Preventing nausea and vomiting in women undergoing regional anesthesia for cesarean section: challenges and solutions

Demilew B.C., Zurbachew N., Getachew N., Mekete G., Teshome D.

Samuel S., Kasahun B., Demeke T., Reshad S., Shemsu N., Kedir A., Achule A., Mamo T., Dendir G., Genetu S., Wolde Y.

Background: Type of anesthesia used for cesarean section can be general, spinal, or epidural. However, peripheral nerve blocks, such as the lower and upper extremity nerve blocks, can be referred to as other types of anesthesia. Spinal anesthesia is the most frequently used method because of its ease, dependability, and rapidity in attaining proper anesthesia. The purpose of this study was to determine the effects of spinal anesthesia induction position on maternal hemodynamics and the timing of hypotension. Method: A prospective observational cohort study design was employed. A simple random sampling technique was used. A total of 190 patients received spinal anesthesia, with 95 in the lateral and 95 in the sitting position in each group. The data were entered into Epi Data version 4.6 and then exported to SPSS version 26 for analysis. Independent sample t-tests and chi-square (χ 2) tests were performed. Kaplan–Meier survival analysis and log-rank test were used and P value ≤0.05 considered significant. Results: The overall incidence rates of hypotension in the lateral and sitting groups were 54.6% [95% CI, 52.3–72.1] and 73.8% [95% CI, 69.8–87.2], respectively (P = 0.025). The timing of first hypotension was 8.86 minute [95% CI, 8.690–13.272] and 15.75 minute [95% CI, 14.569–19.372] (P = 0.001) for sitting and lateral, respectively. Conclusion and recommendation: In this study, we found a significant difference between the lateral and sitting groups with different measurement parameters, such as blood pressure, intraoperative adverse events, and onset of hypotension. The incidence of hypotension, intraoperative adverse effects of spinal anesthesia, and fluid consumption were lower in the lateral groups. Nonetheless, instead of being technically challenging during spinal anesthesia induction, the lateral position results in better hemodynamics and onset of hypotension than in the sitting posture.

Gupta A.K.

Intraoperative nausea and vomiting (IONV) and postoperative nausea and vomiting (PONV) are unpleasant peripartum experiences associated with significant stressors for the obstetric patient. It is imperative to identify risk factors for IONV/PONV, take measures to reduce these factors, and administer IONV/PONV prophylaxis. Patients in whom prophylaxis is not given, or has failed, should be considered for combination therapy.

Yang M., Li S., Drzymalski D., Chen X.

Salazar-Flórez J., Arenas-Cardona L., Marhx N., López-Guerrero E., Echeverri-Rendón Á., Giraldo-Cardona L.

Kotfis K., Wojciechowska A., Zimny M., Jamioł-Milc D., Szylińska A., Kwiatkowski S., Kaim K., Dołęgowska B., Stachowska E., Zukowski M., Pankowiak M., Torbé A., Wischmeyer P.

Background: Preoperative fasting and surgery cause metabolic stress, insulin resistance with ketosis, and postoperative nausea and vomiting (PONV). Oral carbohydrate loading strategy (CHO) improves outcomes in labor and general surgery. We aimed to compare the effectiveness of CHO with standard fasting in patients undergoing elective cesarean delivery (CD) under spinal anesthesia. Methods: A single-center, parallel, prospective randomized controlled trial (RCT) was conducted in a tertiary university obstetrics department at Pomeranian Medical University in Szczecin, Poland. Patients were randomly assigned (1:1 ratio) to the CHO group (oral carbohydrate 2 h before elective CD, n = 75) or the SF group (control—standard fasting, n = 73). The main outcome measures were incidence and severity of PONV at 6 and 24 h after CD, time to the first peristalsis, time to first bowel movement, and biochemical parameters indicating ketosis in mothers and their children. Results: A total of 148 adult females with singleton pregnancies undergoing elective CD under spinal anesthesia (ASA I and II) were included in the final analysis. At 24 h after CD, 8.0% from the CHO group vs. 20.55% reported three or more episodes of vomiting or dry retching as compared to patients in the SF group (p = 0.041). Preoperative CHO supplementation decreased preoperative feelings of hunger (p < 0.001) and thirst (p < 0.001). Laboratory results in the CHO group showed higher plasma pH (p = 0.001) and glucose (p < 0.001), lower F2-isoprostane in plasma (p = 0.049) and urine (p = 0.018), lower urine F2-isoprostane/creatinine ratio (p = 0.045) than in the SF group. HOMA-IR (p < 0.001) and lactate (p < 0.001) were higher in the CHO group than in the control group. Conclusions: There was no significant difference in the incidence or severity of early PONV at 6 h. The incidence of vomiting or dry retching at 24 h after cesarean delivery was lower in the CHO group as compared to standard starvation, but the combined results of PONV frequency and severity on the Wengritzky scale did not differ between the two study groups. Preoperative CHO supplementation decreased preoperative feelings of hunger and thirst, enhancing the comfort of pregnant women. Trial registration: ClinicalTrials.gov identifier: NCT04069806.

Rudingwa P., Thakur N., Balachander H., Panneerselvam S.

Bowe R., Irwin R., Browne G., Harbison M., Gallen S., Yore P.J., MacGearailt E., Popivanov P., Tan T.

Nausea and vomiting are common complications in patients undergoing caesarean delivery under regional anaesthesia. When experienced after surgery, they may delay recovery, reduce patient satisfaction and affect the bonding between mother and baby. Various pharmacological and non-pharmacological approaches for prophylaxis and treatment of postoperative nausea and vomiting (PONV) have been employed with different degree of efficacy. In this pilot randomised controlled trial, we aimed to determine the possible preventative effects of chewing gum on the rate of PONV in expectant mothers undergoing neuraxial anaesthesia for elective lower segment caesarean section. All participants underwent spinal anaesthesia with administration of 10–11.5 mg of intrathecal heavy Bupivicaine 0.5% according to anaesthetists’ preference, Morphine 100 μg and Fentanyl 25 μg. Postoperative analgesia regimen was also standardised. Two hundred ninety-six patients were randomised to an intervention arm to receive chewing gum in addition to standard therapy and to a non-intervention arm to receive standard therapy. After exclusions, 258 patients were followed up 24 h postoperatively. Standard therapy is defined as Ondansetron 4 mg IV intra-operatively. The primary outcomes were the incidences of nausea and vomiting in the first 24 h postoperatively. Secondary outcomes were the number of episodes of nausea or vomiting in the recovery room and on the ward 24 h postoperatively, use of anti-emetics postoperatively, severity of nausea and patient satisfaction with the intervention. Our study revealed no significant differences in rates of postoperative nausea and vomiting between the intervention and standard therapy groups (41.4% v 36.9% p = 0.461). There were no significant differences in secondary outcomes between groups. Chewing gum does not reduce the incidence of PONV after elective LSCS under spinal anaesthesia. Our trial was registered with clinicaltrials.org (NCT04191694).

Manouchehrian N., Rahimi-Bashar F., Pirdehghan A., Shahmoradi F.

BackgroundReducing adverse effects during cesarean delivery and improving the quality of sensory blocks with appropriate doses of intrathecal hyperbaric bupivacaine can play an important role in the safe management of cesarean delivery. The aim of this study was to compare the doses of 10 and 12 mg of intrathecal hyperbaric bupivacaine 0.5% on sensory block level after first spinal failure in cesarean section (CS).MethodsIn this double-blind, randomized clinical trial, 40 candidates of CS after first spinal failure with class I-II based on American Society of Anesthesiologists (ASA) were randomly assigned into two equal groups (n = 20). Group A and B received the spinal anesthesia with 10 mg and 12 mg of hyperbaric bupivacaine (0.5%), respectively. Maximum levels of sensory block, motor block quality, and vital signs were measured in two groups by 60 min after SPA. Incidence of SPA complications during surgery were also recorded. Data were analyzed by SPSS ver.21 software using repeated measures analysis of variance at 95% confidence interval (CI) level.ResultsExcellent quality of sensory blocks and complete quality of motor blocks were achieved in all participants (100%). However, the mean time to onset of anesthesia (4.47 ± 0.69 vs. 3.38 ± 0.47, P &lt; 0.001) and time to reach T10 level (60.73 ± 11.92 vs. 79.00 ± 19.21, P &lt; 0.001) in the Group A, were significantly shorter than in the patients of Group B. The incidence of hypotension (P = 0.001), nausea/vomiting (P = 0.007) and bradycardia (P = 0.012) as well as administration of ephedrine and atropine were significantly higher in Group B compared to Group A.ConclusionSpinal anesthesia can be safely repeated with a 10 mg of hyperbaric bupivacaine 0.5% in a caesarean section after the initial spinal failure.Clinical trial registration[https://en.irct.ir/trial/40714], identifier [IRCT20120915010841N20].

Mostic Stanisic D., Kalezic N., Rajovic N., Ilic Mostic T., Cumic J., Stanisavljevic T., Beleslin A., Stulic J., Rudic I., Divac N., Milic N., Stojanovic R.

The aim was to determine the effect of regional anesthesia (RA) on postoperative vital functions in contrast to general endotracheal anesthesia (GEA) after the cesarean section.Prospective cohort study included consecutive term pregnant women delivered by cesarean section (GEA, n = 284; RA, n = 249).Higher levels of blood pressure and heart rate, as well as lower levels of pulse oximetry were found for GEA in contrast to RA (p < 0.001). The application of RA presented less side-effects (p < 0.05).RA for cesarean section should be preferred when balancing the risks and benefits for the mother and fetus.

Bowe R., Irwin R., Browne G., Harbison M., Gallen S., Yore P., MacGearailt E., Popivanov P., Tan T.

Abstract Background Nausea and Vomiting are common complications in patients undergoing Caesarean delivery under regional anaesthesia. When experienced after surgery, they may not only delay recovery, reduce patient satisfaction and affect the bonding between mother and baby but also may increase the risk of aspiration, which is a recognised cause of maternal death. Various pharmacological and non-pharmacological approaches for prophylaxis and treatment of post-operative nausea and vomiting (PONV) have been employed with different degree of efficacy. Aims In this pilot randomised controlled trial, we aimed to determine the possible preventative effects of chewing gum on the rate of PONV in expectant mothers undergoing neuraxial anaesthesia for elective lower segment caesarean section. Methods 296 patients were randomised to an intervention arm to receive chewing gum in addition to standard therapy and to a non-intervention arm to receive standard therapy. After exclusions 258 patients were followed up 24 hours post-operatively. Standard therapy is defined as Ondansetron 4mg IV intra-operatively. The primary outcomes were the incidences of nausea and vomiting in the first 24 hours post-operatively. Secondary outcomes were the number of episodes of nausea or vomiting in the recovery room and on the ward 24 hours post-operatively, use of anti-emetics post-operatively, severity of nausea and patient satisfaction with the intervention. Results Our study revealed no significant differences in rates of post-operative nausea and vomiting between the intervention and standard therapy groups (41.4% v 36.9% p = 0.461). There were no significant differences in secondary outcomes between groups. Conclusion Chewing gum does not reduce the incidence of PONV after elective LSCS under spinal anaesthesia Trial Registration Our trial was registered with clinicaltrials.org (NCT04191694)

Khatiban M., Mirzaie M., Fazeli A., Tapak L., Khalili Z.

ABSTRACTPurpose This study aimed to determine the effect of cardamom inhalation on intra and postoperative nausea and vomiting (IONV/PONV) of mothers undergoing spinal anesthesia for elective cesarean section. Design A single-blind, randomized, placebo-controlled clinical trial study. Methods Seventy eligible participates were equally randomized to the intervention or placebo group. The demographic and clinical characteristics questionnaire, a 100 mm Visual Analogue Scale (VAS) to measure the severity of nausea; and the mothers' emetic episodes checklist were used. Upon the first episode of nausea, participants inhaled through a plastic bag containing distilled gauze pads in normal saline with or without Cardamom essential oil. Findings Following the intervention, nausea severity in placebo (25.28 ± 32.38) and cardamom (13.14 ± 19.96) groups declined (P < .001), however after controlling the initial severity of nausea, the declining extent was more noticeable in the intervention group than in the placebo group. The episodes of nausea (37.1% vs 65.7%, P = .006), and retching (20% vs 45.7%, P = .028) were significantly lower in the intervention group than in the placebo group. Administration of antiemetic medications was lower in the intervention than the placebo group (37.1% vs 65.7%, P = .009). Conclusions Cardamom aromatherapy was effective in alleviating mothers' experience of nausea and retching across the cesarean surgical continuum. As such, it can be considered as a palliative treatment for IONV/PONV in Cesarean section surgeries.

Bozorgmanesh M., Valibeik S., Shokrpour M., Maktabi M., Kamali A.

Abstract Objectives Postoperative nausea and vomiting (PONV) are common symptoms after cesarean delivery (CD) that affect patients outcomes and satisfaction. The treatment of choice is still evolving, therefore, we aimed to evaluate PONV of combined paracetamol-dexamethasone vs. paracetamol alone. Methods This study is a double-blind randomized controlled trial on 100 patients undergoing cesarean delivery. Participants were randomly assigned into two groups of paracetamol or combined paracetamol-dexamethasone. Nausea and vomiting score, VAS score of pain, and chill were compared between the two groups. Results The result of this study found that mild nausea 2nd h after surgery in the combined group was lesser than paracetamol group (0.03). However, there was no statistically significant difference in nausea and vomiting score in other periods of time between the two groups. VAS score of pain decreased 12th and 6th h after the surgery in the combined and paracetamol group, respectively. Chilling occurred in two patients of combined group and four patients of paracetamol group (p=0.432). Conclusions Dexamethasone added to paracetamol might not improve pain and vomiting after cesarean delivery comparison with just paracetamol. But it can be effective for reducing the score of nausea after the surgery.

Mahmood A.H.

Background: Premedication is used prior to surgery to reduce the adverse effects that might result from general anesthesia. Objective: This study was performed to examine the types and utility of various pre-anesthetic agents in 100 patients aged between 3 and 60 years who were admitted to Baladrooz General Hospital for different surgical operations during February (winter) and April (spring) 2021. Methods: A total of 62 patients received isoflurane, and 7 patients received sevoflurane, both by inhalational administration. The other 31 subjects were administered Marcaine (bupivacaine) by spinal anesthesia. Results: In this study, eight types of pre-anesthetic medication were administered prior to anesthesia, as follows: hydrocortisone (35 patients), metoclopramide (25 patients), atropine (13 patients), dexamethasone (12 patients), midazolam (7 patients), morphine (3 patients), ephedrine (3 patients), and fentanyl (2 patients). The most commonly used pre-anesthetic agent administered with isoflurane was hydrocortisone (37 patients), while the least used were fentanyl and morphine, which were administered to 3 patients each. Hydrocortisone was the premedication most often used (6 patients) with isoflurane, followed by dexamethasone, midazolam, and metoclopramide (5, 2, and 2 patients, respectively). The preanesthetic agent used most often with sevoflurane was hydrocortisone (6 patients), followed by dexamethasone (5 patients) and metoclopramide and midazolam (2 patients each). The premedication most commonly used with bupivacaine was metoclopramide (25 patients), while the least used was midazolam (2 patients). Conclusion: The study showed that several different pre-anesthetic drugs were used prior to anesthetic agents, which suggests that the selection of a pre-anesthetic drug depends on the risks that might be incurred when using a specific anesthetic drug.

Manouchehrian N., Miri Z., Esna-Ashari F., Rahimi-Bashar F.

BackgroundSpinal anesthesia (SPA) is the most common type of anesthesia administered for cesarean section. The main aim of this study was to evaluate the effect of aspiration of CSF (0.2 mL) immediately after SPA with hyperbaric 0.5% bupivacaine on the extent of sensory and motor block.MethodsIn this clinical trial, 60 women at ≥37 weeks of gestation and aged between 18 and 46 years, candidate for cesarean delivery under spinal anesthesia were randomly allocated into two equal groups (n = 30). Group A (CSF-aspiration group) received the spinal anesthesia with 10 mg of hyperbaric 0.5% bupivacaine with aspiration of 0.2 ml of CSF. Group B (no-CSF-aspiration group) received only 10 mg of 0.5% hyperbaric bupivacaine. Pin-prick analgesia and motor block were tested during the induction.ResultsThe mean maximum level of analgesia was T6 in each group. Although the mean time to reach the maximum level of anesthesia (4.43 ± 5.14 vs. 2.76 ± 2.04, P = 0.107) and to reach T10 level (50.56 ± 11.51 vs. 49.10 ± 13.68, P = 0.665) in the CSF-aspiration group is longer than the non-CSF-aspiration group, but this differences were not significant. There were no significant between-group differences regarding sensory and motor block quality (P = 0.389) or failed SPA (four cases in CSF-aspiration group vs. two cases in no-CSF-aspiration group, P = 0.389). The incidence of bradycardia, hypotension, headache, vomiting and nausea were similar in both groups (P &gt; 0.05). In addition, the difference in hemodynamic parameters between the two groups over times was not statistically significant.ConclusionOur finding indicated that the aspiration of 0.2 ml of CSF after injection of spinal anesthesia with hyperbaric 0.5% bupivacaine does not seem to affect the extent of sensory and motor block, success rate, or outcome after SPA in cesarean section.Clinical Trial Registration[https://www.irct.ir/search/result?query=IRCT20120915010841N25], identifier [IRCT20120915010841N25].