Control of Spinal Anesthesia-Induced Hypotension in Adults

Fabrice Ferré, Charlotte Martin, Laetitia Bosch, Matt Kurrek, Olivier Lairez, Vincent Minville, Fabrice Ferré, Charlotte Martin, Laetitia Bosch, Matt Kurrek, Olivier Lairez, Vincent Minville

Abstract

Spinal anesthesia-induced hypotension (SAIH) occurs frequently, particularly in the elderly and in patients undergoing caesarean section. SAIH is caused by arterial and venous vasodilatation resulting from the sympathetic block along with a paradoxical activation of cardioinhibitory receptors. Bradycardia after spinal anesthesia (SA) must always be treated as a warning sign of an important hemodynamic compromise. Fluid preloading (before initiation of the SA) with colloids such as hydroxyethyl starch (HES) effectively reduces the incidence and severity of arterial hypotension, whereas crystalloid preloading is not indicated. Co-loading with crystalloid or colloid is as equally effective to HES preloading, provided that the speed of administration is adequate (ie, bolus over 5 to 10 minutes). Ephedrine has traditionally been considered the vasoconstrictor of choice, especially for use during SAIH associated with bradycardia. Phenylephrine, a α1 adrenergic receptor agonist, is increasingly used to treat SAIH and its prophylactic administration (ie, immediately after intrathecal injection of local anesthetics) has been shown to decrease the incidence of arterial hypotension. The role of norepinephrine as a possible alternative to phenylephrine seems promising. Other drugs, such as serotonin receptor antagonists (ondansetron), have been shown to limit the blood pressure drop after SA by inhibiting the Bezold-Jarisch reflex (BJR), but further studies are needed before their widespread use can be recommended.

Keywords: arterial hypotension; ondansetron; phenylephrine; spinal anesthesia; vasopressor.

Conflict of interest statement

The authors report no conflicts of interest in this work.

© 2020 Ferré et al.

References

    1. Arndt JO. The low pressure system: the integrated function of veins. Eur J Anaesthesiol. 1986;3(5):343–370.
    1. Butterworth JF, Piccione W, Berrizbeitia LD, Dance G, Shemin RJ, Cohn LH. Augmentation of venous return by adrenergic agonists during spinal anesthesia. Anesth Analg. 1986;65(6):612–616. doi:10.1213/00000539-198606000-00009
    1. Shimosato S, Etsten BE. The role of the venous system in cardiocirculatory dynamics during spinal and epidural anesthesia in man. Anesthesiology. 1969;30(6):619–628. doi:10.1097/00000542-196906000-00009
    1. Kinsella SM, Tuckey JP. Perioperative bradycardia and asystole: relationship to vasovagal syncope and the Bezold-Jarisch reflex. Br J Anaesth. 2001;86(6):859–868. doi:10.1093/bja/86.6.859
    1. Campagna JA, Carter C. Clinical relevance of the Bezold-Jarisch reflex. Anesthesiology. 2003;98(5):1250–1260. doi:10.1097/00000542-200305000-00030
    1. Carpenter RL, Caplan RA, Brown DL, Stephenson C, Wu R. Incidence and risk factors for side effects of spinal anesthesia. Anesthesiology. 1992;76(6):906–916. doi:10.1097/00000542-199206000-00006
    1. Caplan RA, Ward RJ, Posner K, Cheney FW. Unexpected cardiac arrest during spinal anesthesia: a closed claims analysis of predisposing factors. Anesthesiology. 1988;68(1):5–11. doi:10.1097/00000542-198801000-00003
    1. Auroy Y, Narchi P, Messiah A, Litt L, Rouvier B, Samii K. Serious complications related to regional anesthesia: results of a prospective survey in France. Anesthesiology. 1997;87(3):479–486. doi:10.1097/00000542-199709000-00005
    1. Asehnoune K, Larousse E, Tadié JM, Minville V, Droupy S, Benhamou D. Small-dose bupivacaine-sufentanil prevents cardiac output modifications after spinal anesthesia. Anesth Analg. 2005;101(5):1512–1515. doi:10.1213/
    1. Meyhoff CS, Hesselbjerg L, Koscielniak-Nielsen Z, Rasmussen LS. Biphasic cardiac output changes during onset of spinal anaesthesia in elderly patients. Eur J Anaesthesiol. 2007;24(9):770–775. doi:10.1017/S0265021507000427
    1. Ferre F, Marty P, Bruneteau L, et al. Prophylactic phenylephrine infusion for the prevention of hypotension after spinal anesthesia in the elderly: a randomized controlled clinical trial. J Clin Anesth. 2016;35:99–106. doi:10.1016/j.jclinane.2016.07.020
    1. Lairez O, Ferre F, Portet N, et al. Cardiovascular effects of low-dose spinal anaesthesia as a function of age: an observational study using echocardiography. Anaesth Crit Care Pain Med. 2015;34(5):271–276. doi:10.1016/j.accpm.2015.02.007
    1. Hofhuizen C, Lemson J, Snoeck M, Scheffer G-J. Spinal anesthesia-induced hypotension is caused by a decrease in stroke volume in elderly patients. Local Reg Anesth. 2019;12:19–26. doi:10.2147/LRA.S193925
    1. Ferre F, Delmas C, Carrié D, Cognet T, Lairez O, Minville V. Effects of spinal anaesthesia on left ventricular function: an observational study using two-dimensional strain echocardiography. Turk J Anaesthesiol Reanim. 2018;46(4):268–271. doi:10.5152/TJAR.2018.48753
    1. Charlson ME, MacKenzie CR, Gold JP, et al. The preoperative and intraoperative hemodynamic predictors of postoperative myocardial infarction or ischemia in patients undergoing noncardiac surgery. Ann Surg. 1989;210(5):637–648. doi:10.1097/00000658-198911000-00012
    1. Dalton JE, Kurz A, Turan A, Mascha EJ, Sessler DI, Saager L. Development and validation of a risk quantification index for 30-day postoperative mortality and morbidity in noncardiac surgical patients. Anesthesiology. 2011;114(6):1336–1344. doi:10.1097/ALN.0b013e318219d5f9
    1. Graves CL, Underwood PS, Klein RL, Kim YI. Intravenous fluid administration as therapy for hypotension secondary to spinal anesthesia. Anesth Analg. 1968;47(5):548–556. doi:10.1213/00000539-196809000-00018
    1. Gentili M, Senlis H, Houssel P, Monnier B, Bonnet F. Single-shot spinal anesthesia with small doses of bupivacaine. Reg Anesth. 1997;22(6):511–514.
    1. Casati A, Moizo E, Marchetti C, Vinciguerra F. A prospective, randomized, double-blind comparison of unilateral spinal anesthesia with hyperbaric bupivacaine, ropivacaine, or levobupivacaine for inguinal herniorrhaphy. Anesth Analg. 2004;99(5):. doi:10.1213/01.ANE.0000132972.61498.F1
    1. Casati A, Fanelli G. Restricting spinal block to the operative side: why not? Reg Anesth Pain Med. 2004;29(1):4–6. doi:10.1016/j.rapm.2003.09.014
    1. Atef H, El-Kasaby A, Omera M, Badr M. Optimal dose of hyperbaric bupivacaine 0.5% for unilateral spinal anesthesia during diagnostic knee arthroscopy. Local Reg Anesth. 2010;3:85–91. doi:10.2147/LRA.S11815
    1. Juelsgaard P, Sand NP, Felsby S, et al. Perioperative myocardial ischaemia in patients undergoing surgery for fractured hip randomized to incremental spinal, single-dose spinal or general anaesthesia. Eur J Anaesthesiol. 1998;15(6):656–663. doi:10.1097/00003643-199811000-00006
    1. Minville V, Asehnoune K, Delussy A, et al. Hypotension during surgery for femoral neck fracture in elderly patients: effect of anaesthetic techniques. A retrospective study. Minerva Anestesiol. 2008;74(12):691–696.
    1. Minville V, Fourcade O, Grousset D, et al. Spinal anesthesia using single injection small-dose bupivacaine versus continuous catheter injection techniques for surgical repair of hip fracture in elderly patients. Anesth Analg. 2006;102(5):1559–1563. doi:10.1213/
    1. Lux EA. Continuous spinal anesthesia for lower limb surgery: a retrospective analysis of 1212 cases. Local Reg Anesth. 2012;5:63–67. doi:10.2147/LRA.S35535
    1. Favarel-Garrigues JF, Sztark F, Petitjean ME, Thicoïpé M, Lassié P, Dabadie P. Hemodynamic effects of spinal anesthesia in the elderly: single dose versus titration through a catheter. Anesth Analg. 1996;82(2):312–316. doi:10.1097/00000539-199602000-00017
    1. Rabinowitz A, Bourdet B, Minville V, et al. The paramedian technique: a superior initial approach to continuous spinal anesthesia in the elderly. Anesth Analg. 2007;105(6):. doi:10.1213/01.ane.0000287655.95619.fa
    1. Biboulet P, Jourdan A, Van Haevre V, et al. Hemodynamic profile of target-controlled spinal anesthesia compared with 2 target-controlled general anesthesia techniques in elderly patients with cardiac comorbidities. Reg Anesth Pain Med. 2012;37(4):433–440. doi:10.1097/AAP.0b013e318252e901
    1. Bonica JJ, Kennedy WF, Akamatsu TJ, Gerbershagen HU. Circulatory effects of peridural block: 3. Effects of acute blood loss. Anesthesiology. 1972;36(3):219–227. doi:10.1097/00000542-197203000-00006
    1. Nishikawa T, Dohi S. [The effects of a small dose of atropine upon sinus bradycardia during spinal anesthesia]. Masui. 1990;39(7):833–838. Japanese.
    1. Holmes F. The supine hypotensive syndrome. Its importance to the anaesthetist. Anaesthesia. 1960;15:298–306. doi:10.1111/j.1365-2044.1960.tb13341.x
    1. Allen TK, Muir HA, George RB, Habib AS. A survey of the management of spinal-induced hypotension for scheduled cesarean delivery. Int J Obstet Anesth. 2009;18(4):356–361. doi:10.1016/j.ijoa.2009.03.014
    1. Mercier FJ. Cesarean delivery fluid management. Curr Opin Anaesthesiol. 2012;25(3):286–291. doi:10.1097/ACO.0b013e3283530dab
    1. Mercier FJ, Diemunsch P, Ducloy-Bouthors A-S, et al. 6% Hydroxyethyl starch (130/0.4) vs Ringer’s lactate preloading before spinal anaesthesia for Caesarean delivery: the randomized, double-blind, multicentre CAESAR trial. Br J Anaesth. 2014;113(3):459–467. doi:10.1093/bja/aeu103
    1. Lim HH, Ho KM, Choi WY, Teoh GS, Chiu KY. The use of intravenous atropine after a saline infusion in the prevention of spinal anesthesia-induced hypotension in elderly patients. Anesth Analg. 2000;91(5):1203–1206. doi:10.1097/00000539-200011000-00029
    1. Ni H-F, Liu H-Y, Zhang J, Peng K, Ji F-H. Crystalloid coload reduced the incidence of hypotension in spinal anesthesia for cesarean delivery, when compared to crystalloid preload: a meta-analysis. Biomed Res Int. 2017;2017:3462529. doi:10.1155/2017/3462529
    1. 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(4):. doi:10.1097/00000539-200204000-00028 French.
    1. Mercier FJ, Bonnet M-P, la Dorie De A, et al. [Spinal anaesthesia for caesarean section: fluid loading, vasopressors and hypotension]. Ann Fr Anesth Reanim. 2007;26(7–8):688–693. doi:10.1016/j.annfar.2007.05.003.
    1. Saravanan S, Kocarev M, Wilson RC, Watkins E, Columb MO, Lyons G. Equivalent dose of ephedrine and phenylephrine in the prevention of post-spinal hypotension in Caesarean section. Br J Anaesth. 2006;96(1):95–99. doi:10.1093/bja/aei265
    1. Thiele RH, Nemergut EC, Lynch C. The clinical implications of isolated alpha(1) adrenergic stimulation. Anesth Analg. 2011;113(2):297–304. doi:10.1213/ANE.0b013e3182120ca5
    1. Guyton AC. Determination of cardiac output by equating venous return curves with cardiac response curves. Physiol Rev. 1955;35(1):123–129. doi:10.1152/physrev.1955.35.1.123
    1. Magder S. Phenylephrine and tangible bias. Anesth Analg. 2011;113(2):211–213. doi:10.1213/ANE.0b013e318220406a
    1. Rebet O, Andremont O, Gérard J-L, Fellahi J-L, Hanouz J-L, Fischer M-O. Preload dependency determines the effects of phenylephrine on cardiac output in anaesthetised patients: a prospective observational study. Eur J Anaesthesiol. 2016;33(9):638–644. doi:10.1097/EJA.0000000000000470
    1. Mercier FJ, Augè M, Hoffmann C, Fischer C, Le Gouez A. Maternal hypotension during spinal anesthesia for caesarean delivery. Minerva Anestesiol. 2013;79(1):62–73.
    1. Ngan Kee WD, Khaw KS, Ng FF, Lee BB. Prophylactic phenylephrine infusion for preventing hypotension during spinal anesthesia for cesarean delivery. Anesth Analg. 2004;98(3). doi:10.1213/01.ANE.0000099782.78002.30
    1. Doherty A, Ohashi Y, Downey K, Carvalho JCA. Phenylephrine infusion versus bolus regimens during cesarean delivery under spinal anesthesia: a double-blind randomized clinical trial to assess hemodynamic changes. Anesth Analg. 2012;115(6):1343–1350. doi:10.1213/ANE.0b013e31826ac3db
    1. Siddik-Sayyid SM, Taha SK, Kanazi GE, Aouad MT. A randomized controlled trial of variable rate phenylephrine infusion with rescue phenylephrine boluses versus rescue boluses alone on physician interventions during spinal anesthesia for elective cesarean delivery. Anesth Analg. 2014;118(3):611–618. doi:10.1213/01.ane.0000437731.60260.ce
    1. Ngan Kee WD, Khaw KS, Lau TK, Ng FF, Chui K, Ng KL. Randomised double-blinded comparison of phenylephrine vs ephedrine for maintaining blood pressure during spinal anaesthesia for non-elective Caesarean section*. Anaesthesia. 2008;63(12):1319–1326. doi:10.1111/j.1365-2044.2008.05635.x
    1. Ngan Kee WD, Lee SWY, Ng FF, Tan PE, Khaw KS. Randomized double-blinded comparison of norepinephrine and phenylephrine for maintenance of blood pressure during spinal anesthesia for cesarean delivery. Anesthesiology. 2015;122(4):736–745. doi:10.1097/ALN.0000000000000601
    1. Wei C, Qian J, Zhang Y, Chang X, Hu H, Xiao F. Prospective, randomised, double-blind, dose-finding study of norepinephrine for preventing spinal-induced hypotension during caesarean delivery under combined spinal-epidural anaesthesia. Eur J Anaesthesiol. 2020. doi:10.1097/EJA.0000000000001152
    1. Fu F, Xiao F, Chen W, et al. A randomised double-blind dose-response study of weight-adjusted infusions of norepinephrine for preventing hypotension during combined spinal-epidural anaesthesia for Caesarean delivery. Br J Anaesth. 2020;124:e108–e114. doi:10.1016/j.bja.2019.12.019
    1. Carvalho B, Dyer RA. Norepinephrine for spinal hypotension during cesarean delivery: another paradigm shift? Anesthesiology. 2015;122(4):728–730. doi:10.1097/ALN.0000000000000602
    1. Sharwood-Smith G, Drummond GB. Hypotension in obstetric spinal anaesthesia: a lesson from pre-eclampsia. Br J Anaesth. 2009;102(3):291–294. doi:10.1093/bja/aep003
    1. Heesen M, Hilber N, Rijs K, et al. A systematic review of phenylephrine vs. noradrenaline for the management of hypotension associated with neuraxial anaesthesia in women undergoing caesarean section. Anaesthesia. 2020;75:800–808. doi:10.1111/anae.14976
    1. Singh PM, Singh NP, Reschke M, Ngan Kee WD, Palanisamy A, Monks DT. Vasopressor drugs for the prevention and treatment of hypotension during neuraxial anaesthesia for Caesarean delivery: a Bayesian network meta-analysis of fetal and maternal outcomes. Br J Anaesth. 2019. doi:10.1016/j.bja.2019.09.045
    1. Villalón CM, Centurión D. Cardiovascular responses produced by 5-hydroxytriptamine: a pharmacological update on the receptors/mechanisms involved and therapeutic implications. Naunyn Schmiedebergs Arch Pharmacol. 2007;376(1–2):45–63. doi:10.1007/s00210-007-0179-1
    1. Yamano M, Kamato T, Nishida A, et al. Serotonin (5-HT)3-receptor antagonism of 4,5,6,7-tetrahydrobenzimidazole derivatives against 5-HT-induced bradycardia in anesthetized rats. Jpn J Pharmacol. 1994;65(3):241–248. doi:10.1254/jjp.65.241
    1. Martinek RM. Witnessed asystole during spinal anesthesia treated with atropine and ondansetron: a case report. Can J Anaesth. 2004;51(3):226–230. doi:10.1007/BF03019100
    1. Ortiz-Gómez JR, Palacio-Abizanda FJ, Morillas-Ramirez F, Fornet-Ruiz I, Lorenzo-Jiménez A, Bermejo-Albares ML. The effect of intravenous ondansetron on maternal haemodynamics during elective caesarean delivery under spinal anaesthesia: a double-blind, randomised, placebo-controlled trial. Int J Obstet Anesth. 2014;23(2):138–143. doi:10.1016/j.ijoa.2014.01.005
    1. Owczuk R, Wenski W, Polak-Krzeminska A, et al. Ondansetron given intravenously attenuates arterial blood pressure drop due to spinal anesthesia: a double-blind, placebo-controlled study. Reg Anesth Pain Med. 2008;33(4):332–339. doi:10.1016/j.rapm.2008.01.010
    1. Owczuk R, Wenski W, Twardowski P, et al. Ondansetron attenuates the decrease in blood pressure due to spinal anesthesia in the elderly: a double blind, placebo-controlled study. Minerva Anestesiol. 2015;81(6):598–607.
    1. Sahoo T, SenDasgupta C, Goswami A, Hazra A. Reduction in spinal-induced hypotension with ondansetron in parturients undergoing caesarean section: a double-blind randomised, placebo-controlled study. Int J Obstet Anesth. 2012;21(1):24–28. doi:10.1016/j.ijoa.2011.08.002
    1. Gao L, Zheng G, Han J, Wang Y, Zheng J. Effects of prophylactic ondansetron on spinal anesthesia-induced hypotension: a meta-analysis. Int J Obstet Anesth. 2015;24(4):335–343. doi:10.1016/j.ijoa.2015.08.012
    1. Terkawi AS, Tiouririne M, Mehta SH, Hackworth JM, Tsang S, Durieux ME. Ondansetron does not attenuate hemodynamic changes in patients undergoing elective cesarean delivery using subarachnoid anesthesia: a double-blind, placebo-controlled, randomized trial. Reg Anesth Pain Med. 2015;40(4):344–348. doi:10.1097/AAP.0000000000000274
    1. Thiele RH, Nemergut EC, Lynch C. The physiologic implications of isolated alpha(1) adrenergic stimulation. Anesth Analg. 2011;113(2):284–296. doi:10.1213/ANE.0b013e3182124c0e
    1. Xiao F, Wei C, Chang X, et al. A prospective, randomized, double-blinded study of the effect of intravenous ondansetron on the effective dose in 50% of subjects of prophylactic phenylephrine infusions for preventing spinal anesthesia-induced hypotension during cesarean delivery. Anesth Analg. 2019. doi:10.1213/ANE.0000000000004534
    1. Koch T, Wenzel V. [Old drugs and new approval procedures: akrinor remains marketable and an application for reapproval of Arginin Vasopressin has been made]. Anaesthesist. 2006;55(6):708–710. doi:10.1007/s00101-006-1011-x. German.
    1. Marcus HE, Behrend A, Schier R, et al. [Anesthesiological management of Caesarean sections: nationwide survey in Germany]. Anaesthesist. 2011;60(10):916–928. doi:10.1007/s00101-011-1931-y. German.
    1. Sternitzke N, Schieffer H, Rettig G, Bette L. [Mechanism of action of oxyfedrine as a partial beta receptor agonist]. Z Kardiol. 1984;73(9):586–593. German.
    1. Sakai K, Shioya A, Hashimoto K. Effect of combining noradrenalinetheophylline and norephedrinetheophylline in various ratios on renal circulation. Arzneimittelforschung. 1972;22(4):698–701.
    1. Lee A, Ngan Kee WD, Gin T. A dose-response meta-analysis of prophylactic intravenous ephedrine for the prevention of hypotension during spinal anesthesia for elective cesarean delivery. Anesth Analg. 2004;98(2):483–90.
    1. Dyer RA, Reed AR. Spinal hypotension during elective cesarean delivery: closer to a solution. Anesth Analg. 2010;111(5):1093––5..
    1. Ngan Kee WD. Prevention of maternal hypotension after regional anaesthesia for caesarean section. Curr Opin Anaesthesiol 2010;23(3):304–309. doi:10.1097/ACO.0b013e328337ffc6

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