Background: Neuraxial anesthesia-associated maternal hypotension in cesarean delivery is the most frequent and troublesome complication poses serious risks to mother and compromises neonatal well-being. The use of intravenous fluid loading as the preventive strategy in this context has been challenged because inconsistent results cause doubt on its real efficacy. We compared hypotension-preventing effect of crystalloid and colloid with different loading regimens given in a volume-escalation manner in neuraxial anesthetized cesarean parturients.
Methods: One thousand parturients with American Society of Anesthesiologists (ASA) physical status I/II undergoing selective cesarean delivery were screened and 939 were assigned into different fluid loading regimens with a multi-stage randomization. The volume of crystalloid or colloid in each loading regimen was determined by an up-and-down sequential method. Rate of hypotension was recorded as the primary outcome, and the median (EV50) and 90% effective volumes (EV90) of fluids were calculated in epidural and spinal blockades.
Results: A total of 469 subjects were analyzed in the crystalloid group and 470 in the colloid group. The numbers of patients developed clinically significant and severe hypotension are significantly decreased, and the effective volume of colloid required in preventing hypotension in both anesthetized populations is relatively lower than that of crystalloid on the intention-to-treat analyses. There is still an occurrence of hypotension at a rate of about 10%-20% even when the EV90 was reached.
Conclusions: Fluid loading is an effective maneuver in balancing maternal circulation when reaching the effective volume of different neuraxial anesthesia, but prophylactic or therapeutic vasoconstrictors should also be prepared and be given at an appropriate time because a significant proportion of women can still develop hypotension.
Clinical Trial Registration: This trial is registered with ClinicalTrials.gov identifier: NCT01013090.
Cesarean Section, Fluid Therapy, Neuraxial Anesthesia, Hemodynamic, Outcomes
2. Ng K, Parsons J, Cyna AM, Middleton P. Spinal versus epidural anesthesia for cesarean section. Cochrane Database Syst Rev 2004; 2: CD003765.
3. Nobili C, Sofi G, Bisicchia C. Prevention of hypotension in spinal anesthesia carried out for cesarean section. Minerva Anestesiol 2003; 69: 392-401.
4. Alexander AM, Lobrano S. Perimortem Cesarean Delivery. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2018.
5. Balki M, Carvalho JC. Intraoperative nausea and vomiting during cesarean section under regional anesthesia. Int J Obstet Anesth 2005; 14: 230-241.
6. Abdelazim I, Alanwar A, Svetlana S, Sakiyeva K, Farghali M, Mohamed M, Zhurabekova G, Karimova B. Complications associated with higher order compared to lower order cesarean sections. J Matern Fetal Neonatal Med 2018:1-161.
7. Mendonca C, Griffiths J, Ateleanu B, Collis RE. Hypotension following combined spinal-epidural anesthesia for Cesarean section. Left lateral position vs. tilted supine position. Anesthesia 2003; 58: 428-431.
8. Bjornestad E, Iversen OE, Raeder J. Wrapping of the legs versus phenylephrine for reducing hypotension in parturients having epidural anesthesia for cesarean section: a prospective, randomized and double-blind study. Eur J Anesthesiol 2009; 26: 842-846.
9. Bannard-Smith J, Yuill G, Washington SJ. Which vasopressor for cesarean section? Br J Hosp Med (Lond) 2009; 70: 725.
10. Mohta M, Agarwal D, Gupta LK, Sethi AK, Tyagi A. Potency of mephentermine for prevention of post-spinal hypotension. Anaesth Intensive Care 2009; 37: 568-570.
11. Murray AM, Morgan M, Whitwam JG. Crystalloid versus colloid for circulatory preload for epidural cesarean section. Anesthesia 1989; 44: 463-466.
12. Ueyama H, He YL, Tanigami H, Mashimo T, Yoshiya I. Effects of crystalloid and colloid preload on blood volume in the parturient undergoing spinal anesthesia for elective Cesarean section. Anesthesiology 1999; 91: 1571-1576.
13. Dahlgren G, Granath F, Pregner K, Rösblad PG, Wessel H, Irestedt L. Colloid vs. crystalloid preloading to prevent maternal hypotension during spinal anesthesia for elective cesarean section. Acta Anesthesiol Scand 2005; 49: 1200-1206.
14. 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.
15. Tamilselvan P, Fernando R, Bray J, Sodhi M, Columb M. 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.
16. 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.
17. 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: 150-155.
18. Siddik-Sayyid SM, Nasr VG, Taha SK, Zbeide RA, Shehade JM, Al Alami AA, Mokadem FH, Abdallah FW, Baraka AS, Aouad MT. A randomized trial comparing colloid preload to coload during spinal anesthesia for elective cesarean delivery. Anesth Analg 2009; 109: 1219-1224.
19. Williamson W, Burks D, Pipkin J, Burkard JF, Osborne LA, Pellegrini JE. Effect of timing of fluid bolus on reduction of spinal-induced hypotension in patients undergoing elective cesarean delivery. AANA J 2009; 77: 130-136.
20. Rout CC, Akoojee SS, Rocke DA, Gouws E. Rapid administration of crystalloid preload does not decrease the incidence of hypotension after spinal anesthesia for elective cesarean section. Brit J Anaesth 1992; 68: 394-397.
21. Dyer RA, Farina Z, Joubert IA, Du Toit P, Meyer M, Torr G, Wells K, James MF. Crystalloid preload versus rapid crystalloid administration after induction of spinal anesthesia (coload) for elective cesarean section. Anaesth Intensive Care 2004; 32: 351-357.
22. Park GE, Hauch MA, Curlin F, Datta S, Bader AM. The effects of varying volumes of crystalloid administration before cesarean delivery on maternal hemodynamics and colloid osmotic pressure. Anesth Analg 1996; 83: 299-303.
23. Muzlifah KB, Choy YC. Comparison between preloading with 10 ml/kg and 20 ml/kg of Ringer's lactate in preventing hypotension during spinal anesthesia for cesarean section. Med J Malaysia 2009; 64: 114-117.
24. National Collaborating Centre for Women’s and Children’s Health. Cesarean section: anesthesia for CS. Guideline for National Institute for Clinical Excellence (NICE). Royal College of Obstetricians and Gynaecologists (RCOG) press. 2004; pp56-pp61.
25. American Society of Anesthesiologists Task Force on Obstetric Anesthesia. Practice guidelines for obstetric anesthesia: an updated report by the American Society of Anesthesiologists Task Force on Obstetric Anesthesia. Anesthesiology 2007; 106: 843-863.
26. Cyna AM, Andrew M, Emmett RS, Middleton P, Simmons SW. Techniques for preventing hypotension during spinal anesthesia for cesarean section. Cochrane Database Syst Rev 2006; 4: CD002251.
27. 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.
28. George RB, McKeen D, Columb MO, Habib AS. 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.
29. 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.
30. Chan WS, Irwin MG, Tong WN, Lam YH. Prevention of hypotension during spinal anesthesia for cesarean section: ephedrine infusion versus fluid preload. Anesthesia 1997; 52: 908-913.
31. Watson CB. Colloid or crystalloid? Anesth Analg 1981; 60: 228-9.
32. Vercauteren MP, Hoffmann V, Coppejans HC, Van Steenberge AL, Adriaensen HA. Hydroxyethylstarch compared with modified gelatin as volume preload before spinal anesthesia for Cesarean section. Br J Anaesth 1996; 76: 731-733.
33. Butwick A, Carvalho B. The effect of colloid and crystalloid preloading on thromboelastography prior to Cesarean delivery. Can J Anaesth 2007; 54: 190-195.
34. Cardoso MM, Bliacheriene S, Freitas CR, César DS, Torres ML. Preload during spinal anesthesia for cesarean section: comparison between crystalloid and colloid solutions. Rev Bras Anestesiol 2004; 54: 781-787.
35. Siddik SM, Aouad MT, Kai GE, Sfeir MM, Baraka AS. Hydroxyethylstarch 10% is superior to Ringer's solution for preloading before spinal anesthesia for Cesarean section. Can J Anaesth 2000; 47: 616-621.
36. Tercanli S, Schneider M, Visca E, Hösli I, Troeger C, Peukert R, Holzgreve W. Influence of volume preloading on uteroplacental and fetal circulation during spinal anesthesia for cesarean section in uncomplicated singleton pregnancies. Fetal Diagn Ther 2002; 17: 142-146.
37. Eltzschig HK, Lieberman ES, Camann WR. Regional anesthesia and analgesia for labor and delivery. N Engl J Med 2003; 348: 319-332.
38. 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: 125-129.
39. Dahlgren G, Granath F, Wessel H, Irestedt L. Prediction of hypotension during spinal anesthesia for Cesarean section and its relation to the effect of crystalloid or colloid preload. Int J Obstet Anesth 2007; 16: 128-134.
40. Morgan PJ, Halpern SH, Tarshis J. The effects of an increase of central blood volume before spinal anesthesia for cesarean delivery: a qualitative systematic review. Anesth Analg 2001; 92: 997-1005.
41. Maayan-Metzger A, Schushan-Eisen I, Todris L, Etchin A, Kuint J. Maternal hypotension during elective cesarean section and short-term neonatal outcome. Am J Obstet Gynecol 2010; 202: 56.e1-e5.
42. Blackwell SC, Pacheco L, Chiossi G, Lee T, Nguyen T. Maternal hypotension during cesarean section: Maayan-Metzger et al. Am J Obstet Gynecol 2010; 202: 93-94.
43. Blackwell SC, Pacheco L, Chiossi G, Lee T, Nguyen T. Discussion: ‘Maternal hypotension during cesarean section’ by Maayan-Metzger et al. Am J Obstet Gynecol 2010; 202: e12-e14.
44. Barbier P, Jonville AP, Autret E, Coureau C. Fetal risks with dextrans during delivery. Drug Saf 1992; 7: 71-73.
45. Karinen J, Räsänen J, Paavilainen T, Alahuhta S, Jouppila R, Jouppila P. Uteroplacental and fetal haemodynamics and cardiac function of the fetus and newborn after crystalloid and colloid preloading for extradural cesarean section anesthesia. Br J Anaesth 1994; 73: 751-757.
46. Littleford J. Effects on the fetus and newborn of maternal analgesia and anesthesia: a review. Can J Anaesth 2004; 51: 586-609.
47. Chanimov M, Gershfeld S, Cohen ML, Sherman D, Bahar M. Fluid preload before spinal anesthesia in Cesarean section: the effect on neonatal acid-base status. Eur J Anesthesiol 2006; 23: 676-679.
48. Jackson R, Reid JA, Thorburn J. Volume preloading is not essential to prevent spinal-induced hypotension at cesarean section. Br J Anaesth 1995; 75: 262-265.
49. Banerjee A, Stocche RM, Angle P, Halpern SH. Preload or coload for spinal anesthesia for elective Cesarean delivery: a meta-analysis. Can J Anaesth 2010; 57: 24-31.
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.