Hydroxyzine for the prevention of pruritus and nausea vomiting from spinal morphine in patients having transabdominal hysterectomy under combined spinal-general anesthesia: A randomized control trial.

Background: Pruritus and nausea vomiting are common side effects of spinal morphine and general anesthesia. Hydroxyzine is one of the antihistamines that are used for treating pruritic and nauseous patients. A randomized prospective double-blind study was undertaken in order to identify the preventive effects of hydroxyzine to prevent pruritus and nausea vomiting in patients who have transabdominal hysterectomy under combined spinal-general anesthesia. Methods: 80 patients scheduled for elective transabdominal hysterectomy under combined spinal-general anesthesia were randomized to receive either hydroxyzine 75 mg and oral midazolam 7.5 mg (atarax or ATR group) or placebo and oral midazolam 7.5 mg (control or C group) as premedication at least half an hour before their operation. Clinical data (vital signs, pruritic score, nauseous score, sedation score, etcetera) were recorded at pre-operative, intraoperative and 48-hour post-operative periods. All patients had spinal block with 0.5% heavy bupivacaine 2 ml with 0.3 mg preservative free morphine and general anesthesia with thiopenthal sodium 5 mg/kg as induction, intubated with atracurium 0.6 mg/kg and maintenance with nitrous oxide in 50% oxygen and isoflurane. A conventional reversal technique was done in all patients. Intravenous fentanyl was used for pain as needed, oral chropheniramine syrup 2 tsp (4 mg/10 ml) every 4 hours was used for pruritus and intravenous ondanzetron (8 mg) was used for nausea/vomiting in the post-operative period. Results: Pruritus and nausea vomiting were observed blindly 24 and 48 hours post-operation. At 24 hours post-operation, there were 5 patients in the ATR group (12.5%) and 6 patients in the control group (15%) who had mild pruritus. There was no significant difference between the two groups (p = 0.745). At 48 hours post-operation, all patients were free of pruritus. There were 2 patients who had mild nausea (5%) and 2 patients who had moderate nausea (5%) in the control group within 24 hours post-operation. In the ATR group there was no patient who had mild or moderate nausea. There was no significant difference between the two groups (p = 0.152). At 48 hours post-operation, there was 1 patient in each group who had mild nausea (2.5%), which had no significant difference. At 24 and 48 hours post-operation, all patients were free of vomiting. Conclusion: Hydroxyzine cannot prevent pruritus and nausea/vomiting from spinal morphine in patients having transabdominal hysterectomy under combined spinal-general anesthesia.

Incidence and risk factors of hypotension during spinal anesthesia for cesarean section at Siriraj Hospital.

OBJECTIVE: Spinal anesthesia is commonly used for cesarean section. Its major adverse effect is hypotension. The objective of this study is to determine the incidence and risk factors of hypotension during spinal anesthesia for cesarean section. MATERIAL AND METHOD: The authors retrospectively reviewed anesthetic records of 991 patients who received spinal anesthesia for cesarean section at Siriraj Hospital. Exclusion criteria were patients with pregnancy included hypertension, received combination of spinal block with other type of anesthesia. RESULTS: The incidence of hypotension (the lowest systolic blood pressure < or = 100 mm Hg) was 76.%. The parameter with increased incidence of hypotension included patient's height < 155 cm (adjusted odd ratio (OR) 1.93, 95%CI 1.19-3.14), baseline systolic blood pressure < or = 120 mmHg (OR 2.14, 95%CI 1.53-2.99) and analgesic level > or = T5 (OR 1.83, 95%CI 1.18-2.84). CONCLUSION: The risk factors associated with increased incidence of hypotension are the patient 's height, baseline systolic blood pressure and level of blockade.

Maternal mortality related to anesthesia : Can it be prevented.

Objective: Maternal mortality is still a problem in developing countries like Thailand. However calculating the maternal mortality rate (MMR) from death certificates might underreport as in other parts of the world. Anesthesia has never been included as a cause of maternal death in Thailand. The objective of this study was to investigate the maternal mortality rate and the causes of maternal death and to see if there is any correlation between the maternal death and anesthetic practice. Methods: Questionnaires were sent to the directors of 800 public hospitals all over Thailand asking for information in the year 2000. The results were then compared with the information obtained in the same way 12 years ago (1988). Results: From 498 out of 800 hospitals (62%) that sent the questionnaires back, which included 358,481 births and 94 maternal deaths in the year 2000. This 62% response was then compared with 89% response in 1988. The MMR was decreased from 31.4:100,000 in 1988 to 26: 100,000 in 2000.The six leading causes of maternal death were hemorrhage, embolism, preeclampsia, AIDS, sepsis and anesthesia.in 2000. In 1988, anesthesia was also the sixth leading cause of maternal death. General anesthesia was still the most frequent choice of anesthesia for cesarean section (70-75 %), without the prophylactic use of 0.3 M sodium citrate and spinal anesthesia was used in only 24-27% in both periods. This due to anesthetic service in Thailand is mainly done by nurse anesthetists who are not allowed to give regional anesthesia. Removal of placenta using a mask anesthetic technique which has an aspiration risk was still used in some hospitals. The causes of deaths were all from general anesthesia, and were the result of difficult intubation and aspiration while there were no death as a result of using spinal anesthesia. In developed countries, spinal anesthesia is the major choice of anesthesia for cesarean section. Conclusions: The MMR in Thailand is still high and some causes are preventable. Health care providers should pay attention and try to reduce it. Anesthesia is the sixth leading cause of maternal death mostly due to difficult intubation and aspiration during using general anesthesia for cesarean section. However the use of general anesthesia for cesarean section in Thailand is still high. To reduce the maternal mortality from anesthesia, spinal anesthesia should be promoted. If general anesthesia is needed, standard techniques to prevent pulmonary aspiration should be used.

Adding droperidol to morphine patient-controlled analgesia: effect on nausea and vomiting.

This prospective, double-blind, randomized, controlled trial was performed to evaluate the antiemetic effectiveness and side effects of adding droperidol to morphine delivered via a patient-controlled analgesia (PCA) device in 94 women undergoing transabdominal hysterectomy with a standardized anesthetic regimen. They were randomly allocated to receive postoperative PCA as either bolus doses of morphine I mg or a combination of morphine 1 mg and 0.0625 mg droperidol with a lockout interval of 5 minutes and no continuous infusion. The incidence of nausea 6-18 hours postoperatively and 18-24 hours postoperatively was significantly lower in the morphine and droperidol group than in the morphine only group and its severity 2-6 hours, 6-18 hours, and 18-24 hours postoperatively was significantly lower. The number needed to treat to prevent nausea comparing the morphine only group at 6-18 and at 18-24 hours postoperatively were 4 and 4 (95% CI 2-27 and 2-11, respectively). The amount of morphine used 6-18 hours postoperatively in the droperidol group was lower than in the morphine only group. Although the incidence of vomiting and the amount of rescue antiemetics were lower in the morphine and droperidol group, the difference was not statistically significant. Postoperative pain scores were not different between the groups. No patients were oversedated. A series of extrapyramidal reactions were observed in one patient in the morphine and droperidol group. The drug and consumable item cost was not different between the groups. We conclude that droperidol added to morphine in PCA reduces nausea. The appropriate dose of droperidol should be further investigated to reduce the incidence of vomiting.

Postoperative analgesic effects of intravenous lornoxicam and morphine with pre-emtive ropivacaine skin infiltration and preperitoneal instillation after transabdominal hysterectomy.

To investigate the effectiveness of intravenous lornoxicam and morphine with the preemptive effects of ropivacaine local skin infiltration and peritoneal instillation in reducing postoperative pain after transabdominal hysterectomy, a randomized, double blinded, placebo-controlled study was done in 88 patients undergoing transabdominal hysterectomy under general anesthesia. The patients were allocated into 4 groups to receive: (group A) only intravenous morphine 10 mg; (group B) intravenous morphine 10 mg and lornoxicam 16 mg; (group C) intravenous morphine 10 mg, lornoxicam 16 mg with 0.5 per cent ropivacaine local skin infiltration before skin incision and 1 per cent ropivacaine instillation before peritoneal incision; (group D) intravenous morphine 10 mg, lornoxicam 16 mg with 1 per cent ropivacaine instillation after peritoneal closure and 0.5 per cent ropivacaine local skin infiltration before skin closure. Pain was assessed by patients using visual analog scales (VAS) at 2, 6, 12, 18, 24, 48 hours after surgery. Time to first analgesic requirement and morphine requirement during the first 6 h were significantly lower in the groups using lornoxicam (group B, C, D) as compared with the group using only morphine (group A). However there was no significant difference between group B and group C or group D which means that the additional analgesic effects of using local anesthetic infiltration and instillation either before (pre-emptive) or after the incision could not be seen in this study. Implication: Intravenous 16 mg of lornoxicam with 10 mg of morphine significantly reduced postoperative pain during the first 6 h after abdominal hysterectomy. Additional effects of using local anesthetic wound infiltration to the use of lornoxicam could not be demonstrated.

EMLA cream and intraperitoneal lidocaine decrease intraoperative pain during postpartum tubal sterilization.

We conducted a randomized, double blinded, placebo controlled trial to evaluate the effectiveness of EMLA cream together with intraperitoneal lidocaine for pain relief in postpartum tubal ligation. In a factorial designed study, 90 postpartum patients were randomly assigned to have 5 g of EMLA or placebo cream applied to the skin in 2 groups of 45 patients and to have intraperitoneal instillation of 20 ml of either 1 per cent, 2 per cent lidocaine or normal saline in 3 groups of 30 patients. A numerical rating pain score (0-10) was used during skin check, skin infiltration and uterine tube manipulation. The pain scores were significantly lower in the EMLA group as compared with the placebo group during the skin forceps check (p < 0.001) and during local skin infiltration (p < 0.05). The pain scores were also significantly lower during intraabdominal manipulation in the group using either 1 per cent or 2 per cent intraperitoneal lidocaine as compared with the group using normal saline (p < 0.001), but no difference was found between the groups using 1 per cent and 2 per cent lidocaine. IMPLICATIONS: Five g of EMLA cream applied to the skin together with 20 ml of 1 per cent lidocaine instilled into the abdominal cavity effectively decrease intraoperative pain in patients undergoing postpartum tubal sterilization under local anesthesia.

Bupivacaine plus fentanyl for intrapartum continuous epidural analgesia.

Labour pain relief using 0.125% bupivacaine plus fentanyl for intrapartum continuous epidural analgesia and intravenous pethidine plus phenergan were evaluated by randomized clinical trial in 40 patients seen at the labour room of Siriraj Hospital. The progression of labour, pain levels at 15 minutes before and after drug administration and in the second stage, the method of delivery and all side effects within two groups were observed and compared. From the study, it was found that continuous epidural analgesia with the new drug combination was more effective in relieving labour. There was no significant difference in the progression of labour and the frequency of instrumental delivery. The main side effects of nausea, vomiting and somnolence were observed to be less in the study group less than other patient but one parturient was found to have developed hypotension.