An Educational Module Explaining the Use of Norepinephrine to Treat Post-Spinal Anesthesia-Induced Hypotension in Parturient Undergoing Elective C-Sections: A Quality Improvement Project

Background: Maternal hypotension following spinal anesthesia poses a critical risk to both mother and neonate due to decreased systemic vascular resistance, compromising uterine blood flow as the uterus lacks autoregulation and relies on maternal blood pressure. Phenylephrine is frequently administered for maternal hypotension, but its limitations such as bradycardia warrant exploration of alternatives. Norepinephrine's alpha and mild beta activity better support maternal cardiac output, reducing the risk of decreased uterine blood flow. Through literature synthesis, this evidence-based project aimed to enhance anesthesia providers' knowledge and attitudes by showcasing the efficacy of norepinephrine as a better first-line treatment to reduce the incidence of maternal hypotension, maternal bradycardia, and fetal compromise post-spinal anesthesia. Methods: The databases utilized in the search included Embase, PubMed, and CINAHL. Exclusion criteria were meta-analyses and literature reviews. IRB was exempt from Florida International University. A 15-question pretest, including 6 demographic, 4 knowledge, and 11 attitude questions, was given via Qualtrics to assess baseline knowledge and attitude toward the practice change. A 15-minute Zoom educational module on norepinephrine's efficacy in managing post-spinal anesthesia hypotension was delivered to anesthesia providers at a level 1 trauma center. A post-survey mirroring the pretest immediately followed to assess anesthesia providers' knowledge acquired and any shifts in attitudes concerning the practice change questions. Data were reported using descriptive statistics, anonymously comparing pre- and post-module assessments via Qualtrics platform. All data collected will be stored securely and confidentially. Results: The results demonstrated significant improvement in participants' knowledge and attitudes towards using norepinephrine for post-spinal anesthesia-induced hypotension during elective c-sections. Post-intervention, 86% were aware of norepinephrine use, and all correctly identified ephedrine’s association with fetal acidosis and phenylephrine’s impact on cardiac output. Additionally, 86% recognized norepinephrine as requiring fewer rescue doses. Self-rated knowledge improved, with 57% feeling confident post-intervention. While phenylephrine remained the preferred vasopressor, openness to using norepinephrine increased, with 72% expressing a positive or neutral stance post-intervention. Discussion: Research shows that norepinephrine is a superior vasopressor for managing post-spinal anesthesia-induced hypotension. Norepinephrine consistently demonstrated a lower incidence of bradycardia, critical in maintaining maternal cardiac output, decreased episodes of reactive hypertension, and fewer provider interventions. Neonatal outcomes assessed by Apgar scores were similar between norepinephrine and phenylephrine, indicating the safety of norepinephrine. Recommendations for clinical practice change include integrating norepinephrine into obstetric protocols and providing regular training on administering norepinephrine to treat post-spinal anesthesia-induced hypotension. This evidence-based practice change brings awareness of norepinephrine's efficacy to enhance maternal hemodynamic stability and improve patient care. Limitations of this study can be overcome by extending the study duration, incorporating live presentations, and expanding the study to multiple clinical sites to further validate and build on these findings.