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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 16  |  Issue : 1  |  Page : 27-32

Prophylaxis or treatment of spinal hypotension during cesarean delivery: phenylephrine versus norepinephrine boluses


1 Department of Anesthesia and Intensive Care, Al-Azhar Faculty of Medicine for Male, Al-Azhar University, Cairo, Egypt
2 Department of Anesthesia and Intensive Care, Al-Azhar Faculty of Medicine for Girl, Al-Azhar University, Cairo, Egypt

Date of Submission21-Apr-2018
Date of Acceptance29-May-2018
Date of Web Publication20-Nov-2018

Correspondence Address:
Mofeed A Abdelmaboud
Department of Anesthesia and Intensive Care, Al-Azhar Faculty of Medicine for Male, Al-Azhar University, Cairo 12992
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/AZMJ.AZMJ_31_18

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  Abstract 


Background Vasopressors have traditionally been used for the prevention and management of neuraxial hypotension.
Aim The primary outcome was to determine which is better, prophylaxis or treatment of spinal hypotension during cesarean delivery and to determine which drug is better, phenylephrine (PE) or norepinephrine (NE). The secondary outcome was to determine possible complications.
Patients and methods According to the percentage degree of fall of systolic blood pressure (SBP) after spinal block, 100 full-term pregnant female patients were classified into either prophylaxis groups: received intravenous bolus of either PE 100 µg (group I) or NE 8 µg (group II) when mean arterial pressure (MAP) fell between 100 and 80% of baseline, or treatment groups: received same bolus of PE (group III) or NE (group VI) when MAP fell below 80% of baseline. Baseline and intraoperative SBP, SBP at first episode of decrease of SBP, time at first episode of decrease of SBP and response (%), incidence of hypertension, bradycardia, number of patients who required atropine, incidence of nausea, vomiting and need for antiemetic, and Apgar score at 1 and 5 min were recorded.
Results The SBP at first episode of decrease of SBP was significantly lower in both treatment groups. The incidence of bradycardia was significantly higher in both PE groups but it did not occur in both NE groups (0%). The incidence of nausea and hypotension-induced nausea was significantly higher in both treatment groups than both prophylaxis groups. The Apgar score at both 1 min and 5 min was significantly lower in group III than in group I, in group IV than in group I, in group III than in group II, and in group IV than in group II.
Conclusion First, spinal hypotension prophylaxis during elective cesarean section gave better results than treatment with less incidence of nausea and hypotension-induced nausea and better Apgar score at 1 and 5 min. Second, NE can be a suitable alternative to PE with no bradycardia and is readily available and less expensive.

Keywords: cesarean delivery, phenylephrine versus norepinephrine boluses, prophylaxis or treatment, spinal hypotension


How to cite this article:
Abdelmaboud MA, Seyam SH, Salem EA. Prophylaxis or treatment of spinal hypotension during cesarean delivery: phenylephrine versus norepinephrine boluses. Al-Azhar Assiut Med J 2018;16:27-32

How to cite this URL:
Abdelmaboud MA, Seyam SH, Salem EA. Prophylaxis or treatment of spinal hypotension during cesarean delivery: phenylephrine versus norepinephrine boluses. Al-Azhar Assiut Med J [serial online] 2018 [cited 2018 Dec 18];16:27-32. Available from: http://www.azmj.eg.net/text.asp?2018/16/1/27/244145




  Introduction Top


Neuraxial anesthesia remains the technique of choice for cesarean deliveries all over the world [1].

The neuraxial blockade produces sympathectomy that is exaggerated by the physiological changes of pregnancy and puerperium, causing hypotension in as much as 55–90% of mothers receiving spinal anesthesia for cesarean section [2].

Vasopressors, causing an increase in systemic vascular resistance and mean arterial pressures (MAPs), have traditionally been used for the management and prevention of neuraxial anesthesia-induced hypotension [1].

Nowadays, the preferred vasopressor for maintaining blood pressure (BP) during spinal anesthesia for cesarean section is phenylephrine (PE) [3]. However, PE at usual doses is a pure α-agonist; its use is usually associated with a reflex decrease in heart rate (HR) and cardiac output (CO) [4].

Prophylactic administration of phenylephrine is associated with a higher incidence of bradycardia and hypertension, and treatment after onset of hypotension is associated with higher ‘incidence and severity of maternal predelivery hypotension’ [5].

Norepinephrine (NE) is a potent α-agonist, but also has weak β-agonist activity, which antagonizes the reflex slowing of HR, and result in more stable hemodynamics [6].


  Patients and methods Top


After approval from the local ethical committee of Anesthesia and Intensive Care Department and Faculty of Medicine, and informed written consent from each patient, this study was carried out at Al-Azhar University hospitals in Cairo in the period spanning from June 2017 to October 2017.

A total of 100 full-term pregnant female individuals was included in this study. Inclusion criteria were as follows: physical status American Society of Anaesthesiologists I or II, full-term pregnancy of single fetus, with baseline systolic blood pressure (SBP) between 90 and 139 mmHg (BMI: 18.5–29.9 kg/m2), and scheduled for elective cesarean section. Exclusion criteria were patient refusal to share in the study, fetal anomalies, diabetes mellitus, any grade of hypertension, even controlled, cardiovascular or cerebrovascular disease, presence of contraindication to spinal block, and hypersensitivity to the drug used in this study.

Patients were transferred to the operating room, and they had two 18 G intravenous cannulae inserted into the peripheral vein and standard noninvasive monitoring was applied including ECG, noninvasive BP and pulse oximeter (Colin BP-608 Evolution, Kyoto, Japan). Patients were placed in the supine position displacing the uterus to the left, with the SBP recorded three times, with three minutes interval to obtain mean baseline values (P0).

A volume of 20 ml/kg of lactated Ringer was given immediately before spinal anesthesia as preload by rapid infusion; thereafter, the rate was reduced to keep the vein open until the delivery of the infant. Spinal anesthesia was given in sitting position under complete aseptic condition using 27 G pencil-point spinal needle (UniEVER CE 0120, made in Nishikata, Koshigaya, , Sait Ama, Japan) at L2-3 or L3-4 interspace, and after cerebrospinal fluid flow from spinal needle; 11 mg (2.1 ml) hyperbaric bupivacaine 0.5% (Sunnypivacaine, batch no. 170518, Cairo-Egypt) was injected slowly intrathecally, then the patient was returned to the supine position with head elevation of 15°, and left uterine displacement was carried out by a wedge placed under the right flank. A volume of 5 l/min oxygen was administered via nasal prongs to all patients. The time at establishment of block (min) and the blockade to skin incision (min) was recorded in each group. The highest sensory level after spinal block was recorded in each group using loss of pinprick sensation. If block was below T6, the block was considered inadequate, and the patient was excluded.

According to the percentage degree of fall of SBP after spinal block, 100 full-term pregnant female individuals were classified into the following:

Prophylaxis groups (52 patients)

  1. Group I (GI; 26 patients): prophylactic intravenous bolus of PE 100 µg when MAP fell between 100 and 80% of baseline (PE prophylaxis).
  2. Group II (GII; 26 patients): prophylactic intravenous bolus of NE 8 µg when MAP fell between 100 and 80% of baseline (NE prophylaxis).


Treatment groups (48 patients)

  1. Group III (GIII; 24 patients): intravenous bolus of PE 100 µg when MAP fell below 80% of baseline (PE treatment).
  2. Group IV (GIV; 24 patients): intravenous bolus of NE 8 µg when MAP fell below 80% of baseline (NE treatment).


SBP was recorded at establishment of block (P1), 1 min after injection of the study drug (P2) and then at 10, 20, 30, and 40 min after block (P3, P4, P5, and P6 respectively). Time of decrease of SBP after spinal block (s) was recorded.

Response (%) was defined according to the following equation:



where A, baseline SBP; B, first episode of decrease of SBP; and C, SBP measured 1 min after injection of the study drug. After estimation of the response (%), the study was terminated [7].

The incidence of hypertension and bradycardia (HR <60 bpm) was recorded. Atropine 0.6 mg was administered for bradycardia defined as HR less than 50 bpm.

Patients were asked to report nausea after spinal block at any time intraoperatively. Intraoperative nausea or vomiting occurring immediately before or after 20% decrease in SBP was recorded as hypotension-induced nausea or vomiting. Intraoperative nausea or vomiting not related to hypotension was treated with metoclopramide 10 mg intravenously.

Apgar scores at 1 and 5 min after delivery and number of patients showed Apgar score less than 7 at 1 min or less than 8 at 5 min were recorded. Blood loss in each group was recorded.


  Aim Top


The primary outcome was to examine which is better, prophylaxis or treatment of spinal hypotension during cesarean delivery, and also to determine which drug is better, NE or PE. The secondary outcome was to determine possible complications (cardiovascular, nausea, and vomiting and Apgar score).

Statistical analysis

Data were expressed as mean±SD, number or percentage and compared using SPSS version V17 (SPSS Inc., Chicago, Illinois, USA). Analysis of variance was utilized for parametric data, and Tukeyʾs test was used if analysis of variance test was significant. χ2-test was used for the percentages and incidence. P value less than 0.05 was considered statistically significant.


  Results Top


The four groups were comparable as regards the demographic data ([Table 1]).
Table 1 Demographic data

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There were no statistically significant differences among groups in the time of establishment of spinal block (min), blockade to skin incision time (min), and estimated blood loss (ml) ([Table 2]).
Table 2 Anesthesia surgical parameters

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There were no significant differences among groups as regards baseline SBP (mmHg), intraoperative SBP, except at establishment of first episode of decrease of SBP, where it was lower in the two therapeutic groups than in the prophylactic groups ([Figure 1]).
Figure 1 Baseline and intraoperative SBP.

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There were no significant differences among groups with regard to time at first episode of decrease of SBP (s), and response (%) ([Table 3]).
Table 3 Systolic blood pressure changes and response to vasopressor

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There were no significant differences among groups with respect to incidence of hypertension and number of patients who required atropine. The incidence of bradycardia was significantly higher in PE (prophylaxis and treatment) groups (24 and 12%, respectively), but it did not occur in patients who received NE for prophylaxis or treatment (0%) ([Figure 2]).
Figure 2 Incidence of hypertension and bradycardia and number of patients required atropine.

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The incidence of nausea and hypotension-induced nausea was significantly higher in both treatment groups compared with both prophylaxis groups, but there were no significant differences among the four groups with regard to the incidence of vomiting and need for antiemetic ([Figure 3]).
Figure 3 Incidence of nausea, vomiting and number of patients required antiemetic.

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The Apgar score at both 1 and 5 min was significantly lower in group III than in group I, in group IV than in group I, in group III than in group II, and in group IV than in group II. There were no significant differences among groups with respect to number of patients showing Apgar score less than 7 at 1 min or less than 8 at 5 min ([Table 4]).
Table 4 Apgar score

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  Discussion Top


Ngan Kee [8] compared NE and PE for treating hypotension during spinal anesthesia for cesarean delivery. Ngan Kee et al. [10] compared NE and PE for maintenance of blood pressure during spinal anesthesia for cesarean delivery Dong et al. [9]. Compared the effect of prophylactic bolus of norepinephrine and phenylephrine on hypotension during spinal anesthesia for cesarean section.

In the current study, there were no significant differences among groups as regards baseline SBP (mmHg), intraoperative SBP, except at establishment of first episode of decrease of SBP, where it was lower in the two therapeutic groups than in the prophylactic groups. There were no significant differences among groups as regards time at first episode of decrease of SBP (s) and response (%).

Ngan Kee [8] demonstrated that the mean SBP at the first episode of hypotension was 84±24 mmHg in the PE treatment group and 84±22 mmHg in the NE treatment group with no significant difference (P=1.00), and SBP after vasopressor dose was 105±31 mmHg in the PE treatment group and 94±29 mmHg in the NE treatment group with no significant difference (P=0.324); response (%) was 74.2±34.5 in the PE treatment group and 48.7±31.0 in the NE treatment group with significant difference (P=0.042).

In the present study, the SBP at first episode of decrease of SBP was 98±17 mmHg in PE prophylaxis, in NE prophylaxis (96±18 mmHg), in PE treatment (90±14 mmHg), and in NE treatment (88±13 mmHg) with no significant difference (P=0.08).

Ngan Kee [8] observed that the SBP at first episode of hypotension was 83±10 mmHg in the PE treatment group and 83±11 mmHg in the NE treatment group with no significant difference (P=0.99).

In this study, there were no significant differences among groups respecting incidence of hypertension and number of patients requiring atropine. The incidence of bradycardia was significantly higher in PE (prophylaxis and treatment) groups (24 and 12%, respectively), but it did not occur in patients receiving NE for prophylaxis or treatment (0%).

Ngan Kee et al. [10] demonstrated that the incidence of bradycardia was significantly lower in the NE group (18.4%) compared with the PE group (55.8%) (P<0.001).

As PE is a potent α-adrenergic agonist without β-activity at clinical doses, its use is often associated with a dose-related reflex slowing of maternal HR and decrease in CO [4].

Ngan Kee et al. [10] found that equipotent dose of NE had similar efficacy to PE with HR maintenance at a higher level, closer to baseline and greater values for CO.

In this study, the incidence of nausea and hypotension-induced nausea were significantly higher in both treatment groups compared with both prophylaxis groups, but there were no significant differences among four groups with regard to incidence of vomiting and need for antiemetic.

Ngan Kee et al. [10] observed that there were no significant difference in the incidence of nausea or vomiting (P=0.67) between the NE (6.1%) and PE groups (3.8%).

Dong et al. [9] found no significant differences in the incidence of hypertension (P=0.68) between NE prophylaxis (3%) and PE prophylaxis (5%) groups but the incidence of bradycaria was significantly lower in NE prophylaxis (2%) and PE prophylaxis (13%) groups (P value 0.02).

In the current study, the Apgar score at 1 min was significantly lower in PE treatment than in PE prophylaxis (P=0.005), in NE treatment than in PE prophylaxis (P<0.001), in PE treatment than in NE prophylaxis (P<0.001), and in NE treatment than in NE prophylaxis (P<0.001). Moreover, Apgar score at 5 min was significantly lower in PE treatment than in PE prophylaxis (P=0.001), in NE treatment than in PE prophylaxis (P<0.012), in PE treatment than in NE prophylaxis (P<0.001), and in NE treatment than in NE prophylaxis (P<0.005). There were no significant differences among groups with respect to number of patients showing Apgar score less than 7 at 1 min or less than 8 at 5 min.

Ngan Kee [8] observed that there were no significant differences with regard to Apgar score at 1 and 5 min between both NE and PE treatment groups.

Ngan Kee et al. [10] found that all Apgar scores at 1 and 5 min were greater than 7 in both NE and PE groups with no significant differences.

Dong et al. [9] observed that no neonate in both PE and NE prophylaxis groups had Apgar score less than 8 at 1 or 5 min, but, at first minute, only one neonate in the PE group had Apgar score of 8, and the rest of the neonates had Apgar scores of 9, and all neonates of both groups had Apgar scores of 9 at 5 min.


  Conclusion Top


First, spinal hypotension prophylaxis during elective cesarean section gave better results than treatment, as it showed less incidence of nausea and hypotension-induced nausea and better Apgar score at 1 and 5 min Second, NE can be a suitable alternative to PE with less incidence of bradycardia, and it is also readily available and less expensive.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Bangash MN, Kong ML, Pearse RM. Use of inotropes and vasopressor agents in critically ill patients. Br J Pharmacol 2012; 165:2015–2033.  Back to cited text no. 1
    
2.
Mercier FJ, Bonnet MP, De la Dorie A, Moufouki M, Banu F, Hanaf A et al. Spinal anaesthesia for caesarean section: fluid loading, vasopressors and hypotension. Ann Fr Anesth Reanim 2007; 26:688–693.  Back to cited text no. 2
    
3.
Ngan Kee WD, Khaw KS. Vasopressors in obstetrics: what should we be using? Curr Opin Anaesthesiol 2006; 19:238–243.  Back to cited text no. 3
    
4.
Stewart A, Fernando R, McDonald S, Hignett R, Jones T, Columb M. The dose-dependent effects of phenylephrine for elective cesarean delivery under spinal anesthesia. Anesth Analg 2010; 111:1230.  Back to cited text no. 4
    
5.
Allen TK, George RB, White WD et al. A double-blind, placebo-controlled trial of four fixed rate infusion regimens of phenylephrine for hemodynamic support during spinal anesthesia for cesarean delivery. Anesth Analg 2010; 111:1221–1229.  Back to cited text no. 5
    
6.
Onwochei DN, Ngan Kee WD, Fung L et al. Norepinephrine intermittent intravenous boluses to prevent hypotension during spinal anesthesia for cesarean delivery: a sequential allocation dose-finding study. Anesth Analg 2017; 125:212–218.  Back to cited text no. 6
    
7.
Goertz AW, Seeling W, Heinrich H, Lindner KH, Rockemann MG. Effect of phenylephrine bolus administra- tion on left ventricular function during high thoracic and lumbar epidural anesthesia combined with general anesthesia. Anesth Analg 1993; 76:541–545.  Back to cited text no. 7
    
8.
Ngan Kee WD. A random-allocation graded dose-response study of norepinephrine and phenylephrine for treating hypotension during spinal anesthesia for cesarean delivery. Anesthesiology 2017; 127:934–941.  Back to cited text no. 8
    
9.
Dong L, Dong Q, Xiumei Song X, Liu Y, Wang Y. Comparison of prophylactic bolus norepinephrine and phenylephrine on hypotension during spinal anesthesia for cesarean section. Int J Clin Exp Med 2017; 10:12315–12321.  Back to cited text no. 9
    
10.
Ngan Kee WD, Lee SW, Ng FF, Tan PE, Khaw KS. Randomized double-blinded comparison of norepinephrine and phenylephrine for maintenance of blood pressure during spinal anesthesia for cesarean delivery. Anesthesiology 2015; 122:736–745.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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