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Context Spinal morphine is a common form of postoperative Intervention Patients received either dexamethasone 10 mg in
analgesia after caesarean section, but it is associated with 100 ml of isotonic saline, intravenously or 100 ml of isotonic
postoperative nausea and vomiting. saline (placebo) prior to surgery.
Objective To evaluate the hypothesis that dexamethasone Main outcome Incidence of postoperative nausea and vomiting
reduces nausea and vomiting in patients undergoing caesarean in the first 24 h were rated and recorded. Pain scores at rest and
section under spinal anaesthesia with morphine. on movement were evaluated using a visual analogue scale.
Design Interventional, randomised, double-blinded, placebo- Results During the first 24 hours, nausea occured in 12/35
controlled study to evaluate a preoperative single dose of (34.4%) patients receiving dexamethasone and in 32/35
dexamethasone. (91.4%) receiving placebo (P < 0.001). During the same time
Setting Patients from a tertiary hospital in the city of Sao Paulo, period, vomiting occured in 12/35 (34.4%) patients receiving
Sao Paulo, Brazil observed from 1 January through 30 June dexamethasone and in 29/35 (82.9%) receiving placebo
2008. (P < 0.001). Pain at rest and pain on movement was lower in
Patients or other participants Seventy full-term pregnant patients who received dexamethasone at some time points
patients (American Society of Anesthesiologists 1 or 2) during the study period.
were studied. Patients were randomly allocated into Conclusion Dexamethasone reduced the cumulative incidence
two groups determined by a computerised table. Exclusion of nausea and vomiting after caesarean section under spinal
criteria were contraindication to regional anaesthesia, anaesthesia with morphine and lowered pain scores on the first
allergy to dexamethasone, opioids or local anaesthetics, postoperative day.
hypertension or diabetes originated during pregnancy and Eur J Anaesthesiol 2013; 30:102105
use of any antiemetic drug received before surgery. Spinal Published online 2 October 2012
anaesthesia consisted of hyperbaric bupivacaine and Keywords: anaesthesia, caesarean section, dexamethasone, morphine,
morphine. spinal
participants. Patients were invited to participate during measurements obtained immediately before the admin-
their admission to a pre-partum room. Patients were istration of spinal anaesthesia. After their infants were
excluded if they had any contraindication to receiving delivered, patients received ketoprofen 100 mg, dipyrone
regional anaesthesia; were allergic to dexamethasone, to 2 g and oxytocin 15 IU intravenously. Starting 6 h after
opioids or local anaesthetics; presented with pregnancy- delivery, patients received diclofenac 75 mg orally every
induced hypertension or diabetes; or had received any 8 h and dipyrone 2 g every 6 h.
antiemetic drug in the 24 h prior to the scheduled
caesarean section. The study was double-blinded and the anaesthesiologist
who was responsible for the postoperative evaluations
Patients were randomly allocated into two groups using a
was not present during surgery. The evaluations were
computer-generated table and received a single dose of
performed every hour for the first 3 h and then at 6, 12 and
dexamethasone 10 mg in 100 ml 0.9% saline immediately
24 h following the administration of spinal morphine.
prior to surgery or placebo (100 ml 0.9% saline).
The primary endpoint was the incidence of nausea and
Spinal anaesthesia was administered with 15 mg of hyper- vomiting in the first 24 h after surgery. Patients who had
baric bupivacaine and 60 mg of morphine. Patients a nausea score more than 1 (0 no nausea; 1 mild;
received 10 ml kg1 of lactated Ringers solution. Blood 2 moderate; and 3 severe nausea) or who had two
pressure was measured every 3 min until delivery and or more episodes of vomiting were treated with dimen-
hypotension was treated with a 0.2 mg bolus of metar- hydrinate 50 mg and pyridoxine 10 mg. Pain was evalu-
aminol. Hypotension was defined as any decrease in the ated using a visual analogue scale (VAS) (0 no pain and
SBP from the control value defined as the mean of three 10 worst pain possible) at rest and on movement. To
Fig. 1
Enrolment
Assessed for eligibility (n = 455)
Excluded (n = 324)
Not meeting inclusion criteria (n = 324)
Declined to participate (n = 0)
Other reasons (n = 0)
Randomised (n = 131)
Allocation
Allocated to dexamethasone (n = 35) Allocated to saline infusion (n = 35)
Received dexamethasone (n = 35) Received saline infusion (n = 35)
Did not receive dexamethasone (n = 0) Did not receive saline infusion (n = 0)
Follow-up
Lost to follow-up (n = 0) Lost to follow-up (n = 0)
Discontinued intervention (n = 0) Discontinued intervention (n = 0)
Analysis
Analysed (n = 35) Analysed (n = 35)
Excluded from analysis (n = 0) Excluded from analysis (n = 0)
Study flow diagram for 70 patients undergoing elective caesarean section under spinal anaesthesia with low-dose morphine.
evaluate pain with movement, patients were asked to Table 2 The effect of dexamethasone on the incidence of nausea,
vomiting and pain at rest and with movement following caesarean
cough while in the recovery room and asked to sit in bed section under spinal anaesthesia
while in the ward. Breakthrough pain (>3 on the VAS or
Dexamethasone Control
when indicated as such by the patient) was treated with group group
tramadol 100 mg infused over 20 min. (n U 35) (n U 35) P
Table 3 Incidence of nausea and vomiting in the post-anaesthesia care unit, ward and first 24 h in dexamthasone and control groups
Nausea (n U 35) Vomiting (n U 35)
Dexamethasone Control P Dexamethasone Control P
Jokela et al. used a reduction in the oxycodone consump- In conclusion, although we observed a trend towards a
tion of patients who were using patient-controlled analge- lower incidence of postoperative nausea and vomiting in
sia pumps, whereas we evaluated pain using VAS pain the dexamethasone group, this effect was significant only
scores at rest and on movement. Other studies have also when considering the cumulative incidence. It was also
demonstrated the potential benefits of steroids for associated with reduced pain scores during the first
improving the quality of postoperative analgesia, both postoperative day.
at rest and with movement, which is of special interest in
the obstetric population, as mothers generally want to Acknowledgements
take care of their babies. Wu et al. also demonstrated that Assistance with the study: the authors would like to thank
the VAS scores during rest or with movement between Dr Joaquim Vieira for his assistance with the study.
6 and 24 h postoperatively were lower in patients who Financial support and sponsorship: this work was supported by the
received dexamethasone.1 The analgesic effects of Department of Anaesthesiology, Santa Casa de Misericordia, Sao
steroids are mainly provided through peripheral inhi- Paulo, Brazil.
bition of phospholipase enzymes which decreases the
Conflicts of interest: none declared.
products of the cyclooxygenase and lipoxygenase path-
ways in the inflammatory response.6 These character-
istics make dexamethasone a suitable drug for the References
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treatment of pain, both at rest and on movement.7 after intrathecal morphine for caesarean: a randomized comparison of
dexamethasone, droperidol and a combination. Int J Obstet Anesth 2007;
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problems is impaired wound healing during the acute cyclizine, dexamethasone and placebo. Br J Anaesth 2003; 90:665670.
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when the total number in our hospital is considered. The dexamethasone improves surgical outcome after laparoscopic
cholecystectomy. A randomized double-blind placebo-controlled trial.
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