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British Journal of Anaesthesia 1995; 74: 373-378

Hypotension during subarachnoid anaesthesia: haemodynamic effects of ephedrine


L. A. H. CRITCHLEY, J. C. STUART, F. CONWAY AND T. G. SHORT

Summary
We have compared the haemodynamic effects of ephedrine alone with ephedrine and colloid for the treatment of hypotension produced by subarachnoid anaesthesia in 30 patients aged 60-90 yr with fractures of the neck of femur. Group one received ephedrine as an initial bolus dose of 0.2 mg kg~1 followed by an infusion of 0.5 mg kg" 1 hr1. Group two received ephedrine and colloid (polygeline, Haemaccel) 8mlkg- 1 . If necessary, up to three rescue bolus doses of ephedrine (0.1 mg kg"1) and then colloid solution (8 ml kg"1) were given to maintain systolic arterial pressure (SAP) at > 75% of baseline. Arterial pressure was measured by automated oscillotonometry, central venous pressure (CVP) by a manometer and cardiac index (Cl), stroke index (SI) and heart rate (HR) by transthoracic electrical bioimpedance. Systemic vascular resistance index (SVRI) was derived. In patients receiving ephedrine only, SVRI, CVP and SI decreased and HR increased (P < 0.0001). Five patients in this group required colloid, the effect of which was to restore CVP, increase Cl and SI, and decrease HR ( P < 0 . 0 2 ) . In patients receiving ephedrine and colloid solution, SVRI decreased arid Cl, SI and HR increased (P < 0.0001). Ephedrine was not a potent arterial vasoconstrictor and SAP was maintained mainly by increases in SI and HR. (Br. J. Anaesth. 1995; 74: 373-378)
Key words
Anaesthetic techniques, subarachnoid. Complications, hypotension. Sympathetic nervous system, ephedrine. Cardiovascular system, effects.

cardiac output, and that in order to maximize the increase in cardiac output, and therefore the increase in systolic arterial pressure (SAP), fluids should be given to maintain CVP and venous filling pressure of the heart. The aims of this study were to determine the haemodynamic effects of ephedrine during subarachnoid block and to see how these effects were modified by concurrent use of fluids. Patients and methods We studied 30 ASA IIIII Chinese patients, aged 60 yr or more, who were suitable to receive subarachnoid block for surgical fixation of fractured neck of femur. Local Ethics Committee approval and written informed patient consent were obtained. All patients had received i.v. fluids soon after admission to hospital and no patient was clinically dehydrated. Patients were excluded if their New York Heart Association dyspnoea class was III or IV or if HR was irregular. Oral diazepam 5-10 mg was given 1 h before surgery. After the patient arrived in the induction room, 10 min elapsed before baseline haemodynamic data were obtained. Patients were given nitrous oxide for analgesia during lateral positioning and subarachnoid puncture. With the patient in a lateral position, subarachnoid puncture was performed with a 22-gauge spinal needle at the L3-4 or L4-5 interspace and 0.5 % bupivacaine 2.5-3.0 ml (Marcain Spinal 0.5% Heavy, Astra) was injected over 10 s. The patient was then returned to the supine position and kept horizontal for the duration of the study. Arterial pressure was measured every minute using an automated oscillotonometer (Dinamap 1846SX, Critikon, FL, USA) and data recorded on the attached printer. CVP measurements were made using a manometer attached to a 16-gauge cannula inserted into the right internal jugular vein. CVP was zeroed at the mid-axillary line and at the fourth to sixth intercostal space with the patient supine. Cardiac output was measured non-invasively by transthoracic electrical bioimpedance (TEB) (BoMed NCCOM3-R7S, BoMed Medical ManuLESTER A. H. CRITCHLEY, BMEDSCI, MB, CHB, FFARCSI, JOYCE C. STUART, MB, CHB, FRCA, FRANCES CONWAY, MB, BCH, FFARCSI, TIMOTHY G. SHORT, MD, FANZCA, Department of Anaesthesia and

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Hypotension commonly accompanies subarachnoid block. However, there is no consensus of opinion on the most appropriate method of treatment [1-3]. In a recent study [4], we found that ephedrine, a combined alpha and beta adrenergic receptor agonist, failed to prevent decreases in central venous pressure (CVP) and systemic vascular resistance index (SVRI) during subarachnoid block. In contrast, metaraminol, predominantly an alpha adrenergic agonist, prevented these decreases in CVP and SVRI and was more effective than ephedrine in preventing hypotension. Because heart rate (HR) and contractility were increased and SVRI decreased, we hypothesized that ephedrine was a poor peripheral vasoconstrictor and worked mainly by increasing

Intensive Care, Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong. Accepted for publication: October 3, 1994.

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facturing Ltd, Irvine, CA, USA). It was connected to the patient according to the manufacturer's instructions [5]. The method used to derive cardiac output has been presented previously [6, 7]. Data were indexed to the patient's body surface area and the average of 16 beats recorded. The variables recorded were cardiac index (CI), stroke index (SI) and HR. Using custom-made software, these data were acquired continuously by an IBM-compatible lap-top computer onto a spreadsheet file (Microsoft Excel, Version 4.0) for later analysis. Arterial pressure and TEB data were collected for 3-5 min before the patient was turned to the lateral position for subarachnoid puncture and continued for at least 25 min afterwards. CVP measurements were made before turning the patient and at 5-min intervals after starting the subarachnoid block. Using blocked randomization with sequentially numbered sealed forms, patients were allocated to one of two treatment regimens for hypotension: ephedrine alone or ephedrine combined with a colloid infusion. Immediately after injection of bupivacaine, all patients received ephedrine as an initial bolus of 0.2 mg kg"1 followed by an infusion of 0.5 mg kg"1 h"1. In the colloid group a rapid infusion of 3.5 % polygeline 8 ml kg"1 (Haemaccel, Behringwerke, Marburg, Germany), given over 2-4 min, was commenced immediately after injection of bupivacaine. We aimed to maintain SAP > 75 % of the value before block. If SAP decreased below this limit on two consecutive readings, the patient received a rescue bolus dose of ephedrine 0.1 mgkg" 1 . If the third rescue bolus was unsuccessful, the patient was given polygeline 8 ml kg"1 and the infusion rate of ephedrine doubled. The level of sensory loss to pinprick was assessed 30 min after subarachnoid block by an independent observer who was blind to the treatment regimen. When data collection was completed, anaesthesia was continued according to standard practice and surgery allowed to start.
DATA ANALYSIS AND STATISTICS

SVRI was calculated using the formula: SVRI = (MAP-CVP) x 80/CI where MAP = mean arterial pressure and CVP was substituted for right atrial pressure. Continuously recorded haemodynamic data were averaged for each 1-min interval during the first 25 min of subarachnoid block. These data were compared within each treatment group and between treatment groups using analysis of variance for repeated measures (ANOVA-RM). The times after commencing the block at which the changes in each variable became significant (P < 0.05) were determined by performing multiple paired Student's t tests. The magnitude of the haemodynamic changes that occurred during subarachnoid block for each variable was calculated by comparing the percentage changes with baseline for each 1-min interval after the block and then taking the mean value for the 10-25-min period after the block. For CVP numerical difference rather than percentage change was used. The magnitude of the haemodynamic changes that occurred after rescue with ephedrine boluses was calculated in a similar manner by comparing the 2-4-min period after rescue with the 2-min period before. Comparisons were made using Student's t test. P < 0.05 was considered significant and results are given as mean (SD). The power of the study was examined using the standardized difference on the magnitude of the changes in SAP before the design demanded intervention. A 25% change from a mean systolic pressure of 150 (SD 30) mm Hg indicated that 15 patients in each group would be sufficient to detect a significant difference at a power of 0.8. Results Fifteen patients were studied in each group. Patient data, characteristics of the subarachnoid block and baseline haemodynamic data are shown in tables 1 and 2. The two groups were similar in age, weight, height, ASA status, sex distribution, level of sensory block at 30 min and baseline haemodynamic
Table 1 Patient characteristics, volume of bupivacaine, the sensory level (thoracic dermatome) to pinprick after 30 min of subarachnoid block and dose of ephedrine administered over 30 min in patients given ephedrine only or ephedrine and colloid to prevent hypotension during subarachnoid block (mean (SD or range) or number). ** P < 0.01 between groups Ephedrine only Ephedrine and colloid (n = 15) (" = 15) Age (yr) 79 (65-93) Weight (kg) 47(6) Height (cm) 154 (10) Sex (M/F) 3/12 ASA status (II/III) 13/2 7 Hypertensive Bupivacaine 0.5 % 2.7 (0.2) (ml) Sensory level (T) 5(3-9) Ephedrine dose 28 (19-43)** (mg) 74(60-89) 49(11) 155 (8)
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Statistical analysis was performed on a Macintosh computer (Apple Computer, Inc, CA, USA) using the software package Statview 4.02 (Abacus Concepts, Inc). Patient characteristics, total dose of ephedrine and the incidence of rescue treatment in the two treatment groups were compared using Student's t test or chi-square test as appropriate. Patients were classified as hypertensive if they had a baseline SAP > 160 mm Hg or if they were receiving regular treatment for hypertension. The sensory levels of the block were treated as non-parametric data and were compared using a Mann-Whitney U test. The haemodynamic data collected before subarachnoid block were averaged to give the baseline values, which were compared between the two treatment groups using Student's t test. When analysing the haemodynamic changes during subarachnoid block, those patients who received rescue colloid in the ephedrine only group were excluded from the main group and analysed separately.

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2.8 (0.3) 5(3-7) 23 (16-35)**

Ephedrine during subarachnoid anaesthesia


Table 2 Baseline haemodynamic variables (mean (SD)) in patients treated with ephedrine only or ephedrine and colloid to prevent hypotension during subarachnoid block. SAP = Systolic arterial pressure, MAP = mean arterial pressure, SVRI = systemic vascular resistance index, CVP = central venous pressure, CI = cardiac index, SI = stroke index and HR = heart rate. No significant differences between groups Ephedrine and Ephedrine only colloid ( = 15) ( = 15) SAP (mm Hg) MAP (mm Hg) SVRI (dvn s cm"5 m"2) CVP (cm H2O) CI (litre min-1 m 2 ) SI (ml rrr2) HR (beat min"1) 150(29) 106(18) 2869 (942) 4.5 (2.5) 3.1 (0.8) 35(8) 88(10) 155 (30) 109(19) 3172(841) 5.9(1.9) 2.8 (0.9) 32(12) 91 (16)

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Table 3 Percentage changes (A) or numerical difference (Diff.) (mean (SD)) compared with baseline values for haemodynamic variables, for the established effects of subarachnoid block in the two treatment groups (10-25 min). Results from patients requiring rescue colloid in the ephedrine only group are presented separately. SAP = Systolic arterial pressure, MAP = mean arterial pressure, SVRI = systemic vascular resistance index, CVP = central venous pressure, CI = cardiac index, SI = stroke index and HR = heart. *P < 0.05, **P < 0.01 compared with baseline values Ephedrine only ( = 10) ASAP (%) AMAP (%) ASVRI (%) Diff. CVP (cm H2O) ACI (%) ASI (%) AHR(%) Rescue colloid ( = 5) Ephedrine and colloid ( = 15) -13(14)** -18(15)** -27(13)** 0.5 (2.4) 13(19)** 5(15) 9(10)**

-18(13)** -26(11)** -17(7)** -27(9)** -17(15)** -42(10)** -2.8(2.4)** 0.5(1.5) 4(14) -18(9)** 27 (12)** 25 (10)** 16(12)* 9(6)*

variables. Significantly more patients received rescue treatment in the ephedrine only group (chi-square: P < 0.005). Rescue treatment was used in 11 patients in this group and in three patients in the ephedrine and colloid group. Patients in the ephedrine only group received more ephedrine during the 30-min study period (P = 0.01). Fourteen hypertensive patients were included in the study. In the ephedrine only group, one patient was receiving a beta blocker and in the ephedrine and colloid group two patients were receiving calcium channel blockers and two patients thiazide diuretics. Hypertensive patients were distributed evenly between the treatment groups, including those patients that required rescue colloid. Five patients in the ephedrine only group received, in addition to ephedrine boluses, rescue treatment for hypotension with i.v. polygeline 8 ml kg"1, which was started between 10 and 20 min after the block. Patient data and baseline haemodynamic variables in these patients were similar to those of the other patients in the study, with the exception of CI (3.8 (0.9)) which was greater than the baseline values in each of the two main treatment groups (P < 0.05). Haemodynamic data from these five patients are

shown separately from the two main treatment groups (table 3, fig. 1). Haemodynamic changes after subarachnoid block are shown in figure 1. The magnitude of these effects between 10 and 25 min is presented in table 3. ANOVA-RM of the haemodynamic data for the ephedrine only group, excluding those patients who required rescue colloid, showed significant decrease in SAP, MAP, SVRI, CVP and SI and an increase in HR (P < 0.0001). These changes became significant (P < 0.05) after 6 min for SAP, MAP and SVRI, after 5 min for CVP, after 1 min for SI and after 2 min for HR. No significant change occurred in CI. ANOVA-RM of the haemodynamic data for the ephedrine and colloid group showed significant decreases in SAP, MAP and SVRI and increases in CVP, CI, SI and HR (P < 0.0001). These changes were significant (P < 0.05) after 9 min for SAP, after 5 min for MAP, after 2 min for SVRI, after 5 min for CVP, between 3 and 12 min for CI, between 4 and 10 min for SI and after 1 min for HR. When the haemodynamic data between the two groups were compared using ANOVA-RM, there were no significant differences in the degree of decrease in SAP, MAP, and SVRI. In the ephedrine only group, CVP and SI were significantly lower and HR was significantly higher than in the ephedrine and colloid group (P < 0.05). ANOVA-RM of the haemodynamic data for the five patients that required rescue colloid showed that after subarachnoid block and before rescue treatment there were significant decreases in SAP, MAP, SVRI and CVP and an increase in HR (P < 0.0001). These changes were significant (P < 0.05) after 5 min for SAP, after 1 min for MAP, after 2 min for SVRI, after 5 min for CVP and after 3 min for HR. There were no significant changes in CI or SI. After administration of rescue colloid, significant increases occurred in CVP, CI, SI and a decrease in HR (P < 0.0001). No significant changes occurred in SAP, MAP or SVRI. When haemodynamic data from these five patients were compared with data from the two main treatment groups using ANOVARM, there were significant differences in all haemodynamic variables except SVRI (P < 0.01). Bolus doses of rescue ephedrine (O.lmgkg"1) were given on 19 occasions to 14 patients. The effect was to increase SAP by 5 (5) %, MAP by 5 (5) % and SVRI by 4 (5)% (P < 0.01). No significant effects occurred in CI, SI or HR. Discussion We found that ephedrine alone, in doses of 2040 mg, was inadequate for treatment of hypotension in one-third of our patients. This was because ephedrine caused only a small increase in SVRI and a large increase in HR. CVP decreased but this could be corrected by infusion colloid. The combination of ephedrine and colloid caused an increase in CI, a major factor in maintaining SAP in this group. TEB provided a simple, non-invasive method of assessing changes in stroke volume and cardiac output. It has been shown to follow pharmacologically induced changes in stroke volume with a

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10 15 Time (min)

25

10 15 20 Time (min)

25

Figure 1 Mean (SEM) haemodynamic variables at baseline (0 min) and during the first 25 min of subarachnoid block for the two groups of patients, including those patients in the ephedrine only group that required rescue colloid. = Ephedrine only; = ephedrine and colloid; = rescue colloid.

coefficient of variation of 7.8 % [8] and has been used successfully in several studies to measure changes in stroke volume and cardiac output during both spinal and general anaesthesia [4,9-12]. Non-invasive arterial pressure recorded at 1-min intervals was sufficiently accurate to measure the changes in SAP. Individual readings have been shown to have a 1 0 % variability [13] and in order to minimize errors, treatment was started only after two consecutive low readings. We chose to study elderly patients requiring emergency surgery for traumatic femoral head fractures. Appropriate treatment of hypotension during subarachnoid block is clinically important in this group because of the high postoperative morbidity and mortality [14, 15]. We also found that this group was highly susceptible to hypotension [16]. However, all patients in the present study were given i.v. fluids before operation and were haemodynamically stable before surgery. The dose regimen

for ephedrine was based on the findings of previous studies. An initial bolus was given so that a therapeutic concentration could be attained rapidly and an infusion was used in order to improve the control over dosage and to prevent unnecessary episodes of hypertension. Greene and Brull have extensively reviewed the literature on hypotension during subarachnoid block [3]. They concluded that the main mechanism involved was sympathetic block causing arterial and venous dilatation. Arterial dilatation results in decreases in total peripheral resistance and SAP of up to 30%. However, venous dilatation can cause severe hypotension as a result of a decrease in venous return and cardiac output. They considered that restoring venous filling pressure by fluid administration or headdown tilt was the most important method of treatment and that it was more appropriate to use a vasopressor that increased cardiac output in addition to total peripheral resistance.

Ephedrine during subarachnoid anaesthesia

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In previous studies of elderly patients receiving subarachnoid block, Coe and Revanas found that preloading was ineffective in preventing hypotension in 60% of healthy elderly patients with blocks above the seventh thoracic dermatome and recommended the use of ephedrine [17]. Hemmingsen, Poulsen and Risbo found that elderly ASA II and III patients were particularly at risk of hypotension and also recommended the use of ephedrine [18]. Previously, we also found that ephedrine was more effective than preloading but not as effective as the alpha agonist metaraminol [4]. These studies support the use of ephedrine in treating hypotension during subarachnoid block and the present study is the first, to our knowledge, to demonstrate how ephedrine exerts its effect. We found significant decreases of up to 42 % in SVRI following subarachnoid block. These decreases were not treated adequately by the ephedrine boluses or infusion. Bolus doses of 0.1 mg kg ' increased SVRI but by only 5 %. Ephedrine vasoconstricts the arterial and venous systems, and stimulates the heart. Arterial vasoconstriction results from stimulation of alpha adrenergic receptors. However, the beta2 adrenergic activity of ephedrine results in vasodilatation of blood vessels, the most prominent effect being on skeletal muscle. The various vascular beds respond differently to alpha and beta2 stimulation and to what extent vasodilatation opposes vasoconstriction when ephedrine is used is unreported. However, the coexistence of arterial vasodilatation may account for our finding that ephedrine had only a limited ability to increase SVRI. It is also possible that tachyphylaxis was responsible for the limited response or that doses of ephedrine used in the study were too low, albeit similar to those used in previous studies. When ephedrine was used alone to treat hypotension, CVP and SI decreased. In a previous study we found decreases in CVP of 2.5 cm H2O and SI of 7-13% when SAP was decreased by 25% [16] and Greene and Brull also reported decreases in CVP of 1.5-2.0 cm H2O in adult patients after subarachnoid block [3]. These decreases are similar to those in the present study and support our findings that ephedrine does not prevent the decrease in venous filling pressure during SAB. Ephedrine boluses also had no demonstrable effect on CVP and SI. Hence, ephedrine appears to have no significant action as a venoconstrictor during subarachnoid block in elderly patients in the doses used in the present study. When ephedrine was used in combination with colloid solution, either treatment or rescue, CI increased by 13-25%. The increased in CI was an important factor in maintaining SAP, as neither ephedrine nor colloid increased SVRI significantly. Administration of colloid seemed to play an important role in enabling CI to increase, as decreases in CVP were prevented and venous filling pressure and end-diastolic volume were maintained. In agreement with the findings of our previous study [16], polygeline 8 ml k g 1 proved to be a suitable volume. In the ephedrine and colloid group, the increase in CI was caused in part by the 9% increase in HR.

However, SI increased also despite a small change in CVP and hence the increase in SI cannot be accounted for purely by an increase in end-diastolic volume. It seems most likely that SI increased as a result of an increase in contractility resulting from the inotropic effect of ephedrine. Previously, we have found that HR increased by 8-13% in elderly patients when SAP decreased by 25 %. The increase in HR was related to the severity of hypotension and returned to baseline on correcting the venous filling pressure with colloid solution [16]. This finding contradicted the review of the subject by Greene and Brull, who reported that HR decreases during SAB [3]. In the present study, significant increases in HR occurred, especially in the ephedrine only group, where HR increased by 26%, and administration of colloids, whether treatment or rescue, reduced this increase to 9 %. These findings probably demonstrate the chronotropic action of ephedrine. Reilly commented on the undesirability of using vasopressors that cause tachycardia, especially in patients with coronary artery disease because of the risk of precipitating myocardial ischaemia [19]. In the ephedrine only group, the increase in HR of 26% would be undesirable in some patients. Our findings demonstrate that fluid loading with colloid has an important part to play when ephedrine is used to prevent hypotension during subarachnoid block. We found that ephedrine in the doses used in the study had only limited action as a peripheral vasoconstrictor and relied on its ability to increase cardiac output in order to maintain SAP. This ability was enhanced by fluid loading. In patients with severe ischaemic heart disease or renal disease, where increases in cardiac output or fluid volume are undesirable, hypotension would be treated more appropriately with an infusion of a pure peripheral vasoconstrictor. References
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