Prophylactic norepinephrine infusion or leg wrapping for postspinal hypotension in elective caesarean delivery

Abstract

BACKGROUND Because of its alpha and beta agonist properties, norepinephrine infusion is currently being studied for the prevention of spinal hypotension during caesarean delivery. Vasopressor infusions are not always possible if there is an unavailability of infusion pumps. Leg wrapping with crepe bandage is an effective technique for prevention of postspinal hypotension and could be useful in resource-poor settings. OBJECTIVE The aim of this study was to compare the incidence of hypotension with norepinephrine infusion or leg wrapping with a control group in women undergoing caesarean delivery with spinal anaesthesia. DESIGN Randomised, double-blind, controlled trial. SETTING Single centre, tertiary level institute, India. Study period 3 April 2018 to 31 March 2019. PATIENTS One hundred and forty-four women aged 19 to 40 years with a singleton pregnancy. INTERVENTION In group Leg Wrapping, crepe bandage was applied tightly from metatarsus to groin. Group Norepinephrine and the control group received sham leg wrapping. In group Norepinephrine, the women received a norepinephrine infusion according to their body weight, while group Leg Wrapping and the control group received a 0.9% normal saline infusion at a similar rate. All three groups received a 500 ml co-load of Ringer's solution over 15 min. Noninvasive SBP was monitored every 2 min until delivery, and every 5 min thereafter. Any hypotensive event (SBP < 20% of baseline) was treated with an intravenous bolus of norepinephrine (7.5 μg). MAIN OUTCOME MEASURES The primary outcome was the incidence of hypotension. The secondary outcomes were performance error measurements, and the incidences of hypertension, bradycardia, norepinephrine rescue bolus and neonatal outcomes. RESULTS The incidences of hypotension were significantly lower in the norepinephrine infusion group and the leg wrapping groups than the control group (P values 0.021 for both). Performance error calculations showed that SBP was maintained closer to baseline with the norepinephrine infusion. CONCLUSION Norepinephrine infusion and leg wrapping can both reduce the incidence of postspinal hypotension during elective caesarean delivery compared with saline infusion alone. TRIAL REGISTRATION Clinical trial number and registry URL: CTRI/2018/04/012917 registered at Clinical Trial Registry of India http://www.ctri.nic.in/Clinicaltrials/login.php.

Prophylactic Norepinephrine and Phenylephrine Boluses to Prevent Postspinal Anesthesia Hypotension During Cesarean Section: A Randomized Sequential Allocation Dose-Finding Study

“… 20 Because norepinephrine better maintains CO, reduces the incidence of bradycardia, and improves hemodynamic stability, it was recently put forward as an advantageous alternative to phenylephrine. 21 We found that the incidence of bradycardia was significantly lower in the norepinephrine group relative to the PE group. However, other maternal adverse events and neonatal outcomes were comparable between the two groups.…”

A stitch in time saves early spinal anaesthesia-induced hypotension

“…Secondly, the recommended volume of crystalloid for a rapid infusion coload ranges between 15 and 20 ml kg −1 3 . This is in contrast to the low volume (7 ml kg −1 ) and slow infusion rate used in the present study 1 …”

“…We applaud the authors for addressing the very pertinent issue of managing postspinal hypotension during elective caesarean delivery. 1 This randomised controlled trial reported a reduction in the incidence of spinal anaesthesia-induced hypotension using either norepinephrine infusion or leg wrapping compared to a control group. However, there are several aspects of the clinical management that make it difficult to properly understand the results.…”

“…Firstly, in the norepinephrine infusion group, the infusion was not commenced until after patients were turned supine with a wedge under the right hip. 1 The international consensus statement on the management of hypotension with vasopressors during caesarean section recommends starting the prophylactic vasopressor infusion immediately after the intrathecal local anaesthetic injection. 2 Also, the authors did not administer a bolus of vasopressor before commencing the infusion.…”

“…3 This is in contrast to the low volume (7 ml kg À1 ) and slow infusion rate used in the present study. 1 Thirdly, the best clinical practice guidelines recommend maintenance of systolic arterial pressure at least 90% of an accurate baseline obtained before spinal anaesthesia and to avoid a decrease to less than 80% baseline. 2 A vasopressor bolus should be administered when systolic pressure is less than 90% of baseline.…”