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Ephedrine versus phenylephrine as a vasopressor for spinal anaesthesia-induced hypotension in parturients undergoing high-risk caesarean section: meta-analysis, meta-regression and trial sequential analysis.
Int J Obstet Anesth 2019; 37:16-28IJ

Abstract

BACKGROUND

Phenylephrine is the preferred vasopressor for the prevention and treatment of spinal anaesthesia-induced hypotension during caesarean section, because studies on low-risk elective patients found it to have a less detrimental effect on umbilical artery pH compared with ephedrine. However, limited data exist from high-risk parturients and parturients with uteroplacental insufficiency.

METHODS

We systematically searched for randomised, controlled, double-blinded trials of these two vasopressors in high-risk caesarean sections. We applied conventional meta-analysis, trial sequential analysis, computing the required information size that would exclude type I and II errors, contour-enhanced funnel plot testing for publication bias, meta-regression to assess the dose-response relationship, and the Grading of Recommendations Assessment, Development, and Evaluation system (GRADE). The incidence of fetal acidosis (umbilical arterial pH <7.2) was the primary outcome.

RESULTS

Eight trials (712 patients) with low risk of bias were identified. Pooling six studies of patients with preeclampsia and other reasons for fetal compromise, as well as subgroup analysis of the preeclampsia studies, revealed no significant differences in the incidence of fetal acidosis. Trial sequential analysis showed that the required information size was not reached. The funnel plot was not suggestive of publication bias. Meta-regression showed no dose-response relationship. The GRADE score was moderate quality.

CONCLUSIONS

Despite several studies and a large number of patients there was insufficient evidence to make a recommendation for choice of vasopressor in high-risk caesarean section. Trials with adequate power to detect differences in the incidence of fetal acidosis between ephedrine and phenylephrine are required to provide evidence-based guidance.

Authors+Show Affiliations

Department of Anaesthesia, Kantonsspital Baden, Baden, Switzerland. Electronic address: michael.heesen@ksb.ch.Department of Anaesthesiology, Erasmus University Medical Centre, Rotterdam, The Netherlands.Department of Anaesthesia, Kantonsspital Baden, Baden, Switzerland.Department of Anesthesiology, Sidra Medicine, Doha, Qatar.Department of Anaesthesia, University Hospital RWTH Aachen, Aachen, Germany.Department of Anaesthesiology, Erasmus University Medical Centre, Rotterdam, The Netherlands.Department of Anaesthesiology, Erasmus University Medical Centre, Rotterdam, The Netherlands.

Pub Type(s)

Journal Article

Language

eng

PubMed ID

30477997

Citation

Heesen, M, et al. "Ephedrine Versus Phenylephrine as a Vasopressor for Spinal Anaesthesia-induced Hypotension in Parturients Undergoing High-risk Caesarean Section: Meta-analysis, Meta-regression and Trial Sequential Analysis." International Journal of Obstetric Anesthesia, vol. 37, 2019, pp. 16-28.
Heesen M, Rijs K, Hilber N, et al. Ephedrine versus phenylephrine as a vasopressor for spinal anaesthesia-induced hypotension in parturients undergoing high-risk caesarean section: meta-analysis, meta-regression and trial sequential analysis. Int J Obstet Anesth. 2019;37:16-28.
Heesen, M., Rijs, K., Hilber, N., Ngan Kee, W. D., Rossaint, R., van der Marel, C., & Klimek, M. (2019). Ephedrine versus phenylephrine as a vasopressor for spinal anaesthesia-induced hypotension in parturients undergoing high-risk caesarean section: meta-analysis, meta-regression and trial sequential analysis. International Journal of Obstetric Anesthesia, 37, pp. 16-28. doi:10.1016/j.ijoa.2018.10.006.
Heesen M, et al. Ephedrine Versus Phenylephrine as a Vasopressor for Spinal Anaesthesia-induced Hypotension in Parturients Undergoing High-risk Caesarean Section: Meta-analysis, Meta-regression and Trial Sequential Analysis. Int J Obstet Anesth. 2019;37:16-28. PubMed PMID: 30477997.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Ephedrine versus phenylephrine as a vasopressor for spinal anaesthesia-induced hypotension in parturients undergoing high-risk caesarean section: meta-analysis, meta-regression and trial sequential analysis. AU - Heesen,M, AU - Rijs,K, AU - Hilber,N, AU - Ngan Kee,W D, AU - Rossaint,R, AU - van der Marel,C, AU - Klimek,M, Y1 - 2018/10/19/ PY - 2018/06/10/received PY - 2018/10/01/revised PY - 2018/10/13/accepted PY - 2018/11/28/pubmed PY - 2018/11/28/medline PY - 2018/11/28/entrez KW - Caesarean section KW - Fetal compromise KW - Meta-analysis KW - Spinal-anaesthesia KW - Vasopressor SP - 16 EP - 28 JF - International journal of obstetric anesthesia JO - Int J Obstet Anesth VL - 37 N2 - BACKGROUND: Phenylephrine is the preferred vasopressor for the prevention and treatment of spinal anaesthesia-induced hypotension during caesarean section, because studies on low-risk elective patients found it to have a less detrimental effect on umbilical artery pH compared with ephedrine. However, limited data exist from high-risk parturients and parturients with uteroplacental insufficiency. METHODS: We systematically searched for randomised, controlled, double-blinded trials of these two vasopressors in high-risk caesarean sections. We applied conventional meta-analysis, trial sequential analysis, computing the required information size that would exclude type I and II errors, contour-enhanced funnel plot testing for publication bias, meta-regression to assess the dose-response relationship, and the Grading of Recommendations Assessment, Development, and Evaluation system (GRADE). The incidence of fetal acidosis (umbilical arterial pH <7.2) was the primary outcome. RESULTS: Eight trials (712 patients) with low risk of bias were identified. Pooling six studies of patients with preeclampsia and other reasons for fetal compromise, as well as subgroup analysis of the preeclampsia studies, revealed no significant differences in the incidence of fetal acidosis. Trial sequential analysis showed that the required information size was not reached. The funnel plot was not suggestive of publication bias. Meta-regression showed no dose-response relationship. The GRADE score was moderate quality. CONCLUSIONS: Despite several studies and a large number of patients there was insufficient evidence to make a recommendation for choice of vasopressor in high-risk caesarean section. Trials with adequate power to detect differences in the incidence of fetal acidosis between ephedrine and phenylephrine are required to provide evidence-based guidance. SN - 1532-3374 UR - https://www.unboundmedicine.com/medline/citation/30477997/Ephedrine_versus_phenylephrine_as_a_vasopressor_for_spinal_anaesthesia_induced_hypotension_in_parturients_undergoing_high_risk_caesarean_section:_meta_analysis_meta_regression_and_trial_sequential_analysis_ L2 - https://linkinghub.elsevier.com/retrieve/pii/S0959-289X(18)30261-9 DB - PRIME DP - Unbound Medicine ER -