Brazilian Journal of Anesthesiology
https://app.periodikos.com.br/journal/rba/article/doi/10.1590/S0034-70942012000300004
Brazilian Journal of Anesthesiology
Scientific Article

Volume mediano efetivo de cristaloides na prevenção de hipotensão arterial em pacientes submetidas à cesariana com raquianestesia

The median effective volume of crystalloid in preventing hypotension in patients undergoing cesarean delivery with spinal anesthesia

Xu ShiQin; Wu HaiBo; Zhao QingSong; Shen XiaoFeng; Guo XiRong; Wang FuZhou

http://dx.doi.org/10.1590/S0034-70942012000300004 Braz J Anesthesiol, vol.62, n3, p.318-324, 2012
PDF Português
PDF English
Downloads: 0
Views: 989

Resumo

JUSTIFICATIVA E OBJETIVOS: A hipotensão materna associada à raquianestesia no parto cesáreo é a complicação mais frequente e problemática, com sérios riscos para a mãe e comprometimento do bem-estar neonatal. Nesse contexto, o volume efetivo de cristaloides por via intravenosa como uma estratégia de prevensão ainda não foi estimado. MÉTODOS: Oitenta e cinco parturientes com estado físico ASA I/II submetidas à cesariana seletiva foram selecionadas e 67 mulheres elegíveis foram designadas para receber uma pré-carga de cristaloides com 2 mL de bupivacaína hiperbárica a 0,5% (10 mg) mais 50 µg de morfina. O volume de cristaloides foi determinado por um método sequencial up-and-down. Os cristaloides foram infundidos a uma taxa de 100 a 150 mL.min-1 antes da anestesia espinal. O volume inicial de cristaloides foi de 5 mL.kg-1. Os dados do efeito do volume foram ajustados para o modelo sigmoidal de máxima eficácia e a mediana do volume efetivo (VE50) e seu intervalo de confiança (IC) de 95% foram calculados usando a estimativa de máxima verossimilhança e a regressão logística de Firth corrigida. RESULTADOS: Sessenta e sete parturientes completaram o estudo e foram analisadas. Vinte e oito pacientes (41,8%) desenvolveram hipotensão, com queda da pressão arterial sistólica (PAS) superior a 20% do valor basal. O VE50 de cristaloides foi de 12,6 mL.kg-1 (IC 95%, 11,6 a 14,8 mL.kg-1). Com a correção de Firth, a probabilidade conjunta do volume efetivo de cristaloides a 13 mL.kg-1 foi de 50,2% (IC 95%, 30,0% a 83,1%). CONCLUSÕES: O VE50 estimado da pré-carga de cristaloides necessário para prevenir a hipotensão induzida por anestesia espinhal em parto cesáreo é de 13 mL.kg-1 (valor aproximado). Porém, a profilaxia ou terapia com vasoconstritores também deve ser preparada e administrada no momento oportuno.

Palavras-chave

anestesia, regional, raquianestesia, cirurgia, cesárea, complicações, hipotensão, hidratação

Abstract

BACKGROUND AND OBJECTIVES: Spinal anesthesia-associated maternal hypotension in Cesarean delivery is the most frequent and troublesome complication, posing serious risks to mothers and compromising neonatal well-being. The effective volume of intravenous crystalloid as the preventive strategy in this context has not been estimated. METHODS: Eighty-five parturients with ASA physical status I/II undergoing elective Cesarean delivery were screened and 67 eligible women were assigned to receive pre-spinal crystalloid loading. Hyperbaric 0.5% bupivacaine 2 mL (10 mg) plus morphine 50 µg was given to all patients. The volume of crystalloid was determined by an up-and-down sequential method. The crystalloid was infused at a rate of 100-150 mL.min-1 prior to the spinal anesthetic injection. The initial volume of crystalloid was 5 mL.kg-1. Volume-effect data were fitted to a sigmoidal maximum efficacy model and the median effective volume (EV50) and corresponding 95% confidence interval (95% CI) were estimated using maximum likelihood estimation and logistic regression with Firth's correction. RESULTS: A total of 67 subjects completed the study and were analyzed. Twenty-eight (41.8%) patients developed hypotension with their systolic blood pressure (SBP) decreasing > 20% of baseline. The EV50 of crystalloid were 12.6 mL.kg-1 (95% CI, 11.6 to 14.8 mL.kg-1). With Firth's correction, the pooled probability of an effective preventive volume of crystalloid at 13 mL.kg-1 was 50.2% (95% CI, 30% to 83.1%). CONCLUSIONS: The estimated EV50 of the preloaded crystalloid required to prevent spinal anesthesia-induced hypotension in a Cesarean section is, approximately, 13 mL.kg-1. However, prophylactic or therapeutic vasoconstrictors should also be prepared and administered at an appropriate time.

Keywords

anesthesia, spinal, cesarean section, isotonic solutions, hypotension

Referências

Nobili C, Sofi G, Bisicchia C. Prevention of hypotension in spinal anesthesia carried out for cesarean section. Minerva Anestesiol. 2003;69:392-401.

Häger RM, Daltveit AK, Hofoss D. Complications of cesarean deliveries: rates and risk factors. Am J Obstet Gynecol. 2004;190:428-434.

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

Chongsuvivatwong V, Bachtiar H, Chowdhury ME. Maternal and fetal mortality and complications associated with cesarean section deliveries in teaching hospitals in Asia. J Obstet Gynaecol Res. 2010;36:45-51.

Ueyama H, He YL, Tanigami H. Effects of crystalloid and colloid preload on blood volume in the parturient undergoing spinal anesthesia for elective Cesarean section. Anesthesiology. 1999;91:1571- 1576.

Dahlgren G, Granath F, Pregner K. Colloid vs. crystalloid preloading to prevent maternal hypotension during spinal anesthesia for elective cesarean section. Acta Anesthesiol Scan. 2005;49:1200- 1206.

Ko JS, Kim CS, Cho HS. 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.

Tamilselvan P, Fernando R, Bray J. The effects of crystalloid and colloid preload on cardiac output in the parturient undergoing planned cesarean delivery under spinal anesthesia: a randomized trial. Anesth Analg. 2009;109:1916-1921.

Teoh WH, Sia AT. Colloid preload versus coload for spinal anesthesia for cesarean delivery: the effects on maternal cardiac output. Anesth Analg. 2009;108:1592-1598.

Carvalho B, Mercier FJ, Riley ET. 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;18:150-155.

Siddik-Sayyid SM, Nasr VG, Taha SK. A randomized trial comparing colloid preload to coload during spinal anesthesia for elective cesarean delivery. Anesth Analg. 2009;109:1219-1224.

Williamson W, Burks D, Pipkin J. Effect of timing of fluid bolus on reduction of spinal-induced hypotension in patients undergoing elective cesarean delivery. AANA J. 2009;77:130-136.

Rout CC, Akoojee SS, Rocke DA. Rapid administration of crystalloid preload does not decrease the incidence of hypotension after spinal anesthesia for elective cesarean section. Brit J Anesth. 1992;68:394-397.

Dyer RA, Farina Z, Joubert IA. Crystalloid preload versus rapid crystalloid administration after induction of spinal anesthesia (coload) for elective cesarean section. Anesth Intensive Care. 2004;32:351- 357.

Park GE, Hauch MA, Curlin F. The effects of varying volumes of crystalloid administration before cesarean delivery on maternal hemodynamics and colloid osmotic pressure. Anesth Analg. 1996;83:299- 303.

Muzlifah KB, Choy YC. Comparison between preloading with 10 ml/ kg and 20 ml/kg of Ringers lactate in preventing hypotension during spinal anesthesia for cesarean section. Med J Malaysia. 2009;64:114- 117.

Cesarean section: anesthesia for CS. Guideline for National Institute for Clinical Excellence (NICE). 2004:56-61.

Practice guidelines for obstetric anesthesia: an updated report by the American Society of Anesthesiologists Task Force on Obstetric Anesthesia. Anesthesiology. 2007;106:843-863.

Cyna AM, Andrew M, Emmett RS. Techniques for preventing hypotension during spinal anesthesia for cesarean section. Cochrane Database Syst Rev. 2006;4:CD002251.

Banerjee A, Stocche RM, Angle P. Preload or coload for spinal anesthesia for elective Cesarean delivery: a meta-analysis. Can J Anesth. 2010;57:24-31.

Durham SD, Flournoy N, Rosenberger WF. A random walk rule for phase I clinical trials. Biometrics. 1997;53:745-760.

Pace NL, Stylianou MP. Advances in and limitations of up-and-down methodology: a précis of clinical use, study design, and dose estimation in anesthesia research. Anesthesiology. 2007;107:144-152.

George RB, McKeen D, Columb MO. Up-down determination of the 90% effective dose of phenylephrine for the treatment of spinal anesthesia-induced hypotension in parturients undergoing cesarean delivery. Anesth Analg. 2010;110:154-158.

Lewis M, Thomas P, Wilkes RG. Hypotension during epidural analgesia for Cesarean section: Arterial and central venous pressure changes after acute intravenous loading with two litres of Hartmann's solution. Anesthesia. 1983;38:250-253.

Chan WS, Irwin MG, Tong WN. Prevention of hypotension during spinal anesthesia for cesarean section: ephedrine infusion versus fluid preload. Anesthesia. 1997;52:908-913.

Watson CB. Colloid or crystalloid?. Anesth Analg. 1981;60:228-.

Siddik SM, Aouad MT, Kai GE. Hydroxyethylstarch 10% is superior to Ringers solution for preloading before spinal anesthesia for Cesarean section. Can J Anesth. 2000:616-621.

Maayan-Metzger A, Schushan-Eisen I, Todris L. Maternal hypotension during elective cesarean section and short-term neonatal outcome. Am J Obstet Gynecol. 2010;202:56.e1-e5.

Karinen J, Räsänen J, Paavilainen T. Uteroplacental and fetal haemodynamics and cardiac function of the fetus and newborn after crystalloid and colloid preloading for extradural cesarean section anesthesia. Br J Anesth. 1994;73:751-757.

Littleford J. Effects on the fetus and newborn of maternal analgesia and anesthesia: a review. Can J Anesth. 2004;51:586-609.

5dd2e1590e8825321dc63493 rba Articles
Links & Downloads
2352-2291 (Eletrônico) 0104-0014 (Impresso)
Braz J Anesthesiol ©2024 Todos os direitos reservados.

Braz J Anesthesiol

Share this page
Page Sections