Metoclopramide for nausea and vomiting prophylaxis during and after Caesarean delivery: a systematic review and meta-analysis

Commonly used antiemetics for prophylaxis of postoperative nausea and vomiting after Caesarean delivery with neuraxial morphine: a network meta-analysis

BACKGROUND

Dopamine antagonists, 5-HT3 antagonists, and dexamethasone are frequently used in obstetrics to prevent postoperative nausea and vomiting (PONV). However, the superiority of any drug class is yet to be established. This network meta-analysis aimed to compare the efficacy of these antiemetics for PONV prophylaxis in women receiving neuraxial morphine for Caesarean delivery.

METHODS

We searched PubMed, Embase, CENTRAL, Web of Science, and Wanfang Data for eligible randomised controlled trials. Primary outcomes were the incidences of postoperative nausea (PON) and postoperative vomiting (POV) within 24 h after surgery. We used a Bayesian random-effects model and calculated odds ratios with 95% credible intervals for dichotomous data. We performed sensitivity and subgroup analyses for primary outcomes.

RESULTS

A total of 33 studies with 4238 women were included. In the primary analyses of all women, 5-HT3 antagonists, dopamine antagonists, dexamethasone, and 5-HT3 antagonists plus dexamethasone significantly reduced PON and POV compared with placebo, and 5-HT3 antagonists plus dexamethasone were more effective than monotherapy. In the subgroup analyses, similar results were seen in women receiving epidural morphine or intrathecal morphine alone but not in women receiving intrathecal morphine with fentanyl or sufentanil. However, most included studies had some concerns or a high risk of bias, and the overall certainty of the evidence was low or very low.

CONCLUSIONS

Combined 5-HT3 antagonists plus dexamethasone are more effective than monotherapy in preventing PONV associated with neuraxial morphine after Caesarean delivery. Future studies are needed to determine the role of prophylactic antiemetics in women receiving intrathecal morphine and lipophilic opioids.

SYSTEMATIC REVIEW PROTOCOL

PROSPERO CRD42023454602.

Epidural administration of 2% Mepivacaine after spinal anesthesia does not prevent intraoperative nausea and vomiting during cesarean section: A prospective, double-blinded, randomized controlled trial

BACKGROUND

Intraoperative nausea and vomiting (IONV) is a common symptom during cesarean section (CS) delivery causing significant discomfort to patients. Combined spinal and epidural anesthesia (CSEA) can provide both intraoperative anesthesia and postoperative analgesia. During CSEA, it is reasonable to administer local anesthetics to the epidural space before patient complaints to compensate for the diminished effect of spinal anesthesia. Therefore, we hypothesized that intraoperative epidural administration of 2% mepivacaine would reduce the incidence of IONV.

METHODS

Patients who were scheduled for elective CS were randomly allocated to 2 groups. Patients and all clinical staff except for an attending anesthesiologist were blinded to the allocation. After the epidural catheter was inserted at the T11-12 or T12-L1 interspace, spinal anesthesia was performed at the L2-3 or L3-4 interspace to intrathecally administer 10 mg of 0.5% hyperbaric bupivacaine. Twenty min after spinal anesthesia, either 5 mL of 2% mepivacaine (group M) or saline (group S) was administered through an epidural catheter. Vasopressors were administered prophylactically to keep both the systolic blood pressure ≥ 80 % of the baseline value with the absolute value ≥ 90 mm Hg and the mean blood pressure ≥ 60 mm Hg. The primary endpoint was the incidence of IONV. The secondary endpoints were degree of nausea, the degree and incidence of pain, and Bromage score.

RESULTS

Ninety patients were randomized, and 3 patients were excluded from the final analysis. There was no significant difference in the incidence of IONV between the groups (58% in group M and 61% in group S, respectively, P = .82). In contrast, the incidence and degree of intraoperative pain in group M were significantly lower compared to group S. In addition, the incidence of rescue epidural administration of fentanyl (18% vs 47%) or mepivacaine (2.3% vs 25%) for intraoperative pain was lower in group M compared to group S.

CONCLUSIONS

Our results indicate that epidural administration of 2% mepivacaine 20 minutes after spinal anesthesia does not reduce the incidence of IONV in CS under CSEA. However, intraoperative epidural administration of 2% mepivacaine was found to improve intraoperative pain.

Dural puncture epidural versus conventional epidural analgesia for labor: a systematic review and meta-analysis of randomized controlled studies

Dural puncture epidural (DPE) technique is a modification of the conventional epidural (EP) technique in that the dura is intentionally punctured with a spinal needle but without any spinal injection. This meta-analysis aimed to evaluate the benefits and risks associated with the DPE technique for labor analgesia. Randomized trials comparing DPE analgesia with EP analgesia for labor pain relief were systematically searched in the database of Medline, Embase, Cochrane Controlled Trials Register, Web of Science, and China Biology Medicine till 1^st August 2021. The primary outcome was the percentage of patients with satisfactory pain relief following DPE or EP analgesia, which was defined as visual analog scale (VAS) pain scores ≤ 3/10 (or 30/100) measured 10 min and 20 min after initiation of labor analgesia. Totally ten trials with 1099 patients were included in this review. DPE technique increased the percentage of patients with VAS pain score ≤ 3/10 (or 30/100) both at 10 min (RR 1.43; 95% CI 1.17, 1.74; p < 0.001; I² = 0%) and 20 min (RR 1.13; 95% CI 1.04, 1.22; p = 0.005; I² = 0%) after labor analgesia. No adverse event was found with DPE analgesia. We conclude that compared with EP analgesia, DPE analgesia is beneficial for labor pain relief by shortening the time to achieve satisfactory pain control. Meanwhile, DPE analgesia is not associated with increased adverse maternal/fetal events.

[Neuraxial Morphine for Postoperative Analgesia after Caesarean Deliveries]

The use of neuraxial morphine, in combination with nonopioid analgesic regimens for postoperative analgesia after Caesarean deliveries is common practice, especially in the Anglo-American world. Neuraxial morphine offers a longer-lasting superior analgesia than intravenous opioids or patient-controlled analgesia. If neuraxial anaesthesia is being used for a caesarean delivery, it may be recommended to concomitantly administer neuraxial morphine for the postoperative analgesia.A low dose of neuraxial morphine in a healthy parturient bears a low morbidity and mortality risk. The optimal frequency, duration and modality of respiratory monitoring for patients at low risk for respiratory depression is dependent on the dose of morphine administered and the patient-specific and obstetric risk profile.

Interventions for preventing nausea and vomiting in women undergoing regional anaesthesia for caesarean section

BACKGROUND

Nausea and vomiting are distressing symptoms which are experienced commonly during caesarean section under regional anaesthesia and in the postoperative period.  OBJECTIVES: To assess the efficacy of pharmacological and non-pharmacological interventions versus placebo or no intervention given prophylactically to prevent nausea and vomiting in women undergoing regional anaesthesia for caesarean section.

SEARCH METHODS

For this update, we searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP) (16 April 2020), and reference lists of retrieved studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of studies and conference abstracts, and excluded quasi-RCTs and cross-over studies.

DATA COLLECTION AND ANALYSIS

Review authors independently assessed the studies for inclusion, assessed risk of bias and carried out data extraction. Our primary outcomes are intraoperative and postoperative nausea and vomiting. Data entry was checked. Two review authors independently assessed the certainty of the evidence using the GRADE approach.

MAIN RESULTS

Eighty-four studies (involving 10,990 women) met our inclusion criteria. Sixty-nine studies, involving 8928 women, contributed data. Most studies involved women undergoing elective caesarean section. Many studies were small with unclear risk of bias and sometimes few events. The overall certainty of the evidence assessed using GRADE was moderate to very low. 5-HT3 antagonists: We found intraoperative nausea may be reduced by 5-HT3 antagonists (average risk ratio (aRR) 0.55, 95% confidence interval (CI) 0.42 to 0.71, 12 studies, 1419 women, low-certainty evidence). There may be a reduction in intraoperative vomiting but the evidence is very uncertain (aRR 0.46, 95% CI 0.29 to 0.73, 11 studies, 1414 women, very low-certainty evidence). There is probably a reduction in postoperative nausea (aRR 0.40, 95% CI 0.30 to 0.54, 10 studies, 1340 women, moderate-certainty evidence), and these drugs may show a reduction in postoperative vomiting (aRR 0.47, 95% CI 0.31 to 0.69, 10 studies, 1450 women, low-certainty evidence). Dopamine antagonists: We found dopamine antagonists may reduce intraoperative nausea but the evidence is very uncertain (aRR 0.38, 95% CI 0.27 to 0.52, 15 studies, 1180 women, very low-certainty evidence). Dopamine antagonists may reduce intraoperative vomiting (aRR 0.41, 95% CI 0.28 to 0.60, 12 studies, 942 women, low-certainty evidence) and postoperative nausea (aRR 0.61, 95% CI 0.48 to 0.79, 7 studies, 601 women, low-certainty evidence). We are uncertain if dopamine antagonists reduce postoperative vomiting (aRR 0.63, 95% CI 0.44 to 0.92, 9 studies, 860 women, very low-certainty evidence). Corticosteroids (steroids): We are uncertain if intraoperative nausea is reduced by corticosteroids (aRR 0.56, 95% CI 0.37 to 0.83, 6 studies, 609 women, very low-certainty evidence) similarly for intraoperative vomiting (aRR 0.52, 95% CI 0.31 to 0.87, 6 studies, 609 women, very low-certainty evidence). Corticosteroids probably reduce postoperative nausea (aRR 0.59, 95% CI 0.49 to 0.73, 6 studies, 733 women, moderate-certainty evidence), and may reduce postoperative vomiting (aRR 0.68, 95% CI 0.49 to 0.95, 7 studies, 793 women, low-certainty evidence). Antihistamines: Antihistamines may have little to no effect on intraoperative nausea (RR 0.99, 95% CI 0.47 to 2.11, 1 study, 149 women, very low-certainty evidence) or intraoperative vomiting (no events in the one study of 149 women). Antihistamines may reduce postoperative nausea (aRR 0.44, 95% CI 0.30 to 0.64, 4 studies, 514 women, low-certainty evidence), however, we are uncertain whether antihistamines reduce postoperative vomiting (average RR 0.48, 95% CI 0.29 to 0.81, 3 studies, 333 women, very low-certainty evidence). Anticholinergics: Anticholinergics may reduce intraoperative nausea (aRR 0.67, 95% CI 0.51 to 0.87, 4 studies, 453 women, low-certainty evidence) but may have little to no effect on intraoperative vomiting (aRR 0.79, 95% CI 0.40 to 1.54, 4 studies; 453 women, very low-certainty evidence). No studies looked at anticholinergics in postoperative nausea, but they may reduce postoperative vomiting (aRR 0.55, 95% CI 0.41 to 0.74, 1 study, 161 women, low-certainty evidence). Sedatives: We found that sedatives probably reduce intraoperative nausea (aRR 0.65, 95% CI 0.51 to 0.82, 8 studies, 593 women, moderate-certainty evidence) and intraoperative vomiting (aRR 0.35, 95% CI 0.24 to 0.52, 8 studies, 593 women, moderate-certainty evidence). However, we are uncertain whether sedatives reduce postoperative nausea (aRR 0.25, 95% CI 0.09 to 0.71, 2 studies, 145 women, very low-certainty evidence) and they may reduce postoperative vomiting (aRR 0.09, 95% CI 0.03 to 0.28, 2 studies, 145 women, low-certainty evidence). Opioid antagonists: There were no studies assessing intraoperative nausea or vomiting. Opioid antagonists may result in little or no difference to the number of women having postoperative nausea (aRR 0.75, 95% CI 0.39 to 1.45, 1 study, 120 women, low-certainty evidence) or postoperative vomiting (aRR 1.25, 95% CI 0.35 to 4.43, 1 study, 120 women, low-certainty evidence). Acupressure: It is uncertain whether acupressure/acupuncture reduces intraoperative nausea (aRR 0.55, 95% CI 0.41 to 0.74, 9 studies, 1221 women, very low-certainty evidence). Acupressure may reduce intraoperative vomiting (aRR 0.52, 95% CI 0.33 to 0.80, 9 studies, 1221 women, low-certainty evidence) but it is uncertain whether it reduces postoperative nausea (aRR 0.46, 95% CI 0.27 to 0.75, 7 studies, 1069 women, very low-certainty evidence) or postoperative vomiting (aRR 0.52, 95% CI 0.34 to 0.79, 7 studies, 1069 women, very low-certainty evidence). Ginger: It is uncertain whether ginger makes any difference to the number of women having intraoperative nausea (aRR 0.66, 95% CI 0.36 to 1.21, 2 studies, 331 women, very low-certainty evidence), intraoperative vomiting (aRR 0.62, 95% CI 0.38 to 1.00, 2 studies, 331 women, very low-certainty evidence), postoperative nausea (aRR 0.63, 95% CI 0.22 to 1.77, 1 study, 92 women, very low-certainty evidence) and postoperative vomiting (aRR 0.20, 95% CI 0.02 to 1.65, 1 study, 92 women, very low-certainty evidence). Few studies assessed our secondary outcomes including adverse effects or women's views.

AUTHORS' CONCLUSIONS

This review indicates that 5-HT3 antagonists, dopamine antagonists, corticosteroids, sedatives and acupressure probably or possibly have efficacy in reducing nausea and vomiting in women undergoing regional anaesthesia for caesarean section. However the certainty of evidence varied widely and was generally low. Future research is needed to assess side effects of treatment, women's views and to compare the efficacy of combinations of different medications.

Effect of continuous infusion of a subhypnotic dose of propofol on nausea and vomiting after carboprost administration at cesarean delivery: A randomized, double-blind, placebo-controlled trial

OBJECTIVE

To investigate whether continuous infusion of propofol at a subhypnotic dose prevents nausea and vomiting following carboprost administration at cesarean delivery.

METHODS

A prospective, randomized, double-blind, placebo-controlled trial conducted at West China Second University Hospital, from June 28, 2017 to January 30, 2018. Pregnant women were randomly allocated to propofol or saline infusion immediately before receiving carboprost at cesarean delivery under combined spinal-epidural (CSE) anesthesia. Propofol was given at an infusion rate of 1.0 mg/kg/h following a loading dose of 0.3 mg/kg. Primary outcome was incidence of intraoperative nausea and vomiting (IONV). Potential sedative effect of propofol infusion was assessed using Modified Observer's Assessment of Alertness and Sedation (MOAA/S) scoring and continuous Bispectral Index (BIS) monitoring.

RESULTS

The incidence of IONV was lower in patients who received propofol compared with saline (46.7% vs 76.7%, OR 0.27; 95% CI, 0.092-0.78, P = 0.016 for nausea; 26.7% vs 53.3%, OR 0.50; 95% CI, 0.25-0.95, P = 0.032 for retching; 10.0% vs 50.0%, OR 0.11; 95% CI, 0.03-0.44, P < 0.001 for vomiting). There were no differences in MOAA/S scoring or BIS between the two groups.

CONCLUSION

A subhypnotic dose of propofol reduces the incidence of nausea and vomiting following carboprost administration at cesarean delivery under CSE anesthesia, without measurable effect on patients' consciousness or alertness. ClincalTrials.gov: NCT03185156.

Comparison of the prophylactic effect of dexamethasone and dexmedetomidine and their combination in reducing postoperative nausea and vomiting in patients undergoing laparoscopic cholecystectomy

Nausea and vomiting are some of the most common complaints of patients after any anesthesia, which is often associated with postoperative pain. The double-blind clinical trial study aimed to compare the prophylactic effect of dexamethasone and dexmedetomidine and their combination in reducing postoperative nausea and vomiting in patients undergoing laparoscopic cholecystectomy. One hundred sixty-two patients undergoing laparoscopic cholecystectomy were enrolled in the study. In the first group of patients, 25 mg of dexmedetomidine were administered slowly. In comparison, the patients in the second group received dexamethasone (4 ml/2 mg) with 0.1 mg/kg of normal saline solution. The third group received a combination of dexmedetomidine and dexamethasone. Hemodynamic changes were recorded during surgery and after surgery, and the patients were admitted to recovery. Nausea and vomiting scores were recorded 2 and 4 hours after surgery. Blood pressure and heart rate were lower in the dexmedetomidine group at all times (P<0.05). Two hours after surgery, the dexamethasone and dexmedetomidine combination group had less vomiting (P=0.012). The incidence of nausea 2 and 4 hours after surgery was lower in the dexamethasone and dexmedetomidine combination group (P<0.05). Blood pressure and heart rate were lower in the dexmedetomidine group at all times. The dexmedetomidine and dexamethasone combination decreased postoperative nausea and vomiting in patients. Therefore, we recommend using a dexmedetomidine and dexamethasone combination for reducing postoperative nausea and vomiting.

The Health Impact of Surgical Techniques and Assistive Methods Used in Cesarean Deliveries: A Systemic Review

Cesarean delivery is one of the most frequently performed surgeries in women throughout the world. However, the most optimal technique to minimize maternal and fetal morbidities is still being debated due to various clinical situations and surgeons' preferences. The contentious topics are the use of vacuum devices other than traditional fundal pressure to assist in the delivery of the fetal head and the techniques of uterine repair used during cesarean deliveries. There are two well-described techniques for suturing the uterus: The uterus can be repaired either temporarily exteriorized (out of abdominal cavity) or in situ (within the peritoneal cavity). Numerous studies have attempted to compare these two techniques in different aspects, including operative time, blood loss, and maternal and fetal outcomes. This review provides an overview of the assistive method of vacuum devices compared with fundal pressure, and the two surgical techniques for uterine repair following cesarean delivery. This descriptive literature review was performed to address important issues for clinical practitioners. It aims to compare the advantages and disadvantages of the assistive methods and surgical techniques used in cesarean deliveries. All of the articles were retrieved from the databases Medline and PubMed using the search terms cesarean delivery, vacuum, and exteriorization. The searching results revealed that after exclusion, there were 9 and 13 eligible articles for vacuum assisted cesarean delivery and uterine exteriorization, respectively. Although several studies have concluded vacuum assistance for fetal extraction as a simple, effective, and beneficial method during fetal head delivery during cesarean delivery, further research is still required to clarify the safety of vacuum assistance. In general, compared to the use of in situ uterine repairs during cesarean delivery, uterine exteriorization for repairs may have benefits of less blood loss and shorter operative time. However, it may also carry a higher risk of intraoperative complications such as nausea and vomiting, uterine atony, and a longer time to the return of bowel function. Clinicians should consider these factors during shared decision-making with their pregnant patients to determine the most suitable techniques for cesarean deliveries.

Management strategies for the treatment and prevention of postoperative/postdischarge nausea and vomiting: an updated review

Postoperative nausea and vomiting (PONV) and postdischarge nausea and vomiting (PDNV) remain common and distressing complications following surgery. The routine use of opioid analgesics for perioperative pain management is a major contributing factor to both PONV and PDNV after surgery. PONV and PDNV can delay discharge from the hospital or surgicenter, delay the return to normal activities of daily living after discharge home, and increase medical costs. The high incidence of PONV and PDNV has persisted despite the introduction of many new antiemetic drugs (and more aggressive use of antiemetic prophylaxis) over the last two decades as a result of growth in minimally invasive ambulatory surgery and the increased emphasis on earlier mobilization and discharge after both minor and major surgical procedures (e.g. enhanced recovery protocols). Pharmacologic management of PONV should be tailored to the patient’s risk level using the validated PONV and PDNV risk-scoring systems to encourage cost-effective practices and minimize the potential for adverse side effects due to drug interactions in the perioperative period. A combination of prophylactic antiemetic drugs with different mechanisms of action should be administered to patients with moderate to high risk of developing PONV. In addition to utilizing prophylactic antiemetic drugs, the management of perioperative pain using opioid-sparing multimodal analgesic techniques is critically important for achieving an enhanced recovery after surgery. In conclusion, the utilization of strategies to reduce the baseline risk of PONV (e.g. adequate hydration and the use of nonpharmacologic antiemetic and opioid-sparing analgesic techniques) and implementing multimodal antiemetic and analgesic regimens will reduce the likelihood of patients developing PONV and PDNV after surgery.

Methodological tools and sensitivity analysis for assessing quality or risk of bias used in systematic reviews published in the high-impact anesthesiology journals

Background

A crucial element in the systematic review (SR) methodology is the appraisal of included primary studies, using tools for assessment of methodological quality or risk of bias (RoB). SR authors can conduct sensitivity analyses to explore whether their results are sensitive to exclusion of low quality studies or a high RoB. However, it is unknown which tools do SR authors use for assessing quality/RoB, and how they set threshold for quality/RoB in sensitivity analyses. The aim of this study was to assess quality/RoB assessment tools, the types of sensitivity analyses and quality/RoB thresholds for sensitivity analyses used within SRs published in high-impact pain/anesthesiology journals.

Methods

This was a methodological study. We analyzed SRs published from January 2005 to June 2018 in the 25% highest-ranking journals within the Journal Citation Reports (JCR) “Anesthesiology” category. We retrieved the SRs from PubMed. Two authors independently screened records, full texts, and extracted data on quality/RoB tools and sensitivity analyses. We extracted data about quality/RoB tools, types of sensitivity analyses and the thresholds for quality/RoB used in them.

Results

Out of 678 analyzed SRs, 513 (76%) reported the use of quality/RoB assessments. The most commonly reported tools for assessing quality/RoB in the studies were the Cochrane tool for risk of bias assessment (N = 251; 37%) and Jadad scale (N = 99; 15%). Meta-analysis was conducted in 451 (66%) of SRs and sensitivity analysis in 219/451 (49%). Most commonly, sensitivity analysis was conducted to explore the influence of study quality/RoB (90/219; 41%) on the results. Quality/RoB thresholds used for sensitivity analysis for those studies were clearly reported in 47 (52%) articles that used them. The quality/RoB thresholds used for sensitivity analyses were highly heterogeneous and inconsistent, even when the same tool was used.

Conclusions

A quarter of SRs reported using quality/RoB assessments, and some of them cited tools that are not meant for assessing quality/RoB. Authors who use quality/RoB to explore the robustness of their results in meta-analyses use highly heterogeneous quality/RoB thresholds in sensitivity analyses. Better methodological consistency for quality/RoB sensitivity analyses is needed.

The effect of ginger and metoclopramide in the prevention of nausea and vomiting during and after surgery in cesarean section under spinal anesthesia

Objective

Postoperative nausea and vomiting is one of the most common side effects after anesthesia in surgeries, such as cesarean section. This study aimed to investigate the effect of ginger and metoclopramide in the prevention of nausea and vomiting during and after cesarean section.

Methods

This clinical trial was conducted on 180 patients aged 18–40 years who underwent cesarean section under spinal anesthesia. The first group received 10 mg of metoclopramide via intravenous injection (metoclopramide group), and the second group received 1 g of oral ginger (ginger group) half an hour before spinal anesthesia. The frequency and severity of nausea and vomiting during surgery and at 2, 6, 12, and 24 hours postoperatively were compared in both groups. To analyze the results, the t-test, chi-square test, and Mann-Whitney test were used.

Results

There was no significant difference in the frequency of nausea and vomiting between the 2 groups during operation, 2 hours and 6 hours after surgery (P=0.182, 0.444 and 0.563 respectively). The severity of nausea and vomiting was also similar in the 2 groups (P=0.487 and 0.652 respectively); however, the metoclopramide group had a lower systolic blood pressure (P<0.001; df=2.176; f=18.66) and mean arterial pressure (P<0.001; df=2.176; f=6.36) than the ginger group.

Conclusion

The results revealed that ginger reduced nausea and vomiting to the same extent as metoclopramide in patients undergoing cesarean section.

Trial Registration

Iranian Center for Clinical Trials Identifier: IRCT201611028611N3

Strategies of analgesic treatment after cesarean delivery. Current state and new alternatives

The number of caesarean sections performed worldwide is increasing, and with it, the need for the optimal analgesia strategies. Deficient postoperative analgesia increases the need for opioids, delays recovery, and is associated with chronic pain and postpartum depression. It is essential to find good postoperative pain control strategies that facilitate early mobility, early recovery, and early hospital discharge with minimal side effects on the mother and infant. Multimodal analgesia based on neuroaxial anaesthesia with morphine in combination with non-opioids such as non-steroidal anti-inflammatory drugs and paracetamol, gives the best post-caesarean analgesia outcome, and allows anaesthesiologists to reserve opioids, corticoids, gabapentin, magnesium or ketamine for situations where neuroaxial anaesthesia cannot be performed, for high-risk patients, or when pain is difficult to control. Peripheral nerve block techniques can also be added, such as transverse abdominis plane block, erector spinae block, or continuous wound infiltration.

Sub-hypnotic dose of propofol as antiemetic prophylaxis attenuates intrathecal morphine-induced postoperative nausea and vomiting, and pruritus in parturient undergoing cesarean section - a randomized control trial

Background

Postoperative Nausea and Vomiting (PONV) is a dreadful and uncomfortable experience that significantly detracts patients’ quality of life after surgery. This study aimed to examine the antiemetic effect of a single sub-hypnotic dose of propofol as prophylaxis for PONV.

Method

In this prospective, double-blind, randomized control trial, 345 parturients presented for elective cesarean section at the Obstetric unit of Tamale Teaching Hospital were recruited. Each recruited parturient was randomly assigned to one of three groups; Propofol group (n = 115) represented those who received propofol 0.5 mg/kg, Metoclopramide group (n = 115) represented those who received metoclopramide 10 mg and, Control group (n = 115) represented those who received 0.9% saline. Spinal anesthesia with 0.5% hyperbaric bupivacaine 7.5–10 mg, and intrathecal morphine 0.2 mg was employed for the anesthesia.

Results

The data indicate that 108 (93.9%) parturients from the control group, 10 (8.7%) from the propofol group and 8 (7.0%) from the metoclopramide group experienced some incidence of PONV. There was no significant difference in the incidence of PONV (nausea, vomiting, and none) between the propofol and the metoclopramide groups (P = 0.99; 0.31; and 0.35 respectively). Parturients who received antiemetic agents were 105 (97.2%), 1 (10.0%) and 3 (37.5%) from the control, propofol and metoclopramide groups respectively. The data indicated that 98 (85.2%) parturients from the control, 3 (2.6%) from propofol group, and 100 (87.0%) from the metoclopramide group experienced some levels of pruritus. There was a significant difference in the incidence of pruritus (mild, moderate, and no pruritus) between the metoclopramide and propofol groups (P <  0.01; P <  0.01; and P <  0.01 respectively).

Conclusion

A sub-hypnotic dose of propofol is effective as metoclopramide in the prevention of PONV in parturient undergoing cesarean section under spinal anesthesia with intrathecal morphine. Sub-hypnotic dose of propofol significantly reduces the incidence of postoperative pruritus following intrathecal morphine use.

Trial registration

Current control trial, registered at ISRCTN trial registry: ISRCTN15475205. Date registered: 03/04/2019. Retrospectively registered.

Modern pediatric formulations of the soft candies in the form of a jelly: determination of metoclopramide content and dissolution

In pediatrics, it is crucial to ameliorate the unpleasant taste of oral pharmaceutical formulations in order to facilitate patient compliance. Scientists' attempt to develop modern products for children is included among the new trends in pharmaceutical technology. Designing the preparation procedures and selecting the age-appropriate dosage form should be based on a benefit-risk approach, taking into account safety, efficacy, ease of use and accessibility to the patient. Part of this process should examine the necessity for taste masking, considering organoleptic and physicochemical properties of the active pharmaceutical ingredient. This research describes the incorporation of metoclopramide hydrochloride in the form of a soft candy (jelly) containing pomegranate juice. The low cost excipients and the ease of preparation are such characteristics that qualify the proposed technique as one of the alternative methods for modern drug formulations. At the same time, metoclopramide is quantitatively determined by developing a reverse phase HPLC method. The method is accurate (%RSD = 2.63, %mean recovery = 100.75) and can be used for routine analysis. The stability of metoclopramide was satisfactory after 6 months of storage (recovery 103.43%). Dissolution of the drug exceeded 92%. The proposed formulation enclosing metoclopramide in a jelly is modern, palatable and can be administered to children.

Effect of metoclopramide administration to mothers on neonatal bilirubin and maternal prolactin: a randomized, controlled, clinical trial

BACKGROUND

Jaundice is a common neonatal problem. This study was conducted to determine the effect of metoclopramide on neonatal bilirubin and maternal prolactin (primary outcomes) and milk volume (secondary outcome).

METHODS

This triple-blind, randomized, controlled, clinical trial was conducted on 112 mothers. The participants were assigned to the intervention (metoclopramide) and control groups (placebo) using block randomization. Ten-mg metoclopramide and placebo tablets were taken by the participants three times a day. The intervention began in the first 2-10 hours after childbirth and continued until the fifth day. The mothers' prolactin level was measured on the first morning after the intervention and on the sixth day (1 day after the intervention was over). Neonatal total bilirubin was also measured before the intervention and on the sixth day.

RESULTS

After the intervention, the two groups did not differ significantly in terms of the mean neonatal indirect bilirubin (P = 0.565) and milk volume (P = 0.261), but the mean serum prolactin was significantly higher in the metoclopramide group compared to the placebo group (adjusted mean difference 37; 95% confidence interval 58.1-16.5; P = 0.001).

CONCLUSIONS

Metoclopramide increased maternal serum prolactin but had no effects on neonatal jaundice. The insufficient numbers of studies on this subject mandate further research.

An update on the management of postoperative nausea and vomiting

Postoperative nausea and vomiting (PONV) and postdischarge nausea and vomiting (PDNV) remain common and distressing complications following surgery. PONV and PDNV can delay discharge and recovery and increase medical costs. The high incidence of PONV has persisted in part because of the tremendous growth in ambulatory surgery and the increased emphasis on earlier mobilization and discharge after both minor and major operations. Pharmacological management of PONV should be tailored to the patients' risk level using the PONV and PDNV scoring systems to minimize the potential for these adverse side effects in the postoperative period. A combination of prophylactic antiemetic drugs should be administered to patients with moderate-to-high risk of developing PONV in order to facilitate the recovery process. Optimal management of perioperative pain using opioid-sparing multimodal analgesic techniques and preventing PONV using prophylactic antiemetics are key elements for achieving an enhanced recovery after surgery. Strategies that include reductions of the baseline risk (e.g., adequate hydration, use of opioid-sparing analgesic techniques) as well as a multimodal antiemetic regimen will improve the likelihood of preventing both PONV and PDNV.

Optimal Pain Management After Cesarean Delivery

Cesarean delivery rates are increasing worldwide, and effective postoperative pain management is a key priority of women undergoing cesarean delivery. Inadequate pain management in the acute postoperative period is associated with persistent pain, greater opioid use, delayed functional recovery, and increased postpartum depression. In addition to pain relief, optimal management of patients after cesarean delivery should address the goals of unrestricted maternal mobility, minimal maternal and neonatal side effects, rapid recovery to baseline functionality, and early discharge home. Multimodal analgesia should include neuraxial morphine in conjunction with nonopioid adjuncts, with additional oral or intravenous opioids reserved for severe breakthrough pain.

Preoperative Use of 10-mg Metoclopramide and 50-mg Dimenhydrinate in the Prophylaxis of Postoperative Nausea and Vomiting in Elective Caesarean Births: A Prospective Randomized Clinical Study

BACKGROUND

The purpose of this study was to assess the efficacy and outcomes of preoperative prophylactic metoclopramide and dimenhydrinate use in elective cesarean births.

METHODS

Participants (n = 84) scheduled for elective cesarean births were randomized equally into placebo (10 cc 0.9 % NaCl), 10-mg metoclopramide or 50-mg dimenhydrinate groups. Oral alimentation was prohibited 8 h before the surgery; however, patients continued drinking water until 4 h before surgery. Placebo and antiemetics were administered 1 h before the anticipated procedure in a 5-ml syringe. In metoclopramide and dimenhydrinate group, an ampoule of the agents was completed to 5 ml by adding 0.9 % NaCl. In the control group 5 ml of 0.9 % NaCl was used. All prophylactic agents were administered intramuscularly. All patients received a general anesthesia. The placebo group (control group) was compared with the metoclopramide and dimenhydrinate groups.

RESULTS

Demographic data including maternal age, height, weight, body mass index, gravidity, parity, miscarriage, induced abortion, the number of offspring, and the medical history did not show significant differences among the three groups. Postoperative nausea, vomiting, and the use of rescue medication ratios were significantly lower in metoclopramide and dimenhydrinate groups compared with the placebo group (p < 0.05); however, the difference between the metoclopramide and dimenhydrinate groups was not significant (p > 0.05).

CONCLUSION

Dimenhydrinate and metoclopramide significantly decrease postoperative nausea, vomiting, and the need for rescue antiemetic medication. Both agents have similar efficacy and may be used as an alternative to each other.

Effect of Sub hypnotic Doses of Propofol and Midazolam for Nausea and Vomiting During Spinal Anesthesia for Cesarean Section

Background:

Spinal anesthesia has been associated with intraoperative nausea and vomiting (IONV), especially during cesarean section, which is attributed to several mechanisms.

Objectives:

In the present study, therapeutic and preventive properties of sub hypnotic dose midazolam and propofol and their effects on the occurrence and severity of intraoperative nausea and vomiting during elective cesarean section under spinal anesthesia were evaluated.

Patients and Methods:

In a randomized, double-blind, and placebo-controlled clinical trial, 90 parturients, ASA class I and II, aged 20-30 years, who undergone spinal anesthesia for cesarean section were randomly allocated to one of three groups receiving midazolam (1 mg bolus and 0.1 mg/kg/hr, n=30), propofol (20 mg bolus and 0.1 mg/kg/hr, n = 30), and placebo (saline, n=30) intravenously (IV) immediately after umbilical cord clamping. Bupivacaine hydrochloride (10 mg) was used for induction of the anesthesia. Patients’ hemodynamics was monitored at 3-minute intervals. Furthermore, intraoperative and post-delivery emetic episodes, severity of emesis, scores of sedation and ephedrine consumption were recorded.

Results:

The incidence of nausea, retching, and vomiting was significantly higher in the control group compared to propofol and midazolam groups. Overall, PONV (postoperative nausea and vomiting) in midazolam group was as low as propofol group without any significant hemodynamic changes as seen in placebo group or even with propofol group.

Conclusions:

Subhypnotic doses of midazolam or propofol are effective in the prevention of nausea and vomiting during and after cesarean section with spinal anesthesia and does not significantly influence hemodynamic of the patients.

Prophylaxis and treatment of the side-effects of neuraxial morphine analgesia following cesarean delivery

PURPOSE OF REVIEW

Neuraxial morphine is commonly used for analgesia after cesarean delivery, but is frequently associated with postoperative nausea and vomiting (PONV) and pruritus. This review describes the recent advances in the management of those side-effects.

RECENT FINDINGS

Neuraxial-morphine-induced side-effects are dose related; therefore, the minimum effective dose should be used. Dexamethasone, 5HT3 receptor antagonists, antihistamines, and anticholinergics reduce the incidence of PONV, whereas metoclopramide 10 mg does not appear to be effective for PONV prophylaxis in this patient population. Combination antiemetic therapy provides improved prophylaxis compared with monotherapy, but has seldom been studied in women undergoing cesarean delivery with neuraxial morphine. Studies of P6 acupressure reported inconsistent results. Polymorphism of the μ-opioid receptor may affect the severity of neuraxial-morphine-induced pruritus. Opioid antagonists and mixed agonist/antagonists appear to be the most useful for the management of opioid-induced pruritus. Prophylactic 5HT3 receptor antagonists and dexamethasone do not seem to be effective for reducing the incidence of pruritus. In contrast, ondansetron, pentazocine, and dimenhydrinate may be useful for treating established pruritus.

SUMMARY

PONV and pruritus are frequent side-effects of neuraxial morphine. Future studies investigating combination antiemetic therapy, long-acting antiemetics, and strategies to manage pruritus are needed.

Prophylaxis of intra- and postoperative nausea and vomiting in patients during cesarean section in spinal anesthesia

Background

This paper describes a randomized prospective study conducted in 308 patients undergoing caesarean section in spinal anaesthesia at a single hospital between 2010 and 2012 to find a suitable anti-emetic strategy for these patients.

Material/Methods

Spinal anesthesia was performed in left prone position, at L3/L4 with hyperbaric 0.5% Bupivacaine according to a cc/cm body height ratio. There were no opioids given peri-operatively. The patients received either no prophylaxis (Group I) or tropisetron and metoclopramide (Group II) or dimenhydrinate and dexamethasone (Group III), or tropisetron as a single medication (Group IV). The primary outcome was nausea and/or vomiting (NV) in the intraoperative, early (0–2 h) or late (2–24 h) postoperative period.

Multivariate statistical analysis was conducted with a regression analysis and a backward elimination of factors without significant correlation.

Results

All prophylactic agents significantly reduced NV incidence intraoperatively. Relative risk reduction for NV by prophylaxis was most effective (59.5%) in Group II (tropisetron and metoclopramide). In Group III (dimenhydrinate and dexamethasone), NV risk was reduced by 29.9% and by 28.7% in Group IV (tropisetron mono-therapy). The incidence of NV in the early (0–2 h) and the late (2–24 h) postoperative period was low all over (7.8%), but the relative risk reduction of NV in the early postoperative period was 54.1% (Group IV), 45.1% (Group III), and 34.8% (Group II), respectively. In the late postoperative period, there was no significant difference between the 4 groups.

Conclusions

We recommend a prophylactic medication with tropisetron 2 mg and metoclopramide 20 mg for patients during caesarean section. These agents are safe, reasonably priced, and highly efficient in preventing nausea and vomiting.

Effect of acupressure on post-operative nausea and vomiting in cesarean section: a randomised controlled trial

BACKGROUND

Because of potential side effects of chemical treatments and in order to decrease the risk of nausea and vomiting in post-operative patients, there is a necessary requirement for some alternative therapeutic methods such as Acupressure.

AIM

The present randomized clinical trial study aimed to compare the effects of Acupressure and Metoclopramide on postoperative nausea and vomiting in Caesarean Sections.

SETTING AND DESIGN

The patients who were subjected to caesarean surgeries, who were referred to the Ilam Mustafa Hospital in the west of Iran, were enrolled in this randomised clinical trial study.

MATERIAL AND METHODS

Totally, 102 patients who were selected for elective Caesarean Section were included in this study. Patients were randomly assigned to one of three groups, with 34 cases in each group. All groups were matched for effective factors on nausea and vomiting in inclusion and exclusion criteria. The control group did not receive any intervention, the second group received 10 mg Metoclopramide intravenously, immediately prior to anaesthesia induction and in the third group, Acupressure bands were applied at the P6 points on both wrists, 15 minutes before anaesthesia induction. Intra-operative and post-operative emetic episodes were recorded by a trained investigator. The patients who experienced nausea were evaluated on a linear numeric scale which ranged from 0 (no) to 10 (severe). Statistics and Results: The incidence of nausea and vomiting in postoperative periods was lower in Metoclopramide and Acupressure groups as compared that in the control group. The frequency of anti-emetic which was used was significantly higher in control group as compared to those in the other groups (p<0.001). No side effects or complications were caused by any intervention.

CONCLUSION

In parturients who underwent caesarean deliveries which were performed under spinal anaesthesia in this study, use of Metoclopramide and Acupressure was found to be equally effective for reducing emetic symptoms (nausea, retching, and vomiting).

Antiemetics added to phenylephrine infusion during cesarean delivery: a randomized controlled trial

OBJECTIVE

To estimate whether the addition of metoclopramide or its combination with ondansetron to a prophylactic phenylephrine infusion provides improved intraoperative nausea and vomiting prophylaxis compared with phenylephrine infusion alone.

METHODS

Women scheduled for elective cesarean delivery were randomized to one of three groups: placebo (placebo plus placebo); metoclopramide (metoclopramide 10 mg plus placebo); or combination (metoclopramide 10 mg plus ondansetron 4 mg). The first study drug was administered before spinal placement and the second was administered after cord clamping. Spinal anesthesia was standardized. The primary outcome was intraoperative nausea and vomiting.

RESULTS

Three-hundred patients completed the study in two centers. Intraoperative nausea and vomiting occurred in 49%, 31%, and 23% of patients in the placebo, metoclopramide, and combination groups, respectively (P<.001). There was a significant difference between the two centers in exteriorization of the uterus (93% compared with 39%; P<.001) and intraoperative nausea and vomiting rates (47% compared with 20%; P<.001). In a multivariable model adjusting for center, exteriorization of the uterus, age, and hypotension, intraoperative nausea and vomiting were significantly lower in the metoclopramide and combination groups compared with placebo (odds ratio [OR] 2.34, 95% confidence interval [CI] 1.24--4.42; P=.001 and OR 4.06, 95% CI 2.06--7.97; P<.001, respectively). Postoperative nausea and vomiting were reduced with the combination compared with placebo at 2 hours (39% compared with 20%; P<.017), but not at 2-6 hours or at 6-24 hours.

CONCLUSION

Metoclopramide with ondansetron reduced intraoperative nausea and vomiting and early postoperative nausea and vomiting compared with placebo. Metoclopramide alone also decreased intraoperative but not postoperative nausea and vomiting. Surgical factors contributed to a significant difference in intraoperative nausea and vomiting between the two centers.

Systemic metoclopramide to prevent postoperative nausea and vomiting: a meta-analysis without Fujii's studies

Previous evidence suggested that 10 mg systemic metoclopramide is not effective to prevent postoperative nausea and/or vomiting (PONV) in patients receiving general anaesthesia. However, the evidence included data with questioned validity by the author Yoshitaka Fujii. The objective of the current study was to examine the effect of a systemic dose of 10 mg metoclopramide to prevent PONV. This quantitative systematic review was performed according to the PRISMA guidelines. A wide search was performed to identify randomized clinical trials that evaluated systemic 10 mg metoclopramide as a prophylactic agent to reduce PONV. Meta-analysis was performed using a random-effect model. Thirty trials evaluating the effect of 10 mg systemic metoclopramide in 3328 subjects on PONV outcomes were included. Metoclopramide reduced the incidence of 24 h PONV compared with control, odds ratio (OR) [95% confidence interval (CI)] of 0.58 (0.43-0.78), number needed to treat (NNT)=7.8. When evaluated as separate outcomes, metoclopramide also decreased the incidence of nausea over 24 h, OR (95% CI) of 0.51 (0.38-0.68), NNT=7.1, and vomiting over 24 h, OR (95% CI) of 0.51 (0.40-0.66), NNT=8.3. A post hoc analysis examining three studies with questioned validity performed by the author Yoshitaka Fujii that would meet criteria for inclusion in the current study did not demonstrate a significant benefit of metoclopramide compared with control on the incidence of 24 h PONV. Our findings suggest that metoclopramide 10 mg i.v. is effective to prevent PONV in patients having surgical procedures under general anaesthesia. Metoclopramide seems to be a reasonable agent to prevent PONV.