Colostomy as a definitive treatment in an ALS patient with acute colonic Pseudo-obstruction refractory to medical management, a case report.

BACKGROUND: Amyotrophic lateral sclerosis (ALS) is a fatal motor neuron disease, and ALS patients may experience disturbed gastrointestinal motility often resulting in acute colonic pseudo-obstruction (ACPO). There is currently a paucity in the literature to guide the treatment of patients with both ALS and ACPO. CASE PRESENTATION: Here we describe a 39-year-old male patient with advanced ALS who developed ACPO. His condition was refractory to both medical and procedural managements including polyethylene glycol, senna, and docusate suppository, metoclopramide, linaclotide, erythromycin, prucalopride, neostigmine, and repeated colonoscopies. He ultimately underwent successful colostomy for palliation. Here we report the peri-operative multidisciplinary approach taken with this case, the surgical procedures, the potential risks, and the outcome. CONCLUSION: The patient is delighted with the result and requested publication of this case to raise awareness of constipation in ALS patients and promote the consideration of colostomy as a treatment option for patients with ileus resistant to conservative management. Ultimately, a multidisciplinary team approach is required to properly assess the risks and benefits to achieve good clinical outcomes.

Association of Postoperative Nausea and Vomiting Incidence With Neutrophil-Lymphocyte Ratio in Ambulatory Maxillofacial Surgery.

PURPOSE: Postoperative nausea and vomiting (PONV) constitutes an important factor in ambulatory surgery. The mechanisms of the antiemetic action of potent anti-inflammatory corticosteroids, which are used extensively for the treatment of PONV, as well as the association between PONV and inflammation, have not been investigated sufficiently. We aimed to establish the association between the neutrophil-lymphocyte ratio (NLR) and postoperative antiemetic administration, as well as to investigate whether the NLR would be a biomarker for PONV. MATERIALS AND METHODS: The anesthesia records of American Society of Anesthesiologists (ASA) physical status I or II patients who underwent ambulatory routine oral surgery under general anesthesia were evaluated after we obtained ethical approval from the faculty ethics committee. A 5-point scale was used to score PONV. Metoclopramide (Metpamid, Istanbul, Turkey) was used as the first choice in patients who had a PONV scale score of 1 or higher. Data regarding metoclopramide administration during extubation and discharge periods were analyzed. Sixty-four patients were randomized and enrolled in the study with an NLR less than 2 (group I, n = 37) or an NLR greater than 2 (group II, n = 27), and metoclopramide administration was evaluated in each case. The association between the NLR and metoclopramide administration was analyzed statistically by a descriptive statistical method in detecting frequencies; the χ2 test was used in comparison of the groups and the t test in independent groups. RESULTS: The metoclopramide administration frequency for PONV was 5.4% in group I and 96.3% in group II. The metoclopramide administration frequency in group II was statistically higher than that in group I (P < .001). CONCLUSIONS: We are of the opinion that the NLR can be easily calculated with data obtained from the complete blood count and could be a marker for PONV. Antiemetic prophylaxis could be given after evaluation of the NLR. However, we suggest that this result should be supported with further prospective studies using larger series.

Interventions for treating hyperemesis gravidarum.

BACKGROUND: Hyperemesis gravidarum is a severe form of nausea and vomiting in pregnancy affecting 0.3% to 1.0% of pregnancies, and is one of the most common indications for hospitalization during pregnancy. While a previous Cochrane review examined interventions for nausea and vomiting in pregnancy, there has not yet been a review examining the interventions for the more severe condition of hyperemesis gravidarum. OBJECTIVES: To assess the effectiveness and safety, of all interventions for hyperemesis gravidarum in pregnancy up to 20 weeks' gestation. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register and the Cochrane Complementary Medicine Field's Trials Register (20 December 2015) and reference lists of retrieved studies. SELECTION CRITERIA: Randomized controlled trials of any intervention for hyperemesis gravidarum. Quasi-randomized trials and trials using a cross-over design were not eligible for inclusion.We excluded trials on nausea and vomiting of pregnancy that were not specifically studying the more severe condition of hyperemesis gravidarum. DATA COLLECTION AND ANALYSIS: Two review authors independently reviewed the eligibility of trials, extracted data and evaluated the risk of bias. Data were checked for accuracy. MAIN RESULTS: Twenty-five trials (involving 2052 women) met the inclusion criteria but the majority of 18 different comparisons described in the review include data from single studies with small numbers of participants. The comparisons covered a range of interventions including acupressure/acupuncture, outpatient care, intravenous fluids, and various pharmaceutical interventions. The methodological quality of included studies was mixed. For selected important comparisons and outcomes, we graded the quality of the evidence and created 'Summary of findings' tables. For most outcomes the evidence was graded as low or very low quality mainly due to the imprecision of effect estimates. Comparisons included in the 'Summary of findings' tables are described below, the remaining comparisons are described in detail in the main text.No primary outcome data were available when acupuncture was compared with placebo, There was no clear evidence of differences between groups for anxiodepressive symptoms (risk ratio (RR) 1.01, 95% confidence interval (CI) 0.73 to 1.40; one study, 36 women, very low-quality evidence), spontaneous abortion (RR 0.48, 95% CI 0.05 to 5.03; one study, 57 women, low-quality evidence), preterm birth (RR 0.12, 95% CI 0.01 to 2.26; one study, 36 women, low-quality evidence), or perinatal death (RR 0.57, 95% CI 0.04 to 8.30; one study, 36 women, low-quality evidence).There was insufficient evidence to identify clear differences between acupuncture and metoclopramide in a study with 81 participants regarding reduction/cessation in nausea or vomiting (RR 1.40, 95% CI 0.79 to 2.49 and RR 1.51, 95% CI 0.92 to 2.48, respectively; very low-quality evidence).In a study with 92 participants, women taking vitamin B6 had a slightly longer hospital stay compared with placebo (mean difference (MD) 0.80 days, 95% CI 0.08 to 1.52, moderate-quality evidence). There was insufficient evidence to demonstrate a difference in other outcomes including mean number of episodes of emesis (MD 0.50, 95% CI -0.40 to 1.40, low-quality evidence) or side effects.A comparison between metoclopramide and ondansetron identified no clear difference in the severity of nausea or vomiting (MD 1.70, 95% CI -0.15 to 3.55, and MD -0.10, 95% CI -1.63 to 1.43; one study, 83 women, respectively, very low-quality evidence). However, more women taking metoclopramide complained of drowsiness and dry mouth (RR 2.40, 95% CI 1.23 to 4.69, and RR 2.38, 95% CI 1.10 to 5.11, respectively; moderate-quality evidence). There were no clear differences between groups for other side effects.In a single study with 146 participants comparing metoclopramide with promethazine, more women taking promethazine reported drowsiness, dizziness, and dystonia (RR 0.70, 95% CI 0.56 to 0.87, RR 0.48, 95% CI 0.34 to 0.69, and RR 0.31, 95% CI 0.11 to 0.90, respectively, moderate-quality evidence). There were no clear differences between groups for other important outcomes including quality of life and other side effects.In a single trial with 30 women, those receiving ondansetron had no difference in duration of hospital admission compared to those receiving promethazine (MD 0.00, 95% CI -1.39 to 1.39, very low-quality evidence), although there was increased sedation with promethazine (RR 0.06, 95% CI 0.00 to 0.94, low-quality evidence) .Regarding corticosteroids, in a study with 110 participants there was no difference in days of hospital admission compared to placebo (MD -0.30, 95% CI -0.70 to 0.10; very low-quality evidence), but there was a decreased readmission rate (RR 0.69, 95% CI 0.50 to 0.94; four studies, 269 women). For other important outcomes including pregnancy complications, spontaneous abortion, stillbirth and congenital abnormalities, there was insufficient evidence to identify differences between groups (very low-quality evidence for all outcomes). In other single studies there were no clear differences between groups for preterm birth or side effects (very low-quality evidence).For hydrocortisone compared with metoclopramide, no data were available for primary outcomes and there was no difference in the readmission rate (RR 0.08, 95% CI 0.00 to 1.28;one study, 40 women).In a study with 80 women, compared to promethazine, those receiving prednisolone had increased nausea at 48 hours (RR 2.00, 95% CI 1.08 to 3.72; low-quality evidence), but not at 17 days (RR 0.81, 95% CI 0.58 to 1.15, very low-quality evidence). There was no clear difference in the number of episodes of emesis or subjective improvement in nausea/vomiting. There was insufficient evidence to identify differences between groups for stillbirth and neonatal death and preterm birth. AUTHORS' CONCLUSIONS: On the basis of this review, there is little high-quality and consistent evidence supporting any one intervention, which should be taken into account when making management decisions. There was also very limited reporting on the economic impact of hyperemesis gravidarum and the impact that interventions may have.The limitations in interpreting the results of the included studies highlights the importance of consistency in the definition of hyperemesis gravidarum, the use of validated outcome measures, and the need for larger placebo-controlled trials.

Comparison of the Effects of Haloperidol, Metoclopramide, Dexmedetomidine and Ginger on Postoperative Nausea and Vomiting After Laparoscopic Cholecystectomy.

Nausea is a mental sensation of unease and discomfort before vomiting. Vomiting refers to the return of the contents of the upper gastrointestinal tract to the mouth caused by contractions of chest and abdomen muscles. Postoperative nausea and vomiting is an unpleasant experience with high treatment costs. Therefore, this study aimed to compare the effects of haloperidol, metoclopramide, dexmedetomidine, and ginger on postoperative nausea and vomiting after laparoscopy. This double-blind clinical trial was performed on all laparoscopy candidates at Valiasr hospital, Arak, Iran. The patients were randomly divided into four groups (haloperidol, metoclopramide, dexmedetomidine and ginger), and all patients underwent general anesthesia using fentanyl, midazolam, atracurium, and propofol. After intubation, tube fixation, and stable hemodynamic conditions, the patients received four ginger capsules with a hint of lemon. A group of patients received 25 µg of dexmedetomidine. In the Plasil group, 10 mg of metoclopramide was given 30 minutes before the completion of surgery. In addition, 0.5 cc of haloperidol (5 mg) was administered to a group of patients. Heart rate, blood pressure, and oxygen saturation were recorded from the beginning of surgery, every 15 minutes until the end of the surgery. Furthermore, the occurrence of nausea and vomiting was recorded during recovery, 2 and 4 hours after surgery. Data were then analyzed using the SPSS software v.23. Eighty-eight patients were enrolled in the study. The youngest and the oldest were 30 years and 70 years old, respectively, and the mean age was 48.02 ± 9.31 years. Moreover, the number of women in the four groups was higher than that of men. Blood pressure in the dexmedetomidine group was lower than the other four groups (P <0.05). The lowest heart rate was observed in the haloperidol group, while the highest heart rate was seen in the plasil group (P <0.05). The occurrence of vomiting and nausea was not significantly different between the four groups (P <0.05). Our results showed no significant difference in postoperative nausea and vomiting between the four drugs. Due to the hemodynamic changes induced by each drug, it is best to use these drugs based on the patient's condition. Ginger is also a herbal remedy that has fewer side effects, and this drug can be a good option for patients when there is no contraindication.

Morbidity in a juvenile green sea turtle (Chelonia mydas) due to ocean-borne plastic.

An emaciated 2.36-kg juvenile green sea turtle, Chelonia mydas, was found floating off of Melbourne Beach, Florida, USA (28 degrees 2'4"N, 80 degrees 32'32"W). The turtle exhibited signs of cachexia, positive buoyancy, lethargy, and obstipation; was covered with barnacles; and was anorexic at the time of presentation. Dorsal-ventral radiographs with positive contrast confirmed obstruction of the gastrointestinal tract. Serum chemistry abnormalities reflected metabolic/nutritional deficiencies. Gastrointestinal prokinetics and oral/enema mineral oil applications were effective in relieving gastrointestinal obstruction with the turtle defecating a total of 74 foreign objects over a period of a month. After the removal of the foreign material, the turtle quickly regained normal behavior and health. The lack of blood parameters demonstrating infection or inflammation; the failure to respond to antibiotic and antifungal treatment as well as the parallel improvement in behavior and health after incremental evacuation of the plastic is highly suggestive of a cause and effect association.

Persistent hiccups after attempted interscalene brachial plexus block.

OBJECTIVE: We describe a case of persistent hiccups after attempted interscalene brachial plexus block. CASE REPORT: A 38-year-old man was admitted for arthroscopic repair of a right shoulder injury. An interscalene block was attempted in the preoperative area and combined with general anesthesia for surgery. The procedure lasted 5(1/4) hours. After transfer to the recovery room, the patient complained of severe right shoulder pain and had no discernible sensory or motor block. He was noted to be hiccuping. The patient was discharged home the following morning but returned 2 days later complaining of persistent hiccups since surgery, with associated insomnia and nausea. He was readmitted and given chlorpromazine 50 mg intravenously every 8 hours and metoclopramide 10 mg intravenously every 6 hours. The patient was discharged 4 days later on chlorpromazine 25 mg by mouth every 8 hours and baclofen 5 mg by mouth every 12 hours, with hiccups greatly reduced in both intensity and frequency. Hiccups ceased 1 day after discharge. Eighteen days after surgery, he was off all medication with no return of his hiccups; 1 month later he remains hiccup free. CONCLUSIONS: Persistent hiccups have many postulated causes, including several that are common in the perioperative period, but this is the first time to our knowledge that persistent hiccups have been described in association with attempted interscalene brachial plexus block.

A proposed mechanism for diurnal/nocturnal bruxism: hypersensitivity of presynaptic dopamine receptors in the frontal lobe.

There are many reports in the literature concerning nocturnal bruxism, however, diurnal (non-sleep)/nocturnal bruxism is rarely mentioned. We report three patients with diurnal/nocturnal bruxism. They differed from the usual features of nocturnal bruxism in hypoperfusion of the left frontal lobe, a poor response to l-dopa or bromocriptine therapy and a favourable response to metoclopramide. Hypersensitive presynaptic dopamine receptors may be the underlying pathology responsible for this type of bruxism. Regional differences in dopamine receptor pharmacology may explain the perplexing relationship of bruxism to both hyper- and hypo-dopaminergic states.

Radionuclide gastric emptying studies in patients with anorexia nervosa.

To evaluate gastric emptying in anorexia nervosa patients, 26 patients (17 females, two males, ranging in age from 13 to 40 yr) with upper GI symptoms ingested 150-200 microCi [99mTc]triethelenetetraamine polysterene resin in cereal and were imaged in the supine position. Data were accumulated at 5 min intervals to obtain the gastric emptying time (GET). The results of the studies were divided into three categories: prolonged, 13 patients; rapid, 11; and normal 3. Twelve of 13 patients with prolonged GET were given 10 mg metoclopramide i.v. injections; nine of the 12 patients had a good response and three had no response. Five of the nine patients underwent metoclopramide therapy and four of the patients showed benefit from the therapy. One patient discontinued metoclopramide therapy because of somnolence. Although all patients had subjective symptoms of gastric dysfunction, our results indicated only 50% had objectively prolonged GET, and another 50% showed normal or even rapid GET. Therefore, this radionuclide study enables quantitatively objective documentation of gastric emptying, separation of those patients with rapid or normal GET from those with prolonged GET, thereby avoiding the possible side effects from metoclopramide medication, and prediction of effectiveness of metoclopramide therapy in patients with prolonged GET.

Chronic cough and gastroesophageal reflux disease: experience with specific therapy for diagnosis and treatment.

STUDY OBJECTIVE: To evaluate experience using a therapeutic trial of proton-pump inhibitor therapy with or without a prokinetic agent in diagnosis and treatment of gastroesophageal reflux disease (GERD)-related cough. DESIGN: A review of experience with 214 patients with cough of > or = 3 weeks referred over 3.5 years. An anatomic diagnostic protocol was used to identify and treat those with GERD-related cough. SETTING: A pulmonary specialty practice affiliated with the University of Rochester School of Medicine and Dentistry. PATIENTS: One hundred eighty-three patients were identified with chronic cough and were included in the study. Thirty-one patients were disqualified because of abnormal chest radiographic findings, inadequate follow-up, or cough being not the primary complaint. Fifty-six patients were identified as having GERD-related cough. INTERVENTIONS: A once-daily dose of a proton-pump inhibitor was prescribed. A prokinetic agent was added if esophageal dysfunction was suspected or response was inadequate. Those who did not respond underwent 24-h esophageal pH monitoring. RESULTS: GERD was the single cause of cough in 24 patients (43%). Twenty-nine patients (52%) had GERD plus another cause, and 3 patients (5%) had GERD with more than two causes. Twenty-four patients (43%) had cough only, while 32 patients (57%) had other symptoms of GERD. Proton-pump therapy was successful in 42 patients (79%). Twenty-four patients responded to proton-pump inhibitor therapy, and 18 patients responded when metoclopramide or cisapride was added. The remaining two patients responded to a histamine type-2 blocker or cisapride alone. The cough was eliminated or markedly improved in 38 patients (86%) after 4 weeks and by 8 weeks in the remaining 6 patients. Six of the nonresponders had aspiration diagnosed by bronchoscopy. Four patients had fundoplication recommended, and two patients responded to alternative interventions. CONCLUSIONS: Four to 6 weeks of a proton-pump inhibitor alone or in combination with a prokinetic agent successfully diagnoses and treats four of five patients with GERD-related cough. Twenty-four-hour esophageal pH monitoring will confirm the diagnosis in the others. These patients may be candidates for fundoplication. Nonresponders often aspirate as an additional aggravating factor.

Effective outpatient use of polyethylene glycol-electrolyte bowel preparation for radical cystectomy and ileal conduit urinary diversion.

In this prospective study we examined the oral electrolyte-overload method of bowel preparation for patients who were to undergo radical cystectomy and ileal conduit urinary diversion. We found it to be a safe and effective mechanical bowel preparation that can be used by outpatients. It was well tolerated and resulted in adequate bowel cleansing and a low incidence of postoperative wound infections and pyelonephritis. A major advantage of this method is that it reduced the period of preoperative hospitalization.

Postoperative alkaline reflux gastritis.

1. The syndrome of reflux gastritis is produced by the actions of bile and upper intestinal and pancreatic secretions alone or in combination on an altered gastric mucosa. 2. The triad of epigastric pain unrelieved by antacids, bilious vomiting, and weight loss, particularly after a gastric operation should make one suspect this syndrome. Anemia due to loss of blood and dysphagia occur less frequently. 3. The definitive diagnosis is made by endoscopy. Barium studies are of less value. Acid secretory studies are not diagnostic and are of academic interest. 4. Medical treatment utilizes antacids and cholestyramine alone or together. Good, long-lasting results with these are infrequent. Despite these results, medical treatment should be tried first. 5. Surgical treatment consists of diversion of the biliary and upper intestinal secretions from the stomach and doing a vagotomy with or without a distal gastric resection to prevent a marginal ulcer from developing. 6. The two most popular operations are a Roux-en-Y diversion or interposed peristaltic jejunal limb. The simplicity of the former has made this more popular with most American surgeons. 7. The results of surgery are good to excellent in 75 to 95 per cent of cases. Relief of symptoms, improvement in histologic and secretory studies, and weight gain should be anticipated. 8. Less than optimal results are reported when the surgical diversion has not been total, gastric stasis persists, or other postgastrectomy sequelae accompany reflux gastritis.

Metoclopramide enhances the effect of photodynamic therapy on xenografted human squamous cell carcinoma of the head and neck.

OBJECTIVE: Photodynamic therapy (PDT) is a promising new treatment modality for head and neck cancer that is based on the uptake of a systemically administered photosensitizer in tumor tissue and local illumination of the lesion by a high-intensity visible light source, typically a tunable argon-pumped dye laser. We developed a new photosensitizer named silicon phthalocyanine [SiPc(OH) OSi(CH3)2(CH2)3N(CH3)2, abbreviated as SiPc IV], which yields superior PDT responses in vitro and in vivo compared with other clinically used photosensitizers. However, tumor regrowth following SiPc IV-based PDT is still a therapeutic problem. The benzamide derivatives, for example, have been shown to enhance tumor ablation when used during radiotherapy and chemotherapy. Therefore, we used metoclopramide hydrochloride, a benzamide derivative, to evaluate its effects on PDT response. DESIGN: Intradermally injected human squamous cell carcinoma cells were grown to 40 to 80 mm3 in athymic nude mice and irradiated with 675-nm light (75 J/cm2, 75 mW/cm2) 24 hours after the intraperitoneal injection of SiPc IV (1.0 mg/kg). Metoclopramide hydrochloride (2 to 48 mg/kg) was injected intraperitoneally 1 hour before and 24 and 48 hours after irradiation. RESULTS: Tumors exposed to PDT alone showed 80% to 90% tumor regression with regrowth in most animals within 20 days. Tumors treated with metoclopramide hydrochloride (48 mg/kg) plus PDT demonstrated 100% tumor regression without regrowth up to the time of killing (150 days). No observable toxic effects were clinically apparent with the high doses of metoclopramide. CONCLUSIONS: Our results show that administering metoclopramide in combination with PDT may be a promising approach to the management of head and neck cancer.

The antiemetic activity of tetrahydrocannabinol versus metoclopramide and thiethylperazine in patients undergoing cancer chemotherapy.

A double blind-cross-over randomised clinical trial has been conducted to compare the antiemetic effects of tetrahydrocannabinol, thiethylperazine and metoclopramide. There were no significant differences in the antiemetic effects of these drugs. The incidence of adverse reactions as recorded by both the staff and the patients was significantly higher in the tetrahydrocannabinol group than in either the metoclopramide or thiethylperazine groups. This trial has established that in the dosages used tetrahydrocannabinol given by mouth has an antiemetic effect of approximately the same order as thiethylperazine and metoclopramide. However, its adverse effects are sufficiently greater than those of the other agents to prevent is widespread usage for this purpose. Tetrahydrocannabinol taken by mouth is not recommended as a routine antiemetic agent in cancer chemotherapy.

[A new granular effervescent 10-mg formulation of cisapride in the treatment of gastroesophageal reflux]. / Una nuova formulazione di cisapride, granulato effervescente 10 mg, nel trattamento della malattia da reflusso gastroesofageo.

The efficacy and tolerability of Cisapride effervescent granules for treatment of gastroesophageal reflux disease were compared to a metoclopramide-dimeticone combination. The double-blind study was performed in two groups of 10 patients each who received 3 sachets daily of either drug for 8 weeks. Cisapride effervescent granules induced a statistically significant improvement of 75% of symptoms (6/8) while this improvement was obtained with the reference drug for only 60% (3/5). Statistical evaluation showed Cisapride effervescent granules to be more effective than the reference drug for 2 of 5 evaluable symptoms; mean global improvement amounted to 83 vs 58%. Final physician opinion was more favorable to Cisapride effervescent granules than to the reference drug (p < 0.005). Treatment did not have to be withdrawn nor were clinically significant changes of laboratory values observed. Both drugs were found to be well tolerated without differences between the two groups. Three patients treated with Cisapride effervescent granules complained of short-lasting mild abdominal discomfort the relations of which to the drug was doubtful, and which subsided spontaneously without need to withdraw treatment or to apply other types of therapy.

[Gastric phytobezoar].

A case of a large gastric phytobezoar (5 x 8 cm) is presented. It was diagnosed at operation in the stomach of a post vagotomy-pyloroplasty patient, and all attempts at removal (crushing, lavage and diathermy) failed. Complete removal of the phytobezoar was accomplished in 3 endoscopy sessions using a very large snare introduced through an overtube. The patient was told to refrain from cellulose- and fiber-rich food (such as persimmons and oranges) and was given prokinetic drugs, including cisapride, domperidone and metoclopramide.

Acute dystonia mimicking angioedema of the tongue: a video-illustrated case.

We report a case of acute dystonia of the face, jaw and tongue caused by metoclopramide and mimicking angioedema. The patient had attacks for several years before the correct diagnosis was made and we present the first ever published video footage of an attack. This adverse drug reaction is known, but might be underdiagnosed since it can mimic a wide range of other diseases.

Formulation and evaluation of metoclopramide solid lipid nanoparticles for rectal suppository.

OBJECTIVES: The purpose of this study was to formulate and characterize metoclopramide solid lipid nanoparticles (MCP-SLNs) and incorporating it into suppository bases for treatment of nausea and vomiting, produced with chemotherapeutic agents, using one dose per day. METHODS: MCP-SLNs was prepared using high shear homogenization (hot homogenization) technique using different surfactants (tween 80, poloxamer 407, poloxamer 188 and cremophore) in two different concentrations (2.5% and 5%) then solid lipid nanoparticle (SLN), whose release percentage above 50%, was incorporated into suppository for treatment of nausea and vomiting. The prepared SLN and suppositories were then evaluated and characterized. KEY FINDINGS: Formulation of poloxamer 407 with compritol and drug (F9) produced highest in-vitro % release (80%). Transmission electron microscopy showed that SLN had round and spherical shape in form of solid dispersion or drug-enriched core. Particle size analysis of SLN showed a size range of 24.99-396.8 nm. Negative zeta potential proves complete drug entrapment. In-vivo study of MCP-SLN suppositories produced the same %GE as the market metoclopramide (MCP) suppository (Primperan) with sustained release effect. CONCLUSION: MCP-SLN suppositories (formula F) can reverse decrease in %GE because of emesis with sustained release effect. So it succeeded to be an alternative to MCP suppositories with no multiple dosing.

Adjunctive atropine versus metoclopramide: can we reduce ketamine-associated vomiting in young children? a prospective, randomized, open, controlled study.

OBJECTIVES: Pediatric procedural sedation and analgesia (PPSA) with ketamine administration occurs commonly in the emergency department (ED). Although ketamine-associated vomiting (KAV) is a less serious complication of ketamine administration, it seems to be cumbersome and not uncommon. The authors evaluated the incidence of KAV and the prophylactic effect of adjunctive atropine and metoclopramide in children receiving ketamine sedation in the ED setting. METHODS: This prospective, randomized, open, controlled study was conducted in children receiving ketamine sedation in the ED of a university-affiliated, tertiary hospital with 85,000 ED visits, including 32,000 pediatric patients from October 2010 to September 2011. The primary outcome was a measure of the incidence of KAV in the ED and after discharge according to the adjunctive drug administered. Secondary outcome measures included the time to resumption of a normal diet after ketamine sedation. RESULTS: Of the 1,883 children administered ketamine for primary wound repair during the study period, a convenience sample of 338 patients aged 4 months to 5 years was enrolled. The incidences of KAV were 28.4% in the ketamine alone group, 27.9% in the ketamine with adjunctive atropine group, and 31.2% in the ketamine with adjunctive metoclopramide group (p = 0.86). The vomiting rate after discharge was 9.2% in the ketamine alone group. The nothing-by-mouth (NPO) status before sedation did not influence the incidence of KAV in any of the groups. Mean times to resumption of normal diet after ketamine administration were 7 hours 59 minutes in the ketamine alone group, 7 hours 35 minutes in the ketamine with atropine group, and 8 hours 1 minute in the ketamine with metoclopramide group (p = 0.64). CONCLUSIONS: In this study, a high rate (28.4%) of KAV was observed, consistent with prior reports using the intramuscular (IM) route. However, the authors were unable to reduce KAV using adjunctive atropine or metoclopramide. Parents or caregivers should be given more detailed discharge instructions about vomiting and diet considering the relatively long time to resuming a normal diet after ketamine sedation and the fact that KAV often occurred after ED discharge.

Comparison of ondansetron and metoclopramide antiemetic prophylaxis in maxillofacial surgery patients.

PURPOSE: The purpose of this study was to compare the efficacy of ondansetron and metoclopramide, administered for the prophylaxis of vomiting in patients undergoing oral and maxillofacial surgery under general anesthesia. METHODS: One hundred patients undergoing mandibular osteotomy surgery were studied. Patients were allocated randomly to receive 1 of 2 treatment regimens: 0.15 mg/kg ondansetron or 0.5 mg/kg metoclopramide intravenously 30 minutes before extubation. All were adults and were treated by one surgeon and all operations were the same and lasted 2.5 to 3.0 hours. The patients were assessed at 3 time periods: 0 to 3 hours, 3 to 12 hours, and 12 to 24 hours postoperatively for emesis. RESULT: The data from this study showed that during the first 24-hour postoperative period, patients receiving ondansetron following general anesthesia had an 11% (11 patients) incidence of emesis compared with 28% (22 patients) in the group that received metoclopramide. CONCLUSION: In this study, ondansetron (0.1 mg/kg) was twice as effective in preventing postoperative vomiting compared with metoclopramide.