Original Article
A survey of the management of spinal-induced hypotension for scheduled cesarean delivery

https://doi.org/10.1016/j.ijoa.2009.03.014Get rights and content

Abstract

Background

Intravenous fluids and vasopressors are used for managing spinal-induced hypotension during cesarean delivery, but the choice of vasopressor and the type and timing of fluid administration remain controversial.

Methods

We conducted an electronic survey of all members of the Society for Obstetric Anesthesia and Perinatology between February and March 2007 to determine their preferences for preventing and treating spinal-induced hypotension with respect to fluid and vasopressor administration.

Results

The response rate was 292/746 (39%). Fifty percent worked in academic institutions and 56% had >50% of their clinical responsibility to obstetric anesthesia. For prophylaxis, 35% used fluid preloading, 30% fluid preloading with vasopressors, and 12% fluid co-loading with vasopressors. Of those using vasopressors for prophylaxis, 32% used ephedrine, 26% used phenylephrine, and 33% based their choice on heart rate. For treatment, 32% used ephedrine, 23% used phenylephrine, and 41% used either agent based on heart rate. Anesthesiologists in academic practice were less likely to use fluid preloading only (P = 0.028) and more likely to use fluid co-loading and vasopressors (P = 0.003). They were also more likely to administer phenylephrine for prophylaxis compared with those in private practice (P = 0.042).

Conclusion

Significant variations in practice exist in the prevention and treatment of spinal-induced hypotension. Fluid preloading and the prophylaxis and treatment of hypotension with ephedrine continue to be common practices.

Introduction

Spinal-induced hypotension complicates up to 80% of spinal anesthetics administered for scheduled cesarean delivery.1 It may be associated with maternal dizziness, nausea and vomiting. Spinal-induced hypotension also leads to placental hypoperfusion with subsequent fetal hypoxia, acidosis and neurological injury.2 Several strategies for prevention and treatment have been described but there appears to be no consensus on which of these is most effective.2 Recent evidence suggests that phenylephrine is the vasopressor of choice for the management of spinal-induced hypotension at cesarean delivery.3, 4, 5, 6 Furthermore, it has been suggested that the administration of phenylephrine as a continuous infusion in combination with fluid co-loading may be the most effective method of prevention.4 A survey of anesthetic practice in the UK identified fluid preloading and ephedrine as the most common agents used for the prevention of spinal-induced hypotension.7 Subsequently, other approaches have been observed to be effective in the treatment and prevention, and have prompted changes in clinical practice.8

We therefore conducted a survey of the members of the Society for Obstetric Anesthesia and Perinatology (SOAP) to determine their current practices for treating and preventing spinal-induced hypotension associated with spinal anesthesia for scheduled cesarean delivery with respect to vasopressor use and fluid administration.

Section snippets

Methods

We developed a web-based survey questionnaire using ASP.NET and C#.NET programming language and tested an initial pilot version. The survey questions were initially developed by the four authors, two attending anesthesiologists (AH, HM) and two obstetric anesthesiology fellows (TA, RG), after reviewing recent publications on vasopressor and fluid therapy use in obstetric anesthesia. The questionnaire was initially distributed in a non-random, non-anonymous fashion to six other anesthesiologists

Results

We initially received 310 responses (184 to the first e-mail and an additional 126 to the second), which represented an overall response rate of 31%. However the responses from nurse anesthetists and anesthesiologists in training were significantly under-represented (18 of a possible 241 responses) and therefore excluded from further analysis. The remaining 292 responses represented a response rate of 39% (292/746). Ninety-two percent of the respondents were from North America, 57% were

Discussion

This survey highlights the different techniques being used for prevention and treatment of hypotension associated with spinal anesthesia in patients scheduled for cesarean delivery, as well as the significant variation in practice between anesthesiologists who practice in academic institutions compared with their colleagues in private practice, and between anesthesiologists with a greater clinical responsibility to obstetric anesthesiology, compared to those with <50% of their practice devoted

Acknowledgements

The authors would like to thank William D. White, MPH, for statistical assistance and Kenneth Childs, for developing the electronic form of the survey and setting up the database.

References (17)

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This study was presented in part at the American Society of Anesthesiologists annual meeting, San Francisco, California, October 13–17, 2007.

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