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.

Variable versus fixed-rate infusion of phenylephrine during cesarean delivery: a randomized controlled trial.

BACKGROUND: Phenylephrine is the most commonly used vasopressor for prophylaxis against maternal hypotension during cesarean delivery; however, the best regimen for its administration is not well established. Although variable infusion protocols had been suggested for phenylephrine infusion, evidence-based evaluation of variable infusion regimens are lacking. The aim of this work is to compare variable infusion, fixed on-and-off infusion, and intermittent boluses of phenylephrine for prophylaxis against maternal hypotension during cesarean delivery. METHODS: A randomized controlled study was conducted, including full-term pregnant women scheduled for elective cesarean delivery. Participants were divided into three groups which received phenylephrine by either intermittent boluses (1.5 mcg/Kg phenylephrine), fixed on-and-off infusion (with a dose of 0.75 mcg/Kg/min), or variable infusion (with a starting dose of 0.75 mcg/Kg/min). The three groups were compared with regard to frequency of: maternal hypotension (primary outcome), second episode hypotension, reactive hypertension, and bradycardia. Other outcomes included heart rate, systolic blood pressure, physician interventions, and neonatal outcomes. RESULTS: Two-hundred and seventeen mothers were available for final analysis. The 2 infusion groups showed less incidence of maternal hypotension {26/70 (37%), 22/71 (31%), and (51/76 (67%)} and higher incidence of reactive hypertension compared to the intermittent boluses group without significant differences between the two former groups. The number of physician interventions was highest in the variable infusion group compared to the other two groups. The intermittent boluses group showed lower systolic blood pressure and higher heart rate compared to the two infusion groups; whilst the two later groups were comparable. CONCLUSION: Both phenylephrine infusion regimens equally prevented maternal hypotension during cesarean delivery compared to intermittent boluses regimen. Due to higher number of physician interventions in the variable infusion regimen, the current recommendations which favor this regimen over fixed infusion regimen might need re-evaluation.

The Impact of Goal-Directed Fluid Therapy in Prolonged Major Abdominal Surgery on Extravascular Lung Water and Oxygenation: A Randomized Controlled Trial.

BACKGROUND: A growing interest had been paid to goal-directed fluid therapy (GDT) in abdominal surgery; however, its impact on the respiratory profile was not well investigated. AIM: We evaluated the impact of GDT on postoperative extravascular lung water and oxygenation after prolonged major abdominal surgery. METHODS: A randomised, controlled study was conducted in Kasr Alainy hospital from April 2016 till December 2017 including 120 adult patients scheduled for prolonged major abdominal surgery. Patients were randomised into either GDT group (n = 60) who received baseline restricted fluid therapy (2 mL/Kg/hour) which is guided by stroke volume variation, or control group (n = 60) who received standard care. Both study groups were compared according to hemodynamic data, fluid requirements, lung ultrasound score, and PaO2/fraction of inspired oxygen ratio (P/F ratio). RESULTS: Intraoperatively, GDT group received less volume of fluids and showed higher intraoperative mean arterial pressure compared to the control group. Postoperatively, lung ultrasound score was lower, and P/F ratio was higher in the GDT group compared to the control group. The number of patients who showed a significant postoperative increase in LUS was higher in the control group 44 (73%) patients versus 14 (23%) patients, P < 0.001). CONCLUSIONS: Using stroke volume variation for guiding fluid therapy in prolonged, major abdominal operations were associated with better hemodynamic profile, less intraoperative fluid administration, lower extravascular lung water and better oxygenation compared to standard care.

Multi-Modal Analgesic Technique for Pain Control in Patients Undergoing Diagnostic Gynecological Laparoscopy: Randomized Controlled Clinical Trial.

BACKGROUND: Advancement in minimally invasive laparoscopic surgeries make it one of the best choices for both the surgeon and the patient. The anesthesiologist had to improve the techniques used to control post-operative pain. AIM: In this study, we hyposethized that multi-modal analgesic technique which is a combination of two simple techniques (intraperitoneal lidocaine and pulmonary recruitment) allow better result than using only one of them. PATIENTS AND METHOD: This randomised controlled, double-blind study was conducted in Kasr-Alainy hospital, faculty of medicine, Cairo University, Egypt from September 2017 till February 2018. Fifty female patients, scheduled for diagnostic gynecologic laparoscopy were included in the study. Patients were randomly allocated using random computer allocation with numbered closed opaque envelopes into four study group. GM (n = 12): Patients received pulmonary recruitment maneuver and intra-peritoneal Lidocaine, GL (n = 13): Patients received intra-peritoneal Lidocaine, GP (n = 13): Patients received Pulmonary Recruitment Maneuver, GC (n = 12): Patients received passive exsufflation through the port site. In the ward, patients were asked to fulfil a questionnaire about pain severity using (VAS) at 1, 3, 6-hour post-operative both the patients and the anesthesiologist that assess the (VAS) were blind of the patient group. RESULTS: Regarding pain score between groups VAS 1 (the primary outcome) was lowest in GM {4.5 (3-5)} in comparison with other groups (P value = 0.015), while VAS 3 & VAS 6 wasn't statistically significant between groups. Regarding Time of first rescue analgesia; GM {3 (1.75-4)} showed the longest time in between groups (P-value = 0.042). As regard nausea and vomiting; there was no statistically significant difference in in-between groups. CONCLUSION: Application of Multi-modal analgesic technique allows better analgesia for a longer duration than the use of the sole technique for control of abdominal pain in patients undergoing diagnostic gynaecological laparoscopy.

Norepinephrine versus phenylephrine infusion for prophylaxis against post-spinal anaesthesia hypotension during elective caesarean delivery: A randomised controlled trial.

BACKGROUND: Prophylactic vasopressors are fundamental during caesarean delivery under spinal anaesthesia. The aim of this work is to compare the efficacy and safety of phenylephrine and norepinephrine when used in variable infusion rate during caesarean delivery. METHODS: A randomised, double-blinded, controlled trial was conducted including mothers scheduled for elective caesarean delivery under spinal anaesthesia. Participants were allocated to two groups norepinephrine group (n = 60), and phenylephrine group (n = 63). Participants received prophylactic vasopressors after spinal block at rate started at 0.05 mcg/kg/min and 0.75 mcg/kg/min respectively. The rate of vasopressor infusion was manually adjusted according to maternal systolic blood pressure. Both groups were compared according to incidence of post-spinal hypotension (the primary outcome), incidence of bradycardia, incidence of reactive hypertension, systolic blood pressure, heart rate, rescue vasopressor consumption, number of physician interventions, and neonatal outcomes. RESULTS: One hundred and twenty-three mothers were available for final analysis. Both groups were comparable in the incidence of post-spinal hypotension (32% versus 30%, P = 0.8). The number of physician intervention was lower in norepinephrine group. The incidence of bradycardia and the incidence of reactive hypertension were potentially lower in norepinephrine group without reaching statistical significance, (13% vs. 21%, P = 0.3) and (12% vs. 24%, P = 0.1). Rescue vasopressor consumption, and neonatal outcomes were comparable between both groups. CONCLUSION: When given in a manually adjusted infusion, norepinephrine effectively maintained maternal SBP during caesarean delivery under spinal anaesthesia with lower number of physician interventions, and likely less incidence of reactive hypertension and bradycardia compared to phenylephrine.

Evaluation of gastric residual volume in fasting diabetic patients using gastric ultrasound.

BACKGROUND: Diabetic patients are claimed to have high risk of delayed gastric emptying; however, the evidence concerning residual gastric volume in fasting diabetic patients is not consistent. The aim of this work is to evaluate residual gastric volume in fasting diabetic patients for elective surgery. METHODS: Fifty patients scheduled for elective surgery under general anaesthesia were included in the study. The study included 25 patients with at least 6-year history of diabetes and 25 healthy controls. Gastric ultrasound was performed to measure antral cross-sectional area in semi-sitting and right lateral positions. Nasogastric tube was inserted after induction of anaesthesia to aspirate and calculate the volume of gastric contents. Both study groups were compared according to antral cross-sectional area, residual gastric volume, risk of aspiration, in addition to demographic data. RESULTS: The diabetic group showed higher median (quartiles) antral cross-sectional area (13.8 [9.5-19.5] mm2 versus 8.8 [5.5-10.5] mm2 , P < 0.001), and higher calculated gastric residual volume, (177 [96-275] mL versus 83 [50-109] mL, P < 0.001) compared to the control group. The diabetic group also showed higher aspirated volume through the nasogastric tube compared to the control group (150 [85-210] mL versus 75 [35-87] mL, P < 0.001). The correlation was very good between calculated residual gastric volume using ultrasound measures and volume of aspirated gastric contents through nasogastric tube. CONCLUSION: Patients with long standing diabetes showed higher residual gastric volume compared to healthy controls after fasting 8 hours for elective surgery.

Norepinephrine Infusion for Preventing Postspinal Anesthesia Hypotension during Cesarean Delivery: A Randomized Dose-finding Trial.

BACKGROUND: Norepinephrine has been recently introduced for prophylaxis against postspinal hypotension during cesarean delivery; however, no data are available regarding its optimum dose. The objective of this study is to compare three infusion rates of norepinephrine for prophylaxis against postspinal hypotension during cesarean delivery. METHODS: The authors conducted a double-blinded, randomized, controlled study including full-term pregnant women scheduled for cesarean delivery. Norepinephrine infusion was commenced after subarachnoid block. Patients were randomized into three groups, which received norepinephrine with starting infusion rates of 0.025 µg · kg(-1) · min(-1), 0.050 µg · kg(-1) · min(-1), and 0.075 µg · kg(-1) · min(-1). Infusion was stopped when intraoperative hypertension occurred. The primary outcome was the frequency of postspinal hypotension (defined as decreased systolic blood pressure less than 80% of the baseline reading). The three groups were compared according to the following: systolic blood pressure, heart rate, frequency of intraoperative hypertension, frequency of bradycardia, and neonatal outcomes. RESULTS: Two hundred eighty-four mothers were included in the analysis. The frequency of postspinal hypotension was lower for both the 0.050-µg · kg(-1) · min(-1) dose group (23/93 [24.7%], odds ratio: 0.45 [95% CI: 0.24 to 0.82], P = 0.014) and the 0.075-µg · kg(-1) · min(-1) dose group (25/96 [26.0%], odds ratio: 0.48 [95% CI:0.26 to 0.89], P = 0.022) compared with the 0.025-µg · kg(-1) · min(-1) dose group (40/95 [42.1%]). The two higher-dose groups (the 0.050-µg · kg(-1) · min(-1) group and the 0.075-µg · kg(-1) · min(-1) group) had higher systolic blood pressure and lower heart rate compared with the 0.025 µg · kg(-1) · min(-1) group. The three groups were comparable in the frequency of intraoperative hypertension, incidence of bradycardia, and neonatal outcomes. CONCLUSIONS: Both the 0.050-µg · kg(-1) · min(-1) and 0.075-µg · kg(-1) · min(-1) norepinephrine infusion rates effectively reduced postspinal hypotension during cesarean delivery compared with the 0.025-µg · kg(-1) · min(-1) infusion rate.

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 .