients with severe preeclampsia consented to an observational study. The monitor employed used pulse wave form analysis to estimate nominal stroke volume. Calibration was by lithium dilution. CO and systemic vascular resistance were derived from the measured stroke volume, heart rate, and mean arterial pressure. In addition, the hemodynamic effects of phenylephrine, the response to delivery and oxytocin, and hemodynamics during recovery from SA were recorded. Hemodynamic values were averaged for defined time intervals before, during, and after SA. Results Cardiac output remained stable from induction of SA until the time of request for analgesia. Mean arterial pressure and systemic vascular resistance decreased significantly from the time of adoption of the supine position until the end of surgery. After oxytocin administration, systemic vascular resistance decreased and heart rate and CO increased. Phenylephrine, 50 mug, increased mean arterial pressure to above target values and did not significantly change CO. At the time of recovery from SA, there were no clinically relevant changes from baseline hemodynamic values. Conclusions Spinal anesthesia in severe preeclampsia was associated with clinically insignificant changes in CO. Phenylephrine restored mean arterial pressure but did not increase maternal CO. Oxytocin caused transient marked hypotension, tachycardia, and increases in CO.

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