A comparative study of effects of glycopyrrolate and ondansetron on nausea and vomiting in cesarean section under spinal anesthesia

Comparative Efficacy of Different Classes of Antiemetic Medications for the Prevention of Nausea and Vomiting in Cesarean Section: A Network Meta-Analysis

Background

Antiemetic medications have been associated with the prevention of nausea and vomiting in cesarean section, although less is known about the comparative efficacy of different medication classes.

Methods

We conducted a systematic review with network meta-analyses to compare and rank antiemetic medication classes (5-HT3 receptor antagonists, dopamine receptor antagonists, corticosteroids, antihistamines, anticholinergic agents, sedatives, and opioid antagonists or partial agonists) in terms of preventing intra- and postoperative nausea and vomiting among patients undergoing cesarean section. We included all randomized controlled trials (RCTs) that evaluated any antiemetic medication classes' treatment for target outcomes. Network meta-analysis was conducted with a frequentist approach using the R netmeta package. A total of 58 trials were included (6,665 women undergoing cesarean section; mean age, 28.1 years). Results: Compared with placebo, all interventions reduced the odds of intraoperative nausea (except antihistamines), intraoperative vomiting (except antihistamines), postoperative nausea (except anticholinergic agents and opioid antagonists), and postoperative vomiting (except opioid antagonists). In terms of intraoperative nausea and both intra- and postoperative vomiting, sedatives ranked first among other medication classes.

Conclusions

The relative effect sizes for various classes of antiemetic medication in preventing nausea and vomiting in the cesarean section were modeled using the principles of network meta-analysis which may facilitate informed clinical decision-making.

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.

Comparison of the Effects of Sugammadex, Neostigmine, and Pyridostigmine on Postoperative Nausea and Vomiting: A Propensity Matched Study of Five Hospitals

Thus far, few studies have compared the effects of sugammadex and cholinesterase inhibitors on postoperative nausea and vomiting (PONV), and the results have been controversial. Here, we compared the effects of sugammadex, neostigmine, and pyridostigmine on PONV by means of a five hospital analysis with propensity score matching. We analyzed adults aged ≥ 18 years who underwent general anesthesia between January 2014 and December 2019. Following propensity score matching, 7793 patients were included in each of the neostigmine and sugammadex matched patient groups (absolute standardized difference (ASD), 0.01–0.07), and 10,197 patients were included in each of the pyridostigmine and sugammadex matched patient groups (ASD, 0.01–0.02), while 19,377 patients were included in each of the pyridostigmine and neostigmine matched patient groups. (ASD, 0.01–0.19). The odds of PONV were low in the sugammadex group (odds ratio, 0.65; 95% confidence interval, 0.59–0.72; p < 0.0001) and pyridostigmine group (odds ratio, 0.22; 95% confidence interval, 0.20–0.24; p < 0.0001) compared to the neostigmine group, while there was no difference between sugammadex and pyridostigmine (odds ratio, 0.95; 95% confidence interval, 0.86–1.04; p = 0.281). Therefore, sugammadex and pyridostigmine may lower the incidence of PONV compared to neostigmine in patients undergoing general anesthesia.

Prevalence, risk factors, and optimized management of moderate-to-severe thirst in the post-anesthesia care unit

Post-operative thirst is common and may cause intense patient discomfort. The aims of this retrospective study conducted in a high-volume post-anesthesia care unit (PACU) were as follows: (1) to examine the prevalence of moderate-to-severe post-operative thirst—defined as a numerical rating scale (NRS) score of 4 or higher, (2) to identify the main risk factors for moderate-to-severe post-operative thirst, and (3) to maximize the efficacy and safety of thirst management through a quality improvement program. During a 1-month quality improvement program conducted in August 2018, a total of 1211 adult patients admitted to our PACU were examined. Moderate-to-severe thirst was identified in 675 cases (55.8%). The use of glycopyrrolate during anesthesia was associated with moderate-to-severe thirst (71.7% versus 66.4%, respectively, p = 0.047; adjusted odds ratio: 1.46, p = 0.013). Following a safety assessment, ice cubes, room temperature water, or an oral moisturizer were offered to patients. A generalized estimating equation model revealed that ice cubes were the most effective means for thirst management—resulting in an estimated thirst intensity reduction of 0.93 NRS points at each 15-min interval assessment (p < 0.001)—followed by room temperature water (− 0.92/time-point, p < 0.001) and the oral moisturizer (− 0.60/time-point; p < 0.001). Patient satisfaction (rated from 1 [definitely dissatisfied] to 5 [very satisfied]) followed a similar pattern (ice cubes: 4.22 ± 0.58; room temperature water: 4.08 ± 0.55; oral moisturizer: 3.90 ± 0.55, p < 0.001). The use of glycopyrrolate—an anticholinergic agent that reduces salivary secretion—was the main independent risk factor for moderate-to-severe post-operative thirst. Our findings may provide clues towards an optimized management of thirst in the immediate post-operative period.

Utilization of Pre-Anesthetic Medications for Major Surgical Procedures at a Tertiary Care Center: A Descriptive Cross-sectional Study

Introduction:

Drug utilization research is an important tool to analyze the use of drugs with special emphasis on medical, social, and economic consequences in society. This study aims to find out the utilization of pre-anesthetic medications in a major surgical procedure.

Methods:

A descriptive cross-sectional study was conducted from 15th April - 15th August 2019 in the postoperative ward at Birat Medical College and Teaching Hospital. The convenience sampling method was used after ethical clearance from the Institutional Review Committee (IRC) of Birat Medical College and Teaching Hospital, Biratnagar, Nepal. About 400 patients were studied. The collected data were entered into a statistical package for social science version 20 for further calculations at 95% Confidence Interval.

Results:

Out of 400 patients, 215 (53.8%) of patients were underwent into different major surgeries. All patients received midazolam 2 mg except children (1 mg) and Pethidine 25 mg along with 0.2 mg glycopyrrolate 352 (88%), ondansetron 276 (69%) and others 58 (14.5%) as a preanesthetic agent. For general anesthesia propofol, 30 mg have been utilized followed by fentanyl 306 (76.5%) and others (halothane, isoflurane, etc) 115 (28.8%). In case of prophylactic drug were ceftriaxone 500 mg, 100 mg metoclopramide 387 (96.8%), dexamethasone 251 (62.8%), tramadol 237 (59.3%), 15 mg ketorolac 368 (92%), ranitidine 163 (40.8%), and pantoprazole 237 (59.3%).

Conclusions:

The most commonly administered pre-anesthetic drugs were midazolam, pethidine, glycopyrrolate, and ondansetron. The incidence of postoperative nausea and vomiting the patient within 24 hours after surgery was significantly very low.

The Effects of Hydroxyethyl Starch 6% and Crystalloid on Volume Preloading Changes following Spinal Anesthesia

BACKGROUND

Hypotension is one of the most common complications after spinal anesthesia for cesarean delivery. Normally, preloading with fluids, especially crystalloids, is used to prevention of hypotension.

METHODS

In the present randomized clinical trial study, 120 parturients presenting for elective cesarean section with the American Society of Anesthesiologists Class I and II received either 15 cc normal saline or 7 cc/kg hydroxyethyl starch 6% (Voluven) fluid. Information regarding to systolic, diastolic, mean arterial pressure, and heart rate, incidence of hypotension, adverse effects, the total dose of atropine, and ephedrine were recorded in before and 3, 6, 9, 15, and 20 min after spinal anesthesia. Furthermore, Apgar score of newborn at the 1st and 5th min after birth was recorded.

RESULTS

There was no significant difference in mean arterial pressure at different stages such as: Exactly after spinal and 3, 6, 15, and 20 min after spinal anesthesia between two groups (P > 0.05). Total dose of ephedrine and atropine were similar between groups (P > 0.05), respectively. There was no significant difference in Apgar score at the 1st and 5th min after birth between two groups. There were not any adverse effects of drugs in two groups.

CONCLUSIONS

The results of this study show that hydroxyethyl starch 6% compared to normal saline are similar to prevent hypotension during spinal anesthesia for cesarean delivery.

A Cross-Sectional Pharmacoepidemiological Study of the Utilization Pattern of Pre-Anesthetic Medications in Major Surgical Procedures in a Tertiary Care Hospital

Objective 

A study of the utilization pattern of pre-anesthetic medications in major surgical procedures.

Material and methods 

A cross-sectional, pharmacoepidemiological study was conducted among patients undergoing surgical procedures in routine or emergency conditions under general anesthesia. The utilization of pre-anesthetic medicines in all patients was reported.

Results

A total of 110 patients (mean age - 42.36 years; 57.27% males) were enrolled. The major (>10%) indications for surgery were carcinoma/tumor - 25 (22.73%), perforation peritonitis - 20 (18.18%), and intestinal obstruction - 11 (10%). All patients received ranitidine plus metoclopramide. Injections of ondansetron, midazolam, pentazocin, anticholinergic agents, and fentanyl were used in 103 (93.64%), 103 (93.64%), 92 (83.64%), 84 (76.36%), and 23 (20.91%) patients, respectively. The dosage of ondansetron was 4 mg in 95 patients (86.36%), while 89.09% patients received 1 mg of midazolam. In 86 patients (78.18%), pentazocine was used in a 15 mg dose. Among the anticholinergic agents, glycopyrrolate was used in 76 patients (69.09%). Glycopyrrolate was used in a 0.2 mg dose in 74 patients (97.37%). The major indications for the use of fentanyl were carcinoma - 8 (34.8%), perforation peritonitis - 4 (17.4%), and surgery for intestinal obstruction - 3 (13%).

Conclusion

The administration of ondansetron, midazolam, and pentazocin is very common (>80% patients) as pre-anesthetic medication. Glycopyrrolate was the preferred anticholinergic agent. In cancer patients, the use of fentanyl is common.

Influence of Difference in Timing of Perioperative Administration of Low-dose Ketamine on Postoperative Analgesia

Background:

Preemptive analgesia is a part of multimodal regime for effective postoperative analgesia. Ketamine is said to possess preemptive effects, which has been simultaneously refuted by other studies. Hence, we designed this randomized, double-blinded trial to establish the influence of timing of perioperative ketamine administration for superior postoperative analgesia.

Methods:

Ninety patients undergoing infraumbilical surgeries under spinal anesthesia were randomized to receive ketamine either preincision (Group KI), preincision and during skin closure (Group KII), or only during skin closure (Group KIII). Outcomes studied were postoperative pain, sedation, and incidence of side effects.

Results:

Analysis of variance statistics for postoperative visual analog scales (VAS) for pain showed no significant difference in three groups. However, there was a significant difference between Groups KII and KIII in the immediate postoperative period (95% confidence interval [CI] of mean VAS for Group KI = 0.9249–1.4889; 95% CI for Group KII = 1.4406–1.8260; P = 0.043). Sedation scores in the immediate, 4 h and 8 h postoperative showed a significant difference between Group KI and Group KII (P = 0.007, 0.008, 0.001, respectively) and between Group KI and KIII (KI: KIII - P = 0.0008, 0.0006, 0.02, respectively). Although the incidence of psychotomimetic effect was more in Groups KIII, it was not statistically significant.

Conclusion:

Ketamine possesses postoperative analgesic effects in the immediate postoperative period only when its preemptive administration is supplemented with repeat administration during closure. Incidences of side effects were comparable in all groups.