Assessment of Pulse Transit Time To Indicate Cardiovascular Changes During Obstetric Spinal Anaesthesia
Assessment of Pulse Transit Time To Indicate Cardiovascular Changes During Obstetric Spinal Anaesthesia
Assessment of Pulse Transit Time To Indicate Cardiovascular Changes During Obstetric Spinal Anaesthesia
doi:10.1093/bja/aei266
Results. We analysed data from 58 normotensive patients and 15 patients with pregnancyinduced hypertension (PIH). PTT increased with the onset of spinal anaesthesia as arterial pressure decreased. An increase of 20% in PTT was 74% sensitive and 70% specific in indicating
a decrease in mean arterial pressure of more than 10%. Changes in PTT were related to changes
in mean arterial pressure (r2=0.55, P<0.0001). Arterial pressure changes were greater and PTT
increased significantly more quickly in the normotensive patients than in the patients with
hypertension [median, quartiles: 32 (14, 56) ms min1 compared with 7 (6, 18) ms min1;
P<0.01, MannWhitney U-test]. However, the relationship between PTT and arterial pressure
was similar for the normotensive patients and the patients with PIH.
Conclusion. PTT measurement gave a beat-to-beat indication of arterial pressure during spinal
anaesthesia, and could be developed to allow prediction of the onset of hypotension.
Br J Anaesth 2006; 96: 1005
Keywords: anaesthesia, obstetric; anaesthetic techniques, regional, spinal; cardiovascular
system; monitoring, pulse transit time; pregnancy
Accepted for publication: September 24, 2005
Data from this study were presented in part at the Obstetric Anaesthetists Association Meeting at Nottingham, UK, on May 10, 2002 and
at the 13th World Congress of the International Society for the Study of
Hypertension in Pregnancy at Toronto, Canada, on June 2, 2002.
The Board of Management and Trustees of the British Journal of Anaesthesia 2005. All rights reserved. For Permissions, please e-mail: journals.permissions@oxfordjournals.org
Method. We obtained ethics approval for an observational study of PTT during the onset of
spinal anaesthesia in patients having elective or urgent Caesarean section. PTT was measured
as the difference in time between the peak of the ECG R wave and the upstroke of the toe
plethysmograph. Arterial pressure was measured by non-invasive sphygmomanometry.
Methods
Results
Ninety-two patients were studied; we obtained data suitable
for analysis from 58 normotensive patients and 15 with PIH.
There were no obvious systematic differences in the reasons
for exclusion between the two groups of patients (Table 1).
The two groups were similar in respect of height and weight,
but, as might be expected, heart rate was less, arterial pressure was greater and gestational age was less in the patients
with PIH (Table 2). Before the spinal anaesthetic, normotensive patients were given 400 (300, 500) ml of
Hartmanns solution and the patients with PIH received
150 (100, 225) ml. The dose of bupivacaine was 13
(12.5, 13.5) mg in both the normotensive and the hypertensive patients. Most patients received diamorphine 300 mg, but
nine were given 400 mg. Ephedrine had to be given to 46 of
the normotensive patients and three of the patients with PIH
(P<0.001); other vasopressor and vagolytic agents
(phenylephrine, atropine and glycopyrollate) were also
used more frequently in the normotensive patients.
Data from five patients were not analysed because
vasopressor drugs were given prophylactically by personal
preference of the anaesthetist immediately after spinal
101
Normotensive
PIH
74
18
9
5
1
1
0
0
58
1
0
0
0
1
1
15
The local ethics committee approved collection and recording of data from routine cardiovascular monitoring devices,
but not the modification of routine management in any other
way. We obtained informed verbal consent for the data
collection. We recorded PTT during the onset of spinal
anaesthesia in non-labouring women having Caesarean section for routine elective or urgent indications. Patients were
recruited as they presented over a 6-month period; of these,
74 were normotensive. Eighteen patients had severe PIH,
defined using standard criteria10 as hypertension which
developed after 20 weeks of gestation and required antihypertensive medication with nifedipine, labetalol or
methyldopa, singly or in combination. We included patients
with or without proteinuria. We undertook this study before
our unit introduced i.v. magnesium sulphate treatment for
severe PIH.
The values were obtained from before the spinal anaesthetic to the time the patient was ready for surgery. Vasopressor or vagolytic drugs were given by the clinician
managing the anaesthesia, according to normal practice,
in response to changes in arterial pressure, heart rate, or
the onset of symptoms suggestive of hypotension, such as
dizziness, nausea or vomiting. Some of these clinicians did
not routinely give vasopressor agents prophylactically,
others did, and some gave them occasionally.
Patients were placed in a supine wedged position and an
infusion of Hartmanns solution was started. ECG monitoring and an automated arterial pressure (NIBP) recording cuff
were applied (Cardiocap 2; Datex). The baseline arterial
pressure was recorded as the mean of three measurements
taken at 2-min intervals. An oximeter probe was placed on
the second toe of the left foot. Spinal anaesthesia was then
administered with the patient in either the sitting or left
lateral position. A 24 gauge Sprotte needle was used to
give between 2.5 and 2.7 ml of hyperbaric bupivacaine
0.5% with diamorphine 0.3 or 0.4 mg according to the
anaesthetists preference. The patient was then returned to
the wedged supine position. The time was recorded, and the
events that were marked electronically included the following: the connection of monitoring equipment; the initial
change of position for the spinal; the return to a wedged
supine position; the administration of vasopressor or other
i.v. drugs; and the transfer of the patient to the operating
theatre. IV fluids given before spinal anaesthesia and the
total given over the study period were recorded. Heart rate
and NIBP were recorded at 2-min intervals. The ECG and
photoplethysmograph signals from the analogue output of
the Cardiocap monitor were transferred to a purpose-built
analogue computer constructed by Leiden University. This
computed the time between the peak of the ECG R wave and
the maximum rate of the plethysmograph wave upswing.
The time intervals and digital signals from the Datex monitor were recorded in digital form on a Satellite Pro 4300
(Toshiba) laptop computer.
Before data analysis, spurious ECG and photoplethysmograph signals generated by patient movement were removed.
These artefacts were defined using an Excel function (Excel
version 9.0, 1999; Microsoft, Redmond, WA, USA) as values that were 20% less or greater than the rolling mean
PTT, and were filtered from the data before analysis.
Statistical analysis was with GraphPad Prism version 3.02
and Analyse-It software for Excel, version 1.71 (Analyse-it
Software, Leeds, UK). Data are presented as medians
(quartile values) unless stated otherwise.
Sharwood-Smith et al.
Table 2 Patient details and cardiovascular measurements before and after spinal anaesthesia. Values are median (interquartile values). ns, not significant. Students
t-test, *P<0.05, **P<0.0001; MannWhitney U-test, #P<0.01
Pregnancy-induced hypertension
58
32 (30, 35)
162 (158, 168)
70 (61, 78)
39 (39, 39)
15
32 (30, 37)
162 (160, 170)
72 (62, 83)
36 (33, 38)
89 (78, 102)
80 (74, 94)
99 (91, 104)
126 (118, 138)
390 (345, 422)
**
**
*
87 (78, 109)
80 (71, 101)
ns
92 (86, 99)
124 (116, 136)
413 (373, 454)
**
ns
*
79 (75, 98)
89 (98, 111)
22 (11, 29)
119 (111, 134)
417 (389, 495)
75 (54, 118)
21%
7 (6, 18)
5.0 (3.2, 7.7)
ns
**
ns
ns
*
ns
ns
#
#
83 (78, 95)
116 (108, 126)
**
**
Cardiovascular values
Before spinal anaesthesia
Heart rate (beats min1)
Arterial pressure (mm Hg)
Mean
Systolic
Pulse transit time (ms)
After spinal anaesthesia
Heart rate (beats min1)
Arterial pressure (mm Hg)
Mean
Systolic
Pulse transit time (ms)
69 (60, 78)
97 (87, 108)
Doses of ephedrine 6 mg
Doses of atropine
Doses of phenylephrine
700
Spinal
600
Sitting
500
400
150
300
100
200
50
100
0
Patient details
Number
Age
Height (cm)
Weight (kg)
Gestation (weeks)
Significance
0
10
15
20
Time (min)
25
30
than in the patients with PIH [7 (6, 18) ms min1] (P< 0.01,
MannWhitney U-test).
The relationship between PTT and MAP was examined
before and after spinal anaesthesia (Fig. 2). There was a
102
Normotensive subjects
A 800
Normotensive patients
PIH patients
PTT (ms)
550
600
400
200
450
350
250
50
100
Mean arterial pressure (mm Hg)
150
50
60
70
80
90 100 110 120
Mean arterial pressure (mm Hg)
130
140
B 800
PTT (ms)
100
400
Sensitivity (%)
80
200
50
100
Mean arterial pressure (mm Hg)
150
60
40
20
5% decrease in mean arterial pressure
10% decrease in mean arterial pressure
0
0
20
40
60
1-Specificity (%)
80
100
Discussion
To our knowledge, the relationship between PTT and arterial
pressure has not previously been studied systematically
during obstetric spinal anaesthesia. We chose to study
this scenario because rapid and substantial changes in arterial pressure are relatively frequent. We found that changes in
PTT were related to arterial pressure changes and that the
relationship between PTT and arterial pressure was the same
in normotensive patients and those with PIH.
We measured the time interval between the ECG R wave
and the upsweep of the plethysmograph.11 12 This time
includes two principal components, the time between electrical activation of the ventricle and cardiac ejection, and the
103
600
Sharwood-Smith et al.
104
Acknowledgements
We thank Professor A. Dahan, University of Leiden, for the loan of the
analogue computer for processing the ECG and optical plethysmograph
signals (Ajax). This study was supported by a grant from the Obstetric
Anaesthetists Association.
12
13
14
15
16
17
18
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