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Corcoran TB, Myles PS, Forbes AB, Cheng AC, Bach LA, O'Loughlin E, Leslie K, Chan MTV, Story D, Short TG, Martin C, Coutts P, Ho KM. Dexamethasone and Surgical-Site Infection. N Engl J Med 2021; 384:1731-1741. [PMID: 33951362 DOI: 10.1056/nejmoa2028982] [Citation(s) in RCA: 73] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND The glucocorticoid dexamethasone prevents nausea and vomiting after surgery, but there is concern that it may increase the risk of surgical-site infection. METHODS In this pragmatic, international, noninferiority trial, we randomly assigned 8880 adult patients who were undergoing nonurgent, noncardiac surgery of at least 2 hours' duration, with a skin incision length longer than 5 cm and a postoperative overnight hospital stay, to receive 8 mg of intravenous dexamethasone or matching placebo while under anesthesia. Randomization was stratified according to diabetes status and trial center. The primary outcome was surgical-site infection within 30 days after surgery. The prespecified noninferiority margin was 2.0 percentage points. RESULTS A total of 8725 participants were included in the modified intention-to-treat population (4372 in the dexamethasone group and 4353 in the placebo group), of whom 13.2% (576 in the dexamethasone group and 572 in the placebo group) had diabetes mellitus. Of the 8678 patients included in the primary analysis, surgical-site infection occurred in 8.1% (354 of 4350 patients) assigned to dexamethasone and in 9.1% (394 of 4328) assigned to placebo (risk difference adjusted for diabetes status, -0.9 percentage points; 95.6% confidence interval [CI], -2.1 to 0.3; P<0.001 for noninferiority). The results for superficial, deep, and organ-space surgical-site infections and in patients with diabetes were similar to those of the primary analysis. Postoperative nausea and vomiting in the first 24 hours after surgery occurred in 42.2% of patients in the dexamethasone group and in 53.9% in the placebo group (risk ratio, 0.78; 95% CI, 0.75 to 0.82). Hyperglycemic events in patients without diabetes occurred in 22 of 3787 (0.6%) in the dexamethasone group and in 6 of 3776 (0.2%) in the placebo group. CONCLUSIONS Dexamethasone was noninferior to placebo with respect to the incidence of surgical-site infection within 30 days after nonurgent, noncardiac surgery. (Funded by the Australian National Health and Medical Research Council and others; PADDI Australian New Zealand Clinical Trials Registry number, ACTRN12614001226695.).
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Affiliation(s)
- Tomás B Corcoran
- From Royal Perth Hospital (T.B.C., P.C., K.M.H.), the University of Western Australia (T.B.C., E.O., K.M.H.), Murdoch University (K.M.H.), and Fiona Stanley Hospital (E.O.), Perth, and the Alfred Hospital (P.S.M., A.C.C., L.A.B.), Monash University (T.B.C., P.S.M., A.B.F., A.C.C., L.A.B., K.L., C.M.), the University of Melbourne (K.L., D.S.), and Royal Melbourne Hospital (K.L.), Melbourne, VIC - all in Australia; the Chinese University of Hong Kong, Hong Kong (M.T.V.C.); and Auckland City Hospital and the University of Auckland - both in Auckland, New Zealand (T.G.S.)
| | - Paul S Myles
- From Royal Perth Hospital (T.B.C., P.C., K.M.H.), the University of Western Australia (T.B.C., E.O., K.M.H.), Murdoch University (K.M.H.), and Fiona Stanley Hospital (E.O.), Perth, and the Alfred Hospital (P.S.M., A.C.C., L.A.B.), Monash University (T.B.C., P.S.M., A.B.F., A.C.C., L.A.B., K.L., C.M.), the University of Melbourne (K.L., D.S.), and Royal Melbourne Hospital (K.L.), Melbourne, VIC - all in Australia; the Chinese University of Hong Kong, Hong Kong (M.T.V.C.); and Auckland City Hospital and the University of Auckland - both in Auckland, New Zealand (T.G.S.)
| | - Andrew B Forbes
- From Royal Perth Hospital (T.B.C., P.C., K.M.H.), the University of Western Australia (T.B.C., E.O., K.M.H.), Murdoch University (K.M.H.), and Fiona Stanley Hospital (E.O.), Perth, and the Alfred Hospital (P.S.M., A.C.C., L.A.B.), Monash University (T.B.C., P.S.M., A.B.F., A.C.C., L.A.B., K.L., C.M.), the University of Melbourne (K.L., D.S.), and Royal Melbourne Hospital (K.L.), Melbourne, VIC - all in Australia; the Chinese University of Hong Kong, Hong Kong (M.T.V.C.); and Auckland City Hospital and the University of Auckland - both in Auckland, New Zealand (T.G.S.)
| | - Allen C Cheng
- From Royal Perth Hospital (T.B.C., P.C., K.M.H.), the University of Western Australia (T.B.C., E.O., K.M.H.), Murdoch University (K.M.H.), and Fiona Stanley Hospital (E.O.), Perth, and the Alfred Hospital (P.S.M., A.C.C., L.A.B.), Monash University (T.B.C., P.S.M., A.B.F., A.C.C., L.A.B., K.L., C.M.), the University of Melbourne (K.L., D.S.), and Royal Melbourne Hospital (K.L.), Melbourne, VIC - all in Australia; the Chinese University of Hong Kong, Hong Kong (M.T.V.C.); and Auckland City Hospital and the University of Auckland - both in Auckland, New Zealand (T.G.S.)
| | - Leon A Bach
- From Royal Perth Hospital (T.B.C., P.C., K.M.H.), the University of Western Australia (T.B.C., E.O., K.M.H.), Murdoch University (K.M.H.), and Fiona Stanley Hospital (E.O.), Perth, and the Alfred Hospital (P.S.M., A.C.C., L.A.B.), Monash University (T.B.C., P.S.M., A.B.F., A.C.C., L.A.B., K.L., C.M.), the University of Melbourne (K.L., D.S.), and Royal Melbourne Hospital (K.L.), Melbourne, VIC - all in Australia; the Chinese University of Hong Kong, Hong Kong (M.T.V.C.); and Auckland City Hospital and the University of Auckland - both in Auckland, New Zealand (T.G.S.)
| | - Edmond O'Loughlin
- From Royal Perth Hospital (T.B.C., P.C., K.M.H.), the University of Western Australia (T.B.C., E.O., K.M.H.), Murdoch University (K.M.H.), and Fiona Stanley Hospital (E.O.), Perth, and the Alfred Hospital (P.S.M., A.C.C., L.A.B.), Monash University (T.B.C., P.S.M., A.B.F., A.C.C., L.A.B., K.L., C.M.), the University of Melbourne (K.L., D.S.), and Royal Melbourne Hospital (K.L.), Melbourne, VIC - all in Australia; the Chinese University of Hong Kong, Hong Kong (M.T.V.C.); and Auckland City Hospital and the University of Auckland - both in Auckland, New Zealand (T.G.S.)
| | - Kate Leslie
- From Royal Perth Hospital (T.B.C., P.C., K.M.H.), the University of Western Australia (T.B.C., E.O., K.M.H.), Murdoch University (K.M.H.), and Fiona Stanley Hospital (E.O.), Perth, and the Alfred Hospital (P.S.M., A.C.C., L.A.B.), Monash University (T.B.C., P.S.M., A.B.F., A.C.C., L.A.B., K.L., C.M.), the University of Melbourne (K.L., D.S.), and Royal Melbourne Hospital (K.L.), Melbourne, VIC - all in Australia; the Chinese University of Hong Kong, Hong Kong (M.T.V.C.); and Auckland City Hospital and the University of Auckland - both in Auckland, New Zealand (T.G.S.)
| | - Matthew T V Chan
- From Royal Perth Hospital (T.B.C., P.C., K.M.H.), the University of Western Australia (T.B.C., E.O., K.M.H.), Murdoch University (K.M.H.), and Fiona Stanley Hospital (E.O.), Perth, and the Alfred Hospital (P.S.M., A.C.C., L.A.B.), Monash University (T.B.C., P.S.M., A.B.F., A.C.C., L.A.B., K.L., C.M.), the University of Melbourne (K.L., D.S.), and Royal Melbourne Hospital (K.L.), Melbourne, VIC - all in Australia; the Chinese University of Hong Kong, Hong Kong (M.T.V.C.); and Auckland City Hospital and the University of Auckland - both in Auckland, New Zealand (T.G.S.)
| | - David Story
- From Royal Perth Hospital (T.B.C., P.C., K.M.H.), the University of Western Australia (T.B.C., E.O., K.M.H.), Murdoch University (K.M.H.), and Fiona Stanley Hospital (E.O.), Perth, and the Alfred Hospital (P.S.M., A.C.C., L.A.B.), Monash University (T.B.C., P.S.M., A.B.F., A.C.C., L.A.B., K.L., C.M.), the University of Melbourne (K.L., D.S.), and Royal Melbourne Hospital (K.L.), Melbourne, VIC - all in Australia; the Chinese University of Hong Kong, Hong Kong (M.T.V.C.); and Auckland City Hospital and the University of Auckland - both in Auckland, New Zealand (T.G.S.)
| | - Timothy G Short
- From Royal Perth Hospital (T.B.C., P.C., K.M.H.), the University of Western Australia (T.B.C., E.O., K.M.H.), Murdoch University (K.M.H.), and Fiona Stanley Hospital (E.O.), Perth, and the Alfred Hospital (P.S.M., A.C.C., L.A.B.), Monash University (T.B.C., P.S.M., A.B.F., A.C.C., L.A.B., K.L., C.M.), the University of Melbourne (K.L., D.S.), and Royal Melbourne Hospital (K.L.), Melbourne, VIC - all in Australia; the Chinese University of Hong Kong, Hong Kong (M.T.V.C.); and Auckland City Hospital and the University of Auckland - both in Auckland, New Zealand (T.G.S.)
| | - Catherine Martin
- From Royal Perth Hospital (T.B.C., P.C., K.M.H.), the University of Western Australia (T.B.C., E.O., K.M.H.), Murdoch University (K.M.H.), and Fiona Stanley Hospital (E.O.), Perth, and the Alfred Hospital (P.S.M., A.C.C., L.A.B.), Monash University (T.B.C., P.S.M., A.B.F., A.C.C., L.A.B., K.L., C.M.), the University of Melbourne (K.L., D.S.), and Royal Melbourne Hospital (K.L.), Melbourne, VIC - all in Australia; the Chinese University of Hong Kong, Hong Kong (M.T.V.C.); and Auckland City Hospital and the University of Auckland - both in Auckland, New Zealand (T.G.S.)
| | - Pauline Coutts
- From Royal Perth Hospital (T.B.C., P.C., K.M.H.), the University of Western Australia (T.B.C., E.O., K.M.H.), Murdoch University (K.M.H.), and Fiona Stanley Hospital (E.O.), Perth, and the Alfred Hospital (P.S.M., A.C.C., L.A.B.), Monash University (T.B.C., P.S.M., A.B.F., A.C.C., L.A.B., K.L., C.M.), the University of Melbourne (K.L., D.S.), and Royal Melbourne Hospital (K.L.), Melbourne, VIC - all in Australia; the Chinese University of Hong Kong, Hong Kong (M.T.V.C.); and Auckland City Hospital and the University of Auckland - both in Auckland, New Zealand (T.G.S.)
| | - Kwok M Ho
- From Royal Perth Hospital (T.B.C., P.C., K.M.H.), the University of Western Australia (T.B.C., E.O., K.M.H.), Murdoch University (K.M.H.), and Fiona Stanley Hospital (E.O.), Perth, and the Alfred Hospital (P.S.M., A.C.C., L.A.B.), Monash University (T.B.C., P.S.M., A.B.F., A.C.C., L.A.B., K.L., C.M.), the University of Melbourne (K.L., D.S.), and Royal Melbourne Hospital (K.L.), Melbourne, VIC - all in Australia; the Chinese University of Hong Kong, Hong Kong (M.T.V.C.); and Auckland City Hospital and the University of Auckland - both in Auckland, New Zealand (T.G.S.)
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Hashimoto K, Tsuji A, Takenaka S, Ohmura A, Ueki R, Noma H, Imamura M, Miyoshi Y, Kariya N, Tatara T, Hirose M. C-reactive Protein Level on Postoperative Day One is Associated with Chronic Postsurgical Pain After Mastectomy. Anesth Pain Med 2018; 8:e79331. [PMID: 30250822 PMCID: PMC6139699 DOI: 10.5812/aapm.79331] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2018] [Revised: 06/21/2018] [Accepted: 08/03/2018] [Indexed: 11/16/2022] Open
Abstract
Background C-reactive protein (CRP) is an acute phase reactant released in response to inflammation or tissue injury. Inflammation is one of the pathogenic factors related to transition from acute postsurgical pain (APSP) to chronic postsurgical pain (CPSP). Although several risk factors are reportedly associated with CPSP, the effects of CRP levels on CPSP have not been examined. Objectives The present study investigated the relationship between perioperative risk factors, including CRP levels on postoperative day one and CPSP, in patients undergoing mastectomy. Methods Preoperative anxiety and depression levels were evaluated in female patients undergoing mastectomy under general anesthesia, with or without peripheral nerve block. Patients with chronic preoperative pain and/or preoperative breast pain were excluded. The intensity of postoperative pain was prospectively examined one and six days, and three and twelve months after surgery using a numerical rating scale (NRS). Results The current researchers conducted univariate and multivariate linear regression analyses to explore risk factors for CPSP in 36 patients. Patient demographics, preoperative psychological states, and anesthetic managements showed no relationship with CPSP. On the other hand, pain intensity of APSP and CRP levels on postoperative day one was significantly associated with the pain intensity of CPSP. Conclusions Postoperative CRP level is likely to be associated with the development of CPSP after mastectomy.
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Affiliation(s)
- Kazuma Hashimoto
- Department of Anesthesiology and Pain Medicine, Hyogo College of Medicine, Hyogo, Japan
| | - Ayano Tsuji
- Department of Anesthesiology and Pain Medicine, Hyogo College of Medicine, Hyogo, Japan
| | - Shiho Takenaka
- Department of Anesthesiology and Pain Medicine, Hyogo College of Medicine, Hyogo, Japan
| | - Akimune Ohmura
- Department of Anesthesiology and Pain Medicine, Hyogo College of Medicine, Hyogo, Japan
| | - Ryusuke Ueki
- Department of Anesthesiology and Pain Medicine, Hyogo College of Medicine, Hyogo, Japan
| | - Hideki Noma
- Department of Anesthesia, Takarazuka City Hospital, Hyogo, Japan
| | - Michiko Imamura
- Division of Breast and Endocrine Surgery, Department of Surgery, Hyogo College of Medicine, Hyogo, Japan
| | - Yasuo Miyoshi
- Division of Breast and Endocrine Surgery, Department of Surgery, Hyogo College of Medicine, Hyogo, Japan
| | - Nobutaka Kariya
- Department of Anesthesiology and Pain Medicine, Hyogo College of Medicine, Hyogo, Japan
| | - Tsuneo Tatara
- Department of Anesthesiology and Pain Medicine, Hyogo College of Medicine, Hyogo, Japan
| | - Munetaka Hirose
- Department of Anesthesiology and Pain Medicine, Hyogo College of Medicine, Hyogo, Japan
- Corresponding Author: Department of Anesthesiology and Pain Medicine, Hyogo College of Medicine, 1-1 Mukogawa-cho, Nishinomiya, Hyogo 663-8501, Japan . Tel: +81-798456392, Fax: +81-798456393,
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