Epinephrine vs. phenylephrine infusion for prophylaxis against maternal hypotension after spinal anesthesia for cesarean delivery: a randomized controlled trial.

BACKGROUND: The hemodynamic effects of relatively low-dose epinephrine and phenylephrine infusions during cesarean delivery under spinal anesthesia were compared. METHODS: This randomized controlled trial included full-term pregnant women who underwent elective cesarean delivery. After spinal anesthesia, participants received either epinephrine (0.03 mcg/kg/min) or phenylephrine (0.4 mcg/kg/min) infusion that continued until 5 min after delivery. The primary outcome was a composite outcome of the occurrence of any of hypotension, hypertension, bradycardia, and/or tachycardia. Neonatal outcomes, including umbilical artery blood gas and Apgar scores, were assessed. RESULTS: In total, 98 patients in each group were analyzed, and the number of patients with the composite outcome was comparable between the epinephrine and phenylephrine groups (30/98 [31%] vs. 31/98 [32%], respectively; P = 0.877). However, the incidence of hypotension was likely lower in the epinephrine group than in the phenylephrine group (P = 0.066), and the number of hypotensive episodes per patient was lower in the epinephrine group than in the phenylephrine group. On the other hand, the incidence of tachycardia was higher in the epinephrine group than that in the phenylephrine group. The incidence of hypertension was comparable between the two groups and none of the participants developed bradycardia. Neonatal outcomes were comparable between the two groups. CONCLUSIONS: Epinephrine and phenylephrine infusion produced comparable maternal hemodynamics and neonatal outcomes. Epinephrine was associated with a higher incidence of maternal tachycardia and likely lower incidence of maternal hypotension than phenylephrine. IRB number: MD-245-2022. CLINICAL TRIAL REGISTRATION: This study was registered on May 31, 2023 at clinicaltrials.gov registry, NCT05881915, URL: https://classic. CLINICALTRIALS: gov/ct2/show/NCT05881915term=NCT05881915&draw=2&rank=1.

The use of epinephrine infusion for the prevention of spinal hypotension during Caesarean delivery: A randomized controlled dose-finding trial.

BACKGROUND: This study aimed to compare three epinephrine doses for the prevention of spinal hypotension during Caesarean delivery. METHODS: This randomized controlled trial included full-term pregnant women undergoing elective Caesarean delivery under spinal anesthesia. The participants received prophylactic epinephrine infusions at rates of 0.01, 0.02, or 0.03 mcg/kg/min. Spinal hypotension (systolic blood pressure <80% of baseline) was managed with a 9-mg ephedrine bolus. The primary outcome was the incidence of spinal hypotension. Secondary outcomes included total ephedrine requirement, the incidence of severe spinal hypotension, excessive tachycardia and hypertension, and neonatal outcomes. RESULTS: The final analysis included 271 patients. The incidence of hypotension was lowest in the 0.03 mcg group (11/90 [12%]), followed by the 0.02 mcg (32/91 [35%]) and the 0.01 mcg (55/90 [61%]) groups (p < 0.001). The median ephedrine requirements (quartiles) were also the lowest in the 0.03 mcg group (0 [0-0] mg), followed by the 0.02 mcg (0 [0-9] mg) and the 0.01 mcg (9 [0-18] mg) groups. The incidence of severe hypotension was lower in the 0.03 mcg and 0.02 mcg groups than in the 0.01 mcg group (3/90 [3%], 5/91 [6%], and 15/90 [17%], respectively). The incidences of excessive tachycardia, hypertension, and neonatal outcomes were comparable among the groups. CONCLUSION: The use of epinephrine to prevent spinal hypotension during Caesarean delivery is feasible and effective. An initial dose of 0.03 mcg/kg/min produced the lowest incidence of hypotension compared to 0.02 mcg/kg/min and 0.01 mcg/kg/min doses. The three doses were comparable in terms of the incidence of tachycardia, hypertension, and neonatal outcomes. STUDY REGISTRATION: ClinicalTrials.gov Identifier: NCT05279703.

Accuracy of noninvasive blood pressure measured at the ankle during cesarean delivery under spinal anesthesia.

In this study, we evaluated the accuracy of oscillometric noninvasive blood pressure (NIBP) measured at the ankle in detecting low arm NIBP during cesarean delivery under spinal anesthesia. In this prospective observational study, a cohort of full-term mothers undergoing elective cesarean delivery under spinal anesthesia was examined. Simultaneous NIBP measurements were obtained from the arm and the ankle. The primary outcome was the accuracy of the ankle NIBP in detecting arm systolic blood pressure (SBP) < 90 mmHg. Other outcomes included the accuracy of ankle NIBP in detecting SBP < 80% of the baseline value. The area under the receiver operating characteristic curve (AUC) was calculated to evaluate the accuracy of ankle NIBP in detecting low arm NIBP. The Bland-Altman analysis was conducted to evaluate the agreement between values. We analyzed 1729 pairs of readings obtained from 97 mothers. Ankle SBP showed good accuracy in detecting SBP < 90 mmHg, with an AUC (95% confidence interval [CI]) of 0.90 (0.89-0.91) and a negative predictive value (NPV) of 99 (98-99%) at a cutoff value of ≤ 103 mmHg. Furthermore, ankle SBP showed good accuracy in detecting SBP < 80% of the baseline value, with an AUC (95% CI) of 0.84 (0.82-0.89) and an NPV of 95 (93-96%) at a cutoff value of ≤ 76% of the ankle baseline SBP. The mean bias between the two sites of measurement was - 5.4 ± 15.5, - 2.0 ± 11, and 0.5 ± 12.1 mmHg for SBP, diastolic blood pressure, and mean arterial pressure, respectively. In conclusion, ankle NIBP measurement is not interchangeable with arm NIBP measurement. However, ankle NIBP measurement showed good accuracy for ruling out low arm NIBP during a cesarean delivery.Clinical trial rejistration: NCT04199156.

Comparison of two Norepinephrine rescue bolus for Management of Post-spinal Hypotension during Cesarean Delivery: a randomized controlled trial.

BACKGROUND: Data on the best norepinephrine bolus dose for management of hypotension are limited. The aim of this study was to compare the efficacy and safety of two norepinephrine bolus doses in the rescue management of maternal hypotension during cesarean delivery. METHODS: This randomized, controlled trial included mothers scheduled for cesarean delivery with spinal anesthesia with a prophylactic norepinephrine infusion. Following spinal anaesthesia administration, a participant was considered hypotensive if systolic blood pressure was ≤80% compared to the baseline reading. Participants were allocated to receive either 6 mcg or 10 mcg norepinephrine bolus for the management of hypotensive episodes. The hemodynamic response after administration of norepinephrine bolus was recorded. The episode was considered successfully managed if systolic blood pressure returned to within 80% from the baseline reading within 2 min after norepinephrine bolus administration, and did not drop again within 6 min after the norepinephrine bolus. The primary outcome was the incidence of successful management of the first hypotensive episode. Other outcomes included systolic blood pressure, heart rate, incidence of maternal bradycardia, and reactive hypertension. RESULTS: One hundred and ten mothers developed hypotensive episodes and received norepinephrine boluses for management. The number of successfully managed first hypotensive episodes was 50/57 (88%) in the 6 mcg-treated episodes and 45/53 (85%) in the 10 mcg-treated episodes (p = 0.78). Systolic blood pressure was comparable after administration of either bolus dose. Heart rate was lower after administration of 10 mcg bolus compared to 6 mcg bolus, without significant bradycardia requiring atropine administration. The incidence of reactive hypertension was comparable between both groups. CONCLUSION: In mothers undergoing elective cesarean delivery under prophylactic norepinephrine infusion at 0.05 mcg/kg/min, there was no advantage to the use of 10 mcg norepinephrine bolus over 6 mcg norepinephrine bolus for the rescue management of first hypotensive episode. Neither of the 2 bolus doses reached a 100% success rate. The incidences of bradycardia and reactive hypertension were comparable between both norepinephrine doses. TRIAL REGISTRATION: At clinicaltrial.gov registry system on January 4, 2019 Clinical trial identifier: NCT03792906.

Role of Intraoperative Transesophageal Echocardiography in Cardiac Surgery: an Observational Study.

AIM: This study is based on the hypothesis that the routine use of transesophageal echocardiography in cardiac surgery will influence the surgical decision taken by the surgeon intra-operatively in Kasr-Alainy hospitals. METHODS: Patients were examined with intraoperative transesophageal echocardiography (TEE) before and after cardiopulmonary bypass. Complete and comprehensive intraoperative TEE examinations will be performed by TEE certified cardiac anesthesiologists. Data that will be collected from the intraoperative examination and will be compared with preoperative transthoracic echocardiography, and the surgical decision that was taken preoperatively will be revised again with the cardiothoracic surgeon before the start of surgery. Also, TEE will be used again after weaning from bypass for revision and assessment of our decision. RESULTS: We examined the utility of TEE in 100 patients undergoing different types of cardiac procedures in Kasr Al-Ainy hospital. This prospective clinical investigation found that the pre- and post-CPB TEE examinations influenced surgical decision making in 10% of all evaluated patients. CONCLUSION: Intraoperative TEE has the potential to influence clinical decision making for cardiac surgical patients significantly. It is useful in surgical planning, guiding various hemodynamic interventions, and assessing the immediate results of surgery. Thus, IOTEE should be used routinely in all patients undergoing all types of cardiac surgeries.

Thoracic fluid content: a novel parameter for detection of pulmonary edema in parturients with preeclampsia.

Acute pulmonary oedema is a serious complication of preeclampsia. Early detection of pulmonary edema in preeclampsia would improve fluid management and would also allow earlier detection of severe cases. The aim of this work is to evaluate the ability of thoracic fluid content measured by electrical cardiometry for early detection of pulmonary edema in parturients with preeclampsia. A prospective observational study included a cohort of preeclamptic parturients. On admission, lung ultrasound score was calculated, and thoracic fluid content was recorded using electrical cardiometry ICON device. Area under receiver operating characteristic (AUROC) curve was calculated for lung ultrasound score, thoracic fluid content for detection of pulmonary edema. Spearman correlation coefficient was calculated for correlation between lung ultrasound score and thoracic fluid content. Sixty patients were included in the study; of them, 6 patients (10%) required diuretics for pulmonary edema. Patients with pulmonary edema had higher lung ultrasound score and thoracic fluid content compared to other patients. Good correlation was reported between Lung ultrasound score and thoracic fluid content (r = 0.82). Thoracic fluid content and lung ultrasound score showed excellent diagnostic properties for pulmonary edema {AUROC: 0.941 (0.849-0.986), best cut-off value: 40 k ohm-1}, and {AUROC: 0.961 (0.887-0.994), best cut-off value of 15.7}. In parturients with preeclampsia, both lung ultrasound score and thoracic fluid content showed excellent properties for detection pulmonary edema. The high negative predictive value of both tests makes them useful screening tests to rule out pulmonary edema. The excellent correlation between both measures suggests that electrical cardiometry could be a promising surrogate to ultrasound for assessment of extravascular lung water.

Hemodynamic effects of lateral tilt before and after spinal anesthesia during cesarean delivery: an observational study.

BACKGROUND: Post-spinal hypotension is a common maternal complication during cesarean delivery. Aortocaval compression by the gravid uterus has been assumed as a precipitating factor for post-spinal hypotension. The role of left lateral tilting position in improving maternal cardiac output after subarachnoid block (SAB) is unclear. The aim of this work is to investigate the effect of left lateral tilting on maternal hemodynamics after SAB. METHODS: A prospective observational study was conducted including 105 full term pregnant women scheduled for cesarean delivery. Mean arterial pressure, heart rate, cardiac output (measured by electrical cardiometry), stroke volume, and systemic vascular resistance were recorded in three positions (supine, 150, and 300 left lateral positions) before SAB, after SAB, and after delivery of the fetus. RESULTS: Before SAB, no significant hemodynamic changes were reported with left lateral tilting. A significant decrease was reported in mean arterial pressure, cardiac output, stroke volume, and systemic vascular resistance after SAB (in supine position). When performing left lateral tilting, there was an increase in cardiac output, heart rate, and mean arterial pressure. No difference was reported between the two tilt angles (150 and 300). CONCLUSIONS: Changing position of full term pregnant woman after SAB from supine to left lateral tilted position results increased cardiac output and mean arterial pressure. There is no difference between the two tilt angles (150 and 300). TRIAL REGISTRATION: clinicaltrials.gov ( NCT02828176 ) retrospectively registered.

Leg elevation decreases the incidence of post-spinal hypotension in cesarean section: a randomized controlled trial.

BACKGROUND: Maternal hypotension is a common complication after spinal anesthesia for cesarean section (CS). In this study we investigated the role of leg elevation (LE) as a method for prevention of post-spinal hypotension (PSH) for cesarean section. METHODS: One hundred and fifty full term parturients scheduled for CS were included in the study. Patients were randomized into two groups: Group LE (leg elevation group, n = 75) and group C (Control group, n = 75). Spinal block was performed in sitting position after administration of 10 mL/Kg Ringer's lactate as fluid preload. After successful intrathecal injection of local anesthetic, Patients were positioned in the supine position. Leg elevation was performed for LE group directly after spinal anesthesia and maintained till skin incision. Intraoperative hemodynamic parameters (Arterial blood pressure and heart rate), intra-operative ephedrine consumption, incidence of PSH, and incidence of nausea and vomiting were reported. RESULTS: LE group showed lower incidence of PSH (34.7% Vs 58.7%, P = 0.005) compared to the control group. Arterial blood pressure was higher in the LE group compared to the control group in the first two readings after spinal block. Other readings showed comparable arterial blood pressure and heart rate values between both study groups; however, LE showed less ephedrine consumption (4.9 ± 7.8 mg Vs 10 ± 11 mg, P = 0.001). CONCLUSION: LE performed immediately after spinal block reduced the incidence of PSH in parturients undergoing CS. TRIAL REGISTRATION: The study was registered at Pan African Clinical Trials Registry system on 5/10/2015 with trial number PACTR201510001295348 .