Vasopressor drugs for the prevention and treatment of hypotension during neuraxial anaesthesia for Caesarean delivery: a Bayesian network meta-analysis of fetal and maternal outcomes

Abstract

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.

Incidence and Associated Factors for Neuraxial Anaesthesia-Related Hypotension in COVID-19 Parturients Undergoing Caesarean Delivery: A Multicenter Case-Control Study

“…Latest meta-analysis showed that vasoconstrictor (such as metaraminol, norepinephrine and phenylephrine) intervention was effective and safe in preventing and treating neuraxial anaesthesiarelated hypotension in healthy parturients. Leg compression and uid load might be also helpful (Pereira, Grando et al, 2011;Chooi, Cox et al, 2020;Singh, Singh et al, 2020). Present study also reported similar intervention of vasoconstrictor and uids in COVID-19 parturients.…”

Hypotension after spinal anaesthesia is not always the rule in parturients undergoing caesarean section

“…18 Interestingly, a recent meta-analysis by Singh and colleagues demonstrated that prophylactic use of phenylephrine, and ephedrine had the highest probability among other vasopressors used to adversely affect fetal acid-base status, and thus fetal outcome. 19 In another meta-analysis by Fitzgerald and colleagues showed that phenylephrine had caused maternal bradycardia more common than other vasopressors which were used. 20 Our study demonstrated that, if the risk factors for post-spinal hypotension were avoided, prophylactic vasopressor administration might not be always necessary.…”

The application of a neural network to predict hypotension and vasopressor requirements non-invasively in obstetric patients having spinal anesthesia for elective cesarean section (C/S)

“…additional intravenous fluid) in patients predicted to need substantial vasopressor administration can minimize the need for pharmacologic intervention, it would be of significant clinical value. A recent review article has shown that vasopressor interventions can adversely affect the fetal acid base status [34].…”