Effect of fentanyl on nausea and vomiting in cesarean section under spinal anesthesia: a randomized controlled study

Prevalence and associated factors of intraoperative Nausea and Vomiting of mothers who gave birth with cesarean section under regional anesthesia: a systematic review and meta-analysis; 2023

INTRODUCTION

Cesarean section is one of the most common obstetric procedures performed worldwide under spinal anesthesia which is a commonly practiced rapid, simple, and safe method. Vomiting and nausea are frequent side effects of many surgical procedures. However, with cesarean sections performed under regional anesthesia, this issue occurs even more frequently. The existing evidence regarding the prevalence and associated factors of intraoperative nausea and vomiting is inconsistent. Therefore, this systematic review and meta-analysis aimed to determine the pooled prevalence and associated factors of intraoperative nausea and vomiting.

METHODS

This is a systematic review and meta-analysis study that was done based on studies published within the last 10 years on the prevalence and associated factors of intraoperative nausea and vomiting during cesarean section under regional anesthesia. After PubMed, Google Scholar, HINAR, Scopus, Science Direct, and grey literature extensive search for primary studies, their quality was assessed with JBI and modified Newcastle Ottawa appraisal assessment tool and data was extracted. STATAMP version 17.0 was used for all possible analyses of the study.

RESULTS

Twenty-nine studies were met the inclusion criteria of this systematic review and meta-analysis. However, only 21 studies were included by excluding eight studies due to inappropriate method & outcomes and language other than English. The pooled prevalence of intraoperative nausea and vomiting was 36% (95% CI- 31%, 41%) with heterogeneity (I2-93.1%). Premedicated with metoclopramide, uterus exteriorization, motion sickness, preeclampsia, and intraoperative propofol were associated with the prevalence of intraoperative nausea and vomiting significantly.

CONCLUSION

The pooled prevalence of intraoperative nausea and vomiting during cesarean section under regional anesthesia was high (36%) which needs more strategies for prevention.

Balancing acts: The dual faces of fentanyl in medicine and public health

Fentanyl is a potent synthetic opioid widely used in medicine for its effective analgesic properties, particularly in surgical procedures and in the treatment of severe, chronic pain. In recent decades, however, there has been a worrying increase in the illicit use of fentanyl, particularly in North America. This rise in illicit use is concerning because fentanyl is associated with polydrug abuse, which adds layers of complexity and dangerous. This review provides a comprehensive examination of fentanyl, focusing on its synthesis and medical use. It also discusses the significance of the piperidine ring in medicinal chemistry as well as the critical role of fentanyl in pain management and anesthesia. Furthermore, it addresses the challenges associated with the abuse potential of fentanyl and the resulting public health concerns. The study aims to strike a balance between the clinical benefits and risks of fentanyl by advocating for innovative uses while addressing public health issues. It examines the chemistry, pharmacokinetics and pharmacodynamics of fentanyl and highlights the importance of personalized medicine in the administration of opioids. The review underscores the necessity of continuous research and adaptation in both clinical use and public health strategies.

Effect of epidural dexmedetomidine in single-dose combined with ropivacaine for cesarean section

BACKGROUND

Dexmedetomidine has arousal sedation and analgesic effects. We hypothesize that epidural dexmedetomidine in single-dose combined with ropivacaine improves the experience of parturient undergoing cesarean section under epidural anesthesia. This study is to investigate the effect of 0.5 µg/kg epidural dexmedetomidine combined with epidural anesthesia (EA) in parturients undergoing cesarean section.

METHODS

A total of 92 parturients were randomly divided into Group R (receiveing epidural ropivacaine alone) Group RD (receiveing epidural ropivacaine with 0.5 µg/kg dexmedetomidine). The primary outcome and second outcome will be intraoperative NRS pain scores and Ramsay Sedation Scale.

RESULTS

All 92 parturients were included in the analysis. The NRS were significantly lower in Group RD compared to Group R at all observation timepoint (P > 0.05). Higher Ramsay Sedation Scale was found in Group RD compared to Group R (P < 0.001). No parturient has experienced sedation score of 4 and above. No significant difference regarding the incidence of hypotension, bradycardia and nausea or vomiting, Apgar scores and the overall satisfaction with anesthesia was found between Group R and Group RD (P > 0.05).

CONCLUSION

Epidural dexmedetomidine of 0.5 µg/kg added slightly extra analgesic effect to ropivacaine in EA for cesarean section. The sedation of 0.5 µg/kg epidural dexmedetomidine did not cause mother-baby bonding deficit. Satisfaction with anesthesia wasn't significantly improved by epidural dexmedetomidine of 0.5 µg/kg. No additional side effect allows larger dose of epidural dexmedetomidine attempt.

TRIAL REGISTRATION

This study was registered at www.chictr.org.cn (ChiCTR2000038853).

The Effect of Aromatherapy Administration in the Decrease of Nausea in Post-Spinal Anesthesia Patients

Objective: This study aims to know the effect of aromatherapy on reducing nausea in post spinal anesthesia patients. Method: This research is a literature study. In the strategy to find the journal framework used is PICOT. The keywords used are "Aromatherapy and nausea and vomiting and postoperative and spinal anesthesia". The data sources used are e-resources from PubMed and Google Scholar in the form of articles or journals. The inclusion criteria in this study were national and international journals from different databases and related to research variables, namely nausea, with aromatherapy inhalation intervention, as well as articles discussing the effects of inhaled aromatherapy on nausea in postoperative patients with spinal anesthesia. Deadline for publication of articles within the last 5 years (2016-2021). The exclusion criteria for this study were national and international databases and had nothing to do with the study variables, no intervention was given, there was no reflexology effect on anxiety levels in burn patients and the publication time of the article was more than 5 years. Results: In searching for articles using 2 databases, each was found from PubMed 1871 search results and Google Scholar 951 search results. After disqualification related to the year of publication, 485 articles were obtained in the last 5 years, and in the end 8 articles were obtained that matched the criteria obtained. Of the 8 articles that have been reviewed, it was found that postoperative patients with spinal anesthesia experienced nausea Conclusion: Based on a systematic review conducted on 8 articles, it can be concluded that the administration of aromatherapy is very useful for reducing nausea in postoperative patients with spinal anesthesia. There are many choices of aromatherapy that can be given to patients, ranging from lavender aromatherapy, ginger aromatherapy, peppermint aromatherapy, lemon essential oil aromatherapy and rose aromatherapy. So it is suggested that aromatherapy inhalation intervention can be applied to patients who experience postoperative nausea with spinal anesthesia.

Multi-Indicator Intelligent Monitoring of Clinical Observations to Reduce Cesarean Section

In order to analyze multi-index monitoring and the effect of reducing cesarean section, this paper selects March 2018 and March 2019 in two obstetrics and gynecology hospitals, referred to as hospital A and hospital B. As research objects, 313 pregnant women were divided into multi-index group and conventional group, while analyzing various indicators of each group of cesarean collection. The results show that the total CNAXE rate was 48.10% and 39.29%, respectively, for 2018 and 2019, respectively, and the cesarean section of the conventional group was 65.75% and 63.64%. By contrasting data of multi-index group and conventional group, hospital B differences were significant (P < 0.05), and hospital A difference was extremely significant (P < 0.01). In Cesarean section, obstetric sectors can help maternal treatment strategies by monitoring a series of related indicators for maternal to reduce Cesarean section and improve prognosis.

Application of painless nursing in cesarean delivery parturients due to the failure of natural childbirth via labor analgesia

OBJECTIVE

To evaluate the application of painless nursing in cesarean delivery parturients due to the failure of natural childbirth via labor analgesia.

METHODS

A total of 124 parturients who were transferred to cesarean delivery due to the failure of natural childbirth via labor analgesia were selected and randomly divided into two groups. The control group received routine nursing, while the research group was given painless nursing in the operating room, which mainly included interventions in terms of the environment, labor process, and delivery procedure. The visual analog scale (VAS), gestation outcome, stress response, anxiety, sleep quality, and nursing satisfaction were compared between the two groups.

RESULTS

Compared with the control group, the sleep quality score was significantly lower in the research group (all P<0.001). Compared with before nursing, the anxiety and VAS scores of the two groups were significantly decreased after nursing (P<0.001). Additionally, the anxiety and VAS scores of the research group after nursing were significantly lower than those of the control group (P<0.001). There was no significant difference for the gestation outcome between the two groups (P>0.05). Compared with before nursing, the levels of malondialdehyde (MDA) and reactive oxygen species (ROS) after nursing were significantly downregulated, while the level of superoxide dismutase (SOD) was significantly upregulated in both groups (all P<0.001). Compared with the control group, the levels of MDA and ROS were significantly lower, while SOD level was significantly higher in the research group after nursing (all P<0.001). Compared with the control group, the nursing satisfaction was significantly higher in the research group (P<0.05).

CONCLUSION

The painless nursing for cesarean delivery parturients in the operating room due to the failure of natural childbirth via labor analgesia can effectively improve the sleep quality and negative moods of the parturients, reduce the degree of pain and stress response in the process of delivery, and result in better satisfaction and compliance.

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.

Impact of Opioid Consumption in Patients With Functional Gastrointestinal Disorders

Objective: We aimed to determine the burden of opioid consumption in a cohort of patients with functional gastrointestinal disorders.

Methods: All patients diagnosed with functional gastrointestinal disorders and referred to our university hospital were evaluated from 2013 to the beginning of 2019. Irritable bowel syndrome and functional dyspepsia diagnoses were determined according to Rome criteria and severity according to irritable bowel syndrome severity scoring system. Vomiting was quantified using a 5-point Likert scale, and constipation severity was measured using the Knowles-Eccersley-Scott-Symptom questionnaires. Quality of life was quantified by the GastroIntestinal Quality of Life Index. Patients were categorized as being treated on a chronic basis with either tramadol, step II opioids, step III opioids or as being opioid-free.

Results: 2933 consecutive patients were included. In our cohort, 12.5% had only irritable bowel syndrome, 39.3% had only functional dyspepsia, 24.9% had a combination of both, and 23.4% had other functional gastrointestinal disorders. Among them, the consumption of tramadol, step II (tramadol excluded) and step III opioids was 1.8, 1.3 and 0.3 % respectively in 2013 and 4.3, 3.4 and 1.9% in 2018 (p < 0.03). Opioid consumption was associated with increased vomiting (p = 0.0168), constipation (p < 0.0001), symptom severity (p < 0.001), more altered quality of life (p < 0.0001) and higher depression score (p = 0.0045).

Conclusion: In functional gastrointestinal disorders, opioid consumption has increased in the last years and is associated with more GI symptoms (vomiting, constipation and GI severity), higher depression and more altered quality of life.

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.