-
Recommendations from the guidelines:
- Hypotension following spinal or combined spinal-epidural anaesthesia at caesarean section causes both maternal and fetal/neonatal adverse effects.
- Hypotension is frequent – vasopressors should be used routinely and preferably prophylactically.
- α‐agonist drugs are the most appropriate agents to treat or prevent hypotension following spinal anaesthesia. Although those with a small amount of β‐agonist activity may have the best profile (noradrenaline (norepinephrine), metaraminol), phenylephrine is currently recommended due to the amount of supporting data. Single‐dilution techniques, and/or prefilled syringes should be considered.
- Left lateral uterine displacement and intravenous (i.v.) colloid pre‐loading or crystalloid coloading, should be used in addition to vasopressors.
- The aim should be to maintain systolic arterial pressure (SAP) at ≥ 90% of an accurate baseline obtained before spinal anaesthesia, and avoid a decrease to < 80% baseline. We recommend a variable rate prophylactic infusion of phenylephrine using a syringe pump. This should be started at 25–50 μg.min−1 immediately after the intrathecal local anaesthetic injection, and titrated to blood pressure and pulse rate. Top‐up boluses may be required.
- Maternal heart rate can be used as a surrogate for cardiac output if the latter is not being monitored; both tachycardia and bradycardia should be avoided.
- When using an α‐agonist as the first‐line vasopressor, small doses of ephedrine are suitable to manage SAP < 90% of baseline combined with a low heart rate. For bradycardia with hypotension, an anticholinergic drug (glycopyrronium (glycopyrrolate) or atropine) may be required. Adrenaline (epinephrine) should be used for circulatory collapse.
- The use of smart pumps and double (two drug) vasopressor infusions can lead to greater cardiovascular stability than that achieved with physician‐controlled infusions.
- Women with pre‐eclampsia develop less hypotension after spinal anaesthesia than healthy women. Abrupt decreases in blood pressure are undesirable because of the potential for decreased uteroplacental blood flow. A prophylactic vasopressor infusion may not be required but, if used, should be started at a lower rate than for healthy women.
- Women with cardiac disease should be assessed on an individual basis; some conditions are best managed with phenylephrine (an arterial constrictor without positive inotropic effect), whereas others respond best to ephedrine (producing positive inotropic and chronotropic effect).
- S M Kinsella, B Carvalho, R A Dyer, R Fernando, N McDonnell, F J Mercier, A Palanisamy, SiaA T HATHDepartment of Women's Anaesthesia, KK Women's and Children's Hospital, Singapore., M Van de Velde, A Vercueil, and Consensus Statement Collaborators.
- Department of Anaesthesia, St Michael's Hospital, Bristol, UK.
- Anaesthesia. 2018 Jan 1; 73 (1): 71-92.
no abstract available
This article appears in the collection: Which is the best vasopressor to avoid hypotension during spinal anaesthesia for Caesarean section?.
Notes
Recommendations from the guidelines:
- Hypotension following spinal or combined spinal-epidural anaesthesia at caesarean section causes both maternal and fetal/neonatal adverse effects.
- Hypotension is frequent – vasopressors should be used routinely and preferably prophylactically.
- α‐agonist drugs are the most appropriate agents to treat or prevent hypotension following spinal anaesthesia. Although those with a small amount of β‐agonist activity may have the best profile (noradrenaline (norepinephrine), metaraminol), phenylephrine is currently recommended due to the amount of supporting data. Single‐dilution techniques, and/or prefilled syringes should be considered.
- Left lateral uterine displacement and intravenous (i.v.) colloid pre‐loading or crystalloid coloading, should be used in addition to vasopressors.
- The aim should be to maintain systolic arterial pressure (SAP) at ≥ 90% of an accurate baseline obtained before spinal anaesthesia, and avoid a decrease to < 80% baseline. We recommend a variable rate prophylactic infusion of phenylephrine using a syringe pump. This should be started at 25–50 μg.min−1 immediately after the intrathecal local anaesthetic injection, and titrated to blood pressure and pulse rate. Top‐up boluses may be required.
- Maternal heart rate can be used as a surrogate for cardiac output if the latter is not being monitored; both tachycardia and bradycardia should be avoided.
- When using an α‐agonist as the first‐line vasopressor, small doses of ephedrine are suitable to manage SAP < 90% of baseline combined with a low heart rate. For bradycardia with hypotension, an anticholinergic drug (glycopyrronium (glycopyrrolate) or atropine) may be required. Adrenaline (epinephrine) should be used for circulatory collapse.
- The use of smart pumps and double (two drug) vasopressor infusions can lead to greater cardiovascular stability than that achieved with physician‐controlled infusions.
- Women with pre‐eclampsia develop less hypotension after spinal anaesthesia than healthy women. Abrupt decreases in blood pressure are undesirable because of the potential for decreased uteroplacental blood flow. A prophylactic vasopressor infusion may not be required but, if used, should be started at a lower rate than for healthy women.
- Women with cardiac disease should be assessed on an individual basis; some conditions are best managed with phenylephrine (an arterial constrictor without positive inotropic effect), whereas others respond best to ephedrine (producing positive inotropic and chronotropic effect).
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