Comparison of Efficacy of Bolus Dosages of Norepinephrine, Phenylephrine, and Ephedrine in Treating Post-Spinal Hypotension During Elective Cesarean Section: A Randomized Double-Blinded Controlled Trial

Anilkumar Sangappa Ganeshnavar, Archana Endigeri, Prashant Kumar Reddy Chitti, Vinduja Nair, Chaitra Konappanavar

Abstract


Background and Aims: Currently, the widely used vasopressors for spinal induced hypotension after caesarean deliveries are phenylephrine and ephedrine. Norepinephrine is a substitute vasopressor during caesarean deliveries due to its ability in treating hypotension while maintaining heart rate (HR). The objective of current research was to compare the safety and efficiency among bolus dosages of norepinephrine (6mcg), phenylephrine(100mcg), and Ephedrine (6mg) in treating post spinal hypotension during elective caesareans.

Material and methods: Following the ethical committee's approval and obtaining written informed consent, ASA grade II and III patients aged between 18-35 years undergoing elective LSCS were randomized into 3 groups of 45 each among A, B and C (n=45) to receive norepinephrine, phenylephrine or ephedrine, boluses respectively after 20% fall in blood pressure. In present research, the efficacy and safety profiles of all three drugs along with maternal and neonatal outcomes were compared.

Results: Total number of drug boluses needed for rescuing maternal hypotension in group A (1.78 ± 0.74 vs 1.93 ± 0.69 vs 2.38 ± 0.81, F value = 7.89; p-value <0.001) was less compared with group B and group C. Tachycardia was high in group C (26.7% vs 15.6% vs 37.8%, p=0.001) than in groups A & B. Incidence of bradycardia (HR<60bpm) was higher in group B (20% vs 24.4% vs 6.7%, p=0.001). Maternal complications were comparable among groups. There were no significant statistical variations in neonatal results among groups.

Conclusions: Norepinephrine is a potent drug and has a better hemodynamic profile than phenylephrine and ephedrine because of fewer fluctuations in the heart rate and perhaps cardiac output.


Keywords


Norepinephrine, Phenylephrine, Ephedrine, Caesarean section, spinal anaesthesia, hypotension

References


Hasanin A, Mokhtar AM, Badawy AA, Fouad R. Post-spinal anesthesia hypotension during cesarean bdelivery, a review article. Egypt J Anaesth 2017; 33:189-93.

Kinsella S, Carvalho B, Dyer R, et al. International consensus statement on the management of hypotension with vasopressors during caesarean section under spinal anaesthesia. Anaesthesia. 2018;73:71–92. [PubMed] [Google Scholar]

Gunasekaran P, Elakkumanan LB, Balach H, Satyaprakash M. Comparing slow and rapid bolus of ephedrine in pregnant patients undergoing planned cesarean section under spinal anesthesia. J Anaesthesiol Clin Pharmacol 2017;33:92-6.

Xu C, Liu S, Huang YZ, Guo XW, Xiao HB, Qi DY. Phenylephrinevs ephedrinein cesarean delivery under spinal anesthesia: A systematic literature review and meta-analysis. Int J Surg 2018; 60:48-59.

Mets B. Should norepinephrine, rather than phenylephrine, be considered the primary vasopressor in anesthetic practice? Anesth Analg. 2016;122:1707–14. [PubMed] [Google Scholar]

Choudhary M, Bajaj JK. Study coparing phenylephrine bolus and infusion for maternal hypotension and neonatal outcome during cesarean section under spinal anesthesia. Anesth Essays Res 2018; 12:446-51.

Kee WD. The use of vasopressors during spinal anaesthesia for caesarean section. Curr Opin Anesthesiol 2017; 30:319-25.

Aitkenhead AR, Smith G; Maternal and Neonatal Physiology. Textbook of Anaesthesia by Churchhill Livingstone. 4th Edition; Page 77-81.

Xian W, Shen X, Liu S, Yang J, Xu S. The efficacy and safety of norepinephrine and its feasibility as a replacement for phenylephrine to manage maternal hypotension during elective cesarean delivery under spinal anesthesia. Biomed Res Int 2018: 1869189. doi: 10.1155/2018/1869189.

Ling D, Qian D, Xiumei S, Yang L, Yuelan W. Comparison of prophylactic bolus norepinephrine and phenylephrine on hypotension during spinal anesthesia for cesarean section. Int J Clin Exp Med 2017; 10:12315-21.

Onwochei DN, Ngan KW, Fung L, Downey K, Xiang YY, Carvalho JC. Norepinephrine intermittent intravenous boluses to prevent hypotension during spinal anesthesia for cesarean delivery: A sequential allocation dose finding study. Anesth Analg 2017; 125:212-8.

Sharkey AM, Siddiqui N, Downey K, Xiang YY, Guevara J, Carvalho JC. Comparison of intermittent intravenous boluses of phenylephrine and norepinephrine to prevent and treat spinal-induced hypotension in cesarean deliveries: randomized controlled trial. Anesthesia & Analgesia. 2019 Nov 1;129(5):1312-8.

Phogat A, Kavishvar N. Comparison of Norepinephrine with Ephedrine Boluses for the Treatment of Maternal Hypotension during Cesarean Section Under Spinal Anesthesia: A Prospective Observational Study. Journal of Obstetric Anaesthesia and Critical Care. 2023 Jul 1;13(2):198-203.

Ngan Kee WD, Lee SW, Ng FF et al: Randomized double-blinded comparison of norepinephrine and phenylephrine for maintenance of blood pressure during spinal anesthesia for cesarean delivery. Anesthesiology, 2015;122: 736–45.

Xu S, Shen X, Liu S, Yang J, Wang X. Efficacy and safety of norepinephrine versus phenylephrine for the management of maternal hypotension during cesarean delivery with spinal anesthesia: A systematic review and meta-analysis. Medicine 2019;98: e14331.

Medlej K, Kazzi AA, Chehade AE, Eldine MS, Chami A, Bachir R, et al. Complications from administration of vasopressors through peripheral venous catheters: An observational study. J Emeg Med 2018; 54:47-53.


Refbacks



Creative Commons License
This work is licensed under a Creative Commons Attribution 4.0 International License.