Authors: Du C-C et al.
BMC Anesthesiology, published February 12, 2026
This randomized controlled trial examined whether an individualized, fluid responsiveness–guided strategy could better prevent spinal anesthesia–induced hypotension (SAIH) during cesarean delivery compared with standard prophylactic approaches. Hypotension after spinal anesthesia remains one of the most common complications in obstetric anesthesia, often managed with fluid loading, vasopressors, or a combination of both. However, a uniform approach may not be optimal because patients differ in their responsiveness to intravascular volume expansion.
The investigators designed a stratified randomized trial using carotid corrected flow time (FTc) to determine whether patients were fluid responsive. Parturients scheduled for cesarean delivery were classified as either fluid responsive (FR+) or non–fluid responsive (FR–) prior to spinal anesthesia. Each group was then randomized to receive either prophylactic colloid infusion (fluid loading) or norepinephrine infusion. This created four groups: FR(+)/Co, FR(+)/NE, FR(–)/Co, and FR(–)/NE.
The primary outcomes were the incidence of spinal anesthesia–induced hypotension and the maximum decrease in mean arterial pressure. Secondary outcomes included neonatal umbilical cord blood gas values, Apgar scores, intraoperative hemodynamics, and maternal postoperative recovery measures.
Among fluid-responsive patients, prophylactic colloid infusion and norepinephrine infusion performed similarly. The incidence of hypotension was 16.7% in the fluid-loading group and 15.1% in the norepinephrine group, indicating that either approach effectively maintained hemodynamic stability when the patient was capable of responding to volume expansion.
The results differed significantly in the non–fluid-responsive cohort. In these patients, fluid loading alone was much less effective. The incidence of hypotension reached 34.2% in the FR(–)/Co group compared with only 13.6% in the FR(–)/NE group. This suggests that when patients are not preload responsive, prophylactic vasopressor infusion is substantially more effective at preventing spinal-induced hypotension.
Neonatal outcomes were largely similar across groups, though a small difference was observed in cord blood lactate levels among fluid-responsive patients. Lactate levels were slightly higher in the FR(+)/NE group compared with FR(+)/Co, which the authors interpreted as a possible indicator of mild fetal hypoperfusion. However, the clinical significance of this difference remains uncertain.
Maternal recovery outcomes also differed slightly. Among fluid-responsive patients, those receiving norepinephrine had longer postoperative gastrointestinal recovery times compared with those receiving fluid loading. The mechanism for this finding is unclear but may relate to vasoconstrictive effects of norepinephrine on splanchnic circulation.
Overall, the study supports a tailored approach to preventing spinal anesthesia–induced hypotension during cesarean delivery. By determining fluid responsiveness before spinal anesthesia, clinicians may be able to choose the most appropriate prophylactic strategy: fluid loading for preload-responsive patients and norepinephrine infusion for those who are not.
What You Should Know
Spinal anesthesia–induced hypotension during cesarean delivery is common and traditionally managed with fluids, vasopressors, or both.
This study suggests that identifying fluid responsiveness before spinal anesthesia may help guide the most effective preventive strategy.
Fluid loading works well for patients who are fluid responsive but performs poorly when patients are not.
In non–fluid-responsive patients, prophylactic norepinephrine infusion significantly reduced hypotension compared with fluid loading.
These findings support individualized hemodynamic management rather than a one-size-fits-all approach.
Key Points
Randomized stratified trial using carotid corrected flow time to assess fluid responsiveness.
Fluid-responsive patients had similar hypotension rates with fluid loading or norepinephrine.
Non–fluid-responsive patients had much higher hypotension with fluid loading compared with norepinephrine.
Norepinephrine may therefore be the preferred prophylactic strategy in patients who are not fluid responsive.
Individualized hemodynamic management may improve maternal stability during cesarean delivery.
Thank you to BMC Anesthesiology for allowing us to summarize this article.