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LETTER TO THE EDITOR

Is Ephedrine the Best Vasopressor for Treating Spinal Anesthesia-Induced Hypotension in Patients with Pre-Eclampsia?

Department of Anesthesiology and Pain Management; University Hospital; Nîmes, France; guy.aya{at}chu-nimes.fr

In Response:

We thank Dr Slack for his letter (1) questioning the choice of ephedrine for the treatment of spinal anesthesia-induced hypotension in pre-eclamptic patients (2), based on the possibility of increasing the risk of postpartum seizures. Ephedrine and related alkaloids have been associated with adverse events, ranging from headache to death, and including seizures and cerebrovascular accidents. However, these events occurred in subjects taking large doses of ephedrine or associated compounds as dietary supplements for a longer period of time.

This is not the case for patients with severe pre-eclampsia, to whom ephedrine is given for the treatment of spinal anesthesia-induced hypotension. Pre-eclamptic patients exhibit a high vascular sensitivity to vasopressors. Small doses of ephedrine are sufficient to restore arterial blood pressure to pre-spinal anesthesia values. Ephedrine has a long history of use for treatment of spinal anesthesia-induced hypotension in both healthy and pre-eclamptic parturients. In pregnant women, the only side effects reported are transient hypertension and tachycardia at large doses (3,4), and possibly cardiac arrhythmias (5). Furthermore, Smiley et al. (6) reported two patients with neurovascular disease who underwent spinal anesthesia for cesarean delivery. These patients experienced spinal hypotension and were given ephedrine for treatment. There was no significant alteration in transcranial Doppler signals or values during the decrease in arterial blood pressure or in response to ephedrine. Pre-eclamptics could respond differently as they have increased cerebral perfusion pressure and cerebrovascular resistance at baseline (7).

Most significantly, ephedrine has been used for decades in pre-eclamptic patients. However, there are no reports of seizures attributed to ephedrine given for preventing or for treating spinal anesthesia-hypotension in any patient. This suggests that the risk of seizures with ephedrine and related alkaloids is related to chronic misuse and abuse of ephedrine, not to its medical use. Nevertheless, whether ephedrine is better than other vasopressors for treating spinal hypotension in pre-eclamptic patients remains to be established.

REFERENCES

1. Slack MR. Is ephedrine the best vasopressor for treating spinal anesthesia-induced hypotension in patients with pre-eclampsia? Anesth Analg 2006;103:1584.[Free Full Text]
2. Aya GMA, Vialles N, Issam TI, et al. Spinal anesthesia-induced hypotension: a risk comparison between patients with severe pre-eclampsia and healthy women undergoing preterm cesarean delivery. Anesth Analg 2005;101:869–75.[Abstract/Free Full Text]
3. Ngan Kee WD, Gin T. A quantitative, systematic review of randomized controlled trials of ephedrine versus neosynephrine for the management of hypotension during spinal anesthesia for cesarean delivery. Anesth Analg 2002;94:920–6.[Abstract/Free Full Text]
4. Lee A, Ngan Kee WD, Gin T. A dose-response meta-analysis of prophylactic intravenous ephedrine for the prevention of hypotension during spinal anesthesia for elective cesarean delivery. Anesth Analg 2004;98:483–90.[Abstract/Free Full Text]
5. Coven G, Arpesella R, Ciceri M, et al. Accelerated idioventricular rhythm during spinal anesthesia for cesarean section. Int J Obstet Anesth 2003;12:121–5.[Web of Science][Medline]
6. Smiley RM, Ridley DM, Hartmann A, et al. Transient Doppler blood flow measurement during cesarean section in two patients with cerebral vascular disease. Int J Obstet Anesth 2002;11:211–15.[Web of Science][Medline]
7. Williams KP, Wilson S. Variation in cerebral perfusion pressure with different hypertensive states in pregnancy. Am J Obstet Gynecol 1998;179:1200–3.[Web of Science][Medline]

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