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Patient Position and Hypotension after Spinal Placement for Cesarean Delivery
Abstract Number: F-39
Abstract Type: Original Research
Spinal anesthesia is associated with a high incidence of hypotension. The position after spinal injection affects the speed of onset of sympathetic blockade, and may also alter blood pressure changes. A previous study supporting the lateral position as more hemodynamically stable(1) conflicted 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 were slowly reclined from a seated position would have even greater hemodynamic stability due to a slower rise in sympathetic blockade.
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 a standard spinal in one of three positions: Lateral (L), Seated (S) or seated followed by a five-minute Recline starting at 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 strict protocol. Secondary outcomes included the maximum height of the spinal blockade and the duration of the motor and sensory blockade.
105 patients were enrolled, 13 patients were excluded from the study for various protocol reasons. We found no difference in age, height, weight, gestation or fetal weight (P>NS for all). There was no difference in baseline BP in the holding area (p=0.78) but S and R groups had higher BP when in the OR (p=0.02). The Recline group required fewer fluid boluses and pressors than the lateral group (P<0.01) and fewer fluid boluses than the sitting (P=0.01) group. The lowest SBP and time to lowest BP (P<0.05 for both) (Figure) were lowest in the L group and greatest in the R group. 40% of patients experienced nausea and only 4 patients (4%) vomited (P=NS for all). There was no difference in the height of spinal level achieved at 15 minutes, surgical success, or the motor and sensory blockade duration.
A gradual recline after spinal injection improves BP stability and reduces the need for treatment. The maximum height and duration of the spinal anesthesia was not affected.