Preventing Vomiting in Children Undergoing Tonsillectomy

Preventing Vomiting in Children Undergoing Tonsillectomy Efficacy of Preoperative Administration of Metoclopramide and Dexamethasone in Preventing Vomiting in Children Undergoing Tonsillectomy Shatha Abutineh Ph., Ola Samawi Ph., Lana Mattar Ph., Dr. Osama Al-Elwan, Dr. Basem Al-Kousheh Abstract Objective: 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. Patients and Methods: Ninety patients between the age of 3-14 years who planned for tonsillectomy were enrolled in our study. Patients were randomly divided into three main groups: Group I: In which children 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). All episodes of Postoperative vomiting were recorded Results: 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. 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 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 Conclusion: Metoclopramide found to be more effective than dexamethasone in preventing vomiting in children undergoing tonsillectomy. Key words: Dexamethasone, Metoclopramide, Tonsillectomy. Introduction Tonsillectomy is considered one of the foremost performed surgical procedures in pediatric age group with a reported 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 often perceive Postoperative nausea and vomiting as one of the foremost bothering side effects of anesthesia and many believe about it as distressing as the pain related to the operation (5). Postoperative nausea and vomiting can contribute to the event of medical 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 used as prophylactic medicine in these patients to prevent vomiting. However, its use is restricted by low efficiency and the chance and risk of unwanted adverse effects, such as extrapyramidal symptoms (8). Dexamethasone is considered to be a steroid of low price, with low rate of adverse 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 Methods Ninety 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 groups: Group I: In which children 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 recovery 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 addition 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 first 4 hours and 4-24 hours after the end of general anesthesia. We defined Vomiting as expulsion of the contents of stomach through the mouth; and complete response was defined as absence of Postoperative vomiting without a need for antiemetic. Antiemetic was given when there are 2 or more attacks of Postoperative vomiting in the first 24 hours after general anesthesia. Results: 90 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. Characteristics Group I (n = 30) Group II (n = 30) Group III (n = 30) Age (yr) 4.9 Â ± 3.1 4.8 Â ± 3.2 4.6 Â ± 3.2 Weight (kg) 19.7 Â ± 5.7 20.6 Â ± 5.5 20.1 Â ± 5.3 Sex (male/female) 19/11 20/10 18/12 Type of surgery Tonsillectomy -Adenotonsillectomy 8 22 6 24 6 24 Duration of surgery (min) 17.8 Â ± 3.7 16.6 Â ± 4.2 18.1 Â ± 3.5 Duration of anesthesia (min) 35.1 Â ± 6.3 36.2 Â ± 5.3 36.2 Â ± 6.1 No 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). Discussion Complications of tonsillectomy in children are not uncommon and include pain which may result in poor oral intake, dehydration, vomiting, infection, fever and bleeding. Tonsillectomy 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 mediated by many different mechanisms. The antiemetic and nausea inhibitory effects of metoclopramide are related to its central dopaminergic effects (8). Metoclopramide in high doses was found to be very 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 short 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 benefit 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 earlier return 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. Conclusion Metoclopramide found to be more effective than dexamethasone in preventing vomiting in children undergoing tonsillectomy. References 1. Litman RS, Wu CL, et al. Ondansetron reduces vomiting after tonsillectomy in children. Anesth Analg. 1994 Mar;78(3):478-81 2. Furst SR, et al. Prophylactic antiemetic treatment with ondansetron in children undergoing tonsillectomy. Anesthesiology, 81 (1994), pp. 799-803 3. Ferrari LR, et al. Metoclopramide reduces the incidence of vomiting after tonsillectomy in children. Anesth Analg, 75 (1992), pp. 351-354 4. Rose JB, et al. Postoperative Nausea and Vomiting in Pediatric Patients. British Journal of Anaesthesia1999;83:104 -117. 5. Ledesma MJS, et al. A comparison of three antiemetic combinations for the prevention of postoperative nausea and vomiting. Anesth Analg. 2002 Dec;95(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 2003;41:99-117. 9. Weimert TA, et al. Electro dissection tonsillectomy. Arch Otolaryngology Head Neck Surgery 1990; 116:186-8. 10. Rich W, et al. Methylprednisolone as an antiemetic during cancer chemotherapy: a pilot study. Gynecol Oncol. 1980;9:193-198 11. Harris AL. Cytotoxic-therapy-induced vomiting is mediated via enkephalin pathways. Lancet 1982;1:714-6. 12. Young SN. Mechanism of decline in rat brain 5-hydroxytryptamine after induction of liver tryptophan pyrrolase by hydrocortisone: roles of tryptophan catabolism and kynurenine synthesis. British Journal Pharmacology. 1981 Nov;74(3):695-700 13. Sagar S. The current role of antiemetic drugs in oncology: a recent revolution in patient symptom control. Cancer Treatement Revion 1991;18:95-135. 14. Apfel CC, et al. How to study postoperative nausea and vomiting. Acta Anaesthesiol Scandaneivia, 2002; 46:921-928. 15. Watcha MF Management of postoperative vomiting in pediatric patients. Current Opinion Anaesthesia, 2003; 16:575-583. 16. Scuderi PE. Pharmacology of antiemetics. Int Anesthesiol Clin, 2003; 41:41-66. 17. Gan TJ, Meyer T, Apfel CC et al Consensus guidelines for managing postoperative nausea and vomiting. Anesthesia Analgesia, 2003; 97:62-71. 18. Heatley DG. Perioperative intravenous steroid treatment and tonsillectomy. Archives of Otolaryngology Head Neck Surgery. 2001; 127:1007-1008. 19. Shott SR. Tonsillectomy and postoperative vomiting: do steroids really work? Archives of Otolaryngology Head Neck Surgery. 2001; 127:1009-1010. 20. Vosdoganis F et al (1999). The effect of single dose IV dexamethasone in tonsillectomy in children. Anaesthesia and Intensive Care 27 489-492 21. Catlin FI, et al. The effect of steroid therapy on recovery from tonsillectomy in children. Archives of Otolaryngoogyl Head Neck Surgery. 1991;117(6):649-52. 22. Volk MS, et al. The effects of pre operative steroids on tonsillectomy patients. Otolaryngology Head Neck Surgery. 1993; 109:26-30. 23. Ohlms LA, et al. Use of intra operative steroids in pediatric tonsillectomy. Arch Otolaryngology Head Neck Surgery. 1995; 121:737-742.

Star Trek - The Next Generation :: essays research papers

Star Trek - The Next Generation   Ã‚  Ã‚  Ã‚  Ã‚  Star date: 41176.8 Captain's log. This is my (Captain Jean-Luc Picard of the U.S.S. Enterprise #NCC-17O1 D) account of the events leading up to and beyond the Federation and Romulan war (2380-2385 AD).   Ã‚  Ã‚  Ã‚  Ã‚  Star date: 32851.2: The Enterprise received a distressed call from a fleeing scout ship. SOS... I am ... under ... attack!! request ... asylum ... Federation ... Space!!..   Ã‚  Ã‚  Ã‚  Ã‚  The ship was pushing the limits of its engines as it hurtled out of the neutral zone -- the volume of space that serves as a no-ones-land separating the United Federation of Planets and the Romulan Empire. A powerful Romulan warbird was mercilessly firing wave after wave of disrupter blasts at the small defenseless scout ship. Once the scout was in Federation space, the warbird broke off the attack and quickly retreated back to Romulan space.   Ã‚  Ã‚  Ã‚  Ã‚  We hailed the ship and found out from her captain that he was alone. His name was Shaq, captain of the Check Mate. He claimed to be a Romulan captain in search of Federation asylum. I had never heard of such a thing; in Romulan society, loyalty to the Romulan Empire is more sacred than life itself. In any event, I was certain that we would learn a lot more during the next few days.   Ã‚  Ã‚  Ã‚  Ã‚  Star date: 32851.5: Captain Shaq claimed that he was defecting in order to prevent intergalactic war. He told us that the Romulan Empire has plans for an abominable new weapon for use against the Federation and any others who might dare to resist total domination of the Romulans. The weapon, called the Metagenic Device, would be launched from orbit to any planet and release a deadly virus throughout the planet's atmosphere. The virus would then quickly infect all forms of life and cause fatal mutations in the DNA of its victims. Within twenty-four hours, all life would cease. Within thirty-six hours, the virus itself would break down becoming inviolable, leaving the planet's resources free for plunder.   Ã‚  Ã‚  Ã‚  Ã‚  At this time we did not know if we should trust Captain Shaq, so I decided to send an away team to investigate his ship and its computer record. As I was ordering my number 1 officer, Commander Riker, with the away team over to the Checkmate, Shaq warned me against such action claiming that he had initiated a self-destruct sequence before leaving his vessel. Seconds later, the scout ship exploded. We immediately questioned Captain Shaq as to why he initiated the self-destruct. He replied, that though he wanted to prevent the war, he was no traitor and would not willingly give up the secrets of his

Humanities Religion Paper Essay

Throughout the span of this course I have learned what it takes to build a successful empire. There are many tactics that are involved in constructing an empire that is stable, which include an effective irrigation system, having an army, land for crops to grow, a system of government, the development of social classes, a trading system, tools and specialized skills for the making of goods, and a shared standpoint of religious beliefs. The one thing that I found most intriguing is how throughout the period of time every civilization has had some sort of caste system. A caste system is a social structure which separates individuals of a civilization into their inherited social class; it can also prohibit the marriage of two individuals of different caste. In the time we live in now you can still separate people into a variety of different social classes such as: upper class, upper middle-class, middle-class, lower middle-class and poor. But let’s rewind a few thousand years in to one of the earliest known civilizations, the Mesopotamians. The history of Mesopotamians can be separated into two categories, the Sumerian period and the Semitic period. During these periods I see the caste system come into play because Priests were at the top of the chain, they were the ones who controlled religious and economic dealings. The Law Code of Hammurabi, I would also consider to be part of a caste system. Majority of the Law code’s requirements deal with the relationship between a husband and wife, along with the relationship between other members of the family, these are a couple of the passages from the code: 131. If a man accuses his wife and she has not been taken lying with another man, she shall take an oath in the name of god and she shall return to her house (book). 145. If a man takes his wife and she does not present him with children, and he sets his face to take a concubine, that man may take a concubine and bring her into his house (book). Even though these do not directly deal with a certain social standing they do however show the standing of women during this period, and also these laws would apply to anyone in any social class. The Egyptians had their own form of the caste system. Egypt was structured so that there was an upper and lower caste. They had a strongly controlled government ruled by one single ruler, the pharaoh. The pharaoh was regarded as a living god, the equal of any other deity (book). Right below the pharaoh was the priest, whose responsibility was to preserve the tradition of religious beliefs. Pharaohs are at the top of the chain, government officials fall directly below the pharaoh and consist of nobles and priests. Next on the chain below the government officials would be the soldiers, merchants and artisans fell directly under the soldiers, farmers were second to last on the chain and then at the very bottom you find the slaves. During ancient Greece time in the city of Athens, I see a form of the caste system fall into place. Social classes during the ancient Greece period applied strictly to men and women took their social standing from their husbands. Any person born into an Athenian family is considered to be a citizen and part of the upper class during this period. The middle class was comprised with merchants, merchants were any men who were non-citizens and are ineligible to become a citizen. The lower class was any freed slave. A slave could become free only if his/her ransom was paid off by a family member. Again you see the slaves fall at the very bottom of all caste systems. Athenians viewed their slaves as barbarians because most, if not all were from a foreign region. I have also learned that the Romans had a set caste system. In my book it states that the Romans had an extremely hard working middle class that were devoted to their central government. When I was reading this, all I could think about is how my family would be considered middle class and how hard working both my parents are. They are devoted to making sure I am provided with what I need, which is what Augustine wanted for the Romans. Augustine’s social reforms were intended directly at the upper classes and were anticipated to return his people to traditional family values. During the Roman republic citizens were split into two classes the patricians and the plebeians. Patricians also known as aristocrats filled the upper class; they had elite rights to the Roman Senate and magistrates. The lower class was known as the plebeians. The plebeians would elect leaders to represent them and their interests while also protecting the lower class people against states officials who treated them discriminatorily. The Aryans are the true developers of the caste system. They made a separation between nobility and the common people. The caste system of the Aryans divided their society into castes of priesthood, the warriors, the laborers and the serfs. India went through many changes and so did their caste system. The caste system was one the shaping social forces in India, reinforced by many laws concerning marriage, table exclusion, laws of rituals purity and so on (book). I have found the caste system of India the most fascinating so far, I believe it most accurately represents the way we caste individuals now.

Motor Accident Claims And Compensation - 2451 Words

DISSERTATION SYNOPSIS ON MOTOR ACCIDENT CLAIMS AND COMPENSATION SUBMITTED FOR THE PARTIAL FULFILLMENT OF THE COURSE REQUIREMENT OF X SEMESTER AREA OF RESEARCH TRANSPORTATION LAW SUBMITTED TO: Mr. Udayakumara Ramakrishna B.N. FACULTY IN CHARGE, TRANSPORTATION LAW SUBMITTED BY: REGISTRATION NO. – 10A047 SEMESTER - X GUJARAT NATIONAL LAW UNIVERSITY, GANDHINAGAR, 16TH FEBRUARY, 2015 INTRODUCTION Transportation is a very basic thing which is part of our day-to-day life and daily experience of the common people. As there are many rules, regulation and laws in this country which directly dealing with this matter. As this is the very important and basic thing because as country like us we can’t avoid matter related to transportation because as every country have their basic facilities and daily work through this. As we talking about transportation law then in this case Indian authority are not so conscious about the Transportation law and law abiding. Because as taking example of Indian practice for the rules and regulation for the transportation then in this case most of the time people even don’t know what kind of rules are there, what are the regulations, insurance policies, accidental claims and remedy for that? As in this situation first of all they have to know what are rules and then any insurance guidelines and what remedies they are available with them thr ough courts. If any misfortune happens during journey then who is having liability of the damage and lossShow MoreRelatedCar Accidents Essay992 Words   |  4 PagesCar accidents are a leading cause of both morbidity and disability. A car accident is said to have occurred when a motor vehicle collides with another motor vehicle, a pedestrian, an animal, a structure, a building or road equipment. Despite strict laws that govern speeding, drunk driving, distracted driving and overall driver negligence, car accidents continue to increase. New data from the National Safety Council shows that car accident fatalities have increased by a third from 2014 to 2016 inRead MoreA Brief Note On The Tampa Bay Auto Accident949 Words   |  4 Pages[Auto Accidents] The Tampa Bay Auto Accident Attorney with the experience you need and the personal attention you deserve. What should you do after a car accident? In Florida there are over 16,000 million drivers and more than 200,000 car accidents per year. It’s likely that one day you will be involved in a car accident. Here are some important guidelines to follow if you are in an accident: †¢ Never leave the scene of a car accident. If you do, you risk criminal charges. †¢ Check to see if thereRead MoreWrite An E Book For Clauson Law4864 Words   |  20 PagesGoal: to write an e-book for Clauson Law Total Word Count In This Document: 4882 Title Suggestions: ?A Guide To Handling Motor Vehicle Accidents?, ?What To Do After A Motor Vehicle Accident?, ?Everything You Should Know About Motor Vehicle Accidents The Law? Introduction One day you are going about your daily routine and business as if it were any other day. you wake up, wash up, get ready for school or work, eat breakfast, and get in your car to go to your classes or your office. Or maybeRead MoreRisk Management : Colorado State University Global1289 Words   |  6 Pagesstep of traditional risk management is to identify loss exposures. The first loss exposure identified is property damage due to tornadoes. Second, slips or falls of guests or employees on the campus is a personal or personnel loss exposure. Third, motor vehicle incidents, a liability, involving employees driving CSU-Global vehicles are an exposure. A fourth loss exposure is privacy of student or employee information caused by cyber risks. Sexual transgression crimes and the civil lawsuits from theRead MoreInsurance Company Essay1021 Words   |  5 PagesCompanies after a Car accident in Kansas City, MO? The roads in Kansas City, MO are congested every single day. To make matters worse, many people drive over the posted speed limit. This inevitably leads to motor vehicle accidents. Whenever the motor vehicle accident is serious and leads to personal injury and/or property damage, the driver is required to report the incident to both his insurance company and that of the other party. When you first get involved in a car accident, resist the impulseRead MoreTort Law Reform And The Law Of Negligence994 Words   |  4 Pages211 CLR 540; 194 ALR 337; Harriton v Stephens (2006) 226 CLR 52; 226 ALR 391; Caltex refineries (Qld) Pty Ltd v Stavar (2009).75 NSWLR 649; 259 ALR 616. The plaintiff must also be foreseeable: Seltsam Pty Ltd v McNeill (2006) DDCR 1. The ‘compensation culture’ was ‘hysterical’ in 1990’s in relation to Tort of Negligence of public liability insurers. The action requested by Government to investigate on a national level of process (which involved the investigations, research and production ofRead More1. Paixà £o And Another v Road Accident Fund 2012 (6) SA 377 (SCA) 2. The court of the first900 Words   |  4 PagesPaixà £o And Another v Road Accident Fund 2012 (6) SA 377 (SCA) 2. The court of the first instance was at the South Gauteng High Court, Johannesburg and the judge was Mathopo J. 3. Paixao and Another v Road Accident Fund [2011] ZAGPJHC 68 4. The Road Accident Fund is the South Africans state insurer, which is entailed in law regulations relating to the issue of delict in accordance with the Act for damages or loss, for people in society who are involved in motor vehicle accidents. 5. Widowed, Mrs PaixaoRead MoreCases Based Off Civil Wrongs Are Known As Torts1042 Words   |  5 Pagesor awarded in compensation for a loss or an injury Personal Experience My tort experience, revolves around a motor vehicle accident. To explain, I had caused an accident which under normal circumstances would not have happened. The incident involved the liquid form of magnesium chloride, which is used to prevent ice buildup in winter driving conditions. This product was applied by the City and/or State s Department of Transportation (DOT). On the particular evening my accident had happened,Read MoreWarranties Are An Important Contract Term1716 Words   |  7 Pageswould have resulted in cover terminating automatically from the time of the breach with the contract essentially becoming voided from the date of the breach. The insured would still be required to pay the premium and the insurer could repudiate the claim as the policy would have been voided from the date of the breach. Since the Insurance Act, warranties are still an important contract term although breach of a warranty will not result in termination of the policy. The Insurance Act has amendedRead MoreBusiness Law Irish1299 Words   |  6 Pages1. A person’s conduct can give rise to a negligence claim if he or she fails to act with reasonable care and another person suffers some harm as a result. If you have been the victim of negligence that has resulted in a personal injury or an injury to your property, you can file a negligence claim. In addition to knowing whether or not you have suffered harm due to someone else’s negligence, it is important you understand basic procedural rules to filing your negligence complaint. In order to prove