MAHMUT ARSLAN, GÖZEN ÖKSÜZ, BORA BİLAL, Cengizhan YAVUZ, Mehmet KANDİLCİK, ADEM DOĞANER, FEYZA ÇALIŞIR

Can Perfusion Index or Pleth Variability Index Predict Spinal Anesthesia-Induced Hypotension During Caesarean Section?

Objective: Although spinal anesthesia is the preferred anesthetic method for cesarean sections, it leads to hypotension in a significant proportion of the patients. In this study, we assessed the predictive ability of perfusion index (PI) and Pleth variability index (PVI) in different positions, for prediction of hypotension after spinal anesthesia administered for cesarean delivery. Methods: Ninety parturients scheduled for elective lower segment cesarean section under spinal anesthesia were enrolled in the study. In the preoperative holding area, PI and PVI values were recorded in the supine, semi-recumbent, passive leg raise and left lateral positions. Then, partu- rients were taken to the operating room; their PI and PVI values were recorded again in the supine and sitting positions. Spinal anesthesia was performed with 0.5% hyperbaric bupivacaine (10 mg) injected through L3-L4 or L4-L5 interspaces with the patient in the sitting position. PI and PVI values were recorded one minute after induction of spinal anesthesia as postspinal measure- ments. The effects of independent variables on hypotension were examined with logistic regres- sion analysis. The relationship between PI and PVI values and incidence of hypotension was evaluated using ROC analysis. Results: The incidence of hypotension was 60 percent. Postspinal PVI was found to have a weak predictive value for postspinal hypotension (AUC=0.663, 95% CI 0.530-0.796, p=0.024). Conclusion: Among the parameters evaluated, only postspinal PVI was associated with spinal anesthesia-induced hypotension in cesarean section. However, it may not be useful in routine clinical practice due to its low specificity and sensitivity.

Sezaryen Operasyonlarında Spinal Anesteziye Bağlı Hipotansiyon Perfüzyon İndeksi veya Pleth Variabilite İndeks ile Öngörülebilir mi?

Amaç: Sezaryen operasyonlarında tercih edilen anestezi yöntemi spinal anestezidir, ancak hasta- ların önemli bir kısmında hipotansiyona yol açar. Bu çalışmada, farklı pozisyonlardaki perfüzyon indeksi (Pİ) ve pleth variabilite indeksi (PVİ) değerlerinin sezaryen operasyonu için uygulanan spinal anestezi sonrası gelişen hipotansiyonu öngörme kabiliyetini değerlendirdik. Yöntem: Spinal anestezi ile alt segment sezaryen operasyonu olacak 90 gebe çalışmaya dahil edildi. Preoperatif hazırlık odasında supin, yarı oturur, pasif bacak kaldırma ve sol lateral dekübit pozisyonlarda iken, Pİ ve PVİ değerleri kaydedildi. Sonra hastalar ameliyat odasına alındı ve supin ve oturur pozisyonlarda Pİ ve PVİ değerleri yeniden kaydedildi. Oturur pozisyonda L3-L4 veya L4-L5 aralıklarından 10 mg %0.5 bupivakain ile spinal anestezi uygulandı. Spinal anesteziden bir dk sonraki Pİ ve PVİ değerleri postspinal değerleri olarak kaydedildi. Bağımsız değişkenlerin hipo- tansiyon üzerine etkileri logistik regresyon analizi ile değerlendirildi. Pİ ve PVİ değerleri ile hipo- tansiyon arasındaki ilişki ROC analizi ile değerlendirildi. Bulgular: Hipotansiyon insidansı %60 idi. Spinal sonrası hipotansiyon için post-spinal PVİ değeri- nin zayıf prediktif değeri olduğunu saptadık (AUC=0.663, 95% CI 0.530-0.796, p=0.024). Sonuç: Değerlendirilen parametreler arasında, sezaryen operasyonlarında spinal anesteziye bağlı gelişen hipotansiyonla yalnızca post-spinal PVİ arasında ilişki saptandı. Ancak, bu değerin düşük spesifisite ve sensitivitesi nedeniyle rutin klinik uygulamada yararlı olmayabilir.

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Lee JE, George RB, Habib AS. Spinal-induced hypoten- sion: incidence, mechanisms, prophylaxis, and mana- gement: Summarizing 20 years of research. Best Pract Res Clin Anaesthesiol. 2017;31:57-68. https://doi.org/10.1016/j.bpa.2017.01.001

Klohr S, Roth R, Hofmann T, Rossaint R, Heesen M. Definitions of hypotension after spinal anaesthesia for caesarean section: literature search and application to parturients. Acta Anaesthesiol Scand. 2010;54:909-21. https://doi.org/10.1111/j.1399-6576.2010.02239.x

Kinsella S, Carvalho B, Dyer R, et al. International con- sensus statement on the management of hypotension with vasopressors during caesarean section under spi- nal anaesthesia. Anaesthesia. 2018;73:71-92. https://doi.org/10.1111/anae.14080

Ouzounian JG, Masaki DI, Abboud TK, Greenspoon JS. Systemic vascular resistance index determined by tho- racic electrical bioimpedance predicts the risk for maternal hypotension during regional anesthesia for cesarean delivery. Am J Obstet Gynecol. 1996;174:1019- 1025. https://doi.org/10.1016/S0002-9378(96)70343-5

Hanss R, Bein B, Ledowski T, et al. Heart rate variability predicts severe hypotension after spinal anesthesia for elective cesarean delivery. Anesthesiology. 2005;102:1086-93. https://doi.org/10.1097/00000542-200506000-00005

Berlac PA, Rasmussen YH. Peroperative cerebral near- infrared spectroscopy (NIRS) predicts maternal hypo- tension during elective caesarean delivery in spinal anaesthesia. Int J Obstet Anesth. 2005;14:26-31. https://doi.org/10.1016/j.ijoa.2004.06.003

Kuwata S, Suehiro K, Tsujimoto S, et al. Pleth variability index can predict spinal anaesthesia-induced hypoten- sion in patients undergoing caesarean delivery. Acta Anaesthesiologica Scandinavica. 2018;62:75-84. https://doi.org/10.1111/aas.13012

Sun S, Huang SQ. Role of pleth variability index for predicting hypotension after spinal anesthesia for cesarean section. Int J Obstet Anesth. 2014;23:324-9. https://doi.org/10.1016/j.ijoa.2014.05.011

Yokose M, Mihara T, Sugawara Y, Goto T. The predictive ability of non-invasive haemodynamic parameters for hypotension during caesarean section: A prospective observational study. Anaesthesia. 2015;70:555-62. https://doi.org/10.1111/anae.12992

Toyama S, Kakumoto M, Morioka M, et al. Perfusion index derived from a pulse oximeter can predict the incidence of hypotension during spinal anaesthesia for caesarean delivery. Br J Anaesth. 2013;111:235-41. https://doi.org/10.1093/bja/aet058

Xu Z, Xu T, Zhao P, et al. Differential Roles of the Right and Left Toe Perfusion Index in Predicting the Incidence of Postspinal Hypotension During Cesarean Delivery. Anesth Analg. 2017;125:1560-6. https://doi.org/10.1213/ANE.0000000000002393

Wrench I, Hammon L, Handa S, Mahajan R. Changes in pleth variability index and detection of hypotension during spinal anaesthesia for caesarean section . Int J Obstet Anesth. 2015;24:388-9. https://doi.org/10.1016/j.ijoa.2015.07.001

Zieleskiewicz L, Noel A, Duclos G, et al. Can point-of- care ultrasound predict spinal hypotension during caesarean section? A prospective observational study. Anaesthesia. 2018;73:15-22. https://doi.org/10.1111/anae.14063

Sakata K, Yoshimura N, Tanabe K, et al. Prediction of hypotension during spinal anesthesia for elective cesa- rean section by altered heart rate variability induced by postural change. Int J Obstet Anesth. 2017;29:34-8. https://doi.org/10.1016/j.ijoa.2016.09.004

Goldman JM, Petterson MT, Kopotic RJ, Barker SJ. Masimo signal extraction pulse oximetry. J Clin Monit Comput. 2000;16:475-83. https://doi.org/10.1023/A:1011493521730

Cannesson M, Desebbe O, Rosamel P, et al. Pleth vari- ability index to monitor the respiratory variations in the pulse oximeter plethysmographic waveform ampli- tude and predict fluid responsiveness in the operating theatre. Br J Anaesth. 2008;101:200-6. https://doi.org/10.1093/bja/aen133

Lee HC, Tsai YF, Tsai HI, et al. Pulse oximeter-derived pleth variability index is a reliable indicator of cardiac preload in patients undergoing liver transplantation. Transplant Proc. 2016;48:1055-8. https://doi.org/10.1016/j.transproceed.2015.12.106

Zimmermann M, Feibicke T, Keyl C, et al. Accuracy of stroke volume variation compared with pleth variabi- lity index to predict fluid responsiveness in mechani- cally ventilated patients undergoing major surgery. Eur J Anaesthesiol. 2010;27:555-61. https://doi.org/10.1097/EJA.0b013e328335fbd1

Hood JA, Wilson RJ. Pleth variability index to predict fluid responsiveness in colorectal surgery. Anesth Analg. 2011;113:1058-63. https://doi.org/10.1213/ANE.0b013e31822c10cd

Keller G, Cassar E, Desebbe O, Lehot JJ, Cannesson M. Ability of pleth variability index to detect hemodyna- mic changes induced by passive leg raising in sponta- neously breathing volunteers. Crit Care. 2008;12:R37. https://doi.org/10.1186/cc6822

Lu W, Dong J, Xu Z, et al. The pleth variability index as an indicator of the central extracellular fluid volume in mechanically ventilated patients after anesthesia induction: comparison with initial distribution volume of glucose. Med Sci Monit. 2014;20:386-92. https://doi.org/10.12659/MSM.890073

Duggappa DR, Lokesh M, Dixit A, et al. Perfusion index as a predictor of hypotension following spinal anaest- hesia in lower segment caesarean section. Indian J Anaesth. 2017;61:649-54. https://doi.org/10.4103/ija.IJA_429_16

Chamberlain DP, Chamberlain BD. Changes in the skin temperature of the trunk and their relationship to sympathetic blockade during spinal anesthesia. Anesthesiology. 1986;65:139-43. https://doi.org/10.1097/00000542-198608000-00002

Schiller Y. The anatomy and physiology of the sympat- hetic innervation to the upper limbs. Clin Auton Res. 2003;13:12-5. https://doi.org/10.1007/s10286-003-1102-6