EFFICACY OF FLUID ADMINISTRATION BY INFERIOR VENA CAVA ULTRASONOGRAPHY GUIDANCE VERSUS EMPIRICAL METHOD FOR PREVENTION OF ARTERIAL HYPOTENSION IN SPINAL ANESTHESIA PATIENTS UNDERGOING ORTHOPAEDIC SURGERIES - A RANDOMIZED CONTROLLED STUDY
Main Article Content
Keywords
Inferior Vena Cava, Echocardiography.
Abstract
Background: Spinal anesthesia is widely used for lower-limb orthopedic surgery but is frequently complicated by arterial hypotension due to sympathetic blockade and venous pooling. Empirical fluid loading has inconsistent efficacy and risks fluid overload. Ultrasonographic assessment of the inferior vena cava (IVC) collapsibility index (IVCCI) offers a non-invasive means of predicting fluid responsiveness and guiding individualized fluid therapy.
Methods: In this single-center, randomized controlled trial, 100 ASA I–II adults aged 18–40 years scheduled for elective orthopedic surgery under spinal anesthesia were allocated to either IVC ultrasonography-guided fluid administration (Group A) or empirical fluid preloading (Group B). Group A received 500 ml Ringer Lactate boluses if IVCCI ≥ 36%, repeated until <36%. Group B received a fixed preload of 5 ml/kg Ringer Lactate. The primary outcome was incidence of post-spinal arterial hypotension (systolic BP <90 mmHg or diastolic BP <60 mmHg) within 30 minutes. Secondary outcomes included total crystalloid volume and vasopressor (mephentermine) requirement.
Results: Hypotension occurred in 8% of Group A versus 28% of Group B (p = 0.019). Group A received more total fluid (726 ± 71.6 ml) than Group B (611.1 ± 113.4 ml, p < 0.001), but fewer mephentermine boluses (0.12 ± 0.33 vs. 0.34 ± 0.56, p = 0.018). Mixed-effects models showed significantly better maintenance of systolic and mean arterial pressure in Group A (p < 0.01).
Conclusion: IVC ultrasonography-guided fluid therapy significantly reduced the incidence of post-spinal hypotension and vasopressor use compared with empirical preloading, supporting its use for individualized perioperative hemodynamic management in orthopedic anesthesia.
References
[2] Sessler DI. Hypothermia and hypotension during spinal anesthesia. Anesth Analg 2008;106(1):265-72.
[3] van Zundert AA. Incidence, risk factors and consequences of hypotension following spinal anesthesia for cesarean section. Br J Anaesth 2013;111(1):99-104.
[4] Gan TJ. A randomized comparison of phenylephrine versus ephedrine infusions for management of spinal-induced hypotension in cesarean delivery. Anesthesiology, 2013;118(1):99-107.
[5] Caironi, P. Respiratory and circulatory changes following spinal anesthesia in patients undergoing orthopedic surgery. Anesth Analg 2018;126(2):543-649.
[6] Monnet X. Dynamic changes in arterial pressure during volume expansion. Intensive Care Medicine 2011;37(1):123-30.
[7] Cavalcanti AB. The relationship between volume status and hypotension after spinal anesthesia for cesarean section. BMC Anesthesiology 2012;12(1):52.
[8] Lichtenstein DA, Mezière GA. Relevance of lung ultrasound in the diagnosis of acute respiratory failure: The BLUE protocol. Chest 2008;134(1):117-25.
[9] Cecconi M. Consensus on circulatory shock and hemodynamic monitoring. Intensive Care Medicine 2014;40(12):1795-815.
[10] Berzosa M. Inferior vena cava diameter variations as a guide to fluid therapy. Journal of Critical Care 2005;20(4):357-64.
[11] Preau, M. IVC diameter and collapsibility index as noninvasive measures of volume status in critically ill septic patients. Chest 2006;130(6):1752-9.
[12] American Society of Echocardiography. ASE guidelines for the use of echocardiography in clinical practice. Journal of the American Society of Echocardiography 2015;28(1):e1-39.
[13] Shishido T. Predictive value of inferior vena cava collapsibility index for hypotension after induction of general anesthesia. Br J Anaesth 2017;119(4):659-64.
[14] Ma Q. Inferior vena cava ultrasound-guided fluid management reduces the incidence of hypotension in spinal anesthesia for cesarean section: a randomized controlled trial. Journal of Clinical Anesthesia 2019;58:92-97.
[15] Beattie J. Preoperative optimization for orthopedic surgery patients with medical comorbidities. Br J Anaesth 2016;116(Suppl 1):i41-9.
[16] Arnold MA, Ng M. Point-of-care ultrasound: A practical guide for healthcare professionals. Journal of Emergency Nursing 2016;42(6):593-600.
[17] Lee JY. Inferior vena cava ultrasound-guided fluid management reduces spinal anesthesia-induced hypotension in elderly patients undergoing hip surgery: a randomized controlled trial. Eur J Anaesthesiol 2018;35(6):414-20.
[18] Ni TT, Zhou ZF, He B, et al. Inferior vena cava collapsibility index can predict hypotension and guide fluid management after spinal anesthesia. Front Surg 2022;9:831539.
[19] Ceruti S, Favre M, Biggiogero M, et al. Prevention of arterial hypotension after spinal anaesthesia using vena cava ultrasound: a randomised controlled trial. Br J Anaesth 2018;120(4):823-31.
[20] Salama ER, Elkashlan M. Pre-operative ultrasonographic evaluation of inferior vena cava collapsibility index and caval-aorta index as predictors for hypotension after spinal anaesthesia: a prospective observational study. Eur J Anaesthesiol 2019;36(4):297-302.
[21] Favre M, Ceruti S, Biggiogero M, et al. Fluid administration guided by inferior vena cava ultrasound before spinal anaesthesia may reduce post-procedural hypotension rate. medRxiv [preprint]. 2021. doi:10.1101/2021.06.20.21258944.
[22] Saporito A, Ceruti S, Favre M, et al. PROtocolized care to reduce hypotension after spinal anesthesia (PRO-HYPO): ultrasound-guided fluid pre-loading. Ultrasound J 2014;7(Suppl 1):A3.
[23] Renu R, Sharma UD, Sharma V, et al. Ultrasound-guided assessment of inferior vena cava collapsibility index and fluid optimisation to minimise spinal-induced hypotension in femur-fracture surgery. Int J Pharm Clin Res 2023;15(11):1263-8.
Article Sidebar
Article Details
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
All articles published in JPTCP are licensed under Copyright Creative Commons Attribution-NonCommercial 4.0 International License.
Dr. Lavish Gulabrao Gaikwad
Junior Resident, Department of Anaesthesiology, Government Medical College, Nagpur, Maharashtra, India.
Dr. Megha Tajne
Professor & HOD, Department of Anaesthesiology, Government Medical College, Nagpur, Maharashtra, India.
Dr. Tanisha Uikey
Undergraduate Student, Datta Meghe Institute of Higher Education and Research, Nagpur, Maharashtra, India.
Dr. Avishkar Gaikwad
Undergraduate Student, Datta Meghe Institute of Higher Education and Research, Nagpur, Maharashtra, India.
Dr. Kasireddy Spoorthi
Junior Resident, Department of Anesthesiology, Government Medical College, Nagpur, Maharashtra, India.