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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 30  |  Issue : 6  |  Page : 653-657

Preventing intraoperative nausea and vomiting during cesarean delivery under spinal anesthesia: A comparison of effects of prophylactic cyclizine, metoclopramide, and placebo


1 Department of Anaesthesia, University of Nigeria Teaching Hospital, Ituku/Ozalla, Nigeria
2 Department of Anaesthesia, University of Nigeria Ituku/Ozalla Campus, Nigeria

Date of Submission03-May-2021
Date of Decision18-Sep-2021
Date of Acceptance16-Sep-2021
Date of Web Publication27-Dec-2021

Correspondence Address:
A O Amucheazi
Department of Anaesthesia, University of Nigeria Ituku/Ozalla Campus
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/NJM.NJM_78_21

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  Abstract 


Background: Nausea and vomiting are undesirable intraoperative events among women during cesarean delivery under subarachnoid block. Therefore, prophylaxis is recommended. Aims: This study was undertaken to compare the effect of intravenous cyclizine with metoclopramide administered before achieving subarachnoid block. Patients, Materials and Methods: The study was conducted among women booked for elective cesarean section using the subarachnoid technique. This is a prospective, randomized, double-blinded study that compared the effect of single doses of cyclizine, metoclopramide, and placebo in preventing intraoperative nausea and vomiting among the selected patients. We obtained ethical clearance from the Hospital Research and Ethics Committee as well as written informed consent from each patient involved. The inclusion criteria include women aged 18–45 years with term singleton pregnancy scheduled for elective cesarean section, having the American Society of Anesthesiologists (ASA) physical status grades 1 and 2, with no known contraindications to spinal anesthesia, allergy to study drugs or local anesthetic agents. Patients were excluded if they declined, have a history of allergy to metoclopramide or cyclizine, have pregnancy-induced hypertension, hyperemesis gravidarium, motion sickness, gastrointestinal disease or glucose intolerance. One hundred and twenty parturients with ASA status I-II were recruited and assigned to three groups. All medications were administered intravenously: normal saline in Group I, metoclopramide in Group II, and cyclizine in Group III. Data were collected with study pro forma produced for the study. The Statistical Package for the Social Sciences (SPSS) Version 20.0 was used for analysis of the data collected. Results: The incidence of nausea was least in Group III. There were similar findings for retching and vomiting. Conclusion: We, therefore, concluded that cyclizine is superior to metoclopramide in preventing nausea in women undergoing cesarean section under spinal anesthesia.

Keywords: Cyclizine, intraoperative vomiting, parturient, spinal anesthesia


How to cite this article:
Okonna F G, Amucheazi A O, Onyekwulu F A. Preventing intraoperative nausea and vomiting during cesarean delivery under spinal anesthesia: A comparison of effects of prophylactic cyclizine, metoclopramide, and placebo. Niger J Med 2021;30:653-7

How to cite this URL:
Okonna F G, Amucheazi A O, Onyekwulu F A. Preventing intraoperative nausea and vomiting during cesarean delivery under spinal anesthesia: A comparison of effects of prophylactic cyclizine, metoclopramide, and placebo. Niger J Med [serial online] 2021 [cited 2022 May 23];30:653-7. Available from: http://www.njmonline.org/text.asp?2021/30/6/653/333834




  Introduction Top


Spinal anesthesia is currently the preferred anesthetic technique for cesarean section when applicable. The technique, however, has its complications,[1] one of which is intraoperative nausea and vomiting (IONV). This may or may not be accompanied retching. The incidence of IONV during spinal anesthesia has been found to vary between 37% and 75% when no prophylactic antiemetic is given compared to when prophylaxis is given.[1] These symptoms may have an unfavorable impact on the birthing experience. Nausea and vomiting can also complicate intraoperative care as the patient may be predisposed to aspiration of vomitus. Furthermore, the protrusion of abdominal contents would cause disturbance to the surgeon during the procedure.[2]

A number of pharmacological agents have been administered for the treatment and prevention of IONV: 5-hydroxyltryptamine (5-HT3) antagonist (e.g., ondansetron and granisetron), dopamine receptor antagonist (e.g., metoclopramide), butyrophenones (e.g., droperidol), and anticholinergic agents (e.g., atropine).[3] Certain critical limiting factors are linked with them. These include cost with 5-HT3 antagonist and extra-pyramidal symptoms (tremor, bradykinesia, and dyskinesia) with dopamine receptor antagonist.[3] Antihistamines (H1 receptor antagonist) such as cyclizine have antiemetic effect but have not been commonly used in our local population as prophylaxis for nausea and vomiting during spinal anesthesia. The purpose of this study is to assess the effect of cyclizine, metoclopramide, and placebo given before subarachnoid block for the prophylaxis of IONV in our hospital.

Aims

The aim of this study was to evaluate the efficacy and safety of intravenous cyclizine, metoclopramide, and placebo, in preventing IONV during cesarean section under spinal anesthesia.




  Patients Materials and Methods Top


Study population

This comprised of women scheduled for elective cesarean section under spinal anesthesia in our hospital.

Study design

This is a prospective, randomized, double-blinded, placebo study. The power of study was 80% with a significance level of 5% while a provision of 10% was made for attrition. A total of 120 parturients were recruited. The participants were divided into 3 groups by envelope randomization. They were 40 in each group: Group I – saline, Group II – metoclopramide, and Group III – cyclizine. Twenty (20) minutes before establishing spinal anesthesia, Group I received 2 ml of 0.9% saline, Group II received 10 mg of metoclopramide in 2 ml, and Group III were given 50 mg of cyclizine diluted with water for injection to 2 ml intravenously. Patients were monitored and records of nausea, vomiting, and retching, and vital signs and side effects of drugs were made. Neonatal APGAR scores were also recorded.

Each patient had been educated on the nausea numerical rating scale for assessing the severity of nausea: 0 (indicating “No nausea or no urge to vomit”) to 10 (indicating “unbearable nausea or unbearable urge to vomit”). Following strict asepsis, subarachnoid block was achieved using 25G Quincke spinal needle and hyperbaric bupivacaine 0.5%, 12.5 mg (2.5 ml). Vital signs monitored were noninvasive blood pressure, heart rate, arterial oxygen saturation (SpO2), electrocardiography, and respiratory rate using DAS 4000 multiparameter monitor (General Electric, Wisconsin USA). The figures obtained were recorded on the anesthetic chart every 2 min for the first 10 min and thereafter every 5 min for the duration of the surgery and in the recovery room.

Nausea was graded: 1–3 = mild nausea, 4–6 = moderate nausea, while 7–10 = severe nausea. For rescue antiemetics, intravenous promethazine 25 mg was administered when patients had moderate-to-severe nausea and vomiting. Patients were monitored for hypotension. Hypotension was defined as decrease in systolic or mean arterial blood pressure of >20% from the baseline value. Hypotension was treated using crystalloid infusion and ephedrine administration at 6 mg intravenous boluses. Total dose of ephedrine administered to each patient was recorded. Sedation was assessed using a 6-point scale (Inova Sedation Assessment Scale): 1 = alert, 2 = occasionally drowsy, 3 = dosing intermittently, 4 = asleep easy to awaken, 5 = difficult to awaken, 6 = unresponsive. APGAR scores for the neonates in the Ist and 5th min were also recorded.

Data collection

Data were collected with study instrument designed for the study.

Study criteria (inclusion and exclusion criteria)

The inclusion criteria include women aged 18–45 years with term singleton pregnancy scheduled for elective cesarean section, having the American Society of Anesthesiologists physical status Grades 1 and 2, with no known contraindications to spinal anesthesia, allergy to study drugs or local anesthetic agents. Patients were excluded if they declined, have a history of allergy to metoclopramide or cyclizine, have pregnancy-induced hypertension or glucose intolerance. Other exclusion criteria were an established history of gastrointestinal disease, motion sickness or hyperemesis gravidarium, intake of antiemetic or emetogenic medications (e.g. opioids) within the previous 24 h or had local anesthetic systemic toxicity.

Ethical consideration

Ethical clearance was obtained from the Hospital Research and Ethics Committee as well as written informed consent from each patient.

Data analysis

Statistical analysis was performed using the Statistical Package for the Social Sciences (SPSS) Version 20.0 (SPSS Inc., Chicago, IL, USA). Continuous and categorical variables across the groups were summarized using frequency, percentages, means, and standard deviations. Continuous variables over time within the groups were compared using analysis of variance. Chi-square test was used to analyze association between categorical variables. Results were presented as tables and charts and P < 0.05 were considered statistically significant.




  Results Top


One hundred and twenty (120) patients were enrolled in the study. One patient was converted to general anesthesia due to failed spinal, one required intraoperative analgesic, one had received another antiemetic drug mistakenly administered by the assistant, and another one was sedated due to anxiety. Therefore, a number of 4 patients were excluded from the analysis. The remaining 116 parturients were 39 in Group I, 39 in Group II, and 38 in Group III. They were similar in their demographic characteristics, P > 0.05 [Table 1].
Table 1: Demographic characteristics

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Nausea occurred in 14 (36.9%) of patients in Group I, 6 (16.4%) in Group II, and 1 (2.6%) of patients in Group III. The severity of nausea is also shown in [Table 2]. Retching occurred in 7 (17.9%) and 2 (5.1%) of patients in Groups I and II, respectively. Retching was not documented in Group III. Vomiting occurred in 5 (12.8%), 2 (5.1%), and none of patients in Groups I to III, respectively. However, vomiting was not statistically significant (χ2 = 5.664, P = 0.059) [Table 2].
Table 2: Intraoperative nausea retching vomiting among the groups

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In Group I, 9 (60%) of patients experienced hypotension with IONV while the figures for Groups II and III were 4 (26.7%) and 1 (5.3%), respectively [Table 3].
Table 3: Hypotension and intraoperative nausea and vomiting

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For Group I, 15 (38.5%) had a drop in blood pressure but 12 (30.8%) required administration of ephedrine. In Group II, 15 (38.5%) became hypotensive but 11 (28.2%) required ephedrine. While in Group III, 19 (50%) were hypotensive, however, 13 (34.2%) required ephedrine administration [Table 4].
Table 4: Hypotension versus ephedrine and antiemetic use among the groups

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The study also revealed that rescue antiemetic was used more among patients in the placebo group in Group I [Table 4].

Sedation was most common in Group III (χ2 = 43.614, P = 0.001). SpO2 ranged from 95% to 100% in room air. All neonatal APGAR scores in the 1st min were between 7–9 and 9–10 in the 5th min [Table 5].
Table 5: Side effects associated with the use of study drugs

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  Discussion Top


This prospective study demonstrated that administration of 50 mg of cyclizine intravenously before induction of anesthesia is more effective than metoclopramide for the prevention of nausea during the procedure. Malak et al., in their study, found that cyclizine was effective when compared with ondansetron and prochlorperazine.[4] Furthermore, Khurshid et al. in their study found cyclizine effective as in our study.[5] Nortcliffe et al. compared cyclizine and dexamethasone for the prevention of IONV after spinal anesthesia for cesarean section. Their study showed that cyclizine reduced the incidence of nausea from 67% to 33% while dexamethasone reduced the incidence from 67% to 60%.[6] In another study by Grimsehl et al. comparing cyclizine and ondansetron use during laparoscopic day-case gynecological surgery, there was no difference between the two.[7]

Dandona et al. compared metoclopramide with ondansetron in women who had cesarean delivery under spinal anesthesia. They found that the effect of metoclopramide when administered alone is inferior to that of ondansetron.[8] Isazadehfar et al. also found that ondansetron was more effective than metoclopramide.[9] Voigt et al. also in their study also found that a combination of metoclopramide with tropisetron was more effective than administration of only metoclopramide.[10] However, according to Gebremedhum et al., when compared to a placebo, metoclopramide was more effective.[11]

Magni et al. in 2016 reported an incidence of 32% and 7% of nausea and vomiting, respectively, among placebo group.[12] Their finding, though lower than the result in this work (35.9% and 12.8%), could be attributed to the use of lower dose of hyperbaric bupivacaine 10 mg (2 ml). Van de Velde also found that this dose has been noted to cause low incidence of hypotension, nausea, and vomiting.[13]

Hypotension can lead to reduce blood flow to the brain. Furthermore, brain stem ischemia may activate the circulatory, respiratory, and vomiting centers in the medulla.[14] Furthermore, it leads to gut ischemia and release of emetogenic substances such as serotonin.[14] Therefore, hypotension should be actively treated. In our study, the incidence of hypotension was similar across the groups. Furthermore, the dose of ephedrine was not different across the groups (P > 0.05).

Butwick et al. showed that when hypotension occurred, the incidence of IONV was more.[15] However, our study could not demonstrate that further study is needed to show whether this association between hypotension and IONV is true.

Cyclizine is known to have antiemetic effect with histaminic and anticholinergic properties which may cause sedation.[4] The sedative effect of cyclizine was observed in this study. Grimsehl et al. demonstrated that cyclizine for patients undergoing laparoscopic day-case gynecological surgery caused sedation among patients.[7] Sedation may be beneficial to anxious patients.

The APGAR scores of babies whose mothers received any of the study drugs were similar compared to the placebo group. Cyclizine is well tolerated even in pregnancy and has no neonatal and maternal respiratory depression.

Limitations

The authors could not determine the plasma levels of the study drugs in cord blood because of lack of facilities.




  Conclusion Top


Intravenous cyclizine 50 mg administered before induction of spinal anesthesia significantly decreased the incidence of IONV in women undergoing cesarean section under spinal anesthesia.

Acknowledgment

The authors thank the staff of the department that participated in the study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Semiz A, Akpak YK, Yılanlıoğlu NC, Babacan A, Gönen G, Çam Gönen C, et al. Prediction of intraoperative nausea and vomiting in caesarean delivery under regional anaesthesia. J Int Med Res 2017;45:332-9.  Back to cited text no. 1
    
2.
Ashagrie HE, Filatie TG, Melese DY, Mustepe SY. The incidence and factors associated with intra operative nausea and vomiting during caesarean section under spinal anaesthesia. An institution based cross sectional study. Int J of Surgery Open 2020;26:49-54  Back to cited text no. 2
    
3.
Jelting Y, Klen C, Harlander T, Eberhart I, Roewer N, Kranke P. Preventing nausea and vomiting in women undergoing regional anaesthesia for caesarean section: Challenges and solutions. Local and Reg Anaesth 2017;10:83-90.  Back to cited text no. 3
    
4.
Malak AM, Shameem A, Hle CA, Qureshi MA. Comparison of ondansentron, cyclizine and prochlorperazine for post operative nausea and vomiting prophylaxis in laparoscopic cholecystectomy. Anaes Pain Intensive Care 2017;21:453-7.  Back to cited text no. 4
    
5.
Khurshid A, Akram M, Sheikh MN. To compare the efficacy of cyclizine, prochlorperazine and ondansentron in the prevention of postoperative nausea and vomiting following laparoscopic cholecystectomy. J Med Physiol Biophys 2019;52:16.  Back to cited text no. 5
    
6.
Nortcliffe SA, Shah J, Buggy DJ. Prevention of postoperative nausea and vomiting after spinal morphine for Caesarean section: Comparison of cyclizine, dexamethasone and placebo. Br J Anaesth 2003;90:665-70.  Back to cited text no. 6
    
7.
Grimsehl K, Whiteside JB, Mackenzie N. Comparison of cyclizine and ondansetron for the prevention of postoperative nausea and vomiting in laparoscopic day-case gynaecological surgery. Anaesthesia 2002;57:61-5.  Back to cited text no. 7
    
8.
Dandona S, Batra N. Pre-operative ondansentron versus metoclopramide for prevention of post operative nausea and vomiting in elective lower segment caesarean section under spinal anaesthesia. J Med Sci Clin Res 2014;2:940-8.  Back to cited text no. 8
    
9.
Isazadehfar K, Entezariasl M, Shahbazzadegan B, Nourani Z, Shafaee Y. The comparative study of ondansetron and metoclopramide effects in reducing nausea and vomiting after laparoscopic cholecystectomy. Acta Med Iran 2017;55:254-8.  Back to cited text no. 9
    
10.
Voigt M, Fröhlich CW, Hüttel C, Kranke P, Mennen J, Boessneck O, et al. Prophylaxis of intra- and postoperative nausea and vomiting in patients during cesarean section in spinal anesthesia. Med Sci Monit 2013;19:993-1000.  Back to cited text no. 10
    
11.
Gebremedhum E, Endalew E, Kassahum GH, Kasa A. Effect of metoclopramide prophylaxis on the reduction of intraoperative and early post operative nausea and vomiting after emergency caesarean section under spinal anaesthesia. J Anesth Clin Res 2018;9:2.  Back to cited text no. 11
    
12.
Magni BJ, Dyer RA, Van DD, Nugteren JV. Incidence of intraoperative nausea and vomiting during spinal anaesthesia for caesarean section in two Cape Town state hospitals. South Afr J Anaesth Analg 2016;22:131-4.  Back to cited text no. 12
    
13.
Van de Velde M. Low-dose spinal anesthesia for cesarean section to prevent spinal-induced hypotension. Curr Opin Anaesthesiol 2019;32:268-70.  Back to cited text no. 13
    
14.
Habib AS, George RB, McKeen DM, White WD, Ituk US, Megalla SA, et al. Antiemetics added to phenylephrine infusion during cesarean delivery: A randomized controlled trial. Obstet Gynecol 2013;121:615-23.  Back to cited text no. 14
    
15.
Butwick AJ, Columb MO, Carvalho B. Preventing spinal hypotension during Caesarean delivery: What is the latest? Br J Anaesth 2015;114:183-6.  Back to cited text no. 15
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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