Dicrotic Notch and Hypotension at Caesarean Under Spinal Anaesthesia
Condition: Hypotension
MeSH terms: Hypotension
Study type: Observational

Summary: 
      BACKGROUND:

      Hypotension occurs commonly during spinal anaesthesia for caesarean section and may result in
      detrimental effects to the mother and foetus. A previous pilot study where images of the
      pulse oximeter waveform study were taken, found that the dicrotic wave moved away from the
      systolic wave during the onset of hypotension.

      AIMS:

      The investigators wish to download electronic data which describe the pulse oximeter pulse
      wave to more accurately assess movement of the diastolic wave relative to the systolic wave
      during spinal anaesthesia for caesarean section.

      METHODOLOGY:

      20 women undergoing caesarean section under spinal anaesthesia will be recruited by informed
      consent for this observational study. Data downloaded from the pulse oximeter will be
      analysed to identify movement of the dicrotic wave relative to the systolic wave and this
      will be related to changes in blood pressure.

      EXPECTED OUTCOMES:

      The investigators will establish best way to analyse changes in the pulse oximeter waveform
      and the relationship between changes in pulse oximeter waveform morphology and the onset of
      hypotension during spinal anaesthesia for caesarean section.

      IMPLICATIONS:

      Analysis of movement of the dicrotic wave could be used to anticipate and thus avoid severe
      hypotension during spinal anaesthesia for caesarean section.
    

Detailed description: 
      BACKGROUND:

      When a baby is delivered by a surgical procedure (a caesarean section) the women will usually
      have a spinal anaesthetic. With a spinal anaesthetic local anaesthetic is injected into the
      spinal fluid to make the woman numb from her chest to her feet allowing her to be comfortable
      but awake during the birth. One of the common side effects of a spinal anaesthetic is that
      the woman's blood pressure may fall making her feel unwell and (rarely) causing stress to the
      unborn baby.

      During a caesarean section the blood pressure is usually measured every few minutes using a
      cuff around the upper arm. However, the blood pressure may fall too quickly to be detected in
      a timely fashion by this intermittent means. One of the other monitors used in all cases is
      called a pulse oximeter. When this is attached to the patient's finger it detects the pulse
      rate and how much oxygen there is in the blood. The pulse oximeter also produces an image of
      the pulse wave in the finger. There is one pulse wave for every time the heart beats and it
      has two components. The main part of the wave (the systolic wave) is caused by the heart beat
      and the second part of the wave (the dicrotic wave) is a result of some of the energy from
      the heart beat bouncing back from blood vessels.

      In a previous study we used a digital camera to take images of the pulse oximeter monitor
      screen so that we could record changes in the shape of the pulse wave. We found that as
      patients' blood pressure fell the dicrotic wave moved further away from the systolic wave. We
      now intend to down load the electronic data that make up the pulse oximeter waveform, so that
      we can analyse the changes that occur more accurately.

      We believe that falling blood pressure may be detected earlier using analysis of movement of
      the dicrotic wave than by our standard monitoring. This is because currently blood pressure
      is measured intermittently whereas the pulse oximeter waveform is displayed continuously.
      Drugs could then be given promptly to stop the blood pressure from falling so low that the
      woman feels unwell or the unborn baby is affected.

      AIMS:

      Our aim is to observe changes in the position of the dicrotic wave during spinal anaesthesia
      for caesarean section and relate these to the occurrence of low blood pressure.

      METHODOLOGY:

      Following ethical approval 20 women undergoing caesarean section under spinal anaesthesia
      will be recruited by written informed consent. In theatre the electronic data which describe
      the pulse oximeter waveform will be downloaded by means of a data logger. In parallel, we
      will manually record the other perioperative data including the blood pressure. We will then
      use the data to establish the best way of accurately and reproducibly identifying the
      dicrotic wave when it moves in relation to the onset of low blood pressure. As this is an
      observational study, the management of the case will be at the discretion of the attending
      anaesthetist in discussion with the patient and will not be altered by inclusion in the
      study.

      EXPECTED OUTCOMES:

        1. We will establish the best way to detect movement of the dicrotic wave.

        2. We will establish the temporal relationship between movement of the dicrotic wave and
           fall in blood pressure during spinal anaesthesia for caesarean section.

      IMPLICATIONS:

      Anaesthetists will be able to use movement of the dicrotic wave to anticipate and avert low
      blood pressure during spinal anaesthesia for caesarean section.
    

Intervention name(s): Dicrotic wave analysis
Intervention type(s): Other
Intervention description(s): We will download data from the pulse oximeter that is being used to monitor the patient during their surgery.
Observational model: Cohort
Time perspective: Prospective
Sampling method: Non-Probability Sample
Study population: 
        Women undergoing planned caesarean section under spinal anaesthesia
      
Keywords: Pulse oximeter; Caesarean section; hypotension; Spinal anaesthesia