Imai Eriya, Kataoka Yuki, Watanabe Jun, Okano Hiromu, Kamimura Yuji, Tsuji Tatsuya, Ogura Yasuhiro, Kodaira Ami, Yamazaki Tsutomu
Department of Social Medical Sciences, Graduate School of Medicine, International University of Health and Welfare, Minato City, Tokyo, Japan.
Division of Anesthesia, Mitsui Memorial Hospital, Chiyoda City, Tokyo, Japan.
J Anesth. 2025 Jun 16. doi: 10.1007/s00540-025-03528-4.
Postspinal hypotension (PSH) during cesarean section (CS) often causes maternal intraoperative nausea and vomiting (IONV) and fetal acidosis. Phenylephrine (PE) and norepinephrine (NE) are commonly used for management; however, the optimal agent and method (bolus vs. infusion) remains uncertain. This review assessed bolus and infusion of PE and NE for IONV and PSH during CS.
Systematic searches of MEDLINE, Embase, CENTRAL, and unpublished studies identified randomized controlled trials (RCTs) on PE and NE administration during CS under spinal anesthesia. Primary outcomes included IONV and PSH, whereas secondary outcomes encompassed Apgar scores, umbilical artery pH, rescue vasopressor bolus requirements, and adverse events. A random-effects meta-analysis and the Confidence in Network Meta-Analysis tool were utilized.
Among 74 RCTs (7798 patients), NE and PE infusion reduced IONV compared with PE bolus (risk ratio [RR]: 0.47; 95% confidence interval [CI] 0.34-0.66; RR: 0.54; 95% CI 0.42-0.69, high confidence). Similarly, these approaches reduced PSH (NE infusion: RR: 0.25; 95% CI 0.21-0.31, high confidence; PE infusion: RR: 0.29; 95% CI 0.24-0.34, moderate confidence). Rescue vasopressor bolus requirements showed a similar trend. Apgar scores and umbilical artery pH were comparable across all groups. Adverse event varied, with bradycardia more common with PE, tachycardia with boluses, and dizziness with PE bolus. Hypertension was more frequent with infusions. In prophylactic studies, hypotension trends persisted, but no differences were observed in IONV.
Prophylactic continuous infusion appears to be a favorable strategy for managing PSH and IONV during CS. No significant difference was observed between PE and NE infusions in preventing PSH and IONV.
剖宫产（CS）期间的脊柱后低血压（PSH）常导致产妇术中恶心呕吐（IONV）和胎儿酸中毒。去氧肾上腺素（PE）和去甲肾上腺素（NE）常用于处理；然而，最佳药物和方法（推注与输注）仍不确定。本综述评估了剖宫产期间推注和输注PE及NE对IONV和PSH的影响。
对MEDLINE、Embase、CENTRAL以及未发表的研究进行系统检索，以确定在脊髓麻醉下剖宫产期间给予PE和NE的随机对照试验（RCT）。主要结局包括IONV和PSH，次要结局包括阿氏评分、脐动脉pH值、血管升压药抢救推注需求以及不良事件。采用随机效应荟萃分析和网状荟萃分析置信度工具。
在74项RCT（7798例患者）中，与PE推注相比，NE和PE输注降低了IONV（风险比[RR]：0.47；95%置信区间[CI]0.34 - 0.66；RR：0.54；95%CI 0.42 - 0.69，高置信度）。同样，这些方法降低了PSH（NE输注：RR：0.25；95%CI 0.21 - 0.31，高置信度；PE输注：RR：0.29；95%CI 0.24 - 0.34，中等置信度）。血管升压药抢救推注需求呈现类似趋势。所有组的阿氏评分和脐动脉pH值相当。不良事件各不相同，PE更常导致心动过缓，推注导致心动过速，PE推注导致头晕。输注导致高血压更常见。在预防性研究中，低血压趋势持续存在，但IONV方面未观察到差异。
预防性持续输注似乎是剖宫产期间处理PSH和IONV的有利策略。在预防PSH和IONV方面，PE和NE输注之间未观察到显著差异。
