Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Archana Dambal

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Dr. Archana Dambal
Department of General Medicine,
Belgaum Institute of Medical Sciences,Belgaum, Karnataka,INDIA,
On 30 Nov 2018




Dr Bhanu K Bhakhri

"The Journal of Clinical and Diagnostic Research (JCDR) has been in operation since almost a decade. It has contributed a huge number of peer reviewed articles, across a spectrum of medical disciplines, to the medical literature.
Its wide based indexing and open access publications attracts many authors as well as readers
For authors, the manuscripts can be uploaded online through an easily navigable portal, on other hand, reviewers appreciate the systematic handling of all manuscripts. The way JCDR has emerged as an effective medium for publishing wide array of observations in Indian context, I wish the editorial team success in their endeavour"



Dr Bhanu K Bhakhri
Faculty, Pediatric Medicine
Super Speciality Paediatric Hospital and Post Graduate Teaching Institute, Noida
On Sep 2018




Dr Mohan Z Mani

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I wish all success to your journal and look forward to sending you any suitable similar article in future"



Dr Mohan Z Mani,
Professor & Head,
Department of Dematolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

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Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011

Important Notice

Original article / research
Year : 2011 | Month : October | Volume : 5 | Issue : 5 | Page : 948 - 952

Comparison of Bolus Phenylephrine, Ephedrine and Mephentermine for Maintenance of Arterial Pressure during Spinal Anaesthesia in Caesarean Section

Ganeshanavar Anilkumar, Ambi Uday S., Shettar Adarsh E., Koppal Ramesh, R. Ravi

Corresponding Authori. MD, Assistant Professor, Dept. of Anaesthesiology, SN Medical College and HSK Hospital, Bagalkot, Karnataka, India. MD, Assistant Professor, Dept. of Anaesthesiology, SN Medical College and HSK Hospital, Bagalkot, Karnataka, India. MD, Associate Professor, Dept. of Anaesthesiology, SN Medical College and HSK Hospital, Bagalkot, Karnataka, India. MD DA. Professor, Dept. of Anaesthesiology, JJM Medical College and Bapuji Hospital, Davangere , Karnataka, India.

Correspondence Address :
Anilkumar Ganeshanavar (MD)
Assistant Professor, Department of Anaesthesiology,
SN Medical College and HSK Hospital,
Bagalkot, Karnataka, India-587101.
Phone: +918354-235400.
E-mail: anilganesh22@gmail.com

Abstract

Introduction: Hypotension following spinal anaesthesia for Caesarean section one of the common problem encountered by an anaesthesiologist. This study was aimed at comparing the efficacy of IV bolus Phenylephrine, Ephedrine, Mephentermine for maintenance of arterial blood pressure during spinal anesthesia in caesarean section.

Materials and Methods: Ninty American Society of An esthesiologists (ASA) type 1 and 2 patients scheduled for elective as well as emergency caesarean section under spinal anaesthesia who developed hypotension were selected. These were allocated into 3 groups of 30 each to receive Group P-Phenylephrine 100 8g, Group E- Ephedrine 6 mg, and Group M-Mephentermine 6 mg in 1 ml as bolus IV.

Results: On intergroup comparison rise of diastolic blood pressure at 2, 4, and 6 minutes post study drugs weresignificantly less in Ephedrine group and Mephentermine group as compared to the Phenylephrine group (p<0.05). Similarly elevation of systolic arterial pressure in Phenylephrine group was significantly higher compared to other two groups for first 6 minutes. Thereafter the differences narrowed off. No significant differences were observed between changes in systolic and diastolic blood pressure of Ephedrine and Mephentermine group at any time. In Phenylephrine group, post study drug values of heart rate were decreased significantly from the values at onset of the hypotension till the end of the surgery when compared to other two groups (p<0.001).

Conclusion : Phenylephrine group had quicker control of blood pressure compared to the other two groups. However, as the time elapsed all drugs achieved comparable control of blood pressure. Phenylephrine did show some advantage over others with regard to reduction in heart rate.

Keywords

Hypotension, Anaesthesia, LSCS

How to cite this article :

Ganeshanavar Anilkumar, Ambi Uday S., Shettar Adarsh E., Koppal Ramesh, R. Ravi. COMPARISON OF BOLUS PHENYLEPHRINE, EPHEDRINE AND MEPHENTERMINE FOR MAINTENANCE OF ARTERIAL PRESSURE DURING SPINAL ANAESTHESIA IN CAESAREAN SECTION. Journal of Clinical and Diagnostic Research [serial online] 2011 October [cited: 2019 Aug 25 ]; 5:948-952. Available from
http://www.jcdr.net/back_issues.asp?issn=0973-709x&year=2011&month=October&volume=5&issue=5&page=948-952&id=1537

Introduction
With the increasing incidence of Caesarean section (1), the anaesthesiologist is trapped in a delicate web of decision making over the type of anaesthetic technique to be employed which guarantees the safety of both the mother and fetus. In the recent decades there has been a worldwide shift in obstetric anesthesia practice in favour of regional anaesthesia with spinal anaesthesia being the most popular among them (2). Spinal anaesthesia was introduced into clinical practice by German Surgeon Karl August Bier in 1898. (3) Its popularity is due to the advantages it confers – relative simplicity, rapidity, certainty, duration, low failure rates, minimal side effects, an awake mother, least exposure of mother and fotus to anaesthetic drug and circumvention of life threatening complications like aspiration, failed intubations and depressed neonate. But, like any other anaesthetic technique, it is not devoid of complications, the most common being hypotension which may adversely affect both mother and fotus. The usual approach to use vasopressors in this clinical setting is reactive rather than proactive, spinal anaesthesia induced maternal hypotension is allowed to develop and then treated accordingly. Current study aimed to compare the efficacy of IV bolus Phenylephrine, Ephedrine and Mephentermine for maintenance of arterial blood pressure following spinal anaesthesia for elective as well as emergency caesarean section.

Material and Methods

This comparative study was done on parturient coming for elective as well as emergency lower segment Caesarean section conducted under spinal anaesthesia in S.N. Medical College and H.S. Hospital Bagalkot, Karnataka, India in Nov. 2010–August 2011. After approval from the institutional ethics committee, ninety parturients ASA I and II scheduled for elective as well as emergency Caesarean section and who developed hypotension after subarachnoid block (SAB) were included.

All parturients were at term, had uncomplicated singleton pregnancy with cephalic presentation and did not weigh more than 70 Kg. The protocol was explained to all patients in detail in their own language and informed written consent was taken. Following criteria’s were adopted for selecting parturients. Inclusion Criteria: Patients scheduled for elective as well as emergency lower segment Caesarean section; Aged between 20-35 years; Patients with ASA Class I and II; Baseline systolic blood pressure between 100-140 mmHg and diastolic blood pressure between 70-89 mmHg; And developed hypotension during the operation. Hypotension was defined as fall in systolic pressure >20% from the baseline value or a value less than 90 mmHg (4).

Exclusion Criteria
Patients with medical complications like diabetes mellitus, cardiovascular diseases, severe anaemia, and cerebrovascular diseases; wt more than 70 kg; Patients with obstetrical complications like antepartum haemorrhage, pregnancy induced hypertension, cord complications (nuchal cord or cord prolapse), fotal malformations or malpresentations; Patients with autonomic neuropathy, spinal deformities, other neurological diseases, infections in the lumbar area, coagulation abnormalities and hypovoluemia due to any cause.

Ranitidine 50 mg and Metaclopramide 10 mg were given intravenously as a routine practice before surgery. Patients were divided into three groups of 30 each. First 30 cases which satisfied the inclusion criteria were assigned to the Phenylephrine group and next 30 to Ephedrine group and last to mephentermine group. This was an open label study.

Dose: Group P: Phenylephrine 100 8g (0.1 mg) in 1 ml as IV bolus Group E: Ephedrine 6 mg in 1 ml as IV bolus and Group M: Mephentermine 6 mg in 1 ml as IV bolus was used as indicated.

Hyperbaric bupivacaine 0.5% was used for establishing spinal anaethesia. After preloading, pulse rate, systolic and diastolic arterial pressure were recorded thrice when middle value was taken as a base line values. The same parameters were recorded after subarachnoid block, then at every 1 min for 20 min and thereafter every 5 min till the end of surgery. Whenever hypotension occurred the study drug was given IV. The number of boluses and time taken to recover from hypotension were noted. The bradycardia i.e. a pulse rate of 60 min-1 or less was treated with atropine 0.3 mg I.V.

Results were expressed as mean ± SD. Comparability of groups were analysed with Analysis of Variance (ANOVA) test. Student’s two-tailed ‘t’ test was applied to analysed parametric data. P value <0.05 was considered significant. SPSS software 13 version was used to calculate the statistics.

Results

Base line demographics were comparable and are presented in the (Table/Fig 1).

The mean value with standard deviation of total Phenyephrine dose in Group P, total Ephedrine dose in Group E and total Mephentermine dose in Group M were 0.13 ± 0.05, 9.56 ± 4.62 and 9.78 ± 4.01 respectively. There was significant statistical difference in the total dose of Phenylephrine, Ephdrine and Mephentermine used (p<0.05) (Table/Fig 2).

No statistical significant difference were found between 3 groups with regards to level of thoracic sensory block at the onset of surgery (p>0.05).

On intergroup comparison rise of systolic blood pressure and diastolic at 2, 4 and 6 minutes post study drugs were significantly less in Ephedrine group and Mephentermine group as compared to Phenylephrine group (p<0.05) (Table/Fig 3).

In Group P, 77% required single bolus dose while 17% two and 6% three to maintain systolic pressure within 20% limit of basal value.

On intergroup comparison rise of diastolic blood pressure at 2, 4, and 6 minutes post study drugs were significantly less in Ephedrine group and Mephentermine group as compared to the Phenylephrine group (p<0.05). No significant differences were observed between changes in systolic and diastolic blood pressure of Ephedrine and Mephentermine group (Table/Fig 4).

In Group E 57% required single, 27% two and 16% three bolus doses, whereas In Group M 47% required single, 43% two, and 10% three doses.

Heart rate raised in all three groups during hypotension. In group P, post study drug values of heart rate were decreased significantly from the values at onset of the hypotension till the end of the surgery when compared to other two groups (p<0.001). No significant differences were observed between heart rate changes in Ephedrine and Mephentermine group (Table/Fig 5).

There was no significant effect of vasopressor on fotus in terms of Apgar score at 1 and 5 minutes.

Discussion

Caesarean section is one of the oldest operations in recorded history, however anaesthesia for Caesarean section is just a century old and is not bereft of controversies. Over time, regional anaesthesia especially spinal anaesthesia proved to be the most preferred technique for Caesarean section (5), (6). The reason being, the unique potential of spinal technique to provide anaesthesia with a blend of low degree of physiologic trespass and with profound degrees of sensory denervation and muscle relaxation. Thus, the safety of spinal anaesthesia is of dual nature; pharmacological as well as physiologic. However one main hurdle with this technique is the troublesome and persistent incidence of hypotension especially in gravid parturients. Hypotension is the commonest serious problem endangering both the mother and the child (5), (7). Dinesh Sahu et al (8) found that maternal hypotension during spinal anaesthesia for Caesarean delivery was a persistent problem in approximately 85% of cases (8). This high incidence and severity of maternal hypotension following spinal anaesthesia could beattributed to various factors like the amount of local anaesthetic injected, sympathetic blockade, uterus impairing venous return from extremities in supine position etc (6).

When a drug is used to treat the same many questions arise in mind of the anaesthetist. What level of hypotension should they treat?, what will be effects of hypotension on mother and unborn baby and if treated what effects will the drug have on the duo. Also the degree of hypotension that requires treatment itself is controversial with various authors using different cutoffs (9),(10),(11). In this study three drugs were evaluated. Each having its own pharmalocogical properties. Phenylephrine being a synthetic noncatecholamine primarily stimulating alpha1 – adrenergic receptors by a direct action. Ephedrine being a indirectly acting synthetic noncatecholamine, that stimulates alpha and beta adrenergic receptors. Mephentermine is an indirect acting synthetic non-catecholamine that stimulates alpha and beta adrenergic receptors.

All the three vasopressor effectively maintained arterial pressure within 20% limit of baseline value though phenylephrine maintained better in first 6 minutes of bolus dose as compared to ephedrine and mephentermine. This may be due to that, phenylephrine has peak effect within one minute, whereas ephedrine has 2-5 minutes and mephentermine has 5 minutes. After this time all three drugs were comparable in their control of blood pressure.

Thomas et al reported that bolus phenylephrine is as effective as ephedrine in restoring maternal arterial pressure above 100 mmHg (12). Similarly, Moran et al reached the same conclusion and further concluded that the drug appears to have no adverse neonatal effects (13). Current study also did not find any significant effect of vasopressor on fotus in terms of Apgar score at 1 and 5 minutes.

In our study cardiovascular stability was better with phenylephrine. It caused significant reduction in heart rate after the bolus dose, which is a consistent effect in phenylephrine treated women in their studies also (13),(14),(15). In ephedrine and mephentermine group the heart rate increased compared to pre-operative values. This was alike to an earlier Indian study by Dinesh Sahu (8). This is probablydue to beta adrenergic effect of ephedrine and mephentermine which the phenylephrine lacks.

Thomas D.G. et al (12) reported a high (58%) incidence of bradycardia (heart rate less than 60 beats /min) when phenylephrine was given as IV bolus after induction of spinal anaesthesia, but in our study the incidence for such extreme hypotension was nil. Selection of patients and different criteria of treating hypotension could have caused the difference. In the current study the only side effects noticed were nausea and vomiting. No extreme hypertension and headache was noticed as found in two cases in the study by Taylor JC et al (16).

Conclusion

We have found that phenylephrine, ephedrine and mephentermine are effective in IV bolus form in maintenance of arterial pressure within 20% limit of baseline, though phenylephrine has quicker peak effect in comparison to ephedrine and mephentermine and it causes reduction in heart rate, which may be advantageous in cardiac patients and patients in whom tachycardia is undesirable.

References

1.
Pernoll ML, Mandell JE. Caesarean section. Chapter 30, Principles and Practice of Obstetric Analgesia and Anaesthesia, 2nd Edn., Bonica JJ and McDonald JS, Williams and Wilkins, 1995:968-1009.
2.
Clyburn P. Spinal anaesthesia for caesarean section: time for reappraisal? (Editorial) Anaesthesia 2005;60:633-3.
3.
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