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.
Acidosis
/ epidemiology
Anesthesia, Obstetrical
/ adverse effects
Anesthesia, Spinal
/ adverse effects
Cesarean Section
Ephedrine
/ therapeutic use
Female
Fetal Diseases
/ epidemiology
Humans
Hypotension
/ prevention & control
Phenylephrine
/ therapeutic use
Pregnancy
Vasoconstrictor Agents
/ therapeutic use
Caesarean section
Fetal compromise
Meta-analysis
Spinal-anaesthesia
Vasopressor
Journal
International journal of obstetric anesthesia
ISSN: 1532-3374
Titre abrégé: Int J Obstet Anesth
Pays: Netherlands
ID NLM: 9200430
Informations de publication
Date de publication:
Feb 2019
Feb 2019
Historique:
received:
10
06
2018
revised:
01
10
2018
accepted:
13
10
2018
pubmed:
28
11
2018
medline:
20
8
2019
entrez:
28
11
2018
Statut:
ppublish
Résumé
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. 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. 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. 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.
Sections du résumé
BACKGROUND
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
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
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
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.
Identifiants
pubmed: 30477997
pii: S0959-289X(18)30261-9
doi: 10.1016/j.ijoa.2018.10.006
pii:
doi:
Substances chimiques
Vasoconstrictor Agents
0
Phenylephrine
1WS297W6MV
Ephedrine
GN83C131XS
Types de publication
Comparative Study
Journal Article
Meta-Analysis
Langues
eng
Pagination
16-28Commentaires et corrections
Type : ErratumIn
Informations de copyright
Copyright © 2018 Elsevier Ltd. All rights reserved.