Brazilian Journal of Anesthesiology
https://bjan-sba.org/article/doi/10.1590/S0034-70942011000400003
Brazilian Journal of Anesthesiology
Scientific Article

Efeitos da infusão contínua profilática de fenilefrina sobre a estratégia de redução da massa de anestésico local em pacientes submetidas à raquianestesia para cesariana

Effects of prophylactic continuous infusion of phenylephrine on reducing the mass of local anesthetic in patients undergoing spinal anesthesia for cesarean section

Vinícius Pereira de Souza; José Luiz Gomes do Amaral; Maria Ângela Tardelli; Américo Massafuni Yamashita

http://dx.doi.org/10.1590/S0034-70942011000400003 Braz J Anesthesiol, vol.61, n4, p.416-424, 2011
PDF Português
PDF English
Downloads: 0
Views: 1023

Resumo

JUSTIFICATIVA E OBJETIVOS: A redução da massa de anestésico local minimiza os efeitos da hipotensão arterial pós-raquianestesia para cesariana e a incidência de eventos adversos maternos preservando o bem-estar fetal, mas pode resultar em anestesia insuficiente. A hipotensão associada às maiores massas de anestésico subaracnóideo pode ser controlada com infusão contínua profilática de fenilefrina. Foram avaliados os efeitos da infusão contínua profilática de fenilefrina para controle pressórico sobre os resultados maternos e conceptuais em cesarianas com diferentes doses de bupivacaína hiperbárica na raquianestesia. MÉTODO: Realizou-se ensaio clínico prospectivo, não aleatório, com 60 gestantes a termo admitidas para cesariana eletiva. Alocaram-se as pacientes em dois grupos, na dependência da dose de bupivacaína hiperbárica administrada na raquianestesia, 12 ou 8 mg, acrescida de 5 µg de sufentanil e 100 µg de morfina. Realizou-se hidratação com 10 mL.kg-1 de solução lactato de Ringer antes do bloqueio. Logo após, iniciou-se infusão contínua de 100 µg.min-1 de fenilefrina, mantendo a pressão arterial nos valores basais. Avaliaram-se: nível de bloqueio anestésico, o consumo de vasopressores, incidência de eventos adversos maternos e condições do recém-nascido. RESULTADOS: Os dados maternos foram semelhantes entre os grupos quanto a: nível de bloqueio anestésico, consumo de fenilefrina por tempo, incidências de hipotensão, hipertensão, bradicardia, náuseas, vômitos, dispneia, dor e tremores. Os dados conceptuais evidenciaram semelhança entre os grupos quanto à gasometria e à dosagem de lactato nos vasos umbilicais. Todos os recém-nascidos apresentaram pH > 7,2. CONCLUSÕES: Mantendo-se a pressão arterial com infusão profilática contínua de fenilefrina, a incidência de eventos adversos maternos e as condições de nascimento conceptuais não diferem quando a raquianestesia é realizada com 12 mg ou 8 mg de bupivacaína hiperbárica.

Palavras-chave

ANESTESIA, ANESTÉSICOS, ANESTÉSICOS, CIRURGIA, COMPLICAÇÕES, DROGAS, TÉCNICAS ANESTÉSICAS, TÉCNICAS ANESTÉSICAS

Abstract

BACKGROUND AND OBJECTIVE: Reducing the mass of local anesthetic minimizes the effects of hypotension after spinal anesthesia for cesarean section and the incidence of maternal adverse events preserving fetal well-being, but it may result in insufficient anesthesia. Hypotension associated with greater masses of subarachnoid anesthesia can be controlled by prophylactic continuous infusion of phenylephrine. The effects of prophylactic continuous infusion of phenylephrine on pressure control on maternal and fetus results in cesarean sections with different doses of hyperbaric bupivacaine in spinal anesthesia. METHODS: A non-randomized prospective study of 60 gravidas at term scheduled for elective cesarean sections was undertaken. Patients were allocated into two groups depending on hyperbaric bupivacaine dose administered for spinal anesthesia, 12 or 8 mg, along with 5 µg of sufentanil and 100 µg of morphine. Patients were hydrated with 10 mL.kg-1 of Ringer's lactate before the anesthesia. Shortly after, continuous infusion of 100 µg.min-1 of phenylephrine was initiated to maintain blood pressure at baseline levels. The following parameters were evaluated: level of anesthetic blockade, consumption of vasopressors, incidence of maternal events, and conditions of the newborn. RESULTS: Maternal data was similar in both groups regarding the level of anesthetic blockade, phenylephrine consumption along time, incidence of hypotension, hypertension, bradycardia, nausea, vomiting, dyspnea, pain, and tremors. Conceptual data showed similarities between both groups regarding blood gases and umbilical vein lactate levels. The pH of all newborns was > 7.2. CONCLUSIONS: On maintaining the blood pressure with prophylactic continuous infusion of phenylephrine the incidence of maternal adverse events and conditions of birth do not differ whether spinal anesthesia is performed with 12 mg or 8 mg of hyperbaric bupivacaine.

Keywords

Phenylephrine, Anesthesia, Cesarean Section, Hypotension, Bupivacaine

References

Jenkins JG, Khan MM. Anaesthesia for caesarean section: a survey in a UK region from 1992 to 2002. Anaesthesia. 2003;58:1114-1118.

Stamer UM, Wiese R, Stuber F. Change in anaesthetic practice for Caesarean section in Germany. Acta Anaesthesiol Scand. 2005;49:170-176.

Ng K, Parsons J, Cyna AM. Spinal versus epidural anaesthesia for caesarean section. Cochrane Database Syst Rev. 2004.

Hawkins JL, Gibbs CP, Orleans M. Obstetric anesthesia work force survey, 1981 versus 1992. Anesthesiology. 1997;87:135-143.

Bloom SL, Spong CY, Weiner SJ. Complications of anesthesia for cesarean delivery. Obstet Gynecol. 2005;106:281-287.

Khaw KS, Ngan Kee WD, Lee SW. Hypotension during spinal anaesthesia for caesarean section: implications, detection, prevention and treatment. Fetal Maternal Med Rev. 2006;17:157-183.

Kinsella SM, Lohmann G. Supine hypotensive syndrome. Obstet Gynecol. 1994;83(5):774-788.

Cyna AM, Andrew M, Emmett RS. Techniques for preventing hypotension during spinal anaesthesia for caesarean section. Cochrane Database Syst Rev. 2006;4.

Ngan Kee WD, Khaw KS, Lee BB. A dose-response study of prophylactic intravenous ephedrine for the prevention of hypotension during spinal anesthesia for cesarean delivery. Anesth Analg. 2000;90:1390-1395.

Rathmell JP, Lair TR, Nauman B. The role of intrathecal drugs in the treatment of acute pain. Anesth Analg. 2005;101(^s5):30-43.

Lew E, Yeo SW, Thomas E. Combined spinal-epidural anesthesia using epidural volume extension leads to faster motor recovery after elective cesarean delivery: a prospective, randomized, double-blind study. Anesth Analg. 2004;98:810-814.

Ben-David B, Miller G, Gavriel R. Low-dose bupivacaine-fentanyl spinal anesthesia for cesarean delivery. Reg Anesth Pain Med. 2000;25:235-239.

Fan SZ, Susetio L, Wang YP. Low dose of intrathecal hyperbaric bupivacaine combined with epidural lidocaine for cesarean section: a balance block technique. Anesth Analg. 1994;78:474-477.

Vercauteren MP, Coppejans HC, Hoffmann VL. Small-dose hyperbaric versus plain bupivacaine during spinal anesthesia for cesarean section. Anesth Analg. 1998;86:989-993.

Vercauteren MP, Coppejans HC, Hoffmann VH. Prevention of hypotension by a single 5-mg dose of ephedrine during small-dose spinal anesthesia in prehydrated cesarean delivery patients. Anesth Analg. 2000;90:324-327.

Choi DH, Ahn HJ, Kim JA. Combined low-dose spinal-epidural anesthesia versus single-shot spinal anesthesia for elective cesarean delivery. Int J Obstet Anesth. 2006;15:13-17.

Ngan Kee WD, Khaw KS, Ng FF. Compariso of phenylephrine infusion regimens for maintaining maternal blood pressure during spinal anaesthesia for Caesarean section. Br J Anaesth. 2004;92:469-474.

Ngan Kee WD, Khaw KS. Vasopressors in obstetrics: what should we be using?. Curr Opin Anaesthesiol. 2006;19:238-243.

Ngan Kee WD, Khaw KS, Ng FF. Prevention of hypotension during spinal anesthesia for cesarean delivery: an effective technique using combination phenylephrine infusion and crystalloid cohydration. Anesthesiology. 2005;103:744-750.

Dyer RA, Joubert IA. Low-dose spinal anaesthesia for caesarean section. Curr Opin Anaesthesiol. 2004;17:301-308.

Roofthooft E, Van de Velde M. Low-dose spinal anaesthesia for Caesarean section to prevent spinal-induced hypotension. Curr Opin Anaesthesiol. 2008;21:259-262.

Bryson GL, Macneil R, Jeyaraj LM. Small dose spinal bupivacaine for Cesarean delivery does not reduce hypotension but accelerates motor recovery. Can J Anaesth. 2007;54:531-537.

Balki M, Carvalho JC. Intraoperative nausea and vomiting during cesarean section under regional anesthesia. Int J Obstet Anesth. 2005;14:230-241.

Braga Ade F, Braga FS, Poterio GM. Sufentanil added to hyperbaric bupivacaine for subarachnoid block in Caesarean section. Eur J Anaesthesiol. 2003;20:631-635.

Gordon K, Lima RT, Yamashita AM. Anestesia subaracnoidea para cesariana com bupivacaína hiperbárica a 0,5% associada a sufentanil e fentanil. Rev Bras Anestesiol. 1997;47:211-218.

Palmer CM, Emerson S, Volgoropolous D. Dose-response relationship of intrathecal morphine for postcesarean analgesia. Anesthesiology. 1999;90:437-444.

Dahl JB, Jeppesen IS, Jorgensen H. Intraoperative and postoperative analgesic efficacy and adverse effects of intrathecal opioids in patients undergoing cesarean section with spinal anesthesia: a qualitative and quantitative systematic review of randomized controlled trials. Anesthesiology. 1999;91:1919-1927.

Sarvela J, Halonen P, Soikkeli A. A double-blinded, randomized comparison of intrathecal and epidural morphine for elective cesarean delivery. Anesth Analg. 2002;95:436-440.

Chen XZ, Chen H, Lou AF. Dose-response study of spinal hyperbaric ropivacaine for cesarean section. J Zhejiang Univ Sci B. 2006;7:992-997.

Yentis SM. Height of confusion: assessing regional blocks before caesarean section. Int J Obstet Anesth. 2006;15:2-6.

Hocking G, Wildsmith JA. Intrathecal drug spread. Br J Anaesth. 2004;93:568-578.

Ngan Kee WD. Prevention of maternal hypotension after regional anaesthesia for caesarean section. Curr Opin Anaesthesiol. 2010;23:304-309.

Ngan Kee WD, Khaw KS. Low-dose spinal anesthesia with low-dose phenylephrine infusions for cesarean delivery: better but not necessarily best. Anesthesiology. 2009;111:210-211.

Langesaeter E, Rosseland LA, Stubhaug A. Continuous invasive blood pressure and cardiac output monitoring during cesarean delivery: a randomized, double-blind comparison of low-dose versus high-dose spinal anesthesia with intravenous phenylephrine or placebo infusion. Anesthesiology. 2008;109:856-863.

Mercier FJ, Bonnet MP, De la Dorie A. Rachianesthésie pour césarienne: remplissage, vasopresseurs et hypotension. Ann Fr Anesth Reanim. 2007;26:688-693.

Macarthur A, Riley ET. Obstetric anesthesia controversies: vasopressor choice for postspinal hypotension during cesarean delivery. Int Anesthesiol Clin. 2007;45:115-132.

Lai FM, Jenkins JG. Ventricular bigeminy during phenylephrine infusion used to maintain normotension during caesarean section under spinal anaesthesia. Int J Obstet Anesth. 2007;16:288-290.

Ngan Kee WD, Khaw KS, Ng FF. Prophylactic phenylephrine infusion for preventing hypotension during spinal anesthesia for cesarean delivery. . 2004;98:815-821.

Reynolds F, Seed PT. Anaesthesia for Caesarean section and neonatal acid-base status: a meta-analysis. Anaesthesia. 2005;60:636-653.

Cooper DW, Carpenter M, Mowbray P. Fetal and maternal effects of phenylephrine and ephedrine during spinal anesthesia for cesarean delivery. Anesthesiology. 2002;97:1582-1590.

Ramin SM, Ramin KD, Cox K. Comparison of prophylactic angiotensin II versus ephedrine infusion for prevention of maternal hypotension during spinal anesthesia. Am J Obstet Gynecol. 1994;171:734-739.

Ngan Kee WD, Lee A, Khaw KS. A randomized double-blinded comparison of phenylephrine and ephedrine infusion combinations to maintain blood pressure during spinal anesthesia for cesarean delivery: the effects on fetal acid-base status and hemodynamic control. Anesth Analg. 2008;107:1295-1302.

Ngan Kee WD, Khaw KS, Tan PE. Placental transfer and fetal metabolic effects of phenylephrine and ephedrine during spinal anesthesia for cesarean delivery. Anesthesiology. 2009;111:506-512.

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;94:920-926.

Erkinaro T, Kavasmaa T, Pakkila M. Ephedrine and phenylephrine for the treatment of maternal hypotension in a chronic sheep model of increased placental vascular resistance. Br J Anaesth. 2006;96:231-237.

Magness RR, Rosenfeld CR. Systemic and uterine responses to alpha-adrenergic stimulation in pregnant and nonpregnant ewes. Am J Obstet Gynecol. 1986;155:897-904.

Reidy J, Douglas J. Vasopressors in obstetrics. Anesthesiol Clin. 2008;26:75-88.

ACOG Committee Opinion No. 348, November 2006: Umbilical cord blood gas and acid-base analysis. Obstet Gynecol. 2006;108:1319-1322.

Valenzuela P, Guijarro R. The effects of time on pH and gas values in the blood contained in the umbilical cord. Acta Obstet Gynecol Scand. 2006;85:1307-1309.

Carvalho B, Cohen SE, Lipman SS. Patient preferences for anesthesia outcomes associated with cesarean delivery. Anesth Analg. 2005;101:1182-1187.

5dd6bb500e8825da0a13f287 rba Articles
Links & Downloads
2352-2291 (Electronic) 0104-0014 (Printed)
Braz J Anesthesiol ©2024 All rights reserved.

Braz J Anesthesiol

Share this page
Page Sections