A retrospective analysis of the use of intravenous dexamethasone for postoperative nausea and vomiting in total joint replacement

Perioperative Dexamethasone Split Between 2 Doses Further Reduced Early Postoperative Nausea and Vomiting Than Single-Dose Dexamethasone: A Randomized Blinded Placebo-Controlled Trial

BACKGROUND

We investigated whether 2 doses of dexamethasone are more effective than a single dose in reducing early postoperative nausea and vomiting (PONV) during total knee arthroplasty (TKA).

METHODS

A total of 150 patients between June 2021 and June 2022 were randomized into 3 groups: 2 doses of normal saline (group A), a single dose of 10 mg dexamethasone before surgery and normal saline after surgery (group B), and 2 doses of 5 mg dexamethasone during the perioperative period (group C). Primary outcomes were incidences and severity of PONV within 24 hours after surgery, the number and consumption of patients requiring morphine and metoclopramine, and visual analog scale scores for nausea and vomiting at 2, 4, 6, and 24 hours after surgery. Blood glucose levels on days 1, 2, and 3 after operation and incidences of surgical site infection (SSI) as well as gastrointestinal bleeding (GIB) within 45 days after operation were compared.

RESULTS

Within 24 hours after operation, the number and consumption of patients requiring morphine and metoclopramide in groups B and C were significantly lower than those in group A. Incidences and severity of PONV in groups B and C were significantly lower than those in group A. And these differences between groups B and C were significant. At 2, 4, 6, and 24 hours after operation, there were significant differences in visual analog scale scores of PONV between groups A and B, A and C, as well as B and C. On postoperative days 1, 2, and 3, there were no significant differences in blood glucose levels among the groups, and there were no incidences of SSI or GIB in any group within 45 days after operation.

CONCLUSION

Dexamethasone significantly reduces PONV within 24 hours after TKA, does not result in significant changes in postoperative blood glucose levels, and does not increase the risk of SSI or GIB, particularly on group C.

REGISTRATION NUMBER

ChiCTR2400088512.

REGISTRATION CENTER

Chinese Clinical Trial Registry (ChiCTR). WEBSITE: www.chictr.org.cn.

Impact of Perioperative Dexamethasone Administration on Infection and Implant Osseointegration in a Preclinical Model of Orthopedic Device-Related Infection

Glucocorticoids may be given prior to major orthopedic surgery to decrease postoperative nausea, vomiting, and pain. Additionally, many orthopedic patients may be on chronic glucocorticoid therapy. The aim of our study was to investigate whether glucocorticoid administration influences Orthopedic-Device-Related Infection (ODRI) in a rat model. Screws colonized with Staphylococcus epidermidis were implanted in the tibia of skeletally mature female Wistar rats. The treated groups received either a single shot of dexamethasone in a short-term risk study, or a daily dose of dexamethasone in a longer-term interference study. In both phases, bone changes in the vicinity of the implant were monitored with microCT. There were no statistically significant differences in bacteriological outcome with or without dexamethasone. In the interference study, new bone formation was statistically higher in the dexamethasone-treated group (p = 0.0005) as revealed by CT and histopathological analysis, although with relatively low direct osseointegration of the implant. In conclusion, dexamethasone does not increase the risk of developing periprosthetic osteolysis or infection in a pre-clinical model of ODRI. Long-term administration of dexamethasone seemed to offer a benefit in terms of new bone formation around the implant, but with low osseointegration.

Efficacy and safety of intraperitoneal dexamethasone on postoperative nausea and vomiting following laparoscopy: study protocol for a systematic review and meta-analysis

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.

Effects of Dexamethasone on Postoperative Glycemic Control in Diabetic Patients Following Primary Total Joint Arthroplasty: A Retrospective Cohort Study

INTRODUCTION

Concerns regarding the effects of dexamethasone on diabetics' glucose control have stymied its use following total joint arthroplasty (TJA). This study aimed to evaluate the effects of two intravenous (IV) perioperative doses of dexamethasone on glucose levels, pain scores, and inpatient opioid consumption following TJA in diabetic patients.

METHODS

A retrospective review of 523 diabetic patients who underwent primary elective THA and 953 diabetic patients who underwent primary elective TKA between May 6, 2020 and December 17, 2021. Patients who received one dose (1D) of perioperative dexamethasone 10 mg IV were compared to patients who received two doses (2D). Primary outcomes included postoperative glucose levels, opioid consumption as morphine milligram equivalences (MMEs), postoperative pain as Verbal Rating Scale (VRS) pain scores, and postoperative complications.

RESULTS

The 2D TKA cohort had significantly greater average and maximum blood glucose levels from 24 to 60 hours compared to the 1D TKA cohort. The 2D THA cohort had significantly greater average blood glucose levels at 24 to 36 hours compared to the 1D THA cohort. However, the 2D TKA group had significantly reduced opioid consumption from 24 to 72 hours and reduced total consumption compared to the 1D TKA group. VRS pain scores did not differ between cohorts for both TKA and THA at any interval.

CONCLUSION

Administration of a second perioperative dose of dexamethasone was associated with increased postoperative blood glucose levels. However, the observed effect on glucose control may not outweigh the clinical benefits of a second perioperative dose of glucocorticoids.

Dexamethasone Is Associated With a Statistically Significant Increase in Postoperative Blood Glucose Levels Following Primary Total Knee Arthroplasty

Background

Dexamethasone has the potential to cause a transient increase in blood glucose levels. Recent evidence has suggested the potential for a linearly increased risk of periprosthetic joint infection beginning at blood glucose levels of ≥115 mg/dL and an optimal cutoff of 137 mg/dL. We designed the following study to determine (1) what percentage of our patients had postoperative day 1 (POD1) glucose levels above 137 mg/dL and (2) if the administration of dexamethasone further increased this risk.

Methods

All primary total knee arthroplasties performed from 1998 to 2021 at our institution were identified and retrospectively reviewed. Patient demographics, dexamethasone administration, and perioperative glucose levels were recorded. Outcomes included POD1 glucose levels, infection rate, and all-cause reoperations and revisions.

Results

The average POD1 glucose level for the entire cohort (n = 5353) was 138.7 mg/dL. The percentage of patients with a glucose level of 137 mg/dL or higher was significantly greater in patients that received dexamethasone (55.2% vs 37.7%; P < .0001). Significantly higher glucose levels were seen with dexamethasone administration in both diabetic (187.7 vs 173.4 mg/dL; P < .0001) and nondiabetic patients (137.7 vs 128.0 mg/dL; P < .0001). Dexamethasone use was associated with a nonstatistically significant increase in infection rates (1.7% vs 1.0%; P = .177).

Conclusions

Administration of dexamethasone is associated with a statistically significant increase in POD1 glucose levels, regardless of diabetic status. Dexamethasone use should continue to be closely monitored given the potential risks of elevated postoperative glucose levels and the potential for periprosthetic infection.

Implementation of a rapid recovery protocol in total knee arthroplasty. A randomized controlled trial

BACKGROUND

Rapid recovery (RP) in total knee arthroplasty may increase the functionality while reducing costs. The aim of this study is to prove the benefits of a rapid recovery program compared to our classic protocol.

PATIENTS AND METHODS

We performed a RCT (NCT03823573) in patients undergoing otal knee arthroplasty. Intervention group (RP protocol) received local infiltration of levo-bupivacaine in the periarticular tissue and supervized ambulation 4-6h after surgery. Control (C) group received a femoral nerve block with levo-bupivacaine, while a drain was used. Ambulation after its removal. All the patients completed an Oxford Knee Score prior to surgery and 6 months after discharge. An ecodoppler to assess the presence of deep vein thrombosis was made one month after discharge. Minimum follow-up was of 6 months.

RESULTS

A total of 175 patients were included in the trial (92 patients in the control group, 83 patients in the RP group). There were no differences in sex, age, implanted prosthesis, hemoglobin drop, need for transfusion, range of motion on discharge (C: 82.6°, RP: 85°) and at the end of the follow-up (C: 105.1, RP: 106.6), Oxford Knee Score improvement (C: 17.5 points; RP: 19.3 points), patient satisfaction or re-admissions at the emergency department (C: 7.6%; RP: 10.8%). Significancy was found on time of ischemia (C: 81.29min; RP: 85.35min; P=0.03), need for morphine shots (C: 19.7%; RP: 38.6%; P=0.007), hospital stay (C: 3.84 days; RP: 2.54 days, P<0.0001) and time until ambulation (C: 2.46 days; RP: 0.23 days; P<0.0001).

CONCLUSION

Rapid recovery protocols can reduce hospital stay without increasing complications or need for re-admission.

Postoperative Infection Risk in Total Joint Arthroplasty After Perioperative IV Corticosteroid Administration: A Systematic Review and Meta-Analysis of Comparative Studies

BACKGROUND

Perioperative corticosteroid administration is associated with reduced postoperative nausea, pain, and enhanced recovery after surgery. However, potential complications including wound and periprosthetic joint infections remain a concern for surgeons after total joint arthroplasty (TJA).

METHODS

A systematic review of the search databases PubMed, Google Scholar, and EMBASE was made in January 2021 to identify comparative studies evaluating infection risk after perioperative corticosteroid administration in TJA. PRISMA guidelines were used for this review. Meta-analysis was used to assess infection risk in accordance with joint and corticosteroid dosing regimen used.

RESULTS

201 studies were returned after initial search strategy, with 29 included for review after application of inclusion and exclusion criteria. Studies were categorized as using low- or high-dose corticosteroid with single or repeat dosing regimens. Single low-dose corticosteroid administration was not associated with an increased risk of infection (P = .4; CI = 0.00-0.00). Single high-dose corticosteroid was not associated with an increased infection risk (P = .3; CI = 0.00-0.01) nor did repeat low-dose regimens result in increased risk of infection (P = .8; CI = -0.02-0.02). Studies assessing repeat high-dosing regimens reported no increased infection, with small numbers of participants included. No significant risk difference in infection risk was noted in hip (P = .59; CI = -0.03-0.02) or knee (P = .2; CI = 0.00-0.01) arthroplasty. Heterogeneity in patient profiles included in studies to date was noted.

CONCLUSION

Use of perioperative corticosteroid in TJA does not appear to be associated with increased risk of postoperative infection in patients with limited comorbidities. Further research is warranted to evaluate postoperative complications after TJA in these at-risk patient populations.

Dexamethasone decreases postoperative opioid and antiemetic use in shoulder arthroplasty patients: a prospective, randomized controlled trial

BACKGROUND

Multimodal pain control can be beneficial in relieving postoperative pain and limiting narcotic use following orthopedic procedures. Additionally, with increasing interest in outpatient arthroplasty procedures, providers have interest in adequate early postoperative pain control and complications. The purpose of this study was to investigate the effect of dexamethasone on pain, postoperative nausea and vomiting, and length of stay following total shoulder arthroplasty (TSA) and reverse total shoulder arthroplasty (RTSA).

METHODS

One hundred twelve patients undergoing TSA or RTSA by a single surgeon were assessed for inclusion in this investigation. We performed a prospective randomized controlled trial to investigate the effect of 10 mg of dexamethasone administered within 90 minutes of surgery. Primary outcome assessed was the average morphine equivalent use over the first 24 hours postsurgery. Secondary outcomes included postoperative visual analog scale (VAS) scores, antiemetic use, postoperative nausea and vomiting, and complications.

RESULTS

A total of 75 patients were included in the final analysis, with 32 patients (42.7%) randomized to the control group and 43 (57.3%) randomized to the dexamethasone group. Body mass index was significantly greater in the control group (33.8 vs. 30.3, P = .014); otherwise, there were no significant demographic differences between groups. Average ondansetron use was significantly lower in the dexamethasone group compared with controls for the 0- to 4-hour interval (0.1 vs. 0.9 mg, respectively, P = .006) and was lower overall for the first 24 hours (0.3 vs. 1.0 mg, P = .025). Differences in VAS scores were significantly lower in the dexamethasone group at all time points (P < .05 for all). The average VAS score over the 24-hour period for the dexamethasone group was also significantly lower than the controls (3 vs. 6, P < .001). Morphine equivalent use was significantly lower in the dexamethasone group compared with controls at 12-16 hours (1.7 vs. 4.0 mg, respectively, P = .004) and at 16-20 hours (1.7 vs. 3.4 mg, respectively, P = .006). When averaged over the first 24 hours, morphine equivalent was also significantly lower in the dexamethasone group (16.1 vs. 25.4 mg, P = .007). There was no significant difference in glucose control or complications between groups.

CONCLUSION

Dexamethasone decreases opioid requirements in the first 24 hours following surgery, provides improved pain control, and decreases antiemetic use following shoulder arthroplasty. Dexamethasone is an important multimodal adjunct for controlling pain and postoperative nausea and vomiting following primary TSA.

Efficacy and safety analysis of dexamethasone-lipiodol emulsion in prevention of post-embolization syndrome after TACE: a retrospective analysis

Background

To investigate the efficacy and safety of dexamethasone-lipiodol emulsion in the prevention of post-embolization syndrome after TACE.

Method

The data of 255 patients who underwent TACE in the interventional department from June 2017 to June 2020 were collected. This is a retrospective assessment of patients who were non-randomly treated with dexamethasone in TACE. The patients were divided into two groups: TACE using lipiodol + chemotherapeutic emulsion group (TACE group, N = 133); TACE using lipiodol + dexamethasone + chemotherapeutic emulsion group (TACE + dexamethasone group, N = 122). Primary study endpoint: incidence of abdominal pain, fever, nausea and vomiting 0–72 h after TACE in both groups. Secondary study endpoints: incidence of infection after TACE in both groups.

Results

Incidence of post-embolization syndrome after TACE (TACE group vs TACE + dexamethasone group): abdominal pain, 55.6% versus 36.1% (P value 0.002); fever, 37.6% versus 13.1% (P value 0.000); nausea, 60.9% versus 41.0% (P value 0.001); vomiting, 48.1% versus 21.3% (P value 0.000). Incidence of infection after TACE (TACE group vs TACE + dexamethasone group): 1.5% versus 2.5% (P value 0.583).

Conclusion

The lipiodol + dexamethasone emulsion can significantly reduce the incidence rate of post-embolization syndrome after TACE, with exact effect and high safety.

The role of perioperative intravenous low-dose dexamethasone in rapid recovery after total knee arthroplasty: a meta-analysis

PURPOSE

The purpose of this meta-analysis was to evaluate the overall safety and effectiveness of perioperative intravenous dexamethasone to facilitate postoperative rehabilitation in patients after total knee arthroplasty (TKA).

METHODS

A comprehensive literature search was performed using the Embase, PubMed, Cochrane Library, and China National Knowledge Infrastructure (CNKI) databases for relevant randomized controlled trials (RCTs) from inception to 2020. Methodological quality of the trials was assessed using the Cochrane Risk of Bias Tool, and the relevant data were extracted using a predefined data extraction form.

RESULTS

Ten RCTs with 1100 knees were included. Our study showed a significant reduction in pain using a postoperative pain visual analog scale (VAS) at 24 hours and 48 hours, total opioid consumption at 24 hours and 48 hours, postoperative nausea and vomiting (PONV), active range of motion (ROM) limitation, and passive ROM limitation at 72 hours in dexamethasone-treated groups compared with controls.

CONCLUSION

Intravenous low-dose dexamethasone is potentially useful in the perioperative setting for reducing postsurgical immediate ROM limitations, pain, opioid consumption, and PONV. There are no data that directly attribute an increase in postoperative complications to intravenous dexamethasone. More high-quality studies are necessary to draw these conclusions.

Impact of Dexamethasone on Length of Stay and Early Pain Control in Direct Anterior Approach Total Hip Arthroplasty With Neuraxial Anesthesia

BACKGROUND

Dexamethasone has been shown to reduce postoperative pain and opioid consumption for total joint arthroplasty patients; however, its impact on patients who received neuraxial anesthesia (NA) is not well described. We examined the impact of perioperative dexamethasone on outcomes for patients undergoing direct anterior approach total hip arthroplasty (THA) under NA.

METHODS

A retrospective review was conducted for 376 THA patients from a single institution. Univariate analysis was used to compare postoperative outcomes for 164 THA patients receiving dexamethasone compared to 212 who did not receive dexamethasone.

RESULTS

No differences in age, gender, body mass index, or American Society of Anesthesiologists (ASA) Score were observed between the groups. Patients receiving perioperative dexamethasone reported statistically significantly lower postanesthesia care unit (PACU) pain numeric rating scale (Dexamethasone 1.6 vs No dexamethasone 2.3, P = .014) and received lower PACU morphine milligram equivalents (MME) (Dexamethasone 8.57 vs No dexamethasone 11.44, P < .001). Patients receiving dexamethasone had significantly shorter LOS (Dexamethasone 29.40 vs No dexamethasone 35.26 hrs., P < .001).

CONCLUSION

Perioperative dexamethasone is associated with decreased postoperative pain and narcotic consumption, and shorter length of stay for patients undergoing primary direct anterior approach THA with NA.

"Outpatient"-Same-calendar-day Discharge Hip and Knee Arthroplasty

As the length of stay for hip and knee arthroplasty has decreased over the years, "outpatient," or same-calendar-day discharge has become increasingly common. Outpatient arthroplasty offers several possible benefits over traditional inpatient arthroplasty, including potential for cost reductions, faster rehabilitation, improved patient satisfaction, and reduced reliance on hospital resources. Despite these possible benefits, concerns remain over feasibility and patient safety. To date, multiple studies have demonstrated that, for select patients, "outpatient" hip and knee arthroplasty can be safe and effective and yield complication and readmission rates similar to inpatient procedures at potentially significant cost savings. Successful outpatient pathways have emphasized careful patient selection, detailed patient education, enlistment of strong social support, utilization of multimodal analgesia and strong "episode ownership," and involvement on behalf of the surgical team. As outpatient hip and knee arthroplasty becomes increasingly common, continued investigation into all aspects of the surgical episode is warranted.

Efficacy of Preoperative Usage of Dexamethasone in Diabetic Patients Undergoing Total Hip or Knee Arthroplasty for Control of Nausea and Vomiting

BACKGROUND

Dexamethasone has been used in surgical patients to decrease nausea, vomiting, and postoperative pain. However, it is not well studied how much dexamethasone complicates glucose control in diabetic patients and whether this leads to poor surgical outcomes.

METHODS

We analyzed 256 diabetic patients who underwent elective hip and knee arthroplasty and evaluated the groups that received dexamethasone intraoperatively (201 patients), those who received dexamethasone postoperatively (237 patients), and those who did not receive the steroid intraoperatively (55 patients) and postoperatively (19 patients).

RESULTS

256 diabetic patients were included in the study. The mean age of the group was 68.7 (SD ± 9-10) years. Patients were divided into 123 males (48%) and 133 females (52%). 174 (78%) patients had a total knee replacement operation, and 82 (32%) patients had total hip replacement operation. The mean hemoglobin A1c was 6.728 (SD ± 0.99). The mean ASA score was 2.86 (SD ± 0.38). 201 (78.5%) patients received preoperative or intraoperative dexamethasone, and 237 (92.6%) patients received it postoperatively. The mean blood glucose for all patients raised from 131.9 to 172.2 mg/dL (P = .012) postoperatively, 206.1 mg/dL in the first 24 hours, and 146.2 mg/dL (P = .39) in the second postoperative day. The change was significant in patients who had poorly controlled diabetes (P < .01) preoperatively. There was no significant difference in our study regarding dexamethasone use and effect on postoperative nausea (P = 1.0) and vomiting (P = .52). There was an improvement in pain scores in the patients who received dexamethasone postoperatively which was statistically significant (P = .054).

CONCLUSION

Dexamethasone use in diabetic patients for control of postoperative nausea and vomiting in those undergoing elective total knee and hip arthroplasty had a negative impact on glycemic control specifically in those with poorly controlled diabetes and should be avoided.

[Risk factors for nausea and vomiting after adolescent idiopathic scoliosis surgery]

OBJECTIVE

To explore risk factors for postoperative nausea and vomiting (PONV) that requires intervention with medications during adolescent idiopathic scoliosis (AIS) surgery.

METHODS

We analyzed the data of 986 patients with AIS (including 156 male and 830 female patients) undergoing scoliosis surgery through a posterior approach between December, 2012 and January, 2016 in Nanjing Drum Tower Hospital. The data were collected from the patients including ASA grade, body mass index (BMI), Cobb angle, preoperative respiratory and cardiovascular diseases, operation time, type of anesthesia, quantity of intraoperative liquid infusion, blood loss, urine volume, the lowest MAP and CVP, intraoperative fentanyl consumption, and intraoperative administration of dexmedetomidine, dexamethasone, ondansetran and droperidol. The incidence of PONV in 48 h following the surgery, hemoglobin variation after operation (ΔHb), postoperative analgesia, times of use and types of antiemetic drugs, and postoperative hospital stay were recorded for all the patients. The potential risk factors of PONV within 48 h were analyzed using univariate analysis and multivariate logistic regression.

RESULTS

Of the 986 patients analyzed, 151 (15.3%) experienced PONV within 48 h following surgeries for AIS. Multivariate logistic regression analysis suggested that an high intraoperative fentanyl dose (> 0.65 mg; OR=9.303, 95% CI: 2.373-8.622, P < 0.001), an obvious ΔHb (> 28.5 g/L; OR=1.107, 95% CI: 1.060-1.157, P < 0.001), and postoperative analgesia with fentanyl (OR=11.671, 95% CI: 2.381-11.284, P < 0.001) were risk factors for PONV. Intraoperative administration of dexmedetomidine (OR=0.027, 95% CI: 0.006-0.123, P=0.002) and dexamethasone combined with ondansetron (OR=0.241, 95%CI: 0.066-0.886, P=0.032) were protective factors against PONV.

CONCLUSIONS

A high-dose intraoperative fentanyl consumption, a marked ΔHb, and postoperative analgesia with fentanyl are risk factors for PONV while intraoperative administration of dexmedetomidine and dexamethasone combined with ondansetron are protective factors against PONV following surgeries for AIS.