Aruna Godwin

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Spinal Hypotension in Elective C sectionHow to
prevent it.

• Aruna Godwin
• Department of Anesthesiology
• Rashid Hospital Trauma Centre
• Dubai Health Authority - UAE

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• USA up to 39
• x 10 in 70 years
• Europe up to 20..25
• UAE up to 29
• Brazil up to 80 in private

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• Local anesthesic
• Levo-bupi Bupi 8 mg
• Ropi 12mg
• Fat-soluble opioids
• Sufentanil 5 mcg
• Fentanyl 10 mcg up to 25 mcg
• Post op. analgesia
• Intra thecal morphin 100 mcg
• TAP blocks
• Continuous wound infiltration

Gautier P BJA 2003 Rackelboom T Obst
Gynecol Oct 2010 ONeil Patricia ASA 2010
Gautier P BJA 2003
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• Effects of hypotension.
• Dose of Spinal anesthetic.
• Vasopressor of choice.
• Intravenous fluid loading strategies.

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• Maternal
• Nausea vomiting
• loss of consciouness
• aspiration
• Foetal
• Decreased Uteroplacental perfusion
• Umbilical Ph low
• Foetal acidosis
• APGAR
• ,

Datta, S Alper,Anesthesiology Ngan
Kee,Anesthesiology. Sykes GS,Lancet
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• Intrathecal opioids are synergistic with local
  anesthetics and intensify sensory block without
  increasing sympathetic block.

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Incidence of Hypotension Gp 7mg Gp 8mg Gp 9mg
P 0.04 30 55 70

• Time taken to reach T4 was similar.
• No patient had inadequate anesthesia

Leo S Anesth Analg. 2009
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Forest plot for hypotension comparing LD vs CD
individual trials and meta-analysis.
Arzola C , and Wieczorek P M Br. J. Anaesth. 2011
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Bupivacaine - sparing effect of fentanyl in
spinal anesthesia for cesarean delivery.

• CONCLUSIONS
• The optimal dose of hyperbaric bupivacaine to
  produce surgical anesthesia was 12 mg, which was
  accompanied by high sensory block. With the
  addition of 10 microg of fentanyl, the dose of
  bupivacaine could be reduced to 8 mg in spinal
  anesthesia for cesarean delivery

Choi DH Reg Anesth Pain Med. 2000
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• Low dose spinal anesthesia with Intrathecal
  opioids improved maternal haemodynamics.

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• Non pharmacological methods
• 15 left lateral tilt... gt Still 70- 80
• Pharmacological methods
• Vasopressors (Phenylephrine or ephedrine)
• IV fluid loading

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• Ephedrine or Phenylephrine ???
• Prophylactic infusion, on demand or combined
  with fluid loading.

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• Ephedrine
• Recent evidence suggests that ephedrine causes
  neonatal acidosis, and large doses may be harmful
  in a compromised fetus, by increasing oxygen
  demand and anaerobic metabolism.
• Placental transfer and fetal metabolic effects of
  phenylephrine and ephedrine during spinal
  anesthesia for cesarean delivery.

Riley ET. Int Anesthesiol Clin 2007. Ngan
Kee WD, Karmakar MK Anesthesiology 2009.
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• Phenylephrine.
• Has direct effect on alpha-1 receptor..
• Potent short-acting vasoconstrictor.
• Better neonatal outcome and higher umbilical
  artery pH values .
• Incidence of maternal bradycardia was as high
  27 without coloading, 17 with coloading with
  crystalloids.

CooperDW,Anesthesiology2002
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This shows the effect of choice of vasopressor on
umbilical cord arterial pH. Data are mean
difference with 95 confidence intervals.
Lee A, Anesth Analg 2002
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• Ephedrine vs Phenylephrine iv bolus
• Phenylephrine 100mcg iv vs Ephedrine 5-10mg
  iv
• ( Phenylephrine had a faster onset of action, low
  incidence of IONV).
• Lower dose of phenylephrine (40-80mcg iv ) failed
  to reduce the incidence of IONV and
  hypotension.
• Combination of low dose phenylephrine 20mcg and
  ephedrine 5mg not effective.
• Ngan Kee,Anesthesia 2008,
• Dyer,Anesthesiology2009,
• Datta,Anesth2005.

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Prophylactic Phenylephrine infusions vs
bolus Phenylephrine inf 25-50mcgm/min better
than phenylephrine iv bolus.

Phenylephrine 25-50mcg/min inf 100mcg bolus
Incidence of hypotension 13-23 85-88
Allen TK Analg2010 ,
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• Prophylactic Phenylephrine infusions
• High dose 100 mcgm/min is associated with
  hypertensive episodes and maternal bradycardia.
  
• Titration recommmended.
• Ngan Kee,Anesth Analg2008.

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• The Proposal
• Low dose prophylactic phenylephrine infusions
  in combination with iv fluid loading.

Ngan Kee,Curr opin Anesthesiol,2010
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8 - 10 min
coloading
preloading
Spinal
Time
incision
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• Preloading Vs no preloading

• Dose study 10, 20 up to 30 mL/kg
• No difference in BP
• No difference in CO

• Crystalloid preloading no longer recommended.

Rout et al. Anesthesiology 1993 Park et al.
Anesth Analg 1996 Mercier F in Editorial
Anesth Analg oct2011
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• Meta analysis

Morgan PJ Anesth Analg 2001
ˆdextrans and gelatine C.I. in obst
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Type of iv fluid 1.5L RL 0.5L HES 1.0L HES
Incidence of hypotension 75 58 17
Ueyama, Anesthesiology 1999
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Meta analysis

• Meta analysis
• Emmet RS Cochrane library 2006

Emmet RS Cochrane library 2006
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Colloid preloading 10- 15ml/kg more effective
than crystalloid preloading in preventing spinal
induced hypotension.
Riley ET, Anesth Analg 1995
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• Crystalloid preload vs rapid coload

Preload Coload P
Vol infused (mL) 1474 1386 0.13
Duration of Infusion (min) 20 9.8 0.01
SA inj to U incision (min) 11.6 13.1 0.58
Eph pre delivery (mg) 10 0-20 0 0-10 0.03
Pat w/o Ephedrine 9/25 16/25 0.047
Incidence of Hypotension 60 36
Dyer et al. Anaesth Intensive Care 2004
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• No preload Phenylephrine (0) vs rapid coload (1)

Ngan kee WD et al. Anesthesiology 2005
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Crystalloid coloading 20ml/kg more effective than
crystalloid preloading in preventing spinal
induced hypotension.
Dyer et al. Anaesth Intensive Care 2004
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• Colloid HES 130/0.4
• preloading (P) vs coloading (C) (15ml/kg)

Pgt
Teoh W et al. Anesth. Analg 2009
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• RCS Colloid Preload to Coload During Spinal
  Anesthesia for Elective Cesarean Delivery

Neonat. outcomes
Siddik-Sayyid S Anesth Analg 2009
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Colloid coloading Colloid preloading
Teoh W et al. Anesth. Analg 2009
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A A
Requirements
CO
SBP
SV
HR
McDonald S, Anesth Analg October 2011
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Colloid coload Crystalloid
coload
McDonald S, Anesth Analg October 2011
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• Spinal Anesthesia Don't do too much !
• Bupi 8mg is sufficient with opioids
• Post op analgesia...

• Aruna Godwin
• Department of Anesthesiology
• Rashid Hospital Trauma Centre
• Dubai Health Authority - UAE