Which vasopressor for caesarean section?

One of the longest running debates in obstetric anaesthesia surrounds the prevention and treatment of maternal hypotension during caesarean section. Anaesthetic techniques have evolved and maternal mortality and morbidity is markedly reduced, but hypotension remains a problem, particularly following neuraxial blockade. Despite over 30 years of research no definitive consensus has been reached on the best treatment strategy and particular controversy surrounds the use of vasopressive agents. This article explores the evidence relating to the three most commonly used agents in the UK: ephedrine, phenylepherine and metaraminol.

Long term results of a randomised prospective study of preservation of the intercostobrachial nerve.

AIM: We have previously reported in a randomised controlled trial comparing intercostobrachial nerve (ICBN) preservation with division that no difference in symptoms was seen between the groups at 3 months follow-up although a reduced area of sensory loss was measured on the arm. To determine if longer follow-up provides evidence for ICBN preservation, follow-up of patients in the trial at 3 years (range 32-38 months) postoperatively was performed. METHODS: Sensory symptoms and deficits, pain, shoulder movements, arm circumference and the presence of neuromas were documented in 73 patients from the original group of 120. RESULTS: No difference in survival or axillary recurrence was observed. The only symptom which differed between the two groups was a subjective assessment of 'different sensation' (P=0.006). No significant difference was observed in other sensory symptoms, pain, shoulder movement, arm circumference or presence of neuromas. A larger area of sensory deficit was measured in women with sacrificed nerves compared to preserved (P=0.009). CONCLUSION: Preservation of the intercostobrachial nerve does not affect patient survival. It improves patient sensory deficit significantly and modestly improves long-term symptoms.