Intrathecal Neostigmine for Prevention of PDPH

The Efficacy of Neostigmine as an Adjuvant to Bupivacaine for Intrathecal Block in Reducing the Incidence and Severity of Post-Dural Puncture Headache for Parturients Scheduled for Elective Caesarean Section

Neuraxial blocks continue to be the cornerstone of anesthesia and postoperative analgesia for normal vaginal delivery and elective caesarean section due to its approved safety and efficiency for decades. Post-dural puncture headache (PDPH) is still one of the most common complications of neuraxial anesthetic techniques. The headache could be severe and limit the activities of the new mother to care for her baby, prolong hospital stay.

PDPH is defined as a headache that develops within five days of dural puncture and can't be attributed to any other types of headache and mostly is postural in character.

Neostigmine methylsulfate is a synthetic carbamic acid ester which reversibly inhibits the enzyme Acetylcholine esterase (AChE) that makes more Acetylcholine molecules available at cholinergic receptors. Neostigmine is used in anesthesia mainly as a reversal for non-depolarizing neuromuscular agents.

Intrathecal (IT) neostigmine was tried as an adjuvant to local anesthetics in IT block for elective cesarean sections to decrease local anesthetic consumption and to prolong postoperative analgesia. Side effects of IT neostigmine are dose-dependent with doses more than 25 µg especially nausea and vomiting and could be decreased by increasing the baricities of the local anesthetic solutions and by early head up position after IT injection. However, its effect on PDPH was not investigated before in literature.

Parturients will be randomly assigned into one of two groups: the intervention group will receive 20 µg with IT Bupivacaine and the control group will receive an equivalent volume of dextrose 5% with the IT Bupivacaine.

The objective of the current study is to evaluate the efficacy and safety of IT neostigmine as an adjuvant to bupivacaine in reducing the incidence and severity of post-dural puncture headache in parturients scheduled for an elective cesarean section.

Study Overview

• Status: Completed
• Conditions: Post-Dural Puncture Headache
• Intervention / Treatment: Drug: Neostigmine Methylsulfate; Drug: Dextrose 5% in water

Detailed Description

The study will be performed from July 2018 to July 2019 at Fayoum University hospital after approval of the local institutional ethics committee and local institutional review board. The study design will be prospective, randomized, double-blind, parallel groups, placebo-controlled clinical trial. A detailed informed consent will be signed by the eligible participants before recruitment and randomization.

Randomization will be done by using computer-generated random numbers that will be placed in separate opaque envelopes that will be opened by study investigators just before IT block. Neither the participants, the study investigators, the attending clinicians, nor the data collectors will be aware of groups' allocation until the study end. The Consolidated Standards of Reporting Trials (CONSORT) recommendations for reporting randomized, controlled clinical trials will be followed.

Preoperative preparations and Premedication:

The study solutions will be prepared in a one milliliter syringe as following: For the intervention group (N), it will contain 20 µg of Neostigmine® (0.5 mg/ml ampules manufactured by Amriya for pharmaceutical industries in Alexandria, Egypt) neostigmine ampule will be diluted in 4 ml dextrose 5% to make a solution of 100 µg/ml, 0.2 ml of this solution will be used, while in the control group an equal volume (0.2 ml) of dextrose 5% will be prepared. The syringes used will be labeled as A and B per their content. The identical coded syringe will be prepared by trained anesthesia technicians who will not be included in the study.

All parturients will receive 150 mg Ranitidine oral tablet on the night before and on the morning of the operation as a premedication.

Intraoperative technique and management:

Upon arrival to the operating room standard monitors (Pulse oximeter, Noninvasive blood pressure monitoring, and Electrocardiogram) will be applied and continued all over the operation, an eighteen gauge (18G) peripheral intravenous (IV) cannula will be inserted, and 10 ml/kg of Ringer lactate solution warmed to 37°C will be infused over 15 minutes as a preload.

IT block will be performed via a midline approach into the L4-5 interspaces in sitting position with complete aseptic condition using a 25 gauge Quincke spinal needle after giving 3 ml of lidocaine 2% (60 mg) as a subcutaneous infiltration. After confirming free cerebrospinal fluid (CSF) flow through the needle a 2.5 ml of hyperbaric bupivacaine 0.5 % in addition to the content of the prepared study syringe will be slowly injected. Then, the parturient will be immediately placed in the supine position with 15° left tilt, and an oxygen mask will be applied at 2 l/min.

After ensuring sufficient anesthesia level, the surgical procedure will start with continuous hemodynamics monitoring and recording. If the systolic blood pressure (SBP) decreased to 20% below the baseline or less than 90 mmHg, ephedrine 5 mg will be administered intravenously. Also, if heart rate (HR) will be less than 50 beats/min, atropine sulfate 0.5 mg will be administered intravenously. Any intraoperative or postoperative nausea or vomiting will be managed with 10 mg of metoclopramide Upon delivery of the fetus, ten units of oxytocin will be given by IV infusion, and if the uterus is not well contracted, additional increments of 5 units will be added accordingly. One gm of Ceftriaxone will be also given after delivery of the fetus by IV infusion.

Postoperative monitoring, Pain control and follow up:

At the end of surgery, Participant will be transferred to postoperative anesthesia care unit (PACU) with standard monitoring applied. All Participants will receive 75 mg diclofenac sodium intramuscular every 12 hours as a pain management per institution policy, 1,23 4 mg of morphine will be given IV if rescue analgesia is needed postoperatively every 10 minutes with a maximum of 20 mg in 6 hours or 32 mg in 24 hours. The participant will be transferred to obstetrics ward after fulfilling the criteria of modified Aldrete scoring system. 24 Assessment for post-dural puncture headache and other associated symptoms will be done from day 0 to day five postoperatively and if the participant will be discharged home, follow up will be done by a phone call. If there will be a complaint of a headache, the participant will be asked to come back to the hospital for proper assessment and management either on an outpatient or inpatient bases per the headache severity.

The participants who will be diagnosed to have PDPH per the criteria of the International Headache Society (HIS) will be treated by using oral medications Panadol extra™ (paracetamol 1gm + caffeine 130 mg) (Manufactured by: Alexandria company for pharmaceuticals & chemical industries under license: GlaxoSmithKline Consumer Healthcare Ltd. Ireland) at 6-hour interval in addition to hydration and bed rest. Severe Intractable headache (VAS ≥ 40) persistent for more than 48 hours with no response to conservative measures will be managed with an epidural blood patch after participant approval and consent signing.

Statistical analysis and sample size estimation:

Continuous variables will be tested for normal distribution by the Shapiro-Wilk test (P ≤ 0.05). Parametric data will be expressed as mean and standard deviation (SD) and analyzed by using the independent t-test. Data with kurtosis or skewness will be depicted as median and interquartile range and compared for significant difference by implementation of Mann-Whitney U test. Categorical variables will be presented as numbers and frequencies and the chi-square test or Fisher exact test will be used to analyze the significant differences between the two arms. A P value ≤ 0.05 will be considered statistically significant. Data will be analyzed using SPSS (SPSS 16.0, SPSS Inc., Chicago, II, USA).

The sample size calculation based on that a 15 % reduction in the incidence of PDPH between the two arms could be of clinically important relevance. The reported incidence of PDPH with the use of 25 gauge Quincke needle is 25 %. Sample size of 100 participants per group were found sufficient assuming (two tail) α = 0.05, β = 0.2 (80 % power), and 1:1 allocation ratio. We will plan to recruit 120 participants per group to account for data loss or protocol violation. The sample size calculation performed with G*Power software version 3.1.9.2 (Institute of Experimental Psychology, Heinrich Heine University, Dusseldorf, Germany).

• Study Type: Interventional
• Enrollment (Actual): 240
• Phase: Phase 4

Contacts and Locations

Study Locations

• Egypt
  • Faiyum Governorate
    • Madīnat al Fayyūm, Faiyum Governorate, Egypt, 63514
      • Fayoum University hospital

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 20 years to 40 years (Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: Female

Description

Inclusion Criteria:

• American society association (ASA) physical status II parturients who will be scheduled for an elective caesarean section by IT anesthesia

Exclusion Criteria:

• significant renal, hepatic, and cardiovascular diseases
• pre-eclampsia
• any contraindication to regional anesthesia such as local infection or bleeding disorders
• allergy to neostigmine
• long-term opioid use
• a history of chronic pain, migraine, cluster headache
• digestive problems with nausea or vomiting
• cognitive or memory disorders
• history of urinary retention; bronchial asthma
• perioperative blood transfusion

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Prevention
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Quadruple

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Active Comparator: The Intervention Group (N); Neostigmine Methylsulfate intervention : A one milliliter syringe will contain 20 µg of Neostigmine methyl sulfate. 0.5 mg ampule (1 ml) will be diluted in 4 ml dextrose 5% to make a solution of 100 µg/ml, 0.2 ml of this solution will be added to 2.5 ml of hyperbaric bupivacaine 0.5 % used for intrathecal injection.	Drug: Neostigmine Methylsulfate; 20 µg Neostigmine Methylsulfate intrathecal in 0.2 ml of Dextrose 5% solution; Other Names: Neostigmine (0.5 mg); Drug: Dextrose 5% in water; intrathecal; Other Names: Dextrose 5% in Water (D5W)
Placebo Comparator: The Control Group (P); Dextrose 5% in water intervention : an equal volume (0.2 ml) of dextrose 5% will be added to 2.5 ml of hyperbaric bupivacaine 0.5 % used for intrathecal injection.	Drug: Dextrose 5% in water; intrathecal; Other Names: Dextrose 5% in Water (D5W)

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
incidence of post-dural puncture headache	any headache that develops within five days of dural puncture and can't be attributed to any other types of headache and mostly is postural in character	At day 5 from intrathecal block

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Visual analog score of post-dural puncture headache (PDPH) at presentation	Severity of PDPH at presentation estimated by visual analog score (VAS) (where 0 = no headache, and 100 = worst imaginable headache)	At 24 hours after headache onset
Visual analog score of post-dural puncture headache (PDPH) after medical treatment	Severity of PDPH after 48 hours from receiving medical treatment estimated by visual analog score (VAS) (where 0 = no headache, and 100 = worst imaginable headache)	At 48 hours after starting medical treatment
highest Visual analog score of post-dural puncture headache	Severity of PDPH estimated by visual analog score (VAS) (where 0 = no headache, and 100 = worst imaginable headache)	At 48 hours after starting medical treatment
Percent of participants with neck stiffness	incidence of neck stiffness in participants with PDPH in each group	At 48 hours after headache onset
Percent of participants in need for epidural blood patch	Severe Intractable headache (VAS ≥ 40) persistent for more than 48 hours with no response to conservative measures will be managed with an epidural blood patch after participant approval and consent signing	After 48 hours from onset of headache
Percent of participants complained from intraoperative nausea and vomiting	Any intraoperative nausea or vomiting related to intrathecal neostigmine injection	From intrathecal block until discharge from PACU, assessed up to 24 hours
Percent of participants complained from postoperative nausea and vomiting	Any postoperative nausea or vomiting related to PDPH	AT 48 hours after PDPH
incidence of urine retention	postoperative inability to pass urine	At 48 hours from intrathecal block
incidence of memory and cognitive disorders	any observed or complained memory or cognitive disorders	At 48 hours from intrathecal block
incidence of hypotension	systolic blood pressure (≤ 20 % of baseline level or < 90 mmhg	From intrathecal block until discharge from PACU, assessed up to 24 hours
ephedrine requirements	ephedrine used measured in milligrams	From intrathecal block until discharge from PACU, assessed up to 24 hours
incidence of desaturation	(SPO2 < 92 %)	From intrathecal block until discharge from PACU, assessed up to 24 hours
incidence of respiratory depression	Respiratory rate (RR) < 8 bpm	From intrathecal block until discharge from PACU, assessed up to 24 hours
incidence of bradycardia	heart rate < 50 beat per minute	From intrathecal block until discharge from PACU, assessed up to 24 hours
atropine requirements	atropine used measured in milligrams	From intrathecal block until discharge from PACU, assessed up to 24 hours
incidence of shivering	any shivering	From intrathecal block until discharge from PACU, assessed up to 24 hours
time to the first requirement of analgesic supplement	calculated in minutes	From intrathecal block until discharge from PACU, assessed up to 24 hours
total analgesic consumption	amount of morphine used in milligrams	At 24 hour after intrathecal block
the assessment of duration of sensory blockade	measured in minutes, assessed by a pinprick test	From intrathecal block until the first appearance of pain at the T10 dermatome, assessed up to 24 hours
the assessment of duration of motor blockade	measured in minutes, assessed by the modified Bromage score (0, no motor loss; 1, inability to flex the hip; 2, inability to flex the knee; and 3, inability to flex the ankle)	From intrathecal block until the modified Bromage score will be zero, assessed up to 24 hours
Age	in years	6 hours before intervention
Weight	in kilograms (kg)	6 hours before intervention
Height	in meters (m)	6 hours before intervention
Body mass index	in kg/m square	6 hours before intervention
Headache onset	in hours	After intrathecal block for five days till appearance of PDPH
Duration of surgical procedures	in minutes	After completion of surgical procedures, within about two hours of intervention

Collaborators and Investigators

• Sponsor: Fayoum University Hospital

Publications and helpful links

General Publications

• Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia. 2013 Jul;33(9):629-808. doi: 10.1177/0333102413485658. No abstract available.
• Arevalo-Rodriguez I, Munoz L, Godoy-Casasbuenas N, Ciapponi A, Arevalo JJ, Boogaard S, Roque I Figuls M. Needle gauge and tip designs for preventing post-dural puncture headache (PDPH). Cochrane Database Syst Rev. 2017 Apr 7;4(4):CD010807. doi: 10.1002/14651858.CD010807.pub2.
• Nath S, Koziarz A, Badhiwala JH, Alhazzani W, Jaeschke R, Sharma S, Banfield L, Shoamanesh A, Singh S, Nassiri F, Oczkowski W, Belley-Cote E, Truant R, Reddy K, Meade MO, Farrokhyar F, Bala MM, Alshamsi F, Krag M, Etxeandia-Ikobaltzeta I, Kunz R, Nishida O, Matouk C, Selim M, Rhodes A, Hawryluk G, Almenawer SA. Atraumatic versus conventional lumbar puncture needles: a systematic review and meta-analysis. Lancet. 2018 Mar 24;391(10126):1197-1204. doi: 10.1016/S0140-6736(17)32451-0. Epub 2017 Dec 7.
• Fattahi Z, Hadavi SM, Sahmeddini MA. Effect of ondansetron on post-dural puncture headache (PDPH) in parturients undergoing cesarean section: a double-blind randomized placebo-controlled study. J Anesth. 2015 Oct;29(5):702-7. doi: 10.1007/s00540-015-2000-5. Epub 2015 Mar 27.
• Cossu AP, De Giudici LM, Piras D, Mura P, Scanu M, Cossu M, Saba M, Finco G, Brazzi L. A systematic review of the effects of adding neostigmine to local anesthetics for neuraxial administration in obstetric anesthesia and analgesia. Int J Obstet Anesth. 2015 Aug;24(3):237-46. doi: 10.1016/j.ijoa.2015.05.002. Epub 2015 May 19.

Study record dates

Study Major Dates

• Study Start (Actual): August 4, 2018
• Primary Completion (Actual): February 5, 2019
• Study Completion (Actual): February 10, 2019

Study Registration Dates

• First Submitted: June 13, 2018
• First Submitted That Met QC Criteria: July 2, 2018
• First Posted (Actual): July 16, 2018

Study Record Updates

• Last Update Posted (Actual): July 15, 2019
• Last Update Submitted That Met QC Criteria: July 12, 2019
• Last Verified: July 1, 2019

More Information

Terms related to this study

• Keywords: postural headache; intrathecal neostigmine for prevention of PDPH
• Additional Relevant MeSH Terms: Brain Diseases; Central Nervous System Diseases; Nervous System Diseases; Pain; Neurologic Manifestations; Headache Disorders; Headache Disorders, Secondary; Headache; Post-Dural Puncture Headache; Physiological Effects of Drugs; Neurotransmitter Agents; Molecular Mechanisms of Pharmacological Action; Autonomic Agents; Peripheral Nervous System Agents; Cholinergic Agents; Enzyme Inhibitors; Cholinesterase Inhibitors; Parasympathomimetics; Neostigmine
• Other Study ID Numbers: M335

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: No

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No
• product manufactured in and exported from the U.S.: No