Obstetrik hastalarda, SARS-CoV-2 spinal sonrası hipotansiyon için risk faktörü müdür?

Amaç: COVID-19 pandemisinin başından itibaren, sezaryen operasyonlarında genel anestezide entübasyon ve ekstübasyon sırasında olası virüs yayılımını önlemek için Nöroaksiyel anestezi uygulanması önerilmektedir. Ancak yapılan bazı çalışmalarda aktif COVID-19 varlığında spinal anestezi güvenliğinin, hipotansiyon nedeniyle tartışmalı olduğu belirtilmektedir. Bu çalışmamızda amacımız COVID-19’lu gebe hastalardaki spinal sonrası hipotansiyon oranını literatürde ki COVID 19 olmayan hastalarla karşılaştırarak, Nöroaksiyel anestezinin güvenirliliğini tespit etmektir. Gereç ve Yöntem: Pandeminin başından, Aralık 2020 yılına kadar olan COVID-19’lu gebelerin medikal kayıtları retrospektif olarak çalışmaya dahil edilmiştir. Demografik- vital, özellikle sistolik ve diastolik kan basınçları, kullanılan efedrin-atropin dozları, infüzyon volümleri ve bulantı- kusma sıklığı analiz edilmiştir. Bulgular: Spinal anestezinin neden olduğu hipotansiyon hastaların 54’ünde görülmüştür. (%21,69). Vazopressor (efedrin) tüm hipotansif hastalarda kullanılmıştır. Demografik veriler, kullanılan bupivakain ve spinal anestezi öncesi kullanılan kristaloid volüm miktarı hipotansif olan ve olmayan hastalar arasında farklılık göstermemiştir. Sonuç: Literatürde ilk defa çalışmamızda tek merkezli 249 COVID 19 (+) hastanın spinal anestezi sonrası hipotansiyon oranları ile literatürde ki spinal anestezi sonrası hipotansiyon oranları arasında istatiksel olarak fark olmadığı gösterilmiştir. COVID-19 hastalarında rejyonel anestezinin güvenle uygulanabileceğini önermekteyiz.

Anahtar Kelimeler:

hipotansiyon, SARS-CoV-2, obstetrik anestezi, rejyonel anestezi, , spinal anestezi

Is SARS-CoV-2 a risk factor for hypotension during spinal anesthesia for obstetric patients?

Background: Since the onset of COVID-19, recommendations suggest the use of neuraxial anesthesia, over general anesthesia for cesarian section to avoid the risks of aerosolization associated with intubation and extubation. But the safety of performing spinal anesthesia is unclear especially for post spinal hypotension, during the presence of active COVID-19. According to a few studies there was a controversial discussion about the safety of regional anesthesia. In this study we aimed to compare the incidence of hypotension in COVID-19 pregnant patients between non-COVID 19 pregnant patients in the literature to see if the spinal anesthesia is safe or if it poses an additional risk. Materials and Methods: Medical records of COVID-19 pregnant women for cesarean section from the beginning of the pandemic up to December 2020 were retrospectively retrieved. All the demographic-vital data, including systolic and diastolic blood pressure (SBP-DBP), ephedrine-atropine doses, infusion volumes, and nausea and vomiting were retrospectively analyzed. Results: Spinal anesthesia induced hypotension was seen 54 of the patients (21,69%). And vasopressors (Ephedrine) were used to all hypotensive patients. Demographic data’s, the amount of bupivacaine and crystalloid volume which used before the spinal anesthesia showed no differences between hypotensive and non-hypotensive patients. Conclusion: This is the first retrospective study which shows 249 COVID 19 patients’ data in one center that no significant difference was seen in the incidence of hypotension associated with spinal anesthesia for COVID-19 cesarean section compared to non-COVID group in literature. We recommend using of regional anesthesia safely for patients and anesthesiologists during active COVID-19 patients.

Keywords:

hypotension, , SARS-C0V-2, spinal anesthesia, regional anesthesia, obstetrical anesthesia,

PDF

___

1- Allotey J, Stallings E, Bonet M, Yap M, Chatterjee S, Kew T, et al. for PregCOV-19 Living Systematic Review Consortium. Clinical manifestations, risk factors, and maternal and perinatal outcomes of coronavirus disease 2019 in pregnancy: living systematic review and meta-analysis. BMJ. 2020 Sep 1;370:m3320.
2- Pierce-Williams RAM, Burd J, Felder L, Khoury R, Bernstein PS, Avila K, et al. Clinical course of severe and critical coronavirus disease 2019 in hospitalized pregnancies: a United States cohort study. Am J Obstet Gynecol MFM. 2020 Aug;2(3):100134.
3- Uppal V, Sondekoppam RV, Landau R, El-Boghdadly K, Narouze S, Kalagara HKP. Neuraxial anaesthesia and peripheral nerve blocks during the COVID-19 pandemic: a literature review and practice recommendations. Anaesthesia. 2020 Oct;75(10):1350-1363.
4- COVID-19 Guidance for Regional Anesthesia Neuraxial Anesthesia and Peripheral Nerve Blocks. https://esraeurope.org/wp-content/uploads/2020/04/ESRAASRA-COVID-19-Guidelines-.pdf
5- Wax RS, Christian MD. Practical recommendations for critical care and anesthesiology teams caring for novel coronavirus (2019-nCoV) patients. Can J Anaesth. 2020 May;67(5):568-576.
6- Chen R, Zhang Y, Huang L, Cheng BH, Xia ZY, Meng QT. Safety and efficacy of different anesthetic regimens for parturients with COVID-19 undergoing Cesarean delivery: a case series of 17 patients. Can J Anaesth. 2020 Jun;67(6):655-663.
7- Benhamou D, Meyer HK, Morau E, Chassard D, Mercier FJ; French Obstetric Anesthesia Working Group (Club Anesthésie-Réanimation en Obstétrique [CARO]). Spinal anesthesia for Cesarean delivery in women with COVID-19 infection: questions regarding the cause of hypotension. Can J Anaesth. 2020;67(8):1097-1098.
8- Hashemi M, Taheri M, Aminnejad R. Spinal anesthesia in COVID-19 patients, more research is needed. Braz J Anesthesiol. 2020;70(2):185-186.
9- Macfarlane AJR, Harrop-Griffiths W, Pawa A. Regional anaesthesia and COVID-19: first choice at last?. Br J Anaesth. 2020;125(3):243-247.
10- Chen R, Zhang YY, Zhou Q, Meng QT. In reply: Spinal anesthesia for Cesarean delivery in women with COVID-19 infection: questions regarding the cause of hypotension. Can J Anaesth. 2020 Aug;67(8):1099-1100. doi: 10.1007/s12630-020-01664-x.
11- Miller AJ, Arnold AC. The renin-angiotensin system in cardiovascular autonomic control: recent developments and clinical implications. Clin Auton Res 2019; 29: 231-43.
12- Zhang Y, Chen R, Cao C, et al. The Risk of Neuraxial Anesthesia-Related Hypotension in COVID-19 Parturients Undergoing Cesarean Delivery: A Multicenter, Retrospective, Propensity Score Matched Cohort Study. Front Med (Lausanne). 2021; 8:713733. 13- Madden N, Emeruwa UN, Polin M, Bejerano S, Gyamfi-Bannerman C, Booker WA. SARS-CoV-2 and hypertensive disease in pregnancy. Am J Obstet Gynecol MFM. 2021; 25;4(1):100496.
14- Karasu D, Kilicarslan N, Ozgunay SE, Gurbuz H. Our anesthesia experiences in COVID-19 positive patients delivering by cesarean section: A retrospective single-center cohort study. J Obstet Gynaecol Res. 2021 Aug;47(8):2659-2665.
15- Mercier FJ, Augè M, Hoffmann C, Fischer C, Le Gouez A. Maternal hypotension during spinal anesthesia for caesarean delivery. Minerva Anestesiol. 2013 Jan;79(1):62-73. Epub 2012 Nov 18.
16- Lato K, Bekes I, Widschwendter P, Friedl TWP, Janni W, Reister F, et al. Hypotension due to spinal anesthesia influences fetal circulation in primary caesarean sections. Arch Gynecol Obstet. 2018;297(3):667-674.
17- Dyer RA, Reed AR. Spinal hypotension during elective cesarean delivery: closer to a solution. Anesth Analg 2010; 111:1093-5.
18- Mercier FJ. Fluid Loading for Cesarean Delivery Under Spinal Anaesthesia: Have We Studied All the Options? Anesth Analg 2011; 113:677-80.
19- Fakherpour A, Ghaem H, Fattahi Z, Zaree S. Maternal and anaesthesia-related risk factors and incidence of spinal anaesthesia-induced hypotension in elective caesarean section: a multinomial logistic regression. Indian J Anaesth. (2018) 62:36-46.
20- Russell IF. Levels of anaesthesia and intraoperative pain at caesarean section under regional block. Int J Obstet Anesth 1995; 4:71-7.
21- Mercier FJ, Bonnet MP, De la Dorie A, Moufouki M, Banu F, Hanaf A et al. Spinal anaesthesia for caesarean section: fluid loading, vasopressors and hypotension. Ann Fr Anesth Reanim 2007; 26:688-93.
22- Kinsella SM, Whitwam JG, Spencer JA. Reducing aortocaval compression: how much tilt is enough? BMJ 1992; 305:539-40.
23- Langesaeter E, Rosseland LA, Stubhaug A. Continuous invasive blood pressure and cardiac output monitoring during cesarean delivery: a randomized, double-blind comparison of low-dose versus high-dose spinal anesthesia with intravenous phenylephrine or placebo infusion. Anesthesiology 2008; 109:856-863.
24- Sharwood-Smith G, Drummond GB. Hypotension in obstetric spinal anaesthesia: a lesson from pre-eclampsia. Br J Anaesth 2009; 102:291-4.
25- Dyer RA, Reed AR, van Dyk D, Arcache MJ, Hodges O, Lombard CJ, et al. Hemodynamic effects of ephedrine, phenylephrine, and the coadministration of phenylephrine with oxytocin during spinal anesthesia for elective cesarean delivery. Anesthesiology. 2009 Oct;111(4):753-65.
26- Roofthooft E, Van de Velde M. Low-dose spinal anaesthesia for Caesarean section to prevent spinal-induced hypotension. Curr Opin Anaesthesiol 2008;21(3):259-62
27- Benhamou D, Wong C. Neuraxial anesthesia for cesarean delivery: what criteria define the "optimal" technique? Anesth Analg. 2009 Nov;109(5):1370-3.
28- Goodnight WH, Soper DE. Pneumonia in pregnancy. Crit Care Med 33, Suppl: S390– S397, 2005.
29- Thomas-Rüddel D, Winning J, Dickmann P, Ouart D, Kortgen A, Janssens U, Bauer M. Coronavirus disease 2019 (COVID-19): update for anesthesiologists and intensivists March 2020. Anaesthesist. 2021 Dec;70(Suppl 1):1-10.
30- Adhikari EH, SoRelle JA, McIntire DD, Spong CY. Increasing severity of COVID-19 in pregnancy with Delta (B.1.617.2) variant surge. Am J Obstet Gynecol; 2021 Sep 14.