Beruflich Dokumente
Kultur Dokumente
DOI 10.1007/s12630-012-9705-9
Received: 28 November 2011 / Accepted: 20 March 2012 / Published online: 24 April 2012
Canadian Anesthesiologists Society 2012
Abstract
Purpose The purpose of this Continuing Professional
Development module is to review the physiology of
maternal hypotension induced by spinal anesthesia in
pregnant women, and the effects of fluids and vasopressors.
Principal findings Maternal hypotension induced by
spinal anesthesia is caused mainly by peripheral vasodilatation and is not usually associated with a decrease in
cardiac output. Although the intravenous administration of
fluids helps to increase cardiac output, it does not always
prevent maternal hypotension. Three strategies of fluid
administrations are equivalent for the prevention of
maternal hypotension and a reduced need for vasopressors: (1) colloid preload; (2) colloid coload; and (3)
crystalloid coload. Crystalloid preload is not as effective as
any of those three strategies. Unlike phenylephrine,
ephedrine can cause fetal acidosis. Therefore, phenylephrine is recommended as first line treatment of maternal
hypotension. A phenylephrine infusion (25-50 lgmin-1)
appears to be more effective than phenylephrine boluses to
prevent hypotension, and nausea and vomiting. In preeclamptic patients, spinal anesthesia produces less hypotension than in normal pregnant women and fluid volumes
up to 1,000 mL are usually well tolerated. Therefore mild
to moderate intravascular volume loading is recommended,
keeping in mind the increased risk for pulmonary edema in
this population. In pre-eclamptic patients, hypotension can
be treated either with ephedrine or phenylephrine, and
phenylephrine infusions are not recommended.
C. Loubert, MD (&)
Departement danesthesie, Hopital Maisonneuve-Rosemont,
5415, boul. lAssomption, Montreal, QC H1T 2M4, Canada
e-mail: loubertch@yahoo.fr
123
Conclusion A volume loading regimen other than crystalloid preload should be adopted. A phenylephrine
infusion during elective Cesarean delivery is beneficial for
the mother and safe for the newborn.
2.
3.
4.
5.
Fluid and vasopressor management for Cesarean delivery under spinal anesthesia
605
despite the onset of the sympathetic block, as long as parturients do not receive phenylephrine infusions.9-12
Therefore, these data contradict the concept that spinal
anaesthesia causes a major decrease in cardiac output.
Moreover, Tamilselvan et al. reported that the corrected
ejection time, a measurement of ventricular filling, did not
change after the onset of spinal blockade; these results are
against a significant decrease in venous return.11 It should
also be noted that Langesaeter et al. showed that the
decrease in peripheral vascular resistance is rather associated with a significant increase in cardiac output.8 A study
by Dyer et al. also showed that this increased cardiac output
correlated with an increased maternal heart rate.13 It is
important to note that all the patients included in those
studies had received 500-1,500 mL of either crystalloids or
colloids. Table 1 shows a schematic representation of the
hemodynamic changes occurring during spinal anaesthesia.
Table 1 Changes, relative to baseline, in various hemodynamic parameters following the administration of a spinal anesthesia
Intravascular loading
Spinal anesthesia
Phenylephrine
Ephedrine
/?
!!
%%
Cardiac output
%%
/ ? to %
!!
%%
Blood pressure
/?
!! to !!!
%%
%%
Heart rate
/?
%% (sometimes !!!)
! to !!
%%
Venous return
%%
/?
123
Fluid and vasopressor management for Cesarean delivery under spinal anesthesia
605
despite the onset of the sympathetic block, as long as parturients do not receive phenylephrine infusions.9-12
Therefore, these data contradict the concept that spinal
anaesthesia causes a major decrease in cardiac output.
Moreover, Tamilselvan et al. reported that the corrected
ejection time, a measurement of ventricular filling, did not
change after the onset of spinal blockade; these results are
against a significant decrease in venous return.11 It should
also be noted that Langesaeter et al. showed that the
decrease in peripheral vascular resistance is rather associated with a significant increase in cardiac output.8 A study
by Dyer et al. also showed that this increased cardiac output
correlated with an increased maternal heart rate.13 It is
important to note that all the patients included in those
studies had received 500-1,500 mL of either crystalloids or
colloids. Table 1 shows a schematic representation of the
hemodynamic changes occurring during spinal anaesthesia.
Table 1 Changes, relative to baseline, in various hemodynamic parameters following the administration of a spinal anesthesia
Intravascular loading
Spinal anesthesia
Phenylephrine
Ephedrine
/?
!!
%%
Cardiac output
%%
/ ? to %
!!
%%
Blood pressure
/?
!! to !!!
%%
%%
Heart rate
/?
%% (sometimes !!!)
! to !!
%%
Venous return
%%
/?
123
606
C. Loubert
Pre-loading
fluid administration prior
to spinal anaesthesia
Crystalloids
Comparison
Colloids
123
Regimen I
Crystalloid pre-load
Regimen II
Colloid pre-load
Comparison
Co-loading
fluid administration starting
at administration of spinal
anesthesia
Regimen III
Crystalloids co-load
Identical neonatal
outcomes
Regimen IV same as
regimen II in terms of:
Hypotension
Vasopressor requirement
Regimen IV better than
regimen II in terms of :
Increased cardiac output
(15 mLkg-1 volume)
Regimen IV same as
regimen III in terms of:
Hypotension
Vasopressor requirement
(phenylephrine infusion).
Regimen IV
Colloids co-load
Fluid and vasopressor management for Cesarean delivery under spinal anesthesia
607
123
608
Vasopressors
In Canada, ephedrine and phenylephrine are the two most
commonly used vasopressors to treat hypotension induced
by spinal anaesthesia during Cesarean delivery. Traditionally, phenylephrine was used only as a second line
agent, as there were concerns about its predominant
vasoconstrictive action that could result in a reduction of
local utero-placental perfusion and compromise fetal wellbeing. However, many studies showed in elective Cesarean
deliveries that giving ephedrine resulted in more fetal
acidosis than phenylephrine.12,38-41 In a key study by Ngan
Kee et al., the authors performed umbilical cord arterial
blood gas analysis; they showed a significant decrease in
pH, base excess and oxygen content, as well as an increase
in neonatal PaCO2 if the parturient had received large
doses of ephedrine.39 It is also important to note that in all
the newborns in the study, none of the Apgar scores at one
and five minutes was less than 7 and 9, respectively. These
results can be explained by a more important placental
transfer of ephedrine than phenylephrine, and possibly by a
fetal b-adrenergic stimulating effect of ephedrine, as evidenced by higher serum lactate, glucose and epinephrine
levels in newborns of mothers who had received ephedrine.40 In some studies, there are trends towards a lower
PaO2 values in the umbilical cord venous blood when
mothers receive phenylephrine.39,40,42 These findings may
be a result of the vasoconstrictor effect of phenylephrine on
utero-placental vessels, and a subsequent increased oxygen
extraction by the fetus.40 The possibility to extract more
oxygen would provide a certain safety margin in the
event of compromised utero-placental blood flow during
normal pregnancy. However, this safety margin should
not be taken for granted in cases where signs of fetal distress are present, and this situation might influence the
choice of vasopressors.
There is general agreement among experts to recommend
the use of phenylephrine as first line therapy for the treatment of arterial hypotension induced by spinal
anesthesia.15,24,43 A recent study showed that the ED90 (the
dose required for effective treatment of arterial hypotension
123
C. Loubert
Fluid and vasopressor management for Cesarean delivery under spinal anesthesia
609
Pre-eclampsia
A detailed discussion regarding the pathophysiological
concepts and anesthetic considerations relevant to preeclampsia is beyond the scope of this Continuing Professional Development module. We will therefore direct
the reader to the excellent review written on this topic by
Gogarten.53 Except for the usual contra-indications of
neuraxial anesthesia, spinal anesthesia involving usual
clinical doses of bupivacaine is now regarded as a safe
approach for pre-eclamptic patients requiring Cesarean
delivery.53-57 Experimental data show that the incidence
of hypotension induced by the spinal anesthestic and the
requirement for vasopressors are reduced in this
Conclusion
The practice of obstetrical anesthesia is in constant evolution, and the changing management of arterial
hypotension induced by spinal anesthesia for Cesarean
delivery is a clear illustration of the progress in clinical
care we observe. The introduction of colloids, co-loading
strategies, and phenylephrine infusions in daily practice
greatly improves the management of hypotension and
increases maternal comfort during elective caesarean
deliveries under spinal anesthesia. The safety of both
123
610
C. Loubert
Resume
Objectif Lobjectif de ce module de developpement
continu est de revoir les concepts physiologiques de
lhypotension maternelle induite par le bloc rachidien chez
la femme enceinte et les effets du remplissage vasculaire et
des vasopresseurs.
Constatations principales Lhypotension maternelle
induite par la rachianesthesie est principalement causee
par une vasodilatation peripherique, et ne saccompagne
pas habituellement dune diminution du debit cardiaque.
Bien que ladministration intraveineuse de liquides
contribue a` augmenter le debit cardiaque, elle ne previent
pas toujours lhypotension maternelle. Trois strategies
dadministration de liquides sont equivalentes quant a` la
prevention de lhypotension arterielle et a` la reduction des
besoins en vasopresseurs: (1) le preremplissage avec des
collodes; (2) le coremplissage avec des collodes; et (3) le
coremplissage avec des cristallodes. Le preremplissage
avec des cristallodes nest pas aussi efficace que lune ou
lautre de ces trois strategies. Contrairement a` la
phenylephrine, lephedrine peut causer une acidose ftale.
La phenylephrine est donc recommandee en premie`re
intention pour traiter lhypotension maternelle. Une
perfusion de phenylephrine (25 a` 50 lgmin-1) semble plus
efficace que la phenylephrine en bolus pour prevenir
lhypotension ainsi que les nausees et vomissements. Chez
les patientes pre-eclamptiques, la rachianesthesie produit
moins dhypotension que chez les parturientes normales et
des quantites de liquides pouvant atteindre 1,000 mL sont
en general bien tolerees. On recommande donc un
remplissage vasculaire leger a` modere, tout en considerant le
risque majore dde`me pulmonaire dans cette population.
Lhypotension se traite aussi bien avec lephedrine que la
phenylephrine chez les parturientes pre-eclamptiques et une
perfusion de phenylephrine nest pas recommandee chez ces
patientes.
Conclusion Une strategie de remplissage vasculaire
autre que le preremplissage avec des cristallodes devrait
etre employee. Ladministration de phenylephrine en
perfusion lors de cesariennes programmees est benefique
pour la me`re et securitaire pour le nouveau-ne.
3.
4.
5.
123
Fluid and vasopressor management for Cesarean delivery under spinal anesthesia
23-
4-
5-
611
123
612
C. Loubert
Tableau 1 Variations par rapport a` la ligne de base que prennent differents parame`tres hemodynamiques suite a` ladministration de la
rachianesthesie
Remplissage vasculaire
Rachianesthesie
Phenylephrine
Ephedrine
/?
!!
%%
%%
Tension arterielle
Frequence cardiaque
/?
/ ? a` %
!! a` !!!
/?
Retour veineux
%%
!!
%%
%%
%% (parfois !!!)
%%
! a` !!
/?
%%
123
Fluid and vasopressor management for Cesarean delivery under spinal anesthesia
Tableau 2 Comparaison des
quatres strategies de
remplissage vasculaire possibles
pour la prevention et le
traitement de lhypotension
arterielle maternelle
Prremplissage
administration de
liquides avant la
rachianesthsie
Cristallodes
Comparaison
Stratgie I
Prremplissage
Cristallodes
Stratgie II
Prremplissage
Collodes
Coremplissage
administration de liquides
ds le dbut de la
rachianesthsie
Stratgie II meilleure
que stratgie I quant :
Rduction de
lhypotension
Besoins en
Comparaison
vasopresseurs
Maintien du dbit
cardiaque
Rduction des nauses
Collodes
613
Points daboutissement
nonataux identiques
Stratgie IV identique
stratgie III quant :
Rduction de lhypotension
Besoins en vasopresseurs
(perfusion de
phnylphrine).
Stratgie IV identique
stratgie II quant :
Rduction de lhypotension
Besoins en vasopresseurs
Stratgie IV
Stratgie IV meilleure que Coremplissage
Collodes
stratgie II quant :
Augmentation du dbit
cardiaque
(vol de 15 mLkg-1)
123
614
C. Loubert
Les vasopresseurs
Le coremplissage aux collodes (strategie IV vs
strategie II et strategie III)
Leffet du coremplissage aux collodes a ete compare
au preremplissage aux collodes dans quatres etudes
distinctes.25,33-35 Dans aucune des publications les
investigateurs nont pu mettre en evidence la superiorite
dune strategie par rapport a` lautre, tant sur le plan de
lincidence dhypotension maternelle et des besoins en
vasopresseurs que sur le plan des scores dApgar et de
lequilibre acido-basique ftal. Tout au plus, Teoh et coll.
ont demontre que les patientes ayant recu un volume
dhydroxyethylamidon de 15 mLkg-1 en preremplissage
presentaient une augmentation significative de leur debit
cardiaque par rapport a` la ligne de base, augmentation qui
netait pas soutenue dix minutes apre`s la rachianesthesie.35
Une seule etude jusqua` present a compare le coremplissage
avec 1,000 mL dhydroxyethylamidon a` un coremplissage
avec un volume equivalent de cristallodes chez des
parturientes qui recevaient par ailleurs une perfusion de
phenylephrine.19 Les auteurs nont note aucune difference
entre les groupes ni sur le plan hemodynamique ni sur le
123
Fluid and vasopressor management for Cesarean delivery under spinal anesthesia
615
Cesariennes urgentes
Presque toutes les etudes comparant lephedrine a` la
phenylephrine sur le plan maternel et ftal ont ete realisees
chez des sujets sains dont la grossesse etait devolution
normale et qui ne presentaient ni comorbidites, ni indicateurs
de souffrance ftale. Lextrapolation des resultats de ces
etudes aupre`s de patientes presentant des signes
dhypoperfusion uteroplacentaire se frappe a` des obstacles
significatifs. En loccurrence, une etude effectuee sur un
mode`le animal dhypoperfusion placentaire sugge`re que la
phenylephrine est associee a` une reduction du debit et a` une
augmentation des resistances vasculaires uteroplacentaires
ainsi qua` une augmentation de la concentration ftale en
lactates.51 Une seule etude prospective et randomisee aupre`s
de 158 femmes enceintes subissant une cesarienne urgente
sous rachianesthesie pour des indications de possible
souffrance ftale a demontre que ladministration de
phenylephrine en bolus etait cliniquement aussi securitaire
que lephedrine sur les plans de lequilibre acidobasique du
nouveau-ne et de son evolution clinique.52 Ces resultats ont
ete confirmes dans une etude retrospective recente aupre`s de
patientes presentant diverses comorbidites.42
123
616
123
C. Loubert
Conclusion
La pratique de lanesthesie obstetricale est en constante
evolution, et les changements que lon observe dans la prise
en charge de lhypotension arterielle induite par la
rachianesthesie pour laccouchement par cesarienne en
temoignent de facon eloquente. Lintroduction des collodes,
du concept de coremplissage et de la perfusion de
phenylephrine dans la pratique courante ameliore grandement
le controle de lhypotension arterielle et participe certainement
au confort maternel lors de cesariennes programmees sous
rachianethesie. La securite des deux types de liquide et de
la phenylephrine semble maintenant bien acceptee par la
communaute scientifique. Ainsi, il reste a` savoir si lune
ou lautre de ces prophylaxies volemiques et strategies
dutilisation de vasopresseurs procure un avantage aux femmes
enceintes en bonne sante sur le plan des complications
maternelles a` plus long terme, comme linfection des plaies et le
sepsis, la cicatrisation, le saignement postoperatoire et le temps
dhospitalisation. Ces questions feront surement lobjet de
plusieurs etudes tre`s interessantes a` venir.
Cas cliniques
Une femme enceinte de 28 ans en bonne sante se presente
au bloc operatoire pour subir une cesarienne programmee.
Fluid and vasopressor management for Cesarean delivery under spinal anesthesia
3.
4.
5.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
References
19.
1. Russell IF. Levels of anaesthesia and intraoperative pain at caesarean section under regional block. Int J Obstet Anesth 1995; 4:
71-7.
2. Mercier FJ, Bonnet MP, De la Dorie A, et al. Spinal anaesthesia
for caesarean section: fluid loading, vasopressors and hypotension
(French). Ann Fr Anesth Reanim 2007; 26: 688-93.
3. Klohr S, Roth R, Hofmann T, Rossaint R, Heesen M. Definitions
of hypotension after spinal anaesthesia for caesarean section:
20.
21.
617
123
618
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
C. Loubert
associated with spinal anesthesia for elective cesarean section.
Anesthesiology 1993; 79: 262-9.
Tercanli S, Schneider M, Visca E, et al. Influence of volume
preloading on uteroplacental and fetal circulation during spinal
anaesthesia for caesarean section in uncomplicated singleton
pregnancies. Fetal Diagn Ther 2002; 17: 142-6.
Rout CC, Akoojee SS, Rocke DA, Gouws E. Rapid administration
of crystalloid preload does not decrease the incidence of hypotension after spinal anaesthesia for elective caesarean section. Br
J Anaesth 1992; 68: 394-7.
Ngan Kee WD. Prevention of maternal hypotension after regional
anaesthesia for caesarean section. Curr Opin Anaesthesiol 2010;
23: 304-9.
Nishikawa K, Yokoyama N, Saito S, Goto F. Comparison of
effects of rapid colloid loading before and after spinal anesthesia
on maternal hemodynamics and neonatal outcomes in cesarean
section. J Clin Monit Comput 2007; 21: 125-9.
Ngan Kee WD, Khaw KS, Lee BB, Ng FF, Wong MM. Randomized controlled study of colloid preload before spinal
anaesthesia for caesarean section. Br J Anaesth 2001; 87: 772-4.
Dahlgren G, Granath F, Pregner K, Rosblad PG, Wessel H,
Irestedt L. Colloid vs. crystalloid preloading to prevent maternal
hypotension during spinal anesthesia for elective cesarean section. Acta Anaesthesiol Scand 2005; 49: 1200-6.
Siddik SM, Aouad MT, Kai GE, Sfeir MM, Baraka AS.
Hydroxyethylstarch 10% is superior to Ringers solution for
preloading before spinal anesthesia for cesarean section. Can J
Anesth 2000; 47: 616-21.
Ko JS, Kim CS, Cho HS, Choi DH. A randomized trial of crystalloid versus colloid solution for prevention of hypotension
during spinal or low-dose combined spinal-epidural anesthesia
for elective cesarean delivery. Int J Obstet Anesth 2007; 16: 8-12.
Hahn RG, Resby M. Volume kinetics of Ringers solution and
dextran 3% during induction of spinal anaesthesia for caesarean
section. Can J Anaesth 1998; 45: 443-51.
Dyer RA, Farina Z, Joubert IA, et al. Crystalloid preload versus
rapid crystalloid administration after induction of spinal anaesthesia (coload) for elective caesarean section. Anaesth Intensive
Care 2004; 32: 351-7.
Cardoso MM, Santos MM, Yamaguchi ET, Hirahara JT, Amaro
AR. Fluid preload in obstetric patients. How to do it? Rev Bras
Anestesiol 2004; 54: 13-9.
Carvalho B, Mercier FJ, Riley ET, Brummel C, Cohen SE. Hetastarch co-loading is as effective as pre-loading for the
prevention of hypotension following spinal anesthesia for cesarean delivery. Int J Obstet Anesth 2009; 18: 150-5.
Siddik-Sayyid SM, Nasr VG, Taha SK, et al. A randomized trial
comparing colloid preload to coload during spinal anesthesia for
elective cesarean delivery. Anesth Analg 2009; 109: 1219-24.
Teoh WH, Sia AT. Colloid preload versus coload for spinal
anesthesia for cesarean delivery: the effects on maternal cardiac
output. Anesth Analg 2009; 108: 1592-8.
Laxenaire MC, Charpentier C, Feldman L. Anaphylactoid reactions to colloid plasma substitutes: incidence, risk factors,
mechanisms. A French multicenter prospective study (French).
Ann Fr Anesth Reanim 1994; 13: 301-10.
Westphal M, James MF, Kozek-Langenecker S, Stocker R, Guidet
B, Van Aken H. Hydroxyethyl starches: different productsdifferent effects. Anesthesiology 2009; 111: 187-202.
Lee A, Ngan Kee WD, Gin T. A quantitative, systematic review of
randomized controlled trials of ephedrine versus phenylephrine
for the management of hypotension during spinal anesthesia for
cesarean delivery. Anesth Analg 2002; 94: 920-6.
Ngan Kee WD, Lee A, Khaw KS, Ng FF, Karmakar MK, Gin T.
A randomized double-blinded comparison of phenylephrine
and ephedrine infusion combinations to maintain blood
123
40.
41.
42.
43.
44.
45.
46.
47.
48.
49.
50.
51.
52.
53.
54.
55.
56.
Fluid and vasopressor management for Cesarean delivery under spinal anesthesia
cesarean delivery in severe preeclampsia. Anesthesiology 2008;
108: 802-11.
57. Reidy J, Douglas J. Vasopressors in obstetrics. Anesthesiol Clin
2008; 26: 75-88, vi-vii.
58. Karinen J, Rasanen J, Alahuhta S, Jouppila R, Jouppila P.
Maternal and uteroplacental haemodynamic state in pre-
619
eclamptic patients during spinal anaesthesia for caesarean section. Br J Anaesth 1996; 76: 616-20.
59. Bauer ST, Cleary KL. Cardiopulmonary complications of preeclampsia. Semin Perinatol 2009; 33: 158-65.
123