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 Table of Contents  
ORIGINAL ARTICLE
Year : 2012  |  Volume : 2  |  Issue : 1  |  Page : 10-15

Crystalloid preload versus crystalloid coload for parturients undergoing cesarean section under spinal anesthesia


Department of Anaesthesiology and Critical Care, Christian Medical College, Ludhiana, Punjab, India

Date of Web Publication4-Aug-2012

Correspondence Address:
Aparna Williams
Department of Anesthesiology and Critical Care, Christian Medical College and Hospital, Ludhiana - 141008, Punjab
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2249-4472.99309

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  Abstract 

Context: There is a paucity of studies comparing crystalloid preload and coload in parturients undergoing cesarean section under spinal anesthesia from India.
Aims: To compare crystalloid preload and coload for the prevention of maternal hypotension in parturients undergoing cesarean section under spinal anesthesia. Secondary outcomes studied included requirement of ephedrine for treatment of hypotension, maternal nausea and vomiting, neonatal APGAR scores and acid base status.
Settings and Design: Tertiary level, teaching hospital. Prospective, randomized study.
Materials and Methods: Hundred parturients, aged 20 to 40 years, American Society of Anesthesiologist (ASA) physical status 1 or 2, with singleton, uncomplicated pregnancies scheduled for cesarean section under spinal anesthesia were randomized into two groups. Subjects in group P received 15 ml/kg of lactated Ringer's (RL) solution as preload over 20 min before the placement of spinal block, while those in group C received 15 ml/kg of RL over 20 min, starting as soon as CSF was tapped.
Statistical Analysis Used: Student's t-test, Chi-square test, Fisher's test.
Results: The number of parturients developing hypotension in group P and C was 30 and 23 respectively and was comparable statistically. More number of patients developed nausea (19 versus 10, P = 0.0473) and vomiting (14 versus 6, P = 0.0455) in group P as compared to group C and these values were statistically significant. The mean number of doses of ephedrine required (2.6 in group P and 1.8 in group C) and the total dose of ephedrine used (14.2 mg and 12.6 mg in groups P and C respectively) in the groups were comparable statistically.
Conclusions: Both preloading and coloading with 15 ml/ kg of RL solution are ineffective in the prevention of spinal-induced maternal hypotension. We recommend frequent monitoring of maternal blood pressure (at 1-min intervals) and prompt treatment of maternal hypotension with vasopressors for better neonatal outcomes.

Keywords: Anesthesia, coload, hypotension, preload, spinal


How to cite this article:
Jacob JJ, Williams A, Verghese M, Afzal L. Crystalloid preload versus crystalloid coload for parturients undergoing cesarean section under spinal anesthesia. J Obstet Anaesth Crit Care 2012;2:10-5

How to cite this URL:
Jacob JJ, Williams A, Verghese M, Afzal L. Crystalloid preload versus crystalloid coload for parturients undergoing cesarean section under spinal anesthesia. J Obstet Anaesth Crit Care [serial online] 2012 [cited 2021 May 10];2:10-5. Available from: https://www.joacc.com/text.asp?2012/2/1/10/99309


  Introduction Top


Spinal anesthesia is a rapid, simple and reliable technique of anesthesia for parturients undergoing cesarean section. Despite the advantages of spinal anesthesia, the potential for hypotension with this technique poses the greatest threat to the mother and fetus, leading to maternal nausea and vomiting and fetal hypoxia. Without preventive measures, the incidence of post spinal hypotension in parturients can be as high as 82%. [1] Even with the use of various preventive measures, the incidence of hypotension following spinal anesthesia has been reported as 53% [2] to 80%. [3] Sustained maternal hypotension is associated with fetal hypoxia and acidosis as a result of placental hypo perfusion. [4],[5] Thus, prevention of hypotension may be beneficial for both the mother and the fetus.

Volume preloading with crystalloid solutions for the prevention of spinal-induced hypotension received rapid acceptance since it was first introduced by Griess et al. [6] Earlier studies demonstrated immense success of crystalloid preloading in prevention of maternal hypotension after spinal anesthesia. [7],[8] However, the results of these studies have been questioned by other investigators, who showed that even large volumes of crystalloid have minimum effect on the incidence of hypotension. [9],[10] In a recent systematic review including ten randomized controlled trials of crystalloid preload for the prevention of hypotension, Morgan et al. have reported a median incidence of hypotension as 46%. [11] The practice of preloading in obstetric patients undergoing cesarean section has now been abandoned by several anesthesiologists. [12],[13]

In the recent past, coloading has generated interest for the prevention of spinal-induced hypotension. Mercier et al. suggested that applying fluid loading at the time of administering the intrathecal local anesthetic (coload) may be a more rational approach for the prevention of post spinal hypotension. Coload might be physiologically more appropriate because the maximal effect can be achieved during the time of the block. [14] This might increase intravascular volume expansion during vasodilatation from the sympathetic blockade and limit fluid redistribution and excretion. [15]

The present study was designed to test the hypothesis that rapid administration of crystalloids at the time of induction of spinal anesthesia (coload) is associated with less hypotension than the rapid administration of an equivalent volume of crystalloid preload. The secondary outcomes studied were ephedrine requirement for maintaining the maternal blood pressure, maternal nausea and vomiting, fetal APGAR scores, fetal umbilical arterial and umbilical venous blood gas analysis.


  Materials and Methods Top


This prospective, randomized study was conducted after institutional ethics committee approval and written informed consent of patients. The study included 100 parturients, aged 20 to 40 years, American Society of Anesthesiologist (ASA) physical status 1 or 2, with singleton, uncomplicated pregnancies scheduled for cesarean section under spinal anesthesia. Exclusion criteria included patients with chronic hypertension or PIH, eclampsia, known cardiovascular disease, hematocrit of less than 30%, any contraindications to spinal anesthesia, height < 150 cm. The patients were randomized using computer generated random numbers into group P (preload group) and group C (co-load group) including 50 patients each. The patients were kept nil per oral as per American Society of Anesthesiologists (ASA) guidelines. [16]

All patients received ranitidine 150 mg orally on the night before and in the morning of the day of surgery. The patients were given metoclopramide 10 mg intravenously 30 min prior to surgery. For the study, all patients had two intra venous cannulae, one for administration of fluid and the other was used to give the drugs. On arrival to the operation room, non-invasive monitoring was instituted, including ECG, NIBP, SPO 2 and baseline heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP) were recorded using the Dash 3000 (GE Marquette TM) monitor.

All patients received 2.4 ml of 0.5% hyperbaric bupivacaine over 15 s intrathecally, in the left lateral position in the L3-4 or L4-5 inter vertebral space with 25 gauge Quincke's spinal needle. In group P, the patients received 15 ml/kg of RL solution over 20 min (min) before the spinal block. The patients in group C were given 15 ml/kg of RL solution over 20 min as soon as CSF was tapped. After the spinal injection, the patients were put in the supine position with a 15 degrees wedge under the right hip. The sensory level was assessed using pin prick to 25 G needle every 5 min till the level stabilized for at least three consecutive readings. After achieving a block height of T 5, the surgery was allowed to commence.

The following parameters were recorded every minute after the spinal injection till the first 10 min, every 5 min till the next 20 min and every 10 min thereafter till the end of the surgery: HR, SBP, DBP and SpO 2 . Maternal hypotension was defined as a decrease in SBP to less than 80% of the baseline SBP value or SBP < 90 mm Hg, whichever was lower. Hypotension was treated with crystalloid boluses and 6 mg ephedrine given intravenously every 3 min, until the SBP recovered to the baseline value. The choice of crystalloid used to treat hypotensive episodes and the volume thereof was left to the judgement of the attending anesthesiologist. Bradycardia was defined as a HR less than 50 beats per minute and was treated with intravenous atropine 0.6 mg. The number of doses and the total dose of ephedrine required to treat hypotension was recorded.

The patients were observed for and were actively questioned regarding presence of nausea. All episodes of nausea and vomiting were recorded. Other side effects like pruritis, headache, hypertension and shivering were also noted. The induction to delivery time (I-D interval) and the time from uterine incision to delivery of the baby (U-D interval) were recorded. After the delivery of the baby, the mother was given 15 units of oxytocin as an infusion. The attending neonatologist who was unaware of the study group, to which the patient belonged, determined APGAR scores of the baby at 1 min and 5 min after the delivery. Blood gas estimation was performed with the ABL 555 (Radiometer, Copenhagen, Denmark) analyzer on samples collected from the doubly clamped segments of the umbilical artery and umbilical vein. The total intravenous fluid administered and blood loss during the procedure was noted. In the event of excessive intraoperative blood loss (blood loss > 800 ml), the patient was withdrawn from the study and appropriate treatment rendered.

Data was tabulated using Microsoft excel (2007) and analyzed using the Epi Info (version 8) software. Student's t-test was used for quantitative data and the Chi square or Fisher's exact test for qualitative data. A P-value of < 0.05 was considered to be statistically significant.


  Results Top


The patient characteristics like age, weight, height, ASA status, I-D interval, U-D interval, duration of surgery, average blood loss, and average total fluid administered were comparable among the two groups. The median sensory level achieved in groups P and C was T4 and T3 respectively and these were comparable statistically [Table 1].
Table 1: Patient characteristics

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The baseline mean values of maternal HR, SBP, and DBP for the two groups were comparable statistically [Table 1]. [Figure 1]depicts the mean SBP tracings of the two groups with time. The minimum mean SBP values recorded in the two groups were 90.6 ± 12.8 mm Hg in group C and 86.8 ± 10.2 mm Hg in group P (P = 0.1028). [Figure 2] depicts the average heart rates of the study groups which were comparable statistically at all times.
Figure 1: Mean systolic blood pressure trends with time in the study groups

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Figure 2: Mean heart rate trends with time among the study groups

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The number of parturients developing hypotension in group P and C was comparable statistically (P = 0.1607). More number of patients developed nausea in group P as compared to group C (P = 0.0473). The number of patients having vomiting was also higher in group P as compared to group C (P = 0.0455). The number of patients having bradycardia, shivering and reactive hypertension were comparable among the two groups [Table 2].
Table 2: Peri-operative adverse effects

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The number of doses of ephedrine required (P = 0) and the total dose of ephedrine used (P = 0.1528) in the groups were comparable statistically [Figure 3]. None of the neonates had an APACHE score of < 7 at 1 min and 5 min intervals. The values of blood gas analysis including umbilical arterial and umbilical venous pH, pCO 2 , pO 2 and base excess were statistically comparable [Table 3].
Figure 3: Comparison of mean number of doses of ephedrine and mean total doses of ephedrine used in the preload and co-load groups

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Table 3: Neonatal outcome

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  Discussion Top


Hypotension is the most common side effect after spinal anesthesia. In our study, 60 % of patients in the preload group developed hypotension. Previous studies using 15 ml/kg of RL as preload in the obstetric population have reported the instance of hypotension as 55% [17] and 45.5%. [18] Many studies have now questioned the value of traditional preloading techniques for prevention of spinal anesthesia induced hypotension during cesarean section. The first study to challenge the role of preloading was that of Clark et al., [19] who studied the use of fluid loading, both with and without uterine displacement, comparing them with controls with neither prophylactic measure. One of the possible reasons for the decreased efficacy of crystalloid solutions as prophylaxis against spinal induced hypotension is that as much as 75% of any crystalloid diffuses into the interstitial space. [20] Pauta et al. suggested that preload is rapidly redistributed and may induce atrial natriuretic peptide secretion resulting in peripheral vasodilatation followed by an increased rate of excretion of the preloaded fluid. [21]

The effects of varying the amount of crystalloid preload volume prior to spinal anesthesia were studied by Park etal. [9] who compared 10, 20 and 30 ml/kg crystalloid preload and showed that there was no difference in the incidence of hypotension. The ineffectiveness of high dose crystalloid preload was also reported by Tercanli et al., who reported the incidence of hypotension as 45.5% in both the low volume group, receiving 150 ml. of crystalloid preload and the high volume receiving 15 ml/kg of crystalloid preload. [18] Although crystalloid administration is safe in most patients, there is evidence to suggest that large volumes of crystalloid preload can be counterproductive as they can induce hemodilution [22] and can predispose the susceptible parturient to the development of pulmonary edema possibly because of an increase in the lung water during pregnancy. [23]

Volume kinetic studies of RL solution during spinal and general anesthesia by Ewaldsson et al., concluded that the arterial pressure is better maintained by a fluid bolus just after the induction of anesthesia than by preloading. [24] It was suggested that loading fluid at the time of administering the intrathecal local anesthetic (coloading) might be a physiologically more appropriate and rational approach as the maximal effect can be achieved during the time of the block. [14] Dyer et al. suggested that coloading might increase intravascular volume expansion during vasodilatation from the sympathetic blockade and limit fluid redistribution and excretion. Rapid crystalloid coloading soon after induction of spinal anesthesia rather than as preload over 20 min before spinal anesthesia for elective cesarean section was reported to be advantageous in terms of managing maternal blood pressure prior to delivery. [15] The results from our study showed that the incidence of hypotension was lesser in the coload group as compared to the preload group (46% cf 60%) but this difference was not significant statistically. Earlier studies comparing crystalloid preloading and coloading in obstetric population have reported variable incidence of hypotension in the preload and coload groups. Mercier et al. compared one litre of crystalloid as preload and coload and reported the incidence of hypotension as 62.5% and 50% in the coload and preload groups respectively. [14] Dyer et al. compared 20 ml/kg of RL solution (administered over 20 min) in parturients and reported 84% hypotension in the preload group and 60% in the coload group. [15] Cardoso et al. compared 10 ml/kg of RL as coload and preload in parturients and reported the incidence of hypotension as 22.5% and 25% in the coload and preload groups respectively. [25] Contrary to these findings, Bouchnak et al. reported a higher incidence of hypotension in the coload group (96.6%) than in the preload group (86.6%) while comparing 20 ml/kg of crystalloid (given over 15 min) as coload or preload in the obstetric population. [26] The wide variations in the incidence of hypotension in these studies may be explained by differences in the definitions of hypotension used in the studies, the different volumes of crystalloids used and the differing rates of administration of the crystalloids.

Our findings are similar to those of Bannerjee et al. who report the incidence of hypotension in the coload group as 59.3% compared with 62.4% in the preload group in a meta analysis of the use of coload or preload during spinal anesthesia for cesarean section. They found the difference between the two groups to be statistically not significant. [27]

There is no doubt that persistent hypotension has adverse effects on the maternal well-being in the form of nausea, vomiting, dizziness [28],[3] and it decreases the uterine blood flow [8],[4] resulting in deleterious effects on the fetus. [29],[30] The deleterious effects of hypotension during our study were observed as an increased incidence of maternal nausea and vomiting. A constant observation during earlier similar studies is that the incidence of nausea and vomiting during spinal anesthesia was in close association with hypotension. [31],[32] Similar results were observed during our study as the higher incidence of nausea and vomiting was found in group P, which experienced more hypotension as compared to group C. These results support the suggestion that the mechanism of the nausea alone or along with vomiting may be maternal hypotension and hypoxemia in the chemoreceptor trigger zone as a consequence of the maternal hypotension. [33]

Crystalloid coload has been reported to decrease ephedrine requirement to maintain the maternal blood pressure. [15] In our study, the mean number of supplemental ephedrine doses administered and the mean total dose of ephedrine administered was more in the preload group than in the coload group but the differences in the mean number of bolus doses (P = 0) and total dose of ephedrine used (P = 0.1528) were not statistically significant among the groups.

There was no evidence of any significant acidosis (pH < 7.20) in any of the neonates as all the neonates had an umbilical arterial pH > 7.3 indicating that all the newborns were robust. Thus the prompt treatment of the hypotension observed in the two groups was responsible for the maintenance of the acid-base status of the neonates within the physiological range.

The absence of a control group and non-blinding methodology are two drawbacks of our study. Also the attending anesthesiologist was free to give crystalloid boluses along with intravenous ephedrine to treat the episodes of hypotension, which may have led to more volume being given to patients in the preload group who experienced a higher incidence of hypotension. Although we did observe that patients in the preload group received a larger total volume of crystalloids as compared to those in the coload group, this difference was statistically not significant; hence it would not affect the final results.

In conclusion, both preloading and coloading with 15 ml/kg of RL solution, when used alone, are ineffective in the prevention of hypotension in the obstetric population receiving spinal anesthesia. Valuable time need not be wasted in preloading the parturient as preloading alone is ineffective for the prevention of maternal hypotension, during cesarean section under spinal anesthesia. Frequent measurement of the blood pressure in the subjects (at 1 min intervals) for prompt recognition of hypotension and administration of vasopressors for maintaining the maternal blood pressure close to the baseline can ensure better neonatal outcome.

 
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    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]


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