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SECTION EDITOR
DENISE J. WEDEL
MD*,
Hector J. Melendez,
MD*,
PhD
*Department of Surgery, School of Medicine, Universidad Industrial de Santander; and Department of Preventive
Medicine and Biometrics, Uniformed Services University of the Health Sciences
432
crystalloid administration at the time of spinal block resulted in a significant reduction in the proportion of patients developing CVSE from 9.9% to 2.3%. The corresponding relative proportion was 0.23 (95% confidence
interval, 0.07 0.78; P 0.019), and one additional case of
CVSE was avoided for each 13 patients receiving crystalloids at the time of spinal block instead of placebo. Administration of crystalloids at the time of spinal block seems to
be effective because it provides additional intravascular
fluids during the period of highest risk of CVSE after spinal anesthesia.
(Anesth Analg 2002;94:4327)
crystalloids administered before spinal block significantly reduced the incidence of cardiovascular side
effects (CVSE), but only during the first 15 min of
anesthesia.
Although the time elapsed between administration
of fluids and spinal anesthesia may influence efficacy,
no previous study has evaluated the benefits of crystalloid administration at varying times before spinal
block. We have conducted a clinical trial to evaluate
the efficacy of crystalloids administered 20 min before
or at the time of spinal anesthesia, as compared with
not administering crystalloids (Placebo group), in preventing SIH and CVSE in a group of general and
specialty surgery patients.
Methods
The study was approved by the Research Ethics Committee of the School of Medicine, Universidad Industrial de Santander, Bucaramanga, Colombia. Written
informed consent was obtained from all participants
or their parents. General and specialty surgery patients 11 yr old undergoing spinal anesthesia were
eligible for the study, excluding pregnant women,
those with a pelvic mass 10 cm, and those with
cardiac or pulmonary decompensation. Participants
2002 by the International Anesthesia Research Society
0003-2999/02
ANESTH ANALG
2002;94:4327
Results
A total of 404 patients were recruited into the study,
142 were assigned to the placebo group, 130 to receive
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Table 1. Distribution of Clinical Characteristics Just Before Spinal Block by Allocated Treatment
Treatment group
Age (yr)
Sex (% male)
Weight (kg)
Bupivacaine dose (mg)
Block height T5 (%)*
ASA physical status (%)
I
II
III
SBP (mm Hg)
DBP (mm Hg)
Heart rate (bpm)
No crystalloids
(placebo)
(n 142)
Crystalloids
before
spinal block
(n 130)
Crystalloids
at time of
spinal block
(n 132)
P value
41.5 (38.544.6)*
59.9 (51.768.0)
61.4 (59.763.2)
14.0 (13.714.2)
63.4 (54.971.3)
42.4 (39.545.2)
50.0 (41.358.7)
64.7 (62.666.8)
14.3 (14.114.5)
68.5 (59.776.3)
42.1 (39.344.9)
50.0 (41.458.6)
64.1 (62.365.8)
14.4 (14.214.6)
73.5 (65.180.8)
0.92
0.16
0.03
0.05
0.20
61.3 (52.769.3)
32.4 (24.840.8)
6.3 (2.911.7)
132.7 (129.7135.6)
75.1 (73.177.1)
82.5 (79.885.2)
60.0 (51.068.5)
37.7 (29.346.6)
2.3 (0.56.6)
137.8 (134.4141.1)
76.9 (74.978.8)
81.5 (78.884.1)
68.9 (60.376.7)
28.8 (21.237.3)
2.3 (0.56.5)
133.2 (130.1136.3)
73.9 (72.175.8)
81.2 (78.683.9)
0.16
0.05
0.12
0.78
Table 2. Absolute and Relative Risk of Hypotension and Cardiovascular Side Effects by Allocated Treatment
Hypotension
Placebo group
Before spinal block
At time of spinal block
Cardiovascular side effects
Placebo group
Before spinal block
At time of spinal block
Absolute risk
(95% CI)
Relative risk
(95% CI)
P value
12.7% (7.719.3%)
19.2% (12.827.1%)
12.1% (7.118.9%)
1.00
1.52 (0.872.65%)
0.96 (0.511.80%)
0.143
0.889
9.9% (5.516.0%)
9.2% (4.915.6%)
2.3% (0.46.5%)
1.00
0.94 (0.451.95%)
0.23 (0.070.78%)
0.860
0.019
Placebo group was administered lactated Ringers solution at a rate of 12 mL/min; Others were administered lactated Ringers solution at 20 mL/kg body
weight 20 min before or starting at the time of spinal block.
95% CI 95% confidence interval.
Discussion
Rapid infusion of large volumes of crystalloid is commonly used as prophylaxis for SIH. The goal of administering fluids before spinal block is to increase
ANESTH ANALG
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Table 3. Risk of Hypotension and Cardiovascular Side Effects by Clinically Relevant Risk Factors in All Study Subjects
Hypotension
Risk factor
Age (yrs)
1119
2029
3039
4049
5059
6069
7084
ASA physical status
I
II
III
Sex
Male
Female
Block height
T5
T5
No. subjects
Risk (%)
95% CI
Risk (%)
95% CI
28
92
82
73
46
47
36
14.3
9.8
7.3
13.7
19.6
25.5
25.0
4.032.7
4.617.8
2.715.2
6.823.8
9.433.9
13.940.3
12.142.2
7.1
5.4
2.4
5.5
8.7
10.6
19.4
0.923.5
1.812.2
0.38.5
1.513.4
2.420.8
3.523.1
8.236.0
256
133
15
9.8
22.6
26.7
6.414.1
15.830.6
7.855.1
2.7
15.0
13.3
1.15.6
9.422.3
1.740.5
216
188
18.6
11.1
13.324.9
7.316.1
9.6
5.1
5.814.7
2.68.9
128
276
10.9
16.3
6.117.7
12.121.2
3.1
9.1
0.97.8
5.913.1
Table 4. Multivariate Adjusted Relative Risk for Hypotension and Cardiovascular Side Effects by Clinical Risk Factors
and Treatment in Patients Undergoing Spinal Anaesthesia
Hypotension
Risk factor
Crystalloid administration
Placebo group
Before spinal block
At time of spinal block
Block height
Age (yr)
1119
2029
3039
4049
5059
6069
7084
Relative
risk
95% CI
P value
Relative
risk
95% CI
P value
1.00
1.54
0.90
1.25
0.892.66
0.531.85
1.041.51
0.121
0.974
0.019
1.00
0.93
0.25
1.47
0.461.88
0.080.83
1.091.98
0.831
0.023
0.011
0.535.98
0.533.81
0.355
0.479
0.3214.92
0.4811.58
0.427
0.293
0.745.02
1.167.88
1.499.20
1.419.68
0.180
0.023
0.005
0.008
0.4411.93
0.8021.24
0.9322.32
1.8637.71
0.327
0.090
0.061
0.006
1.77
1.43
1.00
1.93
3.03
3.70
3.67
2.19
2.35
1.00
2.29
4.12
4.57
8.38
Placebo group was administered lactated Ringers solution at a rate of 12 mL/min; others were administered lactated Ringers solution at 20 mL/kg body
weight 20 minutes before or starting at the time of spinal block.
95% CI 95% confidence interval.
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preventing SIH or CVSE because by the time of highest risk a considerable volume of crystalloids have
already diffused to the interstitial compartment and
can no longer improve venous return and cardiac
output (6,19). The administration of fluids before spinal block may initiate volume overload reflexes that
are then counterproductive during the onset of spinal
block, whereas administration at the time of spinal
block does not require the body to quickly reverse the
direction of volume homeostasis mechanisms.
The use of SIH as an outcome may partly explain
the negative results observed in trials of crystalloids
administered before spinal block (8 11). Although a
reduction of 25%30% in the baseline systolic blood
pressure warrants treatment (14,15), most patients can
safely tolerate such a decrease (20). Thus, this definition of hypotension may result in too many false positive cases and may dilute the estimate of the efficacy
of crystalloids administered before spinal block. On
the contrary, CVSE is a more specific and clinically
meaningful outcome because it includes SIH plus
alarming symptoms usually leading to treatment. Because false positive cases are less likely to occur with
CVSE, this outcome seems to be more appropriate for
evaluating the efficacy of fluid administration. Because patients were instructed to report nausea and
faintness but were unaware of the assigned treatment,
it is unlikely that our results were affected by biased
reporting of cardiovascular symptoms. Similarly, although the anesthesiologists knew the treatment assigned to the patient, observer bias is not a likely
explanation of our findings because blood pressure
was measured with an automatic device.
Age and peak block height were the only variables
independently associated with the risk of SIH and
CVSE in our study. Finding a decreased incidence of
both outcomes in the 30 39 year old group and increasing risk in younger as well as older subjects was
unexpected. Although an increased risk of SIH in patients over 40 years old has been previously reported
(1,25), the actual form of the age-incidence relationship should be further explored in future studies.
Changes in autonomic function and decreased cardiac
reserve may partly explain age-related changes in the
incidence of SIH and CVSE (1).
We found increases of 25% (P 0.019) in the incidence of SIH and 47% (P 0.011) in the incidence of
CVSE for each increment of one segment in peak
sensory block height, and only one case of SIH developed in patients with block height below T6. This
finding is consistent with previous reports of a greater
decrease in systolic blood pressure and an increased
risk of SIH in patients with sensory block level equal
or above T5 (1,8). Higher levels of sensory block correlate with higher cephalic spread of sympathetic
blockade, greater decrease in venous return and cardiac output, and increased risk of SIH. In contrast,
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References
1. Carpenter RL, Caplan RA, Brown DL, et al. Incidence and risk
factors for side effects of spinal anesthesia. Anesthesiology 1992;
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2. Covino BG, Scott DB, Lambert DH. Handbook of spinal anesthesia and analgesia. Philadelphia: WB Saunders, 1994.
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4. Rout CC, Rocke DS, Levin J, et al. A reevaluation of the role of
crystalloid administration for the prevention of hypotension
associated with spinal anesthesia for elective cesarean section.
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5. Rout CC, Akoojee SS, Rocke DA, Gouws E. Rapid administration of crystalloid preload does not decrease the incidence of
hypotension after spinal anesthesia for elective cesarean section.
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6. Rocke DA, Rout CC. Volume preloading, spinal hypotension
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6827.
9. Coe AJ, Revanas B. Is crystalloid preloading useful in spinal
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