Treatment of postoperative nausea and vomiting after spinal anesthesia for cesarean delivery: A randomized, double-blinded comparison of midazolam, ondansetron, and a combination

Authors

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

Abstract

Background: The antiemetic efficacy of midazolam and ondansetron was shown before. The aim of the present study was to compare efficacy of using intravenous midazoalm, ondansetron, and midazolam in combination with ondansetron for treatment of nausea and vomiting after cesarean delivery in parturient underwent spinal anesthesia.
Materials and Methods: One hundred thirty two parturients were randomly allocated to one of three groups: group M (n = 44) that received intravenous midazoalm 30 μg/kg; group O (n = 44) that received intravenous ondansetron 8 mg; group MO (n = 44) that received intravenous midazoalm 30 μg/kg combined with intravenous ondansetron 8 mg if patients had vomiting or VAS of nausea ≥ 3 during surgery (after umbilical cord clamping) and 24 hours after that. The incidence and severity of vomiting episodes and nausea with visual analog scale (VAS) > 3 were evaluated at 2 hours, 6 hours, and 24 hours after injection of study drugs.
Results: The incidence of nausea was significantly less in group MO compared with group M and group O at 6 hours postoperatively (P = 0.01). This variable was not significantly different in three groups at 2 hours and 24 hours after operation. The severity of nausea and vomiting was significantly different in three groups at 6 hours after operation (P < 0.05).
Conclusion: Our study showed that using intravenous midazolam 30 μg/kg in combination with intravenous ondansetron 8 mg was superior to administering single drug in treatment of emetic symptoms after cesarean delivery under spinal anesthesia.

Keywords

1. Tarhan O, Canbay O, Celebi N, Uzun S, Sahin A, Coºkun F, et al. Subhypnotic doses of midazolam prevent nausea and vomiting during spinal anesthesia for cesarean section. Minerva Anestesiol 2007;73:629-33.  Back to cited text no. 1
    
2. Pan PH, Moore CH. Comparing the efficacy of prophylactic metoclopramide, ondansetron, and placebo in cesarean section patients given epidural anesthesia. J Clin Anesth 2001;13:430-5.   Back to cited text no. 2
    
3. Wu JI, Lo Y, Chia YY, Liu K, Fong WP, Yang LC, et al. Prevention of postoperative nausea and vomiting after intrathecal morphine for Cesarean section: A randomized comparison of dexamethasone, droperidol, and a combination. Int J Obstet Anesth 2007;16:122-7.   Back to cited text no. 3
    
4. Pan PH, Moore CH. Intraoperative antiemetic efficacy of prophylactic ondansetron versus droperidol for cesarean section patients under epidural anesthesia. Anesth Analg 1996;83:982-6.  Back to cited text no. 4
    
5. Fujii Y, Tanaka H, Toyooka H. Granisetron prevents nausea and vomiting during spinal anaesthesia for caesarean section. Acta Anaesthesiol Scand 1998;42:312-5.  Back to cited text no. 5
    
6. 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. 6
    
7. Klauser CK, Fox NS, Istwan N, Rhea D, Rebarber A, Desch C, et al. Treatment of severe nausea and vomiting of pregnancy with subcutaneous medications. Am J Perinatol 2011;28:715-21.  Back to cited text no. 7
    
8. Jarvis S, Nelson-Piercy C. Management of nausea and vomiting in pregnancy. BMJ 2011 Jun 17;342:d3606.  Back to cited text no. 8
    
9. Splinter W, Noël LP, Roberts D, Rhine E, Bonn G, Clarke W. Antiemetic prophylaxis for strabismus surgery. Can J Ophthalmol 1994;29:224-6.   Back to cited text no. 9
    
10. 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. 10
    
11. Unlugenc H, Guler T, Gunes Y, Isik G. Comparative study of the antiemetic efficacy of ondansetron, propofol and midazolam in the early postoperative period. Eur J Anaesthesiol 2003;20:668-73.  Back to cited text no. 11
    
12. Olynyk J, Cullen SR, Leahy MF. Midazolam: An effective antiemetic agent for cytotoxic chemotherapy. Med J Aust 1989;150:466.  Back to cited text no. 12
    
13. Safavi MR, Honarmand A. Low dose intravenous midazolam for prevention of PONV in lower abdominal surgery--preoperative vs intraoperative administration. Middle East J Anesthesiol 2009;20:75-81.   Back to cited text no. 13
    
14. Di Florio T. The use of midazolam for persistent postoperative nausea and vomiting. Anaesth Intensive Care 1992;20:383-6.  Back to cited text no. 14
    
15. Phillis JW, Bender AS, Wu PH. Benzodiazepines inhibit adenosine uptake into rat brain synaptosomes. Brain Res 1980;195:494-8.  Back to cited text no. 15
    
16. Takada K, Murai T, Kanayama T, Koshikawa N. Effects of midazolam and flunitrazepam on the release of dopamine from rat striatum measured by in vivo microdialysis. Br J Anaesth 1993;70:181-5.  Back to cited text no. 16
    
17. Hawthorn J, Ostler KJ, Andrews PL. The role of the abdominal visceral innervation and 5-hydroxytryptamine M-receptor in vomiting induced by the cytotoxic drugs cyclophosphamide and cis-platin in the ferret. Q J Exp Physiol 1988;73:7-21.  Back to cited text no. 17
    
18. Kilpatrick GJ, Jones BJ, Tyers MB. The distribution of specific binding of the 5-HT, receptor ligand [3H]GR65630 in rat brain using quantitative autoradiography. Neurosci Lett 1988;94:156-60.  Back to cited text no. 18
    
19. Pearman MH. Single dose intravenous ondansetron in prevention of postoperative nausea and vomiting. Anaesthesia 1994;49:ll-5.  Back to cited text no. 19
    
20. 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. 20
    
21. Klein RL, Sanna E, McQuilkin SJ, Whiting PJ, Harris RA. Effects of 5-HT3 receptor antagonists on binding and function of mouse and human GABAA receptors. Eur J Pharmacol 1994;268:237-46.  Back to cited text no. 21