REVIEW

CURRENT
OPINION Low-dose spinal anesthesia for cesarean section to
prevent spinal-induced hypotension
Marc Van de Velde a,b

Purpose of review
Low-dose combined spinal epidural (CSE) anesthesia is a common technique to anesthetize women for
cesarean section. It is used to reduce the incidence of hypotension while providing excellent anesthetic
conditions.
Recent findings
Low spinal doses produce effective anesthesia but of limited duration. Therefore, an epidural catheter (and
thus CSE) is required to guarantee pain-free surgery. Recent work confirmed that lower spinal doses can
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reduce significantly hypotension.

Summary
Low-dose CSE is a valuable strategy to anesthetize pregnant women for cesarean section but requires
attention and training.
Keywords
cesarean section, hypotension, intraoperative pain, low-dose combined spinal epidural, spinal anesthesia

INTRODUCTION been correlated with severity and duration of hypo-

Worldwide, the cesarean section rate continues to tension [5–7]. The primary effect of spinal anesthe-
rise making a cesarean section the most commonly sia in a healthy woman is a decrease in systemic
performed surgical intervention performed in 28% vascular resistance secondary to small artery vasodi-
&&

of deliveries [1]. Many C-sections are performed
under regional anesthesia, mostly spinal anesthesia.
Spinal-induced hypotension is a common problem
during cesarean delivery with an incidence that can
reach 100% when preventive measures are not used
[2–4]. Significant hypotension can cause serious
maternal and fetal morbidity [5–7]. Various strate-
gies to prevent hypotension are only partially suc-
cessful. The present review will focus on the
usefulness and efficacy of low-dose spinal anesthesia
to prevent maternal hypotension while maintaining
good anesthetic conditions.
Mechanisms, consequences and
management of hypotension
Hypotension is a common consequence of the sym-
pathetic block caused by spinal anesthesia for cesar-
ean section. Maternal symptoms such as nausea,
vomiting, failure to cooperate and dyspnea fre-
quently accompany severe hypotension, and
adverse effects on the fetus, including depressed
Apgar scores and umbilical acidosis (sometimes
resulting in permanent neurologic damage), have
lation, with a modest degree of venodilation [8 ].
There is a compensatory baroreceptor-mediated
increase in heart rate and stroke volume, which
increases cardiac output. When the block reaches
the cervical levels, the preganglionic sympathetic
cardiac accelerator fibers may be blocked resulting
in a failure of compensatory tachycardia.
To reduce the incidence and severity of hypo-
tension, various strategies have been developed [9].
Compensation for venodilation using leg wrapping,
left lateral tilt, intravenous fluid loading with crys-
talloids and colloids have all been tested but are only
marginally or partially successful. IV coloading of
crystalloids and colloids seems to be the most effec-
tive strategy that focuses on parallel administration
a
Department of Anesthesiology, UZLeuven and bDepartment of Cardio-
vascular Sciences, KU Leuven, Belgium
Correspondence to Marc Van de Velde, MD, PhD, EDRA, Professor,
Department of Cardiovascular Sciences, Chair, Department of Anaes-
thesiology, Herestraat 49, B - 3000 Leuven, Belgium. E-mail: marc.van-
develde@uzleuven.be
Curr Opin Anesthesiol 2019, 32:268–270
DOI:10.1097/ACO.0000000000000712

www.co-anesthesiology.com Volume 32  Number 3  June 2019

Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.


KEY POINTS
 Low-dose CSE can reduce hypotension.
 An epidural catheter is required to avoid
breakthrough pain.
 More good studies are required to confirm positive
results of some studies.
of fluids together with performing the spinal block.
However, compensation for arteriolar vasodilation
using vasopressors is also required. Currently, phen-
ylephrine is the vasopressor of choice to be infused
during the establishment of spinal anesthesia [8 ].
&&
Despite the positive effects of prophylactic infusions
of vasopressors and the coadministration of crystal-
loids or colloids, hypotension is not completely
eradicated. Therefore, it was proposed many years
ago to work on the cause of the problem and to
reduce the spinal dose of local anesthetic, thus
reducing severity and incidence of hypotension
[10].
Effects of low-dose spinal anesthesia on
maternal hemodynamics
Lowering the spinal dose for anesthesia for cesarean
section to less than 9 mg bupivacaine usually is
considered to be a so-called ‘low-dose’ spinal anes-
thetic [11]. It is clear from numerous articles that
reducing the spinal dose can reduce the incidence
and severity of hypotension and its detrimental
&&
consequences [12 ,13–19] (Table 1). Several well-
designed trials, summarized in a nice meta-analysis
by Arzola et al. [11], have clearly demonstrated that
the incidence of hypotension and severity is reduced
when a dose below 9 mg bupivacaine is compared
Table 1. Incidence of hypotension in high versus low-dose
bupivacaine-treated patients in some selected studies
comparing low and high-dose spinal anesthesia for
cesarean section
High dose Low dose
Fan et al. 1994 50% 5%
Ben-David et al. 2000 90% 30%
Choi et al. 2006 45% 22%
Van de Velde et al. 2006 64% 16%
Teoh et al. 2006 73% 14%
Kaya et al. 2007 100% 70%
0952-7907 Copyright ß 2019 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
Low-dose spinal anesthesia Van de Velde
with a dose of 9 or more mg of bupivacaine. Also,
less nausea and vomiting were noted.
&&
Klimek et al. [12 ] performed a meta-analysis
comparing combined spinal epidural (CSE) anesthe-
sia with spinal anesthesia and noted that CSE was
not associated with less vasopressor use and also not
associated with better sensory spread. However,
similar doses of bupivacaine were used in both the
CSE and spinal anesthesia groups, indicating that it
is not the technique but the actual intrathecal dose
of local anesthetic that is important. There was a
small difference in the incidence of hypotension
which was a secondary outcome variable in the
meta-analysis.
McNaught and Stocks [13] published a review on
the topic of low-dose spinal anesthesia and epidural
volume extension. They concluded that epidural
physiological saline can extend a spinal block. They
also found that the CSE technique itself results in a
higher sensory level of the block. This is explained
by a change in epidural pressure when the epidural
space is identified with the Tuohy needle, as nega-
tive epidural pressure is neutralized by the open
connection to atmospheric pressure resulting in a
reduction in dural sac volume, similar to injection of
fluid. These authors concluded that low-dose spinal
anesthesia is effective in reducing maternal hemo-
dynamic instability. However, this was recently not
confirmed by the meta-analysis performed by Kli-
&&
mek et al. [12 ].
Risks of lower spinal doses
Many anesthetists would worry that lowering the
spinal dose would reduce the quality of anesthesia
and increase the incidence of pain during cesarean
section. Indeed, Fan et al. [14] and Ben-David et al.
[15] reported more breakthrough pain with bupiva-
caine doses of 5 mg or less. However, Vercauteren
et al. and Choi et al. using between 6 and 7 mg of
bupivacaine combined with opioids reported excel-
lent anesthetic conditions [19–23]. However, these
authors used a CSE technique and could give epidu-
ral top-ups if required or they could anticipate pain
if surgery was unexpectedly prolonged.
Van de Velde et al. [24] reported that epidural
supplementation was required in approximately
20% of patients treated with 6.5 mg bupivacaine
versus only 8% in patients treated with 9.5 mg bupi-
vacaine. Epidural top-ups were usually required if
surgery was prolonged beyond 45–50’. In our rou-
tine practice, we have the policy that if the uterus is
not closed approximately 45 min after start of the
CSE, epidural supplementation will be given pro-
phylactically, virtually eliminating breakthrough
pain. Early pain sensation is only reported in
www.co-anesthesiology.com 269
Obstetric and gynecological anesthesia
patients in which careful block testing was
not performed.
Arzola et al. confirmed these findings [16–18].
When low spinal doses are used, additional epidural
top-ups are more frequently required but this does
not result in more conversions to general anesthesia.
So, low-dose spinal anesthesia does require a CSE
technique to prevent and manage prolonged sur-
gery and give additional (prophylactic) top-ups.
CONCLUSION
Low-dose spinal anesthesia for cesarean section pro-
vides much more hemodynamic stability and can
significantly reduce the incidence and severity of
hypotension and its side-effects. However, to avoid
breakthrough pain, an epidural catheter is required
as anesthetic conditions are only guaranteed for 40–
50’. Hence, a CSE technique needs to be used. Care-
ful block testing prior to surgery and prophylactic
administration of epidural top-ups in the event of
prolonged surgery allows the clinician to guarantee
perfect anesthetic conditions with minimal hypo-
tension, which is easily treated.
Acknowledgements
None.
Financial support and sponsorship
This work was supported by the Department of Anaes-
thesiology, UZLeuven and by KULeuven, Leuven,
Belgium. M.V.D.V. has received support for research
or lectures and consultancy from the following compa-
nies in the last 3 years: Heron, Jansen Pharmaceuticals,
Sinthetica, Smiths Medical, Viforpharma, Flatmedical,
Grunenthal, Nordic Pharma, MSD, Aquettant, Aspen,
MSD, Halyard.
Conflicts of interest
There are no conflicts of interest.
REFERENCES AND RECOMMENDED
READING
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been highlighted as:
& of special interest
&& of outstanding interest
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