Spinal Anesthetics Causing Adverse Effects in Therapeutic Use Clinical Trial
Official title:
Comparison Between Cyclizine and Dexamethasone for Prevention of Nausea and Vomiting After Intrathecal Morphine in Patients Undergoing Cesarean Section
Comparing between cyclizine and dexamethasone in preventing PONV after CS under spinal anesthesia with spinal opiate.
Postoperative nausea and vomiting (PONV) is defined as any nausea, retching, or vomiting
occurring during the first 24-48 h after surgery in patients. PONV is one of the most common
causes of patient dissatisfaction after anesthesia, with reported incidences of 30% in all
post-surgical patients and up to 80% in high-risk patients. In addition, PONV is regularly
rated in preoperative surveys, as the anesthesia outcome the patient would most like to
avoid. While suture dehiscence, aspiration of gastric contents, esophageal rupture, and other
serious complications associated with PONV are rare, nausea and vomiting is still an
unpleasant and all-too-common postoperative morbidity that can delay patient discharge from
the post-anesthesia care unit and increase unanticipated hospital admissions in outpatients.
There are many well-established risk factors for PONV which are classified in two classes:
A) Patient related risk factors:
1. Female gender is consistently the strongest risk factor for PONV, female patient are
three times more likely than men to suffer from PONV.
2. For adult patient, age is a statistically, though not clinically, relevant risk factor,
with the incidence of PONV decreasing as patients age. For pediatric patients, however,
age increases the risk of post-operative vomiting (POV), such that children older than 3
years have been shown to have an increased risk of POV compared with children younger
than 3 years.
3. Obesity is a strong risk factor for PONV: patients with body mass index (BMI) more than
30 have the double risk of PONV.
4. Non-smoking status roughly doubles the patient's risk of PONV. The specific mechanism
underlying smoking's protective effect is unknown ,but one of the most commonly believed
theories is that polycyclic aromatic hydrocarbons in cigarette smoke induce cytochrome
P450 enzyme which increase the metabolism of emetogenic volatile anesthetics.
5. History of gastrointestinal disease as gastritis, gastric ulcer or duodenal ulcer
increases the risk for PONV.
6. History of motion sickness, Meniere's disease or previous PONV indicates a general
susceptibility to PONV.
B) Anesthesia related risk factors:
1. The use of volatile anesthetics is associated with a two-fold increase in the risk of
PONV, with risk increasing in a dose dependent manner.
2. Intraoperative and postoperative opioid use increases the risk of PONV in a dose
dependent manner by the mechanism of reducing muscle tone and peristaltic activity,
thereby delaying gastric emptying, inducing distention, and triggering the vomiting
reflex.
3. The duration of anesthesia can help predict the patient's risk of PONV, since the
duration of anesthesia describes the patient's exposure to emetogenic stimuli like
volatile anesthetics and intraoperative opioids.
Anti-emetic drugs used to treat PONV:
1. The first line is classified into three classes: serotonin antagonists (e.g.
ondansetron), corticosteroids (e.g. dexamethasone), and dopamine antagonists (e.g.
droperidol) have similar efficacy against PONV, with a relative risk reduction of about
25%. Moreover, they act independently and when used in combination, have
additiveeffects.
Dexamethasone : it can be effective in preventing PONV in adults and children. Compared
with other operative medications, dexamethasone has equal or even better efficacy in
reducing the incidence of PONV and has the advantages of low cost and longer
effectiveness as well. The mechanism of the antiemetic action of dexamethasone is still
not clearly known. Glucocorticoids receptors are found in nucleus of the solitary tract,
the raphe nucleus and the area postrema and all are associated with regulating nausea
and vomiting. Dexamethasone may affect PONV by modulating neurotransmission or receptor
density in these nuclei. Clinically, dexamethasone as a preventive drug against PONV has
not caused fatal outcome; therefore, it is generally considered to be an effective and
safe anti-emetic. Nevertheless, its use in this regard may lead to adverse effects,
principally postoperative hyperglycemia and infection.
2. The second line is Cyclizine: a histamine H1 antagonist given by mouth or parenterally
for control of postoperative and drug-induced nausea and vomiting and in motion
sickness. additionally, it has been used in management of vertigo in diseases affecting
the vestibular apparatus. Although the mechanism by which cyclizine exerts its
antiemetic and antivertigo effects has not been fully elucidated, its central
anticholinergic properties are partially responsible. It also possesses anticholinergic,
antihistaminic, central nervous system depressant and local anesthetic effects.
cyclizine is metabolized to its N-demethylated derivative , norcyclizine , which has
little antihistaminic activity compared to cyclizine.
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