Jann-Inn Tzeng

The effect of timing of dexamethasone administration on its efficacy as a prophylactic antiemetic for postoperative nausea and vomiting.

We evaluated the timing effect of a 10-mg IV administration of dexamethasone on its efficacy as a prophylactic antiemetic on postoperative nausea and vomiting (PONV). One hundred twenty women (n = 40 in each of three groups) undergoing abdominal total hysterectomy under general anesthesia were enrolled in this randomized, double-blinded, placebo-controlled study. Group 1 received dexamethasone before the induction of anesthesia, Group 2 received dexamethasone at the end of anesthesia, and Group 3 received placebo (saline). The incidence of PONV was evaluated. During the postoperative period of 0–2 h, patients in Group 1 reported a less frequent incidence of PONV (15%) than those in Groups 2 and 3 (45% and 53%, respectively). Patients in Group 1 also requested less rescue antiemetic (8%) than those in Groups 2 and 3 (30% and 35%, respectively). During the postoperative period of 2–24 h, patients in both Groups 1 and 2 reported less frequent incidences of PONV (25% and 28%) and requested fewer rescue antiemetics (13% and 15%) than those in Group 3 (55% and 38%, respectively). In conclusion, the prophylactic IV administration of dexamethasone immediately before the induction, rather than at the end of anesthesia, was more effective in preventing PONV. Implications We evaluated the effect of timing of dexamethasone administration on its efficacy as a prophylactic antiemetic on postoperative nausea and vomiting. We found that dexamethasone, when given immediately before the induction of anesthesia, was more effective than when given at the end of anesthesia.

Small-dose dexamethasone reduces nausea and vomiting after laparoscopic cholecystectomy: A comparison of Tropisetron with saline

Dexamethasone is an effective antiemetic drug, but the efficacy of small-dose dexamethasone 5 mg on the prophylaxis of postoperative nausea and vomiting (PONV) in patients undergoing laparoscopic chole-cystectomy has not been evaluated. We, therefore, evaluated the prophylactic effect of small-dose dexamethasone (5 mg) on PONV in patients undergoing laparoscopic cholecystectomy. Tropisetron and saline served as controls. One-hundred-twenty patients scheduled for laparoscopic cholecystectomy were enrolled in a randomized, double-blinded, placebo-controlled study. At the induction of anesthesia, the Dexamethasone group received IV dexamethasone 5 mg, the Tropisetron group received IV tropisetron 2 mg, and the Pla- cebo group received IV saline. We found that both dexamethasone and tropisetron significantly decreased the following variables: the total incidence of PONV (P < 0.01), more than four vomiting episodes (P < 0.05), and the proportions of patients requiring rescue antiemetics (P < 0.05). The differences between the Dexamethasone and Tropisetron groups were not significant. We conclude that prophylactic IV dexamethasone 5 mg significantly reduces the incidence of PONV in patients undergoing laparoscopic cholecystectomy. At this dose, dexamethasone is as effective as tropisetron 2 mg and is more effective than placebo.

Comparison of intravenous nalbuphine infusion versus naloxone in the prevention of epidural morphine-related side effects☆

Background and Objectives. Epidural morphine is accepted as an efficient means of postoperative pain management. However, development of side effects such as nausea and vomiting and pruritus has been reported. This study compared the efficacy of intravenous infusions of nalbuphine or naloxone in the prevention of epidural morphine‐related side effects. Methods. Seventy‐five female patients undergoing epidural anesthesia for total hysterectomy were enrolled in a randomized, double‐blind study. At the end of the surgery, all patients received epidural 3 mg morphine (every 12 hours) for postoperative pain. Meanwhile, patients in group 1 received an adjuvant intravenous infusion of nalbuphine 60 μg/kg/h, patients in group 2 received intravenous infusion of naloxone 2 μg/kg/h, and patients in group 3 received intravenous saline infusion only. A rescue analgesic of intramuscular 50 mg meperidine (every 4 hours) was available for each patient. Patients were observed for 24 hours. Results. All patients had adequate postoperative pain relief. However, the proportion of patients requiring rescue analgesia and the total consumption of rescue analgesic were higher in group 2 than in the other two groups. The incidence of nausea and vomiting and pruritus was higher in group 3 than in the other two groups. Conclusions. We found that coadministration of either nalbuphine or naloxone with epidural morphine reduces the incidence of morphine‐related side effects. However, unlike naloxone, nalbuphine did not attenuate the analgesic effect of epidural morphine.

The Prophylactic Effect of Haloperidol Plus Dexamethasone on Postoperative Nausea and Vomiting in Patients Undergoing Laparoscopically Assisted Vaginal Hysterectomy

BACKGROUND:Haloperidol, a major tranquilizer, has been found to have a potent antiemetic effect on postoperative nausea and vomiting (PONV), but the prophylactic effect of haloperidol plus dexamethasone on PONV has not been evaluated. We evaluated the prophylactic effect of haloperidol plus dexamethasone to either given alone, placebo or droperidol on PONV in patients undergoing a laparoscopic-assisted vaginal hysterectomy. METHODS:Four hundred adult women (n = 80 in each of five groups) scheduled for a laparoscopic-assisted vaginal hysterectomy were enrolled in a randomized, double-blind, placebo, and positive-control study. Fifteen minutes after the induction of anesthesia, patients received an IV injection of either saline (group S), droperidol 1.25 mg (group D), haloperidol 2 mg (group H), dexamethasone 5 mg (group Dx), or haloperidol 2 mg plus dexamethasone 5 mg (group H + Dx) to prevent PONV. The occurrence of PONV and medication-related side effects were recorded. RESULTS:The incidences of PONV (0–24 h) in the D (36%), H (37%), Dx (38%), and H + Dx (19%) groups were significantly lower than in the S group (65%; P < 0.05 for each comparison). The H + Dx group had the lowest incidence of PONV (19%; P < 0.05 for each comparison) of the five study groups. No differences were found between the D, H, and Dx groups. Also, no differences were found among the five groups in the side effects of QT prolongation, intensity of postoperative pain, level of sedation, and occurrence of extra-pyramidal symptoms. CONCLUSION:Prophylactic haloperidol 2 mg plus dexamethasone 5 mg produced a greater reduction in the incidence of PONV than did either drug used alone, placebo or droperidol without increasing perioperative adverse outcomes.

Intrathecal tri-cyclic antidepressants produce spinal anesthesia.

Abstract Tri‐cyclic antidepressants (TCAs) have been widely used in treating major depressive disorders. Recent studies further demonstrated that TCAs have potent sodium channel blocking effect, and amitriptyline, one of the TCAs, has a potent spinal anesthetic effect. The aim of the study was to evaluate the spinal anesthetic effect of various TCAs and to see whether these TCAs could likewise act as local anesthetics after a single intrathecal injection. Bupivacaine, a potent and long‐acting traditional local anesthetic, acted as control. The spinal anesthetic effect of nine TCAs (amitriptyline, doxepin, imipramine, trimipramine, clomipramine, protriptyline, desipramine, nortriptyline, and amoxapine) and three traditional local anesthetics (bupivacaine, lidocaine, and mepivacaine) was evaluated in rats and so were dose–response studies of amitriptyline, bupivacaine, and lidocaine. Under a given concentration of 5 mM, bupivacaine had the most potent spinal blockade of motor, propioception, and nociception (P<0.001) and the longest duration of action of nociception (P<0.01) among the three traditional local anesthetics. Under this concentration, amitriptyline had a similar potency but longer duration of spinal blockade of motor, propioception, and nociception (P<0.001) than did bupivacaine, whereas several other TCAs had similar or less potencies of spinal blockade than did bupivacaine. In dose–response studies, amitriptyline had a more potent (P<0.005) and longer duration (P<0.001) of spinal blockade than did bupivacaine. We concluded that intrathecal amitriptyline had a more potent and longer duration of spinal anesthetic effect than did bupivacaine, whereas several other TCAs had similar or less potencies than did bupivacaine.

Dexamethasone prophylaxis of nausea and vomiting after epidural morphine for post-cesarean analgesia

Purpose: To determine the minimum effective dose of dexamethasone in preventing nausea and vomiting associated with epidural morphine for post-Cesarean analgesia.Method: One hundred and eighty parturients (n=45 in each of four groups) requiring epidural morphine for post-Cesarean analgesia were enrolled in this randomized, double-blinded, placebo-controlled study. At the end of surgery, parturients received either dexamethasone, at doses of 10 mg, 5 mg, 2.5 mg, or salineiv. Three milligrams epidural morphine were given to all parturients for postoperative analgesia. The incidence of PONV and side effects were estimated for 24 hr after delivery by blinded, trained nurse anesthetists.Results: Parturients who received dexamethasone, either 10 mg or 5 mg were different from those who received saline alone in the following parameters: the total incidence of nausea and vomiting, incidence of >4 vomiting episodes, number the of parturients requiring rescue antiemetics, and the total number of parturients with no vomiting and/or no antiemetic medication (P<0.05 toP<0.01). The differences between dexamethasone 10 mg and 5 mg were not significant. Dexamethasone 2.5 mg was partially effective.Conclusion: Dexamethasone, 5 mgiv, is suggested as the minimum effective dose in preventing nausea and vomiting associated with epidural morphine for post-Cesarean analgesia.RésuméObjectif: Déterminer la dose efficace minimale de dexaméthasone à utiliser pour prévenir les nausées et les vomissements liés à l’administration épidurale de morphine comme analgésie post-césarienne.Méthode: Cent quatre-vingt parturientes (n=45 dans chacun des quatre groupes), nécessitant une analgésie épidurale post-césarienne avec morphine, ont participé à l’étude randomisée et à double insu contre placebo. Elles ont reçu, à la fin de l’opération, soit 10 mg, 5 mg ou 2,5 mg de dexaméthasone, soit une solution saléeiv. Toutes ont reçu 3 mg de morphine comme analgésie postopératoire épidurale. L’incidence des NVPO et des effets secondaires a été évaluée pendant vingt-quatre heures après l’accouchement par des infirmières impartiales diplômées en anesthésie.Résultats: Les parturientes qui ont reçu 10 mg ou 5 mg de dexaméthasone ont présenté des caractéristiques différentes de celles qui ont reçu le placebo pour les paramètres suivants: l’incidence totale de nausées et de vomissements, l’incidence d’épisodes de vomissements >4, le nombre de patientes qui ont eu besoin d’antiémétiques de secours et le nombre total de parturientes sans vomissements et/ou sans médication antiémétique (P<0,05àP<0,01). Aucune différence significative n’était liée aux doses de 10 mg et de 5 mg de dexaméthasone. La dexaméthasone à 2,5 mg n’a été que partiellement efficace.Conclusion: La dexaméthasone, administrée en doses de 5 mgiv, est suggérée comme la dose efficace minimale pour prévenir les nausées et les vomissements associés à l’analgésie épidurale post-césarienne avec de la morphine.

Prophylacticiv ondansetron reduces nausea, vomiting and pruritus following epidural morphine for postoperative pain control

PurposeTo evaluate the prophylactic effect of ondansetron on nausea and vomiting following epidural morphine for postoperative pain control.MethodsSeventy women (n = 35 in each group) undergoing abdominal total hysterectomy under epidural anesthesia were enrolled in this randomized, double-blinded, and placebo-controlled study. At the end of surgery, all patients received epidural morphine 3 mg for postoperative pain relief. Before morphine injection, the ondansetron group receivediv ondansetron 4 mg, whereas the placebo group received iv saline.ResultsPatients in the ondansetron group reported a lower frequency of total postoperative nausea and vomiting (22%) and lower frequency of rescue antiemetic request (12%) than those in the placebo group (52% and 39%, respectively;P < 0.05). In addition, ondansetron was associated with a reduced incidence of pruritus following epidural morphine (28% vs 58%;P < 0.05).ConclusionWe conclude that iv ondansetron 4 mg is effective in the prevention of nausea, vomiting, and pruritus following epidural morphine for postoperative pain control.RésuméObjectifÉvaluer l’effet prophylactique de l’ondansétron sur les nausées et les vomissements qui suivent l’administration péridurale de morphine analgésique postopératoire.MéthodeSoixante-dix femmes (n = 35 dans chaque groupe) devant subir une hystérectomie abdominale totale sous anesthésie péridurale ont participé à l’étude randomisée, en double aveugle et contrôlée contre placebo. À la fin de l’opération, toutes les patientes ont reçu une analgésie péridurale avec 3 mg de morphine. Avant l’injection de la morphine, 4 mg d’ondansétron iv ont été administrés dans le groupe ondansétron et une solution saline dans le groupe placebo.RésultatsLes patientes ayant reçu l’ondansétron ont présenté une plus faible fréquence de nausées et de vomissements postopératoires totaux (22 %) et ont demandé moins d’antiémétique de secours (12 %), comparées aux femmes du groupe placebo (52 % et 39 %, respectivement; P < 0,05). Aussi, l’ondansétron a été associé à une incidence réduite de prurit après l’administration péridurale de morphine (28 % vs 58%; P < 0,05).ConclusionL’administration iv de 4 mg d’ondansétron est efficace pour prévenir les nausées, les vomissements et le prurit qui suivent l’administration péridurale de morphine analgésique postopératoire.

Dexamethasone for preventing nausea and vomiting associated with epidural morphine: a dose-ranging study.

We conducted a dose-ranging study of dexamethasone for preventing nausea and vomiting within the first 24 h after the administration of epidural morphine. Two hundred twenty-five women (n = 45 in each of the five groups) undergoing simple abdominal total hysterectomy under epidural anesthesia were enrolled in this randomized, double-blind, placebo-controlled study. When the incision closure was completed, patients received IV dexamethasone, 10 mg, 5 mg, or 2.5 mg; IV droperidol 1.25 mg; or saline 2 mL. All patients received epidural morphine 3 mg for postoperative analgesia. We found that patients who received dexamethasone 5 mg or 10 mg or droperidol 1.25 mg were significantly different from those who received saline alone in the following variables: the total incidence of nausea and vomiting, the incidence of more than four vomiting episodes, the number of patients requiring rescue antiemetics, the total number of patients with no vomiting and/or no antiemetic medication (P < 0.05 to P < 0.01). The differences among dexamethasone 10 mg and 5 mg and droperidol 1.25 mg were not significant. Dexamethasone 2.5 mg was ineffective. In conclusion, because dexamethasone 5 mg was as effective as 10 mg as an antiemetic, we recommend the smaller dose for preventing nausea and vomiting associated with epidural morphine.

The prophylactic effect of tropisetron on epidural morphine-related nausea and vomiting: a comparison of dexamethasone with saline.

Tropisetron is a 5-hydroxytryptamine subtype 3 receptor antagonist that is primarily used in the prevention of chemotherapy-induced nausea and vomiting. We evaluated the prophylactic effect of tropisetron on postoperative nausea and vomiting associated with epidural morphine. Dexamethasone and saline served as controls. One-hundred twenty women (n = 40 in each of three groups) undergoing abdominal total hysterectomy under epidural anesthesia were enrolled in this randomized, double-blinded, and placebo-controlled study. At the end of surgery, Group 1 received IV tropisetron 5 mg, whereas Groups 2 and 3 received dexamethasone 5 mg and saline, respectively. We found that tropisetron did not significantly reduce the occurrence of nausea and vomiting associated with epidural morphine. Dexamethasone, however, reduced the total incidence of nausea and vomiting from 59% to 21% (P < 0.01) and the percentage of patients requiring rescue antiemetic from 38% to 13% (P < 0.05). We conclude that IV tropisetron 5 mg did not prevent the occurrence of postoperative nausea and vomiting associated with epidural morphine. IV dexamethasone 5 mg was effective for this purpose.

Haloperidol Plus Ondansetron Prevents Postoperative Nausea and Vomiting in Patients Undergoing Laparoscopic Cholecystectomy

BACKGROUND A combination of antiemetic drugs could be an effective method to prevent severe postoperative nausea and vomiting (PONV). Therefore, we examined the prophylactic effect of haloperidol plus ondansetron on PONV. METHODS We enrolled 210 patients (n = 70 in each of 3 groups) undergoing elective laparoscopic cholecystectomy for this randomized double-blind study. Patients were randomized to intravenous saline 2 mL and intramuscular haloperidol 2 mg (Group H), intravenous ondansetron 4 mg and intramuscular saline 2 mL (Group O), or intravenous ondansetron 4 mg and intramuscular haloperidol 2 mg (Group H+O), administered after induction of general anesthesia and 30 minutes before the conclusion of surgery. We compared the complete response rates, incidence of PONV, nausea scores, the need for rescue medication, patient satisfaction scores, and adverse events during the 24-hour study. RESULTS The H+O group had the highest complete response rate to treatment (79%) compared with group H (61%) and group O (62%) (p < 0.05 for both). Patient satisfaction scores were significantly higher in the H+O group (8.3 +/- 1.8) than in the H (7.0 +/- 2.4) and O (7.2 +/- 2.5) groups (p < 0.05 for both). In addition, nausea scores were significantly lower in the H+O group (1.2 +/- 2.6) than in the H (2.5 +/- 3.3) and O (2.2 +/- 3.1) groups (p < 0.05 for both). CONCLUSION We conclude that the combination of prophylactic haloperidol (2 mg) plus ondansetron (4 mg) provides a higher complete response rate and greater patient satisfaction after laparoscopic cholecystectomy than either drug used alone.