1. The Case 36 year-old female, ASA 1, under went an elective repeat caesarean section under spinal anesthesia using hyperbaric bupivacaine 15mg + fentanyl 10 ug. She delivered a 3.0 k baby boy, 30 minutes after cutting. After which she complained of nausea and vomiting. Metoclopramide 10 mg IV was given but vomiting recurred.

2. The Clinical Question Among ASA 1 adults who will under go elective caesarian section under spinal anesthesia, what effective anti emetic can be used to prevent intra operative nausea and vomiting?

3. The Search

4. The Journal Subhypnotic doses of midazolam, prevent nausea and vomiting during spinal anesthesia in elective caesarean section Tarhan, O et al. Minerva Anestesiologica 2007; 73 629 - 633

5. The Journal Patients: – Ninety, ASA I – II, 28 – 30 yo, for elective ceasarean section under SAB using bupivcaine heavy 8 -10 mg + fenatnyl 10 ug Intervention: – Patients grouped into 3, given: – Propofol, Midazolam, or Saline Comparison: Saline as control Outcome: nausea, retching, vomiting, sedation

6. The Journal Outcome: Scoring for emesis 0 = No symptoms 1 = Nausea (unpleasant sensation of vomiting) 2 = Retching (spasmodic contraction of abdominal wall and diaphragm without expulsion of gastric content ) 3 = Vomiting (same as 2 but with expulsion of gastric contents

7. The Journal Outcome: sedation Ramsay sedation scoring 1 : awake, agitated, anxious 2: awake, cooperative, oriented, tranquil 3: semi - asleep but follows command 4: asleep but briskly responds 5: asleep with sluggish response 6: no response can be elicited

8. Assessing Validity 1. Where patients randomly assigned to treatment groups Yes. Patients were randomly assigned to three treatment groups. Randomization was through computer generated random numbers

9. The treatment groups The test substances were given immediately after cord clamping Propofol (20 mg as bolus, 1 mg/kg/hr as infusion) : N = 30 Based on Numazaki et al Midazolam (1 mg as bolus, 1 mg /hr infusion) : N = 30 Based on Di Florio et al

10. Assessing Validity 2. Was allocation concealed? Unclear. No mention of concealment of allocation although infusion pump and syringes where assigned number by personnel not involved in the study

11. Assessing Validity 3. Were the groups similar at the start of the trial? Yes, patient demographic data was similar between the groups (analyzed using ANOVA and chi- square test)

12. Assessing Validity

13. 4. Were patients treated equally? Yes Ranitidine 150 IV mg preop Preloading 20 ml/ kg of PLRS before induction Bupivacaine 8 – 10 mg + Fenatnyl 10ug given intrathecally L3 – L4 O2 at 5 lpm via mask 20% decrease in BP or (or below SBP <100) treated by fluids and ephedrine 5 – 10 mg IV Fentanyl 100 ug given post op prn for pain

14. Assessing Validity 5. Were patients and caregivers/ outcome assessors blinded to treatment assignment? Yes, identical syringes and infusion pumps were prepared and covered then assigned numbers by a personnel not aware of the study. Emetic episodes were recorded by an anesthesiologist who was not aware of the endpoints

15. Assessing Validity 6. Were all patients who entered the study accounted for ? Yes, 2 patients in the control group had to be given rescue anti emetics and were withdrawn, leaving the group with 28 subjects

16. What were the results

17. The incidence of nausea, retching and vomiting is higher in the control group compared to the propofol and midazolam group (P value <0.05%) EventPropofolMidazolam Control nausea606696 retching3.31043.3 vomiting6.61046.6

18. What were the results

19. Appraising the results 1. How large was the treatment effect? Relative risk (RR) : < 1 ( there is a decrease in the event) EventPropofolMidazolam nausea0.620.69 retching0.080.23 vomiting0.140.21

20. Appraising the results 1. How large was the treatment effect? Absolute risk reduction (ARR) : % Reduction of the event EventPropofolMidazolam nausea3630 retching4033.3 vomiting4036.6

21. Appraising the results 1. How large was the treatment effect? Relative risk reduction (1-RR): % Reduction of the event in relation to the control EventPropofolMidazolam nausea3831 retching9377 vomiting8678

22. Appraising the results 1. How large was the treatment effect? Number needed to treat EventPropofolMidazolam nausea33 retching23 vomiting23

23. Appraising the results 1. How precise was the measurement of the treatment effect? P values obtained for both midazolam and propofol versus control were less than 0.05 % = statistically significant.

24. CONCLUSION A subhypnotic dose of midazolam (1mg/hr) is as effective as subhypnotic dose propofol (1mg/kg/hr) for the prevention of nausea and vomiting in parturients undergoing elective caesarean section under spinal anesthesia

25. Assessing applicability 1. Is my patient so different to those in the study that the results cannot apply? Based on the demography, the results are applicable to our patients.

26. -This study has informed me that midazolam and propofol can be used as anti emetic during elective caesarian section under spinal anesthesia HOWEVER Assessing applicability 2. Will the results help me in caring for my patient?

27. Assessing applicability 3. Is the treatment feasible in my setting? Limitation: Elective caesarean section Cost Availabilty of infusion pump

28. Salamat Po!