Dexamethasone for prophylaxis of nausea and vomiting after epidural morphine for post-Caesarean section analgesia: comparison of droperidol and saline
2000; Elsevier BV; Volume: 85; Issue: 6 Linguagem: Inglês
10.1093/bja/85.6.865
ISSN1471-6771
AutoresJann‐Inn Tzeng, J.J. Wang, Shung‐Tai Ho, Chao-Shun Tang, Y.C. Liu, S.C. Lee,
Tópico(s)Pain Management and Opioid Use
ResumoWe have evaluated the prophylactic effect of i.v. dexamethasone 8 mg in preventing nausea and vomiting during epidural morphine for post-Caesarean section analgesia. Droperidol 1.25 mg and saline served as the control. We studied 120 parturients (n=40 in each group) receiving epidural morphine for post-Caesarean section analgesia, in a randomized, double-blind, placebo-controlled study. All parturients received epidural morphine 3 mg. Both dexamethasone and droperidol significantly decreased the total incidence of nausea and vomiting compared with saline, with incidences of 18, 21 and 51% for the three treatments respectively (P<0.01 and P<0.05 respectively). Parturients who received droperidol reported a more frequent incidence of restlessness (16%) than those who received dexamethasone (P<0.05). We have evaluated the prophylactic effect of i.v. dexamethasone 8 mg in preventing nausea and vomiting during epidural morphine for post-Caesarean section analgesia. Droperidol 1.25 mg and saline served as the control. We studied 120 parturients (n=40 in each group) receiving epidural morphine for post-Caesarean section analgesia, in a randomized, double-blind, placebo-controlled study. All parturients received epidural morphine 3 mg. Both dexamethasone and droperidol significantly decreased the total incidence of nausea and vomiting compared with saline, with incidences of 18, 21 and 51% for the three treatments respectively (P<0.01 and P<0.05 respectively). Parturients who received droperidol reported a more frequent incidence of restlessness (16%) than those who received dexamethasone (P<0.05). Epidural morphine has a potent and long-acting analgesic effect on postoperative pain.1Cousins MJ Mather LE Intrathecal and epidural administration of opioids.Anesthesiology. 1984; 61: 276-310Crossref PubMed Scopus (943) Google Scholar, 2Kundra P Gurnani A Bhattacharya A Preemptive epidural morphine for postoperative pain relief after lumbar laminectomy.Anesth Analg. 1997; 85: 135-138PubMed Google Scholar, 3NganKee WD Lam KK Chen PP Gin T Epidural meperidine after cesarean section. A dose–response study.Anesthesiology. 1996; 85: 289-294Crossref PubMed Scopus (21) Google Scholar, 4Grass JA Sakima NT Schmidt R Michitsch R Zuckerman RL Harris AP A randomized, double-blind, dose–response comparison of epidural fentanyl versus sufentanil analgesia after cesarean section.Anesth Analg. 1997; 85: 365-371PubMed Google Scholar, 5Zakowski MJ Ramanathan S Turndorf H A two-dose epidural morphine regimen for cesarean section patients: therapeutic efficacy.Acta Anaesthesiol Scand. 1992; 36: 698-701Crossref PubMed Scopus (8) Google Scholar It is very convenient for clinical use and is widely accepted for analgesia after Caesarean section.5Zakowski MJ Ramanathan S Turndorf H A two-dose epidural morphine regimen for cesarean section patients: therapeutic efficacy.Acta Anaesthesiol Scand. 1992; 36: 698-701Crossref PubMed Scopus (8) Google Scholar, 6Sanansilp V Areewatana S Tonsukchai N Droperidol and the side effects of epidural morphine after cesarean section.Anesth Analg. 1998; 86: 532-537Crossref PubMed Google Scholar, 7Fuller JG McMorland GH Douglas MJ Palmer L Epidural morphine for analgesia after cesarean section: a report of 4880 patients.Can J Anaesth. 1990; 37: 636-640Crossref PubMed Scopus (132) Google Scholar, 8Stenseth R Sellevold O Breivik H Epidural morphine for postoperative pain: experience with 1085 patients.Acta Anaesthesiol Scand. 1985; 29: 148-156Crossref PubMed Scopus (180) Google Scholar However, high incidences of nausea and vomiting (30–65%) have been reported.9Kotelko DM Rottman RL Wright WC Stone JJ Yamashiro AY Rosenblatt RM Transdermal scopolamine decreases nausea and vomiting following cesarean section in patients receiving epidural morphine.Anesthesiology. 1989; 71: 675-678Crossref PubMed Scopus (61) Google Scholar, 10Chaney MA Side effects of intrathecal and epidural opioids.Can J Anaesth. 1995; 42: 891-903Crossref PubMed Scopus (459) Google Scholar, 11Wang JJ Ho ST Liu YH Ho CM Liu K Chia YY Dexamethasone decreases epidural morphine-related nausea and vomiting.Anesth Analg. 1999; 89: 117-120PubMed Google Scholar Among the antiemetics used currently, 5-HT3 antagonists (e.g. ondansetron, granisetron) possess good efficacy, but cost limits their use.12Italian Group for Antiemetic Research Dexamethasone, granisetron, or both for the prevention of nausea and vomiting during chemotherapy for cancer.N Engl J Med. 1995; 332: 1-5Crossref PubMed Scopus (293) Google Scholar, 13Italian Group for Antiemetic Research Ondansetron versus metoclopramide, both combined with dexamethasone, in the prevention of cisplatin-induced delayed emesis.J Clin Oncol. 1997; 15: 124-130Crossref PubMed Scopus (104) Google Scholar, 14López-Olaondo LL Carrascosa F Pueyo FJ Monedero P Busto N Sáez A Combination of ondansetron and dexamethasone in the prophylaxis of postoperative nausea and vomiting.Br J Anaesth. 1996; 76: 835-840Crossref PubMed Scopus (133) Google Scholar, 15Fujii Y Tanaka H Toyooka H Granisetron–dexamethasone combination reduces postoperative nausea and vomiting.Can J Anaesth. 1995; 42: 387-390Crossref PubMed Scopus (48) Google Scholar Dopamine receptor antagonists (e.g. droperidol, prochorperazine, metoclopramide) are commonly used but are associated with a variety of extrapyramidal symptoms.16Jiménez-Jiménez FJ Garcia-Ruiz PJ Molina JA Drug-induced movement disorder.Drug Safety. 1997; 16: 180-204Crossref PubMed Scopus (129) Google Scholar 17Wang JJ Ho ST Lee SC Liu YC Liu YH Liao YC The prophylactic effect of dexamethasone on postoperative nausea and vomiting in women undergoing thyroidectomy: a comparison of droperidol with saline.Anesth Analg. 1999; 89: 200-203PubMed Google Scholar Antihistaminic and anticholinergic drugs (e.g. scopolamine, hydroxyzine, promethazine) are also effective, but excessive sedation and tachycardia may occur.9Kotelko DM Rottman RL Wright WC Stone JJ Yamashiro AY Rosenblatt RM Transdermal scopolamine decreases nausea and vomiting following cesarean section in patients receiving epidural morphine.Anesthesiology. 1989; 71: 675-678Crossref PubMed Scopus (61) Google Scholar 18Brunton LL Drugs affecting gastrointestinal function.in: Hardman JG Limbird LE Molinoff PB Ruddon RW Gillman AG Goodman and Gillman's The Pharmacological Basis of Therapeutics. 9th edn. McGraw-Hill, New York1996: 899-936Google Scholar 19Watcha MF White PF Postoperative nausea and vomiting. Its etiology, treatment and prevention.Anesthesiology. 1992; 77: 162-184Crossref PubMed Scopus (1483) Google Scholar Dexamethasone is an effective antiemetic after single-dose administration. 11Wang JJ Ho ST Liu YH Ho CM Liu K Chia YY Dexamethasone decreases epidural morphine-related nausea and vomiting.Anesth Analg. 1999; 89: 117-120PubMed Google Scholar, 12Italian Group for Antiemetic Research Dexamethasone, granisetron, or both for the prevention of nausea and vomiting during chemotherapy for cancer.N Engl J Med. 1995; 332: 1-5Crossref PubMed Scopus (293) Google Scholar, 13Italian Group for Antiemetic Research Ondansetron versus metoclopramide, both combined with dexamethasone, in the prevention of cisplatin-induced delayed emesis.J Clin Oncol. 1997; 15: 124-130Crossref PubMed Scopus (104) Google Scholar, 14López-Olaondo LL Carrascosa F Pueyo FJ Monedero P Busto N Sáez A Combination of ondansetron and dexamethasone in the prophylaxis of postoperative nausea and vomiting.Br J Anaesth. 1996; 76: 835-840Crossref PubMed Scopus (133) Google Scholar, 15Fujii Y Tanaka H Toyooka H Granisetron–dexamethasone combination reduces postoperative nausea and vomiting.Can J Anaesth. 1995; 42: 387-390Crossref PubMed Scopus (48) Google Scholar 20Splinter WM Robert DJ Dexamethasone decreases vomiting by children after tonsillectomy.Anesth Analg. 1996; 83: 913-916Crossref PubMed Google Scholar, 21Splinter WM Robert DJ Prophylaxis for vomiting by children after tonsillectomy: dexamethasone versus perphenazine.Anesth Analg. 1997; 85: 534-537Crossref PubMed Google Scholar, 22Wang JJ Ho ST Liu YH et al.Dexamethasone reduces nausea and vomiting after laparoscopic cholecystectomy.Br J Anaesth. 1999; 83: 772-775Crossref PubMed Scopus (153) Google Scholar, 23Fujii Y Tanaka H Toyooka H The effects of dexamethasone on antiemetics in female patients undergoing gynecologic surgery.Anesth Analg. 1997; 85: 913-917Crossref PubMed Google Scholar It is effective in preventing chemotherapy-related emesis and postoperative nausea and vomiting (PONV).12Italian Group for Antiemetic Research Dexamethasone, granisetron, or both for the prevention of nausea and vomiting during chemotherapy for cancer.N Engl J Med. 1995; 332: 1-5Crossref PubMed Scopus (293) Google Scholar, 13Italian Group for Antiemetic Research Ondansetron versus metoclopramide, both combined with dexamethasone, in the prevention of cisplatin-induced delayed emesis.J Clin Oncol. 1997; 15: 124-130Crossref PubMed Scopus (104) Google Scholar, 14López-Olaondo LL Carrascosa F Pueyo FJ Monedero P Busto N Sáez A Combination of ondansetron and dexamethasone in the prophylaxis of postoperative nausea and vomiting.Br J Anaesth. 1996; 76: 835-840Crossref PubMed Scopus (133) Google Scholar, 15Fujii Y Tanaka H Toyooka H Granisetron–dexamethasone combination reduces postoperative nausea and vomiting.Can J Anaesth. 1995; 42: 387-390Crossref PubMed Scopus (48) Google Scholar 20Splinter WM Robert DJ Dexamethasone decreases vomiting by children after tonsillectomy.Anesth Analg. 1996; 83: 913-916Crossref PubMed Google Scholar, 21Splinter WM Robert DJ Prophylaxis for vomiting by children after tonsillectomy: dexamethasone versus perphenazine.Anesth Analg. 1997; 85: 534-537Crossref PubMed Google Scholar, 22Wang JJ Ho ST Liu YH et al.Dexamethasone reduces nausea and vomiting after laparoscopic cholecystectomy.Br J Anaesth. 1999; 83: 772-775Crossref PubMed Scopus (153) Google Scholar, 23Fujii Y Tanaka H Toyooka H The effects of dexamethasone on antiemetics in female patients undergoing gynecologic surgery.Anesth Analg. 1997; 85: 913-917Crossref PubMed Google Scholar Recently, it has also been found to be effective in preventing nausea and vomiting related to epidural morphine in patients undergoing abdominal hysterectomy.11Wang JJ Ho ST Liu YH Ho CM Liu K Chia YY Dexamethasone decreases epidural morphine-related nausea and vomiting.Anesth Analg. 1999; 89: 117-120PubMed Google Scholar We conducted a randomized, double-blinded and placebo-controlled study to evaluate whether dexamethasone was also effective in preventing nausea and vomiting after epidural morphine for post-Caesarean section analgesia. The protocol was approved by the Hospital Committee for Human Investigation and informed consent was obtained from each parturient. One hundred and twenty parturients (ASA I–II; 20–35 yr) scheduled for elective Caesarean section under epidural anaesthesia were enrolled in this randomized, double-blind, placebo-controlled study. No premedication was given. Surgical analgesia to T4 dermatome level was provided by a dose of 2% lignocaine 15–18 ml (with 1:100 000 epinephrine), followed by intermittent small-dose injections of 2% lignocaine (with epinephrine) as necessary through an epidural catheter in the L3–4 or L4–5 interspace. Lactated Ringer's solution 500 ml was given i.v. before surgery. After delivery of the baby, 10 units of i.v. oxytocin and 0.2 mg of i.m. ergonovine were given to all parturients. Estimated fluid deficit and maintenance requirements were replaced with lactated Ringer's solution i.v. During surgery, i.v. midazolam 2.5 mg was given for sedation after delivery of the baby; no supplementary analgesic was given. Before surgery, a randomization table was used to assign parturients to one of three groups (n=40 for each group). At the end of surgery, the dexamethasone group received i.v. dexamethasone 8 mg (2 ml), the droperidol group received i.v. droperidol 1.25 mg (2 ml) and the saline group received i.v. saline (2 ml). One minute later, all parturients received 3 mg of preservative-free morphine in 10 ml of normal saline through the epidural catheter for postoperative analgesia. The randomization process and the identity of the study drugs were blinded from the parturients, the anaesthetists during surgery and the investigators who collected the postoperative data. The incidences of nausea and vomiting were recorded for 24 h. Nausea was defined as a subjectively unpleasant sensation associated with awareness of the urge to vomit; vomiting was the forceful expulsion of gastric contents from the mouth. Nausea and vomiting were evaluated on a 3-point ordinal scale (0=none, 1=nausea, 2=vomiting). The total incidence of nausea and vomiting was calculated. Metoclopramide 10 mg i.v. was available when vomiting occurred or on request. The proportion of parturients requiring rescue antiemetic in each group was recorded. Pain intensity was assessed with a 10-cm visual analogue scale (VAS; 0=no pain, 10=most severe pain) and was recorded between 8:00 a.m. and 10:00 p.m. If parturients requested rescue analgesia for pain control, i.m. diclofenac 75 mg was available. Pruritus was assessed on a 3-point ordinal scale (0=none, 1=pruritus but only in a small area of the body, 2=generalized pruritus). Pruritus was treated with i.m. diphenhydramine (20 mg every 4 h as needed). Restlessness was also evaluated;16Jiménez-Jiménez FJ Garcia-Ruiz PJ Molina JA Drug-induced movement disorder.Drug Safety. 1997; 16: 180-204Crossref PubMed Scopus (129) Google Scholar it was defined as a sensation of nervousness with an inability to keep still. Restlessness was treated with i.m. diphenhydramine 20 mg. The occurrence of any side-effect accompanying dexamethasone usage, such as wound infection or delayed wound healing, was recorded. Sample size was predetermined.24Lerman J Study design in clinical research: sample size estimation and power analysis.Can J Anaesth. 1996; 43: 184-191Crossref PubMed Scopus (126) Google Scholar We expected a 30% difference among groups in the proportion of parturients requiring rescue antiemetic for nausea and/or vomiting.9Kotelko DM Rottman RL Wright WC Stone JJ Yamashiro AY Rosenblatt RM Transdermal scopolamine decreases nausea and vomiting following cesarean section in patients receiving epidural morphine.Anesthesiology. 1989; 71: 675-678Crossref PubMed Scopus (61) Google Scholar, 10Chaney MA Side effects of intrathecal and epidural opioids.Can J Anaesth. 1995; 42: 891-903Crossref PubMed Scopus (459) Google Scholar, 11Wang JJ Ho ST Liu YH Ho CM Liu K Chia YY Dexamethasone decreases epidural morphine-related nausea and vomiting.Anesth Analg. 1999; 89: 117-120PubMed Google Scholar The α error was set at 0.05 (two-sided) and the β error at 0.10. The analysis showed that 37 parturients per group would be sufficient.24Lerman J Study design in clinical research: sample size estimation and power analysis.Can J Anaesth. 1996; 43: 184-191Crossref PubMed Scopus (126) Google Scholar A series of one-way analyses of variance were conducted to examine differences among the three groups with respect to parametric variables. If a significant difference was found, the Bonferroni t-test was used to detect the intergroup differences. The Kruskal–Wallis test was used to determine differences among the three groups with respect to non-parametric variables, and was followed by the Mann–Whitney rank-sum test for intergroup differences. Categorical variables were analysed with a series of 3×2 χ2 tests to determine differences among the three groups, followed by a 2×2 χ2 test for intergroup differences. All follow-up analyses were corrected for the number of simultaneous contrasts using Bonferroni adjustment. A P value less than 0.05 was considered significant. Of the 120 parturients enrolled, seven were withdrawn because of failure of epidural catheterization before surgery. Therefore, 113 parturients completed the trial. There was no significant difference among groups with respect to age, weight, height, parity, duration of anaesthesia and surgery, and lignocaine consumption during surgery (Table 1).Table 1Patient characteristics. Values are median (range)CharacteristicGroupDexamethasone(n=38)Droperidol(n=38)Saline(n=37)Age (yr)31 (20–35)33 (23–35)32 (21–35)Weight (kg)70 (52–86)72 (52–89)71 (51–88)Height (cm)158 (140–172)158 (143–174)157 (142–176)Parity2 (1–3)2 (1–3)2 (1–3)Duration of anaesthesia (min)64 (48–83)58 (49–84)61 (52–87)Duration of surgery (min)52 (34–69)48 (38–70)46 (38–71)Lignocaine consumption (mg)340 (300–420)320 (300–400)340 (300–420) Open table in a new tab After surgery, all parturients received epidural morphine for postoperative pain relief. During the 24-h observation period, 8 parturients in the dexamethasone group and 9 and 11 in the droperidol and saline groups respectively requested rescue analgesia (i.m. diclofenac 75 mg). The number of diclofenac injections was 10 in the dexamethasone group, and 11 and 14 in the droperidol and saline groups respectively. The median time until rescue analgesia was 16 h in the dexamethasone group and 14 h in both the droperidol and the saline group. The differences in the above variables among groups were not significant. All parturients reported low VAS pain scores (0–3) and the differences among groups were not significant. The total incidence of nausea and vomiting was 18% in the dexamethasone group and 21% in the droperidol group, in comparison with 51% in the saline group (P<0.01 and P<0.05 respectively) (Table 2). The proportions of parturients who required rescue antiemetic (metoclopramide) were 11% in the dexamethasone group and 13% in the droperidol group, in comparison with 41% in the saline group (P<0.05) (Table 2).Table 2Incidence of side-effects related to epidural morphine and the proportion of parturients requiring rescue antiemetic. Data are numbers of patients (%) with symptoms in a 24 h observation period. *P<0.05, **P<0.01 compared with saline group, using a 3×3 χ2 test followed by a 2×2 χ2 testSide-effectGroupDexamethasone(n=38)Droperidol(n=38)Saline(n=37)Nausea/vomiting Nausea4 (11)5 (13)11 (30) Vomiting3 (8)3 (8)8 (22) Total7 (18)**8 (21)*19 (51)Patients requiringrescue antiemetic4 (11)*5 (13)*15 (41)Pruritus Pruritus but only in a small area of the body12 (32)12 (32)12 (32) Generalized pruritus5 (13)4 (11)5 (14) Total17 (45)16 (42)17 (46) Open table in a new tab The incidence of pruritus was similar among groups (45% in the dexamethasone group, 42% in the droperidol group and 46% in the saline group) (Table 2). Six parturients (16%) in the droperidol group reported restlessness. No parturient in the other two groups reported this (P<0.05). No parturient reported wound infection or delayed wound healing. In the present study we found that the total incidence of nausea and vomiting after epidural morphine was 51% when no antiemetic was given prophylactically. After pretreatment with either dexamethasone or droperidol, the total incidence of nausea and vomiting was significantly reduced. Both dexamethasone and droperidol were effective in preventing epidural morphine-related nausea and vomiting in parturients undergoing Caesarean section. However, those who received droperidol reported a higher incidence of restlessness. Dexamethasone is effective in preventing nausea and vomiting associated with chemotherapy.12Italian Group for Antiemetic Research Dexamethasone, granisetron, or both for the prevention of nausea and vomiting during chemotherapy for cancer.N Engl J Med. 1995; 332: 1-5Crossref PubMed Scopus (293) Google Scholar 13Italian Group for Antiemetic Research Ondansetron versus metoclopramide, both combined with dexamethasone, in the prevention of cisplatin-induced delayed emesis.J Clin Oncol. 1997; 15: 124-130Crossref PubMed Scopus (104) Google Scholar Recently, dexamethasone has also been reported to be effective in preventing PONV in patients undergoing tonsillectomy, thyroidectomy, cholecystectomy and hysterectomy.17Wang JJ Ho ST Lee SC Liu YC Liu YH Liao YC The prophylactic effect of dexamethasone on postoperative nausea and vomiting in women undergoing thyroidectomy: a comparison of droperidol with saline.Anesth Analg. 1999; 89: 200-203PubMed Google Scholar 20Splinter WM Robert DJ Dexamethasone decreases vomiting by children after tonsillectomy.Anesth Analg. 1996; 83: 913-916Crossref PubMed Google Scholar, 21Splinter WM Robert DJ Prophylaxis for vomiting by children after tonsillectomy: dexamethasone versus perphenazine.Anesth Analg. 1997; 85: 534-537Crossref PubMed Google Scholar, 22Wang JJ Ho ST Liu YH et al.Dexamethasone reduces nausea and vomiting after laparoscopic cholecystectomy.Br J Anaesth. 1999; 83: 772-775Crossref PubMed Scopus (153) Google Scholar, 23Fujii Y Tanaka H Toyooka H The effects of dexamethasone on antiemetics in female patients undergoing gynecologic surgery.Anesth Analg. 1997; 85: 913-917Crossref PubMed Google Scholar In a previous study, we also found that dexamethasone is effective in preventing nausea and vomiting associated with epidural morphine in patients undergoing abdominal hysterectomy.11Wang JJ Ho ST Liu YH Ho CM Liu K Chia YY Dexamethasone decreases epidural morphine-related nausea and vomiting.Anesth Analg. 1999; 89: 117-120PubMed Google Scholar Because of these data, we hypothesized that dexamethasone might also be effective in preventing nausea and vomiting after epidural morphine for analgesia after Caesarean section. The exact mechanism by which dexamethasone, a glucocorticoid, exerts an antiemetic action after epidural morphine is not known. Glucocorticoids have been shown to have various effects on the central nervous system; they regulate transmitter levels, receptor densities and neurone configuration.25Schimmer BP Parker KL Adrenocorticotropic hormone; adrenocortical steroids and their synthetic analogs; inhibitors of the synthesis and actions of adrenocortical hormones.in: Hardman JG Limbird LE Molinoff PB Ruddon RW Gillman AG Goodman and Gillman's The Pharmacological Basis of Therapeutics. 9th edn. McGraw-Hill, New York1996: 1456-1486Google Scholar 26Morimoto M Morita N Ozawa H Yokoyama K Kawata M Distribution of glucocorticoid receptor immunoreactivity and mRNA in the rat brain: an immunohistochemical and in situ hybridization study.Neurosci Res. 1996; 26: 235-269Crossref PubMed Scopus (389) Google Scholar Numerous glucocorticoid receptors are found in the nucleus of the solitary tract, the nucleus of raphe and the area postrema.26Morimoto M Morita N Ozawa H Yokoyama K Kawata M Distribution of glucocorticoid receptor immunoreactivity and mRNA in the rat brain: an immunohistochemical and in situ hybridization study.Neurosci Res. 1996; 26: 235-269Crossref PubMed Scopus (389) Google Scholar 27Funder JW Mineralcorticoid receptors and glucocorticoid receptors.Clin Endocrinol. 1996; 45: 651-656Crossref PubMed Scopus (30) Google Scholar These nuclei are well known to have significant neuronal activity in the regulation of nausea and vomiting.10Chaney MA Side effects of intrathecal and epidural opioids.Can J Anaesth. 1995; 42: 891-903Crossref PubMed Scopus (459) Google Scholar 19Watcha MF White PF Postoperative nausea and vomiting. Its etiology, treatment and prevention.Anesthesiology. 1992; 77: 162-184Crossref PubMed Scopus (1483) Google Scholar Dexamethasone may exert its antiemetic action through these nuclei. We also found that dexamethasone did not influence the efficacy of epidural morphine-related analgesia. Parturients in the three groups required similar amounts of rescue analgesic and reported similar intensities of postoperative pain. Also, i.v. dexamethasone did not influence the occurrence of pruritus related to epidural morphine for post-Caesarean section analgesia. A wide dose range of dexamethasone (8–32 mg) has been used in the management of PONV and emesis associated with chemotherapy.12Italian Group for Antiemetic Research Dexamethasone, granisetron, or both for the prevention of nausea and vomiting during chemotherapy for cancer.N Engl J Med. 1995; 332: 1-5Crossref PubMed Scopus (293) Google Scholar, 13Italian Group for Antiemetic Research Ondansetron versus metoclopramide, both combined with dexamethasone, in the prevention of cisplatin-induced delayed emesis.J Clin Oncol. 1997; 15: 124-130Crossref PubMed Scopus (104) Google Scholar, 14López-Olaondo LL Carrascosa F Pueyo FJ Monedero P Busto N Sáez A Combination of ondansetron and dexamethasone in the prophylaxis of postoperative nausea and vomiting.Br J Anaesth. 1996; 76: 835-840Crossref PubMed Scopus (133) Google Scholar, 15Fujii Y Tanaka H Toyooka H Granisetron–dexamethasone combination reduces postoperative nausea and vomiting.Can J Anaesth. 1995; 42: 387-390Crossref PubMed Scopus (48) Google Scholar 17Wang JJ Ho ST Lee SC Liu YC Liu YH Liao YC The prophylactic effect of dexamethasone on postoperative nausea and vomiting in women undergoing thyroidectomy: a comparison of droperidol with saline.Anesth Analg. 1999; 89: 200-203PubMed Google Scholar, 18Brunton LL Drugs affecting gastrointestinal function.in: Hardman JG Limbird LE Molinoff PB Ruddon RW Gillman AG Goodman and Gillman's The Pharmacological Basis of Therapeutics. 9th edn. McGraw-Hill, New York1996: 899-936Google Scholar, 19Watcha MF White PF Postoperative nausea and vomiting. Its etiology, treatment and prevention.Anesthesiology. 1992; 77: 162-184Crossref PubMed Scopus (1483) Google Scholar, 20Splinter WM Robert DJ Dexamethasone decreases vomiting by children after tonsillectomy.Anesth Analg. 1996; 83: 913-916Crossref PubMed Google Scholar, 21Splinter WM Robert DJ Prophylaxis for vomiting by children after tonsillectomy: dexamethasone versus perphenazine.Anesth Analg. 1997; 85: 534-537Crossref PubMed Google Scholar, 22Wang JJ Ho ST Liu YH et al.Dexamethasone reduces nausea and vomiting after laparoscopic cholecystectomy.Br J Anaesth. 1999; 83: 772-775Crossref PubMed Scopus (153) Google Scholar, 23Fujii Y Tanaka H Toyooka H The effects of dexamethasone on antiemetics in female patients undergoing gynecologic surgery.Anesth Analg. 1997; 85: 913-917Crossref PubMed Google Scholar A dose of 8–10 mg has been used most frequently in the prevention of PONV.17Wang JJ Ho ST Lee SC Liu YC Liu YH Liao YC The prophylactic effect of dexamethasone on postoperative nausea and vomiting in women undergoing thyroidectomy: a comparison of droperidol with saline.Anesth Analg. 1999; 89: 200-203PubMed Google Scholar 20Splinter WM Robert DJ Dexamethasone decreases vomiting by children after tonsillectomy.Anesth Analg. 1996; 83: 913-916Crossref PubMed Google Scholar 23Fujii Y Tanaka H Toyooka H The effects of dexamethasone on antiemetics in female patients undergoing gynecologic surgery.Anesth Analg. 1997; 85: 913-917Crossref PubMed Google Scholar For example, an 8 mg dose of dexamethasone was effective in the prevention of nausea and vomiting after epidural morphine in patients undergoing abdominal hysterectomy.11Wang JJ Ho ST Liu YH Ho CM Liu K Chia YY Dexamethasone decreases epidural morphine-related nausea and vomiting.Anesth Analg. 1999; 89: 117-120PubMed Google Scholar Therefore an 8 mg dose was chosen in this study. However, dose–response studies are needed to determine the optimal dose of dexamethasone. The long-term administration of corticosteroids is associated with side-effects, such as increased risk of infection, delayed wound healing, glucose intolerance and adrenal suppression. However, we were unable to find a report of these adverse effects related to a single dose of dexamethasone, and delayed wound healing or wound infection did not occur in our study. Although a single dose of dexamethasone is considered safe, further study is indicated. Droperidol also has a potent antiemetic effect.28Sniadach MS Alberts MS A comparison of the prophylactic antiemetic effect of ondansetron and droperidol on patients undergoing gynecologic laparoscopy.Anesth Analg. 1997; 85: 797-800Crossref PubMed Google Scholar 29Pandit SK Kothary SP Pandit UA Randel G Levy L Dose–response study of droperidol and metoclopramide as antiemetics for outpatient anesthesia.Anesth Analg. 1989; 68: 798-802Crossref PubMed Scopus (85) Google Scholar Previous studies have demonstrated that its antiemetic effect is equal to that of ondansetron and superior to that of metoclopramide in preventing PONV.28Sniadach MS Alberts MS A comparison of the prophylactic antiemetic effect of ondansetron and droperidol on patients undergoing gynecologic laparoscopy.Anesth Analg. 1997; 85: 797-800Crossref PubMed Google Scholar 29Pandit SK Kothary SP Pandit UA Randel G Levy L Dose–response study of droperidol and metoclopramide as antiemetics for outpatient anesthesia.Anesth Analg. 1989; 68: 798-802Crossref PubMed Scopus (85) Google Scholar The recommended dose for this purpose is 1.25 mg.29Pandit SK Kothary SP Pandit UA Randel G Levy L Dose–response study of droperidol and metoclopramide as antiemetics for outpatient anesthesia.Anesth Analg. 1989; 68: 798-802Crossref PubMed Scopus (85) Google Scholar In our study, we also found that droperidol 1.25 mg is effective in preventing nausea and vomiting related to epidural morphine for post-Caesarean section analgesia. However, droperidol is not devoid of side-effects. Restlessness, a common droperidol-related side-effect, was found in 16% parturients who received droperidol 1.25 mg in our study. Although this side-effect was relieved by the i.m. diphenhydramine, it nevertheless produced mental distress in our patients. Because dexamethasone demonstrated a significant antiemetic effect without evident adverse effects, it may be a valuable treatment for the prophylaxis of epidural morphine-related nausea and vomiting in parturients receiving Caesarean section.
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