Effect of intravenous phenylephrine infusion on dose requirement of intrathecal plain levobupivacaine for cesarean section: A placebo-controlled preliminary study

BACKGROUND: Phenylephrine infusion has been shown to decrease rostral spread of plain and hyperbaric local anesthetic (LA) when compared to ephedrine infusion. However, it does not result in higher dose requirement of hyperbaric LA for cesarean section. There is no trial evaluating the effect of phenylephrine infusion on ED50 of a plain intrathecal LA. METHODS: Pregnant patients with term uncomplicated singleton pregnancy undergoing elective cesarean section were given combined spinal-epidural anesthesia. They received intrathecal plain levobupivacaine 0.5% in a dose decided by up-and-down sequential allocation method along with 25 μg fentanyl. Intravenous infusion of phenylephrine (100 μg/ml) or normal saline was initiated immediately after intrathecal injection. Systolic arterial pressure ≤0.8 times baseline was treated using rescue boluses of phenylephrine 50 μg. RESULTS: Demographic, other patient and surgical characteristics were similar in the two groups. ED50 of intrathecal plain levobupivacaine was significantly greater in phenylephrine group (5.5 mg [95% confidence interval (CI): 5.1–5.9 mg]) compared to saline group (4.2 mg [95% CI: 3.4–5.1 mg]) (P = 0.01). Maximum sensory level, time to achieve adequate block, Apgar scores, and umbilical artery pH were similar in both groups. Total phenylephrine dose and patients having significant bradycardia were lesser in the saline group. CONCLUSIONS: Intrathecal dose requirement of plain levobupivacaine is greater using phenylephrine infusion as compared to saline infusion with rescue phenylephrine boluses. When using phenylephrine as a variable dose regimen titrated to maintain blood pressure within 20% of baseline, the ED50 of plain levobupivacaine is 5.5 mg (95% CI: 5.1–5.9 mg).