Effects of Norepinephrine-Ephedrine Combination on Maternal Hemodynamics in Cesarean Sections Performed Under Spinal Anesthesia

Abstract

Objective: The frequency of maternal hypotension after spinal anesthesia in Caesarean section (CS) may be as high as 90%. The aim of this study was to investigate the effect of the use of the combination of ephedrine and norepinephrine on maternal hemodynamics, neonatal APGAR and acidosis in CS delivery under spinal anesthesia. Methods: This prospective, randomized, double-blind study included pregnant patients aged 18 - 45 years, evaluated as ASA class I-II for surgery, who underwent elective CS under spinal anesthesia. The clinical and laboratory findings, umbilical blood gases, maternal blood pressure and heart rate were also analyzed. The patients were randomly separated into 3 groups: Ephedrine (E), Ephedrine+Norepinephrine (EN), and Norepinephrine (N). Results: Umbilical cord venous blood pH and HCO3 was lower in Group EN than the other groups. APGAR score was lower in Group E. Heart rate in Groups EN and N decreased up to the middle of surgery, then was slightly elevated until the end of surgery. Heart rate persistently decreased in Group E from the beginning to the end of the surgery. SBP decreased significantly at the end of the surgery compared to basal levels in Group EN and N, and did not decrease significantly in Group E. Conclusion: These findings suggest that the addition of norepinephrine to ephedrine might increase the risk of fetal acidosis and affect the APGAR score. The longer duration of action and the higher number of bolus of ephedrine might be associated with a lesser decrease in maternal blood pressure after the middle of the surgery.

Keywords

• Post-spinal hypotension
• vasopressor
• norepinephrine
• ephedrine
• caesarean section

Spinal Anestezi ile Yapılan Sezaryenlerde Norepinefrinin-Efedrin Kombinasyonunun Maternal Hemodinami Üzerine Etkileri

Abstract

References

1. 1. Erdem MK, Özgen S, Coşkun F. Obstetrik Anestezi ve Analjezi. In Kişnişci H, Gökşin E, eds. Temel Kadın Hastalıkları ve Doğum Bilgisi. Ankara: Melisa Matbaacılık, 1996; 173-186.
2. 2. Morgan GE, Mikhail SM. Clinical Anesthesiology. 2nd ed. Stamford: Appleton&Lange; 1996.
3. 3. McDonnell NJ, Paech MJ, Clavisi OM, Scott KL; ANZCA Trials Group. Difficult and failed intubation in obstetric anaesthesia: an observational study of airway management and complications associated with general anaesthesia for caesarean section. Int J Obstet Anesth. 2008;17(4):292-297. doi:10.1016/j.ijoa.2008.01.017
4. 4. Jadon A. Complications of regional and general anaesthesia in obstetric practice. Indian J Anaesth. 2010;54(5):415-420. doi:10.4103/0019-5049.71039
5. 5. Morris S, Harmer M, Reynolds F. The impact of regional anesthesia on maternal mortality. In Reynolds F, eds. Regional Analgesia in Obstetrics. A Millenium Update. London: Springer; 2000: 347-356.
6. 6. Paech MJ. Anesthesia for Cesarean Section: Handbook of in Obstetric Anesthesia. 1st ed.UK: BİOS; 2002: 82-113.
7. 7. Lee A, Ngan Kee WD, Gin T. Prophylactic ephedrine prevents hypotension during spinal anesthesia for Cesarean delivery but does not improve neonatal outcome: a quantitative systematic review. Can J Anaesth. 2002;49(6):588-599. doi:10.1007/BF03017387
8. 8. Schnittger T. Regional anaesthesia in developing countries. Anaesthesia. 2007;62 Suppl 1:44-47. doi:10.1111/j.1365-2044.2007.05297.x.

9. 9. 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):92-97. doi:10.4103/aer.AER_204_17
10. 10. Turkoz A, Togal T, Gokdeniz R, Toprak HI, Ersoy O. Effectiveness of intravenous ephedrine infusion during spinal anaesthesia for caesarean section based on maternal hypotension, neonatal acid-base status and lactate levels. Anaesth Intensive Care. 2002;30(3):316-320. doi:10.1177/0310057X0203000308
11. 11. 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(4):736-745. doi:10.1097/ALN.0000000000000601
12. 12. Ngan Kee WD, Khaw KS. Vasopressors in obstetrics: what should we be using?. Curr Opin Anaesthesiol. 2006;19(3):238-243. doi:10.1097/01.aco.0000192816.22989.ba
13. 13. Hoyme M, Scheungraber C, Reinhart K, Schummer W. Comparison of Norepinephrine and Cafedrine/Theodrenaline Regimens for Maintaining Maternal Blood Pressure during Spinal Anaesthesia for Caesarean Section. Obstetrics & Gynecology an International Journal. Published online August 26, 2015:1-12. doi:10.5171/2015.714966
14. 14. Ngan Kee WD, Khaw KS, Lee BB, Ng FF, Wong MM. Randomized controlled study of colloid preload before spinal anaesthesia for caesarean section. Br J Anaesth. 2001;87(5):772-774. doi:10.1093/bja/87.5.772
15. 15. Lee A, Ngan Kee WD, Gin T. A quantitative, systematic review of randomized controlled trials of ephedrine versus phenylephrine for the management of hypotension during spinal anesthesia for cesarean delivery. Anesth Analg. 2002;94(4):. doi:10.1097/00000539-200204000-00028
16. 16. Doherty A, Ohashi Y, Downey K, Carvalho JC. Phenylephrine infusion versus bolus regimens during cesarean delivery under spinal anesthesia: a double-blind randomized clinical trial to assess hemodynamic changes. Anesth Analg. 2012;115(6):1343-1350. doi:10.1213/ANE.0b013e31826ac3db
17. 17. 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):934-941. doi:10.1097/ALN.0000000000001880
18. 18. 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. 2019;129(5):1312-1318. doi:10.1213/ANE.0000000000003704
19. 19. Practice parameters for hemodynamic support of sepsis in adult patients in sepsis. Task Force of the American College of Critical Care Medicine, Society of Critical Care Medicine. Crit Care Med. 1999;27(3):639-660. doi:10.1097/00003246-199903000-00049
20. 20. Cyna AM, Andrew M, Emmett RS, Middleton P, Simmons SW. Techniques for preventing hypotension during spinal anaesthesia for caesarean section. Cochrane Database Syst Rev. 2006;(4):CD002251. Published 2006 Oct 18. doi:10.1002/14651858.CD002251.pub2
21. 21. Minzter BH, Johnson RF, Paschall RL, Ramasubramanian R, Ayers GD, Downing JW. The diverse effects of vasopressors on the fetoplacental circulation of the dual perfused human placenta. Anesth Analg. 2010;110(3):857-862. doi:10.1213/ANE.0b013e3181c91ebc
22. 22. Ngan Kee WD, Khaw KS, Tam YH, Ng FF, Lee SW. Performance of a closed-loop feedback computer-controlled infusion system for maintaining blood pressure during spinal anaesthesia for caesarean section: a randomized controlled comparison of norepinephrine versus phenylephrine. J Clin Monit Comput. 2017;31(3):617-623. doi:10.1007/s10877-016-9883-z
23. 23. 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):506-512. doi:10.1097/ALN.0b013e3181b160a3
24. 24. Ngan Kee WD, Lee A. Multivariate analysis of factors associated with umbilical arterial pH and standard base excess after Caesarean section under spinal anaesthesia. Anaesthesia. 2003;58(2):125-130. doi:10.1046/j.1365-2044.2003.02888.x