Sneha Dokania, Renu Gurung, Ambuj Jain. Comparison of IV bolus phenylephrine, ephedrine and mephentermine for maintenance of hemodynamic status and its effect on fetal outcome during spinal anesthesia in cesarean section. IAIM, 2019; 6(9): 28-36. Original Research Article Comparison of IV bolus phenylephrine, ephedrine and mephentermine for maintenance of hemodynamic status and its effect on fetal outcome during spinal anesthesia in cesarean section Sneha Dokania1, Renu Gurung2*, Ambuj Jain3 1Consultant, Fortis Hospital, Shalimar Bagh, New Delhi, India 2Associate Professor, Department of Anesthesia, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal 3Consultant, Forensic Medicine, BPS Government Medical College, Khanpur, Haryana, India *Corresponding author email: [email protected] International Archives of Integrated Medicine, Vol. 6, Issue 9, September, 2019. Copy right © 2019, IAIM, All Rights Reserved. Available online at http://iaimjournal.com/ ISSN: 2394-0026 (P) ISSN: 2394-0034 (O) Received on: 15-08-2019 Accepted on: 24-08-2019 Source of support: Nil Conflict of interest: None declared. How to cite this article: Sneha Dokania, Renu Gurung, Ambuj Jain. Comparison of IV bolus phenylephrine, ephedrine and mephentermine for maintenance of hemodynamic status and its effect on fetal outcome during spinal anesthesia in cesarean section. IAIM, 2019; 6(9): 28-36. Abstract Background: Maternal hypotension during spinal anesthesia for cesarean section is a persistent problem which can result in adverse maternal and fetal outcome. Aim: Aim of this study was to compare the efficacy of IV bolus phenylephrine, ephedrine and mephentermine for the maintenance of hemodynamic status and its effect on fetal outcome during spinal anesthesia in cesarean section. Materials and Methods: We did prospective randomized double blind study in 60 patients. They were undergoing elective cesarean section under spinal anesthesia and who developed hypotension after subarachnoid block. The patients were randomly divided into three groups of 20 each. Phenylephrine Group (Group P) received Inj. Phenylephrine 100 mcg IV, Group E received Inj. Ephedrine 6 mg IV and Group M received Inj. Mephentermine 6 mg IV bolus. Whenever hypotension occurred, patients received the study drug. After administration of drugs and their consistence Page 28 Sneha Dokania, Renu Gurung, Ambuj Jain. Comparison of IV bolus phenylephrine, ephedrine and mephentermine for maintenance of hemodynamic status and its effect on fetal outcome during spinal anesthesia in cesarean section. IAIM, 2019; 6(9): 28-36. maintenance till end of 60 minutes. Patients were compared with respect to age, weight, duration of surgery, Systolic BP, Diastolic BP, Mean Arterial Pressure and Heart Rate. Results: The rise of systolic, diastolic and mean arterial pressure in Group P was significantly high for first 4min of bolus dose as compared to Group E & Group M (P<0.05). APGAR scores were ≥7 in all the three groups. Conclusion: It was concluded that IV bolus Mephentermine is as effective as Phenylephrine and Ephedrine in maintenance of arterial blood pressure during spinal anesthesia in cesarean section with good neonatal outcome. Key words Anesthesia, Cesarean section, Spinal Anesthesia, Hypotension, Arterial Blood Pressure, Phenylephrine, Ephedrine, Mephentermine. Introduction Teaching Hospital, Nepal for a period of 4 Spinal anesthesia is an effective and safe method months. Informed consent was taken from each of regional anesthesia. In spite of numerous patient. ASA Gr I and Gr II patients with advantages, it has few complications. The most baseline Systolic BP between 100-140 mm Hg common hemodynamic complication is and Diastolic BP between 70-89 mm Hg hypotension [1] with its incidence upto 50% to scheduled for elective caesarean section who 80% in obstetrics population [2]. Prolonged developed hypotension during intra-op periods maternal hypotension is detrimental to the fetus. were included in the study.Whereas patients with Many prophylactic and rescue measures have medical diseases like diabetes, RHD, severe been recommended for the prevention and anemia, and cerebrovascular diseases, patients treatment of hemodynamic instability, like with obstetrical complications like antepartum preloading or co-loading with crystalloids or hemorrhage, pregnancy induced hypertension, colloid, avoidance of aorto-caval compression cord complications (nuchal cord or cord and use of vasoactive agents. Vasopressors are prolapse), fetal malformations, polyhydramnios, the cornerstone in treatment of hypotension and multiple pregnancies and any during spinal anesthesia. We studied IV bolus contraindication to spinal anesthesia were Phenylephrine, Ephedrine and Mephentermine excluded from the study. for maintenance of hemodynamic status during spinal anesthesia in caesarean section. Patients were randomized into 3 groups of 20 each using sealed envelope technique. Hypothesis Group P – received Phenylephrine 100 During spinal anesthesia in Caesarean section. microgram (1 ml) as iv bolus Intravenous bolus Mephentermine is as effective Group E – received Ephedrine 6 mg (1 ml) as iv as Phenylephrine and Ephedrine in the bolus maintenance of hemodynamic status with no Group M – received Mephentermine 6 mg (1 adverse effects on fetal outcome. ml) as iv bolus Materials and methods Drug was prepared by Anesthetic Assistant or Anesthesia Resident who were not involved in After obtaining the ethical approval from the the study. Institution Review Board and the Department of Anesthesiology, Institute of Medicine, a All patients underwent pre-anesthetic evaluation, prospective randomized double blind study was kept nil per oral for 6 hours and received oral conducted on 60 patients at Tribhuvan University premedication with Ranitidine 150 mg and Page 29 Sneha Dokania, Renu Gurung, Ambuj Jain. Comparison of IV bolus phenylephrine, ephedrine and mephentermine for maintenance of hemodynamic status and its effect on fetal outcome during spinal anesthesia in cesarean section. IAIM, 2019; 6(9): 28-36. Metoclopramide 10 mg the night before and the drugs Inj Adrenaline 10 mcg was given and early morning of surgery. In preparation room repeated as necessary. IV Atropine 0.6mg was Ringer’s Lactate (10 ml/Kg) was infused given for heart rate less than 50 bpm. intravenouly and baseline vital parameters like Heart rate, Systolic BP and Diastolic BP were After delivery of baby, cord was clamped, 5 recorded. Patients were then shifted to OT. ECG, units oxytocin was given as iv bolus followed by BP, SpO2 were attached and monitored. 10 units of injection oxytocin in Ringer’s lactate as slow iv infusion. Pediatrician assessed Under all aseptic precautions and in sitting APGAR scores at 1 and 5 minutes after delivery position, SAB was performed with 25 G and were noted. Total amount of IV fluid given Quincke’s Spinal needle. 2.2 ml of 0.5% (maintenance and bolus), amount of vasopressor Bupivacaine (Heavy) was injected intrathecally and atropine required during intraoperative in 15-20 seconds at L3-4/L2-3 intervertebral space. period was recorded. Any untoward effects like The patient was then placed supine with left nausea / vomiting, shivering, restlessness during lateral tilt. Sensory level (block height) achieved intra-operative period was noted and treated. was assessed in every 5 minutes and sensory level achieved at 15 minutes were recorded for Statistical Analysis the study. The level of Motor blockade was All the data was analyzed using Statistical assessed every 5 minutes and till 15 minutes Package for the Social Sciences (SPSS) 17. according to Bromage Scale. Comparability of groups were analysed using ANOVA, Chi Square, Independent t and Paired t Surgery was started after achieving sensory test. P value ˂ 0.05 was considered significant. block level of T4/T6. Whenever Hypotension occurred, patient received the study drug as IV Results bolus which is considered as 0 min. For purpose Demographic Comparison: All the 3 groups; of this study, Hypotension was defined as fall in Group E, Group P and Group M were systolic pressure >20% from the baseline value comparable with respect to age of patients, or a value less than 90 mmHg [3]. Pulse rate, weight of patients and duration of surgery. There Systolic BP, Diastolic BP and Mean arterial was no statistical significant difference in age pressures were recorded at every 2 minutes till distribution of patients (p = 0.922), weight 20 minutes and thereafter every 5 minutes till 60 distribution of patients (p = 0.965) and duration minutes. If hypotension doesn’t get corrected by of surgery (p = 0.2) as per Table - 1. giving 3 bolus doses of study drug then rescue Table – 1: Patients Characteristics and Relevant Data. Group E – Group M – Group P - P Ephedrine Mephentermine Phenylephrine value Maternal age (Mean ± SD) yrs 27.25 ± 4.711 26.70 ± 4.846 26.75 ± 4.756 0.922 Maternal weight (Mean ± SD) kgs 62.55 ± 11.83 61.70 ± 8.99 62.18 ± 9.81 0.965 Duration of Surgery (Mean ± SD) mins 43.5 ± 11.3 34.15 ± 10.3 37.01 ± 9.7 0.2 Characteristics of Subarachnoid Block:- At 15 Trend of Mean SBP, Mean DBP and Mean minutes, all patients in 3 groups achieved Arterial Pressure: After administration of study sensory level at T4 and motor block of Grade 4 drugs, there was rise in mean Systolic blood Bromage scale. pressure and mean diastolic blood pressure at all the time intervals and were within normal range Comparison of Hemodynamic Parameters:- and were comparable among all three groups. In