Comparative Study Among Ephedrine, Norepinephrine and Phenylephrine Infusions to Prevent Spinal Hypotension During Cesarean Section. A Randomized Controlled Double-Blind Study

Abstract

Background: Spinal anesthesia is the recommended technique in elective cesarean sections. Usage of vasopressors is more widely accepted as an effective method for decreasing postspinal hypotension than fluid loading. However, the ideal vasopressor to prevent spinal hypotension during cesarean section has been a subject of much debate. It should maintain maternal blood pressure and placental perfusion, with minimal adverse effect on fetus and mother. Aim: The primary aim was to compare the effect of prophylactic infusion of phenylephrine versus norepinephrine versus ephedrine in the prevention of postspinal hypotension in elective cesarean section. The secondary aim was to assess their effects on neonate. Methods: Seventy-five patients were enrolled in this study and randomly divided into three groups. Group P received phenylephrine infusion and group N received norepinephrine infusion, while group E received ephedrine infusion. The changes in mean arterial blood pressure and heart rate were recorded throughout the surgery. Maternal and neonatal perioperative complications were controlled and recorded. Results: MAP were higher in the ephedrine group than the phenylephrine and norepinephrine groups. Maternal tachycardia was significantly more common in ephedrine, and bradycardia was more common in phenylephrine group without significant difference. Nausea and vomiting were more common in ephedrine group. Neonatal acidosis was lesser in phenylephrine and norepinephrine groups than in the ephedrine group. Conclusion: Prophylactic infusion of phenylephrine and norepinephrine can be successfully used to prevent postspinal hypotension in parturient undergoing cesarean section with less drawbacks and fetal well-being than ephedrine.

Comparative efficacy and safety of prophylactic norepinephrine and phenylephrine in spinal anesthesia for cesarean section: A systematic review and meta-analysis with trial sequential analysis

“…A total of 12 studies ( Dong et al, 2017 ; Vallejo et al, 2017 ; Hasanin et al, 2019 ; Sharkey et al, 2019 ; Theodoraki et al, 2020 ; Berawala et al, 2021 ; Eskandr et al, 2021 ; Chen et al, 2022 ; Du et al, 2022 ; Guo et al, 2022 ; Singh et al, 2022 ; Zhou et al, 2022 ) were included, all of which were published in the last 5 years. Five ( Dong et al, 2017 ; Chen et al, 2022 ; Du et al, 2022 ; Guo et al, 2022 ; Zhou et al, 2022 ) of the studies were conducted in China, two ( Berawala et al, 2021 ; Singh et al, 2022 ) in India, two ( Hasanin et al, 2019 ; Eskandr et al, 2021 ) in Egypt, and the remaining three ( Vallejo et al, 2017 ; Sharkey et al, 2019 ; Theodoraki et al, 2020 ) in Canada, the United States, and Greece, respectively, with participants ranging from 18 to 45 years. One of the studies involved an intervention in which a dose of the study drug was administered intravenously, immediately after spinal anesthesia, while the remaining administered the study drug at a fixed rate.…”

“…Data related to the incidence of nausea were pooled and recorded in nine studies ( Dong et al, 2017 ; Vallejo et al, 2017 ; Hasanin et al, 2019 ; Sharkey et al, 2019 ; Berawala et al, 2021 ; Eskandr et al, 2021 ; Guo et al, 2022 ; Singh et al, 2022 ; Zhou et al, 2022 ) with minimal heterogeneity between the included articles ( p = 0.21, I 2 = 26%). The fixed effects model ( Figure 6 ) showed no statistical difference in the incidence of nausea between the two groups (RR = 0.79, 95% CI 0.60 to 1.06, p = 0.11).…”

“…Six studies reported on the occurrence of vomiting ( Vallejo et al, 2017 ; Hasanin et al, 2019 ; Sharkey et al, 2019 ; Berawala et al, 2021 ; Eskandr et al, 2021 ; Guo et al, 2022 ) with no significant heterogeneity between them ( p = 0.70, I 2 = 0%). In addition, analysis using a fixed effects model showed that the occurrence of vomiting was not statistically different between the two groups (RR = 0.69, 95% CI 0.37 to 1.27, p = 0.23) ( Figure 7 ).…”

“…Pooled analysis of all the included studies showed that the incidence of bradycardia was recorded in all the 12 articles (Dong et al, 2017;Vallejo et al, 2017;Hasanin et al, 2019;Sharkey et al, 2019;Theodoraki et al, 2020;Berawala et al, 2021;Eskandr et al, 2021;Chen et al, 2022;Du et al, 2022;Guo et al, 2022;Singh et al, 2022;, with no significant heterogeneity between studies (p = 0.44, I 2 = 0%). Meta-analysis using a fixed effects model showed that the incidence of bradycardia was significantly lower and statistically different in the prophylactic norepinephrine group compared to the phenylephrine category (RR = 0.37, 95% CI: 0.28 to 0.49, p < 0.00001), Figure 3 A. Bradycardia was defined as having less than 50 beats/min in three studies (Sharkey et al, 2019;Eskandr et al, 2021;, which were excluded from the analyses. The findings revealed no significant heterogeneity between the two groups (p = 0.29, I 2 = 18%).…”

“…A total of 12 studies (Dong et al, 2017;Vallejo et al, 2017;Hasanin et al, 2019;Sharkey et al, 2019;Theodoraki et al, 2020;Berawala et al, 2021;Eskandr et al, 2021;Chen et al, 2022;Du et al, 2022;Guo et al, 2022;Singh et al, 2022; were included, all of which were published in the last 5 years. Five (Dong et al, 2017;Chen et al, 2022;Du et al, 2022;Guo et al, 2022; of the studies were conducted in China, two (Berawala et al, 2021;Singh et al, 2022) in India, two (Hasanin et al, 2019;Eskandr et al, 2021) in Egypt, and the remaining three (Vallejo et al, 2017;Sharkey et al, 2019;Theodoraki et al, 2020) in Canada, the United States, and Greece, respectively, with participants ranging from 18 to 45 years. One of the studies involved an intervention in which a dose of the study drug was administered intravenously, immediately after spinal anesthesia, while the remaining administered the study drug at a fixed rate.…”