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cardiac arrest like situation after bolus dose of oxytocin
- Niraj Sinha, Hayfa Shaker, Tarek Ansari (16 July 2009)
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Myocardial ischaemia during Caesarean section.
- Simone E Carbert (28 May 2008)
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Cardiovascular effects of Oxytocin
- Rakhee Kotak (4 May 2008)
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Niraj Sinha, anaesthetist Corniche Hospital, Abu Dhabi, UAE, Hayfa Shaker, Tarek Ansari
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Dear Editor I read with interest the article about cardio vascular effects of oxytocin. I would like to share an experience we recently had. A young female (ASA status 1) was scheduled for evacuation of retained product of conceptus. She had bled around 500 ml in ward before arriving in the theatre. She was volume resuscitated with 500 ml of Ringer lactate. Prior to induction she had a BP of 110/60, regular pulse of 80/min and oxygen saturation (SpO2) of 99% on room air. She was induced with propofol and alfentanil; a LMA size 3 was used to secure airway. She had stable vitals while the surgery was in progress. On request of obstetric resident she was given a fast bolus dose of oxytocin 5 units. After 2-3 minutes we noticed that SpO2 started falling down and patient looked very pale. There was no pulse and no heart sound on auscultation while there was a stable ECG rhythm on monitor. A precordial thump was immediately given and cardiac massage was started; a cardiac arrest call was flashed. There was quick response from the patient and vitals returned to normal in no time. Operation was completed successfully and patient was discharged after 2 days. This was a frightening experience and since then we have been using a bolus dose of 2 units of oxytocin only followed by slow infusion of 10 units in 50 ml of normal saline in obstetric procedures. Email: drnirajs@yahoo.co.in Conflict of Interest:None declared |
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Simone E Carbert, Anaesthetic ST3
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Dear Editor I read with interest the article by Svanström and colleagues (1). ECG signs of myocardial ischaemia have been reported during Caesarean section (2,3) , and any intervention associated with a reduction in this would be beneficial. Svanström and colleagues report a reduction in ischaemic changes when using ergometrine for uterine contraction post delivery compared with oxytocin. However there are a number of points within their methodology we would like to discuss. Firstly, during the procedure treatment of hypotension is administered when systolic arterial pressure (SAP) decreased below 95 mm Hg. This may represent a significant reduction from baseline in these patients and many may become symptomatic before this pressure is reached, necessitating the use of vasopressors. Secondly the treatment of hypotension is 5 mg of ephedrine. A survey of UK practice shows that 51% of units are now using phenylepherine in either bolus or infusion form (4). As a pure alpha agonist this can lead to vasoconstriction and an increase in SAP without the tachycardia seen with an ephedrine bolus. Doses of 50-100mcg can be used to offset the haemodynamic effects of bolus doses of oxytocin given after delivery (5). Finally the dose of oxytocin used in this study is 10 IU. As the authors state in their discussion, following the CEMACH 1997-9 report (6) in the UK the recommended dose of oxytocin post delivery in Caesarean section is 5 IU as a slow iv bolus. This reduction in dose from 10 IU is aimed to reduce the hypotensive and resultant reflex tachycardic response previously seen. I therefore hypothesise that by using a technique with a more proactive treatment of hypotension, the use of phenylepherine for vasoconstriction and a reduction in the dose of oxytocin, perhaps the difference in ischaemic ECG changes seen between oxytocin and ergometrine would not be so apparent? Dr S E Carbert ST3 Anaesthetics, Darlington Memorial Hospitial Conflict of Interest: None declared. 1. M.C. Svanström, B.Biber, M.Hanes, G.Johansson, U.Näslund and E.M. Bålfors. Signs of myocardial ischaemia after injection of oxytocin: a randomised double-blind comparison of oxytocin and methylergometrine during Caesarean section. British Journal of Anaesthesia 100 (5): 683- 9(2008) 2. Palmer CM, Norris MC, Giudici MC, et al. Incidence of electrocardiographic changes during Caesarean delivery under regional anaesthesia. Anesth Analg 1990; 70: 36-43 3. McLintic AJ, Pringle SD, Lilley S, et al. Electrocardiographic changes during Caesarean section under regional anaesthesia. Anesth Analg 1992; 74: 51-6 4. A McGlennan, N Patel, B Sujith, R Bell. A survey of pre-loading and vasopressor use during regional anaesthesia for caesarean section. Ijoa Volume 16;Supplement 1;p27 5. Levy DM. Anaethesia for Caesarean section. British Journal of Anaesthesia CEPD Reviews Volume 1 Number 6 2001: 171-176 6. Lewis G, ed Why Mothers Die 1997-1999. The Confidential Enquiry into Maternal Deaths in the United Kingdon. London: RCOG Press, 2001; 135-7 Conflict of Interest:None declared |
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Rakhee Kotak, ST3 Anaesthetics (LAT)
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Editor- The study by Svanström and colleagues provides additional evidence of the effects that oxytocin can have when given as a bolus of 10 IU. It was interesting to read that even in non-pregnant women the cardiovascular effects of oxytocin were significant. In pregnant patients at full-term, with the added changes caused by aortocaval compression and spinal anaesthesia, the dose and speed of injection of oxytocin are obviously important considerations. Another important point highlighted was that, almost a decade ago, the CEMACH report of 1997-9 (1) recommended a dose of 5 IU oxytocin. This has also been discussed in the 2003-5 (2) report, once again re-iterating the importance of a slow bolus of 5 IU oxytocin followed by an infusion if necessary. It was interesting to note that 10 IU oxytocin is the Swedish national healthcare recommendation. Will the members of the study group be changing their own practice as a result of their conclusions? References 1. Thomas TA, Cooper GM. Anaesthesia. In: Lewis G, ed. Why Mothers Die 1997-1999. The Confidential enquiry into Maternal Deaths in the United Kingdom. London: RCOG Press, 2001: 135-7 2. Cooper GM, McClure J. Anaesthesia. In: Lewis G (ed) 2007. The Confidential Enquiry into Maternal and Child Health (CEMACH). Saving Mother’s Lives: reviewing maternal deaths to make motherhood safer- 2003- 2005. The Seventh Report on Confidential Enquiries into maternal Deaths in the United Kingdom. London: CEMACH; 107-18 Conflict of Interest:None declared |
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