PACMAN trial protocol, Perioperative Administration of Corticotherapy on Morbidity and mortality After Non-cardiac major surgery: a randomised, multicentre, double-blind, superiority study

Cost effectiveness and long-term outcomes of dexamethasone administration in major non-cardiac surgery

STUDY OBJECTIVES

Postoperative administration of dexamethasone has been proposed to reduce morbidity and mortality in patients undergoing major non-cardiac surgery. In this ancillary study of the PACMAN trial, we aimed to evaluate the cost effectiveness of dexamethasone in patients undergoing major non-cardiac surgery.

METHODS

Patients included in the multicentric randomized double-blind, placebo-controlled PACMAN trial were followed up for 12 months after their surgical procedure. Patients were randomized to receive either dexamethasone (0.2 mg/kg immediately after the surgical procedure, and on day 1) or placebo. Cost effectiveness between the dexamethasone and placebo groups was assessed for the 12-month postoperative period from a health payer perspective.

RESULTS

Of 1222 randomized patients in PACMAN, 137 patients (11%) were followed up until 12 months after major surgery (71 in the DXM group and 66 in the placebo group). Postoperative dexamethasone administration reduced costs per patient at 1 year by €358.06 (95%CI -€1519.99 to €803.87). The probability of dexamethasone being cost effective was between 12% and 22% for a willingness to pay of €100,000 to €150,000 per life-year, which is the threshold that is usually used in France and was 52% for willingness to pay of €50,000 per life-year (threshold in USA). At 12 months, 9 patients (13.2%) in the DXM group and 10 patients (16.1%) in the placebo group had died. In conclusion, our study does not demonstrate the cost effectiveness of perioperative administration of DXM in major non-cardiac surgery.

Adjuvants for balanced anesthesia in ambulatory surgery

Balanced anesthesia relies on the simultaneous administration of different drugs to attain an anesthetic state. The classic triad of anesthesia is a combination of a hypnotic, an analgesic, and a neuromuscular blocker. It is predominantly the analgesic pillar of this triad that became more and more supported by adjuvant therapy. The aim of this approach is to evolve into an opioid-sparing technique to cope with undesirable side effects of the opioids and is fueled by the opioid epidemic. The optimal strategy for balanced general anesthesia in ambulatory surgery must aim for a transition to a multimodal analgesic regimen dealing with acute postoperative pain and ideally reduce the most common adverse effects patients are faced with at home; sore throat, delayed awakening, memory disturbances, headache, nausea and vomiting, and negative behavioral changes. Over the years, this continuum of "multimodal general anesthesia" adopted many drugs with different modes of action. This review focuses on the most recent evidence on the different adjuvants that entered clinical practice and gives an overview of the different mechanisms of action, the potential as opioid-sparing or hypnotic-sparing drugs, and the applicability specifically in ambulatory surgery.

Perioperative dexamethasone with neuraxial anesthesia for scheduled cesarean delivery and neonatal hypoglycemia

OBJECTIVE

While the use of dexamethasone for cesarean delivery to prevent post-operative nausea and vomiting has become routine, the impact on fetal glucose metabolism is unknown. We aim to examine whether perioperative dexamethasone administration prior to scheduled non-labor cesarean delivery is associated with neonatal hypoglycemia.

STUDY DESIGN

Multi-institution retrospective cohort study of singleton, full-term, non-anomalous pregnancies delivered by scheduled non-labor cesarean delivery with neuraxial anesthesia from 2013 to 2019. The exposure was intravenous dexamethasone after neuraxial anesthesia placement. Primary outcome was neonatal hypoglycemia and secondary outcomes included low Apgar, umbilical artery pH < 7.1, NICU admission, and meconium-stained amniotic fluid. A subgroup analysis was performed on pregnancies complicated by diabetes (both gestational and pre-gestational). Multivariate regression adjusting for baseline differences and potential confounders was used to the determine the strength of association between dexamethasone and adverse outcomes.

RESULTS

Of the 4991 women in the study, 2719 (54.5%) received dexamethasone. Compared to non-receipt, women receiving dexamethasone were older, more likely to be White, non-Hispanic, have private insurance, and less likely to have diabetes. Perioperative dexamethasone receipt was not associated with neonatal hypoglycemia (adjusted OR 0.90, 95% CI 0.71-1.14). In a subgroup analysis of the 466 (9.3%) pregnancies complicated by pre-gestational and gestational diabetes, 219 (47.0%) received dexamethasone and receipt was associated with a significantly increased rate of neonatal hypoglycemia (adjusted OR 1.96, 95% CI 1.28-3.00). No significant associations were found between perioperative dexamethasone and other outcomes.

CONCLUSIONS

Dexamethasone administration after neuraxial anesthesia placement for scheduled non-labor cesarean delivery is associated with altered neonatal glucose metabolism only in pregnancies complicated by diabetes.

An External-Validated Algorithm to Predict Postoperative Pneumonia Among Elderly Patients With Lung Cancer After Video-Assisted Thoracoscopic Surgery

The aim of the study was to develop an algorithm to predict postoperative pneumonia among elderly patients with lung cancer after video-assisted thoracoscopic surgery. We analyzed 3,009 patients from the Thoracic Perioperative Database for Geriatrics in our hospital and finally enrolled 1,585 elderly patients (age≧65 years) with lung cancer treated with video-assisted thoracoscopic surgery. The included patients were randomly divided into a training group (n = 793) and a validation group (n = 792). Patients in the training group were used to develop the algorithm after screening up to 30 potential risk factors, and patients in the validation group were used to internally validate the algorithm. External validation of the algorithm was achieved in the external validation dataset after enrolling 165 elderly patients with lung cancer treated with video-assisted thoracoscopic surgery from two hospitals in China. Of all included patients, 9.15% (145/1,585) of patients suffered from postoperative pneumonia in the Thoracic Perioperative Database for Geriatrics, and 10.30% (17/165) of patients had postoperative pneumonia in the external validation dataset. The algorithm consisted of seven variables, including sex, smoking, history of chronic obstructive pulmonary disease (COPD), surgery duration, leukocyte count, intraoperative injection of colloid, and intraoperative injection of hormone. The C-index from the receiver operating characteristic curve (AUROC) was 0.70 in the training group, 0.67 in the internal validation group, and 0.71 in the external validation dataset, and the corresponding calibration slopes were 0.88 (95% confident interval [CI]: 0.37–1.39), 0.90 (95% CI: 0.46–1.34), and 1.03 (95% CI: 0.24–1.83), respectively. The actual probabilities of postoperative pneumonia were 5.14% (53/1031) in the low-risk group, 15.07% (71/471) in the medium-risk group, and 25.30% (21/83) in the high-risk group (p < 0.001). The algorithm can be a useful prognostic tool to predict the risk of developing postoperative pneumonia among elderly patients with lung cancer after video-assisted thoracoscopic surgery.

Effect of dexamethasone on complications or all cause mortality after major non-cardiac surgery: multicentre, double blind, randomised controlled trial

OBJECTIVE

To assess the effect of dexamethasone on complications or all cause mortality after major non-cardiac surgery.

DESIGN

Phase III, randomised, double blind, placebo controlled trial.

SETTING

34 centres in France, December 2017 to March 2019.

PARTICIPANTS

1222 adults (>50 years) requiring major non-cardiac surgery with an expected duration of more than 90 minutes. The anticipated time frame for recruitment was 24 months.

INTERVENTIONS

Participants were randomised to receive either dexamethasone (0.2 mg/kg immediately after the surgical procedure, and on day 1) or placebo. Randomisation was stratified on the two prespecified criteria of cancer and thoracic procedure.

MAIN OUTCOMES MEASURES

The primary outcome was a composite of postoperative complications or all cause mortality within 14 days after surgery, assessed in the modified intention-to-treat population (at least one treatment administered).

RESULTS

Of the 1222 participants who underwent randomisation, 1184 (96.9%) were included in the modified intention-to-treat population. 14 days after surgery, 101 of 595 participants (17.0%) in the dexamethasone group and 117 of 589 (19.9%) in the placebo group had complications or died (adjusted odds ratio 0.81, 95% confidence interval 0.60 to 1.08; P=0.15). In the stratum of participants who underwent non-thoracic surgery (n=1038), the primary outcome occurred in 69 of 520 participants (13.3%) in the dexamethasone group and 93 of 518 (18%) in the placebo group (adjusted odds ratio 0.70, 0.50 to 0.99). Adverse events were reported in 288 of 613 participants (47.0%) in the dexamethasone group and 296 of 609 (48.6%) in the placebo group (P=0.46).

CONCLUSIONS

Dexamethasone was not found to significantly reduce the incidence of complications and death in patients 14 days after major non-cardiac surgery. The 95% confidence interval for the main result was, however, wide and suggests the possibility of important clinical effectiveness.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03218553.

Preferential inhibition of adaptive immune system dynamics by glucocorticoids in patients after acute surgical trauma

Glucocorticoids (GC) are a controversial yet commonly used intervention in the clinical management of acute inflammatory conditions, including sepsis or traumatic injury. In the context of major trauma such as surgery, concerns have been raised regarding adverse effects from GC, thereby necessitating a better understanding of how GCs modulate the immune response. Here we report the results of a randomized controlled trial (NCT02542592) in which we employ a high-dimensional mass cytometry approach to characterize innate and adaptive cell signaling dynamics after a major surgery (primary outcome) in patients treated with placebo or methylprednisolone (MP). A robust, unsupervised bootstrap clustering of immune cell subsets coupled with random forest analysis shows profound (AUC = 0.92, p-value = 3.16E-8) MP-induced alterations of immune cell signaling trajectories, particularly in the adaptive compartments. By contrast, key innate signaling responses previously associated with pain and functional recovery after surgery, including STAT3 and CREB phosphorylation, are not affected by MP. These results imply cell-specific and pathway-specific effects of GCs, and also prompt future studies to examine GCs' effects on clinical outcomes likely dependent on functional adaptive immune responses.

Attitudes towards the use of perioperative steroids in resectional colorectal cancer surgery in the UK: A qualitative study

Introduction

Resectional surgery remains the mainstay of treatment for colorectal cancer. A heightened postoperative systemic inflammatory response has been shown to correlate negatively with short/long-term outcomes. Perioperative steroid administration may help to alleviate this systemic inflammatory response. This survey has been carried out to assess current attitudes towards perioperative steroid use and to gauge interest in a randomised control trial in this area.

Method

An internet-based survey consisting of 9 questions was circulated via email. Those responses from outside the United Kingdom were excluded.

Result

74 doctors from the United Kingdom, predominantly Consultant Anaesthetists (54%) responded to this survey. 77% gave some or all of their patients steroids, in 75% of cases at the discretion of the anaesthetist. The main perceived benefit was to reduce postoperative nausea and vomiting. Diabetics and those deemed at high risk of wound infection were the group in whom most respondents would be reluctant to give steroids. 32% of respondents had no concerns. 87% of respondents felt that a randomised trial in this field would be of clinical interest with most respondents (58%) preferring a three-armed trial – no steroids vs low dose steroids vs high dose steroids.

Conclusion

This survey indicated that perioperative steroid use is currently widespread. Sufficient equipoise exists for a trial in this area with regard to examining the impact of dexamethasone on postoperative complications and the postoperative systemic inflammatory response. Respondents favoured a 3-armed trial – no steroids vs low-dose steroids vs high-dose steroids.

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Currently, the use of perioperative steroids is common, although not routine in resectional colorectal surgery.

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Perioperative steroids are currently administered with the aim of reducing postoperative nausea and vomiting.

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There is sufficient equipoise to carry out an RCT studying perioperative dexamethasone and outcomes in colorectal resection.