From the Guidelines
The patient's hypotension following epidural analgesia should be treated with vasopressors rather than indiscriminate fluid boluses, as evidenced by the ESPEN expert group recommendations 1. The patient is experiencing hypotension, with a blood pressure of 90/55 mm Hg, which is a common side effect of epidural analgesia due to sympathetic blockade causing peripheral vasodilation. Key points to consider in management include:
- The importance of ensuring the patient is normovolemic before treating hypotension with vasopressors 1
- The potential risks of fluid overload, including hyperosmolar states, hyperchloremic acidosis, and decreased renal blood flow 1
- The benefits of maintaining near-zero fluid and electrolyte balance, which has been shown to reduce the risk of complications and shorten hospital stay 1 The patient's tachycardia (120/min) represents a compensatory response to maintain cardiac output, and the normal upper extremity strength and sensation indicate the epidural is not affecting respiratory muscles or causing a high spinal block. Some key considerations for treatment include:
- Positioning the patient in left lateral decubitus position to relieve aortocaval compression
- Administering vasopressors, such as ephedrine or phenylephrine, to treat hypotension
- Continuous maternal vital sign and fetal heart rate monitoring during treatment
- Maintaining careful monitoring to ensure the epidural can be continued for labor analgesia once hypotension is corrected.
From the Research
Patient's Condition
The patient is a 34-year-old primigravid woman at 37 weeks gestation, admitted in active labor with a request for epidural analgesia for pain control. Shortly after induction of analgesia, she begins to feel light-headed, with a repeat blood pressure of 90/55 mm Hg, pulse of 120/min, and respirations of 15/min.
Relevant Studies
- The patient's condition of hypotension after epidural analgesia may require fluid resuscitation. A study 2 compared lactated Ringer's solution with 0.9% saline for initial fluid resuscitation in sepsis-induced hypotension, finding that lactated Ringer's solution might be associated with improved survival.
- Another study 3 aimed to systematically describe the body of evidence on the use of different types of buffered crystalloid solutions, including lactate and acetate buffered solutions, in hospitalized patients.
- A study on fetal cardiovascular and fluid responses to maternal volume loading with lactated Ringer's or hypotonic solution 4 found that acute increases in maternal vascular pressures do not appear to promote fluid transfer to the ovine fetus.
- A prospective, randomized trial 5 compared the cardiac and hemodynamic responses to a rapid infusion of modified fluid gelatin or lactated Ringer's solution in emergency room patients suffering from shock, finding that modified fluid gelatin resulted in significantly better hemodynamic improvement.
Potential Treatment
- Based on the studies, lactated Ringer's solution may be a suitable choice for fluid resuscitation in this patient, considering its potential benefits in improving survival and hemodynamic responses.
- However, it is essential to monitor the patient's condition closely and adjust the treatment plan as needed, taking into account the patient's individual needs and responses to the treatment.
Key Findings
- The patient's hypotension after epidural analgesia requires prompt attention and potential fluid resuscitation.
- Lactated Ringer's solution may be a suitable choice for fluid resuscitation, considering its potential benefits in improving survival and hemodynamic responses.
- The patient's condition should be closely monitored, and the treatment plan should be adjusted as needed to ensure the best possible outcome.