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Patient Position and Hypotension After Spinal Placement For Cesarean Delivery
Abstract Number: S-47
Abstract Type: Case Report/Case Series
Spinal anesthesia is associated with a high incidence of hypotension. One hypothesis for hypotension prevention is whether patient positioning during placement affects the severity and onset of the drop in blood pressure. A previous study supported the lateral position as more hemodynamically stable (Obasuyi), however this conflicts with our clinical observations. We hypothesized that seated positioning would lead to slower onset and rise of spinal level and therefore less hypotension than the lateral position. In addition, we hypothesized that patients who had seated spinals and then were slowly reclined over 5 minutes would have even greater hemodynamic stability due to a slower rise in the spinal level.
After IRB approval and written informed consent, patients undergoing elective cesarean delivery under spinal anesthesia were enrolled in a randomized controlled trial. They were allocated to receive their spinal in one of three positions: Lateral (L), Seated (S) or seated followed by a five-minute Recline from 30-degrees (R). Blood pressure was observed with a continuous, non-invasive CNAP monitor for twenty minutes and IV fluids and vasopressors were dosed based on a protocol. Secondary outcomes included the maximum height of the spinal blockade and the duration of the motor and sensory blockade.
45 of 105 patients were enrolled. Eight patients were excluded from the study for failed spinal, inability to place in assigned position, or monitor failure. We found a significant difference in lowest SBP and MAP (P<0.05 for both) (see figure 1 for trend) with the (L) group significantly lower than (R). No difference was found in HR, nausea or vomiting. The amount of fluid used was found to be significant among groups (p=0.03), with the (R) group receiving the least fluid (625cc(R) vs 1000cc(S) vs 875(L)). There was no difference in pressor boluses (p=0.16), but the lateral group had a trend towards higher use. There was no difference in the height of spinal level achieved at 15 minutes.
We found that positioning patients laterally for spinal placement led to greater hemodynamic instability when compared with using a gradual recline for the first five minutes following seated placement. In addition, the lateral position was associated with increased IV fluid and vasopressor usage. Despite this difference in hemodynamic stability, the maximum height of the spinal achieved was equivalent between the three groups.