Efficacy of dexamethasone for reducing postoperative nausea and vomiting and analgesic requirements after thyroidectomy

Pharmacologic interventions for postoperative nausea and vomiting after thyroidectomy: A systematic review and network meta-analysis

Objective

To determine the effectiveness of pharmacologic interventions for preventing postoperative nausea and vomiting (PONV) in patients undergoing thyroidectomy.

Design

Systematic review and network meta-analysis (NMA).

Data sources

MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and Google Scholar.

Eligibility criteria, participants, and interventions

Randomized clinical trials that investigated the efficacy of pharmacologic interventions in preventing PONV in patients undergoing thyroidectomy were included. The primary endpoints were the incidences of postoperative nausea and vomiting (PONV), postoperative nausea (PON), postoperative vomiting (POV), use of rescue antiemetics, and incidence of complete response in the overall postoperative phases. The secondary endpoints were the same parameters assessed in the early, middle, and late postoperative phases. The surface under the cumulative ranking curve (SUCRA) values and rankograms were used to present the hierarchy of pharmacologic interventions.

Results

Twenty-six studies (n = 3,467 patients) that investigated 17 different pharmacologic interventions were included. According to the SUCRA values, the incidence of PONV among the overall postoperative phases was lowest with propofol alone (16.1%), followed by palonosetron (27.5%), and with tropisetron (28.7%). The incidence of PON among the overall postoperative phases was lowest with propofol alone (11.8%), followed by tropisetron and propofol combination (14%), and ramosetron and dexamethasone combination (18.0%). The incidence of POV among the overall postoperative phases was lowest with tropisetron and propofol combination (2.2%), followed by ramosetron and dexamethasone combination (23.2%), and tropisetron alone (37.3%). The least usage of rescue antiemetics among the overall postoperative phases and the highest complete response was observed with tropisetron and propofol combination (3.9% and 96.6%, respectively).

Conclusion

Propofol and tropisetron alone and in combination, and the ramosetron and dexamethasone combination effectively prevented PONV, PON, POV in patients undergoing thyroidectomy, with some heterogeneity observed in this NMA of full-text reports. Their use minimized the need for rescue antiemetics and enhanced the complete response.

Trial registration number

CRD42018100002.

The effect of dexamethasone on pain control after thyroid surgery: a meta-analysis of randomized controlled trials

INTRODUCTION

The effect of dexamethasone on postoperative pain after thyroid surgery remains controversial. We conduct a systematic review and meta-analysis to explore the influence of dexamethasone versus placebo on postoperative pain after thyroid surgery.

METHODS

We search PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases through May 2020 for randomized controlled trials (RCTs) assessing the effect of dexamethasone versus placebo on postoperative pain after thyroid surgery. This meta-analysis is performed using the random-effect model.

RESULTS

Eight RCTs involving 734 patients are included in the meta-analysis. Overall, compared with control group for thyroid surgery, dexamethasone shows significantly reduced pain scores (SMD = - 0.82; 95% CI - 1.08 to - 0.56; P < 0.00001), number of required analgesics (OR = 0.18; 95% CI 0.11-0.31; P < 0.00001), analgesic consumption (SMD = - 0.38; 95% CI - 0.63 to - 0.13; P = 0.003), nausea and vomiting (OR = 0.38; 95% CI 0.17-0.86; P = 0.02), as well as rescue antiemetics (OR = 0.40; 95% CI 0.20-0.79; P = 0.008).

CONCLUSIONS

Perioperative dexamethasone is effective to reduce the pain, nausea and vomiting after thyroid surgery.

Impact of drains on nausea and vomiting after thyroid and parathyroid surgery: a randomized controlled trial

OBJECTIVE

Nausea and vomiting are common side effects following thyroid and parathyroid surgery. In a prospective controlled randomized trial, postoperative nausea and vomiting (PONV) and the number of episodes of vomiting were defined as two primary endpoints. We analysed whether the placement of drains after thyroid or parathyroid surgery enhances PONV and/or influences vomiting.

PATIENTS AND METHODS

From November 2007 to January 2012, 136 consecutive patients were included for thyroid or parathyroid surgery and were randomly assigned to group A (drain, n = 69) or group B (no drain, n = 67). PONV was assessed with visual analogue scale (VAS; range 0 to 10) measurements. Furthermore, episodes of vomiting as well as analgetic and antiemetic therapies were recorded. Difference in neck circumference was compared pre- and postoperatively.

RESULTS

Patients' characteristics did not differ between group A and B. Postoperative VAS values for pain were 2.4 ± 0.3 (group A) and 2.6 ± 0.2 (group B) (p = 0.62), and for nausea 1.4 ± 0.2 (group A) and 1.1 ± 0.2 (group B) (p = 0.57). The relative occurrences of episodes for postoperative vomiting were equal in both groups 0.3 ± 0.1 (p = 1.0). Antiemetic drugs were administered 37 times (group A) and 18 times (group B) (p = 0.099). The total number of treatments of patients with antiemetic drugs was 23 (33.3%) in group A vs. 13 (19.4%) in group B (p = 0.081). The neck circumference postoperatively was significantly larger in group B (p = 0.0025).

CONCLUSIONS

Drains after surgery do not enhance postoperative pain, nausea and vomiting. The placement of drains in thyroid surgery is recommended to avoid relevant fluid collection. Drains however may influence the amount of antiemetic drug requirements.

TRIAL REGISTRATION

CLINICALTRIALS.

GOV IDENTIFIER

NCT01679418.

Pharmacologic interventions for postoperative nausea and vomiting after thyroidectomy: A protocol for systematic review and network meta-analysis

BACKGROUND

We aimed to perform a network meta-analysis (NMA) to quantify and rank the efficacy and safety of the pharmacologic interventions for prophylactic use for postoperative nausea and vomiting (PONV) in patients undergoing thyroidectomies.

METHODS

A systematic and comprehensive search will be performed using MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), and Google Scholar, beginning from their inceptions to February 2019. Only randomized clinical trials on the efficacy and safety of pharmacologic interventions for prophylactic use in patients undergoing thyroidectomies will be included.The primary endpoints will be the incidences of postoperative nausea (PON), postoperative vomiting (POV), and PONV in the early, middle, late, and overall phases. The severity of PON, POV, and PONV; the use of rescue antiemetics; the incidence of complete response; and safety issues, such as headache, dizziness, drowsiness, and constipation, will be also assessed.We will conduct both pairwise meta-analysis and NMA. We will use surface under the cumulative ranking curve (SUCRA) values and rankograms to present the hierarchy of pharmacologic interventions. A comparison-adjusted funnel plot will be used to assess the presence of small-study effects. The quality of the studies included will be assessed using the risk of bias tool 2.0. All statistical analyses will be performed using Stata SE version 15.0.

RESULTS

The results of this systematic review and NMA will be published in a peer-reviewed journal.

CONCLUSION

This systematic review and NMA will provide a comprehensive and convincing evidence summary of prophylactic pharmacologic interventions for PONV after a thyroidectomy.

TRIAL REGISTRATION NUMBER

CRD42018100002.

A Narrative Review of the Evidence on the Efficacy of Dexamethasone on Postoperative Analgesic Consumption

OBJECTIVES

The effect of dexamethasone on analgesic consumption has not been adequately studied. The aim of this review was to investigate recent literature regarding the possible effect of dexamethasone on postoperative analgesic consumption.

METHODS

Critical review of randomized trials and prospective consecutive studies investigating the postoperative analgesic effect of dexamethasone was performed. Only studies published during 2006 to 2015 were included.

RESULTS

Forty-one studies met the inclusion criteria; 33 in adults and 8 in children (9 in general surgery, 8 in gynecologic/breast surgery, 8 in orthopedic/spinal surgery, 8 in head/neck surgery, 7 in children's tonsillectomy, and 1 in children's orchiopexy). Literature review demonstrated that dexamethasone can decrease analgesic requirements in patients undergoing laparoscopic cholecystectomies, laparoscopic gynecologic and breast surgery; whereas there is no consensus regarding orthopedic procedures, with positive evidence mostly regarding spinal surgeries. The efficacy of dexamethasone during head and neck surgery is not conclusive; however, its use before thyroid surgery may be beneficial. In children a beneficial impact of dexamethasone administration was revealed on posttonsillectomy reduction of analgesic needs. Studies on other kinds of operations in children are lacking.

CONCLUSIONS

Dexamethasone administered at a dose of 8 mg before surgical incision may be beneficial in laparoscopic cholecystectomies, thyroid, laparoscopic gynecologic and breast surgery, and tonsillectomies in children. Dexamethasone's potential impact on reducing postoperative analgesic requirements should be investigated in more detail in a systematic manner, to support its use in other kinds of operations.

Cervical plexus anesthesia versus general anesthesia for anterior cervical discectomy and fusion surgery: A randomized clinical trial

Both general anesthesia (GA) and cervical plexus anesthesia (CPA) can be used for anterior cervical discectomy and fusion (ACDF) surgery. The aim of this study was to evaluate the influence of anesthetic techniques on perioperative mortality and morbidity in patients undergoing cervical surgery.From January 2008 to December 2015, 356 patients who underwent 1-level ACDF for cervical spinal myelopathy were prospectively reviewed. They were assigned to receive GA (group A) and CPA (group B). The analgesic efficacy of the block was assessed by anesthesia preparation time, the maximum heart rate, and mean arterial blood pressure changes compared with the baseline, time of postoperative revival, and duration of recovery stay. Duration of surgery, blood loss, and anesthesia medical cost were also recorded. Numerical rating scale (NRS) was used to evaluate pain at different time points. Postoperative nausea and vomiting (PONV) was assessed, and postoperative average administered dosages of meperidine and metoclopramide were also recorded. The spinal surgeon satisfaction, anesthetist satisfaction, and patient satisfaction were assessed.Both the anesthesia induction time and postoperative revival time were longer in group A than that in group B; both the duration of surgery and recovery stay were also longer in group A than that in group B, whereas there was no difference in blood loss between the 2 groups. The average dosage of both meperidine and metoclopramide was more in group A than that in group B, and the anesthesia medical cost was greater in group A than that in group B. There were no significant differences in baseline data of systolic blood pressure, diastolic blood pressure, and heart rate between the 2 groups. But the intraoperative data of systolic blood pressure, diastolic blood pressure, and heart rate were higher/larger in group B than that in group A. In group A, there was no complaint of pain in the surgery procedure, but the pain increased after GA, with highest degree at 8 hours postoperation; then the pain degree decreased, and the NRS was 1 at 24 hours postoperation. In group B, intraoperative pain was NRS 4, and pain degree decreased from 4 hours postoperation; the NRS was 2 at 24 hours postoperation. The incidence of severe PONV was higher in group A than that in group B. There was no significant difference in the spinal surgeon satisfaction and anesthetist satisfaction for the anesthetic techniques. There was significant difference in patient satisfaction between the 2 groups, with high satisfaction for GA.General anesthesia is superior to CPA in maintaining better intraoperative hemodynamic stability and providing high patient satisfaction with no intraoperative pain for patients receiving ACDF, but it entails longer surgery and anesthesia time, and requires more postoperative analgesic and anesthesia cost.

Dexamethasone reduces nausea and vomiting but not pain after thyroid surgery: a meta-analysis of randomized controlled trials

BACKGROUND

Postoperative nausea and vomiting (PONV) is a common complication after thyroidectomy. The aim of this article was to evaluate the efficacy of dexamethasone for prevention of PONV and pain in patients undergoing thyroidectomy.

MATERIAL AND METHODS

We performed this meta-analysis based on the QUORUM (Quality of Reporting of Meta-analyses) guidelines. Our study included randomized controlled trials (RCTs) that compared preoperative single-dose administration of dexamethasone with no dexamethasone in patients undergoing thyroidectomy. The primary outcome was occurrence and severity of PONV, and the secondary outcomes included pain, use of analgesics, and steroid-related complications.

RESULTS

Seven RCTs were included, with a total of 611 patients. A statistically and clinically significant difference in the incidence and severity of PONV was found in favor of dexamethasone (SMD, 0.23; 95% CI, 0.13-0.41; P<0.00001; SMD, 0.53; 95% CI, -1.03 to -0.03; P=0.04). However, there was no significant difference in reduction of pain severity and analgesic consumption in using dexamethasone (SMD, -0.83; 95% CI, -1.85 to 0.18; P=0.14; SMD, -0.19; 95% CI, -0.43 to 0.04; P=0.10). No steroid-related complications were noted.

CONCLUSIONS

A single preoperative administration of dexamethasone reduced the incidence and severity of PONV but not pain severity and analgesic consumption in patients undergoing thyroidectomy. Further studies with a larger sample size are needed to further explore the efficacy of dexamethasone on postoperative pain severity and analgesic consumption.

The impact of prophylactic dexamethasone on nausea and vomiting after thyroidectomy: a systematic review and meta-analysis

BACKGROUND

We carried out a systematic review and meta-analysis to evaluate the impact of prophylactic dexamethasone on post-operative nausea and vomiting (PONV), post-operative pain, and complications in patients undergoing thyroidectomy.

METHODS

We searched Pubmed, Embase, and Cochrane Library databases for randomized controlled trials (RCTs) that evaluated the prophylactic effect of dexamethasone versus placebo with or without other antiemetics for PONV in patients undergoing thyroidectomy. Meta-analyses were performed using RevMan 5.0 software.

RESULTS

Thirteen RCTs that considered high quality evidence including 2,180 patients were analyzed. The meta-analysis demonstrated a significant decrease in the incidence of PONV (RR 0.52, 95% CI 0.43 to 0.63, P < 0.00001), the need for rescue anti-emetics (RR 0.42, 95% CI 0.30 to 0.57, P<0.00001), post-operative pain scores (WMD -1.17, 95% CI -1.91 to -0.44, P = 0.002), and the need for rescue analgesics (RR 0.65, 95% CI 0.50-0.83, P = 0.0008) in patients receiving dexamethasone compared to placebo, with or without concomitant antiemetics. Dexamethasone 8-10mg had a significantly greater effect for reducing the incidence of PONV than dexamethasone 1.25-5mg. Dexamethasone was as effective as other anti-emetics for reducing PONV (RR 1.25, 95% CI 0.86-1.81, P = 0.24). A significantly higher level of blood glucose during the immediate post-operative period in patients receiving dexamethasone compared to controls was the only adverse event.

CONCLUSIONS

Prophylactic dexamethasone 8-10mg administered intravenously before induction of anesthesia should be recommended as a safe and effective strategy for reducing the incidence of PONV, the need for rescue anti-emetics, post-operative pain, and the need for rescue analgesia in thyroidectomy patients, except those that are pregnant, have diabetes mellitus, hyperglycemia, or contraindications for dexamethasone. More high quality trials are warranted to define the benefits and risks of prophylactic dexamethasone in potential patients with a high risk for PONV.

Comparison of ramosetron, dexamethasone, and a combination of ramosetron and dexamethasone for the prevention of postoperative nausea and vomiting in Korean women undergoing thyroidectomy: A double-blind, randomized, controlled study

BACKGROUND

Thyroidectomy is associated with a relatively high incidence of postoperative nausea and vomiting (PONV), ranging from 51% to 76%. Because these symptoms are distressing for patients, prophylactic medication to avoid or reduce PONV is recommended.

OBJECTIVE

The aim of the present study was to compare the efficacy of ramosetron, dexamethasone, and a combination of ramosetron and dexamethasone in preventing PONV in Korean women undergoing thyroidectomy.

METHODS

In this double-blind, randomized, controlled trial, consecutive adult female patients who were scheduled to undergo thyroidectomy under general anesthesia at the Kyungpook National University Hospital (Daegu, Korea) were randomly assigned to receive ramosetron 0.3 mg alone, dexamethasone 8 mg alone, or a combination of ramosetron 0.3 mg and dexamethasone 8 mg administered intravenously as a single dose immediately after induction of anesthesia. The primary end point of this study was the total PONV rate up to 24 hours postanesthesia. The secondary end points were the incidence of nausea, incidence of vomiting, severity of nausea (0 = no nausea to 10 = nausea as bad as it could be), use of rescue antiemetic drugs, and the occurrence of adverse events (AEs) determined through interview or spontaneous patient report for 24 hours postanesthesia.

RESULTS

A total of 198 female patients were approached for study inclusion, 18 of whom were excluded. Therefore, 180 Korean women (mean [SD] age, 46.5 [12.6] years; height, 159.8 [2.7] cm; weight, 53.2 [3.6] kg) were enrolled and completed the study. The total PONV rates up to 24 hours postanesthesia were 35%, 13%, and 10% in the dexamethasone, ramosetron, and combination groups, respectively. The PONV rate was significantly lower in the combination group than in the dexamethasone alone group (P = 0.006). The PONV rate was not significantly different in the combination group compared with the ramosetron alone group. The PONV rate in the dexamethasone alone group was significantly higher than that in the ramosetron alone group (P = 0.03). The severity of nausea (median [25th-75th percentiles], 0 [0-0] vs 0 [0-4]; P = 0.009) and rate of use of rescue antiemetic drugs (5% vs 27%; P = 0.006) were significantly lower in the combination group than in the dexamethasone alone group, whereas the severity of nausea (median [25th-75th percentiles], 0 [0-0] vs 0 [0-0]) and rate of use of rescue antiemetic drugs (5% vs 7%) were not significantly different between the combination and ramosetron alone groups. The severity of nausea (median [25th-75th percentiles], 0 [0-4] vs 0 [0-0]; P = 0.033) and the rate of use of rescue antiemetic drugs (27% vs 7%; P = 0.018) were significantly higher in the dexamethasone alone group than in the ramosetron alone group. The rates of AEs (headache: 15%, 20%, and 18%; dizziness: 18%, 22%, and 15%) were not significantly different in the dexamethasone alone, ramosetron alone, or combination groups, respectively.

CONCLUSIONS

The combination of ramosetron and dexamethasone was more effective in reducing PONV than was dexamethasone monotherapy. However, the combination did not show additional benefits compared with ramosetron alone in preventing PONV after thyroidectomy in these Korean women.

Preventing postoperative nausea and vomiting after laparoscopic cholecystectomy: a prospective, randomized, double-blind study

BACKGROUND

Postoperative nausea and vomiting (PONV) are potential complications in patients after laparoscopic cholecystectomy (LC). Combination antiemetic therapy often is effective for preventing PONV in patients undergoing LC, and combinations of antiemetics targeting different sites of activity may be more effective than monotherapy.

OBJECTIVE

The aim of this study was to compare the administration of a subhypnotic dose of propofol combined with dexamethasone with one of propofol combined with metoclopramide to prevent PONV after LC.

METHODS

Sixty adult patients scheduled for LC were randomly assigned to 1 of 2 treatment groups. The patients in group 1 received 0.5 mg/kg propofol plus 8 mg dexamethasone, and those in group 2 received 0.5 mg/kg propofol plus 0.2 mg/kg metoclopramide. The number of patients experiencing nausea and vomiting at 0 to 4, 4 to 12, and 12 to 24 hours postoperatively and as well as additional use of rescue antiemetics were recorded.

RESULTS

The total PONV rates up to 24 hours postanesthesia were 23.3% and 50% for group 1 and group 2, respectively. Comparisons of the data revealed that at 0 to 4 hours, the number of patients experiencing vomiting was 6 (20%) in group 1 and14 (46.7%) in group 2 (P = 0.028). The frequency of vomiting in group 1 was significantly lower than that for group 2 (P = 0.028), and the rate of rescue antiemetic use in group 2 was higher than that in group 1 (20% vs 46.7%; P = 0.028). In the evaluation of PONV based on the nausea and vomiting scale scores, the mean PONV score was 0.4 (0.2) in group 1 compared with 1.0 (0.2) in group 2 (P = 0.017). There were no significant differences between the values at 4 to 12 hours and at 12 to 24 hours. The frequency of adverse reactions (respiratory depression: 1.3%, 1.3%; laryngospasm: 1.3%, 0%; cough: 1.3%, 0%; hiccup: 1.3%, 0%;) was not significantly different in the 2 groups.

CONCLUSIONS

Administration of a subhypnotic dose of 0.5 mg/kg propofol plus 8 mg dexamethasone at the end of surgery was more effective than administration of 0.5 mg/kg propofol plus metoclopramide in preventing PONV in the early postoperative period in adult patients undergoing LC.

Dexamethasone alleviates motion sickness in rats in part by enhancing the endocannabinoid system

Low-dose dexamethasone has been widely used for the prevention of nausea and vomiting after chemotherapy and surgical procedures and to treat motion sickness due to its minimal adverse effects, but the mechanisms underlying its anti-motion sickness effects are poorly understood. Previous studies have demonstrated that the endocannabinoid system is suppressed by motion sickness but stimulated by dexamethasone. The aim of the present study was to determine whether dexamethasone has an anti-motion sickness effect in rats and to elucidate the mechanism of this action. We used HPLC-MS/MS to measure the plasma concentrations of anandamide and 2-arachidonoylglycerol+1-arachidonoylglycerol, and we employed real-time quantitative PCR (qRT-PCR) and/or Western blot analysis to assay the expression of N-acylphosphatidyl-ethanolamine hydrolyzing phospholipase D, sn-1-selective diacylglycerol lipase, fatty acid hydrolase, monoacylglycerol lipase and endocannabinoid CB1 receptor in the dorsal vagal complex and stomach of rats exposed to a motion sickness protocol. The results showed that dexamethasone lowered the motion sickness index and restored the levels of endogenous cannabinoids and the expression of the endocannabinoid CB1 receptor, which declined after the induction of motion sickness, in the dorsal vagal complex and stomach.

Dexamethasone effect on postoperative pain and tramadol requirement after thyroidectomy

Tramadol is a central-acting analgesic associated with nausea and vomiting. Clinical studies have demonstrated that glucocorticoids have analgesic and antiemetic effects when administered perioperatively. The aim of this study is to test the hypothesis that coadministration of tramadol and dexamethasone decreases both postoperative pain and tramadol requirement by patient-controlled analgesia (PCA). Forty female patients undergoing thyroidectomy under general anesthesia were enrolled in a double-blind randomized controlled study and allocated to receive dexamethasone 4 mg i.v. (dexamethasone group, n = 20) or saline (control group, n = 20). At 0, 1, 2, 4 and 22 h of PCA, tramadol consumption and pain were evaluated. Although pain (numerical rating scale 0-10) was significantly lower in the dexamethasone group compared to the control group (2.9 ± 1.4 vs. 3.8 ± 1.2, p = 0.02) at the beginning of PCA, tramadol demand was not significantly different. Although the results herein show a possible beneficial effect of a preoperative single low dose of dexamethasone on postoperative pain, the hypothesis that this corticosteroid decreases tramadol requirement is not supported.

Effect of dexamethasone on the frequency of postdural puncture headache after spinal anesthesia for cesarean section: a double-blind randomized clinical trial

In this study, we evaluated the effect of dexamethasone used as a prophylaxis for nausea and vomiting on the incidence of postdural puncture headache (PDPH) in pregnant women receiving spinal anesthesia for cesarean section. In a prospective, randomized, double-blind, placebo-controlled study, 372 women under spinal anesthesia received 8 mg of dexamethasone or placebo intravenously just after the umbilical cord was clamped. The rate of PDPH and correlated risk factors were evaluated. The prevalence of nausea and vomiting in the dexamethasone and placebo groups was 54.4 and 51.7%, respectively. There was no statistically meaningful difference between the results (P value = 0.673). The overall incidence rate of PDPH was 10.8%, with 28 cases from the dexamethasone group compared with 11 subjects from the placebo group (P value = 0.006). This effect was most prominent on the first day (P value = 0.046) and disappeared on the second day after spinal anesthesia (P value = 0.678). Prophylactic treatment with 8 mg of dexamethasone not only increases the severity and incidence of PDPH, but is also ineffective in decreasing the prevalence of intra-operative nausea and vomiting during cesarean section. The treatment is a significant risk factor for the development of PDPH.

Dexamethasone for prevention of postoperative nausea and vomiting in patients undergoing thyroidectomy: meta-analysis of randomized controlled trials

BACKGROUND

Postoperative nausea and vomiting (PONV) is a common complication after thyroidectomy. Steroids effectively reduce nausea, pain, and inflammation; therefore, preoperative administration of steroids ought to improve these surgical outcomes.

METHODS

We conducted a systematic review of randomized controlled trials (RCTs) that compared preoperative single-dose administration of dexamethasone with no dexamethasone in patients undergoing thyroidectomy. The primary outcome was occurrence of PONV within 24 h, and the secondary outcomes were pain, use of analgesics, and steroid-related complications.

RESULTS

Five RCTs were included with a total of 497 patients. A statistically and clinically significant difference in the incidence of PONV was found in favor of dexamethasone [relative risk (RR) 0.38; 95% confidence interval (CI) 0.30-0.49). The visual analog pain score was significantly diminished (weighted mean difference, WMD)-1.50; 95% CI-2.54 to -0.46) at 24 h. The incidence of analgesics use was also reduced (RR 0.61; 95% CI 0.41-0.90) in the dexamethasone group. No steroid-related complications were noted.

CONCLUSIONS

A single preoperative administration of dexamethasone reduced the incidence of PONV and analgesic requirements in patients undergoing thyroidectomy. Prophylactic use of steroids for patients undergoing thyroidectomy is safe and should be considered for routine clinical practice.

Bilateral superficial cervical plexus block combined with general anesthesia administered in thyroid operations

Background

We investigated the analgesic efficacy of bilateral superficial cervical plexus block in patients undergoing thyroidectomy and to determine whether it reduces the adverse effects of general anesthesia.

Methods

We prospectively recruited 162 patients who underwent elective thyroid operations from March 2006 to October 2007. They were randomly assigned to receive a bilateral superficial cervical block (12 ml per side) with isotonic saline (group A; n = 56), bupivacaine 0.5% (group B; n = 52), or levobupivacaine 0.5% (group C; n = 54) after induction of general anesthesia. The analgesic efficacy of the block was assessed with: intraoperative anesthetics (desflurane), numbers of patients needing postoperative analgesics, the time to the first analgesics required, and pain intensity by visual analog scale (VAS). Postoperative nausea and vomiting (PONV) for 24 h were also assessed by the “PONV grade.” We also compared hospital stay, operative time, and discomfort in swallowing.

Results

There were no significant differences in patient characteristics. Each average end-tidal desflurane concentration was 5.8, 3.9, and 3.8% in groups A, B, and C, respectively (p < 0.001). Fewer patients in groups B and C required analgesics (A: B: C = 33:8:7; p < 0.001), and it took longer before the first analgesic dose was needed postoperatively (group A: B: C = 82.1:360.8:410.1 min; p < 0.001). Postoperative pain VAS were lower in groups B and C for the first 24 h postoperatively (p < 0.001). Incidences of overall and severe PONV were lower, however, there were not sufficient numbers of patients to detect differences in PONV among the three groups. Hospital stay was shorter in group B and group C (p = 0.011). There was no significant difference in operative time and postoperative swallowing pain among the three groups.

Conclusions

Bilateral superficial cervical plexus block reduces general anesthetics required during thyroidectomy. It also significantly lowers the severity of postoperative pain during the first 24 h and shortens the hospital stay.

Prospective assessment of postoperative pain after craniotomy

Pain after craniotomy may be underdiagnosed, despite the fact that it can increase postoperative complications for example arterial hypertension and postoperative hemorrhage. This study investigates the incidence and intensity of pain after craniotomy and characterizes the influencing parameters. During a 1-year period 256 patients undergoing elective craniotomy were prospectively included in the study. Intensity of pain was evaluated 1, 4, and 24 hours after extubation using a verbal numerical rating scale (NRS) ranging from 0 (no pain) to 10 (maximal pain). Routine perioperative pain management was not influenced by the investigators. Parameters including patient-related factors, drug administration, and surgical factors were correlated with incidence and intensity of postcraniotomy pain.

STATISTICAL ANALYSIS

logistic regression and chi using SPSS program (Windows, version 12.0). During the first 24 hours 87% of the patients experienced pain (NRS 1 to 3: 32%, NRS 4 to 7: 44%, NRS 8 to 10: 11%). For postoperative analgesia, the opioid piritramide (a mu-receptor agonist) was administered to 70% and nonopiod analgesics to 73% of the patients. The probability of experiencing postcraniotomy pain was reduced by 3% for each year of life. Maintenance of anesthesia with sevoflurane increased the probability of suffering from postcraniotomy pain by 147% and the absence of corticosteroids by 119%. Other investigated parameters did not influence pain after craniotomy. This study shows that pain is experienced by the majority of patients after craniotomy, despite conventional pain management, emphasizing the necessity for improved and individualized pain management in this special group of patients.

Dexamethasone before total laparoscopic hysterectomy: a randomized controlled dose-response study

PURPOSE

A prospective, randomized, double blind, placebo-controlled study was undertaken to evaluate the efficacy of a single preoperative dose of dexamethasone, in different dosages, in providing postoperative analgesia in patients undergoing total laparoscopic hysterectomy (TLH).

METHOD

The study included 55 patients randomly divided into three groups. Patients in Groups P, D4, and D8 received saline, 4, and 8 mg dexamethasone, respectively, intravenously, 2 h before induction.

RESULTS

The time to first analgesic requirement was significantly delayed in patients in the D8 group compared with the D4 group (P = 0.01) and placebo (P = 0.01). Total postoperative fentanyl consumption was significantly less in patients in the D8 group compared with the D4 group (P = 0.01) and placebo (P = 0.01). Use of 8 mg dexamethasone resulted in a 99.3 mcg decrease in total 24-h fentanyl consumption. Postoperative nausea and vomiting (PONV) was significantly less in the D8 group with a complete response rate (no emetic episodes and no rescue medication for 24 h) of 36.8% compared with the placebo group in which all the patients had PONV. No adverse effects were observed in any group.

CONCLUSION

Dexamethasone at a dose of 8 mg given intravenously 2 h before induction, delays patient request for analgesia and reduces total fentanyl consumption and PONV in patients undergoing TLH.

Effect of intravenous crystalloid infusion on postoperative nausea and vomiting after thyroidectomy: a prospective, randomized, controlled study

BACKGROUND AND OBJECTIVE

Intravenous administration of compound sodium lactate (CSL) 30 ml kg to women undergoing gynaecological laparoscopy reduced the incidence of vomiting, nausea and antiemetic use when compared with 10 ml kg. The aim of this study was to evaluate the effect of intravenous fluid administration on nausea and vomiting after thyroidectomy.

METHODS

With ethics committee approval, 100 patients scheduled for thyroid surgery were included in this prospective, controlled, double blind study. Patients were randomized into two groups: the CSL-10 group (n = 50) received CSL 10 ml kg and the CSL-30 group received CSL 30 ml kg; the administration of fluid was completed by the end of surgery. Standardized anaesthesia was performed. The incidence of nausea and vomiting and need for antiemetics and analgesic therapy were assessed by a blinded observer at 0.5, 2, 6, 12, 18 and 24 h after surgery. Patients' satisfaction was also recorded (0-100).

RESULTS

The incidence of nausea (64%) was similar in both groups (P = 0.1). The incidence of vomiting was 34% in the CSL-10 group and 32% in the CSL-30 group (P = 0.83). Antiemetics (P = 0.84) and analgesic consumption (P = 0.72) did not differ significantly between the two groups. Patients' satisfaction was also comparable (P = 0.39).

CONCLUSION

Intravenous administration of CSL 30 ml kg to patients undergoing thyroidectomy did not reduce the incidence of nausea, vomiting and antiemetic use when compared with CSL 10 ml kg.