Comparing the preventive effect of midazolam and midazolam-dexamethasone on postoperative nausea and vomiting in elective middle ear surgery


1 Department of Anesthesiology, Anesthesiology and Critical Care Research Center, Isfahan University of Medical Sciences, Isfahan, Iran

2 Medical Doctor, Isfahan University of Medical Sciences, Isfahan, Iran


Background: Nausea and vomiting are common postoperative complications with incidence of 20-80% depends on the surgery type, anesthetic drugs, age, sex, etc. This complication may lead to patient discomfort, intraocular, and intracerebral pressures increase, sutures rupture, esophageal injury, and rarely death. Many studies reported that midazolam and dexamethasone alone can decrease postoperative nausea and vomiting (PONV), but their combination has never been studied yet. The aim of this study was to compare the effect of midazolam and midazolam-dexamethasone on PONV after middle ear surgery.
Materials and Methods: 66 ASA I and II patients aged 15-65 year scheduled for elective middle ear surgery under general anesthesia randomly divided into two groups. Immediately after induction of the anesthesia group one (M) received midazolam 0.075 mg/kg and group two (M+D) received combination of midazolam (0.075 mg/kg) plus dexamethasone (0.05 mg/kg). Then the severity of nausea was measured by visual analog scales 0-10 (VAS) in recovery room at 6, 12, and 24 h after surgery. Metoclopramid (0.1 mg/kg) was administrated I.V. slowly if nausea score was above 3 or patient had vomiting. The postoperative need for antiemetics and the duration of stay in recovery room were recorded. Values of P<0.05 were considered statistically significant.
Results: There were no significant differences in age, gender, and weight between the two groups. There was no significant difference in the mean nausea scores between two groups except after 12 h postoperatively (1.39 ± 3.19 in M group vs. 0.42 ± 1.71 in M+D group). The mean vomiting frequency was significantly less in midazolam-dexamethasone group in the recovery room (0.9 ± 0.29 vs. 0 ± 0) and at 6-12 h (1.09 ± 2.41 vs. 0.3 ± 0.8), and 12-24 h (0.42 ± 1.32 vs. 0.03 ± 0.17) postoperatively. During the first 24 h postoperatively, the metoclopramid consumption was significantly less in combination therapy (6.48 ± 9.54) than in the midazolam group (12.9 ± 23.44) (Value<0.5).
Conclusion: The combination of midazolam-dexametazone is more effective than midazolam alone in prevention of postoperative vomiting after middle ear surgery. Therefore, we recommend combination therapy for patients who are prone to PONV.


1. Kranke P, Eberhart LH. Postoperative nausea and vomiting: Rational algorithms for prevention and treatment based on current evidence. Anasthesiol Intensivmed Notfallmed Schmerzther 2009;44:286-94; quiz 295.  Back to cited text no. 1
2. Heidari SM, Saryazdi H, Saghaei M. Effect of intravenous midazolam premedication on postoperative nausea and vomiting after cholecystectomy. Acta Anaesthesiol Taiwan 2004;42:77-80.  Back to cited text no. 2
3. Miller RD. Anestheisa: In: Donlon JV Jr, editor. Chap 63. Philadelphia:Saunders 2000.p. 2173-83.  Back to cited text no. 3
4. Atlee J. Complication in anesthesia: In: Jame, Fletcher MB. Heard. Intractable Nausea and vomiting. Philadelphia:Saunders, 2007 Chap 238. p. 950-3.  Back to cited text no. 4
5. Apfel CC. Postoperative Nausea and Vomiting. In: Miller RD, Eriksson LI, Fleisher LA, editors. Miller's Anesthesia. 7 th ed. Pennsylvania: Elsevier; 2009. p. 2729-55.  Back to cited text no. 5
6. Jokela R. Prevention of postoperative nausea and vomiting-studies on different anti emetics, their combinations and dosing regimens. University of Helsinki, 2003; p 1-79.  Back to cited text no. 6
7. Kreis ME. Postoperative nausea and vomiting. Auton Neurosci 2006;126:86-91.  Back to cited text no. 7
8. Chen JJ, Frame DG, White TJ. Efficacy of ondansetron and prochlorperazine for the prevention of postoperative nausea and vomiting after total hip replacement or total knee replacement procedures. Arch Intern Med 1998;158:2124-9.  Back to cited text no. 8
9. Baric A. Oesophageal rupture in a patient with postoperative nausea and vomiting. Anaesth Intensive Care 2000;28:325-7.  Back to cited text no. 9
10. Pleuvry BJ. Physiology and pharmacology of nausea and vomiting. Anaesth Intensive Care Med 2006;7:473-7.  Back to cited text no. 10
11. Jung JS, Park JS, Kim SO, Lim DG, Park SS, Kwak KH, et al. Prophylactic antiemetic effect of midazolam after middle ear surgery. Otolaryngol Head Neck Surg 2007;137:753-6.  Back to cited text no. 11
12. 12- Husband A, Worsley A. Nausea and vomiting-pharmacological management. Hospital pharmacist, 2007; 14: 189-92.  Back to cited text no. 12
13. Norma IC, Portilla P, Vela RE. "Timing of ondansetron administration to prevent postoperative nausea and vomiting." Puerto Rico Health Sci J 2008;27.1:43-5.  Back to cited text no. 13
14. Lee Y, Wang JJ, Yang YL, Chen A, Lai HY. Midazolam vs ondansetron for preventing postoperative nausea and vomiting: A randomised controlled trial. Anaesthesia 2007;62:18-22.  Back to cited text no. 14
15. FDA > Midazolam. Drog Information Online. Available from: [Last accessed on 2008 Mar 12].  Back to cited text no. 15
16. Ho KY, Chiu JW. Multimodal antiemetic therapy and emetic risk profiling. Ann Acad Med Singapore 2005;34:196-205.  Back to cited text no. 16
17. 5-HT3 antagonist. Wikipedia The Free Encyclopedia. Available from: [Last accessed on 2010 Apr 06].  Back to cited text no. 17
18. Bauer KP, Dom PM, Ramirez AM, O'Flaherty JE. Preoperative intravenous midazolam: Benefits beyond anxiolysis. J Clin Anesth 2004;16:177-83.  Back to cited text no. 18
19. Wang JJ, Ho ST, Tzeng JJ, Tang CS. The effect of timing of Dexamethasone administration on its effi cacy as a prophylactic anti-emetic for PONV. Anesth Analg 2000;91:136-9.  Back to cited text no. 19
20. Maddali MM, Mathew J, Fahr J, Zarroug AW. Postoperative nausea and vomiting in diagnostic gynaecological laparoscopic procedures: Comparison of the efficacy of the combination of dexamethasone and metoclopramide with that of dexamethasone and ondansetron. J Postgrad Med 2003;49:302-6.  Back to cited text no. 20
[PUBMED]  Medknow Journal  
21. Riad W, Marouf H. Combination therapy in the prevention of PONV after strabismus surgery in children: Granisetron, ondansetron, midazolam with dexamethasone. Middle East J Anesthesiol 2009;20:431-6.  Back to cited text no. 21
22. Yeo J, Jung J, Ryu T, Jeon YH, Kim S, Baek W. Antiemetic efficacy of dexamethasone combined with midazolam after middle ear surgery. Otolaryngol Head Neck Surg 2009;141:684-8.  Back to cited text no. 22
23. Unal Y, Ozsoylar O, Arslan M, Sarigüney D, Akçabay M. Comparison of the efficacy of propofol and metoclopramide in preventing postoperative nausea and vomiting after middle ear surgery. Saudi Med J 2009;30:778-82.  Back to cited text no. 23
24. Isik B, Cekmen N, Arslan M, Ozsoylar O, Kordan AZ, Akcabay M. Comparison of the antiemetic effects of ondansetron and dexamethasone on middle ear surgery. Saudi Med J 2006;27:646-51.  Back to cited text no. 24
25. Eberhart LH, Mauch M, Morin AM, Wulf H, Geldner G, Impact of a multimodal anti-emetic prophylaxis on patient satisfaction in high-risk patients for postoperative nausea and vomiting. Anaesthesia 2002;57:1022-7.  Back to cited text no. 25
26. Kim EJ, Ko JS, Kim CS, Lee SM, Choi DH. Combination of antiemetics for the prevention of postoperative nausea and vomiting in high-risk patients. J Korean Med Sci 2007;22:878-82.  Back to cited text no. 26
27. Hache JJ, Vallejo MC, Waters JH, Williams BA. Aprepitant in a multimodal approach for prevention of postoperative nausea and vomiting in high-risk patients: Is there such a thing as "too many modalities"? ScientificWorldJournal 2009;9:291-9.  Back to cited text no. 27
28. Fujii Y, Toyooka H, Tanaka H. Prophylactic antiemetic therapy with a combination of granisetron and dexamethasone in patients undergoing middle ear surgery. Br J Anaesth 1998;81:754-6.  Back to cited text no. 28
29. Biswas BN, Rudra A. Comparison of granisetron and granisetron plus dexamethasone for the prevention of postoperative nausea and vomiting after laparoscopic cholecystectomy. Acta Anaesthesiol Scand 2003;47:79-83.  Back to cited text no. 29
30. Sanjay OP, Tauro DI. Midazolam: An effective antiemetic after cardiac surgery-a clinical trial. Anesth Analg 2004;99:339-43.  Back to cited text no. 30
31. Di Florio T, Goucke CR. The effect of midazolam on persistent postoperative nausea and vomiting. Anaesth Intensive Care 1999;27:38-40.  Back to cited text no. 31
32. Riad W, Altaf R, Abdulla A, Oudan H. Effect of midazolam, dexamethasone and their combination on the prevention of nausea and vomiting following strabismus repair in children. Eur J Anaesthesiol 2007;24:697-701.  Back to cited text no. 32
33. Eberhart LH, Büning EK, Folz B, Maybauer DM, Kästner M, Kalder M, et al. Anti-emetic prophylaxis with oral tropisetron and/or dexamethasone. Eur J Clin Invest 2006;36:580-7.  Back to cited text no. 33