Advertisement

Update on Vasopressors for Cesarean Delivery

  • Stephen Ramage
  • Sarah ArmstrongEmail author
  • Roshan Fernando
Obstetric Anesthesia (LR Leffert, Section Editor)
  • 12 Downloads
Part of the following topical collections:
  1. Obstetric Anesthesia

Abstract

Purpose of Review

The aim of this article is to provide an overview of the current strategies for managing spinal-induced hypotension during cesarean delivery with a particular focus on the evidence guiding the use of vasopressors.

Recent Findings

Phenylephrine is currently regarded as the first-line vasopressor in the prevention and treatment of spinal-induced hypotension following evidence that supports a favorable effect on neonatal acid-base status as well as reduced incidences of nausea and vomiting when compared with ephedrine. Norepinephrine and metaraminol are also effective in the prevention and treatment of hypotension.

Summary

The current consensus for vasopressor use in the treatment of spinal-induced hypotension has been shaped by data gathered from studies involving healthy parturients undergoing elective cesarean deliveries. While these results cannot necessarily be extrapolated to high-risk patients with impaired cardiovascular function or evidence of fetal compromise, these studies may help inform vasopressor choice and establish recommendations for clinical practice.

Keywords

Vasopressor Spinal anesthesia Hypotension Cesarean delivery Aortocaval compression 

Notes

Compliance with Ethical Standards

Conflict of Interest

Stephen Ramage, Sarah Armstrong, and Roshan Fernando declare they have no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Knight M, Nair M, Tuffnell D, Kenyon S, Shakespeare J, Brocklehurst P, et al. Saving lives, improving mothers’ care. Surveillance of maternal deaths in the UK 20120–14 and lessons learned from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2009–14. MBRRACE-UK. 2016; Available from https://www.npeu.ox.ac.uk/downloads/files/mbrrace-uk/reports/MBRRACE-UK%20Maternal%20Report%202016%20-%20website.pdf. Accessed 11 Oct 2018.
  2. 2.
    Colvin JR, Peden CJ. Raising the standard: a compendium of audit recipes for continuous quality improvement in anaesthesia. 2012. Available from https://www.rcoa.ac.uk/system/files/CSQ-ARB-2012_1.pdf. Accessed 11 Oct 2018.
  3. 3.
    Husarova V, McCaul CL. Incidence of general anaesthesia for caesarean section in parturients from different geographic regions. Eur J Anaesthesiol. 2016;33(6):466–8.CrossRefGoogle Scholar
  4. 4.
    Mercier FJ, Augè M, Hoffmann C, Fischer C, Le Gouez A. Maternal hypotension during spinal anesthesia for caesarean delivery. Minerva Anestesiol. 2013;79(1):62–73.Google Scholar
  5. 5.
    Macarthur A, Riley ET. Obstetric anesthesia controversies: vasopressor choice for postspinal hypotension during cesarean delivery. Int Anesthesiol Clin. 2007;45(1):115–32.CrossRefGoogle Scholar
  6. 6.
    Clark RB. Hypotension and caesarean section. Br J Anaesth. 2008;101(6):882–3.CrossRefGoogle Scholar
  7. 7.
    Klöhr S, Roth R, Hofmann T, Rossaint R, Heesen M. Definitions of hypotension after spinal anaesthesia for caesarean section: literature search and application to parturients. Acta Anaesthesiol Scand. 2010;54(8):909–21.CrossRefGoogle Scholar
  8. 8.
    Yokose M, Mihara T, Sugawara Y, Goto T. The predictive ability of non-invasive haemodynamic parameters for hypotension during caesarean section: a prospective observational study. Anaesthesia. 2015;70(5):555–62.CrossRefGoogle Scholar
  9. 9.
    Bishop DG, Cairns C, Grobbelaar M, Rodseth RN. Heart rate variability as a predictor of hypotension following spinal for elective caesarean section: a prospective observational study. Anaesthesia. 2017;72(5):603–8.CrossRefGoogle Scholar
  10. 10.
    Jeon Y-T, Hwang J-W, Kim M-H, Oh A-Y, Park KH, Park H-P, et al. Positional blood pressure change and the risk of hypotension during spinal anesthesia for cesarean delivery: an observational study. Anesth Analg. 2010;111(3):712–5.CrossRefGoogle Scholar
  11. 11.
    • Lee AJ, Landau R. Aortocaval compression syndrome: time to revisit certain dogmas. Anesth Analg. 2017;125(6):1975–85 A fresh look at the decades of evidence surrounding aortocaval compression syndrome and proposes a reevaluation and appraisal of current guidelines regarding entrenched practices. CrossRefGoogle Scholar
  12. 12.
    • Higuchi H, Takagi S, Zhang K, Furui I, Ozaki M. Effect of lateral tilt angle on the volume of the abdominal aorta and inferior vena cava in pregnant and nonpregnant women determined by magnetic resonance imaging. Anesthesiology. 2015;122(2):286–93 This study challenges the presumption that 15° tilt is sufficient. CrossRefGoogle Scholar
  13. 13.
    Kinsella SM, Whitwam JG, Spencer JA. Reducing aortocaval compression: how much tilt is enough? BMJ. 1992;305(6853):539–40.CrossRefGoogle Scholar
  14. 14.
    Lee SWY, Khaw KS, Ngan Kee WD, Leung TY, Critchley LAH. Haemodynamic effects from aortocaval compression at different angles of lateral tilt in non-labouring term pregnant women. Br J Anaesth. 2012;109(6):950–6.CrossRefGoogle Scholar
  15. 15.
    • Lee AJ, Landau R, Mattingly JL, Meenan MM, Corradini B, Wang S, et al. Left lateral table tilt for elective cesarean delivery under spinal anesthesia has no effect on neonatal acid-base status: a randomized controlled trial. Anesthesiology. 2017;127(2):241–9 This study elegantly demonstrates that the effects of maternal position are overcome with vasopressors and IV fluid co-loading. CrossRefGoogle Scholar
  16. 16.
    Kinsella SM, Lohmann G. Supine hypotensive syndrome. Obstet Gynecol. 1994;83(5 Pt 1):774–88.Google Scholar
  17. 17.
    Morgan PJ, Halpern SH, Tarshis J. The effects of an increase of central blood volume before spinal anesthesia for cesarean delivery: a qualitative systematic review. Anesth Analg. 2001;92(4):997–1005.CrossRefGoogle Scholar
  18. 18.
    McDonald S, Fernando R, Ashpole K, Columb M. Maternal cardiac output changes after crystalloid or colloid coload following spinal anesthesia for elective cesarean delivery. Anesth Analg. 2011;113(4):803–10.CrossRefGoogle Scholar
  19. 19.
    Banerjee A, Stocche RM, Angle P, Halpern SH. Preload or coload for spinal anesthesia for elective cesarean delivery: a meta-analysis. Can J Anesth Can d’anesthésie. 2010;57(1):24–31.CrossRefGoogle Scholar
  20. 20.
    Mercier FJ. Cesarean delivery fluid management. Curr Opin Anaesthesiol. 2012;25(3):286–91.CrossRefGoogle Scholar
  21. 21.
    Xiao F, Drzymalski D, Liu L, Zhang Y, Wang L, Chen X. Comparison of the ED50 and ED95 of intrathecal bupivacaine in parturients undergoing cesarean delivery with or without prophylactic phenylephrine infusion. Reg Anesth Pain Med. 2018;43(8):885–9.Google Scholar
  22. 22.
    Hallworth SP, Fernando R, Columb MO, Stocks GM. The effect of posture and baricity on the spread of intrathecal bupivacaine for elective cesarean delivery. Anesth Analg. 2005;100(4):1159–65.CrossRefGoogle Scholar
  23. 23.
    Tang W-X, Li J-J, Bu H-M, Fu Z-J. Spinal anaesthesia with low-dose bupivacaine in marginally hyperbaric solutions for caesarean section. Eur J Anaesthesiol. 2015;32(7):493–8.CrossRefGoogle Scholar
  24. 24.
    Clark V, Van de Velde M, Fernando R, editors. Oxford Textbook of Obstetric Anaesthesia. Vol. 1. Oxford University Press; 2016.  https://doi.org/10.1093/med/9780198713333.001.0001.
  25. 25.
    Kiran S, Singal NK. A comparative study of three different doses of 0.5% hyperbaric bupivacaine for spinal anaesthesia in elective caesarean section. Int J Obstet Anesth. 2002;11(3):185–9.CrossRefGoogle Scholar
  26. 26.
    Arzola C, Wieczorek PM. Efficacy of low-dose bupivacaine in spinal anaesthesia for caesarean delivery: systematic review and meta-analysis. Br J Anaesth. 2011;107(3):308–18.CrossRefGoogle Scholar
  27. 27.
    Ralston DH, Shnider SM, DeLorimier AA. Effects of equipotent ephedrine, metaraminol, mephentermine, and methoxamine on uterine blood flow in the pregnant ewe. Anesthesiology. 1974;40(4):354–70.CrossRefGoogle Scholar
  28. 28.
    Li P, Tong C, Eisenach JC. Pregnancy and ephedrine increase the release of nitric oxide in ovine uterine arteries. Anesth Analg. 1996;82(2):288–93.Google Scholar
  29. 29.
    Hemmings HC, Egan TD, Zimmerman J, Cahalan M. Vasopressors and Inotropes. Pharmacology and Physiology for Anesthesia. 2013. p. 390–404.  https://doi.org/10.1016/B978-1-4377-1679-5.00022-3.
  30. 30.
    Cooper DW, Carpenter M, Mowbray P, Desira WR, Ryall DM, Kokri MS. Fetal and maternal effects of phenylephrine and ephedrine during spinal anesthesia for cesarean delivery. Anesthesiology. 2002;97(6):1582–90.CrossRefGoogle Scholar
  31. 31.
    Ngan Kee WD, Khaw KS, Tan PE, Ng FF, Karmakar MK. Placental transfer and fetal metabolic effects of phenylephrine and ephedrine during spinal anesthesia for cesarean delivery. Anesthesiology. 2009;111(3):506–12.CrossRefGoogle Scholar
  32. 32.
    Thomas D, Gardner S. Comparison of time to peak pressor effect of phenylephrine and ephedrine during spinal anaesthesia for caesarean section. Int J Obstet Anesth. 2004;13(S1):O02.Google Scholar
  33. 33.
    das Neves JFNP, Monteiro GA, de Almeida JR, Sant’ Anna RS, Bonin HB, Macedo CF. Phenylephrine for blood pressure control in elective cesarean section: therapeutic versus prophylactic doses. Brazilian J Anesthesiol. 2010;60(4):391–8.CrossRefGoogle Scholar
  34. 34.
    Siddik-Sayyid SM, Taha SK, Kanazi GE, Aouad MT. A randomized controlled trial of variable rate phenylephrine infusion with rescue phenylephrine boluses versus rescue boluses alone on physician interventions during spinal anesthesia for elective cesarean delivery. Anesth Analg. 2014;118(3):611–8.CrossRefGoogle Scholar
  35. 35.
    Heesen M, Stewart A, Fernando R. Vasopressors for the treatment of maternal hypotension following spinal anaesthesia for elective caesarean section: past, present and future. Anaesthesia. 2015;70(3):252–7.CrossRefGoogle Scholar
  36. 36.
    • Choudhary M, Bajaj JK. Study comparing phenylephrine bolus and infusion for maternal hypotension and neonatal outcome during cesarean section under spinal anesthesia. Anesth Essays Res. 2018;12(2):446–51 Study supporting the delivery of phenylephrine by infusion rather than by bolus. CrossRefGoogle Scholar
  37. 37.
    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(5):1230–7.CrossRefGoogle Scholar
  38. 38.
    Cooper DW, Sharma S, Orakkan P, Gurung S. Retrospective study of association between choice of vasopressor given during spinal anaesthesia for high-risk caesarean delivery and fetal pH. Int J Obstet Anesth. 2010;19(1):44–9.CrossRefGoogle Scholar
  39. 39.
    Ngan Kee WD, Khaw KS, Lau TK, Ng FF, Chui K, Ng KL. Randomised double-blinded comparison of phenylephrine vs ephedrine for maintaining blood pressure during spinal anaesthesia for non-elective caesarean section*. Anaesthesia. 2008;63(12):1319–26.CrossRefGoogle Scholar
  40. 40.
    Tanaka M, Balki M, Parkes RK, Carvalho JCA. ED95 of phenylephrine to prevent spinal-induced hypotension and/or nausea at elective cesarean delivery. Int J Obstet Anesth. 2009;18(2):125–30.CrossRefGoogle Scholar
  41. 41.
    Allen TK, George RB, White WD, Muir HA, Habib AS. 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(5):1221–9.CrossRefGoogle Scholar
  42. 42.
    • Sharkey AM, Siddiqui N, Downey K, Ye XY, Guevara J, Carvalho JCA. Comparison of intermittent intravenous boluses of phenylephrine and norepinephrine to prevent and treat spinal-induced hypotension in cesarean deliveries: randomized controlled trial. Anesth Analg. 2018.  https://doi.org/10.1213/ANE.0000000000003704. Bolus administration of norepinephrine reduces the incidence of bradycardias when compared to phenylephrine.
  43. 43.
    • Vallejo MC, Attaallah AF, Elzamzamy OM, Cifarelli DT, Phelps AL, Hobbs GR, et al. An open-label randomized controlled clinical trial for comparison of continuous phenylephrine versus norepinephrine infusion in prevention of spinal hypotension during cesarean delivery. Int J Obstet Anesth. 2017;29:18–25 Demonstrates the efficacy of norepinephrine infusion for the treatment of spinal-induced hypotension. CrossRefGoogle Scholar
  44. 44.
    Ngan Kee WD. Norepinephrine for maintaining blood pressure during spinal anaesthesia for caesarean section: a 12-month review of individual use. Int J Obstet Anesth. 2017;30:73–4.CrossRefGoogle Scholar
  45. 45.
    • 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(6):934–41 Estimates norepinephrine dose equivalent to phenylephrine. CrossRefGoogle Scholar
  46. 46.
    Ngan Kee WD, Lee SWY, 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(4):736–45.CrossRefGoogle Scholar
  47. 47.
    Ali Elnabtity AM, Selim MF. Norepinephrine versus ephedrine to maintain arterial blood pressure during spinal anesthesia for cesarean delivery: a prospective double-blinded trial. Anesth Essays Res. 2018;12(1):92–7.CrossRefGoogle Scholar
  48. 48.
    Ngan Kee WD, Lee SWY, Ng FF, Khaw KS. Prophylactic norepinephrine infusion for preventing hypotension during spinal anesthesia for cesarean delivery. Anesth Analg. 2018;126(6):1989–94.CrossRefGoogle Scholar
  49. 49.
    • McDonnell NJ, Paech MJ, Muchatuta NA, Hillyard S, Nathan EA. A randomised double-blind trial of phenylephrine and metaraminol infusions for prevention of hypotension during spinal and combined spinal-epidural anaesthesia for elective caesarean section. Anaesthesia. 2017;72(5):609–17 Study identifying efficacy of metaraminol for the treatment of spinal-induced hypotension. CrossRefGoogle Scholar
  50. 50.
    Yentis SM, Jenkins CS, Lucas DN, Barnes PK. The effect of prophylactic glycopyrrolate on maternal haemodynamics following spinal anaesthesia for elective caesarean section. Int J Obstet Anesth. 2000;9(3):156–9.CrossRefGoogle Scholar
  51. 51.
    Yoon H-J, Cho H-J, Lee IH, Jee YS, Kim SM. Comparison of hemodynamic changes between phenylephrine and combined phenylephrine and glycopyrrolate groups after spinal anesthesia for cesarean delivery. Korean J Anesthesiol. 2012;62(1):35–9.CrossRefGoogle Scholar
  52. 52.
    • Patel SD, Habib AS, Phillips S, Carvalho B, Sultan P. The effect of glycopyrrolate on the incidence of hypotension and vasopressor requirement during spinal anesthesia for cesarean delivery. Anesth Analg. 2018;126(2):552–8 The use of glycopyrrolate reduces vasopressor requirements. CrossRefGoogle Scholar
  53. 53.
    Wang M, Zhuo L, Wang Q, Shen M-K, Yu Y-Y, Yu J-J, et al. Efficacy of prophylactic intravenous ondansetron on the prevention of hypotension during cesarean delivery: a dose-dependent study. Int J Clin Exp Med. 2014;7(12):5210–6.Google Scholar
  54. 54.
    Nivatpumin P, Thamvittayakul V. Ephedrine versus ondansetron in the prevention of hypotension during cesarean delivery: a randomized, double-blind, placebo-controlled trial. Int J Obstet Anesth. 2016;27:25–31.CrossRefGoogle Scholar
  55. 55.
    Gao L, Zheng G, Han J, Wang Y, Zheng J. Effects of prophylactic ondansetron on spinal anesthesia-induced hypotension: a meta-analysis. Int J Obstet Anesth. 2015;24(4):335–43.CrossRefGoogle Scholar
  56. 56.
    • Heesen M, Klimek M, Hoeks SE, Rossaint R. Prevention of spinal anesthesia-induced hypotension during cesarean delivery by 5-hydroxytryptamine-3 receptor antagonists. Anesth Analg. 2016;123(4):977–88 Meta-analysis of the evidence supporting the role of ondansetron in reducing spinal-induced hypotension. CrossRefGoogle Scholar
  57. 57.
    Langesaeter E, Dragsund M, Rosseland LA. Regional anaesthesia for a caesarean section in women with cardiac disease: a prospective study. Acta Anaesthesiol Scand. 2010;54(1):46–54.CrossRefGoogle Scholar
  58. 58.
    Henke VG, Bateman BT, Leffert LR. Spinal anesthesia in severe preeclampsia. Anesth Analg. 2013;117(3):686–93.CrossRefGoogle Scholar
  59. 59.
    Dyer RA, Piercy JL, Reed AR, Lombard CJ, Schoeman LK, James MF. Hemodynamic changes associated with spinal anesthesia for cesarean delivery in severe preeclampsia. Anesthesiology. 2008;108(5):802–11.CrossRefGoogle Scholar
  60. 60.
    Karinen J, Räsänen J, Alahuhta S, Jouppila R, Jouppila P. Maternal and uteroplacental haemodynamic state in pre-eclamptic patients during spinal anaesthesia for caesarean section. Br J Anaesth. 1996;76(5):616–20.CrossRefGoogle Scholar
  61. 61.
    Dyer RA, Daniels A, Vorster A, Emmanuel A, Arcache MJ, Schulein S, et al. Maternal cardiac output response to colloid preload and vasopressor therapy during spinal anaesthesia for caesarean section in patients with severe pre-eclampsia: a randomised, controlled trial. Anaesthesia. 2018;73(1):23–31.CrossRefGoogle Scholar
  62. 62.
    • Dyer RA, Emmanuel A, Adams SC, Lombard CJ, Arcache MJ, Vorster A, et al. A randomised comparison of bolus phenylephrine and ephedrine for the management of spinal hypotension in patients with severe preeclampsia and fetal compromise. Int J Obstet Anesth. 2018;33:23–31 No difference in neonatal outcomes comparing ephedrine to phenylephrine in a preeclampsia cohort. CrossRefGoogle Scholar
  63. 63.
    Webster L, Allman L, Iqbal S, Carling A. Obstetric Anaesthetists’ Association. Survey 109. Phenylephrine in obstetric anaesthesia – a survey of UK practice. 2013. Available from http://www.oaa-anaes.ac.uk/ui/content/content.aspx?ID=118. Accessed 13 Oct 2018.
  64. 64.
    McGlennan A, Patel N, Sujith B, Bell R. A survey of pre-loading and vasopressor use during regional anaesthesia for caesarean section. Int J Obstet Anesth. 2007;16(S27).  https://doi.org/10.1016/j.ijoa.2007.04.001.
  65. 65.
    Staikou C, Paraskeva A, Karmaniolou I, Mani A, Chondrogiannis K. Current practice in obstetric anesthesia: a 2012 European survey. Minerva Anestesiol. 2014 Mar;80(3):347–54.Google Scholar
  66. 66.
    NICE, Caesarean section | Guidance and guidelines | NICE. NICE Guidance. 2012. Available from https://www.nice.org.uk/guidance/cg132/chapter/1-Guidance#procedural-aspects-of-cs. Accessed 13 Oct 2018.
  67. 67.
    Practice guidelines for obstetric anesthesia. An updated report by the American Society of Anesthesiologists Task Force on obstetric anesthesia and the Society for Obstetric Anesthesia and Perinatology. Anesthesiology 2016;124(2):270–300.  https://doi.org/10.1097/ALN.0000000000000935.
  68. 68.
    •• Kinsella SM, Carvalho B, Dyer RA, Fernando R, McDonnell N, Mercier FJ, et al. International consensus statement on the management of hypotension with vasopressors during caesarean section under spinal anaesthesia. Anaesthesia. 2018;73(1):71–92 Recommendations for best clinical practice based upon a comprehensive review of the management of spinal-induced hypotension. CrossRefGoogle Scholar
  69. 69.
    Dyer RA, Reed AR, van Dyk D, Arcache MJ, Hodges O, Lombard CJ, et al. Hemodynamic effects of ephedrine, phenylephrine, and the coadministration of phenylephrine with oxytocin during spinal anesthesia for elective cesarean delivery. Anesthesiology. 2009;111(4):753–65.CrossRefGoogle Scholar
  70. 70.
    Smiley RM. More perfect? Int J Obstet Anesth. 2017;29:1–4.CrossRefGoogle Scholar
  71. 71.
    Sumikura H. Do fetuses need vasopressors just before their birth? J Anesth. 2018;32(4):481–2.CrossRefGoogle Scholar
  72. 72.
    Sng BL, Tan HS, Sia ATH. Closed-loop double-vasopressor automated system vs manual bolus vasopressor to treat hypotension during spinal anaesthesia for caesarean section: a randomised controlled trial. Anaesthesia. 2014;69(1):37–45.CrossRefGoogle Scholar
  73. 73.
    Ngan Kee WD, Tam Y-H, Khaw KS, Ng FF, Lee SWY. Closed-loop feedback computer-controlled phenylephrine for maintenance of blood pressure during spinal anesthesia for cesarean delivery. Anesth Analg. 2017;125(1):117–23.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  • Stephen Ramage
    • 1
  • Sarah Armstrong
    • 1
    Email author
  • Roshan Fernando
    • 2
  1. 1.Department of Anaesthetics, Frimley Park HospitalFrimley Health NHS Foundation TrustSurreyUK
  2. 2.Department of Anesthesia and Perioperative Medicine, The Women’s Wellness and Research CentreHamad Medical CorporationDohaQatar

Personalised recommendations