Journal Appraisal

By PGMI Jasleen Dennise V. Monreal

Team Bravo (11 – 20 June 2020)
Journal
Appraisal tool
• Appraised using Critical Appraisal Skills Program Checklist from
Oxford Center for Triple Value Healthcare Ltd www.casp-uk.net
Did the trial address a clearly focused
issue?
• Yes, the authors clearly stated that the aim of the study was to
compare Norepinephrine and Phenylephrine variable, manually
adjusted infusion for maintenance of maternal blood pressure
during caesarean delivery.
Was the assignment of patients to
treatments randomized?
• Yes, a computer-generated sequence was achieved by a statistician
using an online random number generator.
• Patient codes were placed into sequentially numbered sealed
opaque envelopes.
Were all the patients who entered the trial
properly accounted for?
• Yes, the authors set an eligibility criteria for the participants and the patient
who joined the trial was accounted for
• Eligibility Criteria
Inclusion Criteria Exclusion Criteria
Full-term singleton pregnant Patients with uncontrolled
women, admitted for elective cardiac morbidities, hypertensive
caesarean delivery, aged between disorders of pregnancy,
18 and 40 years. peripartum bleeding, coagulation
disorders, and baseline systolic
blood pressure (SBP) < 100
mmHg
Were the patients, health workers and
study personnel blind to the treatment?
• Yes, the study is a randomized, double blind, controlled trial and
was conducted in obstetric department in a single institution.
Were the group similar at the start of the
trial?
• Yes, patients’ characteristics were comparable in the two study
groups.
Aside from the experimental intervention,
were the groups treated equally?
• Yes, all of the study participant are treated equally.
o All of the patients were monitored using electrocardiography, pulse
oximetry, and non-invasive blood pressure monitor.
o Same pre-medication drugs were delivered (metoclopramide 10 mg, and
ranitidine 50 mg)
o Ten milligrams hyperbaric bupivacaine in addition to 20 mcg fentanyl
were injected in L3-L4 or L4-L5 interspace using 25 G spinal needle.
Were the groups treated equally?
After spinal block, patients received the vasopressor infusion according to
the allocated study group:
• NE group (n = 60): received NE infusion with a starting rate of 0.05
mcg/kg/min. Norepinephrine bitartrate (8 mg norepinephrine
bitartrate/4 mL, which is equivalent to 4 mg norepinephrine base/4 mL
produced by Alexandria Co. for pharmaceuticals and chemical industries,
Egypt) was diluted to reach a final concentration of 4 mcg/mL.
• PE group (n = 63): received PE infusion with a starting rate of 0.75
mcg/kg/min. Phenylephrine hydrochloride (10 mg/1 mL ampoule,
produced by Sterop Co. Belgium) was diluted to reach a final
concentration of 50 mcg/mL.
How large was the treatment effect?
Primary Outcome: Incidence of Post-spinal anesthesia hypotension (PSH)
Secondary Outcome: Incidence of severe PSH, incidence of post-delivery
hypotension, SBP (baseline reading and the subsequent 12 readings), heart
rate (baseline reading and the subsequent 12 readings), incidence of
intraoperative nausea and vomiting, incidence of reactive hypertension,
intraoperative requirements of phenylephrine, ephedrine and atropine,
number of physician interventions per mother (physician intervention was
defined as any of the following: vasopressor bolus, atropine bolus, cessation,
re-starting, and changing of the vasopressor infusion rate), intraoperative
fluid intake, umbilical blood gases (pH, PCO2, PO2, and HCO3), and Apgar
score for the neonate at 1 minute and 5 minutes post-delivery.
How large was the treatment effect?
• The incidence of PSH {NE group: 18/60 (30%), PE group: 20/63 (32%), P =
0.8}, severe PSH, nausea, vomiting and rescue vasopressor consumption were
not statistically different between the two groups
• Incidence of reactive hypertension was halved, and incidence of bradycardia
was also nearly halved in NE group compared to PE group, although these
differences did not reach statistical significance (respectively: 12% vs. 24%, P
= 0.1, and 13% vs. 21%, P = 0.3).
• NE group showed lower number of physician interventions per mother
compared to PE group with median (quartiles) number of interventions of 0
(0, 1) and 1(0, 3) respectively (P = 0.001). The number of mothers who
needed at least one physician intervention was lower in NE group compared
to PE group [26 (43%) versus 45 (71%), P = 0.002]
How large was the treatment effect?
• The neonatal outcomes were comparable between both groups.
Summary of Results
• The authors reported that NE and PE effectively controlled
maternal blood pressure during caesarean delivery; however, NE
infusion was associated with less number of physician
interventions.
• There was a potentially lower incidence of bradycardia and
reactive hypertension in NE group compared to PE group without
reaching statistical significance.
Can the results be applied to local
population?
• Yes, the study provides an evidence-based approach in choosing an
appropriate drug for an obstetric patient in preventing post-spinal
anesthesia hypotension, which can be used in the Philippine
setting.
Were all clinically important outcomes
considered?
• The primary and secondary outcomes included in the study are all
clinically relevant for an obstetric patient, however, some
limitations were seen such as it is a single-centered study, the
authors did not include mothers with cardiac morbidities, and all
of the participants were scheduled to elective caesarean delivery.