Prevention and Management of Hypotension During Spinal Anesthesia: A Narrative Review

Background: Spinal anesthesia is widely used in lower limb, lower abdominal, and obstetric surgery due to its rapid onset, extensive sensory and motor blockade, and good analgesic effect. The most frequent complication associated with this method is intraoperative hypotension, which occurs due to sympathetic vasomotor blockade, venous pooling, decreased venous return, and compromised cardiac compensatory response. Obstetric patients may experience decreased organ perfusion during hypotensive episodes. Objective: The purpose of this narrative review is to present the causes, risk factors, manifestations, and interventions that have been shown to prevent and treat hypotension following spinal anesthesia. Methods: Articles were identified through a literature search of PubMed, Scopus, and Google Scholar for the years 2015 to 2026. Keywords used were spinal anesthesia, hypotension, prevention, and management. A total of 87 articles were screened, of which 45 articles were selected for inclusion in the review. Results: Factors associated with hypotension following spinal anesthesia can be grouped into patient-, procedure-, and drug-related factors. Patient factors include pregnancy, age, intravascular volume, and cardiac disease. Procedural factors include block height, local anesthetic dose, speed of injection, and positioning. Drug-related factors include the type of local anesthetic, vasoconstrictors, and adjuncts. Controlled crystalloid (electrolyte) fluid co-loading and early use of vasopressors, particularly phenylephrine or norepinephrine, are effective strategies for prevention. Continuous non-invasive hemodynamic monitoring can facilitate early identification of hemodynamic disturbances and support an appropriate response. The effects of spinal anesthesia-induced hypotension may be greatly reduced through appropriate management. Conclusion: Spinal anesthesia may cause hypotension primarily due to sympathetic blockade. Recognition of relevant patient-, procedural-, and drug-related factors, together with appropriate fluid management, early vasopressor use, and hemodynamic monitoring, can support its prevention and management. Keywords: Anesthesia, Spinal; Hypotension; Blood Pressure; Perioperative Care; Bradycardia; Hemodynamics; Patient Positioning; Fluid Therapy