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Lehtinen V, Salli M, Pyötsiä K, Toivari M, Snäll J. Primary reconstruction of combined orbital and zygomatic complex fractures with patient-specific milled titanium implants - A retrospective study. J Craniomaxillofac Surg 2022; 50:S1010-5182(22)00133-0. [PMID: 36244892 DOI: 10.1016/j.jcms.2022.09.006] [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: 08/27/2021] [Revised: 03/08/2022] [Accepted: 09/19/2022] [Indexed: 11/08/2022] Open
Abstract
The aim of this retrospective study was to compare mid-facial symmetry and clinical outcomes between patients treated with patient-specific and standard implants in primary fracture reconstructions of combined orbital and zygomaticomaxillary complex fractures. Patients who underwent primary reconstruction of orbital and zygomaticomaxillary complex fractures during the study period were identified and background and clinical variables and computed tomography images were collected from patient records. Zygomaticomaxillary complex dislocation and orbital volume were measured from pre- and postoperative images and compared between groups. Out of 165 primary orbital reconstructions, eight patients treated with patient-specific and 12 patients treated with standard implants were identified with mean follow-up time of was 110 days and 121 days, respectively. Postoperative orbital volume difference was similar between groups (0.2 ml for patient-specific vs 0.3 ml for standard implants, p = 0.942) despite larger preoperative difference in patient-specific implant group (2.1 ml vs 1,5 ml, p = 0.428), although no statistical differences were obtained in symmetricity or accuracy between the reconstruction groups. Within the limitations of the study it seems that patient-specific implants are a viable option for primary reconstructions of combined zygomaticomaxillary complex and orbital fractures, because with patient-specific implants at least as symmetrical results as with standard implants can be obtained in a single surgery.
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Affiliation(s)
- Valtteri Lehtinen
- Department of Oral and Maxillofacial Diseases, University of Helsinki and Helsinki University Hospital, Helsinki, Haartmaninkatu 4E, PL 220, 00029 HUS, Helsinki, Finland.
| | - Malla Salli
- Department of Oral and Maxillofacial Diseases, University of Helsinki and Helsinki University Hospital, Helsinki, Haartmaninkatu 4E, PL 220, 00029 HUS, Helsinki, Finland.
| | - Krista Pyötsiä
- Department of Oral and Maxillofacial Diseases, University of Helsinki and Helsinki University Hospital, Helsinki, Haartmaninkatu 4E, PL 220, 00029 HUS, Helsinki, Finland.
| | - Miika Toivari
- Department of Oral and Maxillofacial Diseases, University of Helsinki and Helsinki University Hospital, Helsinki, Haartmaninkatu 4E, PL 220, 00029 HUS, Helsinki, Finland.
| | - Johanna Snäll
- Department of Oral and Maxillofacial Diseases, University of Helsinki and Helsinki University Hospital, Helsinki, Haartmaninkatu 4E, PL 220, 00029 HUS, Helsinki, Finland.
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Effect of Perioperative Systemic Dexamethasone on Pain, Edema, and Trismus in Mandibular Fracture Surgery: A Randomized Trial. J Craniofac Surg 2021; 32:2611-2614. [PMID: 34727465 DOI: 10.1097/scs.0000000000007775] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
ABSTRACT The authors' aim was to evaluate the effect of perioperative systemic dexamethasone (DXM) administration on postoperative pain, edema, and trismus in mandibular fracture patients. The authors conducted a prospective randomized study of 45 patients with one or 2 noncomminuted fractures of the dentate part of the mandible. All patients underwent surgery for intraoral miniplate fixation. Patients in the study group were given a total of 30 mg DXM, while patients in the control group received neither DXM nor placebo. Only paracetamol and opioids were served as analgesics. Pain severity was assessed using the visual analog scale. The effect in facial swelling was measured in centimeters and analyzed as percentage change. Trismus was evaluated as the difference in maximal mouth opening by measuring interincisal distance in millimeters. The Mann-Whitney U test was applied to determine the statistical significance of differences between the groups. Thirty-four patients were included in the statistical analysis. The visual analog scale score was significantly lower in the study group than in the control group at 18 hours postoperatively (P = 0.033). Significant differences in edema or trismus were not found postoperatively between the DXM and control groups. In conclusion, perioperative DXM decreases postoperative pain in mandibular fracture patients when nonsteroidal anti-inflammatory drugs are not used, but it does not seem to be effective in reducing edema or trismus.
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Mohd Daut FN, Seevaunnamtum SP, Nik Mohamad NA, Che Omar S, Wan Hassan WMN. Granisetron vs. Granisetron and Dexamethasone on The Reduction of Postoperative Nausea and Vomiting (PONV) After Caesarean Section With Intrathecal Morphine: A Randomised Controlled Trial. EGYPTIAN JOURNAL OF ANAESTHESIA 2021. [DOI: 10.1080/11101849.2021.1916860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Affiliation(s)
- FN Mohd Daut
- Department of Anesthesiology & Intensive Care, School of Medical Sciences, Health Campus, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
- Hospital Universiti Sains Malaysia, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
| | - SP Seevaunnamtum
- Department of Anesthesiology & Intensive Care, School of Medical Sciences, Health Campus, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
- Hospital Universiti Sains Malaysia, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
| | - NA Nik Mohamad
- Department of Anesthesiology & Intensive Care, School of Medical Sciences, Health Campus, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
- Hospital Universiti Sains Malaysia, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
| | - S Che Omar
- Department of Anesthesiology & Intensive Care, School of Medical Sciences, Health Campus, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
- Hospital Universiti Sains Malaysia, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
| | - WMN Wan Hassan
- Department of Anesthesiology & Intensive Care, School of Medical Sciences, Health Campus, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
- Hospital Universiti Sains Malaysia, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
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Singh AK, Dhungel S, Bhattarai K, Roychoudhury A. Do the Benefits of Systemic Corticosteroids Outweigh Adverse Effects During Maxillofacial Trauma Surgery? A Systematic Review and Meta-Analysis. J Oral Maxillofac Surg 2021; 79:1530.e1-1530.e21. [PMID: 33745861 DOI: 10.1016/j.joms.2021.02.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 02/01/2021] [Accepted: 02/02/2021] [Indexed: 01/08/2023]
Abstract
PURPOSE Perioperative systemic corticosteroids are widely used in maxillofacial trauma surgery to prevent postoperative complications, but potentially perceived benefits are speculative rather than evidence-based. The purpose of our systematic review and meta-analysis was to assess the effects of perioperative systemic corticosteroids on clinically significant outcomes in patients undergoing maxillofacial trauma surgery. METHODS We searched Medline, Embase, CENTRAL, Clinical trial registry, and grey literature as well as references of included trials. Our primary outcomes were facial edema and pain after the surgery. Our secondary outcomes were postoperative nausea and vomiting, neurosensory disturbance, functional recovery, wound infections, and other adverse events. RESULTS Of the 94 trials retrieved, 13 were included (n = 652). Perioperative steroid use was associated with reduced pain and facial edema. We observed a decrease in postoperative nausea and vomiting with the use of systemic corticosteroids (n = 184, OR = 0.53, [0.28, 1.02], I2 = 0%). Four trials reported infections and impaired wound healing associated with steroids (n = 160. OR = 3.37, [1.43. 7.94], I2 = 2%). The 13 trials had an unclear risk of bias. CONCLUSIONS Systemic corticosteroids reduced facial edema and postoperative pain, but impaired wound healing was also reported. The use of systemic steroids in maxillofacial trauma surgery is thus supported only by weak evidence and further research is advocated.
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Affiliation(s)
- Ashutosh Kumar Singh
- Associate Professor, Department of Oral and Maxillofacial Surgery, College of Medical Sciences Teaching Hospital, Bharatpur, Nepal.
| | - Safal Dhungel
- Assistant Professor, Department of Oral and Maxillofacial Surgery, College of Medical Sciences Teaching Hospital, Bharatpur, Nepal
| | - Kushal Bhattarai
- Assistant Professor, Department of Biochemistry, College of Medical Sciences Teaching Hospital, Bharatpur, Nepal
| | - Ajoy Roychoudhury
- Professor and HOD, Department of Oral and Maxillofacial Surgery, All India Institute of Medical Sciences, New Delhi, India
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Chen YT, Cheong DCF, Hung SY, Kao HK, Tsao CK. The "Safe Index" Considering Body Surface Area for Prolonged Dexamethasone Regimen in Airway Control After Head and Neck Microsurgical Reconstruction. Ann Plast Surg 2021; 86:S84-S90. [PMID: 33438957 DOI: 10.1097/sap.0000000000002660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Dexamethasone (Dexa) is frequently administrated to patients receiving head and neck microsurgical reconstruction with nasotracheal intubation postoperatively for airway control. Infection is the greatest concern when prolonging the treatment course. We aimed to find out the relationship between flap infection and the safe dose of Dexa. MATERIALS AND METHODS A retrospective review of enrolling total 156 patients underwent microsurgical free flap reconstruction for head and neck cancers with nasotracheal intubation from December 2015 to December 2016 was conducted. Among them, 139 patients had received prolonged Dexa treatment course (>2 days). Safe index was then defined as the total amount of used Dexa (in milligrams) over body weight (in kilograms), body mass index (in kilograms per square meter) and body surface area (BSA, in square meter). Statistics were performed for the cutoff level of the safe index and to find out the independent risk factors. RESULTS The cutoff level of the safe index was 0.76 for body weight group, 2.28 (10-3 m2) for body mass index group, and 33.84 mg/m2 for BSA group. Safe index for BSA group also outweighed other risk factors in multivariant analysis (odds ratio = 6.242, 95% confidence interval = 2.292-17.002, P = 0.000), which is the only independent risk factors for flap infection in our cohort. CONCLUSIONS Throughout our study, the "safe index" helps clinician easily predict flap infection risk when using Dexa as the medication for airway control after head and neck microsurgical reconstruction.
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Affiliation(s)
- Yu-Ting Chen
- From the Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College, Chang Gung University, Taipei, Taiwan
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Golob Deeb J, Farris E, Reichert A, Carrico CK, Deeb GR. Effect of postoperative steroids on clinical outcomes and radiographic findings of horizontal alveolar ridge augmentation: A retrospective study. J Periodontol 2019; 91:917-924. [PMID: 31811744 DOI: 10.1002/jper.19-0198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 07/17/2019] [Accepted: 09/23/2019] [Indexed: 11/10/2022]
Abstract
BACKGROUND The purpose of the study was to investigate if the prescription of oral postoperative steroids has an effect on clinical outcomes of horizontal ridge augmentation including implant placement and characteristics of the grafted bone. METHODS A retrospective chart review of 73 horizontal ridge augmentation cases was completed to assess the clinical outcomes, 53 of those cases were further assessed radiographically. Information was gathered regarding surgical technique, grafting materials, postoperative healing, medications used postoperatively, bone growth, and density changes as quantified on a cone-beam computed tomography (CBCT) scan. Statistical analysis was completed to identify whether the use of postoperative oral steroids altered outcomes. RESULTS Steroids were used postoperatively following various horizontal ridge augmentation procedures. The use of tenting screws and resorbable membranes with a combination of osseous allograft and xenograft was used in 73 cases, 53 of which had preoperative and postoperative CBCT scans. Graft exposure occurred in five of the cases (9%), with the majority (n = 4) among those with postoperative steroids, but this was not statistically significant (P-value = 0.6510). Use of steroids was also not significantly associated with the number of courses of antibiotics (P-value > 0.05), but it was significantly associated with increased number of postoperative visits (P-value < 0.05). Among the subset for radiographic analysis (n = 53), there were significant clinical and radiographic dimensional changes in alveolar ridge width with an average horizontal bone gain of 3.6 mm. There were no statistically significant differences found in radiographic linear bone gain or clinical outcomes with the addition of steroids. A marginally statistically significant in the density of grafted bone was found with the addition of steroids (P-value > 0.05). CONCLUSION The prescription of postoperative steroids did not make a significant difference in clinical outcomes, success of implant placement or on radiographic assessment of grafted sites following horizontal alveolar ridge augmentation.
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Affiliation(s)
- Janina Golob Deeb
- Department of Periodontics, School of Dentistry, Virginia Commonwealth University, Richmond, VA
| | - Emily Farris
- Department of Periodontics, School of Dentistry, Virginia Commonwealth University, Richmond, VA
| | - Amy Reichert
- Department of Periodontics, School of Dentistry, Virginia Commonwealth University, Richmond, VA
| | - Caroline K Carrico
- Department of Dental Public Health and Policy, Oral Health Research Core, Virginia Commonwealth University, Richmond, VA
| | - George R Deeb
- Department of Oral and Maxillofacial Surgery, School of Dentistry, Virginia Commonwealth University, Richmond, VA
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The Effect of Dexamethasone on Pain Severity After Zygomatic Complex Fractures. J Craniofac Surg 2019; 30:742-745. [DOI: 10.1097/scs.0000000000005188] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Otrocka-Domagała I, Paździor-Czapula K, Gesek M. Dexamethasone-induced impairment of post-injury skeletal muscle regeneration. BMC Vet Res 2019; 15:56. [PMID: 30744624 PMCID: PMC6371463 DOI: 10.1186/s12917-019-1804-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 01/30/2019] [Indexed: 12/14/2022] Open
Abstract
Background Due to the routine use of dexamethasone (DEX) in veterinary and human medicine and its negative impact on the rate of wound healing and skeletal muscle condition, we decided to investigate the effect of DEX on the inflammatory and repair phases of skeletal muscle regeneration. In this study, a porcine skeletal muscle injury model was used. The animals were divided into non-treated and DEX-treated (0.2 mg/kg/day) groups. On the 15th day of DEX administration, bupivacaine hydrochloride-induced muscle injury was performed, and the animals were sacrificed in subsequent days. Regeneration was assessed by histopathology and immunohistochemistry. In the inflammatory phase, the presence and degree of extravasation, necrosis and inflammation were evaluated, while in the repair phase, the numbers of muscle precursor cells (MPCs), myotubes and young myofibres were estimated. Results In the inflammatory phase, DEX increased the severity and prolonged extravasation, prolonged necrosis and inflammation at the site of the muscle injury. In the repair phase, DEX delayed and prolonged MPC presence, impaired and prolonged myotube formation, and delayed young myofibre formation. Furthermore, DEX markedly affected the kinetics of the parameters of the inflammatory phase of the skeletal muscle regeneration more than that of the repair phase. Conclusions DEX impairment of the inflammatory and repair phases of the skeletal muscle regeneration was proven for the first time. The drug appears to affect the inflammatory phase more than the repair phase of regeneration. In light of our results, the possibility of reduction of the regenerative capacity of skeletal muscles should be considered during DEX therapy, and its use should be based on risk–benefit assessment.
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Affiliation(s)
- Iwona Otrocka-Domagała
- Department of Pathological Anatomy, Faculty of Veterinary Medicine, University of Warmia and Mazury, Oczapowskiego Street 13, 10-719, Olsztyn, Poland.
| | - Katarzyna Paździor-Czapula
- Department of Pathological Anatomy, Faculty of Veterinary Medicine, University of Warmia and Mazury, Oczapowskiego Street 13, 10-719, Olsztyn, Poland
| | - Michał Gesek
- Department of Pathological Anatomy, Faculty of Veterinary Medicine, University of Warmia and Mazury, Oczapowskiego Street 13, 10-719, Olsztyn, Poland
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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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Haapanen A, Thorén H, Apajalahti S, Suominen A, Snäll J. Neurosensory recovery after trauma to the orbital floor: a prospective trial with dexamethasone. Br J Oral Maxillofac Surg 2018; 56:810-813. [DOI: 10.1016/j.bjoms.2018.08.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 08/31/2018] [Indexed: 10/28/2022]
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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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More Harm Than Benefit of Perioperative Dexamethasone on Recovery Following Reconstructive Head and Neck Cancer Surgery: A Prospective Double-Blind Randomized Trial. J Oral Maxillofac Surg 2018; 76:2425-2432. [PMID: 29864432 DOI: 10.1016/j.joms.2018.05.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Accepted: 05/05/2018] [Indexed: 01/08/2023]
Abstract
PURPOSE Prospective studies on the effect of dexamethasone after microvascular reconstructive head and neck surgery are sparse despite the widespread use of dexamethasone in this setting. The aim of this study was to clarify whether perioperative use of dexamethasone would improve the quality and speed of recovery. The authors hypothesized that dexamethasone would enhance recovery and diminish pain and nausea. MATERIALS AND METHODS Ninety-three patients with oropharyngeal cancer and microvascular reconstruction were included in this prospective double-blinded randomized controlled trial. Patients in the study group (n = 51) received dexamethasone 60 mg over 3 perioperative days; 42 patients did not receive dexamethasone and served as controls. Patient rehabilitation, postoperative opioid and insulin consumption, postoperative nausea and vomiting (PONV), and C-reactive protein (CRP), leukocyte, and lactate levels were recorded. RESULTS There was significantly less pain in the study group (P = .030) and the total oxycodone dose for 5 days postoperatively was lower (P = .040). Dexamethasone did not significantly lessen PONV for 5 days postoperatively (P > .05). There were no differences between groups in intensive care unit or hospital stay or in other clinical measures of recovery. Patients receiving dexamethasone required significantly more insulin compared with patients in the control group (P < .001). Lactate and leukocyte levels were significantly higher (P < .001) and CRP levels were significantly lower in the study group. CONCLUSION The only benefit of perioperative dexamethasone use was lower total oxycodone dose; however, the disadvantages were greater. Because dexamethasone can have adverse effects on the postoperative course, routine use of dexamethasone as a pain or nausea medication during reconstructive head and neck cancer surgery is not recommended.
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Snäll J, Törnwall J, Suominen AL, Thorén H. Behavior of C-reactive protein in association with surgery of facial fracture and the influence of dexamethasone. Oral Maxillofac Surg 2018; 22:129-134. [PMID: 29335791 DOI: 10.1007/s10006-018-0678-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Accepted: 01/09/2018] [Indexed: 06/07/2023]
Abstract
PURPOSE To clarify pre- and postoperative C-reactive protein (CRP) levels in patients with facial fractures and to investigate the influence of perioperatively administered dexamethasone on postoperative CRP levels. PATIENTS AND METHODS Facial fracture patients were randomized to receive perioperatively a total dose of 30 mg of dexamethasone (Oradexon®), whereas patients in the control group received no glucocorticoid. The analysis included patients who had CRP measured pre- and postoperatively. RESULTS A total of 73 adult patients with facial fractures were included in the final analysis. Mean CRP level was elevated preoperatively and the level increased further after surgery. However, postoperative CRP rise was significantly impeded by dexamethasone (p < 0.001), regardless of gender, age, treatment delay, site of fracture, surgical approach, and duration of surgery. CRP rise halved on the 1st postoperative day when dexamethasone was used. In addition, dexamethasone resulted in a CRP decrease on the 2nd postoperative day, whereas the CRP rise continued in the control group. CONCLUSIONS CRP rise is a normal body response after facial fracture and surgery that can be markedly reduced with dexamethasone. CRP changes should be considered with caution if perioperative dexamethasone is used.
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Affiliation(s)
- Johanna Snäll
- Department of Oral and Maxillofacial Diseases, University of Helsinki and Helsinki University Hospital, FI-00029, Helsinki, Finland.
| | - Jyrki Törnwall
- Department of Oral and Maxillofacial Diseases, University of Helsinki and Helsinki University Hospital, FI-00029, Helsinki, Finland
| | - Anna Liisa Suominen
- University of Eastern Finland, Institute of Dentistry, Kuopio, Finland
- Department of Oral and Maxillofacial Surgery, Kuopio University Hospital, Kuopio, Finland
| | - Hanna Thorén
- Department of Oral and Maxillofacial Surgery, Institute of Dentistry, University of Turku, Turku, Finland
- Department of Oral and Maxillofacial Diseases, Turku University Hospital, Turku, Finland
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Haapanen A, Thorén H, Törnwall J, Suominen A, Snäll J. Postoperative nausea and vomiting in facial fracture patients: A Randomized and controlled trial on the effect of dexamethasone. Int J Oral Maxillofac Surg 2017; 46:1267-1270. [DOI: 10.1016/j.ijom.2017.03.026] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Revised: 11/12/2016] [Accepted: 03/22/2017] [Indexed: 11/25/2022]
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Kormi E, Snäll J, Koivusalo AM, Suominen AL, Thorén H, Törnwall J. Analgesic Effect of Perioperative Systemic Dexamethasone on Blowout Fracture Surgery. J Oral Maxillofac Surg 2017; 75:1232-1237. [DOI: 10.1016/j.joms.2016.09.026] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Revised: 09/18/2016] [Accepted: 09/18/2016] [Indexed: 10/20/2022]
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Snäll J, Törnwall J, Suominen AL, Thorén H. Postoperative leukocyte changes in facial fracture patients: a randomized prospective study with short-term dexamethasone. Oral Maxillofac Surg 2017; 21:241-246. [PMID: 28386783 DOI: 10.1007/s10006-017-0623-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Accepted: 03/29/2017] [Indexed: 06/07/2023]
Abstract
PURPOSE We investigated leukocyte changes in facial fracture patients undergoing surgery. Of specific interest was the effect of perioperative dexamethasone on leukocyte changes. METHODS Facial fracture patients were randomized to receive perioperatively a total dose of 30 mg of dexamethasone, whereas patients in the control group received no glucocorticoid. All patients received antibiotics until postoperative days 7-10. Leukocyte count was measured on postoperative days 1 and 2. Clinical infections were observed during the follow-up. RESULTS A total of 110 adult patients were included in the study. Postoperative leukocytosis was found in 91.2% of patients receiving dexamethasone and in 67.9% of controls. Dexamethasone was associated strongly with leukocyte rise (p < 0.001) on both postoperative days. Transoral surgery and younger age (≤40 years) showed significant associations with leukocytosis on the first postoperative day (p = 0.002). In regression analyses, dexamethasone associated with leukocytosis most significantly (p < 0.001). No association was found with infections. CONCLUSIONS Dexamethasone use was the most significant predictor of leukocyte rise. As a drug response, perioperative dexamethasone caused sixfold postoperative leukocytosis. High-dose dexamethasone-induced leukocytosis may confuse the clinical decision-making especially in assessment of early infections.
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Affiliation(s)
- Johanna Snäll
- Department of Oral and Maxillofacial Diseases, University of Helsinki and Helsinki University Hospital, 00029, Helsinki, Finland.
| | - Jyrki Törnwall
- Department of Oral and Maxillofacial Diseases, University of Helsinki and Helsinki University Hospital, 00029, Helsinki, Finland
| | - Anna Liisa Suominen
- Institute of Dentistry, University of Eastern Finland, Kuopio, Finland
- Department of Oral and Maxillofacial Surgery, Kuopio University Hospital, Kuopio, Finland
| | - Hanna Thorén
- Department of Oral and Maxillofacial Diseases, University of Helsinki and Helsinki University Hospital, 00029, Helsinki, Finland
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Kainulainen S, Törnwall J, Koivusalo A, Suominen A, Lassus P. Dexamethasone in head and neck cancer patients with microvascular reconstruction: No benefit, more complications. Oral Oncol 2017; 65:45-50. [DOI: 10.1016/j.oraloncology.2016.12.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Revised: 11/29/2016] [Accepted: 12/10/2016] [Indexed: 11/25/2022]
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Surgical treatment of unilateral zygomaticomaxillary complex fractures: A 7-year observational study assessing treatment outcome in 153 cases. J Craniomaxillofac Surg 2016; 44:1859-1865. [PMID: 27733307 DOI: 10.1016/j.jcms.2016.09.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Revised: 07/27/2016] [Accepted: 09/02/2016] [Indexed: 01/09/2023] Open
Abstract
This study investigates treatment outcome in zygomaticomaxillary complex (ZMC) fracture repair. METHODS The medical records and CT-images of patients that received treatment for a unilateral ZMC fracture in 2005-2011 were studied. ZMC fractures were categorised as incomplete (type A), tetrapod (type B) or comminuted (type C). The incidence of sequelae, wound infection and secondary surgical interventions was analysed per fracture category. RESULTS A total of 153 patients were treated in the selected period. Persisting sensory disturbances in the area innervated by the infraorbital nerve were observed in 50 cases (37%), facial asymmetry in 19 cases (14%), enophthalmos in 10 cases (7%) and persisting diplopia in 9 cases (7%). Wound infection occurred in 6 cases (4%). Secondary surgical procedures of the ZMC, orbital floor, and/or extraocular muscles were performed in 14 cases (9%). C-type fractures were associated with more secondary corrections for ZMC malreduction (12%, p = 0.03), more secondary reconstructions of the orbital floor (10%, p < 0.01), and more functional corrections of diplopia by extraocular muscle correction (5%, p = 0.02). CONCLUSION Treatment outcome in C-type ZMC fractures is less favourable than treatment outcome in A-type and B-type fractures. Intraoperative imaging, surgical navigation devices and 3D-planning software may improve treatment outcome in C-type ZMC fractures.
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A Survey of the Use of Perioperative Glucocorticoids in Oral and Maxillofacial Surgery. J Oral Maxillofac Surg 2016; 74:1548-51. [DOI: 10.1016/j.joms.2016.02.027] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Revised: 02/25/2016] [Accepted: 02/25/2016] [Indexed: 11/20/2022]
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Snäll J, Apajalahti S, Suominen AL, Törnwall J, Thorén H. Influence of perioperative dexamethasone on delayed union in mandibular fractures: A clinical and radiological study. Med Oral Patol Oral Cir Bucal 2015; 20:e621-6. [PMID: 26241455 PMCID: PMC4598933 DOI: 10.4317/medoral.20553] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Accepted: 06/18/2015] [Indexed: 11/05/2022] Open
Abstract
Background The aim was to clarify the occurrence of delayed union after surgical treatment of mandibular fracture and investigate whether an association exists between perioperative use of dexamethasone and delayed union. Material and Methods Thirty-seven patients were included in a prospective randomized study. Of these patients, 19 (51.4%) were randomized to receive a total dose of 30 mg of dexamethasone and 18 (48.6%) served as controls. Patients underwent clinical and radiological investigation immediately, one month, three months and six months postoperatively. Radiographs were evaluated by an experienced, blinded senior oral radiologist. Results Delayed fracture union was found in 9 patients (24.3%). It was associated significantly with angle fractures (p=0.012). Delayed union occurred more frequently in patients who received dexamethasone (36.8%) than in those who did not (11.1%) (p=0.068). The association of infection with delayed union was significant (p=0.027). Moreover, dexamethasone was significantly (p=0.019) associated with delayed fracture union with concomitant infection. Gender, age group, smoking habit, treatment delay and duration of surgery were not associated with delayed union. Conclusions Infection was associated with delayed union. Short-term high-dose dexamethasone predisposed to complicated fracture union, especially in patients with angle fractures. The relationship between dexamethasone and delayed bone healing without infection remains unresolved. Key words:Mandibular, radiology, fracture union, dexamethasone.
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Affiliation(s)
- Johanna Snäll
- Department of Oral and Maxillofacial Diseases, Helsinki University Central Hospital, P.O. Box 293, HUCH, Finland,
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