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Jones IA, LoBasso MA, Wier J, Gettleman BS, Richardson MK, Ratto CE, Lieberman JR, Heckmann ND. Perioperative Dexamethasone in Diabetic Patients: A Systematic Review and Meta-Analysis of Randomized, Placebo-Controlled Trials. Anesth Analg 2024; 139:479-489. [PMID: 39151134 DOI: 10.1213/ane.0000000000007007] [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: 08/18/2024]
Abstract
BACKGROUND The perioperative use of dexamethasone in diabetic patients remains controversial due to concerns related to infection and adverse events. This study aimed to determine whether clinical evidence supports withholding dexamethasone in diabetic patients due to concern for infection risk. We hypothesized that there is no difference in infectious outcomes between dexamethasone-treated patients and controls. METHODS A literature search was performed on November 22, 2022 to identify randomized, placebo-controlled trials investigating short-course (<72 hours), perioperative dexamethasone that explicitly included diabetic patients and measured at least 1 clinical outcome. Pertinent studies were independently searched in PubMed, Embase, and Cochrane. Authors for all identified studies were contacted with the aim of performing quantitative subgroup analyses of diabetic patients. The primary end point was surgical site infection and the secondary end point was a composite of adverse events. Qualitative remarks were reported based on the total available data and a quality assessment tool. Meta-analyses were performed using inverse variance with random effects. Heterogeneity was assessed via standard χ2 and I2 tests. RESULTS Sixteen unique studies were included, 5 of which were analyzed quantitatively. Of the 2592 diabetic patients, 2344 (1184 randomized to dexamethasone and 1160 to placebo) were analyzed in at least 1 quantitative outcome. Quantitative analysis showed that the use of perioperative dexamethasone had no effect on the risk of surgical site infections (log odds ratio [LOR], -0.10, 95%; 95% confidence interval [CI], -0.64 to 0.44) while significantly reducing the risk of composite adverse events (LOR, -0.33; 95% CI, -0.62 to -0.05). Qualitative analysis reinforced these findings, demonstrating noninferior to superior results across all clinical outcomes. There was high heterogeneity between the included studies. CONCLUSIONS Current evidence suggests perioperative dexamethasone may be given to diabetic patients without increasing the risk of infectious complications. Prospective investigations aimed at optimizing dose, frequency, and timing are needed, as well as studies aimed explicitly at exploring the use of dexamethasone in patients with poorly controlled diabetes.
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Affiliation(s)
- Ian A Jones
- From the Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
| | - Michael A LoBasso
- Department of Anesthesiology and Perioperative Medicine, University of California, Los Angeles, Los Angeles, California
| | - Julian Wier
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Brandon S Gettleman
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Mary K Richardson
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Christina E Ratto
- Department of Anesthesiology, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Jay R Lieberman
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Nathanael D Heckmann
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
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Katerenchuk V, Ribeiro EM, Batista AC. Impact of Intraoperative Dexamethasone on Perioperative Blood Glucose Levels: Systematic Review and Meta-Analysis of Randomized Trials. Anesth Analg 2024; 139:490-508. [PMID: 39151135 DOI: 10.1213/ane.0000000000006933] [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: 08/18/2024]
Abstract
BACKGROUND Dexamethasone is associated with increased blood glucose levels that could impact patient outcomes or management. This study aimed to synthesize the available evidence regarding the impact of an intraoperative single dose of dexamethasone on blood glucose levels. METHODS We searched CENTRAL, MEDLINE, and clinicaltrials.gov for randomized controlled trials (RCTs) comparing a single intraoperative dose of dexamethasone to control in adult patients who underwent noncardiac surgery. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and the review was registered in PROSPERO (CRD42023420562). Data were pooled using a random-effects model. We reported pooled dichotomous data using odds ratios (OR) and continuous data using the mean difference (MD), reporting 95% confidence intervals (95% CIs), and corresponding P-values for both. Confidence in the evidence was appraised using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach. As primary outcomes we assessed maximum blood glucose levels measurement and variation from baseline within 24 hours of surgery; blood glucose levels measurement and variation from baseline at 2, 4, 8, 12, and 24 hours after dexamethasone administration. As secondary outcomes, we evaluated insulin requirements and hyperglycemic events. RESULTS We included 23 RCTs, enrolling 11,154 participants overall. Dexamethasone was associated with a significant increment in blood glucose levels compared to control at all timepoints. The results showed an increase compared to control of 0.37 mmol L-1 (6.7 mg dL-1) at 2 hours (95% CI, 0.16-0.58 mmol L-1 or 2.9-10.5 mg dL-1), 0.97 mmol L-1 (17.5 mg dL-1) at 4 hours (95% CI, 0.67-1.25 mmol L-1 or 12.1-22.5 mg dL-1), 0.96 mmol L-1 (17.3 mg dL-1) at 8 hours (95% CI, 0.55-1.36 mmol L-1 or 9.9-24.5 mg dL-1), 0.90 mmol L-1 (16.2 mg dL-1) at 12 hours (95% CI, 0.62-1.19 mmol L-1 or 11.2-21.4 mg dL-1) and 0.59 mmol L-1 (10.6 mg dL-1) at 24 hours (95% CI, 0.22-0.96 mmol L-1 or 4.0-17.3 mg dL-1). No difference was found between subgroups regarding diabetic status (patients with diabetes versus patients without diabetes) in all the outcomes except 2 (maximum blood glucose levels variation within 24 hours and variation at 4 hours) and dexamethasone dose (4-5 mg vs 8-10 mg) in all the outcomes except 2 (blood glucose levels at 24 hours and hyperglycemic events). CONCLUSIONS Mean blood glucose levels rise between 0.37 and 1.63 mmol L-1 (6.7 and 29.4 mg dL-1) within 24 hours after a single dose of dexamethasone administered at induction of anesthesia compared to control, but in most patients this difference will not be clinically relevant.
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Affiliation(s)
- Vasyl Katerenchuk
- From the Department of Anesthesiology, Centro Hospitalar de Setúbal E.P.E., Setúbal, Portugal
| | - Eduardo Matos Ribeiro
- Department of Anesthesiology, Centro Hospitalar de Lisboa Ocidental E.P.E., Lisboa, Portugal
| | - Ana Correia Batista
- From the Department of Anesthesiology, Centro Hospitalar de Setúbal E.P.E., Setúbal, Portugal
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Kim Y, Yoo S, Kim SH, Kim H, Bae J, Park SK, Kim JT, Lim YJ. Comparison between low-volume local anesthetic with intravenous dexamethasone and conventional volume without dexamethasone for superior trunk block after arthroscopic shoulder surgery: a randomized controlled non-inferiority trial. Reg Anesth Pain Med 2024; 49:558-564. [PMID: 37775273 DOI: 10.1136/rapm-2023-104520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 09/15/2023] [Indexed: 10/01/2023]
Abstract
INTRODUCTION This study aimed to investigate whether low-volume local anesthetic with intravenous dexamethasone can reduce the incidence of diaphragmatic paresis while maintaining the analgesic duration compared with conventional volume of local anesthetic without intravenous dexamethasone when performing ultrasound-guided superior trunk block in patients undergoing arthroscopic shoulder surgery. METHODS Eighty-four adult patients undergoing arthroscopic shoulder surgery under general anesthesia were randomly assigned to receive ultrasound-guided superior trunk block using 7 mL of 0.5% ropivacaine with 0.15 mg/kg of intravenous dexamethasone (treatment group), or 15 mL of 0.5% ropivacaine with intravenous normal saline (control group). The co-primary outcomes were (1) the duration of analgesia (time between block completion and onset of surgical pain with a Numeric Rating Scale pain score of 4 or higher), which was compared against a non-inferiority margin of 3 hours, and (2) the incidence of diaphragmatic paresis evaluated using M-mode ultrasonography in the post-anesthesia care unit. RESULTS The mean duration of analgesia was 12.4 (6.8) and 11.2 (4.6) hours in the treatment and control groups, respectively (mean difference: -1.2 hours; 95% CI -3.8 to 1.3]; p for non-inferiority<0.001), meeting the non-inferiority criteria. The incidence of diaphragmatic paresis was 45.2% and 85.4% in the treatment and control groups, respectively (relative risk: 0.53; 97.5% CI 0.35 to 0.80; p<0.001). CONCLUSIONS Superior trunk block using low-volume local anesthetic with intravenous dexamethasone can reduce the incidence of diaphragmatic paresis while providing non-inferior analgesic duration compared with the conventional volume of local anesthetic in patients undergoing arthroscopic shoulder surgery. TRIAL REGISTRATION NUMBER Clinical Research Information Service of Republic of Korea Registry (KCT0005998).
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Affiliation(s)
- Youngwon Kim
- Department of Anesthesiology and Pain Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Seokha Yoo
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Sae Hoon Kim
- Department of Orthopedic Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hansol Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jinyoung Bae
- Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, Suwon, Gyeonggi-do, Republic of Korea
| | - Sun-Kyung Park
- Department of Anesthesiology and Pain Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jin-Tae Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Young-Jin Lim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
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Jones IA, Wier J, Liu KC, Richardson MK, Yoshida B, Palmer R, Lieberman JR, Heckmann ND. Dexamethasone-Associated Hyperglycemia is Not Associated With Infectious Complications After Total Joint Arthroplasty in Diabetic Patients. J Arthroplasty 2024; 39:S43-S52.e5. [PMID: 38220028 DOI: 10.1016/j.arth.2024.01.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 12/26/2023] [Accepted: 01/09/2024] [Indexed: 01/16/2024] Open
Abstract
BACKGROUND Postoperative infection is a devastating complication of total joint arthroplasty (TJA). Perioperative use of dexamethasone in patients who have diabetes mellitus (DM) remains controversial due to concern for increased infection risk. This study aimed to evaluate the association between dexamethasone and infection risk among patients who have DM undergoing TJA. METHODS This was a retrospective cohort study conducted on adult patients who underwent primary, elective total knee arthroplasty (TKA) or total hip arthroplasty (THA) between January 2016 and December 2021 using a large national database. We identified 110,568 TJA patients (TKA: 66.6%; THA: 33.4%), 31.0% (34,298) of which had DM. Patients who received perioperative dexamethasone were compared to those who did not. The primary end points were the 90-day risk of postoperative periprosthetic joint infection, surgical site infection (SSI), and other non-SSI (urinary tract infection, pneumonia, sepsis). RESULTS When modeling the association between dexamethasone exposure and study outcomes while accounting for the interaction between dexamethasone and morning blood glucose levels, dexamethasone administration conferred no increased odds of postoperative periprosthetic joint infection nor SSI in diabetics. However, dexamethasone significantly lowered the adjusted odds of other postoperative infections in diabetic patients (TKA: adjusted odds ratio = 09, 95% confidence interval = 0.8 to 1.0, P = .030; THA: adjusted odds ratio = 0.7, 95% confidence interval = 0.6 to 0.9, P = .001); specifically in patients with morning blood glucose levels between 110 to 248 mg/dL in TKA and ≤ 172 mg/dL in THA. CONCLUSIONS This study provides strong evidence against withholding dexamethasone in diabetic patients undergoing TJA based on concern for infection. Instead, short-course perioperative dexamethasone reduced infection risk in select patients. The narrative surrounding dexamethasone should shift away from questions about whether dexamethasone is appropriate for diabetic patients, and instead focus on how best to optimize its use.
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Affiliation(s)
- Ian A Jones
- Department of Anaesthesiology & Pain Medicine, University of Washington, Seattle, Washington
| | - Julian Wier
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Kevin C Liu
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Mary K Richardson
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Brandon Yoshida
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Ryan Palmer
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Jay R Lieberman
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Nathanael D Heckmann
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
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Porter SB, Wilson JR, Sherman CE, White LJ, Borkar SR, Spaulding AC. Dexamethasone, Glycemic Control, and Outcomes in Patients With Type 2 Diabetes Mellitus Undergoing Elective, Primary Total Joint Arthroplasty. Arthroplast Today 2024; 27:101391. [PMID: 38800512 PMCID: PMC11126535 DOI: 10.1016/j.artd.2024.101391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Revised: 03/04/2024] [Accepted: 04/01/2024] [Indexed: 05/29/2024] Open
Abstract
Background Dexamethasone (DEX) has been shown to reduce pain and postoperative nausea and vomiting for patients undergoing elective total joint arthroplasty (TJA). We investigated the impact of DEX on glycemic control and outcomes in patients with type 2 diabetes mellitus undergoing elective primary TJA. Methods All patients with type 2 diabetes mellitus undergoing primary elective TJA between January 2016 and December 2021 at 4 sites within 1 hospital system were identified. Propensity scores were calculated to match patients receiving or not receiving DEX. Primary outcomes were perioperative blood glucose levels and the incidence of hyperglycemia. Secondary outcomes were the amount of insulin administered, the occurrence of 30-day postoperative surgical site infections, hospital readmission, and mortality. Results After matching, we identified 1372 patients. DEX administration was associated with a significant increase in mean blood glucose levels in mg/dL on postoperative days (PODs) 0 to 2: POD 0 (28.4, 95% confidence interval [CI]: 24.6-32.1), POD 1 (14.4, 95% CI: 10.1-18.8), POD 2 (12.4, 95% CI: 7.5-17.2) when comparing patients who did or did not receive DEX. Additionally, patients receiving DEX, compared to patients who did not receive DEX, had increased odds of experiencing hyperglycemia on POD 0 (odds ratio: 4.0, 95% CI: 3.1-5.2). DEX was not associated with a significant difference in insulin administration, surgical site infections, hospital readmission, or mortality. Conclusions In our review of 1372 patients with propensity-matched type 2 diabetes mellitus undergoing elective, primary TJA, we found that DEX administration was associated with an increased risk of elevated mean glucose on POD 0-2, hyperglycemia on POD 0, but was not associated with an increase in total insulin dose administered nor occurrence of surgical site infections, hospital readmission, or mortality within 30 days of surgery in patients who received DEX compared to patients who did not receive DEX. Level of Evidence IV.
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Affiliation(s)
- Steven B. Porter
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Jessica R. Wilson
- Division of Endocrinology, Diabetes, and Metabolism, Department of Internal Medicine, Mayo Clinic, Jacksonville, FL, USA
| | | | - Launia J. White
- Division of Health Care Delivery Research, Mayo Clinic, Jacksonville, FL, USA
| | - Shalmali R. Borkar
- Division of Health Care Delivery Research, Mayo Clinic, Jacksonville, FL, USA
| | - Aaron C. Spaulding
- Division of Health Care Delivery Research, Mayo Clinic, Jacksonville, FL, USA
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Dimmen A, Timko S, Greenwood J, McShane F, Ulinski J. 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. JBI Evid Synth 2023; 21:2156-2187. [PMID: 37807873 DOI: 10.11124/jbies-22-00300] [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: 10/10/2023]
Abstract
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.
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Affiliation(s)
- Andrew Dimmen
- Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA
- RFU Center for Interprofessional Evidence Based Practice: A JBI Centre of Excellence, Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA
| | - Sara Timko
- Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA
- RFU Center for Interprofessional Evidence Based Practice: A JBI Centre of Excellence, Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA
| | - Jennifer Greenwood
- Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA
- RFU Center for Interprofessional Evidence Based Practice: A JBI Centre of Excellence, Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA
| | - Franklin McShane
- Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA
- RFU Center for Interprofessional Evidence Based Practice: A JBI Centre of Excellence, Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA
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Alansary AM, Aziz MM, Elbeialy MAK. Dexamethasone Plus Bupivacaine Versus Bupivacaine in Bilateral Transincisional Paravertebral Block in Lumbar Spine Surgeries: A Randomized Controlled Trial. Clin J Pain 2023; 39:458-466. [PMID: 37341712 DOI: 10.1097/ajp.0000000000001141] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Accepted: 06/13/2023] [Indexed: 06/22/2023]
Abstract
OBJECTIVES Few studies examined the analgesic effects of dexamethasone in lumbar paravertebral block, specifically the transincisional approach. This study aimed to compare dexamethasone with bupivacaine versus bupivacaine alone for bilateral transincisional paravertebral block (TiPVB) for postoperative analgesia in lumbar spine surgeries. MATERIALS AND METHODS Fifty patients who were aged 20 to 60 years and had American Society of Anesthesiologists Physical Status (ASA-PS) I or II of either sex were randomly allocated into 2 equal groups. Both groups received combined general anesthesia and bilateral lumbar TiPVB. However, in group 1 (dexamethasone group) (n=25), patients received 14 mL of bupivacaine 0.20% plus 1 mL containing 4 mg of dexamethasone on each side, while, in group 2 (control group) (n=25), patients received 14 mL of bupivacaine 0.20% plus 1 mL of saline on each side. Time to first analgesic need was the primary outcome, while total opioid consumption during the first 24 hours after surgery, the Visual Analog Scale for pain perception (0-10), and the incidence of side effects were secondary outcomes. RESULTS The mean time to the first analgesic requirement was significantly prolonged among patients in the dexamethasone group than the control group (mean±SD: 18.4±0.8 vs. 8.7±1.2 h, respectively) ( P <0.001). Patients in the dexamethasone group had lower total opiates consumption than the control) P <0.001). Although nonsignificant, the incidence of postoperative nausea and vomiting was more frequent among the control group ( P =0.145). DISCUSSION Adding dexamethasone to bupivacaine in TiPVB resulted in a prolonged analgesia-free period and lower opioid consumption in lumbar spine surgeries with comparable incidence of adverse events.
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Affiliation(s)
- Amin M Alansary
- Departments of Anesthesiology, Intensive Care, and Pain Management
| | - Mohamed M Aziz
- Neurosurgery, Faculty of Medicine, Ain Shams University, Cairo, Egypt
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Touil N, Pavlopoulou A, Delande S, Geradon P, Barbier O, Libouton X, Lavand'homme P. Effect of Intravenous Dexamethasone Dose on the Occurrence of Rebound Pain after Axillary Plexus Block in Ambulatory Surgery. J Clin Med 2023; 12:4310. [PMID: 37445344 DOI: 10.3390/jcm12134310] [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: 05/07/2023] [Revised: 06/12/2023] [Accepted: 06/19/2023] [Indexed: 07/15/2023] Open
Abstract
Rebound pain (RP) remains a challenge in ambulatory surgery, characterized by severe pain upon resolution of a peripheral nerve block (PNB). Intravenous (IV) administration of Dexamethasone (DEXA) potentiates PNB analgesic effect and reduces RP incidence although preventive effective dose remains undetermined. This retrospective analysis evaluates the preventive effect of IV DEXA on RP in outpatients undergoing upper limb surgery under axillary block. DEXA was divided into high (HD > 0.1 mg/kg) or low (LD < 0.1 mg/kg) doses. RP was defined as severe pain (NRS ≥ 7/10) within 24 h of PNB resolution. DEXA HD and LD patients were matched with control patients without DEXA (n = 55) from a previous randomized controlled study. Records of 118 DEXA patients were analyzed (DEXA dose ranged from 0.05 to 0.12 mg/kg). Intraoperative IV DEXA was associated with a significant reduction of the pain felt when PNB wore off as well as to a significant reduction of RP incidence (n = 27/118, 23% vs. 47% in controls, p = 0.002) with no effect related to the dose administered (p = 0.053). Our results support the administration of intraoperative DEXA as a preventive measure to reduce the occurrence of RP.
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Affiliation(s)
- Nassim Touil
- Department of Anaesthesiology, Cliniques Universitaires Saint-Luc, Catholic University of Louvain, B-1200 Brussels, Belgium
| | - Athanassia Pavlopoulou
- Department of Anaesthesiology, Cliniques Universitaires Saint-Luc, Catholic University of Louvain, B-1200 Brussels, Belgium
| | - Simon Delande
- Department of Anaesthesiology, Cliniques Universitaires Saint-Luc, Catholic University of Louvain, B-1200 Brussels, Belgium
| | - Pierre Geradon
- Department of Anaesthesiology, Cliniques Universitaires Saint-Luc, Catholic University of Louvain, B-1200 Brussels, Belgium
| | - Olivier Barbier
- Department of Orthopaedic Surgery, Cliniques Universitaires Saint-Luc, Catholic University of Louvain, B-1200 Brussels, Belgium
| | - Xavier Libouton
- Department of Orthopaedic Surgery, Cliniques Universitaires Saint-Luc, Catholic University of Louvain, B-1200 Brussels, Belgium
| | - Patricia Lavand'homme
- Department of Anaesthesiology, Cliniques Universitaires Saint-Luc, Catholic University of Louvain, B-1200 Brussels, Belgium
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Lavand'homme P, Kehlet H. Benefits versus harm of intraoperative glucocorticoid for postoperative nausea and vomiting prophylaxis. Br J Anaesth 2023:S0007-0912(23)00187-3. [PMID: 37183100 DOI: 10.1016/j.bja.2023.04.013] [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: 03/13/2023] [Revised: 04/11/2023] [Accepted: 04/12/2023] [Indexed: 05/16/2023] Open
Abstract
Intraoperative use of glucocorticoids is effective for postoperative nausea and vomiting prophylaxis and can also provide early postoperative analgesic effects, but the consequences for chronic post-surgical pain are debatable. In a secondary analysis of the large pragmatic Perioperative Administration of Dexamethasone and Infection trial (n=8478), the primary outcome of pain at the surgical wound at 6 months after surgery was increased in subjects receiving dexamethasone 8 mg i.v. for postoperative nausea and vomiting prophylaxis, a dose not associated with the detrimental effect of surgical site infection in the original study. In contrast, a more detailed assessment of chronic post-surgical pain after exclusion of patients with preoperative pain at the surgical site showed no differences with or without intraoperative dexamethasone regarding chronic post-surgical pain characteristics (intensity and neuropathic features). Because of several confounding factors especially regarding surgical details, these unexpected findings call for more well-designed studies about the potential risk of intraoperative treatments, such as glucocorticoids, on late post-surgical pain.
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Affiliation(s)
- Patricia Lavand'homme
- Department of Anesthesiology and Acute Postoperative & Transitional Pain Service, Cliniques Universitaires St Luc-University Catholic of Louvain, Brussels, Belgium.
| | - Henrik Kehlet
- Section of Surgical Pathophysiology, Rigshospitalet, Copenhagen, Denmark
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Crowley K, Scanaill PÓ, Hermanides J, Buggy DJ. Current practice in the perioperative management of patients with diabetes mellitus: a narrative review. Br J Anaesth 2023:S0007-0912(23)00128-9. [PMID: 37061429 PMCID: PMC10375498 DOI: 10.1016/j.bja.2023.02.039] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 02/08/2023] [Accepted: 02/23/2023] [Indexed: 04/17/2023] Open
Abstract
The prevalence of diabetes is increasing, and patients with diabetes mellitus have both an increased likelihood of requiring surgery and of developing postoperative complications when they do. We summarise available evidence underpinning current guidelines on preoperative assessment and optimisation, perioperative management of prescribed insulin and oral hypoglycaemic medication, intraoperative glycaemic control, and postoperative patient care.
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Affiliation(s)
- Kieran Crowley
- Department of Anaesthesiology & Perioperative Medicine, Mater University Hospital, School of Medicine, University College Dublin, Dublin, Ireland.
| | - Pádraig Ó Scanaill
- Department of Anaesthesiology & Perioperative Medicine, Mater University Hospital, School of Medicine, University College Dublin, Dublin, Ireland
| | | | - Donal J Buggy
- Department of Anaesthesiology & Perioperative Medicine, Mater University Hospital, School of Medicine, University College Dublin, Dublin, Ireland; Outcomes Research Cleveland Clinic, Cleveland, OH, USA.
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Pang QY, Wang JY, Liang XL, Jiang Y, Liu HL. The safety of perioperative dexamethasone with antiemetic dosage in surgical patients with diabetes mellitus: a systematic review and meta-analysis. Perioper Med (Lond) 2023; 12:4. [PMID: 36890549 PMCID: PMC9993727 DOI: 10.1186/s13741-023-00293-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 02/26/2023] [Indexed: 03/10/2023] Open
Abstract
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.
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Affiliation(s)
- Qian-Yun Pang
- Department of Anesthesiology, Chongqing University Cancer Hospital, No. 181, Hanyu Road, Shapingba District, Chongqing City, 400030, China
| | - Jing-Yun Wang
- School of Medicine, Chongqing University; Chongqing University Cancer Hospital, Chongqing, 400030, China
| | - Xiao-Long Liang
- Department of Anesthesiology, Chongqing University Cancer Hospital, No. 181, Hanyu Road, Shapingba District, Chongqing City, 400030, China
| | - Yan Jiang
- Department of Anesthesiology, Chongqing University Cancer Hospital, No. 181, Hanyu Road, Shapingba District, Chongqing City, 400030, China
| | - Hong-Liang Liu
- Department of Anesthesiology, Chongqing University Cancer Hospital, No. 181, Hanyu Road, Shapingba District, Chongqing City, 400030, China.
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High dose glucocorticoids: will this change the face of multimodal postoperative analgesia and enhanced recovery? Ugeskr Laeger 2023; 40:151-152. [PMID: 36722185 DOI: 10.1097/eja.0000000000001782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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Rhou YJJ, Hor A, Wang M, Wu YF, Jose S, Chipps DR, Cheung NW. Dexamethasone-induced hyperglycaemia in COVID-19: Glycaemic profile in patients without diabetes and factors associated with hyperglycaemia. Diabetes Res Clin Pract 2022; 194:110151. [PMID: 36375566 PMCID: PMC9651935 DOI: 10.1016/j.diabres.2022.110151] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 10/05/2022] [Accepted: 11/06/2022] [Indexed: 11/13/2022]
Abstract
AIMS To evaluate glycaemic profiles of COVID-19 patients without diabetes receiving dexamethasone and determine factors associated with hyperglycaemia. METHODS All subjects without pre-existing diabetes receiving dexamethasone 6 mg for COVID-19 in a non-critical care setting were identified. Glucose profiles were obtained from capillary blood glucose (BG). Univariate and multivariate analyses were performed to identify factors associated with dexamethasone-induced hyperglycaemia (BG ≥ 10 mmol/L). RESULTS Of 254 subjects, 129 (50.8%) were male with age 51.1 ± 18.2 years and weight 89.7 ± 26.3 kg. Hyperglycaemia post-dexamethasone occurred in 121 (47.6%). Glucose excursions began within three hours (6.8 ± 1.4 mmol/L pre-dexamethasone vs 8.7 ± 2.4 mmol/L at ≤ 3 h, p < 0.001) and peaked at 7-9 h (10.5 ± 2.3 mmol/L, p < 0.001 vs pre-dexamethasone). BGs post-intravenous were higher than post-oral administration for the initial six hours. Hyperglycaemic subjects were older (57.8 ± 17.5 years vs 45.0 ± 16.6 years, p < 0.001), had higher initial glucose (6.3 ± 1.0 vs 5.9 ± 0.9 mmol/L, p = 0.004), higher HbA1c (5.8 ± 0.3% [40 ± 3.5 mmol/mol] vs 5.5 ± 0.4% [37 ± 4.1 mmol/mol], p < 0.001) higher C-reactive protein (CRP) (100 ± 68 vs 83 ± 58 mg/L, p = 0.026), and lower eGFR (79 ± 17 vs 84 ± 16 mL/min/1.73 m2, p = 0.045). Mortality was greater in the hyperglycaemia group (9/121 [7.4%] vs 2/133 [1.5%], p = 0.02). Age, HbA1c and CRP were independently associated with hyperglycaemia. CONCLUSIONS Half of subjects without diabetes experienced hyperglycaemia post-dexamethasone for COVID-19, peak occurring after 7-9 h. Age, HbA1c and CRP were associated with hyperglycaemia.
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Affiliation(s)
- Yoon Ji J Rhou
- Department of Diabetes and Endocrinology, Westmead Hospital, Westmead, Sydney, NSW 2145, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, NSW 2006, Australia.
| | - Amanda Hor
- Department of Diabetes and Endocrinology, Westmead Hospital, Westmead, Sydney, NSW 2145, Australia; Faculty of Medicine and Health, University of New South Wales, Sydney, NSW 2052, Australia
| | - Mawson Wang
- Department of Diabetes and Endocrinology, Westmead Hospital, Westmead, Sydney, NSW 2145, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, NSW 2006, Australia
| | - Yu-Fang Wu
- Department of Diabetes and Endocrinology, Westmead Hospital, Westmead, Sydney, NSW 2145, Australia
| | - Suja Jose
- Department of Diabetes and Endocrinology, Westmead Hospital, Westmead, Sydney, NSW 2145, Australia
| | - David R Chipps
- Department of Diabetes and Endocrinology, Westmead Hospital, Westmead, Sydney, NSW 2145, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, NSW 2006, Australia
| | - N Wah Cheung
- Department of Diabetes and Endocrinology, Westmead Hospital, Westmead, Sydney, NSW 2145, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, NSW 2006, Australia
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Peter V, Shenoy U, Rukkiyabeevi B. Effect of a single intraoperative dose of dexamethasone on glycaemic profile in postoperative patients - A double-blind randomised controlled study. Indian J Anaesth 2022; 66:789-795. [PMID: 36590189 PMCID: PMC9795505 DOI: 10.4103/ija.ija_332_22] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 11/04/2022] [Accepted: 11/05/2022] [Indexed: 11/18/2022] Open
Abstract
Background and Aims The effect of a single intraoperative dose of steroids on perioperative blood sugar levels is uncertain. We hypothesised that a single dose of dexamethasone would not unfavourably alter the glucose levels of non-diabetic patients. This study aimed to evaluate the post-operative glycaemic profile after a single dose of intraoperative dexamethasone in non-diabetic patients. The presence of post-operative nausea and vomiting (PONV), pain, surgical site infection (SSI) and length of hospital stay were also evaluated. Methods This randomised, double-blind, controlled study was done by recruiting 150 non-diabetic adult patients of the American Society of Anesthesiologists physical status I/II undergoing elective surgery. Patients in the study group were administered a single dose of dexamethasone (0.15 mg/kg). Blood glucose levels were assessed at various time points for up to 72 hours post-operatively using point-of-care testing. Secondary outcomes such as PONV, pain, fever and SSI were also documented. Data were compared and analysed using Student's t-test, Chi-square test, Mann-Whitney test and analysis of variance test. Results There was an earlier, higher and prolonged elevation in blood glucose levels in patients receiving dexamethasone. The mean (standard deviation) of fasting/postprandial blood sugars on the first, second and third postoperative days respectively was significantly higher in the study group 98.04 (21.89)/139.16 (20.59), 96.64 (19.20)/138.17 (18.05), 96.60 (17.40)/138.32 (15.10) mg/dl as compared to control group 86.9 6 (10.28)/128.95 (10.53), 88.81 (8.87)/131.97 (9.68), 88.16 (8.50)/130.88 (9.48) mg/dl. About 10.7% of the patients who received dexamethasone had blood glucose levels greater than 180 mg/dl. There were no significant differences in the secondary outcomes. Conclusion Even a single dose of dexamethasone in non-diabetic adults causes significant and prolonged postoperative hyperglycaemia.
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Affiliation(s)
- Vigil Peter
- Department of Anaesthesia, Jubilee Mission Medical College and Regional Institute, Thrissur, Kerala, India,Address for correspondence: Dr. Vigil Peter, Alapatt House, Parappukkara P.O, Thrissur, Kerala - 680 310, India. E-mail:
| | - Usha Shenoy
- Department of Anaesthesia, Jubilee Mission Medical College and Regional Institute, Thrissur, Kerala, India
| | - Buena Rukkiyabeevi
- Department of Anaesthesia, Jubilee Mission Medical College and Regional Institute, Thrissur, Kerala, India
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Lejeune D, Hardy PY, Kaba A, Joris J. Postoperative morbidity and mortality in patients with diabetes after colorectal surgery with an enhanced recovery program: A monocentric retrospective study. J Visc Surg 2022:S1878-7886(22)00157-6. [DOI: 10.1016/j.jviscsurg.2022.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
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Sermkasemsin V, Rungreungvanich M, Apinyachon W, Sangasilpa I, Srichot W, Pisitsak C. Incidence and risk factors of intraoperative hyperglycemia in non-diabetic patients: a prospective observational study. BMC Anesthesiol 2022; 22:287. [PMID: 36088294 PMCID: PMC9463729 DOI: 10.1186/s12871-022-01829-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 08/24/2022] [Indexed: 11/29/2022] Open
Abstract
Background Intraoperative hyperglycemia has been associated with multiple postoperative complications such as surgical site infection, myocardial infarction, stroke, and death. These complications are not confined to only diabetic patients. However, the incidence of intraoperative hyperglycemia in non-diabetic patients has not been fully elucidated. Additionally, these patients’ risk factors were not well established in previous studies. Methods Four hundred forty non-diabetic patients who underwent intermediate- to high-risk surgery were included in the study. We prospectively measured the capillary blood glucose level in all patients during surgery. The incidence of intraoperative hyperglycemia was defined as at least one episode of blood glucose level of more than 180 mg/dL. Risk factors for hyperglycemia were assessed using multivariable logistic regression analysis. Results Sixty-five (14.7%) patients developed hyperglycemia during surgery. The independent risk factors for intraoperative hyperglycemia were an American Society of Anesthesiologists status ≥ 3 (odds ratio [OR] 6.09, 95% confidence interval [CI]: 2.67–13.89, p < 0.001), preoperative impaired fasting blood sugar (OR 2.28, 95%CI:1.13–4.61, p = 0.021), duration of anesthesia ≥ 3 h (OR 4.06, 95%CI: 1.23–13.45, p = 0.021), intraoperative hypotension (OR 5.37, 95%CI: 2.35–12.29, p < 0.001), intraoperative blood transfusion (OR 4.35, 95%CI: 2.15–8.79, p < 0.001), and steroid use (OR 2.39, 95%CI: 1.20–4.76, p = 0.013). Surgical site infection was higher in patients with intraoperative hyperglycemia compared with patients without intraoperative hyperglycemia (4 [6.1%] vs. 6 [1.6%], respectively, p = 0.035). Conclusion The incidence of intraoperative hyperglycemia was significant in non-diabetic patients during intermediate- to high-risk surgery. Risk factors should be identified to prevent intraoperative hyperglycemia. Trial registration The study was prospectively registered at https://www.thaiclinicaltrials.org (TCTR20191114001).
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Feeley AA, Feeley TB, Feeley IH, Sheehan E. Postoperative Infection Risk in Total Joint Arthroplasty After Perioperative IV Corticosteroid Administration: A Systematic Review and Meta-Analysis of Comparative Studies. J Arthroplasty 2021; 36:3042-3053. [PMID: 33902983 DOI: 10.1016/j.arth.2021.03.057] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 03/16/2021] [Accepted: 03/31/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Perioperative corticosteroid administration is associated with reduced postoperative nausea, pain, and enhanced recovery after surgery. However, potential complications including wound and periprosthetic joint infections remain a concern for surgeons after total joint arthroplasty (TJA). METHODS A systematic review of the search databases PubMed, Google Scholar, and EMBASE was made in January 2021 to identify comparative studies evaluating infection risk after perioperative corticosteroid administration in TJA. PRISMA guidelines were used for this review. Meta-analysis was used to assess infection risk in accordance with joint and corticosteroid dosing regimen used. RESULTS 201 studies were returned after initial search strategy, with 29 included for review after application of inclusion and exclusion criteria. Studies were categorized as using low- or high-dose corticosteroid with single or repeat dosing regimens. Single low-dose corticosteroid administration was not associated with an increased risk of infection (P = .4; CI = 0.00-0.00). Single high-dose corticosteroid was not associated with an increased infection risk (P = .3; CI = 0.00-0.01) nor did repeat low-dose regimens result in increased risk of infection (P = .8; CI = -0.02-0.02). Studies assessing repeat high-dosing regimens reported no increased infection, with small numbers of participants included. No significant risk difference in infection risk was noted in hip (P = .59; CI = -0.03-0.02) or knee (P = .2; CI = 0.00-0.01) arthroplasty. Heterogeneity in patient profiles included in studies to date was noted. CONCLUSION Use of perioperative corticosteroid in TJA does not appear to be associated with increased risk of postoperative infection in patients with limited comorbidities. Further research is warranted to evaluate postoperative complications after TJA in these at-risk patient populations.
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Affiliation(s)
- Aoife A Feeley
- Department of Orthopaedics, Midland Regional Hospital Tullamore, Puttaghan, Tullamore, Ireland
| | - Tara B Feeley
- Department of Anaesthetics, Starship Children's Hospital, Auckland, New Zealand
| | - Iain H Feeley
- Department of Orthopaedics, National Orthopaedic Hospital Cappagh, Cappoge, Dublin, Ireland
| | - Eoin Sheehan
- Department of Orthopaedics, Midland Regional Hospital Tullamore, Puttaghan, Tullamore, Ireland
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