Preventing Vomiting in Children Undergoing Tonsillectomy

Preventing Vomiting in Children Undergoing TonsillectomyEfficacy of Preoperative Administration of Metoclopramide and dexamethasone in Preventing Vomiting in Children Undergoing TonsillectomyShatha Abutineh Ph., Ola Samawi Ph., Lana Mattar Ph., Dr. Osama Al-Elwan, Dr. Basem Al-KoushehAbstractObjective To carry step up a comparative champaign between metoclopramide and dexamethasone to find out its effect by the way of preoperative administration on the rate of postoperative emesis in children who undergoing tonsillectomy.Patients and Methods Ninety patients between the age of 3-14 years who be after for tonsillectomy were enrolled in our study.Patients were randomly divided into three main comp some(prenominal)s separate I In which children accepted Dexamethasone injection with a dose of 0.15 mg/kg IV (n = 30).Group II In which children reliable Metoclopramide injection with a dose of 0.15 mg/kg IV (n = 30).Group III In which children received 4 ml saline (n = 30).All episodes of postoperative vomiting were recordedResults on that point were no significant differences between these three main separates of patients regarding the age, sex, weight, type of operating theater, continuance of surgery and duration of anesthesia.The incidence of vomiting throughout the initial four hours (0-4 hours) was not wasnt considerably different between the three groups, three patients (10%) in the dexamethasone group compargond with 3 patients (10%) in the metoclopramide group and 4 patients (13%) in the saline group (P 0.05).The incidence of vomiting during (4-24 hours) was more than frequent in the saline group, 8 patients (27%) genuine vomiting (P 0.001). Only three (10%) patients in the metoclopramide group vomited during this period compared with 6 patients (20%) in the dexamethasone groupConclusion Metoclopramide appoint to be more effective than dexamethasone in preventing vomiting in children undergoing tonsillectomy.Key words Dexamethasone, Metocloprami de, Tonsillectomy.IntroductionTonsillectomy is considered one of the foremost performed surgical procedures in paediatric age group with a describe rate of postoperative vomiting ranging between 40%-73% (1-3).The rate of postoperative emesis is found to be higher in pediatric patients than in adults who undergo tonsillectomy (4).Patients a lot perceive Postoperative nausea and vomiting as one of the foremost bformer(a)ing side effects of anesthesia and many retrieve about it as distressing as the pain related to the operation (5). Postoperative nausea and vomiting can contribute to the event of health check complications (6,7), and patients with Postoperative nausea and vomiting consume a lot of resources and need extra health care skilled time compared with patients in whom these complications square measure avoided.Metoclopramide is often utilize as prophylactic medicine in these patients to prevent vomiting. However, its use is restricted by low efficiency and the chance an d assay of unwanted unbecoming effects, such as extrapyramidal symptoms (8).Dexamethasone is considered to be a steroid of low price, with low rate of uncomely effects, prolonged anti vomiting effect in cancer patients, and highly effective in reducing the rate of postoperative vomiting in kids who undergo tonsillectomy (8). However, their actual mechanism in preventing nausea or vomiting continues to be unknown.The aim of our study is to carry out a comparative study between metoclopramide and dexamethasone to find out its effect by the way of preoperative administration on the rate of postoperative emesis in children who undergoing tonsillectomy.Material and MethodsNinety patients of both genders, aged 3-14 years who planned for tonsillectomy were enrolled in the study.The exclusion criteria were, all Children who received steroids, antiemetic and antihistamine drugs twenty four hours prior to surgery.Patients were randomly divided into three main groupsGroup I In which childre n received Dexamethasone injection with a dose of 0.15 mg/kg IV (n = 30).Group II In which children received Metoclopramide injection with a dose of 0.15 mg/kg IV (n = 30).Group III In which children received 4 ml saline (n = 30).The drugs were administered i.v immediately before induction of anesthesia.Patients were instructed to fast from midnight and without giving them any premedication. All the operations were performed by one surgeon using the cold dissection method. The bleeding was controlled by cauterization using bipolar diathermy.All patients were transferred after surgery to the reco real room first before they transferred to the ward. After being transferred to the floor, a soft food was given to all patients throughout their hospital stay. In supplement to that, all patients had given a maintenance intra venous fluid until adequate oral intake was achieved.All attacks of Postoperative vomiting were reported by nurses who do not know about the study group during the fi rst 4 hours and 4-24 hours after the end of general anesthesia. We defined Vomiting as expulsion of the content of stomach through the mouth and complete response was defined as absence of Postoperative vomiting without a need for antiemetic.Antiemetic was given when in that location are 2 or more attacks of Postoperative vomiting in the first 24 hours after general anesthesia.Results90 patients (30 per group) were included in the study. There were no significant differences between these three main groups of patients regarding the age, sex, weight, type of surgery, duration of surgery and duration of anesthesia. (Table 1).Table 1 Demographic characteristics of patients in their respective group.CharacteristicsGroup I(n = 30)Group II(n = 30)Group III(n = 30)Age (yr)4.9 3.14.8 3.24.6 3.2Weight (kg)19.7 5.720.6 5.520.1 5.3Sex (male/female)19/1120/1018/12 slip of surgery Tonsillectomy-Adenotonsillectomy822624624Duration of surgery (min)17.8 3.716.6 4.218.1 3.5Duration of ane sthesia (min)35.1 6.336.2 5.336.2 6.1No significant difference were found between these three groups in regard to the incidence of post operative vomiting in first 4 hours (0-4 hours), three patients (10%) in the dexamethasone group compared with 3 patients (10%) in the metoclopramide group and 4 patients (13%) in the saline group (P 0.05).The incidence of vomiting during (4-24 hours) was more frequent in the saline group, 8 patients (27%) developed vomiting (P 0.001). Only three (10%) patients in the metoclopramide group vomited during this period compared with 6 patients (20%) in the dexamethasone group.Thus Emesis-free within the first 24 hours was achieved significantly more often in patients who had received metoclopramide than in those who had received dexamethasone or placebo (saline).DiscussionComplications of tonsillectomy in children are not uncommon and include pain which whitethorn result in poor oral intake, dehydration, vomiting, infection, fever and bleeding. Ton sillectomy using bipolar method has been used because of the advantage that it decreases the time of operation and it thus reduce the risk of immediate postoperative bleeding (9). However, bipolar dissection method may result in more postoperative pain (9). The mechanism of action of dexamethasone as an antiemetic is by antagonizing the prostaglandin, inhibit release of tryptophan and endorphins (10-13). These therapeutic effects of dexamethasone leaded to common use of it in children undergoing tonsillectomy.Many medications have been used in order to prevent post operative vomiting (14). The ideal drug to be used should have a good efficacy, little adverse effects and cheap (14,15) .The action of metoclopramide is mainly facilitating the release of acetylcholine. This action may be negotiate by many different mechanisms. The antiemetic and nausea repressive effects of metoclopramide are related to its central dopaminergic effects (8).Metoclopramide in high doses was found to be v ery effective in decreasing chemotherapy-induced vomiting. In very low doses it frequently used to treat nausea and vomiting (8). The aim of using these low doses is to decrease central pyramidal and sedative effects which are found to be more common in children than adults. The efficacy of lower doses of metoclopramide in preventing post operative nausea and vomiting is very variable (8). Because of the absolutely half-life of metoclopramide, it is unlikely to produce any antiemetic effect in the recovery period if administered during induction of anesthesia (8,16). Different reports have studied the make of administration of 10 mg metoclopramide in adult patients (17).Several studies regarding the effect of a single preoperative I.V dose of steroid on the morbidity of tonsillectomy has been reported different results (18,19). Many reports have found that preoperative administration of a single dose of I.V steroid have reduced the postoperative pain, emesis with an primarily ret urn to normal oral intake feeding (20-22).On other hand another different studies have found no significant differences (23).However, in our study only three (10%) patients in the metoclopramide group vomited during 4-24 hour period compared with 6 patients (20%) in the dexamethasone group and 8 patients (27%) in the saline group. On the other hand, there was no significant difference between the three groups in regard to the incidence of vomiting during the first four hours.ConclusionMetoclopramide found to be more effective than dexamethasone in preventing vomiting in children undergoing tonsillectomy.References1. Litman RS, Wu CL, et al. Ondansetron reduces vomiting after tonsillectomy in children. Anesth Analg. 1994 Mar78(3)478-812. Furst older et al. Prophylactic antiemetic treatment with ondansetron in children undergoing tonsillectomy. Anesthesiology, 81 (1994), pp. 799-8033. Ferrari LR, et al. Metoclopramide reduces the incidence of vomiting after tonsillectomy in children. Anesth Analg, 75 (1992), pp. 351-3544. Rose JB, et al. Postoperative Nausea and Vomiting in Pediatric Patients. British Journal of Anaesthesia199983104 -117.5. Ledesma MJS, et al. A comparison of three antiemetic combinations for the prevention of postoperative nausea and vomiting. Anesth Analg. 2002 Dec95(6)1590-5.6. Celiker V, et al. Minimum effective dose of dexamethasone for preventing nausia and vomiting after adenotonsillectomy. J Ankra medical school 2003 25(1)21-25.7. Schumann R, et al. Massive subcutaneous emphysema and sudden airway compromise after postoperative vomiting. Anesth Analg 1999 89 796-797.8. Olutoye O, et al. Management of postoperative vomiting in pediatric patients. Int Anesthesiol Clin 20034199-117.9. Weimert TA, et al. Electro dissection tonsillectomy. Arch Otolaryngology Head bed Surgery 1990 116186-8.10. Rich W, et al. Methylprednisolone as an antiemetic during cancer chemotherapy a pilot study. Gynecol Oncol. 19809193-19811. Harris AL. Cytotoxic-thera py-induced vomiting is mediated via enkephalin pathways. Lancet 19821714-6.12. Young SN. Mechanism of decline in rat brain 5-hydroxytryptamine after induction of liver tryptophan pyrrolase by cortisol roles of tryptophan catabolism and kynurenine synthesis. British Journal pharmacological medicine. 1981 Nov74(3)695-70013. Sagar S. The current role of antiemetic drugs in oncology a recent revolution in patient symptom control. crabmeat Treatement Revion 19911895-135.14. Apfel CC, et al. How to study postoperative nausea and vomiting. Acta Anaesthesiol Scandaneivia, 2002 46921-928.15. Watcha MF Management of postoperative vomiting in pediatric patients. Current Opinion Anaesthesia, 2003 16575-583.16. Scuderi PE. Pharmacology of antiemetics. Int Anesthesiol Clin, 2003 4141-66.17. Gan TJ, Meyer T, Apfel CC et al Consensus guidelines for managing postoperative nausea and vomiting. Anesthesia Analgesia, 2003 9762-71.18. Heatley DG. Perioperative intravenous steroid treatment and tonsil lectomy. Archives of Otolaryngology Head Neck Surgery. 2001 1271007-1008.19. Shott SR. Tonsillectomy and postoperative vomiting do steroids really work? Archives of Otolaryngology Head Neck Surgery. 2001 1271009-1010.20. Vosdoganis F et al (1999). The effect of single dose IV dexamethasone in tonsillectomy in children. Anaesthesia and Intensive Care 27 489-49221. Catlin FI, et al. The effect of steroid therapy on recovery from tonsillectomy in children. Archives of Otolaryngoogyl Head Neck Surgery. 1991117(6)649-52.22. Volk MS, et al. The effects of pre operative steroids on tonsillectomy patients. Otolaryngology Head Neck Surgery. 1993 10926-30.23. Ohlms LA, et al. Use of intra operative steroids in pediatric tonsillectomy. Arch Otolaryngology Head Neck Surgery. 1995 121737-742.