Comparison of Norepinephrine and Phenylephrine Infusions for Maintenance of Haemodynamics Following Subarachnoid Block in Lower Segment Caesarean Section

Muhammad  Areeb; Tanvir  Hussain; Sadaf  Mushtaq; Saqib  Ali; Faisal  Imran; Shamila Athar  Siddiqui

doi:10.54112/bcsrj.v6i6.2060

Authors

Muhammad Areeb Department of Anesthesia And Critical Care, National Hospital and Medical Centre, Lahore, Pakistan
Tanvir Hussain Department of Anesthesia And Critical Care, National Hospital and Medical Centre, Lahore, Pakistan
Sadaf Mushtaq Department of Anesthesia And Critical Care, National Hospital and Medical Centre, Lahore, Pakistan
Saqib Ali Department of Anesthesia And Critical Care, National Hospital and Medical Centre, Lahore, Pakistan
Faisal Imran Department of Anesthesia And Critical Care, National Hospital and Medical Centre, Lahore, Pakistan
Shamila Athar Siddiqui Department of Anesthesia And Critical Care, National Hospital and Medical Centre, Lahore, Pakistan

DOI:

https://doi.org/10.54112/bcsrj.v6i6.2060

Keywords:

Cesarean delivery, Anesthesia, Subarachnoid block, Hemodynamics, Hypotension, Norepinephrine, Phenylephrine.

Abstract

Phenylephrine (PE) is widely regarded as the drug of choice for treating maternal hypotension during cesarean delivery under subarachnoid block. However, growing evidence from recent studies indicates that norepinephrine (NE) is an effective alternative. Objective: To compare the outcome of norepinephrine and phenylephrine infusions for maintenance of hemodynamics following subarachnoid block in lower segment caesarean section. Methods: This randomized controlled trial took place at the Department of Anesthesiology, National Hospital and Medical Centre, Lahore, from 1^st July 2024 to 1^st January 2025, enrolling 84 patients undergoing cesarean section under subarachnoid block. Patients were randomly assigned to receive PE or NE infusions, and intraoperative bradycardia (HR <50 bpm) was recorded. Statistical analysis was carried out using the Mann-Whitney U test for continuous variables and the Chi-square or Fisher's exact test for categorical variables, with p ≤ 0.05 considered significant. Stratification for potential confounders was also performed. Results: Baseline demographics were comparable between groups (p > 0.05 each). The incidence of bradycardia was substantially higher with PE (61.9%) compared to NE (9.5%) (p = 0.000). Stratified analyses confirmed lower bradycardia rates with NE across age groups (7.7% vs. 63.6%, p = 0.000; 12.5% vs. 60.0%, p = 0.004), parity groups (8.3% vs. 56.7%, p = 0.000; 16.7% vs. 75.0%, p = 0.019), ASA II patients (9.5% vs. 61.9%, p = 0.000), and term gestations (9.5% vs. 65.0%, p = 0.000). Conclusion: Norepinephrine is a favorable alternative to phenylephrine for preserving maternal blood pressure during subarachnoid block for cesarean delivery. Given its lower incidence of bradycardia across all subgroups, norepinephrine can be considered the preferred vasopressor for routine clinical use in obstetric anesthesia.

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References

Rewari V, Hussain SY. Patient safety in obstetric anesthesia. J Obstet Anaesth Crit Care. 2022;12(2):82-84. https://doi.org/10.4103/JOACC.JOACC_47_22

Iddrisu M, Khan ZH. Anesthesia for cesarean delivery: general or regional anesthesia a systematic review. Ain-Shams J Anesthesiol. 2021;13(1). https://doi.org/10.1186/s42077-020-00121-7

Sung TY, Jee YS, You HJ, Cho CK. Comparison of the effect of general and spinal anesthesia for elective cesarean section on maternal and fetal outcomes: a retrospective cohort study. Anesth Pain Med (Seoul). 2021;16(1):49-55. https://doi.org/10.17085/apm.20072

Çalışkan B, Suvariogulları M, Ekmez M, Şen Ö, Yarsilikal Guleroglu F. Choice of anesthesia technique for emergent cesarean sections during COVID-19 era in a tertiary care hospital. Ulus Travma Acil Cerrahi Derg. 2023;29(4):458-462. https://doi.org/10.14744/tjtes.2023.97580

Kulkarni KR, Naik AG, Deshpande SG. Evaluation of antihypotensive techniques for cesarean section under spinal anesthesia: rapid crystalloid hydration versus intravenous ephedrine. Anesth Essays Res. 2016;10(3):637-642. https://doi.org/10.4103/0259-1162.191118

Olawin AM, Das JM. Spinal anesthesia. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021.

Tiwari JP, Verma SJ, Singh AK. A prospective randomized study comparing the bolus doses of norepinephrine and phenylephrine for the treatment of spinal-induced hypotension in cesarean section. Cureus. 2022;14(7):e27166. https://doi.org/10.7759/cureus.27166

Shitemaw T, Jemal B, Mamo T, Akalu L. Incidence and associated factors for hypotension after spinal anesthesia during cesarean section at Gandhi Memorial Hospital, Addis Ababa, Ethiopia. PLoS One. 2020;15(8):e0236755. https://doi.org/10.1371/journal.pone.0236755

Hasanin A, Amin S, Refaat S, Habib S, Zayed M, Abdelwahab Y, et al. Norepinephrine versus phenylephrine infusion for prophylaxis against post-spinal anesthesia hypotension during elective caesarean delivery: a randomized controlled trial. Anaesth Crit Care Pain Med. 2019;38(6):601-607. https://doi.org/10.1016/j.accpm.2019.03.005

Imai E, Kataoka Y, Watanabe J, Okano H, Kamimura Y, Tsuji T, et al. Norepinephrine vs. phenylephrine for spinal hypotension in cesarean section: a network meta-analysis. J Anesth. 2025;39(1):22-35. https://doi.org/10.1007/s00540-025-03528-4

Xu S, Shen X, Liu S, Yang J, Wang X. Efficacy and safety of norepinephrine versus phenylephrine for the management of maternal hypotension during cesarean delivery with spinal anesthesia: a systematic review and meta-analysis. Medicine (Baltimore). 2019;98(5):e14331. https://doi.org/10.1097/MD.0000000000014331

Bower JR, Kinsella SM. Preventing and treating hypotension during spinal anaesthesia for caesarean section. BJA Educ. 2020;20(11):360-361. https://doi.org/10.1016/j.bjae.2020.08.001

Sun L, Tang Y, Guo F, Liu J, Xu L, Zhu G, et al. Norepinephrine or phenylephrine for the prevention of post-spinal hypotension after caesarean section: a double-blinded, randomized, controlled study of fetal heart rate and fetal cardiac output. J Clin Anesth. 2024;97:111533. https://doi.org/10.1016/j.jclinane.2024.111533

Shafeinia A, Ghaed MA, Nikoubakht N. The effect of phenylephrine infusion on maternal hemodynamic changes during spinal anesthesia for cesarean delivery. Anesth Pain Med. 2020;10(1):e99094. https://doi.org/10.5812/aapm.99094

Khan S, Fiaz Z, Anwar M, Sikander RI, Ali A, Ayesha K. Comparison of phenylephrine infusion vs norepinephrine infusion on maternal hemodynamics and neonatal outcomes during elective lower segment caesarean section under subarachnoid block. Ann PIMS Shaheed Zulfiqar Ali Bhutto Med Univ. 2024;20(1):74-79.

Hasanin A, Mokhtar AM, Badawy AA, Fouad R. Post-spinal anesthesia hypotension during cesarean delivery: a review article. Egypt J Anaesth. 2017;33(2):189-193. https://doi.org/10.1016/j.egja.2017.03.003

Feng K, Wang X, Feng X, Zhang J, Xiao W, Wang F, et al. Effects of continuous infusion of phenylephrine vs. norepinephrine on parturients and fetuses under LiDCOrapid monitoring: a randomized, double-blind, placebo-controlled study. BMC Anesthesiol. 2020;20(1):185. https://doi.org/10.1186/s12871-020-01145-0

Goel K, Luthra N, Goyal N, Grewal A, Taneja A. Comparison of norepinephrine and phenylephrine infusions for maintenance of haemodynamics following subarachnoid block in lower segment caesarean section. Indian J Anaesth. 2021;65(8):600-605. https://doi.org/10.4103/IJA.IJA_185_21

Park HS, Choi WJ. Use of vasopressors to manage spinal anesthesia-induced hypotension during cesarean delivery. Anesth Pain Med (Seoul). 2024;19(2):85-93. https://doi.org/10.17085/apm.24037

Ngan Kee WD, Lee SWY, Ng FF, Lee A. Norepinephrine or phenylephrine during spinal anaesthesia for Caesarean delivery: a randomised double-blind pragmatic non-inferiority study of neonatal outcome. Br J Anaesth. 2020;125(4):588-595. https://doi.org/10.1016/j.bja.2020.05.057

de Queiroz DV, Velarde LGC, Alves RL, Verçosa N, Cavalcanti IL. Incidence of bradycardia during noradrenaline or phenylephrine bolus treatment of post-spinal hypotension in cesarean delivery: a randomized double-blinded controlled trial. Acta Anaesthesiol Scand. 2023;67(6):797-803. https://doi.org/10.1111/aas.14225

Liu P, He H, Zhang SS, Liang Y, Gao ZJ, Yuan H, et al. Comparative efficacy and safety of prophylactic norepinephrine and phenylephrine in spinal anesthesia for cesarean section: a systematic review and meta-analysis with trial sequential analysis. Front Pharmacol. 2022;13:1015325. https://doi.org/10.3389/fphar.2022.1015325

Sharkey AM, Siddiqui N, Downey K, Ye XY, Guevara J, Carvalho JCA. Comparison of intermittent intravenous boluses of phenylephrine and norepinephrine to prevent and treat spinal-induced hypotension in cesarean deliveries: randomized controlled trial. Anesth Analg. 2019;129(5):1312-1318. https://doi.org/10.1213/ANE.0000000000003704

Mao J, Lin K, Liu X, Liu J, Liang G, Sheng Z. Effects of prophylactic infusion of equivalent doses of norepinephrine and phenylephrine in preventing spinal anesthesia-induced hypotension during cesarean delivery on fetal and maternal outcomes: a dual-center, non-inferiority controlled trial. Drug Des Devel Ther. 2025;19:5143-5152. https://doi.org/10.2147/DDDT.S563756