Effects of Intraoperative Dexamethasone Administration in Adult Diabetic Burn Patients

Impact of steroid use and glycemic control on postoperative complications in diabetic gynecologic oncology patients undergoing laparotomy

Objective

We aimed to assess the impact of preoperative steroid administration and perioperative glycemic control on postoperative complications in diabetic gynecologic oncology patients undergoing laparotomy.

Methods

This retrospective cohort study included gynecologic oncology patients with Type I and Type II diabetes (DM) undergoing laparotomy for any gynecologic indication at a single academic center from 10/2017 to 09/2020. The primary outcome was the rate of postoperative complications. Preoperative steroid administration and 24-hour postoperative average serum blood glucose (BG) ≥ 180 mg/dL were the studied exposures. Data was analyzed with SPSS Statistics v.28.

Results

225 patients met inclusion criteria; 47.6 % had postoperative complications. Patient demographics were similar between patients with and without postoperative complications. Patients with complications had higher BMIs (36.8 vs. 34.0; p = 0.03), bowel surgery (33.0 % vs. 17.1 %; p = 0.008), operative time ≥ 240 min (14.2 % vs. 5.1 %; p = 0.02) and average BG ≥ 180 (63.6 % vs. 40.2 %; p < 0.01). On multivariate analysis, bowel surgery (OR 2.4 (1.2-4.8); p = 0.01) and average BG ≥ 180 (OR 2.8 (1.6-4.9); p < 0.01) remained significant predictors of postoperative complications. There were no differences in complication rates (42.3 % vs. 42.6 %; p = 1.0) between patients who received preoperative steroids and those who did not. When stratified by average postoperative BG < 180 mg/dL vs. BG ≥ 180 mg/dL, there was no difference in Clavien-Dindo classification, 30-day readmission rate (28.2 % vs. 22.1 %; p = 0.49) or 30-day mortality rate (2.9 % vs. 0.0 %; p = 0.53).

Conclusion

The administration of preoperative steroids did not increase complication rates. Perioperative hyperglycemia was associated with an increased risk of postoperative complications. Optimizing perioperative glycemic control is imperative to decrease postoperative complications.

Effect of dexamethasone administration for postoperative nausea and vomiting prophylaxis on glucose levels in adults with diabetes undergoing elective surgery: a systematic review with meta-analysis

OBJECTIVE

The objective of this review was to evaluate the effect of intravenous dexamethasone given intraoperatively for postoperative nausea and vomiting prophylaxis on maximal blood glucose level within the initial 24 hours following elective surgery for patients with diabetes.

INTRODUCTION

Postoperative nausea and vomiting is a prevalent adverse effect of anesthesia that leads to morbidity, increased health care costs, and unanticipated hospital admissions. Dexamethasone is an effective prophylactic agent that confers secondary analgesic and anti-inflammatory benefits. However, its use in patients with diabetes remains controversial due to the potential for increased postoperative blood glucose levels.

INCLUSION CRITERIA

This review considered studies with participants 18 years of age or older with type 1 or 2 diabetes undergoing an elective surgical procedure. Eligible studies reported postoperative blood glucose levels in adults with diabetes after receiving a single 4-10 mg prophylactic dose of intravenous dexamethasone intraoperatively for postoperative nausea and vomiting. The primary outcome was maximum blood glucose level in the first 24 hours after surgery. All study designs were eligible for inclusion. Studies were excluded if they lacked a control group with diabetes or if they did not report maximum blood glucose values in both groups.

METHODS

A search of MEDLINE, CINAHL Complete, Embase, Web of Science, TRIP database, and the Cochrane Database of Systematic Reviews was completed in October 2021. Gray literature resources were also searched. No date or language restrictions were applied. Methodological quality was assessed using JBI appraisal tools for randomized controlled trials, cohort studies, and case-control studies. A meta-analysis of maximal postoperative blood glucose level within 24 hours of surgery was performed, as well as subgroup analyses by dexamethasone dose, insulin treatment, and study design type.

RESULTS

Eleven studies (4 randomized controlled trials, 6 cohort studies, and 1 case-control study) were included in this review, with 1 study excluded from meta-analysis and results reported narratively. The total sample size of studies included in meta-analysis was 2567. The administration of dexamethasone significantly increased maximal blood glucose levels in the 24 hours immediately following surgery compared with control groups with diabetes, as demonstrated by randomized controlled trials (mean difference [MD] 39.56 mg/dL; 95% CI 16.18 to 62.94; P < 0.001; I2 = 87%) and observational studies (MD 26.31 mg/dL; 95% CI 7.10 to 45.52; P = 0.007; I2 = 92%). This increase in blood glucose was significant for all doses of dexamethasone: 4 mg (MD 40.81 mg/dL; 95% CI 2.42 to 79.19; P = 0.001; I2 = 91%), 8 mg (randomized controlled trials only; MD 39.45 mg/dL; 95% CI 15.32 to 63.58; P = 0.001; I2 = 86%), and mixed 4-10 mg dose (MD 30.82 mg/dL; 95% CI 6.75 to 54.88; P < 0.012; I2 = 93%). Postoperative hyperglycemia persisted in studies using insulin treatment as well as those not using insulin protocols. The overall certainty of the findings ranged from very low for outcomes that included cohort studies to moderate when outcomes from randomized controlled trials were analyzed separately. However, the quantitative findings of the experimental and observational studies were clinically similar. Risk of bias presented minimal concerns in all included studies.

CONCLUSIONS

Dexamethasone leads to transient postoperative hyperglycemia in patients with diabetes undergoing elective surgery when given as a single 4-10 mg intravenous dose for postoperative nausea and vomiting prophylaxis. The clinical relevance of hyperglycemia is debatable given its small magnitude and transient nature. Without more tightly controlled data, methodological consistency, and baseline blood glucose values, it is impossible to test causal links between hyperglycemia and pre-existing patient factors (eg, hemoglobin A1C levels) or postoperative complications.

REVIEW REGISTRATION

PROSPERO CRD42020185607.

The safety of perioperative dexamethasone with antiemetic dosage in surgical patients with diabetes mellitus: a systematic review and meta-analysis

BACKGROUND

Dexamethasone is commonly used for antiemesis in surgical patients. It has been confirmed that long-term steroid use increases blood glucose level in both diabetic and non-diabetic patients, it is unclear how a single dose of intravenous dexamethasone used pre/intraoperatively for postoperative nausea and vomiting (PONV) prophylaxis would influence the blood glucose and wound healing in diabetic patients.

METHODS

The Pubmed, Cochrane Library, Embase, Web of Science databases, CNKI and Google Scholar were searched. The articles reporting a single dose dexamethasone administered intravenously for antiemesis in surgical patients with diabetes mellitus (DM) were included.

RESULTS

Nine randomized controlled trials (RCTs) and 7 cohort studies were included in our meta-analysis. The results showed that dexamethasone increased glucose level intraoperatively (MD: 0.439, 95% CI: 0.137-0.581, I² = 55.7%, P = 0.004), at the end of surgery (MD: 0.815, 95% CI: 0.563-1.067, I² = 73.5%, P = 0.000), on postoperative day (POD) 1 (MD: 1.087, 95% CI: 0.534-1.640, I² = 88%, P = 0.000), on POD 2 (MD: 0.501, 95% CI: 0.301-0.701, I² = 0%, P = 0.000), and increased peak glucose level within 24 hours of surgery (MD: 2.014, 95% CI: 0.503-3.525, I² = 91.6%, P = 0.009) compared with control. It indicated that dexamethasone caused the increase of perioperative glucose level at different time points by 0.439 to 1.087 mmol/L (7.902 to 19.566 mg/dL), and the increase of peak glucose level within 24 hours of surgery by 2.014 mmol/L (36.252 mg/dL) compared with control. Dexmethasone had no impact on wound infection (OR: 0.797, 95%CI: 0.578-1.099, I² = 0%, P = 0.166) and healing (P < 0.05).

CONCLUSION

Dexamethasone could increase blood glucose by only 2.014 mmol/L (36.252 mg/dL) of peak glucose level within 24 hours of surgery in surgery patients with DM, the increase of glucose level at each time point perioperatively was even lower, and had no effect on wound healing. Thus, dexamethasone with a single dose could be safely used for PONV prophylaxis in diabetic patients.

TRIAL REGISTRATION

The protocol of this systematic review was registered in INPLASY with the registration number INPLASY202270002.

A review of the most impactful published pharmacotherapy-pertinent literature of 2019 and 2020 for clinicians caring for patients with thermal or inhalation injury

Keeping abreast with current literature can be challenging, especially for practitioners caring for patients sustaining thermal or inhalation injury. Practitioners caring for patients with thermal injuries publish in a wide variety of journals, which further increases the complexity for those with resource limitations. Pharmacotherapy research continues to be a minority focus in primary literature. This review is a renewal of previous years' work to facilitate extraction and review of the most recent pharmacotherapy-centric studies in patients with thermal and inhalation injury. Sixteen geographically dispersed, board-certified pharmacists participated in the review. A MeSH-based, filtered search returned 1,536 manuscripts over the previous 2-year period. After manual review and exclusions, only 98 (6.4%) manuscripts were determined to have a potential impact on current pharmacotherapy practices and included in the review. A summary of the 10 articles that scored highest are included in the review. Nearly half of the reviewed manuscripts were assessed to lack a significant impact on current practice. Despite an increase in published literature over the previous 2-year review, the focus and quality remain unchanged. There remains a need for investment in well-designed, high impact, pharmacotherapy-pertinent research for patients sustaining thermal or inhalation injuries.