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Jones IA, LoBasso MA, Wier J, Gettleman BS, Richardson MK, Ratto CE, Lieberman JR, Heckmann ND. Perioperative Dexamethasone in Diabetic Patients: A Systematic Review and Meta-Analysis of Randomized, Placebo-Controlled Trials. Anesth Analg 2024; 139:479-489. [PMID: 39151134 DOI: 10.1213/ane.0000000000007007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/18/2024]
Abstract
BACKGROUND The perioperative use of dexamethasone in diabetic patients remains controversial due to concerns related to infection and adverse events. This study aimed to determine whether clinical evidence supports withholding dexamethasone in diabetic patients due to concern for infection risk. We hypothesized that there is no difference in infectious outcomes between dexamethasone-treated patients and controls. METHODS A literature search was performed on November 22, 2022 to identify randomized, placebo-controlled trials investigating short-course (<72 hours), perioperative dexamethasone that explicitly included diabetic patients and measured at least 1 clinical outcome. Pertinent studies were independently searched in PubMed, Embase, and Cochrane. Authors for all identified studies were contacted with the aim of performing quantitative subgroup analyses of diabetic patients. The primary end point was surgical site infection and the secondary end point was a composite of adverse events. Qualitative remarks were reported based on the total available data and a quality assessment tool. Meta-analyses were performed using inverse variance with random effects. Heterogeneity was assessed via standard χ2 and I2 tests. RESULTS Sixteen unique studies were included, 5 of which were analyzed quantitatively. Of the 2592 diabetic patients, 2344 (1184 randomized to dexamethasone and 1160 to placebo) were analyzed in at least 1 quantitative outcome. Quantitative analysis showed that the use of perioperative dexamethasone had no effect on the risk of surgical site infections (log odds ratio [LOR], -0.10, 95%; 95% confidence interval [CI], -0.64 to 0.44) while significantly reducing the risk of composite adverse events (LOR, -0.33; 95% CI, -0.62 to -0.05). Qualitative analysis reinforced these findings, demonstrating noninferior to superior results across all clinical outcomes. There was high heterogeneity between the included studies. CONCLUSIONS Current evidence suggests perioperative dexamethasone may be given to diabetic patients without increasing the risk of infectious complications. Prospective investigations aimed at optimizing dose, frequency, and timing are needed, as well as studies aimed explicitly at exploring the use of dexamethasone in patients with poorly controlled diabetes.
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Affiliation(s)
- Ian A Jones
- From the Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
| | - Michael A LoBasso
- Department of Anesthesiology and Perioperative Medicine, University of California, Los Angeles, Los Angeles, California
| | - Julian Wier
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Brandon S Gettleman
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Mary K Richardson
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Christina E Ratto
- Department of Anesthesiology, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Jay R Lieberman
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Nathanael D Heckmann
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
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Rajan N, Duggan EW, Abdelmalak BB, Butz S, Rodriguez LV, Vann MA, Joshi GP. Society for Ambulatory Anesthesia Updated Consensus Statement on Perioperative Blood Glucose Management in Adult Patients With Diabetes Mellitus Undergoing Ambulatory Surgery. Anesth Analg 2024; 139:459-477. [PMID: 38517760 DOI: 10.1213/ane.0000000000006791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2024]
Abstract
This consensus statement is a comprehensive update of the 2010 Society for Ambulatory Anesthesia (SAMBA) Consensus Statement on perioperative blood glucose management in patients with diabetes mellitus (DM) undergoing ambulatory surgery. Since the original consensus guidelines in 2010, several novel therapeutic interventions have been introduced to treat DM, including new hypoglycemic agents and increasing prevalence of insulin pumps and continuous glucose monitors. The updated recommendations were developed by an expert task force under the provision of SAMBA and are based on a comprehensive review of the literature from 1980 to 2022. The task force included SAMBA members with expertise on this topic and those contributing to the primary literature regarding the management of DM in the perioperative period. The recommendations encompass preoperative evaluation of patients with DM presenting for ambulatory surgery, management of preoperative oral hypoglycemic agents and home insulins, intraoperative testing and treatment modalities, and blood glucose management in the postanesthesia care unit and transition to home after surgery. High-quality evidence pertaining to perioperative blood glucose management in patients with DM undergoing ambulatory surgery remains sparse. Recommendations are therefore based on recent guidelines and available literature, including general glucose management in patients with DM, data from inpatient surgical populations, drug pharmacology, and emerging treatment data. Areas in need of further research are also identified. Importantly, the benefits and risks of interventions and clinical practice information were considered to ensure that the recommendations maintain patient safety and are clinically valid and useful in the ambulatory setting. What Other Guidelines Are Available on This Topic? Since the publication of the SAMBA Consensus Statement for perioperative blood glucose management in the ambulatory setting in 2010, several recent guidelines have been issued by the American Diabetes Association (ADA), the American Association of Clinical Endocrinologists (AACE), the Endocrine Society, the Centre for Perioperative Care (CPOC), and the Association of Anaesthetists of Great Britain and Ireland (AAGBI) on DM care in hospitalized patients; however, none are specific to ambulatory surgery. How Does This Guideline Differ From the Previous Guidelines? Previously posed clinical questions that were outdated were revised to reflect current clinical practice. Additional questions were developed relating to the perioperative management of patients with DM to include the newer therapeutic interventions.
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Affiliation(s)
- Niraja Rajan
- From the Department of Anesthesiology and Perioperative Medicine, Penn State Health, Hershey Outpatient Surgery Center, Hershey, Pennsylvania
| | - Elizabeth W Duggan
- Department of Anesthesiology and Perioperative Medicine, University of Alabama Birmingham, Birmingham, Alabama
| | - Basem B Abdelmalak
- Departments of General Anesthesiology and Outcomes Research, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Anesthesia for Bronchoscopic Surgery, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
| | - Steven Butz
- Department of Anesthesiology, Division of Pediatric Anesthesiology, Medical College of Wisconsin, Children's Wisconsin Surgicenter, Milwaukee, Wisconsin
| | - Leopoldo V Rodriguez
- Department of Anesthesiology and Perioperative Medicine, Boulder Valley Anesthesiology PLLC, UCHealth Longs Peak Hospital and Surgery Center, Boulder Community Health, Foothills Hospital, Boulder, Colorado
| | - Mary Ann Vann
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Girish P Joshi
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical School, Dallas, Texas
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3
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Katerenchuk V, Ribeiro EM, Batista AC. Impact of Intraoperative Dexamethasone on Perioperative Blood Glucose Levels: Systematic Review and Meta-Analysis of Randomized Trials. Anesth Analg 2024; 139:490-508. [PMID: 39151135 DOI: 10.1213/ane.0000000000006933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/18/2024]
Abstract
BACKGROUND Dexamethasone is associated with increased blood glucose levels that could impact patient outcomes or management. This study aimed to synthesize the available evidence regarding the impact of an intraoperative single dose of dexamethasone on blood glucose levels. METHODS We searched CENTRAL, MEDLINE, and clinicaltrials.gov for randomized controlled trials (RCTs) comparing a single intraoperative dose of dexamethasone to control in adult patients who underwent noncardiac surgery. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and the review was registered in PROSPERO (CRD42023420562). Data were pooled using a random-effects model. We reported pooled dichotomous data using odds ratios (OR) and continuous data using the mean difference (MD), reporting 95% confidence intervals (95% CIs), and corresponding P-values for both. Confidence in the evidence was appraised using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach. As primary outcomes we assessed maximum blood glucose levels measurement and variation from baseline within 24 hours of surgery; blood glucose levels measurement and variation from baseline at 2, 4, 8, 12, and 24 hours after dexamethasone administration. As secondary outcomes, we evaluated insulin requirements and hyperglycemic events. RESULTS We included 23 RCTs, enrolling 11,154 participants overall. Dexamethasone was associated with a significant increment in blood glucose levels compared to control at all timepoints. The results showed an increase compared to control of 0.37 mmol L-1 (6.7 mg dL-1) at 2 hours (95% CI, 0.16-0.58 mmol L-1 or 2.9-10.5 mg dL-1), 0.97 mmol L-1 (17.5 mg dL-1) at 4 hours (95% CI, 0.67-1.25 mmol L-1 or 12.1-22.5 mg dL-1), 0.96 mmol L-1 (17.3 mg dL-1) at 8 hours (95% CI, 0.55-1.36 mmol L-1 or 9.9-24.5 mg dL-1), 0.90 mmol L-1 (16.2 mg dL-1) at 12 hours (95% CI, 0.62-1.19 mmol L-1 or 11.2-21.4 mg dL-1) and 0.59 mmol L-1 (10.6 mg dL-1) at 24 hours (95% CI, 0.22-0.96 mmol L-1 or 4.0-17.3 mg dL-1). No difference was found between subgroups regarding diabetic status (patients with diabetes versus patients without diabetes) in all the outcomes except 2 (maximum blood glucose levels variation within 24 hours and variation at 4 hours) and dexamethasone dose (4-5 mg vs 8-10 mg) in all the outcomes except 2 (blood glucose levels at 24 hours and hyperglycemic events). CONCLUSIONS Mean blood glucose levels rise between 0.37 and 1.63 mmol L-1 (6.7 and 29.4 mg dL-1) within 24 hours after a single dose of dexamethasone administered at induction of anesthesia compared to control, but in most patients this difference will not be clinically relevant.
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Affiliation(s)
- Vasyl Katerenchuk
- From the Department of Anesthesiology, Centro Hospitalar de Setúbal E.P.E., Setúbal, Portugal
| | - Eduardo Matos Ribeiro
- Department of Anesthesiology, Centro Hospitalar de Lisboa Ocidental E.P.E., Lisboa, Portugal
| | - Ana Correia Batista
- From the Department of Anesthesiology, Centro Hospitalar de Setúbal E.P.E., Setúbal, Portugal
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Chen H, Wang Y, Jiang K, Xu Z, Jiang Y, Wu Z, Lu X, Wang C, Weng Y, Wang W, Ding R, Zheng S, Li Y, Fu X, Shi G, Wang J, Chen H, Peng C, Deng X, Qiu Y, Luo Y, Sun B, Shen B. The Effect of Perioperative Dexamethasone on Postoperative Complications After Pancreaticoduodenectomy: A Multicenter Randomized Controlled Trial. Ann Surg 2024; 280:222-228. [PMID: 38385254 DOI: 10.1097/sla.0000000000006240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2024]
Abstract
OBJECTIVE To evaluate the effect of perioperative dexamethasone on postoperative complications after pancreaticoduodenectomy. BACKGROUND The glucocorticoid dexamethasone has been shown to improve postoperative outcomes in surgical patients, but its effects on postoperative complications after pancreaticoduodenectomy are unclear. METHODS This multicenter, double-blind, randomized controlled trial was conducted in four Chinese high-volume pancreatic centers. Adults undergoing elective pancreaticoduodenectomy were randomized to receive either 0.2 mg/kg dexamethasone or a saline placebo as an intravenous bolus within 5 minutes after anesthesia induction. The primary outcome was the Comprehensive Complication Index (CCI) score within 30 days after the operation, analyzed using the modified intention-to-treat principle. RESULTS Among 428 patients for eligibility, 300 participants were randomized and 265 were included in the modified intention-to-treat analyses. One hundred thirty-four patients received dexamethasone and 131 patients received a placebo. The mean (SD) CCI score was 14.0 (17.5) in the dexamethasone group and 17.9 (20.3) in the placebo group (mean difference: -3.8; 95% CI: -8.4 to 0.7; P = 0.100). The incidence of major complications (Clavien-Dindo grade ≥III; 12.7% vs 16.0%, risk ratio: 0.79; 95% CI: 0.44 to 1.43; P = 0.439) and postoperative pancreatic fistula (25.4% vs 31.3%, risk ratio: 0.81; 95% CI: 0.55 to 1.19; P = 0.286) were not significantly different between the two groups. In the stratum of participants with a main pancreatic duct ≤3 mm (n = 202), the CCI score was significantly lower in the dexamethasone group (mean difference: -6.4; 95% CI: -11.2 to -1.6; P = 0.009). CONCLUSIONS Perioperative dexamethasone did not significantly reduce postoperative complications within 30 days after pancreaticoduodenectomy.
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Affiliation(s)
- Haoda Chen
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ying Wang
- Department of Anesthesiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Kuirong Jiang
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Zhiwei Xu
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yu Jiang
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zhichong Wu
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiaojian Lu
- Department of Anesthesiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Chao Wang
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yuanchi Weng
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Weishen Wang
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Rui Ding
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Shifan Zheng
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yilong Li
- Department of Pancreatic and Biliary Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Xu Fu
- Department of Pancreatic and Metabolic Surgery, Nanjing Drum Tower Hospital, the Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Guodong Shi
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Jiancheng Wang
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Hao Chen
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Chenghong Peng
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiaxing Deng
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yudong Qiu
- Department of Pancreatic and Metabolic Surgery, Nanjing Drum Tower Hospital, the Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Yan Luo
- Department of Anesthesiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Bei Sun
- Department of Pancreatic and Biliary Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Baiyong Shen
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Yurkonis AV, Tollinche L, Alter J, Pope SE, Traxler P, Hill HE, Torres A. Standardizing the Dosage and Timing of Dexamethasone for Postoperative Nausea and Vomiting Prophylaxis at a Safety-Net Hospital System. Jt Comm J Qual Patient Saf 2024; 50:601-605. [PMID: 38705746 DOI: 10.1016/j.jcjq.2024.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 03/27/2024] [Accepted: 03/28/2024] [Indexed: 05/07/2024]
Abstract
BACKGROUND A single dose of dexamethasone is routinely given during general anesthesia for postoperative nausea and vomiting (PONV) prophylaxis, although the exact dosage and timing of administration may vary between practitioners. The authors aimed to standardize the dosage and timing of this medication when given to adult patients undergoing general anesthesia for elective surgery. METHODS Baseline data for 7,483 preintervention cases were analyzed. The researchers attempted to use a standard dose of 8 to 10 mg induction of anesthesia, which, based on a literature review, was effective for PONV prophylaxis, had a similar safety profile as a 4 to 5 mg dose (including in diabetic patients), and may confer additional benefits such as improved prophylaxis and quality of recovery. The interventions included standardizing the medication concentration vials, altering electronic health record quick-select button options, simplifying the intraoperative charting process, and educating the anesthesia providers. The research team then tracked compliance with the standard of care for 2,167 cases after the interventions. RESULTS Overall compliance with the standard of care increased from 21.2% preintervention to 53.7% postintervention. The number of patients not receiving dexamethasone was reduced from 29.7% to 19.4%. Patients receiving a compliant dose at a noncompliant time increased from 16.3% to 23.8%. Postanesthesia care unit antiemetic administration also decreased after the interventions. CONCLUSION This study showed improvements in compliance with the dosage of medication with the interventions. However, compliance with the timing of administration remains challenging.
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Jones IA, Wier J, Liu KC, Richardson MK, Yoshida B, Palmer R, Lieberman JR, Heckmann ND. Dexamethasone-Associated Hyperglycemia is Not Associated With Infectious Complications After Total Joint Arthroplasty in Diabetic Patients. J Arthroplasty 2024; 39:S43-S52.e5. [PMID: 38220028 DOI: 10.1016/j.arth.2024.01.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 12/26/2023] [Accepted: 01/09/2024] [Indexed: 01/16/2024] Open
Abstract
BACKGROUND Postoperative infection is a devastating complication of total joint arthroplasty (TJA). Perioperative use of dexamethasone in patients who have diabetes mellitus (DM) remains controversial due to concern for increased infection risk. This study aimed to evaluate the association between dexamethasone and infection risk among patients who have DM undergoing TJA. METHODS This was a retrospective cohort study conducted on adult patients who underwent primary, elective total knee arthroplasty (TKA) or total hip arthroplasty (THA) between January 2016 and December 2021 using a large national database. We identified 110,568 TJA patients (TKA: 66.6%; THA: 33.4%), 31.0% (34,298) of which had DM. Patients who received perioperative dexamethasone were compared to those who did not. The primary end points were the 90-day risk of postoperative periprosthetic joint infection, surgical site infection (SSI), and other non-SSI (urinary tract infection, pneumonia, sepsis). RESULTS When modeling the association between dexamethasone exposure and study outcomes while accounting for the interaction between dexamethasone and morning blood glucose levels, dexamethasone administration conferred no increased odds of postoperative periprosthetic joint infection nor SSI in diabetics. However, dexamethasone significantly lowered the adjusted odds of other postoperative infections in diabetic patients (TKA: adjusted odds ratio = 09, 95% confidence interval = 0.8 to 1.0, P = .030; THA: adjusted odds ratio = 0.7, 95% confidence interval = 0.6 to 0.9, P = .001); specifically in patients with morning blood glucose levels between 110 to 248 mg/dL in TKA and ≤ 172 mg/dL in THA. CONCLUSIONS This study provides strong evidence against withholding dexamethasone in diabetic patients undergoing TJA based on concern for infection. Instead, short-course perioperative dexamethasone reduced infection risk in select patients. The narrative surrounding dexamethasone should shift away from questions about whether dexamethasone is appropriate for diabetic patients, and instead focus on how best to optimize its use.
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Affiliation(s)
- Ian A Jones
- Department of Anaesthesiology & Pain Medicine, University of Washington, Seattle, Washington
| | - Julian Wier
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Kevin C Liu
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Mary K Richardson
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Brandon Yoshida
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Ryan Palmer
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Jay R Lieberman
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Nathanael D Heckmann
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
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Polderman J, Hermanides J, Hulst A. Update on the perioperative management of diabetes mellitus. BJA Educ 2024; 24:261-269. [PMID: 39099754 PMCID: PMC11293569 DOI: 10.1016/j.bjae.2024.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/23/2024] [Indexed: 08/06/2024] Open
Affiliation(s)
- J.A.W. Polderman
- Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - J. Hermanides
- Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - A.H. Hulst
- Amsterdam University Medical Centres, Amsterdam, The Netherlands
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Myles PS, Corcoran TB, Chan MT, Asghari-Jafarabadi M, Wu WKK, Peyton P, Leslie K, Forbes A. Intraoperative dexamethasone and chronic postsurgical pain: a propensity score-matched analysis of a large trial. Br J Anaesth 2024; 133:103-110. [PMID: 38267338 DOI: 10.1016/j.bja.2023.12.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 12/19/2023] [Accepted: 12/20/2023] [Indexed: 01/26/2024] Open
Abstract
BACKGROUND Dexamethasone has been shown to reduce acute pain after surgery, but there is uncertainty as to its effects on chronic postsurgical pain (CPSP). We hypothesised that in patients undergoing major noncardiac surgery, a single intraoperative dose of dexamethasone increases the incidence of CPSP. METHODS We devised a propensity score-matched analysis of the ENIGMA-II trial CPSP dataset, aiming to compare the incidence of CPSP in patients who had received dexamethasone or not 12 months after major noncardiac surgery. The primary outcome was the incidence of CPSP. We used propensity score matching and inverse probability weighting to balance baseline variables to estimate the average marginal effect of dexamethasone on patient outcomes, accounting for confounding to estimate the average treatment effect on those treated with dexamethasone. RESULTS We analysed 2999 patients, of whom 116 of 973 (11.9%) receiving dexamethasone reported CPSP, and 380 of 2026 (18.8%) not receiving dexamethasone reported CPSP, unadjusted odds ratio 0.76 (95% confidence interval 0.78-1.00), P=0.052. After propensity score matching, CPSP occurred in 116 of 973 patients (12.2%) receiving dexamethasone and 380 of 2026 patients (13.8%) not receiving dexamethasone, adjusted risk ratio 0.88 (95% confidence interval 0.61-1.27), P=0.493. There was no difference between groups in quality of life or pain interference with daily activities, but 'least pain' (P=0.033) and 'pain right now' (P=0.034) were higher in the dexamethasone group. CONCLUSIONS Dexamethasone does not increase the risk of chronic postsurgical pain after major noncardiac surgery. CLINICAL TRIAL REGISTRATION Open Science Framework Registration DOI https://doi.org/10.17605/OSF.IO/ZDVB5.
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Affiliation(s)
- Paul S Myles
- Department of Anaesthesiology and Perioperative Medicine, Alfred Hospital, Melbourne, VIC, Australia; Department of Anaesthesiology and Perioperative Medicine and Biostatistics Unit, School of Public Health and Preventative Medicine, Monash University, Melbourne, VIC, Australia.
| | - Tomas B Corcoran
- Department of Anaesthesia and Perioperative Medicine, Royal Perth Hospital, Perth, WA, Australia; Department of Pharmacology, University of Western Australia, Perth, WA, Australia
| | - Matthew T Chan
- Department of Anaesthesiology, The Chinese University of Hong Kong, Hong Kong
| | - Mohammad Asghari-Jafarabadi
- Biostatistics Unit, School of Public Health and Preventative Medicine, Monash University, Melbourne, VIC, Australia
| | - William K K Wu
- Department of Anaesthesiology, The Chinese University of Hong Kong, Hong Kong
| | - Philip Peyton
- Department of Anaesthesia and Perioperative Medicine, Austin Hospital, Heidelberg, VIC, Australia; Department of Anaesthesia and Pain Medicine, Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Kate Leslie
- Department of Anaesthesia and Pain Medicine, Royal Melbourne Hospital, Parkville, VIC, Australia; Department of Critical Care, University of Melbourne, Parkville, VIC, Australia
| | - Andrew Forbes
- Biostatistics Unit, School of Public Health and Preventative Medicine, Monash University, Melbourne, VIC, Australia
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9
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Buckley DN, Beattie WS. Dexamethasone and chronic postsurgical pain: the pendulum meets reductionistic thinking. Br J Anaesth 2024; 133:11-13. [PMID: 38744550 DOI: 10.1016/j.bja.2024.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Revised: 04/04/2024] [Accepted: 04/15/2024] [Indexed: 05/16/2024] Open
Abstract
Reductionist thinking results in the bulk of anaesthesia trial designs being a single intervention to address what are in fact complex processes. The Perioperative Administration of Dexamethasone and Infection (PADDI) trial assessed the safety of a single preoperative dose of dexamethasone. Surprising to most, in the original report, a single dose of dexamethasone increased the incidence of the secondary outcome chronic postsurgical pain. Was this a chance finding or does dexamethasone increase chronic postsurgical pain? In an attempt to address this question, the PADDI investigators have now analysed this prespecified secondary outcome in two ways: as a substudy published earlier in this Journal, and as a retrospective analysis of the ENIGMA-II chronic pain database in this issue of the Journal. The PADDI investigators have now presented enough data to convince us that indeed a single dose of dexamethasone is safe and effective. However, the increase in chronic postsurgical pain seen in the original PADDI publication highlights the complexities, and the possible immunologic mechanisms, behind the genesis of chronic postsurgical pain. These publications from the PADDI group raise questions about other anti-inflammatory agents we use regularly for long-term postoperative pain management, and highlights the need for well-designed clinical trials to address this critically important patient-centred adverse functional outcome.
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Affiliation(s)
- D Norman Buckley
- Department of Anesthesia, Michael G DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - W Scott Beattie
- Department of Anesthesia and Pain Management, University Health Network, University of Toronto, Toronto, ON, Canada.
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10
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Wang JY, Huang HY, Chu WO, Peng TR, Lee MC, Chen SM, Lee JA. Aromatherapy for the prevention of postoperative nausea and vomiting: A systematic review and meta-analysis. Tzu Chi Med J 2024; 36:330-339. [PMID: 38993833 PMCID: PMC11236078 DOI: 10.4103/tcmj.tcmj_240_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 12/19/2023] [Accepted: 03/18/2024] [Indexed: 07/13/2024] Open
Abstract
Objectives Postoperative nausea and vomiting (PONV) are common complications following surgical procedures. While drug-based treatments are standard, there is increasing interest in nonpharmacological alternatives, such as aromatherapy, due to potential benefits and minimal side effects. This study aimed to assess the effectiveness of aromatherapy in preventing PONV. Materials and Methods A comprehensive systematic review and meta-analysis were conducted using PubMed, Cochrane Library, EMBASE, and CINAHL databases for studies published up to May 2023. The included studies were randomized controlled trials (RCTs) and nonrandomized studies of interventions that examined the impact of aromatherapy on PONV. The risk of bias was assessed, and the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach was employed to evaluate the certainty of the evidence. Results Eleven studies were selected for review, with eight RCTs included in the meta-analysis. Aromatherapy effectively reduced postoperative nausea severity (standardized mean difference [SMD]: -0.93, 95% confidence interval [CI]: -1.64 to -0.22; P = 0.010), but the reduction in vomiting episodes was not statistically significant (SMD: -0.81, 95% CI: -1.98-0.37; P = 0.180). Subgroup analysis indicated that ginger essence, lavender, and peppermint oils were particularly effective in managing postoperative nausea. However, due to significant statistical heterogeneity and potential biases in the studies, the results should be interpreted with caution. The certainty of the evidence, as evaluated by the GRADE approach, was low. Conclusion Preliminary evidence supports the potential benefit of aromatherapy in reducing the severity of postoperative nausea. However, given the low certainty of current evidence, more rigorous and standardized research is needed. The safety, affordability, and potential benefits to patient comfort make aromatherapy a promising area for further research in postoperative care.
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Affiliation(s)
- Jian-Ying Wang
- Department of Pharmacy, New Taipei City Hospital, New Taipei, Taiwan
| | - Hsueh-Yang Huang
- Department of Pharmacy, Kaohsiung Armed Forces General Hospital, Kaohsiung, Taiwan
| | - Wan-O Chu
- Department of Pharmacy, Keelung Hospital, Ministry of Health and Welfare, Keelung, Taiwan
| | - Tzu-Rong Peng
- Department of Pharmacy, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei, Taiwan
| | - Ming-Chia Lee
- Department of Pharmacy, New Taipei City Hospital, New Taipei, Taiwan
- School of Pharmacy, College of Pharmacy, Taipei Medical University, Taipei, Taiwan
| | - Shih-Ming Chen
- School of Pharmacy, College of Pharmacy, Taipei Medical University, Taipei, Taiwan
| | - Jen-Ai Lee
- School of Pharmacy, College of Pharmacy, Taipei Medical University, Taipei, Taiwan
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11
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Kummer I, Lüthi A, Klingler G, Andereggen L, Urman RD, Luedi MM, Stieger A. Adjuvant Analgesics in Acute Pain - Evaluation of Efficacy. Curr Pain Headache Rep 2024:10.1007/s11916-024-01276-w. [PMID: 38865074 DOI: 10.1007/s11916-024-01276-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/15/2024] [Indexed: 06/13/2024]
Abstract
PURPOSE OF THE REVIEW Acute postoperative pain impacts a significant number of patients and is associated with various complications, such as a higher occurrence of chronic postsurgical pain as well as increased morbidity and mortality. RECENT FINDINGS Opioids are often used to manage severe pain, but they come with serious adverse effects, such as sedation, respiratory depression, postoperative nausea and vomiting, and impaired bowel function. Therefore, most enhanced recovery after surgery protocols promote multimodal analgesia, which includes adjuvant analgesics, to provide optimal pain control. In this article, we aim to offer a comprehensive review of the contemporary literature on adjuvant analgesics in the management of acute pain, especially in the perioperative setting. Adjuvant analgesics have proven efficacy in treating postoperative pain and reducing need for opioids. While ketamine is an established option for opioid-dependent patients, magnesium and α2-agonists have, in addition to their analgetic effect, the potential to attenuate hemodynamic responses, which make them especially useful in painful laparoscopic procedures. Furthermore, α2-agonists and dexamethasone can extend the analgesic effect of regional anesthesia techniques. However, findings for lidocaine remain inconclusive.
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Affiliation(s)
- Isabelle Kummer
- Department of Anesthesiology, Rescue- and Pain Medicine, Cantonal Hospital of St. Gallen, St. Gallen, Switzerland.
| | - Andreas Lüthi
- Department of Anesthesiology, Rescue- and Pain Medicine, Cantonal Hospital of St. Gallen, St. Gallen, Switzerland
| | - Gabriela Klingler
- Department of Anesthesiology, Rescue- and Pain Medicine, Cantonal Hospital of St. Gallen, St. Gallen, Switzerland
| | - Lukas Andereggen
- Department of Neurosurgery, Cantonal Hospital of Aarau, Aarau, Switzerland
- Faculty of Medicine, University of Bern, Bern, Switzerland
| | - Richard D Urman
- Department of Anesthesiology, The Ohio State University, Columbus, OH, 43210, USA
| | - Markus M Luedi
- Department of Anesthesiology, Rescue- and Pain Medicine, Cantonal Hospital of St. Gallen, St. Gallen, Switzerland
- Department of Anesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Andrea Stieger
- Department of Anesthesiology, Rescue- and Pain Medicine, Cantonal Hospital of St. Gallen, St. Gallen, Switzerland
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12
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Kistler PM, Sanders P, Amarena JV, Bain CR, Chia KM, Choo WK, Eslick AT, Hall T, Hopper IK, Kotschet E, Lim HS, Ling LH, Mahajan R, Marasco SF, McGuire MA, McLellan AJ, Pathak RK, Phillips KP, Prabhu S, Stiles MK, Sy RW, Thomas SP, Toy T, Watts TW, Weerasooriya R, Wilsmore BR, Wilson L, Kalman JM. 2023 Cardiac Society of Australia and New Zealand Expert Position Statement on Catheter and Surgical Ablation for Atrial Fibrillation. Heart Lung Circ 2024; 33:828-881. [PMID: 38702234 DOI: 10.1016/j.hlc.2023.12.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 12/14/2023] [Indexed: 05/06/2024]
Abstract
Catheter ablation for atrial fibrillation (AF) has increased exponentially in many developed countries, including Australia and New Zealand. This Expert Position Statement on Catheter and Surgical Ablation for Atrial Fibrillation from the Cardiac Society of Australia and New Zealand (CSANZ) recognises healthcare factors, expertise and expenditure relevant to the Australian and New Zealand healthcare environments including considerations of potential implications for First Nations Peoples. The statement is cognisant of international advice but tailored to local conditions and populations, and is intended to be used by electrophysiologists, cardiologists and general physicians across all disciplines caring for patients with AF. They are also intended to provide guidance to healthcare facilities seeking to establish or maintain catheter ablation for AF.
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Affiliation(s)
- Peter M Kistler
- The Alfred Hospital, Melbourne, Vic, Australia; The Baker Heart and Diabetes Research Institute, Melbourne, Vic, Australia; University of Melbourne, Melbourne, Vic, Australia; Monash University, Melbourne, Vic, Australia.
| | - Prash Sanders
- University of Adelaide, Adelaide, SA, Australia; Royal Adelaide Hospital, Adelaide, SA, Australia
| | | | - Chris R Bain
- The Alfred Hospital, Melbourne, Vic, Australia; Monash University, Melbourne, Vic, Australia
| | - Karin M Chia
- Royal North Shore Hospital, Sydney, NSW, Australia
| | - Wai-Kah Choo
- Gold Coast University Hospital, Gold Coast, Qld, Australia; Royal Darwin Hospital, Darwin, NT, Australia
| | - Adam T Eslick
- University of Sydney, Sydney, NSW, Australia; The Canberra Hospital, Canberra, ACT, Australia
| | | | - Ingrid K Hopper
- The Alfred Hospital, Melbourne, Vic, Australia; Monash University, Melbourne, Vic, Australia
| | - Emily Kotschet
- Victorian Heart Hospital, Monash Health, Melbourne, Vic, Australia
| | - Han S Lim
- University of Melbourne, Melbourne, Vic, Australia; Austin Health, Melbourne, Vic, Australia; Northern Health, Melbourne, Vic, Australia
| | - Liang-Han Ling
- The Alfred Hospital, Melbourne, Vic, Australia; The Baker Heart and Diabetes Research Institute, Melbourne, Vic, Australia; University of Melbourne, Melbourne, Vic, Australia
| | - Rajiv Mahajan
- University of Adelaide, Adelaide, SA, Australia; Lyell McEwin Hospital, Adelaide, SA, Australia
| | - Silvana F Marasco
- The Alfred Hospital, Melbourne, Vic, Australia; Monash University, Melbourne, Vic, Australia
| | | | - Alex J McLellan
- University of Melbourne, Melbourne, Vic, Australia; Royal Melbourne Hospital, Melbourne, Vic, Australia; St Vincent's Hospital, Melbourne, Vic, Australia
| | - Rajeev K Pathak
- Australian National University and Canberra Heart Rhythm, Canberra, ACT, Australia
| | - Karen P Phillips
- Brisbane AF Clinic, Greenslopes Private Hospital, Brisbane, Qld, Australia
| | - Sandeep Prabhu
- The Alfred Hospital, Melbourne, Vic, Australia; The Baker Heart and Diabetes Research Institute, Melbourne, Vic, Australia; University of Melbourne, Melbourne, Vic, Australia; Monash University, Melbourne, Vic, Australia
| | - Martin K Stiles
- Waikato Clinical School, University of Auckland, Hamilton, New Zealand
| | - Raymond W Sy
- Royal Prince Alfred Hospital, Sydney, NSW, Australia; Concord Repatriation General Hospital, Sydney, NSW, Australia
| | - Stuart P Thomas
- University of Sydney, Sydney, NSW, Australia; Westmead Hospital, Sydney, NSW, Australia
| | - Tracey Toy
- The Alfred Hospital, Melbourne, Vic, Australia
| | - Troy W Watts
- Royal Melbourne Hospital, Melbourne, Vic, Australia
| | - Rukshen Weerasooriya
- Hollywood Private Hospital, Perth, WA, Australia; University of Western Australia, Perth, WA, Australia
| | | | | | - Jonathan M Kalman
- University of Melbourne, Melbourne, Vic, Australia; Royal Melbourne Hospital, Melbourne, Vic, Australia
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13
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Li X, Yu L, Yang J, Fu M, Tan H. Efficacy of preoperative single-dose dexamethasone in preventing postoperative pulmonary complications following minimally invasive esophagectomy: a retrospective propensity score-matched study. Perioper Med (Lond) 2024; 13:46. [PMID: 38807202 PMCID: PMC11134948 DOI: 10.1186/s13741-024-00407-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 05/23/2024] [Indexed: 05/30/2024] Open
Abstract
BACKGROUND The study was performed to investigate the efficacy and safety of preoperative dexamethasone (DXM) in preventing postoperative pulmonary complications (PPCs) after minimally invasive esophagectomy (MIE). METHODS Patients who underwent total MIE with two-field lymph node dissection from February 2018 to February 2023 were included in this study. Patients who were given either 5 mg or 10 mg DXM as preoperative prophylactic medication before induction of general anesthesia were assigned to the DXM group, while patients who did not receive DXM were assigned to the control group. Preoperative evaluations, intraoperative data, and occurrence of postoperative complications were analyzed. The primary outcome was the incidence of PPCs occurring by day 7 after surgery. RESULTS In total, 659 patients were included in the study; 453 patients received preoperative DXM, while 206 patients did not. Propensity score-matched analysis created a matched cohort of 366 patients, with 183 patients each in the DXM and control groups. A total of 24.6% of patients in the DXM group and 30.6% of patients in the control group had PPCs (P = 0.198). The incidence of respiratory failure was significantly lower in the DXM group than in the control group (1.1% vs 5.5%, P = 0.019). Fewer patients were re-intubated during their hospital stay in the DXM group than in the control group (1.1% vs 5.5%, P = 0.019). CONCLUSIONS Preoperative DXM before induction of anesthesia did not reduce overall PPC development after MIE. Nevertheless, the occurrence of early respiratory failure and the incidence of re-intubation during hospitalization were decreased. TRIAL REGISTRATION Chinese Clinical Trial Registry (No. ChiCTR2300071674; Date of registration, 22/05/2023).
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Affiliation(s)
- Xiaoxi Li
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Anesthesiology, Peking University Cancer Hospital & Institute, #52 Fucheng Street, Haidian District, Beijing, 100142, China
| | - Ling Yu
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Anesthesiology, Peking University Cancer Hospital & Institute, #52 Fucheng Street, Haidian District, Beijing, 100142, China
| | - Jiaonan Yang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Anesthesiology, Peking University Cancer Hospital & Institute, #52 Fucheng Street, Haidian District, Beijing, 100142, China
| | - Miao Fu
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Anesthesiology, Peking University Cancer Hospital & Institute, #52 Fucheng Street, Haidian District, Beijing, 100142, China
| | - Hongyu Tan
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Anesthesiology, Peking University Cancer Hospital & Institute, #52 Fucheng Street, Haidian District, Beijing, 100142, China.
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14
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Zufferey PJ, Chaux R, Lachaud PA, Capdevila X, Lanoiselée J, Ollier E. Dose-response relationships of intravenous and perineural dexamethasone as adjuvants to peripheral nerve blocks: a systematic review and model-based network meta-analysis. Br J Anaesth 2024; 132:1122-1132. [PMID: 38281844 DOI: 10.1016/j.bja.2023.12.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 12/15/2023] [Accepted: 12/19/2023] [Indexed: 01/30/2024] Open
Abstract
BACKGROUND Superiority of perineural over intravenous dexamethasone at extending nerve block analgesia has been suggested but without considering the dose-response relationships for each route of administration. METHODS Randomised control studies that evaluated intravenous or perineural dexamethasone as an adjuvant to unilateral peripheral nerve blocks in adults were searched up to October 2023 in MEDLINE, Central, Google Scholar, and reference lists of previous systematic reviews. The Cochrane Risk-of-Bias tool was used. A maximum effect (Emax) model-based network meta-analysis was undertaken to evaluate the dose-response relationships of dexamethasone. RESULTS A total of 118 studies were selected (9284 patients; 35 with intravenous dexamethasone; 106 with perineural dexamethasone; dose range 1-16 mg). Studies with unclear or high risk of bias overestimated the effect of dexamethasone. Bias-corrected estimates indicated a maximum fold increase in analgesia duration of 1.7 (95% credible interval (CrI) 1.4-1.9) with dexamethasone, with no difference between perineural and intravenous routes. Trial simulations indicated that 4 mg of perineural dexamethasone increased the mean duration of analgesia for long-acting local anaesthetics from 11.1 h (95% CrI 9.4-13.1) to 16.5 h (95% CrI 14.0-19.3) and halved the rate of postoperative nausea and vomiting. A similar magnitude of effect was observed with 8 mg of intravenous dexamethasone. CONCLUSIONS Used as an adjuvant for peripheral nerve block, intravenous dexamethasone can be as effective as perineural dexamethasone in prolonging analgesic duration, but is less potent, hence requiring higher doses. The evidence is limited because of the observational nature of the dose-response relationships and the quality of the included studies. SYSTEMATIC REVIEW PROTOCOL PROSPERO CRD42020141689.
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Affiliation(s)
- Paul J Zufferey
- Department of Anaesthesia and Intensive Care, University Hospital of Saint-Etienne, Saint-Etienne, France; Clinical Pharmacology Department, University Hospital of Saint-Etienne, Saint-Etienne, France.
| | - Robin Chaux
- Clinical Pharmacology Department, University Hospital of Saint-Etienne, Saint-Etienne, France
| | - Pierre-Adrien Lachaud
- Department of Anaesthesia and Intensive Care, University Hospital of Saint-Etienne, Saint-Etienne, France; Clinical Pharmacology Department, University Hospital of Saint-Etienne, Saint-Etienne, France
| | - Xavier Capdevila
- Department of Anaesthesiology and Intensive Care Medicine, Lapeyronie University Hospital, Montpellier, France; Basic Science Research Unit, INSERM UMR U1298, NeuroSciences Institute INM, Montpellier, France
| | - Julien Lanoiselée
- Department of Anaesthesia and Intensive Care, University Hospital of Saint-Etienne, Saint-Etienne, France; Clinical Pharmacology Department, University Hospital of Saint-Etienne, Saint-Etienne, France
| | - Edouard Ollier
- Clinical Pharmacology Department, University Hospital of Saint-Etienne, Saint-Etienne, France; Institut National de la Santé et de la Recherche Médicale (INSERM), U1059, Vascular Dysfunction and Hemostasis, Saint-Etienne, France
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15
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Lei G, Yang S, Wu L, Yin Y, Zhang S, Wang G. Intravenous injection of dexamethasone is non-inferior to perineural administration for popliteal sciatic nerve and saphenous nerve blocks: A randomized, controlled, triple-blind study. Heliyon 2024; 10:e28304. [PMID: 38571656 PMCID: PMC10988014 DOI: 10.1016/j.heliyon.2024.e28304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Revised: 03/06/2024] [Accepted: 03/15/2024] [Indexed: 04/05/2024] Open
Abstract
Background The aim of this study was to assess whether intravenous dexamethasone was noninferior to perineural dexamethasone as an adjuvant to ropivacaine for a combination of saphenous and sciatic nerve blocks in patients undergoing foot and ankle surgery. Methods This was a prospective, blinded, randomized noninferiority study. Seventy-five patients, aged 18-75 years, with an American Society of Anesthesiologists (ASA) physical status I-III who underwent foot and ankle surgery were involved. Patients scheduled for ultrasound-guided popliteal sciatic nerve block and saphenous nerve block were randomized to receive 0.375% ropivacaine with 7.5 mg of dexamethasone perineurally (Dex-PN), 10 mg of dexamethasone intravenously (Dex-IV) or neither (Placebo). The primary outcome was the duration of analgesia. The major secondary outcomes were the composite pain intensity and opioid consumption score at 0-48 h intervals after anesthesia. Results The mean analgesic duration was 26.2 h in the Dex-IV group and 27.9 h in the Dex-PN group (duration difference, -1.7; 95% CI, -3.8 to 0.43; P = 0.117), and both durations were significantly longer than that in the placebo group (17.6 h, P < 0.001). Conditions for establishing non-inferiority were met. Conclusions Our findings indicate that a single 10-mg intravenous dose of dexamethasone was noninferior to the combined dose of ropivacaine plus deaxmethasone in terms of duration of analgesia for foot and ankle surgery.
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Affiliation(s)
- Guiyu Lei
- Department of Anesthesiology, Beijing Tongren Hospital, Capital Medical University, Beijing 100730, China
| | - Siliu Yang
- Department of Anesthesiology, Beijing Tongren Hospital, Capital Medical University, Beijing 100730, China
- Department of Anesthesiology, Beijing Dongcheng Maternal and Child Health Care Hospital, Beijing, 100007, China
| | - Lili Wu
- Department of Anesthesiology, Beijing Tongren Hospital, Capital Medical University, Beijing 100730, China
| | - Yue Yin
- Department of Anesthesiology, Beijing Tongren Hospital, Capital Medical University, Beijing 100730, China
| | - Shu Zhang
- Center of Foot and Ankle Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Guyan Wang
- Department of Anesthesiology, Beijing Tongren Hospital, Capital Medical University, Beijing 100730, China
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16
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Steiness J, Hägi-Pedersen D, Lunn TH, Overgaard S, Brorson S, Graungaard BK, Lindberg-Larsen M, Varnum C, Lundstrøm LH, Beck T, Skettrup M, Pedersen NA, Bieder MJ, von Cappeln AG, Pleckaitiene L, Lindholm P, Bukhari SSH, Derby CB, Nielsen MG, Exsteen OW, Vinstrup LØ, Thybo KH, Gasbjerg KS, Nørskov AK, Jakobsen JC, Mathiesen O. Non-opioid analgesic combinations following total hip arthroplasty (RECIPE): a randomised, placebo-controlled, blinded, multicentre trial. THE LANCET. RHEUMATOLOGY 2024; 6:e205-e215. [PMID: 38458208 DOI: 10.1016/s2665-9913(24)00020-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 01/15/2024] [Accepted: 01/16/2024] [Indexed: 03/10/2024]
Abstract
BACKGROUND Multimodal postoperative analgesia following total hip arthroplasty is recommended, but the optimal combination of drugs remains uncertain. The aim of the RECIPE trial was to investigate the relative benefit and harm of the different combinations of paracetamol, ibuprofen, and the analgesic adjuvant dexamethasone for treatment of postoperative pain following total hip arthroplasty. METHODS The RECIPE trial was a randomised, blinded, placebo-controlled trial conducted at nine Danish hospitals. Adults scheduled for total hip arthroplasty were randomly assigned (1:1:1:1) using a computer-generated list with stratification by site to receive combinations of oral paracetamol 1000 mg every 6 h, oral ibuprofen 400 mg every 6 h, or a single-dose of intravenous dexamethasone 24 mg in the following groups: paracetamol plus ibuprofen, ibuprofen plus dexamethasone, paracetamol plus dexamethasone, and paracetamol plus ibuprofen plus dexamethasone. The primary outcome was 24 h intravenous morphine consumption, analysed in a modified intention-to-treat population, defined as all randomly assigned participants who underwent total hip arthroplasty. The predefined minimal important difference was 8 mg. Safety outcomes included serious and non-serious adverse events within 90 days and 24 h. The trial was registered with ClinicalTrials.gov, NCT04123873. FINDINGS Between March 5, 2020, and Nov 15, 2022, we randomly assigned 1060 participants, of whom 1043 (589 [56%] women and 454 [44%] men) were included in the modified intention-to-treat population. 261 were assigned to paracetamol plus ibuprofen, 262 to ibuprofen plus dexamethasone, 262 to paracetamol plus dexamethasone, and 258 to paracetamol plus ibuprofen plus dexamethasone. Median 24 h morphine consumption was 24 mg (IQR 12-38) in the paracetamol plus ibuprofen group, 20 mg (12-32) in the paracetamol plus dexamethasone group, 16 mg (10-30) in the ibuprofen plus dexamethasone group, and 15 mg (8-26) in the paracetamol plus ibuprofen plus dexamethasone group. The paracetamol plus ibuprofen plus dexamethasone group had a significantly reduced 24 h morphine consumption compared with paracetamol plus ibuprofen (Hodges-Lehmann median difference -6 mg [99% CI -10 to -3]; p<0·0001) and paracetamol plus dexamethasone (-4 mg [-8 to -1]; p=0·0013), however, none of the comparisons showed differences reaching the minimal important threshold of 8 mg. 91 (35%) of 258 participants in the paracetamol plus ibuprofen plus dexamethasone group had one or more adverse events, compared with 99 (38%) of 262 in the ibuprofen plus dexamethasone group, 103 (39%) of 262 in the paracetamol plus dexamethasone group, and 165 (63%) of 261 in the paracetamol plus ibuprofen group. INTERPRETATION In adults undergoing total hip arthroplasty, a combination of paracetamol, ibuprofen, and dexamethasone had the lowest morphine consumption within 24 h following surgery and the most favourable adverse event profile, with a lower incidence of serious and non-serious adverse events (primarily driven by differences in nausea, vomiting, and dizziness) compared with paracetamol plus ibuprofen. FUNDING The Novo Nordisk Foundation and Næstved-Slagelse-Ringsted Hospitals' Research Fund.
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Affiliation(s)
- Joakim Steiness
- Department of Anaesthesiology, Zealand University Hospital, Køge, Denmark.
| | - Daniel Hägi-Pedersen
- Department of Anaesthesiology, Næstved-Slagelse-Ringsted Hospitals, Næstved, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Troels Haxholdt Lunn
- Department of Anaesthesiology and Intensive Care, Copenhagen University Hospital, Bispebjerg Hospital, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Søren Overgaard
- Department of Orthopaedic Surgery and Traumatology, Copenhagen University Hospital, Bispebjerg Hospital, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Stig Brorson
- Department of Orthopaedic Surgery, Zealand University Hospital, Køge, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Ben Kristian Graungaard
- Department of Anaesthesiology, Copenhagen University Hospital, Gentofte Hospital, Copenhagen, Denmark
| | - Martin Lindberg-Larsen
- Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Odense, Denmark; Department of Orthopaedic Surgery, Odense University Hospital, Svendborg, Denmark; Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Claus Varnum
- Department of Orthopaedic Surgery, Lillebælt Hospital, Vejle, Denmark; Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Lars Hyldborg Lundstrøm
- Department of Anaesthesiology, Copenhagen University Hospital - North Zealand, Hillerød, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Torben Beck
- Department of Orthopaedic Surgery and Traumatology, Copenhagen University Hospital, Bispebjerg Hospital, Copenhagen, Denmark
| | - Michael Skettrup
- Department of Orthopaedic Surgery, Copenhagen University Hospital, Gentofte Hospital, Copenhagen, Denmark
| | | | - Manuel Josef Bieder
- Department of Orthopaedic Surgery, Næstved-Slagelse-Ringsted Hospitals, Næstved, Denmark
| | | | | | - Peter Lindholm
- Department of Anaesthesiology, Odense University Hospital, Odense, Denmark
| | | | | | - Maria Gantzel Nielsen
- Department of Anaesthesiology and Intensive Care, Copenhagen University Hospital, Bispebjerg Hospital, Copenhagen, Denmark
| | - Oskar Wilborg Exsteen
- Department of Anaesthesiology, Copenhagen University Hospital - North Zealand, Hillerød, Denmark
| | - Louise Ørts Vinstrup
- Department of Anaesthesiology and Intensive Care, Copenhagen University Hospital, Bispebjerg Hospital, Copenhagen, Denmark
| | - Kasper Højgaard Thybo
- Department of Anaesthesiology, Næstved-Slagelse-Ringsted Hospitals, Næstved, Denmark
| | - Kasper Smidt Gasbjerg
- Department of Anaesthesiology, Copenhagen University Hospital, Herlev Hospital, Copenhagen, Denmark
| | - Anders Kehlet Nørskov
- Department of Anaesthesiology, Copenhagen University Hospital - North Zealand, Hillerød, Denmark
| | - Janus Christian Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen, Denmark; Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Ole Mathiesen
- Department of Anaesthesiology, Zealand University Hospital, Køge, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Li B, Yang X, Liu F, Huang H, Zhang B, Li X, Lu Q, Liu P, Fan L. Effect of Perineural or Intravenous Betamethasone on Femoral Nerve Block Outcomes in Knee Arthroplasty: A Randomized, Controlled Study. Orthop Surg 2024; 16:873-881. [PMID: 38384178 PMCID: PMC10984829 DOI: 10.1111/os.14018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 01/23/2024] [Accepted: 01/27/2024] [Indexed: 02/23/2024] Open
Abstract
OBJECTIVES Despite the use of multimodal analgesia, patients undergoing knee arthroplasty still encounter residual moderate pain. The addition of betamethasone to local anesthetic has been shown to improve postoperative pain. However, it remains uncertain whether the positive effects of perineural or intravenous administration of betamethasone on analgesia outcomes lead to better early mobility and postoperative recovery. METHODS Between June 2022 and February 2023, a total of 159 patients who were undergoing knee arthroplasty were included in this study. These patients were allocated randomly into three groups: (i) the NS group, received ropivacaine 0.375% and intravenous 3mL 0.9% normal saline; (ii) the PNB group, received ropivacaine 0.375% plus perineural betamethasone (12mg) 3mL and intravenous 3mL 0.9% normal saline; and (iii) the IVB group, received ropivacaine 0.375% and intravenous betamethasone (12mg) 3mL. RESULTS Both perineural and intravenous administration of betamethasone led to improved median (IQR) numeric rating scale (NRS) scores on the 6-meter walk test, with a score of 1.0 (1.0-2.0) for both groups, compared with 2.0 (1.0-2.0) for the NS group (p = 0.003). Compared to the NS group, both the PNB and IVB groups showed significant reductions in NRS scores at 24 and 36 h after surgery, along with a significant increase in ROM at 24, 36, and 48 h post-operation. Additionally, it exhibited lower levels of cytokine IL-1β and TNF-α in fluid samples, as well as lower level of HS-CRP in blood samples in the PNB and IVB groups compared to the NS group. CONCLUSION The administration of perineural and intravenous betamethasone demonstrated an enhanced analgesic effect following knee arthroplasty. Furthermore, it was associated with reduced levels of IL-1β, TNF-α, and HS-CRP, as well as enhanced knee ROM, which is conducive to early ambulation and postoperative rehabilitation after knee arthroplasty.
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Affiliation(s)
- Binglong Li
- Department of OrthopedicsQilu Hospital of Shandong UniversityJinanChina
- Shandong University Cheeloo College of MedicineJinanChina
| | - Xiaomei Yang
- Shandong University Cheeloo College of MedicineJinanChina
- Department of Anaesthesiology, Qilu HospitalShandong UniversityJinanChina
- Department of Cardiology, the Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, the State and Shandong Province Joint Key Laboratory of Translational Cardiovascular MedicineQilu Hospital of Shandong UniversityJinanChina
| | - Fang Liu
- Shandong University Cheeloo College of MedicineJinanChina
- Department of Anaesthesiology, Qilu HospitalShandong UniversityJinanChina
| | - Huang Huang
- Institute for In Vitro SciencesGaithersburgMDUSA
| | - Baoqing Zhang
- Department of OrthopedicsQilu Hospital of Shandong UniversityJinanChina
| | - Xuezhou Li
- Department of OrthopedicsQilu Hospital of Shandong UniversityJinanChina
| | - Qunshan Lu
- Department of OrthopedicsQilu Hospital of Shandong UniversityJinanChina
| | - Peilai Liu
- Department of OrthopedicsQilu Hospital of Shandong UniversityJinanChina
| | - Lixia Fan
- Department of Anaesthesiology, Qilu HospitalShandong UniversityJinanChina
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18
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Ciarleglio MM, Li J, Peduzzi P. Unresolved issues with noninferiority pragmatic trials: Results of a literature survey. Clin Trials 2024; 21:242-256. [PMID: 37927102 DOI: 10.1177/17407745231206371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2023]
Abstract
BACKGROUND Issues with specification of margins, adherence, and analytic population can potentially bias results toward the alternative in randomized noninferiority pragmatic trials. To investigate this potential for bias, we conducted a targeted search of the medical literature to examine how noninferiority pragmatic trials address these issues. METHODS An Ovid MEDLINE database search was performed identifying publications in New England Journal of Medicine, Journal of the American Medical Association, Lancet, or British Medical Journal published between 2015 and 2021 that included the words "pragmatic" or "comparative effectiveness" and "noninferiority" or "non-inferiority." Our search identified 14 potential trials, 12 meeting our inclusion criteria (11 individually randomized, 1 cluster-randomized). RESULTS Eleven trials had results that met the criteria established for noninferiority. Noninferiority margins were prespecified for all trials; all but two trials provided justification of the margin. Most trials did some monitoring of treatment adherence. All trials conducted intent-to-treat or modified intent-to-treat analyses along with per-protocol analyses and these analyses reached similar conclusions. Only two trials included all randomized participants in the primary analysis, one used multiple imputation for missing data. The percentage excluded from primary analyses ranged from ∼2% to 30%. Reasons for exclusion included randomization in error, nonadherence, not receiving assigned treatment, death, withdrawal, lost to follow-up, and incomplete data. CONCLUSION Specification of margins, adherence, and analytic population require careful consideration to prevent bias toward the alternative in noninferiority pragmatic trials. Although separate guidance has been developed for noninferiority and pragmatic trials, it is not compatible with conducting a noninferiority pragmatic trial. Hence, these trials should probably not be done in their current format without developing new guidelines.
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Affiliation(s)
- Maria M Ciarleglio
- Department of Biostatistics, Yale Center for Analytical Sciences, Yale School of Public Health, New Haven, CT, USA
| | - Jiaxuan Li
- Department of Biostatistics, Yale Center for Analytical Sciences, Yale School of Public Health, New Haven, CT, USA
| | - Peter Peduzzi
- Department of Biostatistics, Yale Center for Analytical Sciences, Yale School of Public Health, New Haven, CT, USA
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19
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Torrance HD, Zhang P, Longbottom ER, Mi Y, Whalley JP, Allcock A, Kwok AJ, Cano-Gamez E, Geoghegan CG, Burnham KL, Antcliffe DB, Davenport EE, Pearse RM, O’Dwyer MJ, Hinds CJ, Knight JC, Gordon AC. A Transcriptomic Approach to Understand Patient Susceptibility to Pneumonia After Abdominal Surgery. Ann Surg 2024; 279:510-520. [PMID: 37497667 PMCID: PMC10829899 DOI: 10.1097/sla.0000000000006050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
Abstract
OBJECTIVE To describe immune pathways and gene networks altered following major abdominal surgery and to identify transcriptomic patterns associated with postoperative pneumonia. BACKGROUND Nosocomial infections are a major healthcare challenge, developing in over 20% of patients aged 45 or over undergoing major abdominal surgery, with postoperative pneumonia associated with an almost 5-fold increase in 30-day mortality. METHODS From a prospective consecutive cohort (n=150) undergoing major abdominal surgery, whole-blood RNA was collected preoperatively and at 3 time-points postoperatively (2-6, 24, and 48 h). Twelve patients diagnosed with postoperative pneumonia and 27 matched patients remaining infection-free were identified for analysis with RNA-sequencing. RESULTS Compared to preoperative sampling, 3639 genes were upregulated and 5043 downregulated at 2 to 6 hours. Pathway analysis demonstrated innate-immune activation with neutrophil degranulation and Toll-like-receptor signaling upregulation alongside adaptive-immune suppression. Cell-type deconvolution of preoperative RNA-sequencing revealed elevated S100A8/9-high neutrophils alongside reduced naïve CD4 T-cells in those later developing pneumonia. Preoperatively, a gene-signature characteristic of neutrophil degranulation was associated with postoperative pneumonia acquisition ( P =0.00092). A previously reported Sepsis Response Signature (SRSq) score, reflecting neutrophil dysfunction and a more dysregulated host response, at 48 hours postoperatively, differed between patients subsequently developing pneumonia and those remaining infection-free ( P =0.045). Analysis of the novel neutrophil gene-signature and SRSq scores in independent major abdominal surgery and polytrauma cohorts indicated good predictive performance in identifying patients suffering later infection. CONCLUSIONS Major abdominal surgery acutely upregulates innate-immune pathways while simultaneously suppressing adaptive-immune pathways. This is more prominent in patients developing postoperative pneumonia. Preoperative transcriptomic signatures characteristic of neutrophil degranulation and postoperative SRSq scores may be useful predictors of subsequent pneumonia risk.
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Affiliation(s)
- Hew D. Torrance
- Division of Anaesthetics, Pain Medicine & Intensive Care Department of Surgery & Cancer, Faculty of Medicine, Imperial College London, London. UK
| | - Ping Zhang
- Wellcome Centre for Human Genetics, University of Oxford, Oxford. UK
- Chinese Academy of Medical Science Oxford Institute, University of Oxford, Oxford, UK
| | - E. Rebecca Longbottom
- Centre for Translational Medicine & Therapeutics, William Harvey Institute, Faculty of Medicine & Dentistry at Queen Mary University of London, London. UK
| | - Yuxin Mi
- Wellcome Centre for Human Genetics, University of Oxford, Oxford. UK
| | - Justin P. Whalley
- Wellcome Centre for Human Genetics, University of Oxford, Oxford. UK
- Center for Cancer Cell Biology, Immunology, and Infection, Chicago Medical School, Rosalind Franklin University of Medicine and Science, North Chicago, IL
| | - Alice Allcock
- Wellcome Centre for Human Genetics, University of Oxford, Oxford. UK
| | - Andrew J. Kwok
- Wellcome Centre for Human Genetics, University of Oxford, Oxford. UK
| | - Eddie Cano-Gamez
- Wellcome Centre for Human Genetics, University of Oxford, Oxford. UK
| | | | - Katie L. Burnham
- Wellcome Sanger Institute, Wellcome Genome Campus, Hinxton, Cambridgeshire, UK
| | - David B. Antcliffe
- Division of Anaesthetics, Pain Medicine & Intensive Care Department of Surgery & Cancer, Faculty of Medicine, Imperial College London, London. UK
| | - Emma E. Davenport
- Wellcome Sanger Institute, Wellcome Genome Campus, Hinxton, Cambridgeshire, UK
| | - Rupert M. Pearse
- Centre for Translational Medicine & Therapeutics, William Harvey Institute, Faculty of Medicine & Dentistry at Queen Mary University of London, London. UK
| | - Michael J. O’Dwyer
- Department of Anaesthesia and Critical Care, St Vincent’s University Hospital, Dublin. Ireland
| | - Charles J. Hinds
- Centre for Translational Medicine & Therapeutics, William Harvey Institute, Faculty of Medicine & Dentistry at Queen Mary University of London, London. UK
| | - Julian C. Knight
- Wellcome Centre for Human Genetics, University of Oxford, Oxford. UK
- Chinese Academy of Medical Science Oxford Institute, University of Oxford, Oxford, UK
| | - Anthony C. Gordon
- Division of Anaesthetics, Pain Medicine & Intensive Care Department of Surgery & Cancer, Faculty of Medicine, Imperial College London, London. UK
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20
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Behem CR, Friedheim T, Holthusen H, Rapp A, Suntrop T, Graessler MF, Pinnschmidt HO, Wipper SH, von Lucadou M, Schwedhelm E, Renné T, Pfister K, Schierling W, Trepte CJC. Goal-directed colloid versus crystalloid therapy and microcirculatory blood flow following ischemia/reperfusion. Microvasc Res 2024; 152:104630. [PMID: 38048876 DOI: 10.1016/j.mvr.2023.104630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 11/11/2023] [Accepted: 11/25/2023] [Indexed: 12/06/2023]
Abstract
OBJECTIVE Ischemia/reperfusion can impair microcirculatory blood flow. It remains unknown whether colloids are superior to crystalloids for restoration of microcirculatory blood flow during ischemia/reperfusion injury. We tested the hypothesis that goal-directed colloid - compared to crystalloid - therapy improves small intestinal, renal, and hepatic microcirculatory blood flow in pigs with ischemia/reperfusion injury. METHODS This was a randomized trial in 32 pigs. We induced ischemia/reperfusion by supra-celiac aortic-cross-clamping. Pigs were randomized to receive either goal-directed isooncotic hydroxyethyl-starch colloid or balanced isotonic crystalloid therapy. Microcirculatory blood flow was measured using Laser-Speckle-Contrast-Imaging. The primary outcome was small intestinal, renal, and hepatic microcirculatory blood flow 4.5 h after ischemia/reperfusion. Secondary outcomes included small intestinal, renal, and hepatic histopathological damage, macrohemodynamic and metabolic variables, as well as specific biomarkers of tissue injury, renal, and hepatic function and injury, and endothelial barrier function. RESULTS Small intestinal microcirculatory blood flow was higher in pigs assigned to isooncotic hydroxyethyl-starch colloid therapy than in pigs assigned to balanced isotonic crystalloid therapy (768.7 (677.2-860.1) vs. 595.6 (496.3-694.8) arbitrary units, p = .007). There were no important differences in renal (509.7 (427.2-592.1) vs. 442.1 (361.2-523.0) arbitrary units, p = .286) and hepatic (604.7 (507.7-701.8) vs. 548.7 (444.0-653.3) arbitrary units, p = .376) microcirculatory blood flow between groups. Pigs assigned to colloid - compared to crystalloid - therapy also had less small intestinal, but not renal and hepatic, histopathological damage. CONCLUSIONS Goal-directed isooncotic hydroxyethyl-starch colloid - compared to balanced isotonic crystalloid - therapy improved small intestinal, but not renal and hepatic, microcirculatory blood flow in pigs with ischemia/reperfusion injury. Whether colloid therapy improves small intestinal microcirculatory blood flow in patients with ischemia/reperfusion needs to be investigated in clinical trials.
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Affiliation(s)
- Christoph R Behem
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Till Friedheim
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hannes Holthusen
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Adina Rapp
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Timo Suntrop
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Michael F Graessler
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hans O Pinnschmidt
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sabine H Wipper
- Department of Vascular Medicine, University Heart and Vascular Center Hamburg (UHZ), Hamburg, Germany
| | - Mirjam von Lucadou
- Institute of Clinical Pharmacology and Toxicology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Edzard Schwedhelm
- Institute of Clinical Pharmacology and Toxicology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Thomas Renné
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland; Center for Thrombosis and Hemostasis (CTH), Johannes Gutenberg University Medical Center, Mainz, Germany
| | - Karin Pfister
- Department of Vascular Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Wilma Schierling
- Department of Vascular Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Constantin J C Trepte
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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21
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Xu C, Wang C, Hu Y, Gu F, Lu J, Zhou Q. Comparing preoperative and postoperative dexamethasone effects on analgesia duration in shoulder surgery. iScience 2024; 27:109019. [PMID: 38352222 PMCID: PMC10863306 DOI: 10.1016/j.isci.2024.109019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 12/24/2023] [Accepted: 01/22/2024] [Indexed: 02/16/2024] Open
Abstract
Dexamethasone is commonly used as an adjuvant to prolong peripheral nerve block analgesia, but the optimal timing is unclear. This randomized equivalence trial tested whether preoperative versus postoperative intravenous dexamethasone have equivalent analgesic effects when combined with interscalene brachial plexus block for shoulder surgery. 168 patients were randomized to receive 5 mg dexamethasone either preoperatively or postoperatively. The primary outcome was duration of analgesia, analyzed for equivalence with a 2-h margin. The mean durations were equivalent between groups (11.5 h preoperative versus 10.7 h postoperative). The confidence intervals fell within the equivalence margin. There were no other clinically significant differences in secondary outcomes like time to first analgesia, motor recovery, opioid consumption, blood glucose, or complications. In conclusion, as an adjuvant for nerve block, preoperative and postoperative intravenous dexamethasone provide equivalent analgesic duration, allowing for flexibility in clinical use. This addresses previous uncertainty about timing while demonstrating equivalent efficacy.
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Affiliation(s)
- Cheng Xu
- Department of Anaesthesiology, Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 600 Yishan Road, Shanghai, China
| | - Chengyu Wang
- Department of Anaesthesiology, Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 600 Yishan Road, Shanghai, China
| | - Yanling Hu
- Department of Anaesthesiology, Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 600 Yishan Road, Shanghai, China
| | - Fei Gu
- Department of Anaesthesiology, Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 600 Yishan Road, Shanghai, China
| | - Jie Lu
- Department of Anaesthesiology, Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 600 Yishan Road, Shanghai, China
| | - Quanhong Zhou
- Department of Critical Care, Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 600 Yishan Road, Shanghai, China
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22
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Dexter F, Loftus RW. Estimation of the contribution to intraoperative pathogen transmission from bacterial contamination of patient nose, patient groin and axilla, anesthesia practitioners' hands, anesthesia machine, and intravenous lumen. J Clin Anesth 2024; 92:111303. [PMID: 37875062 DOI: 10.1016/j.jclinane.2023.111303] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 09/30/2023] [Accepted: 10/18/2023] [Indexed: 10/26/2023]
Abstract
BACKGROUND Earlier studies showed net cost saving from anesthesia practitioners' use of a bundle of infection prevention products, with feedback on monitored Staphylococcus aureus intraoperative transmission. ESKAPE pathogens also include Enterococcus and gram-negative pathogens: Klebsiella, Acinetobacter, Pseudomonas, and Enterobacter. We evaluated whether bacterial contamination of patient nose, patient groin and axilla, anesthesia practitioners' hands, anesthesia machine, and intravenous lumen all contribute meaningfully to ESKAPE pathogen transmission within anesthesia work areas. METHODS The retrospective cohort study used bacterial count data from nine hospitals, 43 months, and 448 ESKAPE pathogen transmission events within anesthesia areas of 86 operating rooms. Transmission was measured within and between pairs of successive surgical cases performed in the same operating room on the same day. RESULTS There were 203 transmission events with S. aureus, 72 with Enterococcus, and 173 with gram negatives. ESKAPE pathogens in the nose contributed to transmission for 50% (99% confidence limit ≥45%) of case pairs, on the groin or axilla for 54% (≥49%), on the hands for 53% (≥47%), on the anesthesia machine for 21% (≥17%), and in the intravenous lumen for 24% (≥20%). ESKAPE pathogens in the nose started a transmission pathway for 27% (≥22%) of case pairs, on the groin or axilla for 24% (≥19%), on the hands for 38% (≥33%), on the anesthesia machine for 11% (≥7.6%), and in the intravenous lumen for 8.0% (≥5.3%). All P ≤ 0.0022 compared with 5%. CONCLUSIONS To prevent intraoperative ESKAPE pathogen transmission, anesthesia practitioners would need to address all five categories of infection control approaches: nasal antisepsis (e.g., povidone-iodine applied the morning of surgery), skin antisepsis (e.g., chlorhexidine wipes), hand antisepsis with dispensers next to the patient, decontamination of the anesthesia machine before and during anesthetics, and disinfecting caps for needleless connectors, disinfecting port protectors, and disinfecting caps for open female Luer type connectors.
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Affiliation(s)
- Franklin Dexter
- University of Iowa, Iowa City, IA, United States of America.
| | - Randy W Loftus
- University of Iowa, Iowa City, IA, United States of America.
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23
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Derby CB, Gasbjerg KS, Hägi-Pedersen D, Lunn TH, Pedersen NA, Lindholm P, Brorson S, Schrøder HM, Thybo KH, Bagger J, Lindberg-Larsen M, Overgaard S, Jakobsen JC, Mathiesen O. Prolonged effects of dexamethasone following total knee arthroplasty: A pre-planned sub-study of the DEX-2-TKA trial. Acta Anaesthesiol Scand 2024; 68:35-42. [PMID: 37709280 DOI: 10.1111/aas.14319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 07/31/2023] [Accepted: 08/08/2023] [Indexed: 09/16/2023]
Abstract
OBJECTIVES The DEX-2-TKA trial demonstrated that one and two doses of 24 mg intravenous dexamethasone reduced opioid consumption and pain after total knee arthroplasty (TKA). We aimed to investigate the prolonged effects of dexamethasone after the 48-h intervention period. DESIGN This was a prospective, pre-planned questionnaire follow-up on postoperative days 3-7 of patients in the DEX-2-TKA trial that randomly received: DX1 (dexamethasone 24 mg + placebo), DX2 (dexamethasone 24 mg + dexamethasone 24 mg), and placebo (placebo + placebo) perioperatively and 24 h later. SETTING A multicenter trial performed at five Danish hospitals. PARTICIPANTS We analyzed 434 of 485 adult participants enrolled in the DEX-2-TKA trial. OUTCOME MEASURES Primary outcome was difference between groups in average of all numerical rating scale (NRS) pain scores reported in the morning, at bedtime, and the daily average pain on postoperative days 3-7. Secondary outcomes were sleep quality and patient satisfaction. RESULTS The median (interquartile range) pain intensity levels for postoperative days 3-7 were: DX2 3.2 (2.1-4.3); DX1 3.3 (2.3-4.1); and placebo 3.3 (2.5-4.7). Hodges-Lehmann median differences between groups were: 0 (95% confidence interval - 0.54 to 0.2), P = 0.38 between DX1 and placebo; 0.1 (-0.47 to 0.33), p = .87 between DX1 and DX2; and 0.1 (-0.6 to 0.13), p = .20 between DX2 and placebo. We found no relevant differences between groups on sleep quality on postoperative days 3-7 nor for patient satisfaction with the analgesic treatment. CONCLUSIONS We found that neither one nor two doses of 24 mg intravenous dexamethasone demonstrated prolonged effects on overall pain or sleep quality on postoperative days 3-7 after total knee arthroplasty. We also found that dexamethasone had no effect on patient satisfaction. TRIAL REGISTRATION NUMBER Clinicaltrials.gov NCT03506789 (main result trial).
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Affiliation(s)
- Cecilie Bauer Derby
- Centre for Anaesthesiological Research, Department of Anesthesiology, Zealand University Hospital, Køge, Denmark
| | - Kasper Smidt Gasbjerg
- Research Centre of Anaesthesiology and Intensive Care Medicine, Department of Anesthesiology, Naestved, Slagelse and Ringsted Hospitals, Naestved, Denmark
| | - Daniel Hägi-Pedersen
- Research Centre of Anaesthesiology and Intensive Care Medicine, Department of Anesthesiology, Naestved, Slagelse and Ringsted Hospitals, Naestved, Denmark
- Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
| | - Troels Haxholdt Lunn
- Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
- Department of Anaesthesia and Intensive Care, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
| | | | - Peter Lindholm
- Department of Anaesthesiology and Intensive Care, Odense University Hospital, Odense, Denmark
| | - Stig Brorson
- Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
- Department of Orthopaedic Surgery, Zealand University Hospital, Køge, Denmark
| | | | - Kasper Højgaard Thybo
- Centre for Anaesthesiological Research, Department of Anesthesiology, Zealand University Hospital, Køge, Denmark
| | - Jens Bagger
- Department of Orthopaedic Surgery and Traumatology, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Martin Lindberg-Larsen
- Orthopaedic Research Unit, Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Søren Overgaard
- Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
- Department of Orthopaedic Surgery and Traumatology, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
- Orthopaedic Research Unit, Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Janus Christian Jakobsen
- Department of Regional Health Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Ole Mathiesen
- Centre for Anaesthesiological Research, Department of Anesthesiology, Zealand University Hospital, Køge, Denmark
- Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
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24
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Søfteland EØ, Aasebøstøl AK, Johnsen G, Bringeland EA. Endoluminal treatment for Zenker's diverticulum - a population-based observational study. Scand J Gastroenterol 2024; 59:218-224. [PMID: 37728323 DOI: 10.1080/00365521.2023.2260036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 09/12/2023] [Indexed: 09/21/2023]
Abstract
BACKGROUND Zenker's diverticulum is a false diverticulum arising in the oesophago-pharyngeal junction. It may cause symptoms like dysphagia and regurgitation. In Central Norway, treatment is centralized to St. Olavs hospital, either as an endoscopic stapled oesophago-diverticulostomy procedure at the Department of Gastrointestinal Surgery or as laser diverticulostomy at the Department of Ear, Nose and Throat Surgery, depending on diverticulum size. METHODS Retrospective, population-based, study from 2001-2020 on patients treated for Zenker's diverticulum, at the time with a rigid endoscopic approach. Patients were identified through the in-hospital register for operations. The two treatment groups were compared on relevant pre-, intra-, and postoperative variables by review of the individual patient records. RESULTS 78 consecutive patients, 36 at Dept. of Ear, Nose and Throat Surgery and 42 at Dept. of Gastrointestinal Surgery, were treated with a total of 104 interventions. Crude incidence for a surgery-demanding Zenker's diverticulum was 0.57 per 100 000 per year. The Dept. of Ear, Nose and Throat Surgery administered significantly less often prophylactic antibiotics than the Dept. of Gastrointestinal Surgery (p < 0.001), administered more frequently intraoperative dexamethasone (p < 0.001), and had significantly more postoperative infections (19.6% vs 3.4%, p = 0.01). No procedure-related mortality was registered. Although no standardized follow-up took place, at a median of 119 months elapsed, observed clinical recurrence was 35% for the endostapler treatment and 51% for the laser treatment procedure. CONCLUSION Both rigid endoscopic stapled oesophago-diverticulostomy and laser diverticulostomy are safe treatments for Zenker's diverticulum, however with a substantial risk of recurrence.
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Affiliation(s)
- Eirik Østensen Søfteland
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Anne Kristin Aasebøstøl
- Department of Ear, Nose and Throat Surgery, St. Olavs hospital, Trondheim University Hospital, Trondheim, Norway
| | - Gjermund Johnsen
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Department of Gastrointestinal Surgery, St. Olavs hospital, Trondheim University Hospital, Trondheim, Norway
| | - Erling Audun Bringeland
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Department of Gastrointestinal Surgery, St. Olavs hospital, Trondheim University Hospital, Trondheim, Norway
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25
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Bansal T, Singhal S, Taxak S, Bajwa SJS. Dexamethasone in anesthesia practice: A narrative review. J Anaesthesiol Clin Pharmacol 2024; 40:3-8. [PMID: 38666172 PMCID: PMC11042091 DOI: 10.4103/joacp.joacp_164_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 10/16/2022] [Accepted: 11/19/2022] [Indexed: 04/28/2024] Open
Abstract
Dexamethasone is routinely used in anesthesia practice and has been regarded as one of the ideal perioperative agents. It is a synthetic glucocorticoid with potent antiinflammatory action. It reduces postoperative nausea and vomiting, pain, postoperative opioid requirements after general anaesthesia as well as spinal anaesthesia. It has been used via intravenous, epidural and perineural routes. It has been used successfully in fascial blocks. It significantly decreases fatigue, shivering and postoperative sore throat and improves quality of recovery.
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Affiliation(s)
- Teena Bansal
- Department of Anaesthesiology and Critical Care, Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India
| | - Suresh Singhal
- Department of Anaesthesiology and Critical Care, Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India
| | - Susheela Taxak
- Department of Anaesthesiology and Critical Care, Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India
| | - Sukhminder Jit Singh Bajwa
- Department of Anaesthesiology and Intensive Care, Gian Sagar Medical College and Hospital, Banur, Patiala, Punjab, India
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Toner AJ, Corcoran TB, Vlaskovsky PS, Nierich AP, Bain CR, Dieleman JM. Inflammation risk before cardiac surgery and the treatment effect of intraoperative dexamethasone. Anaesth Intensive Care 2024; 52:28-36. [PMID: 38000008 DOI: 10.1177/0310057x231195098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2023]
Abstract
Patients who exhibit high systemic inflammation after cardiac surgery may benefit most from pre-emptive anti-inflammatory treatments. In this secondary analysis (n = 813) of the randomised, double-blind Intraoperative High-Dose Dexamethasone for Cardiac Surgery trial, we set out to develop an inflammation risk prediction model and assess whether patients at higher risk benefit from a single intraoperative dose of dexamethasone (1 mg/kg). Inflammation risk before surgery was quantified from a linear regression model developed in the placebo arm, relating preoperatively available covariates to peak postoperative C-reactive protein. The primary endpoint was the interaction between inflammation risk and the peak postoperative C-reactive protein reduction associated with dexamethasone treatment. The impact of dexamethasone on the main clinical outcome (a composite of death, myocardial infarction, stroke, renal failure, or respiratory failure within 30 days) was also explored in relation to inflammation risk. Preoperatively available covariates explained a minority of peak postoperative C-reactive protein variation and were not suitable for clinical application (R2 = 0.058, P = 0.012); C-reactive protein before surgery (excluded above 10 mg/L) was the most predictive covariate (P < 0.001). The anti-inflammatory effect of dexamethasone increased as the inflammation risk increased (-0.689 mg/L per unit predicted peak C-reactive protein, P = 0.002 for interaction). No treatment-effect heterogeneity was detected for the main clinical outcome (P = 0.167 for interaction). Overall, risk predictions from a model of inflammation after cardiac surgery were associated with the degree of peak postoperative C-reactive protein reduction derived from dexamethasone treatment. Future work should explore the impact of this phenomenon on clinical outcomes in larger surgical populations.
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Affiliation(s)
- Andrew J Toner
- Royal Perth Hospital, Perth, Australia
- University of Western Australia, Perth, Australia
| | - Tomas B Corcoran
- Royal Perth Hospital, Perth, Australia
- University of Western Australia, Perth, Australia
- Monash University, Melbourne, Australia
| | | | | | - Chris R Bain
- Monash University, Melbourne, Australia
- Alfred Hospital, Melbourne, Australia
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Xu N, Jiang K, Liu L, Chen L. Efficacy and safety of intraperitoneal dexamethasone on postoperative nausea and vomiting following laparoscopy: study protocol for a systematic review and meta-analysis. BMJ Open 2023; 13:e070371. [PMID: 37996225 PMCID: PMC10668240 DOI: 10.1136/bmjopen-2022-070371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 10/18/2023] [Indexed: 11/25/2023] Open
Abstract
INTRODUCTION Intraperitoneal dexamethasone has been reported to be effective to reduce the incidence of postoperative nausea and vomiting (PONV). Therefore, this meta-analysis will analyse the efficacy and safety of intraperitoneal dexamethasone on PONV following laparoscopy. METHODS AND ANALYSIS Electronic databases (eg, Cochrane Library, PubMed, Excerpta Medica Database, Web of Science, National Institute of Informatics, Oriental Medicine Advanced Searching Integrated System and China National Knowledge Infrastructure) and clinical trial registries will be systematically searched from their inception to 1 October 2022. After the study and data collection processes, we will identify randomised controlled trials that reported details of intraperitoneal dexamethasone on PONV following laparoscopy to conduct a meta-analysis. We will perform the study process and data collection separately. The collected data will be statistically analysed using Review Manager 5.4 software. The risk of bias will be assessed using the Cochrane risk-of-bias tool 2. The Grading of Recommendations Assessment, Development and Evaluation certainty assessment, and a trial sequential analysis will be conducted to ensure the accuracy of this meta-analysis. ETHICS AND DISSEMINATION Ethical approval and patient consent are not required since this study is a systematic review and meta-analysis. The findings of this meta-analysis will be submitted to a peer-reviewed journal for publication. PROSPERO REGISTRATION NUMBER CRD42022362924.
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Affiliation(s)
- Ning Xu
- Department of Anesthesiology, Weihai Central Hospital Affiliated to Qingdao University, Weihai, Shandong, China
| | - Kailian Jiang
- Department of Respiratory and Critical Care Medicine, Weihai Central Hospital Affiliated to Qingdao University, Weihai, Shandong, China
| | - Lulu Liu
- Department of Respiratory and Critical Care Medicine, Weihai Central Hospital Affiliated to Qingdao University, Weihai, Shandong, China
| | - Linmu Chen
- Department of Pain Medicine, Weihai Central Hospital Affiliated to Qingdao University, Weihai, Shandong, China
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Vietor R, Kiendrebeogo R, Tracy E, Plunkett AR. Peripheral nerve block adjuncts: which medication to choose? A narrative review of the current literature. Pain Manag 2023; 13:655-665. [PMID: 37937437 DOI: 10.2217/pmt-2023-0049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2023] Open
Abstract
Enhancing the effect of peripheral nerve blockade by adding other classes of medications has long history of trial and error. Studies have identified multiple potentially beneficial adjuncts that work to either speed the onset of analgesia or prolong its duration. The benefits of these adjuncts must be weighed against the risks of systemic negative side effects. To date, the most commonly used adjuncts, and ones with the most robust scientific efficacy are, dexamethasone, dexmedetomidine and buprenorphine. This narrative review will discuss several classes of local anesthetic adjuncts and provide evidence for the clinical efficacy and side effect profile of the most commonly studied medications.
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Affiliation(s)
- Robert Vietor
- Department of Anesthesiology, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Roland Kiendrebeogo
- Department of Anesthesiology, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Erin Tracy
- Department of Anesthesiology, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Anthony R Plunkett
- Department of Anesthesia & Operative Services. Womack Army Medical Center. Ft. Liberty, NC 28310, USA
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Hannig KE, Hauritz RW, Bjørn S, Jensen HI, Henriksen CW, Jessen C, Bendtsen TF. Pain relief after major ankle and hindfoot surgery with repetitive peripheral nerve blocks: A feasibility study. Acta Anaesthesiol Scand 2023; 67:1266-1272. [PMID: 37280182 DOI: 10.1111/aas.14289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 05/12/2023] [Accepted: 05/23/2023] [Indexed: 06/08/2023]
Abstract
BACKGROUND Major ankle and hindfoot surgery (e.g., ankle, triple and subtalar arthrodesis) typically causes severe postoperative pain, especially the first two postoperative days. Current modalities of postoperative analgesic treatment often include continuous peripheral nerve blocks of the saphenous and sciatic nerves via catheters in order to extend the duration of pain- and opioid-free nerve blockade to 48 h. Unfortunately, the 48 h-efficacy of continuous infusion via a catheter is reduced by a high displacement rate. We hypothesised that one-time repetition of the single injection peripheral nerve blocks would provide effective analgesia with a low opioid consumption the first 48 postoperative hours. METHODS Eleven subjects preoperatively received a popliteal sciatic and a saphenous single injection nerve block with a protracted local anaesthetic mixture. Surgery was performed under general anaesthesia. The one-time repetition of the single injection nerve block was carried out approximately 24 h after the primary nerve block. The main outcomes were pain and cumulative opioid consumption during the first 48 postoperative hours. RESULTS Nine of the 11 (82%) patients had effective analgesia without opioids during the first 48 postoperative hours. Two patients each required a single dose of 7.5 mg of oral morphine equivalents after 43 h. CONCLUSION One-time repetition of single injection saphenous and sciatic nerve blocks consistently provided effective analgesia practically without opioids for 48 h after major elective ankle and hindfoot surgery.
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Affiliation(s)
- Kjartan E Hannig
- Department of Anaesthesiology, Kolding Hospital, a part of Lillebaelt Hospital, University Hospital of Southern Denmark, Denmark
- Department of Anaesthesiology, Vejle Hospital, a part of Lillebaelt Hospital, University Hospital of Southern Denmark, Denmark
| | - Rasmus W Hauritz
- Department of Anaesthesiology, Kolding Hospital, a part of Lillebaelt Hospital, University Hospital of Southern Denmark, Denmark
| | - Siska Bjørn
- Institute of Clinical Medicine, Health, Aarhus University, Aarhus, Denmark
| | - Hanne Irene Jensen
- Department of Anaesthesiology, Kolding Hospital, a part of Lillebaelt Hospital, University Hospital of Southern Denmark, Denmark
- Department of Anaesthesiology, Vejle Hospital, a part of Lillebaelt Hospital, University Hospital of Southern Denmark, Denmark
| | - Claus W Henriksen
- Department of Orthopaedic Surgery, Kolding Hospital, a part of Lillebaelt Hospital, University Hospital of Southern Denmark, Denmark
| | | | - Thomas F Bendtsen
- Department of Anaesthesiology, Aarhus University Hospital, Aarhus, Denmark
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Tsan SEH, Dinsmore J. Dexamethasone Use in Perioperative Neuroscience: Boon or Bane, or Both? J Neurosurg Anesthesiol 2023; 35:351-353. [PMID: 37488714 DOI: 10.1097/ana.0000000000000929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 06/16/2023] [Indexed: 07/26/2023]
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Nielsen NI, Kehlet H, Gromov K, Troelsen A, Husted H, Varnum C, Kjærsgaard-Andersen P, Rasmussen LE, Pleckaitiene L, Foss NB. High dose dexamethasone in high pain responders undergoing total hip arthroplasty: A randomized controlled trial. Eur J Anaesthesiol 2023; 40:737-746. [PMID: 37166257 DOI: 10.1097/eja.0000000000001853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
BACKGROUND Postoperative pain after total hip arthroplasty (THA) may delay postoperative mobilization and discharge. Postoperative pain has been shown to be higher in pain catastrophisers and patients receiving opioids. A single dose of glucocorticoid reduces pain after THA, and an increased dose of glucocorticoids has been found to be effective in patients at high risk of postoperative pain after total knee arthroplasty (TKA), however, the ideal dose in THA remains unknown. OBJECTIVE To evaluate the effect of a high dose (1 mg kg -1 ) vs. intermediate dose (0.3 mg kg -1 ) of dexamethasone on pain after THA. DESIGN A randomized double-blind controlled study. SETTING A two-centre study including two large arthroplasty sites in Denmark was conducted from February 2019 to August 2020. PATIENTS A total of 160 patients undergoing THA by neuraxial block with multimodal analgesia, having a Pain Catastrophising Scale score >20 and/or preoperative opioid use were included. INTERVENTION Patients were randomly assigned to receive dexamethasone 1 mg kg -1 or 0.3 mg kg -1 before THA. MAIN OUTCOME MEASURES Primary outcome was percentage of patients experiencing moderate to severe pain (visual analogue scale, VAS > 30 mm on a 0 to 100 mm scale) on ambulating 24 h after surgery. Secondary outcomes included cumulated pain scores, C-reactive protein (CRP), opioid use, postoperative recovery scores, length of stay, complications, and re-admission within 30 and 90 days. RESULTS No difference was found in percentage of VAS >30 mm 24 h after surgery in the 5-m walk test (VAS > 30/VAS ≤ 30%); 33/42 (44%) vs. 32/43 (43%), relative risk = 1.04 (95% confidence interval 0.72-1.51; P = 0.814) in 1 mg kg -1vs. 0.3 mg kg -1 respectively. No differences were found in CRP and opioid use between groups. Also, no intergroup differences were found in recovery scores, re-admissions, or complications. CONCLUSION 1 mg kg -1vs. 0.3 mg kg -1 dexamethasone improved neither postoperative pain nor recovery in THA in a cohort of predicted high pain responders. TRIAL REGISTRATION ClinicalTrials.gov ID-number NCT03763760 and EudraCT-number 2018-2636-25.
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Affiliation(s)
- Niklas I Nielsen
- From the Department of Anaesthesiology, Copenhagen University, Hvidovre Hospital, Hvidovre, Denmark (NIN, NBF), Section of Surgical Pathophysiology, University of Copenhagen, Blegdamsvej 9, Denmark (HK), Department of Orthopaedic Surgery, Copenhagen University, Hvidovre Hospital, Hvidovre, Denmark (KG, AT, HH), Department of Orthopaedic Surgery, Lillebaelt Hospital - Vejle, Vejle, Denmark (CV, PK-A, LER), Department of Anaesthesiology, Lillebaelt Hospital - Vejle, Vejle, Denmark (LP)
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Chen H, Wang Y, Wang C, Lu X, Li Y, Sun B, Jiang K, Qiu Y, Chen R, Cao L, Chen S, Luo Y, Shen B. The effect of perioperative of dexamethasone on postoperative complications after pancreaticoduodenectomy (PANDEX): a study protocol for a pragmatic multicenter randomized controlled trial. Trials 2023; 24:569. [PMID: 37660052 PMCID: PMC10474642 DOI: 10.1186/s13063-023-07571-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 08/05/2023] [Indexed: 09/04/2023] Open
Abstract
BACKGROUND Pancreaticoduodenectomy (PD) nowadays serves as a standard treatment for patients with disorders of the pancreas, intestine, and bile duct. Although the mortality rate of patients undergoing PD has decreased significantly, postoperative complication rates remain high. Dexamethasone, a synthetic glucocorticoid with potent anti-inflammatory and metabolic effects, has been proven to have a favorable effect on certain complications. However, the role it plays in post-pancreatectomy patients has not been systematically evaluated. The aim of this study is to assess the effect of dexamethasone on postoperative complications after PD. METHODS The PANDEX trial is an investigator-initiated, multicentric, prospective, randomized, double-blinded, placebo-control, pragmatic study. The trial is designed to enroll 300 patients who are going to receive elective PD. Patients will be randomized to receive 0.2 mg/kg dexamethasone or saline placebo, administered as an intravenous bolus within 5 min after induction of anesthesia. The primary outcome is the Comprehensive Complication Index (CCI) score within 30 days after the operation. The secondary outcomes include postoperative major complications (Clavien-Dindo≥3), postoperative pancreatic fistula (POPF), post-pancreatectomy acute pancreatitis (PPAP), infection, and unexpected relaparotomy, as well as postoperative length of stay, 30-day mortality, and 90-day mortality. DISCUSSION The PANDEX trial is the first randomized controlled trial concerning the effect of dexamethasone on postoperative complications of patients undergoing PD, with the hypothesis that the intraoperative use of dexamethasone can reduce the incidence of postoperative complications and improve short-term outcomes after PD. The results of the present study will guide the perioperative use of dexamethasone and help improve the clinical management of post-pancreatectomy patients. TRIAL REGISTRATION ClinicalTrials.gov NCT05567094. Registered on 30 September 30 2022.
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Affiliation(s)
- Haoda Chen
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin Er Road, Shanghai, 200025, China
| | - Ying Wang
- Department of Anesthesiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin Er Road, Shanghai, 200025, China
| | - Chao Wang
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin Er Road, Shanghai, 200025, China
| | - Xiaojian Lu
- Department of Anesthesiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin Er Road, Shanghai, 200025, China
| | - Yilong Li
- Department of Pancreatic and Biliary Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China
- Key Laboratory of Hepatosplenic Surgery (Ministry of Education), The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Bei Sun
- Department of Pancreatic and Biliary Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China
- Key Laboratory of Hepatosplenic Surgery (Ministry of Education), The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Kuirong Jiang
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yudong Qiu
- Department of Biliary and Pancreatic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Rufu Chen
- Department of Pancreatic Surgery, Department of General Surgery, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Liping Cao
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Shi Chen
- Shengli Clinical Medical College of Fujian Medical University, Fuzhou, China
- Department of Hepatobiliary Pancreatic Surgery, Fujian Provincial Hospital, Fuzhou, China
| | - Yan Luo
- Department of Anesthesiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin Er Road, Shanghai, 200025, China.
| | - Baiyong Shen
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin Er Road, Shanghai, 200025, China.
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Epstein RH, Dexter F, Loftus RW. Most hospital patients at risk for bacterial infection undergo an anesthetic: implications for infection control practices related to the anesthesia workspace. Can J Anaesth 2023; 70:1330-1339. [PMID: 37308738 DOI: 10.1007/s12630-023-02515-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Revised: 12/03/2022] [Accepted: 12/21/2022] [Indexed: 06/14/2023] Open
Abstract
PURPOSE Even with nearly 100% compliance with prophylactic antibiotic protocols, many surgical patients (> 5%) develop surgical site infections, some caused by pathogens transmitted from the anesthesia workspace (e.g., anesthesia machine), including multidrug-resistant Staphylococcus aureus. Reducing contamination of the anesthesia workspace substantively reduces the risk of surgical site infections. We estimated the percentage of hospital patients at risk for health care-associated infections who may benefit from the application of basic preventive measures under the control of anesthesia practitioners (e.g., their hand hygiene). METHODS We conducted a retrospective cohort study which included every patient admitted to the University of Miami Health System from April 2021 through March 2022 for hospitalization, surgery, emergency department visits, or outpatient visits. Lists were created for the start date and times of every parenteral antibiotic administered and every anesthetic. RESULTS Among 28,213 patient encounters including parenteral antibiotic(s), more than half (64.3%) also included an anesthetic (99% confidence interval, 62.2 to 66.6). The hypothesis that most antibiotics were administered during encounters when a patient underwent an anesthetic was accepted (P < 0.001). This observation may seem counterintuitive because parenteral antibiotics were administered for fewer than half of the 53,235 anesthetics (34.2%). The result was a consequence of most anesthetics (63.5%) at the health system being conducted in nonoperating room locations, and only 7.2% of such patients received a parenteral antibiotic. CONCLUSIONS Because approximately two-thirds of patients who receive an intravenous antibiotic also undergo an anesthetic, greater use of effective infection control measures in the anesthesia operating room workspace has the potential to substantively reduce overall rates of hospital infections.
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Affiliation(s)
- Richard H Epstein
- Department of Anesthesiology, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Franklin Dexter
- Division of Management Consulting, Department of Anesthesia, University of Iowa, 200 Hawkins Drive, 6-JCP, Iowa City, IA, 52242, USA.
| | - Randy W Loftus
- Department of Anesthesia, University of Iowa, Iowa City, IA, USA
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Scott MJ, Aggarwal G, Aitken RJ, Anderson ID, Balfour A, Foss NB, Cooper Z, Dhesi JK, French WB, Grant MC, Hammarqvist F, Hare SP, Havens JM, Holena DN, Hübner M, Johnston C, Kim JS, Lees NP, Ljungqvist O, Lobo DN, Mohseni S, Ordoñez CA, Quiney N, Sharoky C, Urman RD, Wick E, Wu CL, Young-Fadok T, Peden CJ. Consensus Guidelines for Perioperative Care for Emergency Laparotomy Enhanced Recovery After Surgery (ERAS ®) Society Recommendations Part 2-Emergency Laparotomy: Intra- and Postoperative Care. World J Surg 2023; 47:1850-1880. [PMID: 37277507 PMCID: PMC10241558 DOI: 10.1007/s00268-023-07020-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/28/2023] [Indexed: 06/07/2023]
Abstract
BACKGROUND This is Part 2 of the first consensus guidelines for optimal care of patients undergoing emergency laparotomy (EL) using an Enhanced Recovery After Surgery (ERAS) approach. This paper addresses intra- and postoperative aspects of care. METHODS Experts in aspects of management of high-risk and emergency general surgical patients were invited to contribute by the International ERAS® Society. PubMed, Cochrane, Embase, and Medline database searches were performed for ERAS elements and relevant specific topics. Studies on each item were selected with particular attention to randomized clinical trials, systematic reviews, meta-analyses, and large cohort studies and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. Recommendations were made on the best level of evidence, or extrapolation from studies on elective patients when appropriate. A modified Delphi method was used to validate final recommendations. Some ERAS® components covered in other guideline papers are outlined only briefly, with the bulk of the text focusing on key areas pertaining specifically to EL. RESULTS Twenty-three components of intraoperative and postoperative care were defined. Consensus was reached after three rounds of a modified Delphi Process. CONCLUSIONS These guidelines are based on best available evidence for an ERAS® approach to patients undergoing EL. These guidelines are not exhaustive but pull together evidence on important components of care for this high-risk patient population. As much of the evidence is extrapolated from elective surgery or emergency general surgery (not specifically laparotomy), many of the components need further evaluation in future studies.
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Affiliation(s)
- Michael J. Scott
- Department of Anesthesiology and Critical Care Medicine, Leonard Davis Institute for Health Economics, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104 USA
- University College London, London, UK
| | - Geeta Aggarwal
- Department of Anesthesia and Intensive Care Medicine, Royal Surrey County Hospital, Guildford, Surrey UK
| | - Robert J. Aitken
- Sir Charles Gardiner Hospital, Hospital Avenue, Nedlands, WA 6009 Australia
| | - Iain D. Anderson
- Salford Royal NHS Foundation Trust, Stott La, Salford, M6 8HD UK
- University of Manchester, Manchester, UK
| | - Angie Balfour
- Western General Hospital, NHS Lothian, Edinburgh, EH4 2XU Scotland
| | | | - Zara Cooper
- Harvard Medical School, Kessler Director, Center for Surgery and Public Health, Brigham and Women’s Hospital and Division of Trauma, Burns, Surgical Critical Care, and Emergency Surgery, Brigham and Women’s Hospital, 1620 Tremont Street, Boston, MA 02120 USA
| | - Jugdeep K. Dhesi
- School of Population Health and Environmental Sciences, Faculty of Life Sciences and Medicine, Guy’s and St Thomas’ NHS Foundation Trust, King’s College London, London, UK
- Division of Surgery and Interventional Science, University College London, London, UK
| | - W. Brenton French
- Department of Surgery, Virginia Commonwealth University Health System, 1200 E. Broad Street, Richmond, VA 23298 USA
| | - Michael C. Grant
- Department of Anesthesiology and Critical Care Medicine, Department of Surgery, The Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD 21287 USA
| | - Folke Hammarqvist
- Department of Emergency and Trauma Surgery, Karolinska University Hospital, CLINTEC, Karolinska Institutet, Stockholm, Sweden
- Karolinska University Hospital Huddinge, Hälsovägen 3. B85, 141 86 Stockholm, Sweden
| | - Sarah P. Hare
- Department of Anaesthesia, Perioperative Medicine and Critical Care, Medway Maritime Hospital, Windmill Road, Gillingham, Kent, ME7 5NY UK
| | - Joaquim M. Havens
- Division of Trauma, Burns and Surgical Critical Care, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115 USA
| | - Daniel N. Holena
- Division of Trauma and Acute Care Surgery, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI 53226 USA
| | - Martin Hübner
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Rue du Bugnon 46, 1011 Lausanne, Switzerland
| | - Carolyn Johnston
- Department of Anesthesia, St George’s Hospital, Tooting, London, UK
| | - Jeniffer S. Kim
- Department of Research and Evaluation, Kaiser Permanente Research, Pasadena, CA 9110 USA
| | - Nicholas P. Lees
- Department of General and Colorectal Surgery, Salford Royal NHS Foundation Trust, Scott La, Salford, M6 8HD UK
| | - Olle Ljungqvist
- Faculty of Medicine and Health, School of Health and Medical Sciences, Department of Surgery, Örebro University, Örebro, Sweden
| | - Dileep N. Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals and University of Nottingham, Queen’s Medical Centre, Nottingham, NG7 2UH UK
- MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham, Queen’s Medical Centre, Nottingham, NG7 2UH UK
| | - Shahin Mohseni
- Division of Trauma and Emergency Surgery, Department of Surgery, Orebro University Hospital and School of Medical Sciences, Orebro University, 701 85 Orebro, Sweden
| | - Carlos A. Ordoñez
- Division of Trauma and Acute Care Surgery, Department of Surgery, Fundación Valle del Lili, Cra 98 No. 18 – 49, 760032 Cali, Colombia
- Sección de Cirugía de Trauma y Emergencias, Universidad del Valle – Hospital Universitario del Valle, Cl 5 No. 36-08, 760032 Cali, Colombia
| | - Nial Quiney
- Department of Anesthesia and Intensive Care Medicine, Royal Surrey County Hospital, Egerton Road, Guildford, Surrey, GU5 7XX UK
| | - Catherine Sharoky
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, University of Pennsylvania, Philadelphia, PA 19104 USA
| | - Richard D. Urman
- Department of Anesthesiology, The Ohio State University and Wexner Medical Center, 410 West 10Th Ave, Columbus, OH 43210 USA
| | - Elizabeth Wick
- Department of Surgery, University of California San Francisco, 513 Parnassus Ave HSW1601, San Francisco, CA 94143 USA
| | - Christopher L. Wu
- Department of Anesthesiology, Critical Care and Pain Medicine-Hospital for Special Surgery, Department of Anesthesiology-Weill Cornell Medicine, 535 East 70th Street, New York, NY 10021 USA
| | - Tonia Young-Fadok
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic College of Medicine, Mayo Clinic Arizona, 5777 e. Mayo Blvd., Phoenix, AZ 85054 USA
| | - Carol J. Peden
- Department of Anesthesiology Keck School of Medicine, University of Southern California, 2020 Zonal Avenue IRD 322, Los Angeles, CA 90033 USA
- Department of Anesthesiology, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce St., Philadelphia, PA 19104 USA
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Bloc S, Alfonsi P, Belbachir A, Beaussier M, Bouvet L, Campard S, Campion S, Cazenave L, Diemunsch P, Di Maria S, Dufour G, Fabri S, Fletcher D, Garnier M, Godier A, Grillo P, Huet O, Joosten A, Lasocki S, Le Guen M, Le Saché F, Macquer I, Marquis C, de Montblanc J, Maurice-Szamburski A, Nguyen YL, Ruscio L, Zieleskiewicz L, Caillard A, Weiss E. Guidelines on perioperative optimization protocol for the adult patient 2023. Anaesth Crit Care Pain Med 2023; 42:101264. [PMID: 37295649 DOI: 10.1016/j.accpm.2023.101264] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
OBJECTIVE The French Society of Anesthesiology and Intensive Care Medicine [Société Française d'Anesthésie et de Réanimation (SFAR)] aimed at providing guidelines for the implementation of perioperative optimization programs. DESIGN A consensus committee of 29 experts from the SFAR was convened. A formal conflict-of-interest policy was developed at the outset of the process and enforced throughout. The entire guidelines process was conducted independently of any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence. METHODS Four fields were defined: 1) Generalities on perioperative optimization programs; 2) Preoperative measures; 3) Intraoperative measures and; 4) Postoperative measures. For each field, the objective of the recommendations was to answer a number of questions formulated according to the PICO model (population, intervention, comparison, and outcomes). Based on these questions, an extensive bibliographic search was carried out using predefined keywords according to PRISMA guidelines and analyzed using the GRADE® methodology. The recommendations were formulated according to the GRADE® methodology and then voted on by all the experts according to the GRADE grid method. As the GRADE® methodology could have been fully applied for the vast majority of questions, the recommendations were formulated using a "formalized expert recommendations" format. RESULTS The experts' work on synthesis and application of the GRADE® method resulted in 30 recommendations. Among the formalized recommendations, 19 were found to have a high level of evidence (GRADE 1±) and ten a low level of evidence (GRADE 2±). For one recommendation, the GRADE methodology could not be fully applied, resulting in an expert opinion. Two questions did not find any response in the literature. After two rounds of rating and several amendments, strong agreement was reached for all the recommendations. CONCLUSIONS Strong agreement among the experts was obtained to provide 30 recommendations for the elaboration and/or implementation of perioperative optimization programs in the highest number of surgical fields.
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Affiliation(s)
- Sébastien Bloc
- Clinical Research Department, Ambroise Pare Hospital Group, Neuilly-sur-Seine, France; Department of Anesthesiology, Clinique Drouot Sport, Paris, France.
| | - Pascal Alfonsi
- Department of Anesthesia, University of Paris Descartes, Groupe Hospitalier Paris Saint-Joseph, 185 rue Raymond Losserand, F-75674 Paris Cedex 14, France
| | - Anissa Belbachir
- Service d'Anesthésie Réanimation, UF Douleur, Assistance Publique Hôpitaux de Paris, APHP.Centre, Site Cochin, Paris, France
| | - Marc Beaussier
- Department of Digestive, Oncologic and Metabolic Surgery, Institut Mutualiste Montsouris, Université de Paris, 42 Boulevard Jourdan, 75014, Paris, France
| | - Lionel Bouvet
- Department of Anaesthesia and Intensive Care, Hospices Civils de Lyon, Hôpital Femme Mère Enfant, Lyon, France
| | | | - Sébastien Campion
- AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Département d'Anesthésie-Réanimation, F-75013 Paris, France; Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, F-75005 Paris, France
| | - Laure Cazenave
- Department of Anaesthesia and Critical Care, Hospices Civils de Lyon, Lyon, France; Groupe Jeunes, French Society of Anaesthesia and Intensive Care Medicine (SFAR), 75016 Paris, France
| | - Pierre Diemunsch
- Unité de Réanimation Chirurgicale, Service d'Anesthésie-réanimation Chirurgicale, Pôle Anesthésie-Réanimations Chirurgicales, Samu-Smur, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, 1, Avenue Molière, 67098 Strasbourg Cedex, France
| | - Sophie Di Maria
- Department of Anaesthesiology and Critical Care, AP-HP, Hôpital Pitié-Salpêtrière, Paris, France
| | - Guillaume Dufour
- Service d'Anesthésie-Réanimation, CHU de Pitié-Salpêtrière, 47-83, Boulevard de l'Hôpital, 75013 Paris, France
| | - Stéphanie Fabri
- Faculty of Economics, Management & Accountancy, University of Malta, Malta
| | - Dominique Fletcher
- Université de Versailles-Saint-Quentin-en-Yvelines, Assistance Publique-Hôpitaux de Paris, Hôpital Ambroise-Paré, Service d'Anesthésie, 9, Avenue Charles-de-Gaulle, 92100 Boulogne-Billancourt, France
| | - Marc Garnier
- Sorbonne Université, GRC 29, DMU DREAM, Service d'Anesthésie-Réanimation et Médecine Périopératoire Rive Droite, Paris, France
| | - Anne Godier
- Department of Anaesthesiology and Critical Care, European Georges Pompidou Hospital, Assistance Publique-Hôpitaux de Paris, France
| | | | - Olivier Huet
- CHU de Brest, Anesthesia and Intensive Care Unit, Brest, France
| | - Alexandre Joosten
- Department of Anesthesiology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium; Department of Anesthesiology and Intensive Care, Hôpitaux Universitaires Paris-Sud, Université Paris-Sud, Université Paris-Saclay, Paul Brousse Hospital, Assistance Publique Hôpitaux de Paris (APHP), Villejuif, France
| | | | - Morgan Le Guen
- Paris Saclay University, Department of Anaesthesia and Pain Medicine, Foch Hospital, 92150 Suresnes, France
| | - Frédéric Le Saché
- Department of Anesthesiology, Clinique Drouot Sport, Paris, France; DMU DREAM Department of Anesthesiology and Critical Care, Pitié-Salpêtrière Hospital, Paris, France
| | - Isabelle Macquer
- Bordeaux University Hospitals, Bordeaux, Anaesthesia and Intensive Care Medicine Department, Bordeaux, France
| | - Constance Marquis
- Clinique du Sport, Département d'Anesthésie et Réanimation, Médipole Garonne, 45 rue de Gironis - CS 13 624, 31036 Toulouse Cedex 1, France
| | - Jacques de Montblanc
- Departments of Anesthesiology and Intensive Care Paris-Saclay University, Bicêtre Hospital, Assistance Publique Hôpitaux de Paris, Le Kremlin-Bicêtre, France
| | | | - Yên-Lan Nguyen
- Anesthesiology and Critical Care Medicine Department, Cochin Academic Hospital, APHP, Université de Paris, 75014 Paris, France
| | - Laura Ruscio
- Departments of Anesthesiology and Intensive Care Paris-Saclay University, Bicêtre Hospital, Assistance Publique Hôpitaux de Paris, Le Kremlin-Bicêtre, France; INSERM U 1195, Université Paris-Saclay, Saint-Aubin, Île-de-France, France
| | - Laurent Zieleskiewicz
- Service d'Anesthésie Réanimation, Hôpital Nord, AP-HM, Marseille, Aix Marseille Université, C2VN, France
| | - Anaîs Caillard
- Centre Hospitalier Universitaire La Cavale Blanche Université de Bretagne Ouest, Anaesthesiology, Critical Care and Perioperative Medicine Department, Brest, France
| | - Emmanuel Weiss
- Department of Anaesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP, Nord, Clichy, France; University of Paris, Paris, France; Inserm UMR_S1149, Centre for Research on Inflammation, Paris, France
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Blank M, Katsiampoura A, Wachtendorf LJ, Linhardt FC, Tartler TM, Raub D, Azimaraghi O, Chen G, Houle TT, Ferrone C, Eikermann M, Schaefer MS. Association Between Intraoperative Dexamethasone and Postoperative Mortality in Patients Undergoing Oncologic Surgery: A Multicentric Cohort Study. Ann Surg 2023; 278:e105-e114. [PMID: 35837889 DOI: 10.1097/sla.0000000000005526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE We examined the effects of dexamethasone on postoperative mortality, recurrence-free survival, and side effects in patients undergoing oncologic operations. BACKGROUND Dexamethasone prevents nausea and vomiting after anesthesia and may affect cancer proliferation. METHODS A total of 30,561 adult patients undergoing solid cancer resection between 2005 and 2020 were included. Multivariable logistic regression was applied to investigate the effect of dexamethasone on 1-year mortality and recurrence-free survival. Effect modification by the cancer's potential for immunogenicity, defined as a recommendation for checkpoint inhibitor therapy based on the National Comprehensive Cancer Network guidelines, was investigated through interaction term analysis. Key safety endpoints were dexamethasone-associated risk of hyperglycemia >180 mg/dL within 24 hours and surgical site infections within 30 days after surgery. RESULTS Dexamethasone was administered to 38.2% (11,666/30,561) of patients (6.5±2.3 mg). Overall, 3.2% (n=980/30,561) died and 15.4% (n=4718/30,561) experienced cancer recurrence within 1 year of the operation. Dexamethasone was associated with a -0.6% (95% confidence interval: -1.1, -0.2, P =0.007) 1-year mortality risk reduction [adjusted odds ratio (OR adj ): 0.79 (0.67, 0.94), P =0.009; hazard ratio=0.82 (0.69, 0.96), P =0.016] and higher odds of recurrence-free survival [OR adj : 1.28 (1.18, 1.39), P <0.001]. This effect was only present in patients with solid cancers who were defined as not to respond to checkpoint inhibitor therapy [OR adj : 0.70 (0.57, 0.87), P =0.001 vs OR adj : 1.13 (0.85, 1.50), P =0.40]. A high (>0.09 mg/kg) dose of dexamethasone increased the risk of postoperative hyperglycemia [OR adj : 1.55 (1.32, 1.82), P <0.001], but not for surgical site infections [OR adj : 0.84 (0.42, 1.71), P =0.63]. CONCLUSIONS Dexamethasone is associated with decreased 1-year mortality and cancer recurrence in patients undergoing surgical resection of cancers that are not candidates for immune modulators. Dexamethasone increased the risk of postoperative hyperglycemia, however, no increase in surgical site infections was identified.
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Affiliation(s)
- Michael Blank
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
- Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, New York City, NY
| | - Anastasia Katsiampoura
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Luca J Wachtendorf
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
- Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, New York City, NY
| | - Felix C Linhardt
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
- Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, New York City, NY
| | - Tim M Tartler
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
- Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Dana Raub
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Omid Azimaraghi
- Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, New York City, NY
| | - Guanqing Chen
- Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Tim T Houle
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA
| | - Cristina Ferrone
- Department of Surgery, Cancer Center, Massachusetts General Hospital, Boston, MA
| | - Matthias Eikermann
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, New York City, NY
- Department of Anesthesiology, Essen University Hospital, Essen, Germany
| | - Maximilian S Schaefer
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
- Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
- Department of Anesthesiology, Düsseldorf University Hospital, Düsseldorf, Germany
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Corcoran TB, Martin C, O'Loughlin E, Ho K, Chan M, Forbes A, Leslie K, Myles P. Dexamethasone and persistent wound pain: a prespecified analysis of the randomised Perioperative Administration of Dexamethasone and Infection (PADDI) trial. Br J Anaesth 2023:S0007-0912(23)00177-0. [PMID: 37230849 DOI: 10.1016/j.bja.2023.03.031] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 03/14/2023] [Accepted: 03/27/2023] [Indexed: 05/27/2023] Open
Abstract
BACKGROUND Dexamethasone is commonly administered intraoperatively to prevent postoperative nausea and vomiting and is believed to have analgesic properties. It is unknown whether it has an impact on chronic wound pain. METHODS In this prespecified embedded superiority substudy of the randomised PADDI trial, patients undergoing non-urgent noncardiac surgery received dexamethasone 8 mg or placebo intravenously after induction of anaesthesia, and were followed up for 6 months postoperatively. The primary outcome was the incidence of pain in the surgical wound at 6 months. Secondary outcomes included acute postoperative pain and correlates of chronic postsurgical pain. RESULTS We included 8478 participants in the modified intention-to-treat population (4258 in the dexamethasone group and 4220 in the matched placebo group). The primary outcome occurred in 491 subjects (11.5%) in the dexamethasone arm and 404 (9.6%) subjects in the placebo arm (relative risk 1.2, 95% confidence interval 1.06-1.41, P=0.003). Maximum pain scores at rest and on movement in the first 3 postoperative days were lower in the dexamethasone group compared with the control group {median 5 (inter-quartile range [IQR] 3.0-8.0) vs 6 (IQR 3.0-8.0) and median 7 (IQR 5.0-9.0) vs 8 (IQR 6.0-9.0), P<0.001 for both}. Severity of postoperative pain was not predictive of chronic postsurgical pain. The severity of chronic postsurgical pain and the frequency of neuropathic features did not differ between treatment groups. CONCLUSION Administration of dexamethasone 8 mg i.v. was associated with an increase in the risk of pain in the surgical wound 6 months after surgery. CLINICAL TRIAL REGISTRATION ACTRN12614001226695.
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Affiliation(s)
- Tomás B Corcoran
- Department of Anaesthesia and Pain Medicine, Royal Perth Hospital, Perth, Western Australia, Australia; Discipline of Emergency Medicine, University of Western Australia, Perth, Western Australia, Australia; Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia.
| | - Catherine Martin
- Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
| | - Edmond O'Loughlin
- Discipline of Emergency Medicine, University of Western Australia, Perth, Western Australia, Australia; Department of Anaesthesia, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Kwok Ho
- Department of Anaesthesia and Pain Medicine, Royal Perth Hospital, Perth, Western Australia, Australia; Discipline of Emergency Medicine, University of Western Australia, Perth, Western Australia, Australia; Department of Anaesthesia, Fiona Stanley Hospital, Perth, Western Australia, Australia; School of Veterinary and Life sciences, Murdoch University, Perth, Western Australia, Australia
| | - Matthew Chan
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Special Administrative Region, China
| | - Andrew Forbes
- Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
| | - Kate Leslie
- Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia; Department of Critical Care, Melbourne Medical School, University of Melbourne, Melbourne, VIC, Australia; Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Paul Myles
- Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia; Department of Anaesthesia and Perioperative Medicine, The Alfred Hospital, Melbourne, VIC, Australia
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Lavand'homme P, Kehlet H. Benefits versus harm of intraoperative glucocorticoid for postoperative nausea and vomiting prophylaxis. Br J Anaesth 2023:S0007-0912(23)00187-3. [PMID: 37183100 DOI: 10.1016/j.bja.2023.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 04/11/2023] [Accepted: 04/12/2023] [Indexed: 05/16/2023] Open
Abstract
Intraoperative use of glucocorticoids is effective for postoperative nausea and vomiting prophylaxis and can also provide early postoperative analgesic effects, but the consequences for chronic post-surgical pain are debatable. In a secondary analysis of the large pragmatic Perioperative Administration of Dexamethasone and Infection trial (n=8478), the primary outcome of pain at the surgical wound at 6 months after surgery was increased in subjects receiving dexamethasone 8 mg i.v. for postoperative nausea and vomiting prophylaxis, a dose not associated with the detrimental effect of surgical site infection in the original study. In contrast, a more detailed assessment of chronic post-surgical pain after exclusion of patients with preoperative pain at the surgical site showed no differences with or without intraoperative dexamethasone regarding chronic post-surgical pain characteristics (intensity and neuropathic features). Because of several confounding factors especially regarding surgical details, these unexpected findings call for more well-designed studies about the potential risk of intraoperative treatments, such as glucocorticoids, on late post-surgical pain.
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Affiliation(s)
- Patricia Lavand'homme
- Department of Anesthesiology and Acute Postoperative & Transitional Pain Service, Cliniques Universitaires St Luc-University Catholic of Louvain, Brussels, Belgium.
| | - Henrik Kehlet
- Section of Surgical Pathophysiology, Rigshospitalet, Copenhagen, Denmark
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Dexter F, Brown JR, Wall RT, Loftus RW. The efficacy of multifaceted versus single anesthesia work area infection control measures and the importance of surgical site infection follow-up duration. J Clin Anesth 2023; 85:111043. [PMID: 36566648 PMCID: PMC9892236 DOI: 10.1016/j.jclinane.2022.111043] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 09/28/2022] [Accepted: 12/17/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Earlier a randomized trial showed efficacy of a multifaceted intervention approach for reducing surgical site infection: hand hygiene, vascular care, environmental cleaning, patient decolonization (nasal povidone iodine, chlorhexidine wipes), with feedback on pathogen transmission. The follow-up prospective observational study showed effectiveness when applied to all operating rooms of an inpatient surgical suite. In practice, many organizations will at baseline not be using conditions equivalent to the control groups but instead functionally have had ongoing a single intervention for infection control (e.g., encouraging better hand hygiene). Organizations also differ in how well and long they survey every surgical patient for postoperative surgical site infection. Thus, estimation of the expected net cost savings from implementing multifaceted intervention depends on the relative efficacy of multifaceted approach versus single intervention approaches and on the incidence of surgical site infection, the latter depending itself on the monitoring period for infection development. METHODS The retrospective cohort analysis included 4865 patients from two single intervention and two multifaceted studies, each of the four studies with matched control groups. We used Poisson regression with robust variance to estimate the relative risk reduction in surgical site infections for the multifaceted approach versus single interventions and, with 30-day follow-up versus ≥60-day follow-up for infection. RESULTS The multifaceted approach was associated with an estimated 68% reduction in postoperative surgical site infections relative to single interventions (risk ratio 0.32, 97.5% confidence interval 0.15-0.70, P = 0.001). There were approximately 2.61-fold more surgical site infections detected with follow-up for at least 60 days of medical records relative to 30 days of records reviewed (97.5% CI 1.62 to 4.21, P < 0.001). CONCLUSIONS An evidence-based, multifaceted approach to anesthesia work area infection control can generate substantial reductions in surgical site infections. A follow-up period of at least 60-days is indicated for infection detection.
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Affiliation(s)
- Franklin Dexter
- University of Iowa, 200 Hawkins Drive, Iowa City, IA 52240, United States.
| | - Jeremiah R Brown
- Dartmouth-Hitchcock Medical Center, WTRB 6, Lebanon, NH 03756, United States.
| | - Russell T Wall
- MedStar Georgetown University Hospital, 3800 Reservoir Road, NW, CCC Building, Lower Level, Washington, DC 20007, United States.
| | - Randy W Loftus
- University of Iowa, 200 Hawkins Drive, Iowa City, IA 52240, United States.
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Crowley K, Scanaill PÓ, Hermanides J, Buggy DJ. Current practice in the perioperative management of patients with diabetes mellitus: a narrative review. Br J Anaesth 2023:S0007-0912(23)00128-9. [PMID: 37061429 PMCID: PMC10375498 DOI: 10.1016/j.bja.2023.02.039] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 02/08/2023] [Accepted: 02/23/2023] [Indexed: 04/17/2023] Open
Abstract
The prevalence of diabetes is increasing, and patients with diabetes mellitus have both an increased likelihood of requiring surgery and of developing postoperative complications when they do. We summarise available evidence underpinning current guidelines on preoperative assessment and optimisation, perioperative management of prescribed insulin and oral hypoglycaemic medication, intraoperative glycaemic control, and postoperative patient care.
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Affiliation(s)
- Kieran Crowley
- Department of Anaesthesiology & Perioperative Medicine, Mater University Hospital, School of Medicine, University College Dublin, Dublin, Ireland.
| | - Pádraig Ó Scanaill
- Department of Anaesthesiology & Perioperative Medicine, Mater University Hospital, School of Medicine, University College Dublin, Dublin, Ireland
| | | | - Donal J Buggy
- Department of Anaesthesiology & Perioperative Medicine, Mater University Hospital, School of Medicine, University College Dublin, Dublin, Ireland; Outcomes Research Cleveland Clinic, Cleveland, OH, USA.
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Dexter F, Epstein RH, Loftus RW. Quantifying and Interpreting Inequality in Surgical Site Infections per Quarter Among Anesthetizing Locations and Specialties. Cureus 2023; 15:e36878. [PMID: 37123760 PMCID: PMC10147407 DOI: 10.7759/cureus.36878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2023] [Indexed: 03/31/2023] Open
Abstract
Background Earlier studies have shown that prevention of surgical site infection can achieve net cost savings when targeted to operating rooms with the most surgical site infections. Methodology This retrospective cohort study included all 231,057 anesthetics between May 2017 and June 2022 at a large teaching hospital. The anesthetics were administered in operating rooms, procedure rooms, radiology, and other sites. The 8,941 postoperative infections were identified from International Classification of Diseases diagnosis codes relevant to surgical site infections documented during all follow-up encounters over 90 days postoperatively. To quantify the inequality in the counts of infections among anesthetizing locations, the Gini index was used, with the Gini index being proportional to the sum of the absolute pairwise differences among anesthetizing locations in the counts of infections. Results The Gini index for infections among the 112 anesthetizing locations at the hospital was 0.64 (99% confidence interval = 0.56 to 0.71). The value of 0.64 is so large that, for comparison, it exceeds nearly all countries' Gini index for income inequality. The 50% of locations with the fewest infections accounted for 5% of infections. The 10% of locations with the most infections accounted for 40% of infections and 15% of anesthetics. Among the 57 operating room locations, there was no association between counts of cases and infections (Spearman correlation coefficient r = 0.01). Among the non-operating room locations (e.g., interventional radiology), there was a significant association (Spearman r = 0.79). Conclusions Targeting specific anesthetizing locations is important for the multiple interventions to reduce surgical site infections that represent fixed costs irrespective of the number of patients (e.g., specialized ventilatory systems and nightly ultraviolet-C disinfection).
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Pang QY, Wang JY, Liang XL, Jiang Y, Liu HL. The safety of perioperative dexamethasone with antiemetic dosage in surgical patients with diabetes mellitus: a systematic review and meta-analysis. Perioper Med (Lond) 2023; 12:4. [PMID: 36890549 PMCID: PMC9993727 DOI: 10.1186/s13741-023-00293-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 02/26/2023] [Indexed: 03/10/2023] Open
Abstract
BACKGROUND Dexamethasone is commonly used for antiemesis in surgical patients. It has been confirmed that long-term steroid use increases blood glucose level in both diabetic and non-diabetic patients, it is unclear how a single dose of intravenous dexamethasone used pre/intraoperatively for postoperative nausea and vomiting (PONV) prophylaxis would influence the blood glucose and wound healing in diabetic patients. METHODS The Pubmed, Cochrane Library, Embase, Web of Science databases, CNKI and Google Scholar were searched. The articles reporting a single dose dexamethasone administered intravenously for antiemesis in surgical patients with diabetes mellitus (DM) were included. RESULTS Nine randomized controlled trials (RCTs) and 7 cohort studies were included in our meta-analysis. The results showed that dexamethasone increased glucose level intraoperatively (MD: 0.439, 95% CI: 0.137-0.581, I2 = 55.7%, P = 0.004), at the end of surgery (MD: 0.815, 95% CI: 0.563-1.067, I2 = 73.5%, P = 0.000), on postoperative day (POD) 1 (MD: 1.087, 95% CI: 0.534-1.640, I2 = 88%, P = 0.000), on POD 2 (MD: 0.501, 95% CI: 0.301-0.701, I2 = 0%, P = 0.000), and increased peak glucose level within 24 hours of surgery (MD: 2.014, 95% CI: 0.503-3.525, I2 = 91.6%, P = 0.009) compared with control. It indicated that dexamethasone caused the increase of perioperative glucose level at different time points by 0.439 to 1.087 mmol/L (7.902 to 19.566 mg/dL), and the increase of peak glucose level within 24 hours of surgery by 2.014 mmol/L (36.252 mg/dL) compared with control. Dexmethasone had no impact on wound infection (OR: 0.797, 95%CI: 0.578-1.099, I2 = 0%, P = 0.166) and healing (P < 0.05). CONCLUSION Dexamethasone could increase blood glucose by only 2.014 mmol/L (36.252 mg/dL) of peak glucose level within 24 hours of surgery in surgery patients with DM, the increase of glucose level at each time point perioperatively was even lower, and had no effect on wound healing. Thus, dexamethasone with a single dose could be safely used for PONV prophylaxis in diabetic patients. TRIAL REGISTRATION The protocol of this systematic review was registered in INPLASY with the registration number INPLASY202270002.
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Affiliation(s)
- Qian-Yun Pang
- Department of Anesthesiology, Chongqing University Cancer Hospital, No. 181, Hanyu Road, Shapingba District, Chongqing City, 400030, China
| | - Jing-Yun Wang
- School of Medicine, Chongqing University; Chongqing University Cancer Hospital, Chongqing, 400030, China
| | - Xiao-Long Liang
- Department of Anesthesiology, Chongqing University Cancer Hospital, No. 181, Hanyu Road, Shapingba District, Chongqing City, 400030, China
| | - Yan Jiang
- Department of Anesthesiology, Chongqing University Cancer Hospital, No. 181, Hanyu Road, Shapingba District, Chongqing City, 400030, China
| | - Hong-Liang Liu
- Department of Anesthesiology, Chongqing University Cancer Hospital, No. 181, Hanyu Road, Shapingba District, Chongqing City, 400030, China.
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Systemic glucocorticoids as an adjunct to treatment of postoperative pain after total hip and knee arthroplasty: A systematic review with meta-analysis and trial sequential analysis. Ugeskr Laeger 2023; 40:155-170. [PMID: 36325886 DOI: 10.1097/eja.0000000000001768] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Postoperative analgesic effects of systemic glucocorticoids given as an adjunct to treatment are largely undetermined in alloplastic procedures. OBJECTIVES To investigate the beneficial and harmful effects of peri-operative systemic glucocorticoid treatment for pain after total hip arthroplasty (THA) or total knee arthroplasty (TKA). DESIGN A systematic review of randomised clinical trials (RCTs) with meta-analyses, trial sequential analyses and GRADE. Primary outcome was 24 h intravenous (i.v.) morphine (or equivalent) consumption with a predefined minimal important difference (MID) of 5 mg. Secondary outcomes included pain at rest and during mobilisation (MID, VAS 10 mm), adverse and serious adverse events (SAEs). DATA SOURCES We searched EMBASE, Cochrane CENTRAL, PubMed and Google Scholar up to October 2021. ELIGIBILITY CRITERIA RCTs investigating peri-operative systemic glucocorticoid versus placebo or no intervention, for analgesic pain management of patients at least 18 years undergoing planned THA or TKA, irrespective of publication date and language. RESULTS We included 32 RCTs with 3521 patients. Nine trials were at a low risk of bias. Meta-analyses showed evidence of a reduction in 24 h cumulative morphine consumption with glucocorticoids by 5.0 mg (95% CI 2.2 to 7.7; P = 0.0004). Pain at rest was reduced at 6 h by 7.8 mm (95% CI 5.5 to 10.2; P < 0.00001), and at 24 h by 6.3 mm (95% CI 3.8 to 8.8; P < 0.00001). Pain during mobilisation was reduced at 6 h by 9.8 mm (95% CI 6.9 to 12.8; P < 0.00001), and at 24 h by 9.0 mm (95% CI 5.5 to 12.4, P < 0.00001). Incidence of adverse events was generally lower in the glucocorticoid treatment group. SAEs were rarely reported. The GRADE rated quality of evidence was low to very low. CONCLUSION Peri-operative systemic glucocorticoid treatment reduced postoperative morphine consumption to an individually relevant level following hip and knee arthroplasty. Pain levels were reduced but were below the predefined MID. The quality of evidence was generally low. REGISTRATION PROSPERO ID: CRD42019135034.
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Chen X, Chen Y, He X, Zhou Q. Effects of low-dose dexamethasone on inflammatory factors in drainage fluid and wound healing after thyroid surgery during perioperative period. Int Wound J 2023. [PMID: 36856736 DOI: 10.1111/iwj.14090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 01/07/2023] [Indexed: 03/02/2023] Open
Abstract
This study explored the effect of perioperative use of low-dose dexamethasone on inflammatory factors in drainage fluid and wound healing after thyroid surgery. In the prospective, double-blinded, randomised controlled study, adults who underwent elective thyroidectomy received 0.1 mg/kg of intravenous dexamethasone or a matching volume of placebo (saline) after induction of general anaesthesia. The primary outcome was IL6 and IL10 concentration in drainage at 24 hours postoperative. The secondary endpoint was the SBSES (modified Stony Brook Scar Evaluation Scale) total score at 1 week postoperative. From 8 July to 17 December 2020, 64 patients (mean [SD] age, 40.42 [9.52]; 13 males [20.31%]) were recruited, received operation, and completed the 1-month follow-up. Inflammatory factors in drainage did not differ between the two groups but only had significant differences at different timepoint. The dexamethasone group patients had a higher SBSES total score at 1 week after the treatment but, without statistical significance (dexamethasone vs placebo: 3.13 ± 1.24 vs 2.97 ± 0.93, P = .571). The dexamethasone group patients had a higher SBSES total score (dexamethasone vs placebo: 3.103 ± 1.148 vs 2.868 ± 0.827, P = .011) and colour score (dexamethasone vs placebo: 0.603 ± 0.493 vs 0.412 ± 0.496, P = .026) at 1-week follow-up than the placebo group patients. Preoperative single small-dose intravenous dexamethasone did not show to improve wound healing quality nor reduce incision inflammation but may release pain, and reduce tissue angiogenesis, and thus the scar redness.
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Affiliation(s)
- Xuemei Chen
- Department of Anesthesiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China.,Department of Anesthesiology, Shanghai Jiaotong University Affiliated Shanghai Sixth People's Hospital, Shanghai, China
| | - Yuanyang Chen
- Department of Anesthesiology, Shanghai Jiaotong University Affiliated Shanghai Sixth People's Hospital, Shanghai, China
| | - Xiaojun He
- Department of Cardiovascular Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Quanhong Zhou
- Department of Anesthesiology, Shanghai Jiaotong University Affiliated Shanghai Sixth People's Hospital, Shanghai, China
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Bain CR, Myles PS, Corcoran T, Dieleman JM. Postoperative systemic inflammatory dysregulation and corticosteroids: a narrative review. Anaesthesia 2023; 78:356-370. [PMID: 36308338 PMCID: PMC10092416 DOI: 10.1111/anae.15896] [Citation(s) in RCA: 21] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/22/2022] [Indexed: 12/15/2022]
Abstract
In some patients, the inflammatory-immune response to surgical injury progresses to a harmful, dysregulated state. We posit that postoperative systemic inflammatory dysregulation forms part of a pathophysiological response to surgical injury that places patients at increased risk of complications and subsequently prolongs hospital stay. In this narrative review, we have outlined the evolution, measurement and prediction of postoperative systemic inflammatory dysregulation, distinguishing it from a healthy and self-limiting host response. We reviewed the actions of glucocorticoids and the potential for heterogeneous responses to peri-operative corticosteroid supplementation. We have then appraised the evidence highlighting the safety of corticosteroid supplementation, and the potential benefits of high/repeated doses to reduce the risks of major complications and death. Finally, we addressed how clinical trials in the future should target patients at higher risk of peri-operative inflammatory complications, whereby corticosteroid regimes should be tailored to modify not only the a priori risk, but also further adjusted in response to markers of an evolving pathophysiological response.
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Affiliation(s)
- C R Bain
- Department of Anaesthesiology and Peri-operative Medicine, Alfred Hospital and Monash University, Melbourne, VIC, Australia
| | - P S Myles
- Department of Anaesthesiology and Peri-operative Medicine, Alfred Hospital and Monash University, Melbourne, VIC, Australia
| | - T Corcoran
- Department of Anaesthesia and Pain Medicine, Royal Perth Hospital, Perth, WA, Australia
| | - J M Dieleman
- Department of Anaesthesia and Peri-operative Medicine, Westmead Hospital, Sydney and Western Sydney University, Sydney, NSW, Australia
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Schlesinger T, Weibel S, Kranke P. Postoperative/postdischarge nausea and vomiting: evidence-based prevention and treatment. Curr Opin Anaesthesiol 2023; 36:109-116. [PMID: 36214542 DOI: 10.1097/aco.0000000000001200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
PURPOSE OF REVIEW Postoperative/postdischarge nausea and vomiting (PONV/PDNV) remains a relevant issue in perioperative care. Especially in outpatient surgery, PONV can prevent discharge or lead to unplanned readmission. RECENT FINDINGS Evidence on prophylaxis and treatment of PONV is growing, but implementation remains poor. SUMMARY A liberal, universal PONV management is now endorsed by the guidelines. Specific evidence concerning prevention and (at-home) treatment of PDNV is still scarce.
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Affiliation(s)
- Tobias Schlesinger
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital of Wuerzburg, Wuerzburg, Germany
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Morin N, Taylor S, Krahn D, Baghirzada L, Chong M, Harrison TG, Cameron A, Ruzycki SM. Strategies for intraoperative glucose management: a scoping review. Can J Anaesth 2023; 70:253-270. [PMID: 36450943 DOI: 10.1007/s12630-022-02359-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 06/04/2022] [Accepted: 06/07/2022] [Indexed: 12/03/2022] Open
Abstract
PURPOSE Perioperative hyperglycemia is associated with adverse outcomes for patients with and without diabetes. Guidelines and published protocols for intraoperative glycemic management have substantial variation in their recommendations. We sought to characterize the current evidence-guiding intraoperative glycemic management in a scoping review. SOURCES Our search strategy included MEDLINE (Ovid and EBSCO), PubMed, PubMed Central, EMBASE, CINAHL, Cochrane Library, SciVerse Scopus, and Web of Science and a gray literature search of Google, Google Scholar, hand searching of the reference lists of included articles, OAISter, institutional protocols, and ClinicalTrails.gov. PRINCIPAL FINDINGS We identified 41 articles that met our inclusion criteria, 24 of which were original research studies. Outcomes and exposures were defined heterogeneously across studies, which limited comparison and synthesis. Investigators often created arbitrary and differing categories of glucose values rather than analyzing glucose as a continuous variable, which limited our ability to combine results from different studies. In addition, the study populations and surgery types also varied considerably, with few studies performed during day surgeries and specific surgical disciplines. Study populations often included more than one type of surgery, indication, and urgency that were expected to have varying physiologic and inflammatory responses. Combining low- and high-risk patients in the same study population may obscure the harms or benefits of intraoperative glycemic management for high-risk procedures or patients. CONCLUSION Future studies examining intraoperative glycemic management should carefully consider the study population, surgical characteristics, and pre- and postoperative management of hyperglycemia.
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Affiliation(s)
| | - Sarah Taylor
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Danae Krahn
- Department of Anesthesiology, Perioperative and Pain Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Leyla Baghirzada
- Department of Anesthesiology, Perioperative and Pain Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Michael Chong
- Department of Anesthesiology, Perioperative and Pain Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Tyrone G Harrison
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Room 1422, 3330 Hospital Drive NW, Calgary, AB, T2N 2T9, Canada
| | - Anne Cameron
- Department of Obstetrics and Gynecology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Shannon M Ruzycki
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Room 1422, 3330 Hospital Drive NW, Calgary, AB, T2N 2T9, Canada.
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Chen Y, Chen X, Zhou Q. Different effects of a perioperative single dose of dexamethasone on wound healing in mice with or without sepsis. Front Surg 2023; 10:927168. [PMID: 37114154 PMCID: PMC10126451 DOI: 10.3389/fsurg.2023.927168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Accepted: 03/16/2023] [Indexed: 04/29/2023] Open
Abstract
Introduction Sepsis delays wound healing owing to uncontrolled inflammation. A single perioperative dose of dexamethasone is widely used because of its anti-inflammatory effects. However, the effects of dexamethasone on wound healing in sepsis remain unclear. Methods We discuss the methods to obtain dose curves and explore the safe dosage range for wound healing in mice with or without sepsis. A saline or LPS intraperitoneal injection was applied to C57BL/6 mice. After 24 hours, the mice received a saline or DEX intraperitoneal injection and full-thickness, dorsal wounding operation. Wound healing was observed by image record, immunofluorescence and histological staining. Inflammatory cytokines and M1/M2 macrophages in wounds were determined by ELISA and immunofluorescence, respectively. Results Dose-response curves reflected the safe dosage range of DEX in mice with or without sepsis, from 0.121 to 2.03 mg/kg and from 0 to 0.633 mg/kg, respectively. we found that a single dose of dexamethasone (1 mg/kg, i.p.) promoted wound healing in septic mice, but delayed wound healing in normal mice. In normal mice, dexamethasone delays inflammation, resulting in an insufficient number of macrophages during the healing process. In septic mice, dexamethasone alleviated excessive inflammation and maintained the balance of M1/M2 macrophages in the early and late healing process. Discussion In summary, the safe dosage range of dexamethasone in septic mice is wider than that in normal mice. A single dose of dexamethasone (1 mg/kg) increased wound healing in septic mice, but delayed it in normal mice. Our findings provide helpful suggestions for the rational use of dexamethasone.
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Affiliation(s)
- Yuanyang Chen
- Department of Anesthesiology, Affiliated Shanghai Sixth People's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Xiaoshan Chen
- Department of Anesthesiology, Affiliated Shanghai Sixth People's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Quanhong Zhou
- Department of ICU, Affiliated Shanghai Sixth People's Hospital, Shanghai Jiao Tong University, Shanghai, China
- Correspondence: Quanhong Zhou
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Peter V, Shenoy U, Rukkiyabeevi B. Effect of a single intraoperative dose of dexamethasone on glycaemic profile in postoperative patients - A double-blind randomised controlled study. Indian J Anaesth 2022; 66:789-795. [PMID: 36590189 PMCID: PMC9795505 DOI: 10.4103/ija.ija_332_22] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 11/04/2022] [Accepted: 11/05/2022] [Indexed: 11/18/2022] Open
Abstract
Background and Aims The effect of a single intraoperative dose of steroids on perioperative blood sugar levels is uncertain. We hypothesised that a single dose of dexamethasone would not unfavourably alter the glucose levels of non-diabetic patients. This study aimed to evaluate the post-operative glycaemic profile after a single dose of intraoperative dexamethasone in non-diabetic patients. The presence of post-operative nausea and vomiting (PONV), pain, surgical site infection (SSI) and length of hospital stay were also evaluated. Methods This randomised, double-blind, controlled study was done by recruiting 150 non-diabetic adult patients of the American Society of Anesthesiologists physical status I/II undergoing elective surgery. Patients in the study group were administered a single dose of dexamethasone (0.15 mg/kg). Blood glucose levels were assessed at various time points for up to 72 hours post-operatively using point-of-care testing. Secondary outcomes such as PONV, pain, fever and SSI were also documented. Data were compared and analysed using Student's t-test, Chi-square test, Mann-Whitney test and analysis of variance test. Results There was an earlier, higher and prolonged elevation in blood glucose levels in patients receiving dexamethasone. The mean (standard deviation) of fasting/postprandial blood sugars on the first, second and third postoperative days respectively was significantly higher in the study group 98.04 (21.89)/139.16 (20.59), 96.64 (19.20)/138.17 (18.05), 96.60 (17.40)/138.32 (15.10) mg/dl as compared to control group 86.9 6 (10.28)/128.95 (10.53), 88.81 (8.87)/131.97 (9.68), 88.16 (8.50)/130.88 (9.48) mg/dl. About 10.7% of the patients who received dexamethasone had blood glucose levels greater than 180 mg/dl. There were no significant differences in the secondary outcomes. Conclusion Even a single dose of dexamethasone in non-diabetic adults causes significant and prolonged postoperative hyperglycaemia.
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Affiliation(s)
- Vigil Peter
- Department of Anaesthesia, Jubilee Mission Medical College and Regional Institute, Thrissur, Kerala, India,Address for correspondence: Dr. Vigil Peter, Alapatt House, Parappukkara P.O, Thrissur, Kerala - 680 310, India. E-mail:
| | - Usha Shenoy
- Department of Anaesthesia, Jubilee Mission Medical College and Regional Institute, Thrissur, Kerala, India
| | - Buena Rukkiyabeevi
- Department of Anaesthesia, Jubilee Mission Medical College and Regional Institute, Thrissur, Kerala, India
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Myles PS, Yeung J, Beattie WS, Ryan EG, Heritier S, McArthur CJ. Platform trials for anaesthesia and perioperative medicine: a narrative review. Br J Anaesth 2022; 130:677-686. [PMID: 36456249 DOI: 10.1016/j.bja.2022.10.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 10/27/2022] [Accepted: 10/28/2022] [Indexed: 11/29/2022] Open
Abstract
Large randomised trials provide the most reliable evidence of effectiveness of new treatments in clinical practice. However, the time and resources required to complete such trials can be daunting. An overarching clinical trial platform focused on a single condition or type of surgery, aiming to compare several treatments, with an option to stop any or add in new treatment options, can provide greater efficiency. This has the potential to accelerate knowledge acquisition and identify effective, ineffective, or harmful treatments faster. The master protocol of the platform defines the study population(s) and standardised procedures. Ineffective or harmful treatments can be discarded or study drug dose modified during the life cycle of the trial. Other adaptive elements that can be modified include eligibility criteria, required sample size for any comparison(s), randomisation assignment ratio, and the addition of other promising treatment options. There are excellent opportunities for anaesthetists to establish platform trials in perioperative medicine. Platform trials are highly efficient, with the potential to provide quicker answers to important clinical questions that lead to improved patient care.
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