Comparison of Two Norepinephrine Rescue Bolus Doses for Management of Severe Post-Spinal Hypotension During Elective Caesarean Delivery: A Randomized, Controlled Trial.

Background: Post-spinal hypotension is associated with maternal and neonatal complications; therefore, prompt control maternal blood pressure is necessary. In this study, we aimed to compare the efficacy and safety of two norepinephrine bolus doses in the rescue management of severe maternal hypotension during elective Cesarean delivery. Methods: We included full-term pregnant women scheduled for Cesarean delivery under spinal anesthesia. Patients were randomized to receive either 5-mcg norepinephrine (n=79) or 10-mcg norepinephrine (n=79) for treatment of severe postspinal hypotension (systolic blood pressure ≤60% of baseline reading). The management of the hypotensive episode was considered successful if systolic blood pressure was >80% of the baseline within 2 mins of the bolus. The primary outcome was the incidence of successful management of severe post-spinal hypotension. Secondary outcomes included the incidence of reactive bradycardia, reactive hypertension, umbilical blood gases, and neonatal Apgar score at 5-min post-delivery. Results: We included 73 patients in the 5-mcg group and 76 patients in the 10-mcg group into the final analysis. The incidence of successful management of severe hypotensive episodes was comparable between the two groups (43/73 [59%] and 46/76 [60%] in the 5-and 10-mcg group, respectively, P=0.917). The incidence of reactive hypertension, bradycardia, and neonatal outcomes were comparable between the two groups. Conclusion: In mothers undergoing Cesarean delivery under spinal anesthesia, 10-mcg norepinephrine bolus was not superior to the 5-mcg bolus in the management of severe hypotension. Furthermore, the incidence of reactive bradycardia and hypertension was comparable in the two doses. Clinical Trial Registration: NCT05290740, URL: https://clinicaltrials.gov/ct2/show/NCT05290740.

Comparison of different ratios of propofol-ketamine admixture in rapid-sequence induction of anesthesia for emergency laparotomy: a randomized controlled trial.

BACKGROUND: We aimed to compare the hemodynamic effect of two ratios of propofol and ketamine (ketofol), namely 1:1 and 1:3 ratios, in rapid-sequence induction of anesthesia for emergency laparotomy. METHODS: This randomized controlled study included adult patients undergoing emergency laparotomy under general anesthesia. The patients were randomized to receive either ketofol ratio of 1:1 (n = 37) or ketofol ratio of 1:3 (n = 37). Hypotension (mean arterial pressure < 70 mmHg) was managed by 5-mcg norepinephrine. The primary outcome was total norepinephrine requirements during the postinduction period. Secondary outcomes included the incidence of postinduction hypotension, and the intubation condition (excellent, good, or poor). RESULTS: Thirty-seven patients in the ketofol-1:1 and 35 patients in the ketofol 1:3 group were analyzed. The total norepinephrine requirement was less in the ketofol-1:1 group than in the ketofol-1:3 group, P-values: 0.043. The incidence of postinduction hypotension was less in the ketofol-1:1 group (4 [12%]) than in ketofol-1:3 group (12 [35%]), P-value 0.022. All the included patients had excellent intubation condition. CONCLUSION: In patients undergoing emergency laparotomy, the use of ketofol in 1:1 ratio for rapid-sequence induction of anesthesia was associated with less incidence of postinduction hypotension and vasopressor consumption in comparison to the 1:3 ratio with comparable intubation conditions. CLINICAL TRIAL REGISTRATION: NCT05166330. URL: https://clinicaltrials.gov/ct2/show/NCT05166330 .

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.

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.

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 the effects of dexmedetomidine infusion on oxygenation and lung mechanics in morbidly obese patients with restrictive lung disease.

BACKGROUND: Dexmedetomidine infusion improves oxygenation and lung mechanics in patients with chronic obstructive lung disease; however, its effect in patients with restrictive lung disease has not been thoroughly investigated yet. The aim of this work was to evaluate the effects of dexmedetomidine infusion on oxygenation and lung mechanics in morbidly obese patients with restrictive lung disease. METHODS: Forty-two morbidly obese patients scheduled for bariatric surgery were included in the study. Patients were randomized to receive either dexmedetomidine infusion at a bolus dose of 1mcg/Kg followed by infusion at 1 mcg/Kg/hour for 90 min (Dexmedetomidine group), or normal saline infusion (Control group). Both groups were compared with regard to: oxygenation {P/F ratio: PaO2/fraction of inspired oxygen (FiO2)}, lung compliance, dead space, plateau pressure, blood pressure, and heart rate. RESULTS: Dexmedetomidine group showed significant improvement of the PaO2/FiO2 ratio, and higher lung compliance compared to control group by the end of drug infusion. Dexmedetomidine group demonstrated decreased dead space, plateau pressure, blood pressure, and heart rate compared to control group by the end of drug infusion. CONCLUSION: A 90-min dexmedetomidine infusion resulted in moderate improvement in oxygenation and lung mechanics in morbidly obese patients with restrictive lung disease. TRIAL REGISTRATION: clinicaltrials.gov : NCT02843698 on 20 July 2016.

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.