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Hung KC, Chang LC, Ho CN, Wu JY, Hsu CW, Lin CM, Chen IW. Impact of intravenous steroids on subjective recovery quality after surgery: A meta-analysis of randomized clinical trials. J Clin Anesth 2024; 99:111625. [PMID: 39293148 DOI: 10.1016/j.jclinane.2024.111625] [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: 07/02/2024] [Revised: 08/16/2024] [Accepted: 09/10/2024] [Indexed: 09/20/2024]
Abstract
STUDY OBJECTIVE Quality of postoperative recovery is a crucial aspect of perioperative care. This meta-analysis aimed to evaluate the efficacy of intravenous steroids in improving the quality of recovery (QoR) after surgery, as measured by validated QoR scales. DESIGN Meta-analysis of randomized controlled trials (RCTs). SETTING Operating room. INTERVENTION The use of a single dose of intravenous steroids as a supplement to general anesthesia. PATIENTS Adult patients undergoing surgery. MEASUREMENTS A literature search was conducted using electronic databases (e.g., MEDLINE and Embase) from their inception to June 2024. Randomized controlled trials (RCTs) comparing intravenous steroids with placebo or no treatment in adult patients undergoing surgery under general anesthesia were included. The primary outcome was the QoR scores on postoperative days (POD) 1 and 2-3, as assessed by validated QoR scales (QoR-15 and QoR-40). Secondary outcomes included QoR dimensions, analgesic rescue, pain scores, and postoperative nausea and vomiting (PONV). MAIN RESULTS Eleven RCTs involving 951 patients were included in this study. The steroid group showed significant improvements in global QoR scores on POD 1 (standardized mean difference [SMD]: 0.52; 95 % confidence interval[CI]: 0.22 to 0.82; P = 0.0007) and POD 2-3 (SMD: 0.50; 95 % CI: 0.19 to 0.81; P = 0.001) compared to the control group. Significant improvements were also observed in all QoR dimensions on POD 1, with the effect sizes ranging from small to moderate. Intravenous steroids also significantly reduced the analgesic rescue requirements (RR: 0.77; 95 % CI: 0.67 to 0.88; P = 0.0003), postoperative pain scores (SMD: -0.41; 95 % CI: -0.68 to -0.14; P = 0.003), and PONV incidence (RR: 0.73; 95 % CI: 0.56 to 0.95; P = 0.02). CONCLUSIONS Intravenous administration of steroids significantly improved QoR after surgery. The benefits of steroids extend to all dimensions of QoR and important clinical outcomes such as analgesic requirements, pain scores, and PONV. These findings support the use of steroids as an effective strategy to enhance the postoperative recovery quality.
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Affiliation(s)
- Kuo-Chuan Hung
- Department of Anesthesiology, Chi Mei Medical Center, Tainan city, Taiwan
| | - Li-Chen Chang
- Department of Anesthesiology, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan
| | - Chun-Ning Ho
- Department of Anesthesiology, Chi Mei Medical Center, Tainan city, Taiwan; School of Medicine, College of Medicine, National Sun Yat-sen University, Kaohsiung, Taiwan
| | - Jheng-Yan Wu
- Department of Nutrition, Chi Mei Medical Center, Tainan City, Taiwan
| | - Chih-Wei Hsu
- Department of Psychiatry, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung city, Taiwan
| | - Chien-Ming Lin
- Department of Anesthesiology, Chi Mei Medical Center, Tainan city, Taiwan
| | - I-Wen Chen
- Department of Anesthesiology, Chi Mei Medical Center, Liouying, Tainan city, Taiwan.
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Yadav T, Kumar M, Verma K. Comparison of Intravenous Dexmedetomidine Versus Dexmedetomidine-Dexamethasone Combination for Preventing Postoperative Nausea and Vomiting in Adult Patients After Abdominal Surgeries. Cureus 2024; 16:e65913. [PMID: 39219889 PMCID: PMC11365702 DOI: 10.7759/cureus.65913] [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] [Accepted: 07/31/2024] [Indexed: 09/04/2024] Open
Abstract
INTRODUCTION Postoperative nausea and vomiting (PONV) is a common problem following general anesthesia and is one of the most unpleasant side effects that affects the patient after surgery and is the worst memory of the hospital stay. The present prospective randomized comparative study was designed to compare the effect of intravenous dexmedetomidine with dexmedetomidine-dexamethasone combination for preventing PONV following abdominal surgeries in adult patients and evaluating their sedative and analgesic effects. METHODOLOGY A total of 75 patients (aged 18-65 years) were assigned to undergo this comparative study via block randomization using a sealed envelope system. They were divided into three groups of 25 each: group A (control) received normal saline, group B received dexmedetomidine, and group C received a combination of dexmedetomidine with dexamethasone over 10 minutes after inducing general anesthesia before skin incision. The primary outcome was to assess PONV, where nausea was assessed by the numerical rating scale and vomiting by the number of gastric content expulsions. The secondary outcome, which is postoperative sedation and pain, was assessed by the Ramsay Sedation Score and Visual Analog Score, respectively, for 24 hours postoperatively. RESULT During the first 24 hours after surgery, the incidence of PONV was similar in both dexmedetomidine and combination groups but lower than the control group. Postoperative sedation and analgesia were both statistically and clinically adequate and similar in dexmedetomidine and combination groups. No major side effects requiring pharmacological intervention were reported. CONCLUSION Dexmedetomidine alone is as effective as its combination with dexamethasone in preventing PONV in adult patients following abdominal surgeries.
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Affiliation(s)
- Tanmay Yadav
- Anesthesiology and Critical Care, Vardhman Mahavir Medical College and Safdarjung Hospital, Delhi, IND
| | - Meenakshi Kumar
- Anesthesiology and Critical Care, Vardhman Mahavir Medical College and Safdarjung Hospital, Delhi, IND
| | - Krishika Verma
- Anesthesiology, Critical Care and Pain Medicine, Vardhman Mahavir Medical College and Safdarjung Hospital, Delhi, IND
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Freys JC, Bigalke SM, Mertes M, Lobo DN, Pogatzki-Zahn EM, Freys SM. Perioperative pain management for appendicectomy: A systematic review and Procedure-specific Postoperative Pain Management recommendations. Eur J Anaesthesiol 2024; 41:174-187. [PMID: 38214556 DOI: 10.1097/eja.0000000000001953] [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: 01/13/2024]
Abstract
BACKGROUND Despite being a commonly performed surgical procedure, pain management for appendicectomy is often neglected because of insufficient evidence on the most effective treatment options. OBJECTIVE To provide evidence-based recommendations by assessing the available literature for optimal pain management after appendicectomy. DESIGN AND DATA SOURCES This systematic review-based guideline was conducted according to the PROSPECT methodology. Relevant randomised controlled trials, systematic reviews and meta-analyses in the English language from January 1999 to October 2022 were retrieved from MEDLINE, Embase and Cochrane Databases using PRISMA search protocols. ELIGIBILITY CRITERIA We included studies on adults and children. If articles reported combined data from different surgeries, they had to include specific information about appendicectomies. Studies needed to measure pain intensity using a visual analogue scale (VAS) or a numerical rating scale (NRS). Studies that did not report the precise appendicectomy technique were excluded. RESULTS Out of 1388 studies, 94 met the inclusion criteria. Based on evidence and consensus, the PROSPECT members agreed that basic analgesics [paracetamol and nonsteroidal anti-inflammatory drugs (NSAIDs)] should be administered perioperatively for open and laparoscopic appendicectomies. A laparoscopic approach is preferred because of lower pain scores. Additional recommendations for laparoscopic appendicectomies include a three-port laparoscopic approach and the instillation of intraperitoneal local anaesthetic. For open appendicectomy, a preoperative unilateral transverse abdominis plane (TAP) block is recommended. If not possible, preincisional infiltration with local anaesthetics is an alternative. Opioids should only be used as rescue analgesia. Limited evidence exists for TAP block in laparoscopic appendicectomy, analgesic adjuvants for TAP block, continuous wound infiltration after open appendicectomy and preoperative ketamine and dexamethasone. Recommendations apply to children and adults. CONCLUSION This review identified an optimal analgesic regimen for open and laparoscopic appendicectomy. Further randomised controlled trials should evaluate the use of regional analgesia and wound infiltrations with adequate baseline analgesia, especially during the recommended conventional three-port approach. REGISTRATION The protocol for this study was registered with the PROSPERO database (Registration No. CRD42023387994).
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Affiliation(s)
- Jacob C Freys
- From the Department of Surgery, Agaplesion Bethesda Krankenhaus Hamburg (JCF), Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Münster, Münster, Germany (EMP-Z, MM), Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham (DNL), MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham, Queen's Medical Centre, Nottingham, United Kingdom (DNL), Department of Anaesthesiology, Intensive and Pain Medicine, Ruhr-University Bochum, BG-University Hospital Bergmannsheil gGmbH, Bochum (SMB) and Department of Surgery, DIAKO Ev. Diakonie-Krankenhaus, Bremen, Germany (SMF)
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Wu Q, Zhou Y, Sun S, Li H, Cao S, Shou H. Clinical analysis of acute postoperative pain after total laparoscopic hysterectomy for adenomyosis and uterine fibroids - a prospective observational study. Ann Med 2023; 55:2281510. [PMID: 37994446 PMCID: PMC10836289 DOI: 10.1080/07853890.2023.2281510] [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: 11/14/2022] [Accepted: 11/04/2023] [Indexed: 11/24/2023] Open
Abstract
OBJECTIVE To investigate the outcome of total laparoscopic hysterectomy (TLH) and postoperative pain characteristics and compare the pain severity after TLH for adenomyosis or uterine fibroids. METHODS This prospective observational study collected 101 patients received TLH for adenomyosis (AD group) including 41 patients were injected goserelin (3.6 mg) 28 days before TLH, while other adenomyosis patients received TLH without preoperative treatment, and 113 patients received TLH for uterine fibroids (UF group). Pain scores were evaluated at different time sites from operation day to postoperative 72 h using the numeric rating scale. Clinical data were collected from clinical record. RESULTS Operative time and anaesthetic time were longer in the AD group than those in the UF group (66.88 ± 8.65 vs. 64.46 ± 7.21, p = 0.04; 83.95 ± 10.05 vs. 79.77 ± 6.88, p < 0.01), severe endometriosis was quite more common in AD group (23.76% vs. 2.65%, p < 0.01). Postoperative usage of Flurbiprofen in AD group were more than that of UF group (15.48 ± 38.00 vs. 4.79 ± 18.16, p = 0.02). Total pains and abdominal visceral pains of AD group were more severe compared with UF group in motion and rest pattern at several time sites, while incision pain and shoulder pain were similar. The total postoperative pains after goserelin preoperative treatment in AD group were less than that without goserelin preoperative treatment (p < 0.05). The levels of serum NPY, PGE2 and NGF after laparoscopic hysterectomy of adenomyosis reduced with GnRH agonist pretreatment. CONCLUSIONS Acute postoperative pain for adenomyosis and uterine fibroids showed considerably different severity, postoperative total pain and abdominal visceral pains of TLH for adenomyosis were more severe compared with uterine fibroids. While patients received goserelin before laparoscopic hysterectomy of adenomyosis suffered from less severity of postoperative total pain than that without goserelin preoperative treatment.
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Affiliation(s)
- Qing Wu
- Center for Reproductive Medicine, Department of Gynecology, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital, Hangzhou Medical College), Hangzhou, Zhejiang, China
| | - Yun Zhou
- Department of Obstetrics and Gynecology, Shengli Clinical Medical College of Fujian Medical University and Fujian Provincial Hospital, Fuzhou, China
| | - Saijun Sun
- Tiantai People’s Hospital of Zhejiang Province, Zhejiang, China
| | - Hui Li
- Center for Reproductive Medicine, Department of Gynecology, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital, Hangzhou Medical College), Hangzhou, Zhejiang, China
| | - Shanshan Cao
- Tiantai People’s Hospital of Zhejiang Province, Zhejiang, China
| | - Huafeng Shou
- Center for Reproductive Medicine, Department of Gynecology, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital, Hangzhou Medical College), Hangzhou, Zhejiang, China
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Chen W, Li G, Jiang K, Song J, Du R, Yang H, Gou J, Li Z, Zhu J, Lei J. Dexamethasone for Postoperative Nausea and Vomiting in Papillary Thyroid Carcinoma Patients: A Randomized Clinical Trial. J Am Coll Surg 2022; 235:454-467. [PMID: 35972165 DOI: 10.1097/xcs.0000000000000309] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Postoperative nausea and vomiting (PONV) frequently occur after thyroidectomy. Previous studies have investigated the effects of preoperative dexamethasone for alleviating PONV in various cancers, but studies focused on papillary thyroid carcinoma (PTC) were limited. This study aimed to determine the efficacy of a single preoperative dose of dexamethasone to prevent PONV in patients with PTC. METHODS This single-center, parallel-group, double-blind, placebo-controlled clinical trial was conducted on patients with PTC in West China Hospital. Patients were randomized 1:1 into Group Dex (preoperative 8-mg dexamethasone) or Group Control (0.9% NaCl as control). The primary outcome was the incidence and severity of PONV. The secondary outcomes included postoperative pain, vocal dysfunction, and adverse events. RESULTS Six hundred participants were recruited and randomized. The total incidence of PONV was 33.3% (200 of 600 patients; 95% CI, 29.6-37.1). In the intention-to-treat analysis, PONV occurred in 81 of 300 patients (27.0%; 95% CI, 21.9-32.1) in Group Dex and in 119 of 300 patients (39.7%; 95% CI, 34.1-45.2) in Group Control (p = 0.001), and the absolute risk reduction was 12.7% (95% CI, 5.1-20.0). Patients in Group Dex reported fewer antiemetic requirements than those in Group Control (p = 0.004). Multivariate analysis indicated that dexamethasone administration (OR = 0.546; 95% CI, 0.383-0.777; p = 0.001) was associated with a reduced rate of PONV. Dexamethasone treatment also contributed to alleviating postoperative pain and improving subjective vocal dysfunction, with no increase in adverse events. CONCLUSIONS A single dose of dexamethasone is effective and safe for preventing PONV in PTC patients.
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Affiliation(s)
- Wenjie Chen
- From the Thyroid Surgery Center, West China Hospital of Sichuan University, Chengdu, China (Chen, Li, Jiang, Gou, Li, Zhu, Lei)
- Laboratory of Thyroid and Parathyroid Disease, Frontiers Science Center for Disease-related Molecular Network, West China Hospital, Sichuan University, Chengdu, Sichuan, China (Chen)
| | - Genpeng Li
- From the Thyroid Surgery Center, West China Hospital of Sichuan University, Chengdu, China (Chen, Li, Jiang, Gou, Li, Zhu, Lei)
| | - Ke Jiang
- From the Thyroid Surgery Center, West China Hospital of Sichuan University, Chengdu, China (Chen, Li, Jiang, Gou, Li, Zhu, Lei)
- Department of Head and Neck Surgery, Sun Yat Sen University Cancer Center, Guangzhou, China (Jiang)
| | - Jinen Song
- State Key Laboratory of Biotherapy, Center for Statistical Science, West China Hospital, Sichuan University and Collaborative Innovation Center, Chengdu, China (Song)
| | - Runzi Du
- Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu, China (Du)
| | - Hui Yang
- Department of Otolaryngology Head and Neck Surgery, West China Hospital, Sichuan University, Chengdu, China (Yang)
| | - Juxiang Gou
- From the Thyroid Surgery Center, West China Hospital of Sichuan University, Chengdu, China (Chen, Li, Jiang, Gou, Li, Zhu, Lei)
| | - Zhihui Li
- From the Thyroid Surgery Center, West China Hospital of Sichuan University, Chengdu, China (Chen, Li, Jiang, Gou, Li, Zhu, Lei)
| | - Jingqiang Zhu
- From the Thyroid Surgery Center, West China Hospital of Sichuan University, Chengdu, China (Chen, Li, Jiang, Gou, Li, Zhu, Lei)
| | - Jianyong Lei
- From the Thyroid Surgery Center, West China Hospital of Sichuan University, Chengdu, China (Chen, Li, Jiang, Gou, Li, Zhu, Lei)
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Reactive Oxygen Species Bridge the Gap between Chronic Inflammation and Tumor Development. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2022; 2022:2606928. [PMID: 35799889 PMCID: PMC9256443 DOI: 10.1155/2022/2606928] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 06/10/2022] [Indexed: 02/07/2023]
Abstract
According to numerous animal studies, adverse environmental stimuli, including physical, chemical, and biological factors, can cause low-grade chronic inflammation and subsequent tumor development. Human epidemiological evidence has confirmed the close relationship between chronic inflammation and tumorigenesis. However, the mechanisms driving the development of persistent inflammation toward tumorigenesis remain unclear. In this study, we assess the potential role of reactive oxygen species (ROS) and associated mechanisms in modulating inflammation-induced tumorigenesis. Recent reports have emphasized the cross-talk between oxidative stress and inflammation in many pathological processes. Exposure to carcinogenic environmental hazards may lead to oxidative damage, which further stimulates the infiltration of various types of inflammatory cells. In turn, increased cytokine and chemokine release from inflammatory cells promotes ROS production in chronic lesions, even in the absence of hazardous stimuli. Moreover, ROS not only cause DNA damage but also participate in cell proliferation, differentiation, and apoptosis by modulating several transcription factors and signaling pathways. We summarize how changes in the redox state can trigger the development of chronic inflammatory lesions into tumors. Generally, cancer cells require an appropriate inflammatory microenvironment to support their growth, spread, and metastasis, and ROS may provide the necessary catalyst for inflammation-driven cancer. In conclusion, ROS bridge the gap between chronic inflammation and tumor development; therefore, targeting ROS and inflammation represents a new avenue for the prevention and treatment of cancer.
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Tetzner F, Schlüter-Albrecht S, Rackwitz L, Clarius M, Nöth U, Reyle-Hahn SM. [Pain therapy and anaesthesiological procedures in fast-track arthroplasty]. DER ORTHOPADE 2022; 51:358-365. [PMID: 35412088 DOI: 10.1007/s00132-022-04248-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/14/2022] [Indexed: 12/19/2022]
Abstract
Since the introduction of fast-track surgery in the field of arthroplasty, all disciplines involved have been challenged with the task of close and continuous joint communication in the context of daily routine care. Processes that have been agreed upon interdisciplinarily must be reviewed at regular intervals, and, if necessary, adapted and newly agreed upon with the aim of optimizing the perioperative risks both medically and along the therapeutic pathway. The responsibility of the anaesthesiologist is not only limited to the performance of anaesthesia, but also includes the care of patients with a view to optimal pain therapy, maintenance of homeostasis and ensuring a rapid return of the patient's self-determination.
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Affiliation(s)
- Fabian Tetzner
- Klinik für Anästhesiologie und Interdisziplinäre Intensivmedizin, Evangelisches Waldkrankenhaus Spandau, Stadtrandstraße 555, 13589, Berlin, Deutschland
| | - Sabine Schlüter-Albrecht
- Klinik für Anästhesiologie und Interdisziplinäre Intensivmedizin, Evangelisches Waldkrankenhaus Spandau, Stadtrandstraße 555, 13589, Berlin, Deutschland
| | - Lars Rackwitz
- Klinik für Orthopädie und Unfallchirurgie, Evangelisches Waldkrankenhaus Spandau, Berlin, Deutschland
| | - Michael Clarius
- Klinik für Orthopädie, Orthopädische Chirurgie und Unfallchirurgie, Vulpius Klinik, Bad Rappenau, Deutschland
| | - Ulrich Nöth
- Klinik für Orthopädie und Unfallchirurgie, Evangelisches Waldkrankenhaus Spandau, Berlin, Deutschland
| | - Stephan-Matthias Reyle-Hahn
- Klinik für Anästhesiologie und Interdisziplinäre Intensivmedizin, Evangelisches Waldkrankenhaus Spandau, Stadtrandstraße 555, 13589, Berlin, Deutschland.
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Modir H, Dalaei D, Pazoki S, Naimi A. The therapeutic antiemetic and hemodynamic effects of dexmedetomidine, ephedrine, and dexamethasone in combination with midazolam on laparoscopic cholecystectomy patients: A randomised clinical trial. JOURNAL OF WEST AFRICAN COLLEGE OF SURGEONS 2022; 12:96-103. [PMID: 36213814 PMCID: PMC9536412 DOI: 10.4103/jwas.jwas_133_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 06/28/2022] [Indexed: 12/05/2022]
Abstract
Objective: The objective was to compare the hemodynamic and antiemetic effects of the combination of midazolam with ephedrine, dexamethasone, and dexmedetomidine in laparoscopic cholecystectomy surgical patients. Materials and Methods: This randomised, parallel-group, double-blind clinical trial was conducted by enrollment of 96 patients who were referred for laparoscopic cholecystectomy. Patients assigned into three equal-sized intervention arms having received anaesthesia induction with midazolam-ephedrine, midazolam-dexamethasone, and midazolam-dexmedetomidine using a block randomisation method. Frequency and severity of nausea and vomiting were observed from recovery to 24 h later, adverse events, and sedation on Ramsay sedation scale at recovery, 1, 2, and 4 h postoperatively. Data were recorded and analysed at a significance level lower than 0.05 in SPSS software. Results: The clinical parameters including mean blood pressure at all times and heart rate in 60–90 min were lower in the dexmedetomidine group when compared with other groups. The lowest severity of postsurgery nausea occurrence was observed in the midazolam-dexamethasone group and those receiving midazolam-dexmedetomidine from 4 to 24 h. In addition, vomiting scores were lower throughout recovery up to postoperative 4 h in the dexamethasone and dexmedetomidine groups (all P < 0.05). The highest sedation score was observed in the dexmedetomidine group during recovery up to 2 h (P = 0.001), reflecting a more clinically superior effect than dexamethasone (P = 0.01). Conclusions: A positive implication of dexmedetomidine was observed in attenuating postoperative nausea and vomiting and potentiating sedation. Nevertheless, it is providing a drop in the blood pressure and heart rate. Lending support to the potent adjuvant efficacy of dexamethasone following dexmedetomidine, consequently, a hypothesis can be put forward, stating that the dexmedetomidine and dexamethasone as adjuvants to midazolam are expected to bring the advantages of avoiding the adverse events and improving postoperative sedation.
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Rekei S, Naeimi AR, Mahmodiyeh B, Golmoradi R, Kamali A. Comparison of the prophylactic effect of dexamethasone and dexmedetomidine and their combination in reducing postoperative nausea and vomiting in patients undergoing laparoscopic cholecystectomy. J Med Life 2021; 14:323-330. [PMID: 34377197 PMCID: PMC8321612 DOI: 10.25122/jml-2020-0030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 04/09/2021] [Indexed: 11/27/2022] Open
Abstract
Nausea and vomiting are some of the most common complaints of patients after any anesthesia, which is often associated with postoperative pain. The double-blind clinical trial study aimed to compare the prophylactic effect of dexamethasone and dexmedetomidine and their combination in reducing postoperative nausea and vomiting in patients undergoing laparoscopic cholecystectomy. One hundred sixty-two patients undergoing laparoscopic cholecystectomy were enrolled in the study. In the first group of patients, 25 mg of dexmedetomidine were administered slowly. In comparison, the patients in the second group received dexamethasone (4 ml/2 mg) with 0.1 mg/kg of normal saline solution. The third group received a combination of dexmedetomidine and dexamethasone. Hemodynamic changes were recorded during surgery and after surgery, and the patients were admitted to recovery. Nausea and vomiting scores were recorded 2 and 4 hours after surgery. Blood pressure and heart rate were lower in the dexmedetomidine group at all times (P<0.05). Two hours after surgery, the dexamethasone and dexmedetomidine combination group had less vomiting (P=0.012). The incidence of nausea 2 and 4 hours after surgery was lower in the dexamethasone and dexmedetomidine combination group (P<0.05). Blood pressure and heart rate were lower in the dexmedetomidine group at all times. The dexmedetomidine and dexamethasone combination decreased postoperative nausea and vomiting in patients. Therefore, we recommend using a dexmedetomidine and dexamethasone combination for reducing postoperative nausea and vomiting.
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Affiliation(s)
- Siamak Rekei
- Department of Surgery, Arak University of Medical Sciences, Arak, Iran
| | - Amir Reza Naeimi
- Department of Surgery, Arak University of Medical Sciences, Arak, Iran
| | - Behnam Mahmodiyeh
- Department of Anesthesiology and Critical Care, Arak University of Medical Sciences, Arak, Iran
| | - Roya Golmoradi
- Department of Surgery, Arak University of Medical Sciences, Arak, Iran
| | - Alireza Kamali
- Department of Anesthesiology and Critical Care, Arak University of Medical Sciences, Arak, Iran
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Kim DG, Seo WJ, Cho M, Kim YM, Huh KH, Cheong JH, Hyung WJ, Kim MS, Kim HI. Perioperative, short-, and long-term outcomes of gastric cancer surgery: Propensity score-matched analysis of patients with or without prior solid organ transplantation. Eur J Surg Oncol 2021; 47:3105-3112. [PMID: 33906787 DOI: 10.1016/j.ejso.2021.04.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 03/28/2021] [Accepted: 04/15/2021] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND Details of perioperative outcomes and survival after gastric cancer surgery in prior transplant recipients have received minimal research attention. METHODS We performed an observational cohort study using the database of 20,147 gastric cancer patients who underwent gastrectomy at a single gastric cancer center in Korea. Forty-one solid organ recipients [kidney (n = 35), liver (n = 5), or heart (n = 1)] were matched with 205 controls using propensity score matching. RESULTS Operation time, blood loss, and postoperative pain were similar between groups. Short-term complication rates were similar between transplantation and control groups (22.0% vs. 20.1%, P = 0.777). Transplantation group patients with stage 1 gastric cancer experienced no recurrence, while those with stage 2/3 cancer had significantly higher recurrence risk compared to the controls (P = 0.049). For patients with stage 1 cancer, the transplantation group had a significantly higher rate of non-gastric cancer-related deaths compared to the controls (19.2% vs. 1.4%, P = 0.001). For those with stage 2/3 cancer, significantly lower proportion of the transplantation group received adjuvant chemotherapy compared to the control group (26.7% vs. 80.3%, P < 0.001). The transplantation group had a higher (albeit not statistically significant) rate of gastric cancer-related deaths compared to the controls (40.0% vs. 18.0%, P = 0.087). CONCLUSION Transplant recipients and non-transplant recipients exhibited similar perioperative and short-term outcomes after gastric cancer surgery. From long-term outcome analyses, we suggest active surveillance for non-gastric cancer-related deaths in patients with early gastric cancer, as well as strict oncologic care in patients with advanced cancer, as effective strategies for transplant recipients.
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Affiliation(s)
- Deok Gie Kim
- Transplantation Center, Department of Transplantation Surgery, Wonju Severance Christian Hospital, Wonju, South Korea; Department of Surgery, Yonsei University Wonju College of Medicine, Wonju, South Korea
| | - Won Jun Seo
- Department of Surgery, Korea University College of Medicine, Seoul, South Korea
| | - Minah Cho
- Department of Surgery, Yonsei University College of Medicine, Seoul, South Korea; Gastric Cancer Center, Yonsei Cancer Center, Seoul, South Korea; Open NBI Convergence Technology Research Laboratory, Severance Hospital, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea
| | - Yoo-Min Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, South Korea; Gastric Cancer Center, Yonsei Cancer Center, Seoul, South Korea; Open NBI Convergence Technology Research Laboratory, Severance Hospital, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea
| | - Kyu Ha Huh
- Department of Surgery, Yonsei University College of Medicine, Seoul, South Korea; The Research Institute for Transplantation, Yonsei University College of Medicine, Seoul, South Korea
| | - Jae-Ho Cheong
- Department of Surgery, Yonsei University College of Medicine, Seoul, South Korea; Gastric Cancer Center, Yonsei Cancer Center, Seoul, South Korea; Open NBI Convergence Technology Research Laboratory, Severance Hospital, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea
| | - Woo Jin Hyung
- Department of Surgery, Yonsei University College of Medicine, Seoul, South Korea; Gastric Cancer Center, Yonsei Cancer Center, Seoul, South Korea; Open NBI Convergence Technology Research Laboratory, Severance Hospital, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea
| | - Myoung Soo Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, South Korea; The Research Institute for Transplantation, Yonsei University College of Medicine, Seoul, South Korea
| | - Hyoung-Il Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, South Korea; Gastric Cancer Center, Yonsei Cancer Center, Seoul, South Korea; Open NBI Convergence Technology Research Laboratory, Severance Hospital, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea.
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Kleif J, Thygesen LC, Gögenur I. Moving from an era of open Appendectomy to an era of Laparoscopic Appendectomy: A Nationwide Cohort Study of Adult Patients Undergoing Surgery for Appendicitis. Scand J Surg 2021; 110:512-519. [PMID: 33563095 DOI: 10.1177/1457496921992615] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND AIMS During the last decades, laparoscopic surgery has been introduced as an alternative to open surgery. We aimed to examine to what extent laparoscopic surgery has replaced open surgery for appendicitis in an entire nation during the last two decades. Second, we examined the effects of shifting to laparoscopic surgery for appendicitis on different quality indicators such as length of postoperative stay and mortality. We also examined age as a predictor of 30-day mortality. MATERIALS AND METHODS During the period 2000 to 2015, all adult patients with appendicitis and surgical removal of the appendix were identified in the Danish National Patient Register. Demographics, type of surgery, time of surgery, and duration of postoperative stay were retrieved form Danish National Patient Register. Vital status was retrieved from the Danish Civil Registration System. RESULTS A total of 58,093 patients underwent surgery for appendicitis. In 2000, a total of 274 out of 3717 (7.4%) had a laparoscopic appendectomy, and the postoperative stay was 55 (iqr: 35-88) h and 30-day mortality was 0.91%. In 2015, a total of 3995 out of 4296 (93.0%) had a laparoscopic appendectomy, and the postoperative stay was 16 (iqr: 9-56) h and 30-day mortality was 0.40%. Age as a predictor of 30-day postoperative mortality had an area under the curve of 0.93 (95% confidence interval: 0.92; 0.94). CONCLUSION In Denmark, the standard surgical procedure for appendicitis has changed from open surgery to laparoscopic surgery during the period 2000-2015. At the same time, duration of postoperative stay and 30-day mortality has decreased.
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Affiliation(s)
- J Kleif
- Department of Surgery, North Zealand Hospital, Copenhagen University Hospital, Hillerød, Denmark
| | - L C Thygesen
- National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
| | - I Gögenur
- Department of Surgery, Zealand University Hospital, Center for Surgical Science, Køge, Denmark
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12
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Weibel S, Rücker G, Eberhart LH, Pace NL, Hartl HM, Jordan OL, Mayer D, Riemer M, Schaefer MS, Raj D, Backhaus I, Helf A, Schlesinger T, Kienbaum P, Kranke P. Drugs for preventing postoperative nausea and vomiting in adults after general anaesthesia: a network meta-analysis. Cochrane Database Syst Rev 2020; 10:CD012859. [PMID: 33075160 PMCID: PMC8094506 DOI: 10.1002/14651858.cd012859.pub2] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Postoperative nausea and vomiting (PONV) is a common adverse effect of anaesthesia and surgery. Up to 80% of patients may be affected. These outcomes are a major cause of patient dissatisfaction and may lead to prolonged hospital stay and higher costs of care along with more severe complications. Many antiemetic drugs are available for prophylaxis. They have various mechanisms of action and side effects, but there is still uncertainty about which drugs are most effective with the fewest side effects. OBJECTIVES • To compare the efficacy and safety of different prophylactic pharmacologic interventions (antiemetic drugs) against no treatment, against placebo, or against each other (as monotherapy or combination prophylaxis) for prevention of postoperative nausea and vomiting in adults undergoing any type of surgery under general anaesthesia • To generate a clinically useful ranking of antiemetic drugs (monotherapy and combination prophylaxis) based on efficacy and safety • To identify the best dose or dose range of antiemetic drugs in terms of efficacy and safety SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP), ClinicalTrials.gov, and reference lists of relevant systematic reviews. The first search was performed in November 2017 and was updated in April 2020. In the update of the search, 39 eligible studies were found that were not included in the analysis (listed as awaiting classification). SELECTION CRITERIA Randomized controlled trials (RCTs) comparing effectiveness or side effects of single antiemetic drugs in any dose or combination against each other or against an inactive control in adults undergoing any type of surgery under general anaesthesia. All antiemetic drugs belonged to one of the following substance classes: 5-HT₃ receptor antagonists, D₂ receptor antagonists, NK₁ receptor antagonists, corticosteroids, antihistamines, and anticholinergics. No language restrictions were applied. Abstract publications were excluded. DATA COLLECTION AND ANALYSIS A review team of 11 authors independently assessed trials for inclusion and risk of bias and subsequently extracted data. We performed pair-wise meta-analyses for drugs of direct interest (amisulpride, aprepitant, casopitant, dexamethasone, dimenhydrinate, dolasetron, droperidol, fosaprepitant, granisetron, haloperidol, meclizine, methylprednisolone, metoclopramide, ondansetron, palonosetron, perphenazine, promethazine, ramosetron, rolapitant, scopolamine, and tropisetron) compared to placebo (inactive control). We performed network meta-analyses (NMAs) to estimate the relative effects and ranking (with placebo as reference) of all available single drugs and combinations. Primary outcomes were vomiting within 24 hours postoperatively, serious adverse events (SAEs), and any adverse event (AE). Secondary outcomes were drug class-specific side effects (e.g. headache), mortality, early and late vomiting, nausea, and complete response. We performed subgroup network meta-analysis with dose of drugs as a moderator variable using dose ranges based on previous consensus recommendations. We assessed certainty of evidence of NMA treatment effects for all primary outcomes and drug class-specific side effects according to GRADE (CINeMA, Confidence in Network Meta-Analysis). We restricted GRADE assessment to single drugs of direct interest compared to placebo. MAIN RESULTS We included 585 studies (97,516 randomized participants). Most of these studies were small (median sample size of 100); they were published between 1965 and 2017 and were primarily conducted in Asia (51%), Europe (25%), and North America (16%). Mean age of the overall population was 42 years. Most participants were women (83%), had American Society of Anesthesiologists (ASA) physical status I and II (70%), received perioperative opioids (88%), and underwent gynaecologic (32%) or gastrointestinal surgery (19%) under general anaesthesia using volatile anaesthetics (88%). In this review, 44 single drugs and 51 drug combinations were compared. Most studies investigated only single drugs (72%) and included an inactive control arm (66%). The three most investigated single drugs in this review were ondansetron (246 studies), dexamethasone (120 studies), and droperidol (97 studies). Almost all studies (89%) reported at least one efficacy outcome relevant for this review. However, only 56% reported at least one relevant safety outcome. Altogether, 157 studies (27%) were assessed as having overall low risk of bias, 101 studies (17%) overall high risk of bias, and 327 studies (56%) overall unclear risk of bias. Vomiting within 24 hours postoperatively Relative effects from NMA for vomiting within 24 hours (282 RCTs, 50,812 participants, 28 single drugs, and 36 drug combinations) suggest that 29 out of 36 drug combinations and 10 out of 28 single drugs showed a clinically important benefit (defined as the upper end of the 95% confidence interval (CI) below a risk ratio (RR) of 0.8) compared to placebo. Combinations of drugs were generally more effective than single drugs in preventing vomiting. However, single NK₁ receptor antagonists showed treatment effects similar to most of the drug combinations. High-certainty evidence suggests that the following single drugs reduce vomiting (ordered by decreasing efficacy): aprepitant (RR 0.26, 95% CI 0.18 to 0.38, high certainty, rank 3/28 of single drugs); ramosetron (RR 0.44, 95% CI 0.32 to 0.59, high certainty, rank 5/28); granisetron (RR 0.45, 95% CI 0.38 to 0.54, high certainty, rank 6/28); dexamethasone (RR 0.51, 95% CI 0.44 to 0.57, high certainty, rank 8/28); and ondansetron (RR 0.55, 95% CI 0.51 to 0.60, high certainty, rank 13/28). Moderate-certainty evidence suggests that the following single drugs probably reduce vomiting: fosaprepitant (RR 0.06, 95% CI 0.02 to 0.21, moderate certainty, rank 1/28) and droperidol (RR 0.61, 95% CI 0.54 to 0.69, moderate certainty, rank 20/28). Recommended and high doses of granisetron, dexamethasone, ondansetron, and droperidol showed clinically important benefit, but low doses showed no clinically important benefit. Aprepitant was used mainly at high doses, ramosetron at recommended doses, and fosaprepitant at doses of 150 mg (with no dose recommendation available). Frequency of SAEs Twenty-eight RCTs were included in the NMA for SAEs (10,766 participants, 13 single drugs, and eight drug combinations). The certainty of evidence for SAEs when using one of the best and most reliable anti-vomiting drugs (aprepitant, ramosetron, granisetron, dexamethasone, ondansetron, and droperidol compared to placebo) ranged from very low to low. Droperidol (RR 0.88, 95% CI 0.08 to 9.71, low certainty, rank 6/13) may reduce SAEs. We are uncertain about the effects of aprepitant (RR 1.39, 95% CI 0.26 to 7.36, very low certainty, rank 11/13), ramosetron (RR 0.89, 95% CI 0.05 to 15.74, very low certainty, rank 7/13), granisetron (RR 1.21, 95% CI 0.11 to 13.15, very low certainty, rank 10/13), dexamethasone (RR 1.16, 95% CI 0.28 to 4.85, very low certainty, rank 9/13), and ondansetron (RR 1.62, 95% CI 0.32 to 8.10, very low certainty, rank 12/13). No studies reporting SAEs were available for fosaprepitant. Frequency of any AE Sixty-one RCTs were included in the NMA for any AE (19,423 participants, 15 single drugs, and 11 drug combinations). The certainty of evidence for any AE when using one of the best and most reliable anti-vomiting drugs (aprepitant, ramosetron, granisetron, dexamethasone, ondansetron, and droperidol compared to placebo) ranged from very low to moderate. Granisetron (RR 0.92, 95% CI 0.80 to 1.05, moderate certainty, rank 7/15) probably has no or little effect on any AE. Dexamethasone (RR 0.77, 95% CI 0.55 to 1.08, low certainty, rank 2/15) and droperidol (RR 0.89, 95% CI 0.81 to 0.98, low certainty, rank 6/15) may reduce any AE. Ondansetron (RR 0.95, 95% CI 0.88 to 1.01, low certainty, rank 9/15) may have little or no effect on any AE. We are uncertain about the effects of aprepitant (RR 0.87, 95% CI 0.78 to 0.97, very low certainty, rank 3/15) and ramosetron (RR 1.00, 95% CI 0.65 to 1.54, very low certainty, rank 11/15) on any AE. No studies reporting any AE were available for fosaprepitant. Class-specific side effects For class-specific side effects (headache, constipation, wound infection, extrapyramidal symptoms, sedation, arrhythmia, and QT prolongation) of relevant substances, the certainty of evidence for the best and most reliable anti-vomiting drugs mostly ranged from very low to low. Exceptions were that ondansetron probably increases headache (RR 1.16, 95% CI 1.06 to 1.28, moderate certainty, rank 18/23) and probably reduces sedation (RR 0.87, 95% CI 0.79 to 0.96, moderate certainty, rank 5/24) compared to placebo. The latter effect is limited to recommended and high doses of ondansetron. Droperidol probably reduces headache (RR 0.76, 95% CI 0.67 to 0.86, moderate certainty, rank 5/23) compared to placebo. We have high-certainty evidence that dexamethasone (RR 1.00, 95% CI 0.91 to 1.09, high certainty, rank 16/24) has no effect on sedation compared to placebo. No studies assessed substance class-specific side effects for fosaprepitant. Direction and magnitude of network effect estimates together with level of evidence certainty are graphically summarized for all pre-defined GRADE-relevant outcomes and all drugs of direct interest compared to placebo in http://doi.org/10.5281/zenodo.4066353. AUTHORS' CONCLUSIONS We found high-certainty evidence that five single drugs (aprepitant, ramosetron, granisetron, dexamethasone, and ondansetron) reduce vomiting, and moderate-certainty evidence that two other single drugs (fosaprepitant and droperidol) probably reduce vomiting, compared to placebo. Four of the six substance classes (5-HT₃ receptor antagonists, D₂ receptor antagonists, NK₁ receptor antagonists, and corticosteroids) were thus represented by at least one drug with important benefit for prevention of vomiting. Combinations of drugs were generally more effective than the corresponding single drugs in preventing vomiting. NK₁ receptor antagonists were the most effective drug class and had comparable efficacy to most of the drug combinations. 5-HT₃ receptor antagonists were the best studied substance class. For most of the single drugs of direct interest, we found only very low to low certainty evidence for safety outcomes such as occurrence of SAEs, any AE, and substance class-specific side effects. Recommended and high doses of granisetron, dexamethasone, ondansetron, and droperidol were more effective than low doses for prevention of vomiting. Dose dependency of side effects was rarely found due to the limited number of studies, except for the less sedating effect of recommended and high doses of ondansetron. The results of the review are transferable mainly to patients at higher risk of nausea and vomiting (i.e. healthy women undergoing inhalational anaesthesia and receiving perioperative opioids). Overall study quality was limited, but certainty assessments of effect estimates consider this limitation. No further efficacy studies are needed as there is evidence of moderate to high certainty for seven single drugs with relevant benefit for prevention of vomiting. However, additional studies are needed to investigate potential side effects of these drugs and to examine higher-risk patient populations (e.g. individuals with diabetes and heart disease).
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Affiliation(s)
- Stephanie Weibel
- Department of Anesthesiology and Critical Care, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Gerta Rücker
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center - University of Freiburg, Freiburg, Germany
| | - Leopold Hj Eberhart
- Department of Anaesthesiology & Intensive Care Medicine, Philipps-University Marburg, Marburg, Germany
| | - Nathan L Pace
- Department of Anesthesiology, University of Utah, Salt Lake City, UT, USA
| | - Hannah M Hartl
- Department of Anesthesiology and Critical Care, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Olivia L Jordan
- Department of Anesthesiology and Critical Care, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Debora Mayer
- Department of Anesthesiology and Critical Care, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Manuel Riemer
- Department of Anesthesiology and Critical Care, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Maximilian S Schaefer
- Department of Anaesthesiology, University Hospital Düsseldorf, Düsseldorf, Germany
- Department of Anesthesia, Critical Care & Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Diana Raj
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Queen Elizabeth University Hospital, Glasgow, UK
| | - Insa Backhaus
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Antonia Helf
- Department of Anesthesiology and Critical Care, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Tobias Schlesinger
- Department of Anesthesiology and Critical Care, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Peter Kienbaum
- Department of Anaesthesiology, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Peter Kranke
- Department of Anesthesiology and Critical Care, University Hospital Wuerzburg, Wuerzburg, Germany
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Elvir-Lazo OL, White PF, Yumul R, Cruz Eng H. Management strategies for the treatment and prevention of postoperative/postdischarge nausea and vomiting: an updated review. F1000Res 2020; 9. [PMID: 32913634 PMCID: PMC7429924 DOI: 10.12688/f1000research.21832.1] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/04/2020] [Indexed: 01/10/2023] Open
Abstract
Postoperative nausea and vomiting (PONV) and postdischarge nausea and vomiting (PDNV) remain common and distressing complications following surgery. The routine use of opioid analgesics for perioperative pain management is a major contributing factor to both PONV and PDNV after surgery. PONV and PDNV can delay discharge from the hospital or surgicenter, delay the return to normal activities of daily living after discharge home, and increase medical costs. The high incidence of PONV and PDNV has persisted despite the introduction of many new antiemetic drugs (and more aggressive use of antiemetic prophylaxis) over the last two decades as a result of growth in minimally invasive ambulatory surgery and the increased emphasis on earlier mobilization and discharge after both minor and major surgical procedures (e.g. enhanced recovery protocols). Pharmacologic management of PONV should be tailored to the patient’s risk level using the validated PONV and PDNV risk-scoring systems to encourage cost-effective practices and minimize the potential for adverse side effects due to drug interactions in the perioperative period. A combination of prophylactic antiemetic drugs with different mechanisms of action should be administered to patients with moderate to high risk of developing PONV. In addition to utilizing prophylactic antiemetic drugs, the management of perioperative pain using opioid-sparing multimodal analgesic techniques is critically important for achieving an enhanced recovery after surgery. In conclusion, the utilization of strategies to reduce the baseline risk of PONV (e.g. adequate hydration and the use of nonpharmacologic antiemetic and opioid-sparing analgesic techniques) and implementing multimodal antiemetic and analgesic regimens will reduce the likelihood of patients developing PONV and PDNV after surgery.
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Affiliation(s)
| | - Paul F White
- Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, CA, 90048, USA.,The White Mountain Institute, The Sea Ranch, Sonoma, CA, 95497, USA.,Instituto Ortopedico Rizzoli, University of Bologna, Bologna, Italy
| | - Roya Yumul
- Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, CA, 90048, USA.,David Geffen School of Medicine-UCLA, Charles R. Drew University of Medicine and Science, Los Angeles, CA, 90095, USA
| | - Hillenn Cruz Eng
- Department of Anesthesiology, PennState Hershey Medical Center, Hershey, PA, 17033, USA
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14
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Abstract
BACKGROUND Postoperative nausea and vomiting (PONV) is a common complication after mastectomy. Although many researches have been studied the prophylactic effect of antiemetics, none of the results are effective. To overcome this problem, dexamethasone was used to relieve the occurrence of PONV. Since concerns about steroid-related morbidity still remain, We carried out a meta-analysis to evaluate the impact of prophylactic dexamethasone on PONV, post-operative pain undergoing mastectomy. METHODS Literature search was conducted through PubMed, Web of Science, EMBASE, MEDLINE, and Cochrane library database till June 2019 to identify eligible studies. Meanwhile, we also consulted some Chinese periodicals, such as China Academic Journals, Wanfang and Weipu. The research was reported according to the preferred reporting items for systematic reviews and meta-analysis guidelines. Randomized controlled trials were included in our meta-analysis. Meanwhile, the assessment of the risk of bias was conducted according to the Cochrane Handbook for Systematic Reviews of Interventions version. The pooled data are processed by software RevMan 5.3. RESULTS Four studies with 490 patients were enrolled to this meta-analysis. Our study demonstrated that the dexamethasone group was significantly more effective than the placebo group in term of PONV (risk ratio [RR] = 0.46, 95% confidence intervals [CI]: 0.30-0.70, P = .0003), nausea (RR = 0.26, 95% CI: 0.10-0.68, P = .006) and vomiting (RR = 0.15, 95% CI: 0.04∼0.55, P = .004). The visual analog scale score was significantly diminished at 1 hour (weighted mean difference = -1.40, 95% CI: -1.53 to -1.26, P < .00001) in the dexamethasone group, while, no statistically significant difference was observed between the two groups in terms of visual analog scale at 24 hours (weighted mean difference = -0.56, 95% CI: -1.24 to 0.13, P = 0.11). CONCLUSION Not only does Dexamethasone reduce the incidence of PONV but also decreases postoperative pain. However, we still need larger samples and higher quality studies to determine the relationship between symptoms and administration time to reach the conclusion. TRIAL REGISTRATION NUMBER PROSPERO CRD 42018118575.
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16
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Tan NL, Gotmaker R, Barrington MJ. Impact of Local Infiltration Analgesia on the Quality of Recovery After Anterior Total Hip Arthroplasty: A Randomized, Triple-Blind, Placebo-Controlled Trial. Anesth Analg 2019; 129:1715-1722. [PMID: 31743193 DOI: 10.1213/ane.0000000000004255] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Local infiltration analgesia (LIA) is commonly used in anterior total hip arthroplasty (THA) surgery; however, evidence for its efficacy is lacking. We hypothesized that LIA with 0.2% ropivacaine when compared with injection of placebo (0.9% saline) would improve patient quality of recovery on postoperative day (POD) 1, as measured by the Quality of Recovery-15 (QoR-15) score. METHODS Patients scheduled to have a primary unilateral anterior THA with a single surgeon in a tertiary level metropolitan hospital were randomized to receive LIA with either 2.5 mL/kg of 0.2% ropivacaine or 0.9% saline as placebo. Patients and clinical and study personnel were blinded to group allocation. Perioperative care was standardized and this included spinal anesthesia and oral multimodal analgesia. The primary outcome was a multidimensional (pain, physical comfort, physical independence, emotions, and psychological support) patient-reported quality of recovery scale, QoR-15, measured on POD 1. RESULTS One hundred sixty patients were randomized; 6 patients were withdrawn after randomization and 2 patients had incomplete outcome data. The intention-to-treat analysis included 152 patients. The median (interquartile range [IQR]) QoR-15 score on POD 1 of the ropivacaine group was 119.5 (102-124), compared with the placebo group which had a median (IQR) of 115 (98-126). The median difference of 2 (95% confidence interval [CI], -4 to 7; P = .56) was not statistically or clinically significant. An as-per-protocol sensitivity analysis of 146 patients who received spinal anesthesia without general anesthesia, and the allocated intervention, also showed no evidence of a significant difference between groups. Secondary outcomes (worst pain numerical rating scale at rest and with movement on POD 1, opioid consumption on PODs 1 and 2, mobilization on POD 1, Brief Pain Inventory severity and interference on POD 90, and length of stay) were similar in both groups. CONCLUSIONS LIA with 0.2% ropivacaine when compared with 0.9% saline as placebo did not improve quality of recovery 1 day after anterior THA.
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Affiliation(s)
- Nicole L Tan
- From the Department of Anaesthesia, Critical Care Institute, Epworth HealthCare, Melbourne, Australia
- Department of Medicine and Radiology, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Australia
| | - Robert Gotmaker
- Department of Anaesthesia and Acute Pain Medicine, St Vincent's Hospital, Melbourne, Australia
| | - Michael J Barrington
- Department of Anaesthesia and Acute Pain Medicine, St Vincent's Hospital, Melbourne, Australia
- Department of Medicine and Radiology, Melbourne Medical School, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Australia
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Yang S, Xiao W, Wang S, Meng L, Zhou L, Wan A, Liu Y, Feng S, Wang T. Parecoxib Shortens the Duration of Acute Postoperative Pain After Laparoscopic-Assisted Vaginal Hysterectomy. Front Pharmacol 2019; 10:689. [PMID: 31275150 PMCID: PMC6591448 DOI: 10.3389/fphar.2019.00689] [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: 03/01/2019] [Accepted: 05/27/2019] [Indexed: 11/20/2022] Open
Abstract
The effect of parecoxib sodium on the duration and severity of acute postoperative pain after laparoscopic-assisted vaginal hysterectomy has been inadequately studied. This randomized, controlled trial compared the effects of parecoxib, methylprednisolone, and placebo on the duration of acute postoperative pain after elective laparoscopic-assisted vaginal hysterectomy. Ninety-four eligible patients were randomized to three groups [parecoxib sodium 40 mg (Group P), methylprednisolone 1 mg/kg (Group M), and saline (Group S)]. The duration of pain during coughing [median (interquartile range)] was significantly lower in Group P than in Group M or Group S [26.0 (5.8–48.0) vs. 48.0 (30.0–55.5) vs. 48.0 (36.0–58.5) h; p = 0.025]. The duration of pain during rest was also significantly lower in Group P than in Group M or Group S [5.5 (3.8–21.0) vs. 24.0 (6.0–28.0) vs. 22.0 (5.8–36.0) h; p = 0.009]. Compared with those in Group M and Group S, the patients in Group P reported less intense visceral pain during coughing at 12 (p = 0.050) and 24 h (p = 0.009) as well as at rest at 12 h (p = 0.008). Compared with those in Group P and Group S, the patients in Group M showed lower serum C-reactive protein levels and higher blood glucose levels after surgery. No differences were noted in nausea, vomiting, length of hospital stay, wound infection, and delayed wound healing among the groups. Thus, parecoxib sodium reduces the duration and intensity of acute postoperative pain after laparoscopic-assisted vaginal hysterectomy.
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Affiliation(s)
- Shuyi Yang
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Wei Xiao
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Shijun Wang
- Department of Gynecology and Obstetrics, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Lingzhong Meng
- Department of Anesthesiology, Yale University School of Medicine, New Haven, CT, United States
| | - Liane Zhou
- Department of Gynecology and Obstetrics, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Anxia Wan
- Department of Gynecology and Obstetrics, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yang Liu
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Shuai Feng
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Tianlong Wang
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China.,National Clinical Research Center for Geriatric Diseases, Xuanwu Hospital, Capital Medical University, Beijing, China
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Polderman JAW, Farhang‐Razi V, Dieren S, Kranke P, DeVries JH, Hollmann MW, Preckel B, Hermanides J. Adverse side‐effects of dexamethasone in surgical patients – an abridged Cochrane systematic review. Anaesthesia 2019; 74:929-939. [DOI: 10.1111/anae.14610] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/23/2019] [Indexed: 01/18/2023]
Affiliation(s)
- J. A. W. Polderman
- Department of Anaesthesiology Amsterdam University Medical Centre Amsterdamthe Netherlands
| | - V. Farhang‐Razi
- Department of Anaesthesiology Amsterdam University Medical Centre Amsterdamthe Netherlands
| | - S. Dieren
- Department of Surgery Amsterdam University Medical Centre Amsterdamthe Netherlands
| | - P. Kranke
- Department of Anaesthesia and Critical Care University Hospitals of Wuerzburg Germany
| | - J. H. DeVries
- Department of Endocrinology Amsterdam University Medical Centre Amsterdamthe Netherlands
| | - M. W. Hollmann
- Department of Anaesthesiology and Laboratory of Experimental Intensive Care and Anaesthesiology (L.E.I.C.A.) Amsterdam University Medical Centre Amsterdam the Netherlands
| | - B. Preckel
- Department of Anaesthesiology and Laboratory of Experimental Intensive Care and Anaesthesiology (L.E.I.C.A.) Amsterdam University Medical Centre Amsterdam the Netherlands
| | - J. Hermanides
- Department of Anaesthesiology Amsterdam University Medical Centre Amsterdamthe Netherlands
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Polderman JAW, Farhang‐Razi V, Van Dieren S, Kranke P, DeVries JH, Hollmann MW, Preckel B, Hermanides J. Adverse side effects of dexamethasone in surgical patients. Cochrane Database Syst Rev 2018; 11:CD011940. [PMID: 30480776 PMCID: PMC6426282 DOI: 10.1002/14651858.cd011940.pub3] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND In the perioperative period, dexamethasone is widely and effectively used for prophylaxis of postoperative nausea and vomiting (PONV), for pain management, and to facilitate early discharge after ambulatory surgery.Long-term treatment with steroids has many side effects, such as adrenal insufficiency, increased infection risk, hyperglycaemia, high blood pressure, osteoporosis, and development of diabetes mellitus. However, whether a single steroid load during surgery has negative effects during the postoperative period has not yet been studied. OBJECTIVES To assess the effects of a steroid load of dexamethasone on postoperative systemic or wound infection, delayed wound healing, and blood glucose change in adult surgical patients (with planned subgroup analysis of patients with and without diabetes). SEARCH METHODS We searched MEDLINE, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), in the Cochrane Library, and the Web of Science for relevant articles on 29 January 2018. We searched without language or date restriction two clinical trial registries to identify ongoing studies, and we handsearched the reference lists of relevant publications to identify all eligible trials. SELECTION CRITERIA We searched for randomized controlled trials comparing an incidental steroid load of dexamethasone versus a control intervention for adult patients undergoing surgery. We required that studies include a follow-up of 30 days for proper assessment of the number of postoperative infections, delayed wound healing, and the glycaemic response. DATA COLLECTION AND ANALYSIS Two review authors independently screened studies for eligibility, extracted data from relevant studies, and assessed all included studies for bias. We resolved differences by discussion and pooled included studies in a meta-analysis. We calculated Peto odds ratios (ORs) for dichotomous outcomes and mean differences (MDs) for continuous outcomes. Our primary outcomes were postoperative systemic or wound infection, delayed wound healing, and glycaemic response within 24 hours. We created a funnel plot for the primary outcome postoperative (wound or systemic) infection. We used GRADE to assess the quality of evidence for each outcome. MAIN RESULTS We included in the meta-analysis 37 studies that included adults undergoing a large variety of surgical procedures (i.e. abdominal surgery, cardiac surgery, neurosurgery, and orthopaedic surgery). We excluded one previously included study, as this study was recently retracted. Age range of participants was 18 to 80 years. There is probably little or no difference in the risk of postoperative (wound or systemic) infection with dexamethasone compared with no treatment, placebo, or active control (ramosetron, ondansetron, or tropisetron) (Peto OR 1.01, 95% confidence interval (CI) 0.80 to 1.27; 4603 participants, 26 studies; I² = 32%; moderate-quality evidence). The effects of dexamethasone on delayed wound healing are unclear because the wide confidence interval includes both meaningful benefit and harm (Peto OR 0.99, 95% CI 0.28 to 3.43; 1072 participants, eight studies; I² = 0%; low-quality evidence). Dexamethasone may produce a mild increase in glucose levels among participants without diabetes during the first 12 hours after surgery (MD 13 mg/dL, 95% CI 6 to 21; 10 studies; 595 participants; I² = 50%; low-quality evidence). We identified two studies reporting on glycaemic response after dexamethasone in participants with diabetes within 24 hours after surgery (MD 32 mg/dL, 95% CI 15 to 49; 74 participants; I² = 0%; very low-quality evidence). AUTHORS' CONCLUSIONS A single dose of dexamethasone probably does not increase the risk for postoperative infection. It is uncertain whether dexamethasone has an effect on delayed wound healing in the general surgical population owing to imprecision in trial results. Participants with increased risk for delayed wound healing (e.g. participants with diabetes, those taking immunosuppressive drugs) were not included in the randomized studies reporting on delayed wound healing included in this meta-analysis; therefore our findings should be extrapolated to the clinical setting with caution. Furthermore, one has to keep in mind that dexamethasone induces a mild increase in glucose. For patients with diabetes, very limited evidence suggests a more pronounced increase in glucose. Whether this influences wound healing in a clinically relevant way remains to be established. Once assessed, the two studies awaiting classification and three that are ongoing may alter the conclusions of this review.
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Affiliation(s)
- Jorinde AW Polderman
- Academic Medical Center (AMC) University of AmsterdamDepartment of AnaesthesiologyMeibergdreef 9AmsterdamNetherlands1105 AZ
| | - Violet Farhang‐Razi
- Academic Medical Center (AMC) University of AmsterdamDepartment of AnaesthesiologyMeibergdreef 9AmsterdamNetherlands1105 AZ
| | - Susan Van Dieren
- Academic Medical Center (AMC) University of AmsterdamDepartment of AnaesthesiologyMeibergdreef 9AmsterdamNetherlands1105 AZ
| | - Peter Kranke
- University of WürzburgDepartment of Anaesthesia and Critical CareOberdürrbacher Str. 6WürzburgGermany97080
| | - J Hans DeVries
- Academic Medical CentreDepartment of Internal MedicinePO Box 22700AmsterdamNetherlands1100 DE
| | - Markus W Hollmann
- Academic Medical Center (AMC) University of AmsterdamDepartment of AnaesthesiologyMeibergdreef 9AmsterdamNetherlands1105 AZ
| | - Benedikt Preckel
- Academic Medical Center (AMC) University of AmsterdamDepartment of AnaesthesiologyMeibergdreef 9AmsterdamNetherlands1105 AZ
| | - Jeroen Hermanides
- Academic Medical Center (AMC) University of AmsterdamDepartment of AnaesthesiologyMeibergdreef 9AmsterdamNetherlands1105 AZ
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Sandini M, Ruscic KJ, Ferrone CR, Warshaw AL, Qadan M, Eikermann M, Lillemoe KD, Fernández-del Castillo C. Intraoperative Dexamethasone Decreases Infectious Complications After Pancreaticoduodenectomy and is Associated with Long-Term Survival in Pancreatic Cancer. Ann Surg Oncol 2018; 25:4020-4026. [DOI: 10.1245/s10434-018-6827-5] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Indexed: 01/08/2023]
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Polderman JAW, Farhang‐Razi V, Van Dieren S, Kranke P, DeVries JH, Hollmann MW, Preckel B, Hermanides J. Adverse side effects of dexamethasone in surgical patients. Cochrane Database Syst Rev 2018; 8:CD011940. [PMID: 30152137 PMCID: PMC6513495 DOI: 10.1002/14651858.cd011940.pub2] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND In the perioperative period, dexamethasone is widely and effectively used for prophylaxis of postoperative nausea and vomiting (PONV), for pain management, and to facilitate early discharge after ambulatory surgery.Long-term treatment with steroids has many side effects, such as adrenal insufficiency, increased infection risk, hyperglycaemia, high blood pressure, osteoporosis, and development of diabetes mellitus. However, whether a single steroid load during surgery has negative effects during the postoperative period has not yet been studied. OBJECTIVES To assess the effects of a steroid load of dexamethasone on postoperative systemic or wound infection, delayed wound healing, and blood glucose change in adult surgical patients (with planned subgroup analysis of patients with and without diabetes). SEARCH METHODS We searched MEDLINE, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), in the Cochrane Library, and the Web of Science for relevant articles on 29 January 2018. We searched without language or date restriction two clinical trial registries to identify ongoing studies, and we handsearched the reference lists of relevant publications to identify all eligible trials. SELECTION CRITERIA We searched for randomized controlled trials comparing an incidental steroid load of dexamethasone versus a control intervention for adult patients undergoing surgery. We required that studies include a follow-up of 30 days for proper assessment of the number of postoperative infections, delayed wound healing, and the glycaemic response. DATA COLLECTION AND ANALYSIS Two review authors independently screened studies for eligibility, extracted data from relevant studies, and assessed all included studies for bias. We resolved differences by discussion and pooled included studies in a meta-analysis. We calculated Peto odds ratios (ORs) for dichotomous outcomes and mean differences (MDs) for continuous outcomes. Our primary outcomes were postoperative systemic or wound infection, delayed wound healing, and glycaemic response within 24 hours. We created a funnel plot for the primary outcome postoperative (wound or systemic) infection. We used GRADE to assess the quality of evidence for each outcome. MAIN RESULTS We included in the meta-analysis 38 studies that included adults undergoing a large variety of surgical procedures (i.e. abdominal surgery, cardiac surgery, neurosurgery, and orthopaedic surgery). Age range of participants was 18 to 80 years. There is probably little or no difference in the risk of postoperative (wound or systemic) infection with dexamethasone compared with no treatment, placebo, or active control (ramosetron, ondansetron, or tropisetron) (Peto OR 1.01, 95% confidence interval (CI) 0.80 to 1.27; 4931 participants, 27 studies; I² = 27%; moderate-quality evidence). The effects of dexamethasone on delayed wound healing are unclear because the wide confidence interval includes both meaningful benefit and harm (Peto OR 0.99, 95% CI 0.28 to 3.43; 1072 participants, eight studies; I² = 0%; low-quality evidence). Dexamethasone may produce a mild increase in glucose levels among participants without diabetes during the first 12 hours after surgery (MD 13 mg/dL, 95% CI 6 to 21; 10 studies; 595 participants; I² = 50%; low-quality evidence). We identified two studies reporting on glycaemic response after dexamethasone in participants with diabetes within 24 hours after surgery (MD 32 mg/dL, 95% CI 15 to 49; 74 participants; I² = 0%; very low-quality evidence). AUTHORS' CONCLUSIONS A single dose of dexamethasone probably does not increase the risk for postoperative infection. It is uncertain whether dexamethasone has an effect on delayed wound healing in the general surgical population owing to imprecision in trial results. Participants with increased risk for delayed wound healing (e.g. participants with diabetes, those taking immunosuppressive drugs) were not included in the randomized studies reporting on delayed wound healing included in this meta-analysis; therefore our findings should be extrapolated to the clinical setting with caution. Furthermore, one has to keep in mind that dexamethasone induces a mild increase in glucose. For patients with diabetes, very limited evidence suggests a more pronounced increase in glucose. Whether this influences wound healing in a clinically relevant way remains to be established. Once assessed, the three studies awaiting classification and two that are ongoing may alter the conclusions of this review.
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Affiliation(s)
- Jorinde AW Polderman
- Academic Medical Center (AMC) University of AmsterdamDepartment of AnaesthesiologyMeibergdreef 9AmsterdamNetherlands1105 AZ
| | - Violet Farhang‐Razi
- Academic Medical Center (AMC) University of AmsterdamDepartment of AnaesthesiologyMeibergdreef 9AmsterdamNetherlands1105 AZ
| | - Susan Van Dieren
- Academic Medical Center (AMC) University of AmsterdamDepartment of AnaesthesiologyMeibergdreef 9AmsterdamNetherlands1105 AZ
| | - Peter Kranke
- University of WürzburgDepartment of Anaesthesia and Critical CareOberdürrbacher Str. 6WürzburgGermany97080
| | - J Hans DeVries
- Academic Medical CentreDepartment of Internal MedicinePO Box 22700AmsterdamNetherlands1100 DE
| | - Markus W Hollmann
- Academic Medical Center (AMC) University of AmsterdamDepartment of AnaesthesiologyMeibergdreef 9AmsterdamNetherlands1105 AZ
| | - Benedikt Preckel
- Academic Medical Center (AMC) University of AmsterdamDepartment of AnaesthesiologyMeibergdreef 9AmsterdamNetherlands1105 AZ
| | - Jeroen Hermanides
- Academic Medical Center (AMC) University of AmsterdamDepartment of AnaesthesiologyMeibergdreef 9AmsterdamNetherlands1105 AZ
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Kleif J, Hauge CI, Vilandt J, Gögenur I. Randomized Clinical Trial of Preoperative High-Dose Methylprednisolone on Postoperative Pain at Rest After Laparoscopic Appendectomy. Anesth Analg 2018; 126:1712-1720. [DOI: 10.1213/ane.0000000000002693] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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Kleif J, Gögenur I. Severity classification of the quality of recovery-15 score—An observational study. J Surg Res 2018; 225:101-107. [PMID: 29605019 DOI: 10.1016/j.jss.2017.12.040] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Revised: 12/18/2017] [Accepted: 12/28/2017] [Indexed: 12/23/2022]
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Wasfie T, Tabatabai A, Hedni R, Hollern L, Barber K, Shapiro B. Effect of intra-operative single dose of dexamethasone for control of post-operative nausea and vomiting on the control of glucose levels in diabetic patients. Am J Surg 2018; 215:488-490. [DOI: 10.1016/j.amjsurg.2017.11.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Revised: 11/09/2017] [Accepted: 11/11/2017] [Indexed: 10/18/2022]
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