International consensus statement on the management of hypotension with vasopressors during caesarean section under spinal anaesthesia

Kinsella, Stephen; Carvalho, Brendan; Dyer, Robert A.; Fernando, Roshan; McDonnell, N.; Mercier, F.J.; Palanisamy, Arvind; Sia, Angelia; Velde, Marc Van de; Vercueil, André

doi:10.1111/anae.14080

Cited by 353 publications

(280 citation statements)

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“…A recent consensus statement recommends the use of routine prophylactic phenylephrine infusions in combination with fluid loading and left lateral uterine displacement to minimise the incidence of hypotension after spinal anaesthesia . Titrated phenylephrine infusions require both appropriate syringe drivers, as well as skilled anaesthetists trained to adjust the rate of infusion in response to maternal haemodynamic changes.…”

Section: Discussionmentioning

confidence: 99%

“…Hypotension after spinal anaesthesia is a common and important problem during caesarean section, which may be associated with nausea, vomiting , loss of consciousness, cardiac arrest and death . In South Africa, the majority of anaesthesia‐related mortality is associated with spinal anaesthesia .…”

Section: Introductionmentioning

confidence: 99%

“…The incidence of maternal hypotension may approach 70%, depending on the definition . A recently published consensus statement recommends the prevention of maternal hypotension with a phenylephrine infusion titrated to between 25 and 50 μg.min −1 , in combination with fluid coloading . It further recommends that, if a syringe driver is unavailable, it is acceptable to add 500 μg phenylephrine to the first litre of intravenous (i.v.)…”

Section: Introductionmentioning

confidence: 99%

“…This statement is based on expert opinion, and has not yet been tested in clinical practice. Studies are required evaluating methods for the reliable administration of phenylephrine in resource‐limited settings . This study aimed to compare intermittent phenylephrine boluses with prophylactic combined phenylephrine and fluid co‐administration for the prevention of spinal hypotension in women undergoing elective caesarean section in a resource‐limited setting.…”

Section: Introductionmentioning

confidence: 99%

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Prophylactic phenylephrine and fluid co‐administration to reduce spinal hypotension during elective caesarean section in a resource‐limited setting: a prospective alternating intervention study

et al. 2019

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Summary Spinal hypotension is a common and clinically important problem during caesarean section. Current consensus recommendations for resource‐rich settings suggest the use of a titrated phenylephrine infusion, in combination with fluid coloading, for prevention of maternal hypotension. In resource‐limited settings, where syringe drivers are unavailable, these recommendations advise the addition of 500 μg phenylephrine to the first 1 l of intravenous fluid given after initiation of spinal anaesthesia, with additional vasopressor boluses as required. This prospective, alternating intervention study compared the use of a conventional phenylephrine rescue bolus strategy for prevention of hypotension, defined as systolic arterial pressure < 90 mmHg, with a phenylephrine infusion given according to the consensus recommendation. We studied 300 women having elective caesarean section. There were 77 (51%) women who developed hypotension in the bolus group vs. 55 (37%) in the phenylephrine infusion group (p = 0.011). This represented a 29% reduction in hypotension, with a number needed to treat of 6.8. The six highest systolic arterial pressure readings occurred in the phenylephrine infusion group (range 166–188 mmHg), and there were four instances of bradycardia (heart rate < 50 beats.min−1) with preserved systolic arterial pressure in each group. There were no adverse clinical sequelae, and no differences in neonatal Apgar scores in either group. The consensus recommendation for phenylephrine and fluid co‐administration in resource‐limited settings appears effective in preventing maternal hypotension, but at the cost of sporadic systolic hypertension.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Prophylactic phenylephrine and fluid co‐administration to reduce spinal hypotension during elective caesarean section in a resource‐limited setting: a prospective alternating intervention study

et al. 2019

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“…Though ephedrine has been purported to be safer for use in pregnant woman, 7 current guidelines support the use of phenylephrine, 8 especially prophylactic infusion to prevent hypotension after spinal anesthesia during cesarean section. Nonetheless, mephentermine continues to be used in the developing world due to multiple reasons.…”

Section: Introductionmentioning

confidence: 99%

Improving Fetal-maternal Outcome in Obstetric Anesthesia: Rhythm Disturbances and Vasopressor Use

Hariharan¹,

Bharati²

2018

Exploratory Research and Hypothesis in Medicine

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Clinical commentaryA 30-year-old primigravida, 162 cm in height and weighing 84 kg, was posted for emergency cesarean section at 39 weeks of gestation. Indication for caesarean section was fetal distress combined with nonprogress of labor. Routine preoperative clinical assessment was unremarkable, with hematological and biochemical investigations yielding results within normal limits. There was no history of any cardiac disease or any other co-morbidities.The patient was taken to the Operation Theater table and electrocardiography, noninvasive blood pressure and pulse oximetry monitoring were started. The baseline heart rate was 92 bpm and blood pressure was 110/76 mmHg with oxygen saturation of 100%. Widebore (18G) intravenous access was secured and the patient was preloaded with 500 mL of intravenous Ringer's lactate. Subarachnoid block was then administered under all aseptic precautions, with patient in the sitting position, in the L 3 -L 4 intervertebral space using 25G Quincke's spinal needle. When free and clear flow of cerebrospinal fluid was obtained, bupivacaine hydrochloride (hyperbaric) 0.5% at 11 mg with fentanyl citrate at 10 mcg (opioid) was injected into the subarachnoid space. Immediately after administering the spinal anesthesia, the patient was then turned to a supine position, with a wedge under the right hip. The blood pressure was recorded to be 100/72 mmHg with a heart rate of 90 bpm.After about 5 m postspinal anesthesia, blood pressure dropped to 74/50 mmHg, with heart rate of 84 bpm. Mephentermine hydrochloride (6 mg) was administered intravenously and intravenous fluids were rushed to counter this hypotensive episode. The level of analgesia was assessed to be T 6 . Shortly thereafter, the patient's heart rate dropped to 40 bpm, with blood pressure of 76/54 mmHg. Immediately, 0.6 mg of atropine was injected intravenously, with continued rushing-in of Ringer's lactate. The heart rate stabilized at 44 bpm, with a blood pressure of 76/52 mmHg. The level of analgesia was again assessed and was found to be T 4 .After 2 m, there was sudden rise in heart rate to 94 bpm and the blood pressure stabilized at 92/60 mmHg. This was accompanied by arrhythmias, with missed beats recorded on the electrocardiography monitor (Fig. 1). Since, by now the patient was hemodynamically stable [BP = 114/80 mm Hg, P = 74/min], no further interventions were undertaken, apart from vigilant monitoring, administration of intravenous fluids and gearing up of preparedness for any cardiovascular crisis. The surgery lasted for 1 h, and one live, healthy male baby was delivered. Thereafter, the patient remained hemodynamically stable throughout the surgery, with heart rate varying from 86 bpm to 94 bpm and mean arterial pressure remaining >70 mmHg at all times. After the surgery, the patient was transferred to the postanesthesia care unit and subsequently to a high-dependency unit for overnight observation.Post AbstractRegional anesthesia is the preferred modality for obstetric patients undergoing cesarean section due to ...

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Maternal Oxygen Supplementation Compared With Room Air for Intrauterine Resuscitation

et al. 2021

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IMPORTANCE Supplemental oxygen is commonly administered to pregnant women at the time of delivery to prevent fetal hypoxia and acidemia. There is mixed evidence on the utility of this practice.OBJECTIVE To compare the association of peripartum maternal oxygen administration with room air on umbilical artery (UA) gas measures and neonatal outcomes.DATA SOURCES Ovid MEDLINE, Embase, Scopus, ClinicalTrials.gov, and Cochrane Central Register of Controlled Trials were searched from February 18 to April 3, 2020. Search terms included labor or obstetric delivery and oxygen therapy and fetal blood or blood gas or acid-base imbalance.STUDY SELECTION Studies were included if they were randomized clinical trials comparing oxygen with room air at the time of scheduled cesarean delivery or labor in patients with singleton, nonanomalous pregnancies. Studies that did not collect paired umbilical cord gas samples or did not report either UA pH or UA PaO 2 results were excluded.DATA EXTRACTION AND SYNTHESIS Data were extracted by 2 independent reviewers. The analysis was stratified by the presence or absence of labor at the time of randomization. Data were pooled using random-effects models. MAIN OUTCOMES AND MEASURESThe primary outcome for this review was UA pH. Secondary outcomes included UA pH less than 7.2, UA PaO 2 , UA base excess, 1-and 5-minute Apgar scores, and neonatal intensive care unit admission. RESULTSThe meta-analysis included 16 randomized clinical trials (n = 1078 oxygen group and n = 974 room air group). There was significant heterogeneity among the studies (I 2 = 49.88%; P = .03). Overall, oxygen administration was associated with no significant difference in UA pH (weighted mean difference, 0.00; 95% CI, −0.01 to 0.01). Oxygen use was associated with an increase in UA PaO 2 (weighted mean difference, 2.57 mm Hg; 95% CI, 0.80-4.34 mm Hg) but no significant difference in UA base excess, UA pH less than 7.2, Apgar scores, or neonatal intensive care unit admissions. Umbilical artery pH values remained similar between groups after accounting for the risk of bias, type of oxygen delivery device, and fraction of inspired oxygen. After stratifying by the presence or absence of labor, oxygen administration in women undergoing scheduled cesarean delivery was associated with increased UA PaO 2 (weighted mean difference, 2.12 mm Hg; 95% CI, 0.09-4.15 mm Hg) and a reduction in the incidence of UA pH less than 7.2 (relative risk, 0.63; 95% CI, 0.43-0.90), but these changes were not noted among those in labor (PaO 2 : weighted mean difference, 3.60 mm Hg; 95% CI, −0.30 to 7.49 mm Hg; UA pH<7.2: relative risk, 1.34; 95% CI, 0.58-3.11).CONCLUSIONS AND RELEVANCE This systematic review and meta-analysis suggests that studies to date showed no association between maternal oxygen and a clinically relevant improvement in UA pH or other neonatal outcomes.

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International consensus statement on the management of hypotension with vasopressors during caesarean section under spinal anaesthesia

Cited by 353 publications

References 154 publications

Prophylactic phenylephrine and fluid co‐administration to reduce spinal hypotension during elective caesarean section in a resource‐limited setting: a prospective alternating intervention study

Prophylactic phenylephrine and fluid co‐administration to reduce spinal hypotension during elective caesarean section in a resource‐limited setting: a prospective alternating intervention study

Improving Fetal-maternal Outcome in Obstetric Anesthesia: Rhythm Disturbances and Vasopressor Use

Maternal Oxygen Supplementation Compared With Room Air for Intrauterine Resuscitation

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