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Prophylactic Norepinephrine Infusion for Preventing Hypotension During Spinal Anesthesia for Cesarean Delivery

Ngan Kee, Warwick D., MD, FANZCA, FHKCA*; Lee, Shara W. Y., PhD; Ng, Floria F., RN, BASc*; Khaw, Kim S., MD, FRCA, FHKCA*

doi: 10.1213/ANE.0000000000002243
Obstetric Anesthesiology: Original Clinical Research Report

BACKGROUND: The use of norepinephrine for maintaining blood pressure (BP) during spinal anesthesia for cesarean delivery has been described recently. However, its administration by titrated manually controlled infusion in this context has not been evaluated.

METHODS: In a double-blinded, randomized controlled trial, 110 healthy women having spinal anesthesia for elective cesarean delivery were randomly allocated to 1 of 2 groups. In group 1, patients received an infusion of 5 µg/mL norepinephrine that was started at 30 mL/h (2.5 µg/min) immediately after intrathecal injection and then manually adjusted within the range 0–60 mL/h (0–5 µg/min), according to values of systolic BP measured noninvasively at 1-minute intervals until delivery, with the objective of maintaining values near baseline. In group 2, no prophylactic vasopressor was given, and a bolus of 1 mL norepinephrine 5 µg/mL (5 µg) was given whenever systolic BP decreased to <80% of the baseline value. The study protocol was continued until delivery. The primary outcomes of the study were the incidence of hypotension and the overall stability of systolic BP control versus baseline compared using performance error calculations. In addition, the incidence and timing of hypotension were further compared using survival analysis.

RESULTS: Three patients were excluded from the analysis. Nine patients (17%) in group 1 had 1 or more episodes of hypotension versus 35 (66%) in group 2 (P < .001). Performance error calculations showed that on average, systolic BP was maintained closer to baseline (P < .001) in group 1. Survival curve analysis showed a significant difference between groups (log-rank test P < .001). Four patients in each group had a recorded heart rate <60 beats/min (P = .98). Despite a much greater rate of administration of norepinephrine in group 1 (median, 61.0 [interquartile range, 47.0–72.5] µg) versus group 2 (5.0 [0–18.1] µg) (P < .001), there was no difference in neonatal outcome as assessed by Apgar scores and umbilical cord blood gas analysis.

CONCLUSIONS: In patients having spinal anesthesia for elective cesarean delivery, a manually titrated infusion of 5 µg/mL of norepinephrine was effective for maintaining BP and decreasing the incidence of hypotension, with no detectable detrimental effect on neonatal outcome. Further investigation of the use of dilute norepinephrine infusions for routine use in obstetric patients is suggested.

From the *Department of Anaesthesia and Intensive Care, the Chinese University of Hong Kong, Hong Kong, China

Department of Health Technology and Informatics, the Hong Kong Polytechnic University, Hong Kong, China.

Published ahead of print July 1, 2017.

Accepted for publication April 21, 2017.

Funding: Departmental and Institutional.

The authors declare no conflicts of interest.

Reprints will not be available from the authors.

Address correspondence to Warwick D. Ngan Kee, MBChB, MD, FANZCA, Department of Anaesthesia and Intensive Care, the Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, China. Address e-mail to

© 2018 International Anesthesia Research Society
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