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Ahmed SA, Lotfy HA, Mostafa TAH. The effect of adding dexmedetomidine or dexamethasone to bupivacaine-fentanyl mixture in spinal anesthesia for cesarean section. J Anaesthesiol Clin Pharmacol 2024; 40:82-89. [PMID: 38666154 PMCID: PMC11042101 DOI: 10.4103/joacp.joacp_396_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Accepted: 12/20/2022] [Indexed: 04/28/2024] Open
Abstract
Background and Aims Many strategies are available to prevent spinal-induced hypotension in cesarean section, especially the use of a low dose of spinal anesthesia combined with adjuvants. This study investigated the effect of adding either dexmedetomidine or dexamethasone to the intrathecal bupivacaine-fentanyl mixture on the postoperative analgesia duration, after elective cesarean section. Material and Methods This prospective, randomized, double-blind study was conducted on 90 full-term parturients undergoing elective cesarean section, who were randomly distributed into three groups. They all received spinal anesthesia with the bupivacaine-fentanyl mixture (2.5 ml), in addition to 0.5 ml normal saline (control group), 5 μg dexmedetomidine dissolved in 0.5 ml normal saline (dexmedetomidine group), or 2 mg dexamethasone (dexamethasone group). The time to the first request of morphine rescue analgesia was recorded, in addition to the total dose of morphine consumed in the first 24 h after surgery, the postoperative numerical rating score (NRS), and maternal and fetal outcomes. Results As compared to the control group and the dexamethasone group, the use of dexmedetomidine as an additive to the bupivacaine-fentanyl mixture significantly prolonged the time to the first request of rescue analgesia, decreased postoperative morphine consumption, and decreased the pain score 4 and 6 h after surgery. There was an insignificant difference between the control and dexamethasone groups. Conclusion The use of dexmedetomidine as an additive to bupivacaine-fentanyl mixture in spinal anesthesia for cesarean section prolonged the postoperative analgesia and decreased the postoperative opioid consumption in comparison to the addition of dexamethasone or normal saline.
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Affiliation(s)
- Sameh Abdelkhalik Ahmed
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Hashem Adel Lotfy
- Department of Obstetrics and Gynecology, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Tarek Abdel Hay Mostafa
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, Tanta University, Tanta, Egypt
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Jaafarpour M, Vasigh A, Najafi F, Sayadi H, Shafiei E. A Comparative Study on the Effect of Intrathecal Bupivacaine vs. Ropivacaine on Maternal and Neonatal Outcomes After Cesarean Section: A Systematic Review and Meta-analysis. Anesth Pain Med 2023; 13:e134732. [PMID: 38021336 PMCID: PMC10664161 DOI: 10.5812/aapm-134732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 02/06/2023] [Accepted: 02/15/2023] [Indexed: 12/01/2023] Open
Abstract
Context The type of anesthesia in cesarean section can affect the mother and baby. This study aimed to determine the comparative effect of intrathecal hyperbaric bupivacaine vs. hyperbaric ropivacaine on maternal and neonatal outcomes after cesarean section. Evidence Acquisition PubMed, Web of Science, Embase, Google Scholar, IranDoc, MagIran, and Scopus databases were searched from 1 September 2022 to 1 November 2022. Eighteen clinical trials with 1542 patients were included in the analysis. Results There was no statistically significant difference in hypotension, bradycardia, and Apgar score between the 2 groups (P > 0.05). The risk of nausea (relative risk (RR), 1.526; 95% CI, 1.175 - 1.981; P = 0.001) and vomiting (RR, 1.542; 95% CI, 1.048 - 2.268; P = 0.02) caused by bupivacaine was 0.53% and 0.54% higher than that of ropivacaine. The incidence of shivering (RR, 2.24; 95% CI, 1.480 - 3.39; P = 0.00) was 2.24 times higher in the bupivacaine group than in the ropivacaine group. The average onset time of sensory block (standardized mean difference (SMD), -0.550; 95% CI, -1.054 to -0.045; P = 0.032) and motor block (SMD, -0.812; 95% CI, -1.254 to -0.371; P = 0.000) was significantly lower in the bupivacaine group than in the ropivacaine group. Conclusions Despite the fact that ropivacaine and bupivacaine are effective in cesarean section, ropivacaine is more favorable because of less hemodynamic changes, less duration of sensory and motor block, and fewer side effects, which are effective in patient recovery.
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Affiliation(s)
- Molouk Jaafarpour
- Department of Midwifery, School of Nursing and Midwifery, Ilam University of Medical Sciences, Ilam, Iran
| | - Aminolah Vasigh
- Department of Anesthesiology, School of Allied Medical Sciences, Ilam University of Medical Sciences, Ilam, Iran
| | - Fatemeh Najafi
- Department of Nursing, School of Nursing and Midwifery, Ilam University of Medical Sciences, Ilam, Iran
| | - Hojat Sayadi
- Department of Biostatistics, School of Health, Ilam University of Medical Sciences, Ilam, Iran
- Non-communicable Diseases Research Center, Ilam University of Medical Sciences, Ilam, Iran
| | - Elham Shafiei
- Clinical Research Development Unit, Ayatollah Taleghani Hospital, Ilam University of Medical Sciences, Ilam, Iran
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Abate SM, Mergia G, Nega S, Basu B, Tadesse M. Efficacy and safety of wound infiltration modalities for postoperative pain management after cesarean section: a systematic review and network meta-analysis protocol. Syst Rev 2022; 11:194. [PMID: 36071535 PMCID: PMC9450460 DOI: 10.1186/s13643-022-02068-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 08/30/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Postoperative pain after a cesarean section has negative consequences for the mother during the postoperative period. Over the years, various postoperative pain management strategies have been used following cesarean section. Opioid-based analgesics and landmark approaches have negative side effects, while ultrasound-based regional analgesia necessitates resources and experience, but various wound infiltration adjuvants are innovative with few side effects and are simple to use. The efficacy and safety of each adjuvant, however, are unknown and require further investigation. OBJECTIVE This network meta-analysis is intended to provide the most effective wound infiltration drugs for postoperative management after cesarean section. METHOD A comprehensive search will be conducted in PubMed/MEDLINE, Cochrane Library, Science Direct, CINHAL, and LILACS without date and language restrictions. All randomized trials comparing the effectiveness of wound infiltration drugs for postoperative pain management after cesarean section will be included. Data extraction will be conducted independently by two authors. The quality of studies will be evaluated using the Cochrane risk of bias tool, and the overall quality of the evidence will be determined by GRADEpro software. DISCUSSION The rate of postoperative acute and chronic pain is very high which has a huge impact on the mother, family, healthcare practitioners, and healthcare delivery. It is a basic human right to give every patient with postoperative pain treatment that is realistic in terms of resources, technique, cost, and adverse event profile. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42021268774.
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Affiliation(s)
- Semagn Mekonnen Abate
- Department of Anesthesiology, College of Health Sciences and Medicine, Dilla University, Dilla, Ethiopia.
| | - Getachew Mergia
- Departemnt of Obstetrics and Gynecology, College of Health Sciences and Medicine, Dilla University, Dilla, Ethiopia
| | - Solomon Nega
- Departemnt of Internal Medicine, College of Health Sciences and Medicine, Dilla University, Dilla, Ethiopia
| | - Bivash Basu
- Department of Anesthesiology, College of Health Sciences and Medicine, Dilla University, Dilla, Ethiopia
| | - Moges Tadesse
- School of Public Health, College of Health Sciences and Medicine, Dilla University, Dilla, Ethiopia
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Kanawati S, Barada MA, Naja Z, Rajab O, Sinno L, El Hasan J. Comparison of clinical effects of meperidine and sufentanil added to 0.5% hyperbaric bupivacaine for spinal anesthesia in patients undergoing cesarean delivery: a randomized controlled trial. J Anesth 2022; 36:201-209. [DOI: 10.1007/s00540-021-03031-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 12/03/2021] [Indexed: 11/24/2022]
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Bhiladvala C, Ffrench-O'Carroll R, Dadkhah Y, Bright S, Chau A, Seligman KM. Factors driving the difference in quality of recovery scores between scheduled and unscheduled Caesarean delivery patients. Br J Anaesth 2022; 128:e219-e221. [PMID: 35012740 DOI: 10.1016/j.bja.2021.11.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 10/31/2021] [Accepted: 11/16/2021] [Indexed: 11/02/2022] Open
Affiliation(s)
- Cyrus Bhiladvala
- BC Women's Hospital and Health Centre, Department of Anesthesia, Vancouver BC, Canada
| | | | - Yeganeh Dadkhah
- BC Women's Hospital and Health Centre, Department of Anesthesia, Vancouver BC, Canada
| | - Susan Bright
- BC Women's Hospital and Health Centre, Department of Anesthesia, Vancouver BC, Canada; Department of Anesthesiology, Pharmacology and Therapeutics, Unversity of British Columbia, Vancouver, BC, Canada
| | - Anthony Chau
- BC Women's Hospital and Health Centre, Department of Anesthesia, Vancouver BC, Canada; Department of Anesthesiology, Pharmacology and Therapeutics, Unversity of British Columbia, Vancouver, BC, Canada
| | - Katherine M Seligman
- BC Women's Hospital and Health Centre, Department of Anesthesia, Vancouver BC, Canada; Department of Anesthesiology, Pharmacology and Therapeutics, Unversity of British Columbia, Vancouver, BC, Canada.
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Fahmi A, Aji YK, Aprianto DR, Wido A, Asadullah A, Roufi N, Indiastuti DN, Subianto H, Turchan A. The Effect of Intrathecal Injection of Dextromethorphan on the Experimental Neuropathic Pain Model. Anesth Pain Med 2021; 11:e114318. [PMID: 34540637 PMCID: PMC8438745 DOI: 10.5812/aapm.114318] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Revised: 04/27/2021] [Accepted: 05/18/2021] [Indexed: 12/22/2022] Open
Abstract
Background Peripheral glucocorticoid receptors (GRs) are altered by peripheral nerve injury and may modulate the development of neuropathic pain. Two central pathogenic mechanisms underlying neuropathic pain are neuroinflammation and N-methyl-D-aspartate receptor (NMDAR)-dependent neural plasticity in the spinal cord. Objectives This study examined the effect of the non-competitive NMDAR antagonist dextromethorphan on partial sciatic nerve ligation (PSL)-induced neuropathic pain and the spinal expression of the glucocorticoid receptor (GR). Methods Male mice were randomly assigned into a sham group and two groups receiving PSL followed by intrathecal saline vehicle or dextromethorphan (iDMP). Vehicle or iDMP was administered 8 - 14 days after PSL. The hotplate paw-withdrawal latency was considered to measure thermal pain sensitivity. The spinal cord was then sectioned and immunostained for GR. Results Thermal hyperalgesia developed similarly in the vehicle and iDMP groups prior to the injections (P = 0.828 and 0.643); however, it was completely mitigated during the iDMP treatment (P < 0.001). GR expression was significantly higher in the vehicle group (55.64 ± 4.50) than in the other groups (P < 0.001). The iDMP group (9.99 ± 0.66) showed significantly higher GR expression than the sham group (6.30 ± 1.96) (P = 0.043). Conclusions The suppression of PLS-induced thermal hyperalgesia by iDMP is associated with the downregulation of GR in the spinal cord, suggesting that this analgesic effect is mediated by inhibiting GR-regulated neuroinflammation.
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Affiliation(s)
- Achmad Fahmi
- Neurosurgery Department, Faculty of Medicine, Dr. Soetomo General Academic Hospital, Universitas Airlangga, Surabaya, Indonesia
- Corresponding Author: Neurosurgery Department, Faculty of Medicine, Dr. Soetomo General Academic Hospital, Universitas Airlangga, Surabaya, Indonesia.
| | - Yunus Kuntawi Aji
- Neurosurgery Department, Faculty of Medicine, Dr. Soetomo General Academic Hospital, Universitas Airlangga, Surabaya, Indonesia
| | - Dirga Rachmad Aprianto
- Neurosurgery Department, Faculty of Medicine, Dr. Soetomo General Academic Hospital, Universitas Airlangga, Surabaya, Indonesia
| | - Akbar Wido
- Neurosurgery Department, Faculty of Medicine, Dr. Soetomo General Academic Hospital, Universitas Airlangga, Surabaya, Indonesia
| | - Asadullah Asadullah
- Neurosurgery Department, Faculty of Medicine, Dr. Soetomo General Academic Hospital, Universitas Airlangga, Surabaya, Indonesia
| | | | - Danti Nur Indiastuti
- Department of Pharmacology, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia
| | - Heri Subianto
- Neurosurgery Department, Faculty of Medicine, Dr. Soetomo General Academic Hospital, Universitas Airlangga, Surabaya, Indonesia
| | - Agus Turchan
- Neurosurgery Department, Faculty of Medicine, Dr. Soetomo General Academic Hospital, Universitas Airlangga, Surabaya, Indonesia
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Edinoff AN, Kaplan LA, Khan S, Petersen M, Sauce E, Causey CD, Cornett EM, Imani F, Moradi Moghadam O, Kaye AM, Kaye AD. Full Opioid Agonists and Tramadol: Pharmacological and Clinical Considerations. Anesth Pain Med 2021; 11:e119156. [PMID: 34692448 PMCID: PMC8520671 DOI: 10.5812/aapm.119156] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Accepted: 09/03/2021] [Indexed: 12/22/2022] Open
Abstract
Opioids are mu receptor agonists and have been an important part of pain treatment for thousands of years. In order to use these drugs appropriately and successfully in patients, whether to control pain, to treat opiate-induced side effects, or opiate withdrawal syndromes, a solid understanding of the pharmacology of such drugs is crucial. The most recognized full agonist opioids are heroin, morphine, codeine, oxycodone, meperidine, and fentanyl. Phenanthrenes refer to a naturally occurring plant-based compound that includes three or more fused rings. The opioids derived from the opium plant are phenanthrene derivatives, whereas most synthetic opioids are simpler molecules that do not have multiple rings. Methadone acts as a synthetic opioid analgesic similar to morphine in both quality and quantity; however, methadone lasts longer and in oral form, has higher efficacy, and is considered a diphenylheptane. Fentanyl is a strong synthetic phenylpiperdine derivative that exhibits activity as a mu-selective opioid agonist approximately 50 to 100 times more potent than morphine. Meperidine is another medication which is a phenylpiperdine. Tramadol is considered a mixed-mechanism opioid drug, as it is a centrally acting analgesic that exerts its effects via binding mu receptors and blocking the reuptake of monoamines. Some of the most common adverse effects shared among all opioids are nausea, vomiting, pruritus, addiction, respiratory depression, constipation, sphincter of Oddi spasm, and miosis (except in the case of meperidine). Chronic opioid usage has also established a relationship to opioid-induced hypogonadism and adrenal suppression. Physicians must be stewards of opioid use and use opioids only when necessary.
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Affiliation(s)
- Amber N. Edinoff
- Louisiana State University Health Science Center Shreveport, Department of Psychiatry and Behavioral Medicine, Shreveport, LA, USA
| | - Leah A. Kaplan
- Louisiana State University Shreveport, School of Medicine, Shreveport, LA, USA
| | - Sami Khan
- American University of the Caribbean, School of Medicine, USA
| | - Murray Petersen
- Louisiana State University Health Science Center Shreveport, Department of Psychiatry and Behavioral Medicine, Shreveport, LA, USA
| | - Emily Sauce
- Louisiana State University New Orleans, School of Medicine, New Orleans, LA, USA
| | | | - Elyse M. Cornett
- Louisiana State University Shreveport, Department of Anesthesiology, Shreveport, LA, USA
| | - Farnad Imani
- Pain Research Center, Department of Anesthesiology and Pain Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Omid Moradi Moghadam
- Pain Research Center, Department of Anesthesiology and Pain Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Adam M. Kaye
- Thomas J. Long School of Pharmacy and Health Sciences, University of the Pacific, Department of Pharmacy Practice, Stockton, CA, USA
| | - Alan D. Kaye
- Louisiana State University Shreveport, Department of Anesthesiology, Shreveport, LA, USA
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Effects of colloid preload on the incidence of hypotension in spinal anesthesia for cesarean section: a systematic review and meta-analysis. Chin Med J (Engl) 2021; 134:1043-1051. [PMID: 33883404 PMCID: PMC8116017 DOI: 10.1097/cm9.0000000000001477] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Background: Hypotension is a common complication caused by spinal anesthesia (SA), which may have adverse impacts on the condition of the parturient and fetus. Liquid infusion was found to be relatively effective for reducing the incidence of hypotension. However, the question of whether colloid preload can optimize hemodynamic variables in the cesarean section remains controversial. This study aims to determine the effects of colloid preload on the incidence of hypotension induced by SA in elective cesarean section. Methods: Related keywords were searched on PubMed, EMBASE, and Cochrane Library from inception dates to May 2020. Studies included were evaluated for eligibility and quality. The primary outcome was the intra-operative incidence of hypotension and severe hypotension. The secondary outcomes included the lowest intra-operative systolic blood pressure, the maximal intra-operative heart rate, the intra-operative needs of ephedrine and phenylephrine, the incidence of maternal nausea and/or vomiting, and neonatal outcomes (umbilical artery pH and Apgar scores). Apart from the above, RevMan 5.3 was used for the data analysis. Results: Altogether nine randomized controlled trials were included in the meta-analysis. There were no significant differences in the incidence of intra-operative hypotension, severe hypotension, or neonatal outcomes between the colloid preload group and control group, except for the umbilical artery pH. Conclusion: This meta-analysis suggests that colloid preload does not significantly reduce the incidence of hypotension associated with SA in elective cesarean section.
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Manouchehrian N, Moradi A, Torkashvand L. Comparative Study of Effect of Spinal Anesthesia in Sitting and Lateral Positions on the Onset Time of Sensory Block and Hemodynamic Condition in Cesarean Section: A Randomized Clinical Trial. Anesth Pain Med 2021; 11:e111483. [PMID: 34221941 PMCID: PMC8241818 DOI: 10.5812/aapm.111483] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 01/29/2021] [Accepted: 01/31/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Spinal anesthesia is the method of choice for the cesarean section. Hypotension is a common complication of this method. OBJECTIVES This study aimed to compare the effect of spinal anesthesia in the sitting and lateral positions on the onset time of sensory block and hemodynamic condition in cesarean sections. METHODS In this clinical trial, 106 elective cesarean section candidates under spinal anesthesia were selected and randomly divided into two groups: spinal anesthesia in the sitting position (group S) and the lateral position (group L). The onset time of the sensory block, quality of sensory and motor block, hemodynamic condition, frequency of hypotension, nausea, and vomiting, and the doses of ephedrine and atropine were compared between both groups. Data were analyzed with SPSS version 16 software at a 95% confidence level. RESULTS There was no statistically significant difference between the two groups in terms of age. The frequency of hypotension in L and S groups was 24.5% and 57.7%, respectively (P = 0.001), in minute 6 after spinal anesthesia and 5.7% and 36.5%, respectively (P < 0.001), in minute 8 after spinal anesthesia. The mean time to reach the sensory level of T6 was 1.30 ± 0.43 min versus 4.54 ± 2.12 min (P < 0.001), motor block score in minute 5 was 2.98 ± 0.14 versus 2.82 (P = 0.044), and ephedrine dose was 11.5 mg and 16.92 mg in the L and S groups, respectively (P = 0.010). The maximum sensory-motor block and satisfaction of women with spinal anesthesia were significantly higher in the lateral position than in the sitting position (P < 0.05). CONCLUSIONS Cesarean sections under spinal anesthesia in the lateral position than in the sitting position lead to a more rapid sensory and motor block, reduced ephedrine consumption, and enhanced satisfaction of women.
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Affiliation(s)
- Nahid Manouchehrian
- Department of Anesthesiology, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Abbas Moradi
- Medical Sciences Faculty, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Leyla Torkashvand
- Medical Sciences Faculty, Hamadan University of Medical Sciences, Hamadan, Iran
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Biazar G, Farzi F, Chaibakhsh Y, Habibi MR, Khosousi Sani M, Mirmansouri L. Successful Management of a Suspected Case of Meperidine-Induced Anaphylaxis in Cesarean Delivery. Anesth Pain Med 2020; 10:e104796. [PMID: 34150563 PMCID: PMC8207837 DOI: 10.5812/aapm.104796] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Revised: 06/16/2020] [Accepted: 07/17/2020] [Indexed: 01/03/2023] Open
Abstract
Introduction Meperidine is known as the gold standard drug for shivering after spinal anesthesia (SA). This drug has been used widely and safely during the Cesarean Section (CS). Case Presentation This case report presents an anaphylaxis reaction to a single intravenous dose of 25 mg meperidine, aiming to control shivering during CS under SA a few minutes after surgical incision. Conclusions The condition was well managed with timely intervention. This rare fetal reaction to meperidine is worthy of reporting to make the medical team aware of the potential risks of anaphylaxis due to many routine safe drugs.
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Affiliation(s)
- Gelareh Biazar
- Anesthesiology Research Center, Department of Anesthesiology, Alzahra Hospital, Guilan University of Medical Sciences, Rasht, Iran
| | - Farnoush Farzi
- Anesthesiology Research Center, Department of Anesthesiology, Alzahra Hospital, Guilan University of Medical Sciences, Rasht, Iran
- Corresponding Author: Department of Anesthesiology, Anesthesiology Research Center, Alzahra Hospital, Guilan University of Medical Sciences, P.O. Box: 4144654839, Rasht, Iran.
| | - Yasmin Chaibakhsh
- Anesthesiology Research Center, Department of Anesthesiology, Alzahra Hospital, Guilan University of Medical Sciences, Rasht, Iran
| | - Mohammad Reza Habibi
- Anesthesiology Research Center, Department of Anesthesiology, Alzahra Hospital, Guilan University of Medical Sciences, Rasht, Iran
| | - Mahsa Khosousi Sani
- Reproductive Health Research Center, Department of Obstetrics and Gynecology, Al-Zahra Hospital, School of Medicine, Guilan University of Medical Sciences, Rasht, Iran
| | - Ladan Mirmansouri
- Student Research Committee, School of Pharmacy, Guilan University of Medical Sciences, Rasht, Iran
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