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Spinal Hypotension in Elective C section: How to prevent it.

Spinal Hypotension in Elective C section: How to prevent it. Aruna Godwin Department of Anesthesiology Rashid Hospital Trauma Centre Dubai Health Authority - UAE. Spinal anesthesia is a Gold standard Incidence of hypotension up to 52-80%. USA = up to 39 % x 10 in 70 years

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Spinal Hypotension in Elective C section: How to prevent it.

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  1. Spinal Hypotension in Elective C section:How to prevent it. • Aruna Godwin • Department of Anesthesiology • Rashid Hospital Trauma Centre • Dubai Health Authority - UAE

  2. Spinal anesthesia is a Gold standard Incidence of hypotension up to 52-80% • USA = up to 39 % • x 10 in 70 years • Europe = up to 20..25% • UAE = up to 29 % • Brazil up to 80% in private

  3. 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 ** O’Neil Patricia ASA 2010 Gautier P BJA 2003

  4. Spinal Hypotension in Elective C section: How to prevent it? • Effects of hypotension. • Dose of Spinal anesthetic. • Vasopressor of choice. • Intravenous fluid loading strategies.

  5. 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

  6. Low dose spinal anesthesia • Intrathecal opioids are synergistic with local anesthetics and intensify sensory block without increasing sympathetic block.

  7. A randomized comparison of low doses of hyperbaric bupivacaine in combined spinal-epidural anesthesia for cesarean delivery*. • Time taken to reach T4 was similar. • No patient had inadequate anesthesia * Leo S Anesth Analg. 2009

  8. Forest plot for hypotension comparing LD vs CD: individual trials and meta-analysis. Arzola C , and Wieczorek P M Br. J. Anaesth. 2011

  9. 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

  10. Low dose spinal anesthesia • Low dose spinal anesthesia with Intrathecal opioids improved maternal haemodynamics.

  11. Non pharmacological methods • 15° left lateral tilt... => Still 70- 80%* • Pharmacological methods • Vasopressors (Phenylephrine or ephedrine) • IV fluid loading

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

  13. 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.

  14. 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

  15. A quantitative systematic review of randomized controlled trials of ephedrine compared with phenylephrine for the manage- ment of hypotension during spinal anesthesia for cesarean delivery*. 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;

  16. 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.

  17. Prophylactic Phenylephrine infusions vs bolus: Phenylephrine inf 25-50mcgm/min* better than phenylephrine iv bolus. * Allen TK Analg2010 ,

  18. Prophylactic Phenylephrine infusions : • High dose 100 mcgm/min is associated with hypertensive episodes and maternal bradycardia. ** • Titration recommmended. • * * Ngan Kee,Anesth Analg2008.

  19. The Proposal : • Low dose prophylactic phenylephrine infusions in combination with iv fluid loading. Ngan Kee,Curr opin Anesthesiol,2010

  20. Preloading or coloading ? • Crystalloid or Colloids (HES) ? 8 - 10 min preloading coloading Spinal Time incision

  21. 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

  22. Meta analysis* * Morgan PJ Anesth Analg 2001 ˆdextrans and gelatine C.I. in obst

  23. Ueyama, Anesthesiology: 1999

  24. Meta analysis • Emmet RS Cochrane library 2006 Meta analysis* * Emmet RS Cochrane library 2006

  25. Colloid preloading 10- 15ml/kg more effective than crystalloid preloading in preventing spinal induced hypotension. Riley ET, Anesth Analg 1995

  26. Crystalloid preload vs rapid coload Dyer et al. Anaesth Intensive Care 2004

  27. No preload + Phenylephrine (0) vs rapid coload (1) Ngan kee WD et al. Anesthesiology 2005

  28. Crystalloid coloading 20ml/kg more effective than crystalloid preloading in preventing spinal induced hypotension. Dyer et al. Anaesth Intensive Care 2004

  29. No difference in maternal and neonatal outcomes • Colloid HES 130/0.4 • preloading (P) vs coloading (C) (15ml/kg) P> * Teoh W et al. Anesth. Analg 2009

  30. RCS : Colloid Preload to Coload During Spinal Anesthesia for Elective Cesarean Delivery Neonat. outcomes = Siddik-Sayyid S Anesth Analg 2009

  31. Colloid coloading =Colloid preloading Teoh W et al. Anesth. Analg 2009

  32. A & A Coloading: Colloid vs crystalloid CO Requirements = SBP SV HR McDonald S, Anesth Analg October 2011

  33. Colloid coload = Crystalloid coload… McDonald S, Anesth Analg October 2011

  34. Spinal Hypotension in Elective C section: How to prevent it? Fluid loading + Vasopressor • Crystalloid preloading : NO • Crystalloid rapid coloading : Yes 20ml/kg / 8 min. • Colloids (HES) preloading :YES 10- 15 mL/kg • Colloids coloading = Colloid Preloading • Colloid coloading = crystalloid coloading. • Vasopressor = Phenylephrine to maintain SBP 90-100% baseline).

  35. 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

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