Acta Anaesthesiol Scand 2002;
Acta Anaesthesiol Scand 2002
Printed in Denmark. All rights reserved
ACTA ANAESTHESIOLOGICA SCANDINAVICA
Effect of delayed supine positioning after induction ofspinal anaesthesia for caesarean section
, J. F. S
and H. S. H
Department of Anesthesiology and Intensive Care Medicine, Odense University Hospital, Denmark
The study tested the hypothesis that the inci-dence of hypotension during spinal anaesthesia for caesareansection is less in parturients who remain in the sitting positionfor 3min compared with parturients who are placed in themodiﬁed supine position immediately after induction of spinalanesthesia.
Spinal anaesthesia was induced with the woman inthe sitting position using 2.8ml hyperbaric bupivacaine 0.5% atthe L
interspace. Ninety-eight patients scheduled forelective caesarean section under spinal anaesthesia were ran-domised to assume the supine position on an operating tabletilted 10
to the left (modiﬁed supine position) immediately afterspinal injection (group 0, n
52) or to remain in the sitting posi-tion for 3min before they also assumed the modiﬁed supineposition (group 3, n
46). Isotonic saline 2–300ml was given in-travenously over 15min before spinal injection followed by 15ml/kg over 15–20min after induction of spinal anaesthesia. Ifthe systolic blood pressure decreased to less than 70% of base-line or to less than 100mmHg or if there was any complaint ofnausea, ephedrine was given in 5mg boluses intravenouslyevery 2min.
The blood pressure decreased signiﬁcantly in bothgroups following spinal injection (
0.001). Blood pressure
hypotension frequently complicates spinalanaesthesia for elective caesarean section at term.Preventive measures include left uterine displace-ment, special positioning techniques, vasopressor ad-ministration, ﬂuid preloading and techniques thatmechanically compress the venous compartments ofthe legs (1, 2).Hypotension occurs less frequently and is less se-vere with epidural than with spinal anaesthesia (3–5). The slower onset of epidural anaesthesia givingthe body longer to compensate for the occurrence ofsympathetic blockade might explain this, as the de-gree of sympathetic blockade is similar with spinaland epidural anaesthesia (6). It may therefore be poss-ible to reduce the incidence and severity of maternalhypotension by slowing the onset of spinal anaes-thesia.When spinal anaesthesia is performed with a wo-
variations over time differed signiﬁcantly between the twogroups (
0.05). However, the incidence of maternal hypoten-sion before delivery was similar in the two groups. The differ-ence was caused by the time to the blood pressure nadir beingsigniﬁcantly shorter in group 0 compared with group 3 (9.1
4.5min vs. 11.7
0.01). Similar numbers of patients re-ceived rescue with ephedrine before delivery: 35 (67%) in group0 vs. 26 (57%) in group 3 (NS). The mean total dose of ephedrine before delivery was 10.9mg in group 0 vs. 9.2mg in group 3(NS). There were no differences in neonatal outcome betweenthe two groups.
At elective caesarean section, a 3-min delay be-fore supine positioning does not inﬂuence the incidence of mat-ernal hypotension after induction of spinal anaesthesia in thesitting position with 2.8ml of bupivacaine 0.5% with 8% dex-trose.
Received 28 May 2000, accepted for publication 12 October 2001
anaesthesia; obstetrical; spinal; bupivacaine.
Acta Anaesthesiologica Scandinavica 46 (2002)
man sitting, a hyperbaric solution will pass caudallyunder the inﬂuence of gravity. Once the patient isplaced supine, even in the tilted or wedged supineposition, some degree of vena caval occlusion withconsequent epidural venous plexus engorgement willoccur acutely (7). Gravity and the sudden com-pression of the dural sac forces CSF and the local an-esthetic solution in the cranial direction extending the block to the upper thoracic dermatomes (8–12).Allowing the patient to remain in the sitting positionfor some time after injection of a hyperbaric solutionmay therefore delay the onset of anaesthesia in thethoracic dermatomes and reduce the incidence and se-verity of maternal hypotension. However, when thesitting position is used to site spinal anaesthesia forcaesarean section, it is recommended that the woman be laid supine very quickly (13, 14). We were thereforereluctant to study the effect of longer periods in the