Ephedrine versus phenylephrine as a vasopressor for spinal anaesthesia-induced hypotension in parturients undergoing high-risk caesarean section: meta-analysis, meta-regression and trial sequential analysis

Rijs, K.; Hilber, N.; Kee, Warwick D. Ngan; Rossaint, Rolf; Marel, C. van der; Klimek, Markus

doi:10.1016/j.ijoa.2018.10.006

Cited by 27 publications

(7 citation statements)

References 36 publications

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“…19 Although MAP was decreased more in healthy parturients, no differences in Apgar scores and fetal acidosis were observed between the groups, which was consistent with previous studies. [20][21][22][23] Prematurity linked to the preeclamptic group would be much more likely to affect difference in neonatal outcomes rather than these small differences in MAP decrease.…”

Section: Discussionmentioning

confidence: 99%

Comparative Dose-Response Study of Phenylephrine Bolus for the Treatment of the First Episode of Spinal Anesthesia-Induced Hypotension for Cesarean Delivery in Severe Preeclamptic versus Normotensive Parturients

Zhong

Shen

et al. 2022

DDDT

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Background It is well-known that severe preeclamptic parturients have less vasopressor requirements than normotensive parturients; however, the exact dose difference is poorly documented. This study aimed to determine and compare the ED 50 and ED 90 of a single bolus phenylephrine for the treatment of spinal anesthesia-induced hypotension in parturients with severe preeclampsia and parturients with normotension. Methods Seventy-five parturients with severe preeclampsia scheduled for cesarean delivery under combined spinal-epidural anesthesia were enrolled and randomly allocated to receive a single bolus of phenylephrine at five different doses (40, 50, 60, 70, and 80 μg), whereas 75 parturients with normotension were randomized to receive a single bolus of phenylephrine at five different doses (70, 80, 90, 100, and 110 μg) for the treatment of the first episode of hypotension. Phenylephrine dose values were log-transformed, the proportions of the successful interventions at each dose were converted to probits, and regression analysis was performed. Results The ED 50 and ED 90 (95% CI) of bolus phenylephrine were 72.1 (61.7 to 79.9) μg and 107 (95.9–128.6) μg in parturients with normotension. The ED 50 and ED 90 values in parturients with severe preeclampsia were 47.6 (41.3–52.7) μg and 70.7 (62.9–86.7) μg. The relative median potency was 1.51 (1.16–2.61). Conclusion Under this study conditions, severe preeclamptic parturients required a 34% reduction of ED 50 of phenylephrine dose compared with normotensive parturients.

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Section: Discussionmentioning

confidence: 99%

Comparative Dose-Response Study of Phenylephrine Bolus for the Treatment of the First Episode of Spinal Anesthesia-Induced Hypotension for Cesarean Delivery in Severe Preeclamptic versus Normotensive Parturients

Zhong

Shen

et al. 2022

DDDT

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“…While similar meta-analyses exist, they are not entirely identical to the present study. For instance, several meta-analyses have been published on either the efficacy of multiple antihypertensive agents in spinal anesthesia ( Ryu et al, 2019 ; Singh et al, 2020 ), on the comparison of phenylephrine and ephedrine ( Veeser et al, 2012 ; Heesen et al, 2019 ), or on the treatment of hypotension induced by spinal anesthesia a ( Kumari et al, 2022 ). In contrast, the present study mainly focused on the use of norepinephrine prophylactically, immediately after spinal anesthesia and directly compared the efficacy of the two drugs.…”

Section: Discussionmentioning

confidence: 99%

“…While similar meta-analyses exist, they are not entirely identical to the present study. For instance, several metaanalyses have been published on either the efficacy of multiple antihypertensive agents in spinal anesthesia (Ryu et al, 2019;Singh et al, 2020), on the comparison of phenylephrine and ephedrine (Veeser et al, 2012;Heesen et al, 2019), or on the treatment of hypotension induced by…”

Section: Figure 10mentioning

confidence: 99%

“…Several meta-analyses have been published on either the efficacy of multiple antihypertensive agents in spinal anesthesia ( Ryu et al, 2019 ; Singh et al, 2020 ), comparison of phenylephrine and ephedrine ( Veeser et al, 2012 ; Heesen et al, 2019 ), or analyse the treatment of hypotension induced by spinal anesthesia ( Kumari et al, 2022 ). However, our study focused on prophylaxis and not only highlights a different time point in the use of these drugs but also reflects a distinct line of thought.…”

Section: Introductionmentioning

confidence: 99%

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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

Liu

Zhang

et al. 2022

Front. Pharmacol.

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Background: Phenylephrine is the first-line drug used to maintain blood pressure in cesarean delivery. However, it poses a high risk of bradycardia and depression of cardiac activity in pregnant women. Consequently, norepinephrine has gained popularity over the recent years, as an alternative to Phenylephrine because it is thought that prophylactic use of vasopressors may reduce the incidence of hypotension after spinal anesthesia. This systematic review compared the efficacy of both treatments.Methods: We searched the following databases; CNKI, PubMed, Embase, Web of science, clinicaltrials.gov, Medline and Cochrane Library, for randomized controlled trials comparing the prophylactic efficacy of norepinephrine and phenylephrine on elective cesarean delivery under spinal anesthesia. The search period was from inception to July 2022, and the primary outcome indicator was incidence of bradycardia. Statistical analysis was conducted on Rev manager 5.4, and the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework was used to evaluate the quality of evidence from each main finding.Results: A total of 12 papers were included in the analysis. The incidence of bradycardia (RR = 0.37, 95% CI: 0.28 to 0.49, p < 0.00001) and reactive hypertension (RR = 0.58, 95% CI 0.40 to 0.83, p = 0.003) was significantly lower in the norepinephrine (NE) group compared with the phenylephrine (PE) category. In contrast, there were no statistical differences in the umbilical cord blood gas analysis pH values between the groups (arterial: MD = 0.00, 95% CI −0.00 to 0.01, p = 0.22, vein: MD = 0.01, 95% CI −0.00 to 0.02, p = 0.06). The incidence of hypotension, nausea, and vomiting did not differ significantly between the NE and PE groups (hypotension: 23% vs. 18%; nausea: 14% vs. 18%; vomiting: 5% vs. 7%, respectively).Conclusion: Prophylactic use of norepinephrine is safe and effective in maintaining maternal hemodynamics without causing adverse events to either the pregnant woman or fetus.Systematic Review Registration: website https://www.crd.york.ac.uk/prospero/, identifier CRD42022347095

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“…Previous studies have shown a different response of fetal pH to vasopressors between elective and non‐elective cases. The increased incidence of fetal acidosis seen with ephedrine as opposed to phenylephrine was only found in elective caesarean sections but not in studies of non‐elective caesarean section [30–32]; a meta‐analysis of the pooled data showed there was insufficient evidence to draw a firm conclusion on a difference between the two vasopressors in non‐elective caesarean section [33]. We cannot exclude that there is equipoise between phenylephrine and noradrenaline in terms of fetal acidosis in emergency caesarean sections.…”

Section: Ephedrine Phenylephrine Noradrenalinementioning

confidence: 99%

Noradrenaline – at best it is not worse. A comparison with phenylephrine in women undergoing spinal anaesthesia for caesarean section

Girard

Klimek

2021

Anaesthesia

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Ephedrine versus phenylephrine as a vasopressor for spinal anaesthesia-induced hypotension in parturients undergoing high-risk caesarean section: meta-analysis, meta-regression and trial sequential analysis

Cited by 27 publications

References 36 publications

Comparative Dose-Response Study of Phenylephrine Bolus for the Treatment of the First Episode of Spinal Anesthesia-Induced Hypotension for Cesarean Delivery in Severe Preeclamptic versus Normotensive Parturients

Comparative Dose-Response Study of Phenylephrine Bolus for the Treatment of the First Episode of Spinal Anesthesia-Induced Hypotension for Cesarean Delivery in Severe Preeclamptic versus Normotensive Parturients

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

Noradrenaline – at best it is not worse. A comparison with phenylephrine in women undergoing spinal anaesthesia for caesarean section

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