INRODUCTION: 
Regional anaesthesia has been the preferred technique in 
majority of patients coming for abdominal hysterectomy. Its 
advantage revolved around its simplicity of administration, its 
reliability of action and its minimal side effects. Subarachnoid 
block offers rapid onset of action and good surgical 
anaesthesia. Hypotension occurs usually due to autonomic 
blockade which is two segments higher than the sensory block 
after administration of spinal anaesthesia. Hence volume 
preloading has been recommended for prevention of spinal – 
induced hypotension in this situation. 

NEED FOR STUDY :
This study was conducted to compare the efcacy of 
crystalloid to colloid preloading in reducing the incidence and 
severity of spinal induced hypotension

AIM:
The aim of my study was to assess the safety and efcacy of 
colloid (hydroxyethyl starch) over crystalloid (ringer's lactate) 
preloading in preventing hypotension following spinal 
anaesthesia.

OBJECTIVES:
1. To assess if the preloading is benecial in preventing the 

adverse haemodynamic changes in abdominal 
hysterectomy under spinal anaesthesia. 

2. To nd out the better preloading uid between colloids 
and crystalloids. 

3. To assess the requirement of vasopressors.

METHODS : 
TYPE AND DESIGN OF STUDY : 
Randomized prospective study 

STUDY POPULATION : 
The study population included 60 patients undergoing 
elective abdominal  hysterectomy  under spinal anesthesia 
during november 2018 – August 2019 .

STUDY LOCATION : 
MVJ Medical College and Research Hospital

ETHICAL CLEARANCE : Obtained

INCLUSION CRITERIA:
1. Patients undergoing abdominal hystrectomy.
2. Patients belonging to ASA I  &II.
3. Patients belonging to age group 18-60years.

EXCLUSIVE CRITERIA:
1. Patients refusing spinal anaesthesia.
2. Patients with cardiac disorders.
3. Patients with skin or soft tissue infection at the site of 

needle entry and coagulopathy.
4. Any Contraindications to spinal anaesthesia .

SAMPLE SIZE : 
With a condence interval of 90% , and p value of <0.l, the 
sample size for the current study was calculated to be 60 , with 
a population of 30 in each group.

METHODOLOGY : 
60 patients of ASA I and II posted for Abdominal Hysterectomy 
are considered for the study after permission from hospital 
Ethical committee and written informed consent is obtained 
from every patient. Patients with cardiac disorders, skin or soft 
tissue infection at the site of needle entry ,coagulopathy and 
refusing spinal anaesthesia or with any other contraind 
ications for spinal anaesthesia were excluded from the study . 
Routine pre-anaesthetic evaluation was done. Relevant 
investigations were done.

On arrival into operation theatre patients were placed in 
supine position. Baseline hemodynamic parameters will be 
noted in both groups.IV line is secured using IV cannula 18G 
and xed. Patients were randomly divided into 2 groups of 30 
each. Group A – will receive ringer lactate 10ml/kg in 20 
minutes before giving SAB. Group B – will receive 
hydroxyethyl starch, 5ml/kg in 20 minutes, before giving SAB.
Immediately after preloading ,under aseptic precautions 
patients in both groups received 0.5% Bupivacaine (heavy)  3 
ml in lateral position at L2-L3 / L3-L4 space for Subarachnoid 
block. Patients were turned supine and ringers lactate 
infusion is started .Oxygen was given by facemask at the rate 
of 4-5L/min. Following spinal anaesthesia mean arterial 
pressure were recorded at following intervals - 1, 5, 10, 15, 30, 
45, 60, 90 minutes and 3 hours after spinal anaesthesia. 
Rescue medications were recorded if used.

If the systolic blood pressure goes below 30% of the baseline it 
is taken as hypotension Hypotension was treated with rapid IV 
uid infusion and inj. Ephedrine, 6 mg IV. Blood loss was 
replaced with crystalloids and blood transfusion as required. 
Patients were observed for nausea, vomiting, rigors, and 
allergic reaction. Urine output, total uid requirement and 
blood loss were recorded at the end of surgery and patients 
were observed for 1 hour in recovery room postoperatively and 
PR, NIBP, SPO2 were recorded.

A COMPARATIVE STUDY OF RINGER LACTATE AND HYDROXYETHYL 
STARCH AS A PRELOADING FLUID FOR PREVENTION OF HYPOTENSION 
FOLLOWING SUBARACHNOID BLOCK IN ABDOMINAL HYSTERECTOMY.

Original Research Paper

Dr Kaveti Vihitha 
Reddy 

PG , MVJ MC&RH Medical College And Research Hospital

Dr Tahir S 
Hatturkar 

PG , MVJ MC& RH Medical College And Research Hospital

Anaesthesiology

KEYWORDS : 

VOLUME-9, ISSUE-2, FEBRUARY-2020 • PRINT ISSN No. 2277 - 8160 • DOI : 10.36106/gjra

Dr Somasekharam 
P*

PROF , MVJ MC&RH Medical College And Research Hospital
*Corresponding Author

Dr Jawabulla 
Vazhayil

PG , MVJ Medical College And Research Hospital

30 X GJRA - GLOBAL JOURNAL FOR RESEARCH ANALYSIS



Statistical analysis was performed using ANOVA and chi 
square test

RESULTS:
Table 1 : Demographic characteristics (mean)

There was no signicant difference between two groups 
before the surgery in regards to mean age and weight.

Level of sensory block attained in the both the groups was  ≥ 
T6 and hence was comparable. At the end of surgery level of 
block was ≤  T8 and was comparable.

Both groups pre-induction blood pressure is noted and is 
almost similar. However the incidence of hypotension was 
higher in group A (RL) compared to group B (HES)  (60 % vs 
30% ). (Table 3)

Table 2: Hypotensive episodes and their management

Table : Mean blood pressure (mm of Hg)

The mean arterial pressure was compared among the two 
groups at the pre-set time intervals for this study. The 

differences among the two groups were statistically 
signicant at 0 min ( p =0.005) , 1 min ( p =0.047), 5 min ( p = 
0.042), & 15 min ( p =0.037).

DISCUSSION :
Sympathetic denervation occurs during spinal anaesthesia. 
In spinal anaesthesia the severity of hypotension depends on 
the degree of sympathetic blockade. In spinal anesthesia, 
hypotension is dened as a fall in systolic blood pressure by 
30% of the  baseline.

Various measures have been tried for prevention of 
hypotension induced by spinal anesthesia. 
1)  Preloading 
2)  Leg compression by inatable splint 
3)  Prophylactic use of vasopressors.

All measures have their own limitations. Volume preloading is 
an effective technique to prevent hypotension induced by 
spinal anesthesia. Different crystalloid and colloid have been 
used as preloading uid for prevention of hypotension 
induced by spinal anesthesia. In this study this character has 
been studied by giving Ringer lactate and HES as preloading 
uid before giving spinal anesthesia.

 We had selected Ringer's lactate as preloading uid because 
it is most physiological uid, its osmolality is similar to plasma 
and most of the authors have selected it in their studies as 
preloading uid . Hydroxyethyl starch (HES) is extensively 
during  resuscitation in polytrauma, critically ill patients in 
intensive care settings, vascular and orthopedic surgery and 
in burns and sepsis patients. Its use is contraindicated in 
patient's with renal failure and in those with known sensitivity 
to the drug. The incidence of anaphylactic reactions to 
hydroxyethyl starch is much less than with gelatins and 

7dextrans (0.006%, 0.038% and 0.008% respectively).  In terms 
of cost, performance and low incidence of side effects 6% HES 
is an adequate alternative to 5% albumin. For the above 
reasons, we chose 6% HES as our study uid.  

Severe hypotension is dened as mean arterial pressure 
1 (MAP) below 30% of base line value. We dened hypotension 

as a decrease in mean blood pressure of  30% or more from 
the baseline value. We were not able to completely prevent 
spinal block induced hypotension by preloading with either 
6% HES or Ringer Lactate. But patients who received 6% HES 
had a much lower incidence of hypotension (12%) as 
compared to those who received Ringer Lactate (68%). The 
incidence of hypotension in both the group is less than that 
reported by other authors' who have shown similar results. 
Patients who received 6% HES had signicantly less number 
of hypotensive episodes requiring treatment with ephedrine 
as compared to the patients who had received Ringer Lactate. 
The rst episode of hypotension occurred as early as 5 min 
after the subarachnoid block in the Ringer lactate group 
whereas the earliest hypotensive episode in the 6% HES group 
occurred 10 min after the subarachnoid block.

But in our study the incidence of hypotension between Group A 
and Group B were 60% vs 30%. Moreover the ephedrine 
requirements were more in Group A than Group B which was 
also statistically signicant (p value <0.01).

In the study by Sheikh Imran et al 36.4% of patients in HES 
Group and 63.6% patients in RL Group needed rescue doses 
of Inj.mephentermine.(4)Hydroxyethyl starch remains longer 
in the intravascular compartment than any crystalloid solution 
and is also able to maintain greater colloid osmotic pressure 
in the maternal circulation.  About 75% of any crystalloid 
given diffuses into the interstitial space and 2.5 to 3 times the 
volume of crystalloid is needed to achieve the same degree of 
plasma expansion. Extravascular redistribution of crysta 

VOLUME-9, ISSUE-2, FEBRUARY-2020 • PRINT ISSN No. 2277 - 8160 • DOI : 10.36106/gjra

Variables Group A (RL) Group B (HES) 

Age in Yrs  40.8 39.7

Weight in Kg  59.8 57.3

Group A 
(RL)

Group B 
(HES)

 p value

Incidence of 
hypotension

18(60%) 9 (30%) Not 
signicant

Hypotension corrected 
by additional rapid 
infusion of Ringer's 
lactate

13(43%) 7 (23%) Not 
signicant

Hypotension corrected 
by Injection Ephedrine

5(17%) 2 (7%) p< 0.01

Time Group R Group H p value

Pre op 82.57±10.88 88.97 ± 6.80 0.194

0 77.90 ± 8.85 86.05 ±9.38 0.005

1 mins 64.47±13.26 76.32±12.39 0.047

5 mins 63.20±10.97 74.82±10.15 0.042

10 mins 62.70±10.54 73.30±10.53 0.059

15 mins 60.62 ±11.07 72.85±10.97 0.037

30 mins 68.97 ±9.90 72.32 ±9.19 0.186

45 mins 69.35 ±8.99 72.12 ±8.42 0.735

60 mins 70.77 ±7.36 74.82 ±8.69 0.759

90 mins 71.90 ±6.68 74.17 ±7.80 0.525

180 mins 72.12 ±6.80 76.02 ±7.43 0.549

  X 31GJRA - GLOBAL JOURNAL FOR RESEARCH ANALYSIS



lloids may be so rapid that it may be impossible to infuse them 
fast enough to maintain the intravascular volume and avoid 
hypotension during spinal anaesthesia. We may have been 
able to reduce the incidence of hypotension by giving larger 
volumes of crystalloid solutions. But this would have required 
more time to preload and would have placed both parturient 
and foetus at a greater risk of uid overload.

The patients in the 6% HES group required less intravenous 
uid intraoperatively as compared to the Ringer Lactate 
group. There was no signicant difference in the amount of 
uids received postoperatively between the two groups. The 
study by Singh et al concluded that administering preload 
uid had no benecial effect in preventing hypotension after 
spinal anaesthesia. But from the observations in our study, it is 
clear that preloading with 6% Hydroxyethyl starch is superior 
to the standard preload to Ringer Lactate in preventing post 
spinal hypotension.

CONCLUSION:
From the observations in present study, it is concluded that : 
1.  6% HES (colloid) is better in volume preloadingwith 

minimal haemodynamic changes compared to the Ringer 
Lactate (crystalloids).

2.  There was increased requirement of vasopressors when 
Ringer Lactate (crystalloid) was used and requirement of 
vasopressors was more when preloading with RL 
compared to preloading with 6% HES.

REFERENCES :
1. Verma RK. Mishra LD. Nath SS.Efcacy of polygenic preloading in prevention 

of hypotension following CSEA.Indian J. Anaesthesia 2005;49(2):105-108.
2. Mercier F. Diemunsch.J.P. Bouthors ASD.et.al6% Hydroxyethyl starch (130/0.4) 

vs Ringer’s lactate preloading before spinal anaesthesia for Caesarean 
delivery:the randomized, double-blind, multicentre CAESAR trial.British 
Journal of Anaesthesia 2014;113 (3): 459–67 .

3. Singh B, Singh AP,Bhardwaj A, Singh I. C Comparative study of preloading 
with ringer lactate v/s 6% hexa starch solutions to prevent hypotension 
following spinal anaesthesia in elective surgery. Int J Med and Dent Sci 
2016;5(2):1178-1183.

4. Imran S .Padmanabha S. Rehman H . Sahoo A. A comparative study of 
preloading efcacy of ringers lactate v/s 6% heta starch solutions in 
preventing hypotension following spinal anaesthesia.IOSR- JDMS 
2014;13(3):43-48.

5. Jalandhara B.Makwana JC .A comparative study of crystalloids and colloids 
as preloading in spinal anaesthesia for ptrevention of hypotension .GCSMC J 
MED SCI 2014;III(1) :48-52.

6. Yatish Bevinaguddaiah, Vinayak Seenappa Pujari, Tejesh CA, Manjunath 
AC. “Volume preloading prior to subarachnoid block: comparison between 
hetastarch (6%), polygelatin, ringer`s lactate solution”. Journal of Evolution of 
Medical and Dental Sciences 2013; 2(47): 9220-9227.

7. Lund N.  Anaphylactoid reactions to infusion of polygelatin.  A study in 
pregnant women. Anaesth 1980;35(7):655-9.

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