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Shiv K. Sharma, MD, FRCA, Noor M. Gajraj, MB, BS, FRCA, and J. Elaine Sidawi,
Department of Anesthesiology and Pain Management, University of Texas Southwestern MD Medical School, Dallas, Texas
This study was designed to compare the efficacy of 6% hetastarch to that of crystalloid administration in reducing the incidence and severity of hypotension during spinal anesthesia. Forty ASA grade I patients scheduled for postpartum tubal ligations under spinal anesthesia were randomly allocated to receive either 500 mL of hetastarch solution or 1000 mL of lactated Ringer’s solution prior to spinal anesthesia. Spinal anesthesia was managed identically in both groups by anesthesiologists who were unaware of the type of fluid administered. The incidence of hypotension was 11 of 21(52%) in the lactated Ringer’s solution group and 3 of
19 (16%) in the hetastarch group. The difference in the incidence of hypotension was significant (P < 0.05). The requirement of 5-mg bolus doses of ephedrine to maintain systolic arterial blood pressure > 75% of baseline was significantly greater in the lactated Ringer’s group than in the hetastarch group (15 vs 4, P < 0.05). We conclude that an intravenous infusion of 500 mL of 6% hetastarch solution is more effective than 1000 mL lactated Ringer’s solution in attenuating spinal anesthesia induced hypotension in women undergoing postpartum tubal ligation. (Anesth Analg 1997;84:1114)
ypotension during spinal anesthesia is common and can cause significant morbidity and mortality (1,2). Prior to spinal anesthesia crystalloid administration is recommended to reduce the incidence of hypotension, although its value has been questioned (3-6). Crystalloid solutions have a short intravascular half-life and are poor plasma volume expanders, which may explain why hypotension associated with spinal anesthesia cannot be completely eliminated by crystalloid preloading. Large volumes of crystalloid fluid can also decrease oxygen-carrying capacity, and may increase the risk of pulmonary and peripheral edema during the puerperium (7). Colloid solutions which remain in the circulation for a longer period seem to be an effective alternative. The administration prior to spinal anesthesia of 5% albumin for cesarean section and gelatin for transurethral resection are effective in preventing hypotension (8,9). Hetastarch is a colloid solution widely used for plasma volume expansion in patients with trauma,
Presented at the annual meeting of the International Anesthesia Research Society, Honolulu, HI, March 1995. Accepted for publication September 19, 1996. Address correspondence and reprint requests to Shiv K. Sharma, MD, FRCA, Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical School, 5323 Harry Hines Blvd., Dallas, TX 75235-9068.
01996 by the International 0003.2999/97/$5.00 Anesthesia Research Society
shock, or sepsis. A recent study concluded that preloading with 6% hetastarch and lactated Ringer’s (LR) solution is more effective in reducing the incidence of spinal-induced hypotension during cesarean section than preloading with LR solution alone (10). However, the efficacy of preloading with colloid solutions in reducing the incidence of hypotension after spinal anesthesia in patients undergoing tubal ligation has not been evaluated. The aim of this study was to compare the efficacy of 500 mL of 6% hetastarch solution to that of 1000 mL of LR solution in preventing hypotension during spinal anesthesia in patients undergoing postpartum tubal ligations.
After institutional review board approval, informed, written consent was obtained from 40 ASA grade I patients undergoing tubal ligation within 15-24 h postdelivery. Patients with obesity, diabetes, pregnancy-induced hypertension, chronic hypertension, and heart disease were excluded from the study. Patients were unpremeditated and did not receive sedatives in the 4-h period prior to anesthesia. Patients were transported to the operating room where an l&gauge intravenous (IV) cannula was inserted into a peripheral vein, and sodium citrate 30 mL orally and
1 T-5 (Tl-7) 567 C 106 27. Blood loss during surgery was minimal in all patients. surgical time. Hypotension was defined as a decrease in systolic arterial pressure to less than 75% of the baseline.01) were used for comparison of hemodynamic changes between baseline and subsequent points. After the subarachnoid injection. The patients were randomly allocated to receive either 500 mL of 6% hetastarch or 1000 mL of LR solution.3 157. All statistical tests were performed using program SAS for Windows (SAS Institute Inc. . The sensory level was determined by loss of cold sensation and recorded at 10 min after intrathecal injection. Repeated-measures analysis of variance was used for comparison of serial blood pressure and heart rate measurements during spinal anesthesia. severity and duration of hypotension. With the patient in the sitting position. hyperbaric 5% lidocaine 75 mg with fentanyl 10 Fg was injected intrathecally through a 25gauge Whitacre spinal needle at the L2-3 or L3-4 interspace. The paired Student’s t-test and post-hoc Bonferroni multiple comparisons (using P < 0.1 61.84:111-14 metaclopramide 10 mg IV were administered.2 32. Demographic Data and Operative Details Hetastarch (n = 19) Lactated Ringer’s solution (n = 21) Age (yr) Weight (kg) Height (cm) Surgical time (min) Sensory level at 10 min” IV fluid during surgery (mL) Values are mean IV = intravenous. and Fisher’s exact test for comparison of nonparametric categorical data. In both groups of patients.1 + 6. Patients were continuously monitored with the usual monitors. 27. timing. Although.4 + 5. Statistical significance (P < 0. and who was thus unaware of the type of fluid administered. y1 (%o). P < 0.1-I 6.1 34..3 -e 5. after which an infusion of LR solution was used for fluid maintenance in all patients. All patients received an infusion of LR solution as maintenance fluid during the anesthetic. The episodes of hypotension were transient as they were reversed rapidly by ephedrine. L SD. heart rate changes at five different time points after spinal anesthesia as compared with the baseline values (mean 2 SD) (Lactated Ringer’s = lactated Ringer’s solution). all patients were placed in the supine position and arterial blood pressure and heart rate were recorded at l-min intervals for the first 15 min and subsequently at 3-min intervals. The LR solution group also required significantly more bolus doses of ephedrine (15 vs 4.2 60.05). The incidence of hypotension was significantly greater in the LR solution group than in the hetastarch group (11/21 [52%1 blood pressure and B.1 156. Baseline arterial blood pressure was taken as the average of three preoperative recordings.05) was determined using unpaired Student’s t-test for comparison of parametric data. NC). and the incidence of nausea and vomiting were recorded. P < 0. hypotension was treated promptly with a 5-mg IV bolus of ephedrine repeated every 2 min if hypotension persisted.3 2 4. intraoperative maintenance fluid and thoracic sensory levels were similar between groups (Table 1). Both groups had similar preinduction systolic blood pressures and heart rates (Figure 1). vs 3/19 [16%1. There was no difference in the time to hypotension between the hetastarch group and the LR solution group (5 t 2 min and 6 + 3 min. Spinal anesthesia was then managed by another anesthesiologist who was not present in the operating room during the time of prehydration. Systolic Results Demographic variables.05).6 T-6 (T2-8) 565 t 101 + -a140 - Hetastarch Lactated Ringer’s F E 2 2 h: 120 - t B 0 m p B I w 100 - 80 1 I Baselm I 1 muwte I 3 mmtes I 5 mutes 8 mnites / 10 mmutes 100 l3 90 3 Figure 1. Table 1. ’ Median (range). or as median (range) where appropriate. A.112 REGIONAL COLLOID ANESTHESIA AND VERSUS CRYSTALLOID PAIN MANAGEMENT DURING SPINAL SHARMA BLOCK ET AL ANESTH ANALG 1997. Values were reported as mean -t SD. The incidence.3t 8.2 + 6. respectively).4 + 5. The fluid was administered prior to spinal anesthesia over a 15-min period by an anesthesiologist. Cary.
Excessive crystalloid administration may rarely produce pulmonary and peripheral edema and have little effect on plasma volume. There is evidence to suggest that postpartum patients might be more susceptible to pulmonary edema after the rapid administration of crystalloid. Since 75% of any crystalloid diffuses into the interstitial space. a colloid solution is the more logical choice in preventing hypotension during spinal anesthesia. in both studies the incidence of hypotension during spinal anesthesia with hetastarch administration was only reduced. possibly because of an increase in lung water during pregnancy (7). However.9% saline is a synthetic colloid solution with a mean molecular weight of 450. there was no difference in the mean heart rates at each time between the two groups. it may be disadvantageous in certain groups. attention has been focused on the prophylactic administration of colloid solutions for the prevention of hypotension during spinal anesthesia. but not for the hetastarch group. and the colloid oncotic pressure (34 mm Hg) is similar to that of serum. The decrease in systolic blood pressures from baseline to 1 min postanesthesia was significant for the LR solution group (P < O. However. 5. No patient given albumin developed significant hypotension. decrease in systolic blood pressures from baseline was significant at 3.Ol>. not completely eliminated. the administration of hetastarch was found to be superior to LR solution in preventing spinal anesthesia-induced hypotension in patients undergoing cesarean section. (10) demonstrated that the incidence of hypotension during spinal anesthesia for cesarean section was 45% in patients who received hetastarch 500 mL with LR solution 1000 mL versus 85% in those who received only LR solution 1000 mL.84:111-14 REGIONAL ANESTHESIA COLLOID AND PAIN MANAGEMENT VERSUS CRYSTALLOID DURING SHARMA SPINAL ET AL. However. Advantages of hetastarch include a lower incidence of anaphylactic reactions as compared to other colloids such as dextran and a better efficacy in preventing venous thrombosis.6).ANESTH ANALG 1997. In each group. its efficacy in expanding plasma volume is only transient (11). disadvantages related to its use include increased expense. BLOCK 113 there was no significant difference in the mean systolic blood pressure at each time between the two groups. The pH of hetastarch is 5. the prophylactic administration of gelatin was found to be more effective than saline in reducing the incidence of hypotension in a population of patients undergoing transurethral resection of the prostate under spinal anesthesia (9). such as those with renal impairment or congestive cardiac failure if infused in large volumes.001) (Figure 1). The incidence of hypotension in our study was much lower in both the hetastarch and LR solution groups when compared with the other study comparing hetastarch .05) (Figure 1). There was no difference in the incidence of nausea between the LR solution group and hetastarch group (4/21 [19%1 vs 3/19 [16%1). the two groups were significantly different on average across all times (P < 0. No patient vomited. Also. whereas hypotension developed in approximately 30% of patients who received crystalloid. the number of ephedrine boluses required to treat hypotension was significantly lower in the hetastarch group. The IV administration of colloid has been shown to be associated with less lung water compared with LR solution (12).5 hours and it has the capacity to expand plasma volume to a volume that is greater than the volume infused (13). since it remains in the intravascular compartment for a longer period depending on its physical properties. and a decreased hemoglobin concentration as well as coagulopathy if infused in excess of 2 L. Recently. Although crystalloid administration is safe in most patients. More recently. LR solution 15 mL/kg with 5% glucose was compared with the same solution containing 5% albumin (8). and Karinen et al. the potential for anaphylactic reactions. In recent studies. change in heart rates from baseline to the five different time points was not significant (Figure 1). Discussion Hypotension during spinal anesthesia is the result of sympathetic blockade leading to relative hypovolemia and decreased venous return. and the administration of IV LR solution 15 mL/kg (approximately 1000 mL) before spinal anesthesia has shown to be ineffective in the prevention of hypotension (5). and 10 min after spinal anesthesia (P < 0. However. Riley et al. In patients undergoing postpartum tubal ligation the efficacy of hetastarch in reducing the incidence of hypotension has not been demonstrated.4. The prophylactic administration of crystalloid before regional anesthesia has been considered a safe and effective method of reducing the incidence of hypotension.000. Its intravascular half-time is 25.5. recent reports have suggested that the prophylactic administration of crystalloid is ineffective in eliminating spinal anesthesia-induced hypotension in patients undergoing cesarean section (3. the osmolarity is 310 mOsm/L. 8. In each group. During cesarean section under spinal anesthesia. We found that the intravascular administration of 500 mL of hetastarch was associated with a lower incidence of hypotension after spinal anesthesia when compared with 1000 mL of LR solution. Theoretically. Therefore we chose to compare the efficacy of 1000 mL of LR solution to that of 500 mL of hetastarch in preventing spinal anesthesia-induced hypotension in patients undergoing postpartum tubal ligation. (14) noted a low incidence of maternal hypotension with hetastarch 500 mL alone (38%) as compared with LR 1000 mL (62%) in patients undergoing cesarean section. Hetastarch 6% in 0.
Haljamae H. the routine administration of expensive hetastarch ($50 for 500 mL) compared with LR solution ($1 for 1000 mL) might not be justifiable. Gerner I’. Rasanen J. Therefore. McCrae AF. Pace NA. Einfluss von 6% HES 200/0. Taha SK. Frid I. Kroll W. Prevention and treatment of hypotension during central neural block. Volume preloading is not essential to prevent spinal-induced hypotension at caesarean section. Lung water during the puerperium. et al. Infusionstherpie 1992. We thank Dr.114 REGIONAL COLLOID ANESTHESIA AND VERSUS CRYSTALLOID PAIN MANAGEMENT DURING SPINAL SHARMA BLOCK ET AL. Caplan RA. Anesthesiology 76:906-16. 11. et al. 7. John Philip for helpful review of the manuscript Richard C. Carpenter RL.84:111-14 with LR solution in preventing spinal anesthesiainduced hypotension (10). Ghabach MB. et al. and risk 1992. Culliford AT. 10. Anesth Analg 1994. 6. Br J Anaesth 1995.75:531-5. Akoojee SS.68:394-7. Campbell DM. et al. Kartha RK. Br J Anaesth 1990. There was no adverse reaction to hetastarch in this study. Levin J. et al. The incidence of nausea was very low in both groups and unaffected by the type of fluid administered. Anesth Analg 1995. Baraka AS. Anesthesiology 1993. Br J Anaesth 1995. Rocke DA. However. Comparison of Ringer’s acetate with 3% dextran 70 for volume loading before extradural caesarean section. 4. Br J Anaesth 1992. Rapid administration of crystalloid preload does not decrease the incidence of hypotension after spinal anaesthesia for elective Caesarean section. and References 1. Wennberg E. 9. Rout CC. Brown DL. It is possible that larger volumes of hetastarch might have reduced the incidence of hypotension even further. Carey JS. Comparison of an ephedrine infusion with crystalloid administration for prevention of hypotension during spinal anesthesia. Thorburn J. Rubenstein AJ.70: 672-80. Rao TLK. Alahuhta S.66 auf plasmavolumen und blutegerinnung. Effect of crystalloid and colloid preloading on uteroplacental and maternal haemodynamic state during spinal anesthesia for caesarean section. Incidence factors for side effects of spinal anesthesia. Risser for assisting in statistical analysis. 14. Rocke DA. Cohen SE. Hypotension was transient and was quickly reversed with ephedrine in our study. et al. 13. Pregnant patients at term are more prone to develop hypotension due to the occurrence of aortocaval compression by the fetal head and higher level of sympathetic blockade owing to increased spread of local anesthetic in the cerebrospinal fluid. . Anaesthesia 1987.76:1023-6.65:654-60. Surg Gynecol Obstet 1970. Hemodynamic effectiveness of colloid and electrolyte solutions for replacement of simulated operative blood loss. However. The nausea was mostly mild and did not require antiemetics.79:262-9. with either type of fluid administration hypotension during spinal anesthesia for tubal ligation was mild and quickly corrected with prompt treatment. Jackson R. Anesth Analg 1980.59:655-8. Wildsmith JAW. et al. Flanagan 8.78: 301-5.75:262-5. A reevaluation of the role of crystalloid preload in the prevention of hypotension associated with spinal anesthesia for elective cesarean section. 8. Anesth Analg 1993.81:838-42. et al. MacDonald AF. we have found that 500 mL of hetastarch is more effective than 1000 mL of LR solution in preventing hypotension in patients undergoing postpartum tubal ligation under spinal anesthesia. 3. Riley ET. et al. Colombo T. 12. Prevention of hypotension after spinal anesthesia for cesarean section: six percent hetastarch versus lactated Ringer’s solution. Mathru M. Intravenous albumin administration for prevention of spinal hypotension during cesarean section. 2. This may be explained by the fact that the patient population in our study was nonpregnant.6-0.42:141-7. Rout CC. Br J Anaesth 1993. In summary. Gajraj NM. Victory RA.19:171-80. ANESTH ANALG 1997. Karinen J. 131:679-86. 5. et al. the incidence of hypotension was only reduced but not completely eliminated in this study. Reid JA. MacLennan FM. Intravascular administration of polymerized gelatin versus isotonic saline for prevention of spinal-induced hypotension. Scharsmidt BF.
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