Background: The optimal choice of vasopressor drugs for managing hypotension during neuraxial anaesthesia for Caesarean delivery is unclear. Although phenylephrine was recently recommended as a consensus choice, direct comparison of phenylephrine with vasopressors used in other healthcare settings is largely lacking. Therefore, we assessed this indirectly by collating data from relevant studies in this comprehensive network meta-analysis. Here, we provide the possible rank orders for these vasopressor agents in relation to clinically important fetal and maternal outcomes. Methods: RCTs were independently searched in MEDLINE, Web of Science, Embase, The Cochrane Central Register of Controlled Trials, and clinicaltrials.gov (updated January 31, 2019). The primary outcome assessed was umbilical arterial base excess. Secondary fetal outcomes were umbilical arterial pH and PCO 2. Maternal outcomes were incidences of nausea, vomiting, and bradycardia. Results: We included 52 RCTs with a total of 4126 patients. Our Bayesian network meta-analysis showed the likelihood that norepinephrine, metaraminol, and mephentermine had the lowest probability of adversely affecting the fetal acidbase status as assessed by their effect on umbilical arterial base excess (probability rank order: norepinephrine > mephentermine > metaraminol > phenylephrine > ephedrine). This rank order largely held true for umbilical arterial pH and PCO 2. With the exception of maternal bradycardia, ephedrine had the highest probability of being the worst agent for all assessed outcomes. Because of the inherent imprecision when collating direct/indirect comparisons, the rank orders suggested are possibilities rather than absolute ranks. Conclusion: Our analysis suggests the possibility that norepinephrine and metaraminol are less likely than phenylephrine to be associated with adverse fetal acid-base status during Caesarean delivery. Our results, therefore, lay the scientific foundation for focused trials to enable direct comparisons between these agents and phenylephrine.
Summary
Rapid‐onset epidural local anaesthesia can avoid general anaesthesia for caesarean delivery. We performed a Bayesian network meta‐analysis of direct and indirect comparisons to rank speed of onset of the six local anaesthetics most often used epidurally for surgical anaesthesia for caesarean delivery. We searched Google Scholar, PubMed, EMBASE, Ovid, CINAHL and CENTRAL to June 2019. We analysed 24 randomised controlled trials with 1280 women. The mean (95%CrI) onset after bupivacaine 0.5% was 19.8 (17.3–22.4) min, compared with which the mean (95%CrI) speed of onset after lidocaine 2% with bicarbonate, 2‐chloroprocaine 3% and lidocaine 2% was 6.4 (3.3–9.6) min faster, 5.7 (3.0–8.3) min faster and 3.9 (1.8–6.0) min faster, respectively. Speed of onset was similar to bupivacaine 0.5% after ropivacaine 0.75% and l‐bupivacaine 0.5%: 1.6 (−1.4 to 4.8) min faster and 0.4 (−2.2 to 3.0) min faster, respectively. The rate (95%CrI) of intra‐operative hypotension was least after l‐bupivacaine 0.5%, 315 (236–407) per 1000, and highest after 2‐chloroprocaine 3%, 516 (438–594) per 1000. The rate (CrI) of intra‐operative supplementation of analgesia was least after ropivacaine 0.75% 48 (19–118) per 1000 and highest after 2‐chloroprocaine 3%, 250 (112–569) per 1000.
We describe a case in which spinal anesthesia was undertaken in a pregnant patient with a space-occupying tumor and significant symptomatology. The collaborative efforts of all medical disciplines involved and the willingness of the neurosurgeon to discuss and help determine the safety of neuraxial anesthesia, culminated in placing an external ventricular drain to help monitor and manage intracranial pressure, so that we could proceed with spinal anesthesia and more easily monitor neurologic status.
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