Hypotension and ShockCERU-1401NCT02070276
Predict Fluid Responsiveness in Spinal Anesthesia
A study testing Trans-thoracic echocardiography and Passive Leg Raising Test in people with Hypotension and Shock and Excessive Amount of Blood / Fluid Infusion, run by Ente Ospedaliero Cantonale, Bellinzona at 1 site in Switzerland.
Trial summary
Spinal anesthesia is still the regional anesthesia technique most widely employed in everyday clinical practice. The most feared and common of its well known side effects consist in an abrupt reduction of systemic vascular resistances, with consequence risk of systemic hypotension. Read more about this study
- Who is it for?
- Ages 18 to 80 years
- Conditions the study is for
- Hypotension and Shock, Excessive Amount of Blood / Fluid Infusion
- What is being tested?
- Trans-thoracic echocardiography and Passive Leg Raising Test
- Type of treatment
- Injection or infusion, Surgery or procedure
- Could I receive a placebo?
- No, everyone receives an active treatment
- How many people
- 429 participants
- Where
- 1 siteSwitzerland
- Study dates
- May 2014to Aug 2019
- Phase
- Interventional
- Are there results?
- Yes, posted in the registrySummary in the doctors' view
Key requirements
Who can take part, as listed by the sponsor. Only the study team can confirm whether you are eligible, so take this list to your doctor.
- Ages 18 to 80 years
- All sexes
- No healthy volunteers
- Adult, Older adult
Who may be able to join
- all adult non critical patients requiring elective spinal anesthesia
- both sex
- patients with American Society of Anesthesiology class level I, II and III according to international standards
- spontaneously breathing patients
Who cannot join
- patients already equipped or requiring invasive blood pressure monitoring (arterial catheter, pulmonary catheter, thermodilution catheter)
- patients with pre-procedural hypotension, defined as a response in two consecutive measurements of systolic arterial pressure (SAP) less than 80 mmHg or mean arterial pressure (MAP) less of 60 mmHg.
- patients unable to give informed consent to communication difficulties to language barriers or processes congenital/acquired determinants of mental retard, or any reduction in their ability to understand or want to be able to give their informed consent to the study
- patients where it is not then possible to perform spinal anesthesia for the patient's refusal to technical difficulties in sampling, clinical pathological conditions for determining a high risk of peri- procedural complications.
- patients with International Normalized Ratio > 1.5 and/or activated partial thromboplastin time in therapeutic range (defined as a value more than 1.5-2 times the normal values of the patient), anti-Xa activity in the therapeutic range .
- patients with severe thrombocytopenia (<50 G/l)
Trial locations and contacts
1 site in 1 country.
Switzerland1 site
Ospedale Regionale di Bellinzona e Valli (ORBV) - Sede Bellinzona
Bellinzona, 6500
About this study
Official title: Can Non Invasive Methods for Fluid Responsive Assessment Optimize Preventive Volemic Repletion in Order to Prevent Significant Hypotension After Spinal Anesthesia? A Randomized Trial
Spinal anesthesia is still the regional anesthesia technique most widely employed in everyday clinical practice.
The most feared and common of its well known side effects consist in an abrupt reduction of systemic vascular resistances, with consequence risk of systemic hypotension. To prevent this potentially severe complication, an adequate correction of patients' volume status through a preventive administration of fluids is widely used.
Read more
However this volume repletion is commonly accomplished on an empirical basis, without having a real insight of patient hemodynamic status, carrying the risk of possible volume overload.
Aim of the study is to test the clinical impact of two simple, non-invasive methods to guide volemic repletion before spinal anesthesia on the reduction of significant hypotension rate, compared to empirical fluid administration.
Read the detailed description
The resulting high density of the anesthetic block and the reproducibility of the technique have made of spinal anesthesia the most widely diffused regional anesthesia technique. Nevertheless the procedure still remains the regional anesthesia technique burdened by the potentially most severe side effects, the most frequent of which being systemic arterial hypotension.
Subarachnoidal administration of local anesthetics in fact is associated not only with both a motor and sensory block, but also with a blockade of the autonomic nervous system, which controls peripheral vascular tone. Sympathetic block leads to a sudden decrease in peripheral resistance, with consequent significant increase in vascular bed and relative hypovolemia.
Transient hypotensive episodes can be generally well tolerated by healthy patients, however they may lead to major complications in patients with increased cardiovascular risk. In the common clinical practice, it is usual to administer fluids empirically. An empirical preventive fluid repletion however can represent per se a risk in patients with impaired cardiac and renal functions, since a volume overload of heart chambers with reduced compliance can cause pulmonary edema or congestive heart failure.
Since about ten years both non-invasive and invasive techniques have been developed, with the specific purpose of optimizing fluid status on a rational basis. This methods are based on the correlation between the levels of mean arterial pressure (MAP), systemic vascular resistance (SVR) and cardiac output (CO), according to the equation: MAP = CO * SVR. The latter explains why, in case of vasodilation, unless CO is increased, a lowering of SVR will inevitably translate into a decrease of MAP.
Determinants of blood pressure are:
- volemic status;
- vascular resistance (determined by the control of the sympathetic system);
- cardiac output.
In case of spinal anesthesia the reduction in SVR determines relative hypovolemia (due to an increase in total vascular bed). For this reason after spinal anesthesia appears fundamental an optimization of patients' volemic status through administration of fluids (eventually associated with the administration of amines, in order to contrast massive vasodilation).
The use of methods to assess fluid responsiveness has been extensively studied in critical patients populations. However these techniques have not been studied yet in non critical patients. Spinal anesthesia is a model of pharmacological vasodilation which often generates significant hypotension, for which nowadays an evidence-based rational treatment based on a guided volemic repletion is still lacking.
WORKING HYPOTHESIS:
The use of non-invasive methods that have proven to be accurate for the identification of patient fluid-responsiveness is currently not validated in patients undergoing spinal anesthesia.
Ultrasound of inferior vena cava by is an effective method to determine the responsiveness to fluids in a patient on mechanical ventilation, however it has been proven to be inaccurate in spontaneous ventilating patients in critically ill patients, few data being available in non critical patients. The study of the inferior vena cava is based on the size of the inferior vena cava in its intra-abdominal portion (approximately 2 cm from emergency right atrium) and the pattern of its diameter changes with breathing. This measurement is obtained with M-mode ultrasound through subcostal view..
Passive leg raising test (PLRT) has been proven to be a highly accurate method in predicting fluid responsiveness in spontaneously breathing patients, in a population of critically ill patients. The method is based on the following assumption: active legs elevation, in addition to its effect of venous pool shifting from the lower limbs to the thorax, exerts a contemporary effect of stimulation on the peri-arterial sympathetic system at iliac-femoral level, this causing an orthosympathetic reflex which can increase cardiac output, possibly masking hypovolemia. Passive lower limbs raising instead has the advantage of mobilizing lower limbs venous blood (estimated 300-500 ml), without activating the orthosympathetic reflex. This allows for a quantification of the clinical response to a bolus of fluids, in terms of decrease of blood pressure variations following leg raising.
The hypothesis that investigators want to test is that the use of inferior vena cava ultrasound before spinal anesthesia, compared to the standard method (empirical fluid administration) and a non-invasive method (PLRT) can reduce the impact of systemic hypotension through an adequate titrated volemic repletion, avoiding both hypotension and fluid overload. The final purpose is to ensure spinal anesthesia in the safest possible way.
OBJECTIVES OF THE STUDY:
Aim of the study is to determine whether vena cava ultrasound, a bedside, unexpensive, non invasive methods, which have been tested as predictors of fluid responsiveness in critical patients, is effective in guiding titrated fluid repletion in a non critical population, in order both to decrease post procedural significant hypotension rate and unnecessary fluid overload in patients undergoing spinal anesthesia for elective surgical procedures.
- Being tested
- Trans-thoracic echocardiography, Passive Leg Raising Test
- Keywords
- Fluid therapy, Hypotension, Inferior vein cava, Spinal anesthesia, Ultrasonography
- Medical subject headings
- Hypotension, Shock
What participants receive
What participants receive. In a randomised study each person is assigned to one group by chance.
Trans-thoracic echocardiographyProcedure or surgery
Subcostal evaluation of inferior vena cava dimensions and colorability with cyclic spontaneous breathing in order to determine if the patients will be fluid responsive or not.
Passive Leg Raising TestProcedure or surgery
Application of this test in a standard manner in order to determine if our spontaneous breathing patients are fluid responsive before spinal anesthesia.
| Study group | Role | What they receive |
|---|---|---|
| Standard Clinical Practice | No intervention | This arm is considered the current clinical standard for spinal anesthesia; its used as a control sample and statistical reference. During the induction phase the patient is fitted with a non-invasive blood pressure monitoring, three-lead ECG, pulse oximetry and peripheral intravenous device. The pressure control is set as the standard every 5 minutes until the procedure under spinal anesthesia, the cuff pressure is placed on the arm that is going to be on top during spinal anesthesia. Data is recorded and vital signs of the patient and is put an infusion of crystalloid (0.9% NaCl or Ringer's acetate) with administration of 500 ml during the entire procedure until the beginning of the operation. |
| Trans-thoracic echocardiography | Experimental | In addition to the current clinical standard (arm A of the study) a trans-thoracic echocardiography is performed with the aim of assessing patient's volume status, identifying if he is responsive to fluid and could benefit from their administration. The echocardiography is performed with the subcostal projection to assess the size of the abdominal inferior vena cava and its collapsing during breathing.
According to different pre-established parameters, the patient is defined as unresponsive to fluids or responsive. If it's not responsive, he proceed to spinal anesthesia. Otherwise investigators proceed to the administration of crystalloid (NaCl 0.9% or Hartmann's solution second clinical evaluation) and at the end he's rerun an echocardiographic assessment. Receives: Procedure: Trans-thoracic echocardiography |
| Passive Leg Raising Test | Experimental | In addition to the arm A of the study, is performed a measurement of end-tidal CO2 (EtCO2) by trans-nasal canula with a patient positioned in semi-recumbent position. After, investigators run the Passive Leg Raising Test (PLRT): the position of the bed is changed in such manner to bring the trunk from 45° to 0° and accordingly the legs from 0° to 45°. Measurements are performed before and during the maneuver : an etCO2 increasing more than 12% from baseline was interpreted as fluid-responsive.
If the patient is not responsive to fluids, the patient is moving to the spinal anesthesia. If the patient is responsive investigators proceed to bolus administration, the patient returns to the initial PLRT position and is run again the PLRT until the patient is no longer responsive to fluids. Receives: Procedure: Passive Leg Raising Test |
What is being measured
The primary outcome is the main question the study is designed to answer.
Percentage of Participants With Systemic Hypotensions
Primary objective is to quantify significant hypotension rate after spinal anesthesia in patients brought to euvolemia according to the Trans-Thoracic Echocardiography and PLRT (Passive Leg Raising Test), compared to patients treated with the current standard. For arterial hypotension, in accordance with the international standard definitions, now define a drop in systolic blood pressure over 50 mmHg from baseline, an absolute value of systolic blood pressure less than 80 mm Hg, a mean arterial pressure below 60 mmHg or hypotension clinically symptomatic (dizziness, pallor, sweating, nausea).
Measured: 30 minutes
Secondary outcomes (2)
Pre-anesthesia Fluid Amount
A secondary objective is to quantify the water administration among the three comparison groups before spinal anesthesia, using the patients in the control group as a reference, in order to assess whether these techniques are associated with more fluid administration.
Measured: Time between operating room entry and spinal anesthesia, up to 30 min.
Post-anesthesia Fluid Amount
Another secondary objective is to quantify the water administration among the three comparison groups after spinal anesthesia, using the patients in the control group as a reference, in order to assess whether the techniques of filling, titrate echocardiographic evaluations and/or response to the mobilization of internal liquids are associated with lower dose, does not require more liquid.
Measured: 30 minutes
Timeline
From the start of the study to its completion; the mark is today. Estimated dates are the sponsor’s plan.
- First posted25 Feb 2014 (estimated)
- Study startMay 2014
- Primary completionFeb 2019
- Study completionAug 2019
Resources
- Official record on ClinicalTrials.govThe registry entry this page is built from, with its full change history.
- Posted resultsParticipant flow, outcome measures and adverse events reported by the sponsor.
- Publications (22)Papers the sponsor has linked to this study.
- Other trials for Hypotension and ShockStudies of the same condition, open and under way.
- What the trial phases meanHow a treatment moves from first tests in people to approval.
More details
For doctors and researchers: how the study is designed, who runs it, and its registry IDs.
Study design
- Study type
- Interventional
- Phase
- Phase N/A
- Primary purpose
- Prevention
- Allocation
- Randomised
- Intervention model
- Parallel groups
- Masking
- Single blind
- Who is masked
- Outcomes assessor
- Enrolment
- 429 participants (actual)
Sponsor and investigators
- Lead sponsor
- Ente Ospedaliero Cantonale, Bellinzona
- Sponsor type
- University, hospital or other
- Responsible party
- Principal investigator, Samuele Ceruti, Ente Ospedaliero Cantonale, Bellinzona
- Investigators
- Samuele Ceruti, MD, Principal investigator, Ente Ospedaliero Cantonale - Ospedale Regionale di BellinzonaAndrea Saporito, MD, Study chair, Ente Ospedaliero Cantonale - Ospedale Regionale di Bellinzona
IDs, dates and publications
- ClinicalTrials.gov ID
- NCT02070276
- Sponsor's protocol ID
- CERU-1401
- Other IDs
- ProCRHYSA trial
- Acronym
- CERU-1401
- Status last verified
- Jul 2020
- First submitted
- 18 Feb 2014
- Last updated
- 13 Jul 2020
- Results posted
- Yes, on ClinicalTrials.gov
- Data monitoring committee
- Yes
Publications
Kim HJ, Kim JS. A cardiovascular collapse following vigorous cough during spinal anesthesia. Korean J Anesthesiol. 2013 Dec;65(6 Suppl):S49-50. doi: 10.4097/kjae.2013.65.6S.S49. No abstract available.
PubMed 24478870Nogueira CS, Lima LC, Paris VC, Neiva PM, Otani ET, Couceiro Rde O, Burim F, Ferreira JA Jr, Cadecaro P. A comparative study between bupivacaine (S75-R25) and ropivacaine in spinal anesthesia for labor analgesia. Rev Bras Anestesiol. 2010 Sep-Oct;60(5):484-94. doi: 10.1016/S0034-7094(10)70060-X. English, Portuguese.
PubMed 20863929Xu S, Wu H, Zhao Q, Shen X, Guo X, Wang F. The median effective volume of crystalloid in preventing hypotension in patients undergoing cesarean delivery with spinal anesthesia. Rev Bras Anestesiol. 2012 May-Jun;62(3):312-24. doi: 10.1016/S0034-7094(12)70132-0.
PubMed 22656677Kaimar P, Sanji N, Upadya M, Mohammed KR. A comparison of hypotension and bradycardia following spinal anesthesia in patients on calcium channel blockers and beta-blockers. Indian J Pharmacol. 2012 Mar;44(2):193-6. doi: 10.4103/0253-7613.93847.
PubMed 22529474Zollei E, Bertalan V, Nemeth A, Csabi P, Laszlo I, Kaszaki J, Rudas L. Non-invasive detection of hypovolemia or fluid responsiveness in spontaneously breathing subjects. BMC Anesthesiol. 2013 Nov 5;13(1):40. doi: 10.1186/1471-2253-13-40.
PubMed 24188480Tulli G. Pulse pressure variation and stroke volume variation for prediction of fluid responsiveness in critically ill patients. Crit Care Med. 2013 Jan;41(1):e11. doi: 10.1097/CCM.0b013e318270e5a1. No abstract available.
PubMed 23269163Monge Garcia MI, Gil Cano A, Gracia Romero M, Monterroso Pintado R, Perez Madueno V, Diaz Monrove JC. Non-invasive assessment of fluid responsiveness by changes in partial end-tidal CO2 pressure during a passive leg-raising maneuver. Ann Intensive Care. 2012 Mar 26;2:9. doi: 10.1186/2110-5820-2-9.
PubMed 22449292Cherpanath TG, Geerts BF, Lagrand WK, Schultz MJ, Groeneveld AB. Basic concepts of fluid responsiveness. Neth Heart J. 2013 Dec;21(12):530-6. doi: 10.1007/s12471-013-0487-7.
PubMed 24170232Vieillard-Baron A, Chergui K, Rabiller A, Peyrouset O, Page B, Beauchet A, Jardin F. Superior vena caval collapsibility as a gauge of volume status in ventilated septic patients. Intensive Care Med. 2004 Sep;30(9):1734-9. doi: 10.1007/s00134-004-2361-y. Epub 2004 Jun 26.
PubMed 15375649Pinsky MR, Payen D. Functional hemodynamic monitoring. Crit Care. 2005;9(6):566-72. doi: 10.1186/cc3927. Epub 2005 Nov 22.
PubMed 16356240Lamia B, Ochagavia A, Monnet X, Chemla D, Richard C, Teboul JL. Echocardiographic prediction of volume responsiveness in critically ill patients with spontaneously breathing activity. Intensive Care Med. 2007 Jul;33(7):1125-1132. doi: 10.1007/s00134-007-0646-7. Epub 2007 May 17.
PubMed 17508199Muller L, Bobbia X, Toumi M, Louart G, Molinari N, Ragonnet B, Quintard H, Leone M, Zoric L, Lefrant JY; AzuRea group. Respiratory variations of inferior vena cava diameter to predict fluid responsiveness in spontaneously breathing patients with acute circulatory failure: need for a cautious use. Crit Care. 2012 Oct 8;16(5):R188. doi: 10.1186/cc11672.
PubMed 23043910Jabalameli M, Soltani HA, Hashemi J, Behdad S, Soleimani B. Prevention of post-spinal hypotension using crystalloid, colloid and ephedrine with three different combinations: A double blind randomized study. Adv Biomed Res. 2012;1:36. doi: 10.4103/2277-9175.100129. Epub 2012 Aug 28.
PubMed 23326767Buggy DJ, Power CK, Meeke R, O'Callaghan S, Moran C, O'Brien GT. Prevention of spinal anaesthesia-induced hypotension in the elderly: i.m. methoxamine or combined hetastarch and crystalloid. Br J Anaesth. 1998 Feb;80(2):199-203. doi: 10.1093/bja/80.2.199.
PubMed 9602585Zhang Z, Xu X, Ye S, Xu L. Ultrasonographic measurement of the respiratory variation in the inferior vena cava diameter is predictive of fluid responsiveness in critically ill patients: systematic review and meta-analysis. Ultrasound Med Biol. 2014 May;40(5):845-53. doi: 10.1016/j.ultrasmedbio.2013.12.010. Epub 2014 Feb 2.
PubMed 24495437
Study at a glance
From the registry record, last updated by the sponsor on 13 Jul 2020. Recruitment status is as the sponsor reported it: confirm with the study team.
- Official title
- Can Non Invasive Methods for Fluid Responsive Assessment Optimize Preventive Volemic Repletion in Order to Prevent Significant Hypotension After Spinal Anesthesia? A Randomized Trial
- ClinicalTrials.gov ID
- NCT02070276
- Acronym / sponsor ID
- CERU-1401 / CERU-1401
- Keywords
- Fluid therapy, Hypotension, Inferior vein cava, Spinal anesthesia, Ultrasonography
- Study type
- Interventional
- Recruitment status
- Completed
- Enrolment
- 429 participants (actual)
- Lead sponsor
- Ente Ospedaliero Cantonale, BellinzonaUniversity, hospital or other
- Study start
- May 2014
- Primary completion
- Feb 2019 (actual)
- Study completion
- Aug 2019 (actual)
- First posted
- 25 Feb 2014 (estimated)
- Results
- Posted 19 Dec 2019
Clinical summary
The research question as the sponsor registered it. This describes what the study plans to test, not what it found.
Spinal anesthesia is still the regional anesthesia technique most widely employed in everyday clinical practice.
The most feared and common of its well known side effects consist in an abrupt reduction of systemic vascular resistances, with consequence risk of systemic hypotension. To prevent this potentially severe complication, an adequate correction of patients' volume status through a preventive administration of fluids is widely used.
However this volume repletion is commonly accomplished on an empirical basis, without having a real insight of patient hemodynamic status, carrying the risk of possible volume overload.
Aim of the study is to test the clinical impact of two simple, non-invasive methods to guide volemic repletion before spinal anesthesia on the reduction of significant hypotension rate, compared to empirical fluid administration.
Detailed description
The resulting high density of the anesthetic block and the reproducibility of the technique have made of spinal anesthesia the most widely diffused regional anesthesia technique. Nevertheless the procedure still remains the regional anesthesia technique burdened by the potentially most severe side effects, the most frequent of which being systemic arterial hypotension.
Subarachnoidal administration of local anesthetics in fact is associated not only with both a motor and sensory block, but also with a blockade of the autonomic nervous system, which controls peripheral vascular tone. Sympathetic block leads to a sudden decrease in peripheral resistance, with consequent significant increase in vascular bed and relative hypovolemia.
Transient hypotensive episodes can be generally well tolerated by healthy patients, however they may lead to major complications in patients with increased cardiovascular risk. In the common clinical practice, it is usual to administer fluids empirically. An empirical preventive fluid repletion however can represent per se a risk in patients with impaired cardiac and renal functions, since a volume overload of heart chambers with reduced compliance can cause pulmonary edema or congestive heart failure.
Since about ten years both non-invasive and invasive techniques have been developed, with the specific purpose of optimizing fluid status on a rational basis. This methods are based on the correlation between the levels of mean arterial pressure (MAP), systemic vascular resistance (SVR) and cardiac output (CO), according to the equation: MAP = CO * SVR. The latter explains why, in case of vasodilation, unless CO is increased, a lowering of SVR will inevitably translate into a decrease of MAP.
Determinants of blood pressure are:
- volemic status;
- vascular resistance (determined by the control of the sympathetic system);
- cardiac output.
In case of spinal anesthesia the reduction in SVR determines relative hypovolemia (due to an increase in total vascular bed). For this reason after spinal anesthesia appears fundamental an optimization of patients' volemic status through administration of fluids (eventually associated with the administration of amines, in order to contrast massive vasodilation).
The use of methods to assess fluid responsiveness has been extensively studied in critical patients populations. However these techniques have not been studied yet in non critical patients. Spinal anesthesia is a model of pharmacological vasodilation which often generates significant hypotension, for which nowadays an evidence-based rational treatment based on a guided volemic repletion is still lacking.
WORKING HYPOTHESIS:
The use of non-invasive methods that have proven to be accurate for the identification of patient fluid-responsiveness is currently not validated in patients undergoing spinal anesthesia.
Ultrasound of inferior vena cava by is an effective method to determine the responsiveness to fluids in a patient on mechanical ventilation, however it has been proven to be inaccurate in spontaneous ventilating patients in critically ill patients, few data being available in non critical patients. The study of the inferior vena cava is based on the size of the inferior vena cava in its intra-abdominal portion (approximately 2 cm from emergency right atrium) and the pattern of its diameter changes with breathing. This measurement is obtained with M-mode ultrasound through subcostal view..
Passive leg raising test (PLRT) has been proven to be a highly accurate method in predicting fluid responsiveness in spontaneously breathing patients, in a population of critically ill patients. The method is based on the following assumption: active legs elevation, in addition to its effect of venous pool shifting from the lower limbs to the thorax, exerts a contemporary effect of stimulation on the peri-arterial sympathetic system at iliac-femoral level, this causing an orthosympathetic reflex which can increase cardiac output, possibly masking hypovolemia. Passive lower limbs raising instead has the advantage of mobilizing lower limbs venous blood (estimated 300-500 ml), without activating the orthosympathetic reflex. This allows for a quantification of the clinical response to a bolus of fluids, in terms of decrease of blood pressure variations following leg raising.
The hypothesis that investigators want to test is that the use of inferior vena cava ultrasound before spinal anesthesia, compared to the standard method (empirical fluid administration) and a non-invasive method (PLRT) can reduce the impact of systemic hypotension through an adequate titrated volemic repletion, avoiding both hypotension and fluid overload. The final purpose is to ensure spinal anesthesia in the safest possible way.
OBJECTIVES OF THE STUDY:
Aim of the study is to determine whether vena cava ultrasound, a bedside, unexpensive, non invasive methods, which have been tested as predictors of fluid responsiveness in critical patients, is effective in guiding titrated fluid repletion in a non critical population, in order both to decrease post procedural significant hypotension rate and unnecessary fluid overload in patients undergoing spinal anesthesia for elective surgical procedures.
Study design
- Primary purpose
- Prevention
- Allocation
- Randomised
- Intervention model
- Parallel groups
- Masking
- Single blind (outcomes assessor)
- Number of arms
- 3
| Arm | Type | Receives |
|---|---|---|
| Standard Clinical Practice | No intervention | –This arm is considered the current clinical standard for spinal anesthesia; its used as a control sample and statistical reference. During the induction phase the patient is fitted with a non-invasive blood pressure monitoring, three-lead ECG, pulse oximetry and peripheral intravenous device. The pressure control is set as the standard every 5 minutes until the procedure under spinal anesthesia, the cuff pressure is placed on the arm that is going to be on top during spinal anesthesia. Data is recorded and vital signs of the patient and is put an infusion of crystalloid (0.9% NaCl or Ringer's acetate) with administration of 500 ml during the entire procedure until the beginning of the operation. |
| Trans-thoracic echocardiography | Experimental | Procedure: Trans-thoracic echocardiographyIn addition to the current clinical standard (arm A of the study) a trans-thoracic echocardiography is performed with the aim of assessing patient's volume status, identifying if he is responsive to fluid and could benefit from their administration. The echocardiography is performed with the subcostal projection to assess the size of the abdominal inferior vena cava and its collapsing during breathing. According to different pre-established parameters, the patient is defined as unresponsive to fluids or responsive. If it's not responsive, he proceed to spinal anesthesia. Otherwise investigators proceed to the administration of crystalloid (NaCl 0.9% or Hartmann's solution second clinical evaluation) and at the end he's rerun an echocardiographic assessment. |
| Passive Leg Raising Test | Experimental | Procedure: Passive Leg Raising TestIn addition to the arm A of the study, is performed a measurement of end-tidal CO2 (EtCO2) by trans-nasal canula with a patient positioned in semi-recumbent position. After, investigators run the Passive Leg Raising Test (PLRT): the position of the bed is changed in such manner to bring the trunk from 45° to 0° and accordingly the legs from 0° to 45°. Measurements are performed before and during the maneuver : an etCO2 increasing more than 12% from baseline was interpreted as fluid-responsive. If the patient is not responsive to fluids, the patient is moving to the spinal anesthesia. If the patient is responsive investigators proceed to bolus administration, the patient returns to the initial PLRT position and is run again the PLRT until the patient is no longer responsive to fluids. |
Who may qualify
- Ages
- 18 to 80 years
- Sex
- All
- Healthy volunteers
- Not accepted
- Age groups
- Adult, Older adult
Key inclusion criteria (4 listed)
- all adult non critical patients requiring elective spinal anesthesia
- both sex
- patients with American Society of Anesthesiology class level I, II and III according to international standards
- spontaneously breathing patients
Key exclusion criteria (6 listed)
- patients already equipped or requiring invasive blood pressure monitoring (arterial catheter, pulmonary catheter, thermodilution catheter)
- patients with pre-procedural hypotension, defined as a response in two consecutive measurements of systolic arterial pressure (SAP) less than 80 mmHg or mean arterial pressure (MAP) less of 60 mmHg.
- patients unable to give informed consent to communication difficulties to language barriers or processes congenital/acquired determinants of mental retard, or any reduction in their ability to understand or want to be able to give their informed consent to the study
- patients where it is not then possible to perform spinal anesthesia for the patient's refusal to technical difficulties in sampling, clinical pathological conditions for determining a high risk of peri- procedural complications.
- patients with International Normalized Ratio > 1.5 and/or activated partial thromboplastin time in therapeutic range (defined as a value more than 1.5-2 times the normal values of the patient), anti-Xa activity in the therapeutic range .
Eligibility is decided by the study team after screening; this overview does not establish that a patient qualifies. Full inclusion and exclusion criteria.
Interventions
| Intervention | Type | Arms |
|---|---|---|
| Trans-thoracic echocardiographySubcostal evaluation of inferior vena cava dimensions and colorability with cyclic spontaneous breathing in order to determine if the patients will be fluid responsive or not. | Procedure or surgery | Trans-thoracic echocardiography |
| Passive Leg Raising TestApplication of this test in a standard manner in order to determine if our spontaneous breathing patients are fluid responsive before spinal anesthesia. | Procedure or surgery | Passive Leg Raising Test |
Primary outcome
Percentage of Participants With Systemic Hypotensions
Time frame: 30 minutes
Primary objective is to quantify significant hypotension rate after spinal anesthesia in patients brought to euvolemia according to the Trans-Thoracic Echocardiography and PLRT (Passive Leg Raising Test), compared to patients treated with the current standard. For arterial hypotension, in accordance with the international standard definitions, now define a drop in systolic blood pressure over 50 mmHg from baseline, an absolute value of systolic blood pressure less than 80 mm Hg, a mean arterial pressure below 60 mmHg or hypotension clinically symptomatic (dizziness, pallor, sweating, nausea).
2 secondary outcomes
Pre-anesthesia Fluid Amount
Time frame: Time between operating room entry and spinal anesthesia, up to 30 min.
Post-anesthesia Fluid Amount
Time frame: 30 minutes
Results and safety
Loading the posted results from ClinicalTrials.gov…
Research links
- Official record on ClinicalTrials.govLast updated by the sponsor 13 Jul 2020.
- Posted resultsParticipant flow, baseline, all outcome measures and adverse events.
- Background: PubMed 24478870Kim HJ, Kim JS. A cardiovascular collapse following vigorous cough during spinal anesthesia. Korean J Anesthesiol. 2013 Dec;65(6 Suppl):S49-50. doi: 10.4097/kjae.2013.65.6S.S49. No abstract available.
- Background: PubMed 20863929Nogueira CS, Lima LC, Paris VC, Neiva PM, Otani ET, Couceiro Rde O, Burim F, Ferreira JA Jr, Cadecaro P. A comparative study between bupivacaine (S75-R25) and ropivacaine in spinal anesthesia for labor analgesia. Rev Bras Anestesiol. 2010 Sep-Oct;60(5):484-94. doi: 10.1016/S0034-7094(10)70060-X. English, Portuguese.
- Background: PubMed 22656677Xu S, Wu H, Zhao Q, Shen X, Guo X, Wang F. The median effective volume of crystalloid in preventing hypotension in patients undergoing cesarean delivery with spinal anesthesia. Rev Bras Anestesiol. 2012 May-Jun;62(3):312-24. doi: 10.1016/S0034-7094(12)70132-0.
- Background: PubMed 22529474Kaimar P, Sanji N, Upadya M, Mohammed KR. A comparison of hypotension and bradycardia following spinal anesthesia in patients on calcium channel blockers and beta-blockers. Indian J Pharmacol. 2012 Mar;44(2):193-6. doi: 10.4103/0253-7613.93847.
- Background: PubMed 24188480Zollei E, Bertalan V, Nemeth A, Csabi P, Laszlo I, Kaszaki J, Rudas L. Non-invasive detection of hypovolemia or fluid responsiveness in spontaneously breathing subjects. BMC Anesthesiol. 2013 Nov 5;13(1):40. doi: 10.1186/1471-2253-13-40.
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- Swiss EthicLink provided by the sponsor.
- Cantonal Ethic CommitteeLink provided by the sponsor.
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Referral and contact
AzTrials does not enrol participants or take referrals. Contact the study team or a site listed below; they decide who can take part. This study is not recruiting at the moment.
Samuele Ceruti, MD principal investigator
Ente Ospedaliero Cantonale - Ospedale Regionale di Bellinzona
Andrea Saporito, MD study chair
Ente Ospedaliero Cantonale - Ospedale Regionale di Bellinzona
1 site in 1 country: see every site and its status.
Questions about this trial
What is this clinical trial studying?
A study testing Trans-thoracic echocardiography and Passive Leg Raising Test in people with Hypotension and Shock and Excessive Amount of Blood / Fluid Infusion, run by Ente Ospedaliero Cantonale, Bellinzona at 1 site in Switzerland.
The full registered description is in the About this study section and the official record.
Who may be eligible to take part?
The sponsor lists 4 inclusion and 6 exclusion criteria. Eligibility is decided by the study team after screening, so read the full criteria and contact a listed site.
Is this clinical trial currently recruiting?
The record says: finished, as of the sponsor's last update on 13 Jul 2020. Status can change between updates, so confirm with the study contact before making plans.
Where is the study taking place?
The record lists 1 site in Switzerland. Whether a site is taking part right now should be confirmed with that site. See every site.
What are the possible benefits and risks?
They depend on the study and the treatment, and no study can promise a benefit. The study team explains the known risks during informed consent, before anyone joins; the record itself does not list them.
Are results available for this study?
Yes. Results are posted in the registry (first posted 19 Dec 2019). A summary is in the For doctors view, and the full results are on ClinicalTrials.gov.
How can a doctor refer a patient or contact the research team?
The record lists no contact. The official record names the sponsor, who can be asked directly. AzTrials does not enrol participants or take referrals.
What does the primary outcome measure?
Percentage of Participants With Systemic Hypotensions (time frame: 30 minutes). It is what the study was designed to measure, not a finding.
Where can I read the original study information?
On the ClinicalTrials.gov record for NCT02070276, which also lists 22 linked publications.
Does a listing mean the treatment is approved or proven to work?
No. A listing means the study is registered. It does not show that the treatment is safe, works, or is approved by a regulator.
How often is this information updated?
AzTrials copies changed records from ClinicalTrials.gov every night and reloads the whole registry every week. The sponsor last updated this record on 13 Jul 2020; AzTrials last refreshed its copy on 27 Oct 2026.