Management of spinal-induced hypotension for elective caesarean section: A survey of practices among anesthesiologists from a developing country

Abstract

Background: In developing countries, more than half of the anesthesia-related maternal deaths are related to spinal hypo- tension. Objective: To explore the practices of management of spinal induced hypotension with respect to fluid and vasopressor administration among anesthesiologists from a developing country. Methods: After approval from institutional ethics committee, an online questionnaire was sent to anesthesiologists reg- istered with Pakistan Society of Anesthesiologists between July and August 2018 to determine management strategies for prevention and treatment of spinal-induced hypotension. Results: The response rate was 36% (156/433), majority from academic institution (62.8%) with equal representation from attending and trainee anesthesiologist. For prophylaxis 39.1% respondents did not use vasopressors, 32.7% used fluid preloading with crystalloids (54.7%) as fluid of choice followed by combination of co-loading and vasopressor(22.4%). Phenylephrine was the vasopressor of choice for both prophylaxis (33.1%) and treatment (57%). Attending anesthesiologist used a combination of fluid co-loading and vasopressors for prophylaxis as compared to trainee anesthesiologists (37.2% vs. 17.9%; P=0.035) and selected vasopressors according to patient’s heart rate (33.3% vs. 19.5%; p=0.05). Prophylactic phenylephrine was used more by respondents from the academic institution (p=0.023). Fluid co-loading was used more by respondents with <30 % compared to those with > 30% of clinical responsibility to obstetric anesthesia (P<0.05). Conclusion: Phenylephrine as the vasopressor of choice indicates growing awareness of management strategies among anesthesiologists from developing countries but there is a need to increase its use for prophylaxis. Some variation in practice according to the level of anesthesiologist, practice type and responsibilities to obstetric anesthesia are evident. Keywords: Spinal anesthesia; Hypotension; Cesarean delivery; Vasopressors.