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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 31  |  Issue : 3  |  Page : 174-177

A comparative study between propofol and propofol plus dexamethasone as antiemetic during cesarean section under spinal anesthesia


Department of Anaesthesiology, Regional Institute of Medical Sciences, Imphal, Manipur, India

Date of Web Publication17-Aug-2017

Correspondence Address:
N Ratan Singh
Department of Anaesthesiology, Regional Institute of Medical Sciences, Imphal, Manipur
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-4958.211102

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  Abstract 


Background: Some of the common problems observed during cesarean section under regional anesthesia are nausea, retching, and vomiting. In this study, the effects of subhypnotic dose of propofol (1.0 mg/kg/h) alone and a combination of propofol with dexamethasone (8 mg) were compared for prevention of nausea and vomiting during cesarean delivery under spinal anesthesia.
Materials and Methods: A randomized, double-blind study was carried out on 100 parturients by allocating them into two groups using computer-generated randomization method. Group I (n = 50) received intravenous (IV) saline and Group II (n = 50) received (IV) dexamethasone 8 mg respectively, followed by continuous infusion of propofol (1.0 mg/kg/h). Intraoperative emetic episodes were observed, and safety assessments were performed by an investigator, and propofol infusion was stopped at the end of surgery. Chi-square test and independent Student's t-test were used for statistical analysis wherever appropriate and P < 0.05 was considered significant.
Results: The maternal demographics and operative management were comparable in the two groups. The incidence of nausea, retching, and vomiting in the intraoperative, postdelivery period were: Group I: Versus Group II: Nausea 26% (13/50) versus 8% (4/50) P = 0.014; retching 24% (12/50) versus 4% (2/50) P = 0.004; vomiting 20% (10/50) versus 4% (2/50) P = 0.014, respectively. No clinically significant adverse events were observed in both groups.
Conclusion: The sub hypnotic-dose propofol 1 mg/kg/h combined with dexamethasone 8 mg was more effective than propofol alone for reducing the incidence of intraoperative emetic symptoms in parturient undergoing cesarean delivery under spinal anesthesia.

Keywords: Antiemetic, cesarean delivery, dexamethasone, propofol, spinal anesthesia


How to cite this article:
Nado H, Singh N R, Laithangbam P, Shanti Devi R K, Alemwapang O, Gangmei FL. A comparative study between propofol and propofol plus dexamethasone as antiemetic during cesarean section under spinal anesthesia. J Med Soc 2017;31:174-7

How to cite this URL:
Nado H, Singh N R, Laithangbam P, Shanti Devi R K, Alemwapang O, Gangmei FL. A comparative study between propofol and propofol plus dexamethasone as antiemetic during cesarean section under spinal anesthesia. J Med Soc [serial online] 2017 [cited 2019 Oct 20];31:174-7. Available from: http://www.jmedsoc.org/text.asp?2017/31/3/174/211102




  Introduction Top


Regional anesthesia has been shown to be effective, safe, and the anesthetic of choice for elective and emergency cesarean sections.[1] The incidence of nausea and vomiting during and immediately after cesarean delivery with spinal anesthesia is common and is an annoying problem to all concerned.[2],[3] Despite major advances in spinal, epidural, and combined spinal-epidural anesthesia techniques, the incidence of intraoperative nausea and vomiting (IONV) is more than 66%.[1],[2]

Nausea is defined as a subjective unpleasant sensation associated with awareness and urges to vomit. Retching is defined as labored spasmodic rhythmic contraction of respiratory muscles including diaphragm, chest wall, and abdominal muscles without expulsion of the gastric content. Vomiting is defined as forceful expulsion of the gastric content and is brought about by powerful sustained contraction of the abdominal muscles, descent of diaphragm and opening of the gastric cardia.[4]

In an attempt to decrease the incidence of nausea-vomiting in these patients, a number of antiemetics have been studied.[5] However, most of the currently used antiemetics (antihistamine, butyrophenones, dopamine receptor antagonists) have undesirable adverse effects, such as excessive sedation, hypotension, dry mouth, dysphoria, restlessness, and extrapyramidal symptoms.[4] The condition remains a challenge for anesthesiologists.

Propofol has been used successfully at sub-hypnotic doses of 0.5–1.0 mg/kg/h for the prevention and treatment of chemotherapy-induced emesis[3],[6] and to treat postoperative nausea and vomiting (PONV) without any side effects.[7],[8] Many studies have been conducted to find out the most effective dosing of propofol. In one study, it has been shown that propofol 1.0 mg/kg/h is the minimum effective sub-hypnotic dose for reducing emetic symptoms during cesarean section, and increasing the dose to 2.0 mg/kg/h provides no further benefit.[9] On the other hand, preoperative dexamethasone has been shown to reduce PONV when given in a dose of 8 mg 90 min before laparoscopic cholecystectomy.[10]

As a continuation for a search of the most effective antiemetic, in this study, we have compared intravenous (IV) propofol at 1 mg/kg/h with propofol 1 mg/kg/h combined with dexamethasone 8 mg for the prevention of nausea and vomiting during cesarean delivery under spinal anesthesia.


  Materials and Methods Top


After obtaining approval of the institutional ethics committee and informed consent from the patients concerned, this study was conducted on parturients with American Society of Anesthesiologists (ASA) physical Status I or II[11] aged between 18 and 40 years undergoing cesarean section under spinal anesthesia.

Parturients with hypotension or hypertension, asthma, diabetes mellitus, cardiac disease, coagulopathy, neuropathy, renal or liver diseases, local infection at the site of spinal needle entry or septicemia, exteriorization of the uterus; fetal prematurity (<36 weeks gestation) and also those who have received drugs with antiemetic properties within 24 h before surgery were excluded from the study.

Based on a study by Fujii et al.,[12] the sample size for our study was 50 in each group, assuming the α value of 0.05 and β value of 0.2 (power of study = 1−β = 0.8, i.e., 80%). Patients were allocated to two groups using computer-generated randomization method. The study drugs were prepared in 2 ml syringes wrapped with paper by a colleague not involved in the study containing, either normal saline or dexamethasone in Group I and II, respectively. Group I (n = 50) received IV saline and Group II (n = 50) received IV dexamethasone 8 mg respectively, followed by continuous infusion of propofol (1.0 mg/kg/h) in both groups through a “T” connector attached directly to the venous cannula using a programmable syringe pump immediately after clamping of the umbilical cord. The administration of propofol was stopped at the end of surgery.

On arrival in the operation theater, routine monitoring devices were placed including noninvasive arterial blood pressure, pulse rate, electrocardiogram, and pulse oximetry. A suitable peripheral vein was cannulated for administration of study drugs and another for IV fluids. All patients were premedicated with IV ranitidine 50 mg 1 h before the surgery.

After positioning the patient in left lateral position, spinal anesthesia was performed at the level of L3–L4 space through a midline approach using a 25-gauge Quincke spinal needle with the bevel pointing cephalad. Then 0.5% hyperbaric bupivacaine (2 ml) was injected intrathecally in all patients. After spinal anesthesia, patients was kept in supine position, and immediately the patient's systolic blood pressure and diastolic blood pressure were recorded, and thereafter every 5 min till 20 min then every 10 min till the end of the surgery, along with heart rate and peripheral oxygen saturation. The level of anesthesia was assessed by pinprick before surgical incision. The upper sensory dermatome level of the block (T4, nipple) was assessed and confirmed.

Ramsay sedation score was recorded every 10 min throughout intraoperative period.[13] The findings were analyzed using Statistical package for social sciences for windows (SPSS) version 21.0 (Armonk, NY, IBM corp) Windows-based version 21; Chi-square test and independent Student's t-test were used for analysis wherever appropriate and P < 0.05 was considered as statistically significant.


  Results Top


The groups were comparable with respect to maternal demographics [Table 1]. No statistically significant difference was observed between the two groups (P > 0.05). The level of analgesia was sufficient for cesarean delivery because none of the patients had a sensory level below T4 (nipple) as tested by pinprick bilaterally in the mid clavicular line. Total dose of mephentermine for the treatment of hypotension was similar between the groups, and no significant difference was found between the two groups (P = 0.122). The number of parturients with emetic symptoms in the intraoperative, postdelivery period was lower in Group II compared to Group I: Nausea 8% (4/50) versus 26% (13/50) P = 0.014; retching 4% (2/50) versus 24% (12/50) P = 0.004; vomiting 4% (2/50) versus 20% (10/50) P = 0.014 respectively [Table 2]. [Figure 1] shows the Ramsay sedation score in the two groups and no significant difference was found between the two groups (P = 0.143).
Table 1: Demographic profile

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Table 2: Nausea, retching, and vomiting

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Figure 1: Comparison of Ramsay sedation score

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  Discussion Top


The demographic profile in terms of age, weight, and ASA between the two study groups were comparable, and no statistically significant difference was observed between the two groups (P > 0.05). Datta et al.[14] in their study concluded that in cesarean delivery, the emetic symptoms are influenced by maternal hypotension. Hypotension may cause brainstem hypoperfusion and thus trigger the vomiting center to induce emesis.[15] In this study, intraoperative hypotension was prevented by left uterine displacement, rapid fluid infusion, and administration of IV mephentermine.

Numazaki et al.[16] concluded that subhypnotic dose of propofol 1.0 mg/kg/h reduces the incidence of postdelivery nausea and vomiting in parturients undergoing cesarean delivery without excessive sedation, and is a more effective antiemetic than traditional antiemetics (droperidol and metoclopramide) for reducing the severity of nausea.[17] The exact mechanism by which propofol inhibits intraoperative, postdelivery emesis is unknown, but there are possibilities that propofol possesses direct antiemetic properties according to Smith et al.[18] and that reduced levels of serotonin in the area postrema are related to these antiemetic properties as concluded by Cechetto et al.[19] However, Hvarfner et al.[20] suggested that the release of excitatory amino acids such as glutamate and aspartate may also be involved.

Vomiting was observed by Gan et al.[21] in the propofol group in 19%, which is similar to the findings of our study (20%), thereby suggesting propofol has a direct depressant effects on the chemoreceptor trigger zone, the vagal nuclei, and other centers implicated in nausea and vomiting.

Our results are almost similar with those of Fujii et al.[12] where IV placebo (intralipid), propofol 0.5 mg/kg, or propofol 0.5 mg/kg plus dexamethasone 8 mg was used at the end of surgical procedure for prevention of PONV. The incidence of patients experiencing PONV during the first 24 h after anesthesia was 33% with propofol (P = 0.003), 15% with propofol plus dexamethasone (P = 0.001) when compared to 65% with placebo. They concluded that propofol 0.5 mg/kg combined with dexamethasone 8 mg was more effective than propofol alone for prevention of PONV in laparoscopic cholecystectomy during the first 24 h after anesthesia. In our study, the incidence of IONV in the two groups was 35% in the propofol group alone, and 8% when combined with dexamethasone. Better result with propofol plus dexamethasone combination in our study could be due to the differences in the study design and differences in the type of surgery and anesthesia.

The precise mechanism by which dexamethasone increases the effectiveness of propofol is not known. Dexamethasone lacks the sedative, dysphoric, and extrapyramidal signs associated with traditional antiemetics such as droperidol and metoclopramide. In a review by Bisgaard.[22] dexamethasone was reported to be effective for the treatment of pain after laparoscopic cholecystectomy. Postoperative pain and supplementary opioid requirements were reduced by approximately 50% in patients receiving dexamethasone. Jaffarpour et al.[23] concluded that prophylactic use of 8 mg dexamethasone is effective for reducing emetic symptoms and the analgesic requirements in women undergoing cesarean section under spinal anesthesia.


  Conclusion Top


It can be concluded from this study that IV infusion of propofol 1 mg/kg/h plus dexamethasone 8 mg after clamping of cord in the cesarean section under spinal anesthesia, reduced the incidence of nausea, retching, and vomiting more than propofol 1 mg/kg/h alone.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Balki M, Carvalho A. Intraoperative nausea and vomiting during cesarean section under regional anesthesia. Int J Obstet Anesth 2005;14:230-41.  Back to cited text no. 1
    
2.
Santos A, Datta S. Prophylactic use of droperidol for control of nausea and vomiting during spinal anesthesia for cesarean section. Anesth Analg 1984;63:85-7.  Back to cited text no. 2
    
3.
Borgeat A, Wilder-Smith OH, Wilder-Smith CH, Forni M, Suter PM. Propofol improves patient comfort during cisplatin chemotherapy. A pilot study. Oncology 1993;50:456-9.  Back to cited text no. 3
    
4.
Watcha MF, White PF. Postoperative nausea and vomiting. Its etiology, treatment, and prevention. Anesthesiology 1992;77:162-84.  Back to cited text no. 4
    
5.
Rudra A, Halder R, Sen A. Efficacy of low dose propofol for control of emetic episodes during caesarian delivery with subarachnoid block anaesthesia. Indian J Anaesth 2004;48:31-4.  Back to cited text no. 5
  [Full text]  
6.
Scher CS, Amar D, McDowall RH, Barst SM. Use of propofol for the prevention of chemotherapy-induced nausea and emesis in oncology patients. Can J Anaesth 1992;39:170-2.  Back to cited text no. 6
    
7.
Borgeat A, Wilder-Smith OH, Saiah M, Rifat K. Subhypnotic doses of propofol possess direct antiemetic properties. Anesth Analg 1992;74:539-41.  Back to cited text no. 7
    
8.
Schulman SR, Rockett CB, Canada AT, Glass PS. Long-term propofol infusion for refractory postoperative nausea: A case report with quantitative propofol analysis. Anesth Analg 1995;80:636-7.  Back to cited text no. 8
    
9.
Fujii Y, Numazaki M. Dose-range effects of propofol for reducing emetic symptoms during cesarean delivery. Obstet Gynecol 2002;99:75-9.  Back to cited text no. 9
    
10.
Bisgaard T, Klarskov B, Kehlet H, Rosenberg J. Preoperative dexamethasone improves surgical outcome after laparoscopic cholecystectomy: A randomized double-blind placebo-controlled trial. Ann Surg 2003;238:651-60.  Back to cited text no. 10
    
11.
Fischer SP. Pre-operative evaluation. In: Lars IE, Lee AF, Jeanie PW, WilliamL Y, Miller RD, editors. Miller's Anaesthesia. 7th ed. Philadelphia: Elsevier Churchill Livingstone; 2010. p. 1001-66.  Back to cited text no. 11
    
12.
Fujii Y, Nakayama M. Prevention of PONV with a small dose of propofol alone and combined with dexamethasone in patients undergoing laparoscopic cholecystectomy. Clin Ther 2004;8:1286-91.  Back to cited text no. 12
    
13.
Ramsay MA, Savege TM, Simpson BR, Goodwin R. Controlled sedation with alphaxalone-alphadolone. Br Med J 1974;2:656-9.  Back to cited text no. 13
    
14.
Datta S, Alper MH, Ostheimer GW, Weiss JB. Method of ephedrine administration and nausea and hypotension during spinal anesthesia for cesarean section. Anesthesiology 1982;56:68-70.  Back to cited text no. 14
    
15.
Ratra CK, Badola RP, Bhargava KP. A study of factors concerned in emesis during spinal anaesthesia. Br J Anaesth 1972;44:1208-11.  Back to cited text no. 15
    
16.
Numazaki M, Fujii Y. Subhypnotic dose of propofol for the prevention of nausea and vomiting during spinal anaesthesia for caesarean section. Anaesth Intensive Care 2000;28:262-5.  Back to cited text no. 16
    
17.
Numazaki M, Fujii Y. Reduction of emetic symptoms during cesarean delivery with antiemetics: Propofol at subhypnotic dose versus traditional antiemetics. J Clin Anesth 2003;15:423-7.  Back to cited text no. 17
    
18.
Smith I, White PF, Nathanson M, Gouldson R. Propofol. An update on its clinical use. Anesthesiology 1994;81:1005-43.  Back to cited text no. 18
    
19.
Cechetto DF, Diab T, Gibson CJ, Gelb AW. The effects of propofol in the area postrema of rats. Anesth Analg 2001;92:934-42.  Back to cited text no. 19
    
20.
Hvarfner A, Hammas B, Thörn SE, Wattwil M. The influence of propofol on vomiting induced by apomorphine. Anesth Analg 1995;80:967-9.  Back to cited text no. 20
    
21.
Gan TJ, Ginsberg B, Grant AP, Glass PS. Double-blind, randomized comparison of ondansetron and intraoperative propofol to prevent postoperative nausea and vomiting. Anesthesiology 1996;85:1036-42.  Back to cited text no. 21
    
22.
Bisgaard T. Analgesic treatment after laparoscopic cholecystectomy: A critical assessment of the evidence. Anesthesiology 2006;104:835-46.  Back to cited text no. 22
    
23.
Jaffarpour M, Khani A, Dyrekvandmoghadam A, Khajavikhan J, Saadipour KH. The effect of dexamethasone on nausea, vomiting and pain in parturients undergoing caesarean delivery. J Clin Diagn Res 2008;3:854-8.  Back to cited text no. 23
    


    Figures

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    Tables

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