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OBSTETRIC ANESTHESIA

A Dose-Response Meta-Analysis of Prophylactic Intravenous Ephedrine for the Prevention of Hypotension During Spinal Anesthesia for Elective Cesarean Delivery

Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong, China

Address correspondence to Anna Lee, MPH, PhD, Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, NT, Hong Kong, China. Address e-mail to annalee{at}cuhk.edu.hk

We systematically reviewed available studies to determine the dose-response characteristics of prophylactic IV ephedrine for the prevention of hypotension during spinal anesthesia for cesarean delivery. We searched for randomized controlled trials (RCTs) or cohort studies—obtained through MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, and reference lists of published articles—in which two or more different doses of prophylactic IV ephedrine were used to prevent hypotension during spinal anesthesia for cesarean delivery. Four RCTs and one cohort study were found (total n = 390). There was a significant dose-response relationship in the RCTs pooled for hypotension (slope = -0.0128; 95% confidence interval [CI], -0.0213 to -0.0044), hypertension (slope = 0.0563; 95% CI, 0.0235 to 0.0892), and umbilical arterial pH (slope = -0.03; 95% CI, -0.05 to 0.00). The efficacy of ephedrine for preventing hypotension was small. At 14 mg, the number-needed-to-treat was only 7.6 (95% CI, 4.8–21.1), and this was the same as the number-needed-to-harm (7.6; 95% CI, 3.7–23.4). At larger doses, the likelihood of causing hypertension was actually more than that of preventing hypotension, and there was also a minor decrease in umbilical arterial pH.

IMPLICATIONS: The authors performed a systematic review of dose-response studies of IV bolus ephedrine for preventing hypotension during spinal anesthesia for cesarean delivery. Prophylactic ephedrine cannot be recommended. The efficacy is poor at smaller doses, whereas at larger doses, the likelihood of causing hypertension is actually more than that of preventing hypotension.

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