Dexamethasone versus ondansetron in the prevention of postoperative nausea and vomiting in patients undergoing laparoscopic surgery: a meta-analysis of randomized controlled trials

Perioperative Dexamethasone in Diabetic Patients: A Systematic Review and Meta-Analysis of Randomized, Placebo-Controlled Trials

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.

The risk factors of postoperative nausea and vomiting in patients undergoing laparoscopic sleeve gastrectomy and laparoscopic distal gastrectomy: a propensity score matching analysis

Postoperative nausea and vomiting (PONV) is a common side effect after laparoscopic surgery. The aim of the study is to investigate the variables that could predict PONV in patients who underwent laparoscopic gastrectomy. We divided patients who underwent laparoscopic gastrectomy into PONV and No-PONV groups. Propensity score matching (PSM) was applied to adjust confounding factors for further validation, and ordinal logistic regression analysis was used to identify predictors for PONV. In the ordinal logistic regression analysis, the preoperative neutrophil-to-lymphocyte ratio (NLR) (odds ratio [OR]: 3.19, 95% confidence interval [CI]: 1.38-7.38; p < 0.01) was identified as an independent risk factor for the presence of PONV and a predictor of the severity of PONV (OR: 3.44, 95% CI: 1.67-5.20; p < 0.01) in 94 PSM patients. Besides, NLR was positively correlated with the PONV score (r = 0.534, p < 0.001). In the receiver-operating characteristic (ROC) curve analysis, an NLR with an optimal cutoff value of 1.59 predicted severe PONV with a sensitivity of 72% and specificity of 81%. The NLR was an independent risk factor for the presence of PONV, and a high NLR tends to be positively associated with the severity of PONV after laparoscopic gastrectomy.

The Effectiveness of Ondansetron and Dexamethasone in Preventing Postoperative Nausea and Vomiting After Laparoscopic Cholecystectomy

Background The current research compared the effectiveness of dexamethasone with ondansetron in terms of the frequency of postoperative nausea and vomiting in patients undergoing laparoscopic cholecystectomy. Methodology A comparative cross-sectional study was conducted in the Department of Surgery, Civil Hospital, Karachi, Pakistan, between June 2021 and March 2022. All patients aged between 18 and 70 years who were scheduled for elective laparoscopic cholecystectomy under general anesthesia were included in the study. All women who were on antiemetics or cortisone before surgery pregnant, and had hepatic, or renal malfunction were excluded. Group A included patients who were administered 8 mg of dexamethasone intravenously, and group B included patients who were prescribed 4 mg of ondansetron intravenously. Observation of patients was done for any symptoms such as vomiting, nausea, or the need for any antiemetic medication after the surgery. The number of episodes of vomiting and nausea was recorded in the proforma along with the duration of stay in the hospital. Results A total of 259 patients were examined during the study - 129 (49.8%) in the dexamethasone group (group A) and 130 (50.2%) in the ondansetron group (group B). The mean age of group A was 42.56 ± 11.9 years, with a mean weight of 61.4 ± 8.5 kg. The mean age of group B was 41.19 ± 10.8 years, with a mean weight of 62.56 ± 6.3 kg. Upon assessing the effectiveness of each drug in preventing nausea and vomiting, postoperatively, it was found that both drugs were equally effective in preventing nausea in the majority of the patients (73.85% vs. 65.89%; P = 0.162). However, ondansetron was significantly more effective in preventing vomiting in patients than dexamethasone (91.54% vs. 79.07%; P = 0.004). Conclusions This study concluded that the use of either dexamethasone or ondansetron effectively reduces the incidence of postoperative nausea and vomiting. However, ondansetron was significantly more effective in reducing the incidence of vomiting in patients after laparoscopic cholecystectomy than dexamethasone.

Combination of dexamethasone and ondansetron in prophylaxis nausea and vomiting in gynecological operation

BACKGROUND

Postoperative nausea and vomiting occur in about 20-30% of women; however, some reports have estimated the rate at 70% in at-risk individuals. Gynecological and obstetrical operations are among the most frequent types of surgeries to be associated with nausea and vomiting postoperatively. Ondansetron and dexamethasone have been compared in a variety of studies for postoperative prophylaxis.

AIM OF THE STUDY

This study was conducted in order to compare the efficacy and safety of dexamethasone and ondansetron, alone or in combination, for prevention of postoperative nausea and vomiting in a sample of Iraqi women undergoing gynecological surgeries.

PATIENTS AND METHODS

The study was conducted in Al-Diwaniyah Province, a region belonging to the Mid-Euphrates sector of Iraq, at the Child and Maternity Teaching Hospital. The study started in June 2021 and the work with the research was accomplished in September 2022. The study included a total of 100 women undergoing different gynecological surgeries such as ovarian cystectomy, oophorectomy, ectopic pregnancy, total abdominal hysterectomy, and myomectomy. All participants involved in the study were categorized randomly into four groups, namely, dexamethasone, ondansetron, combined, and placebo groups.

RESULTS

The rates of nausea in the different groups were analyzed. The rates of nausea in dexamethasone, ondansetron, and combined groups revealed a significant decrease compared with that of placebo group (P < 0.05), and the rate was significantly lower in combined group when compared with dexamethasone and ondansetron groups (P < 0.05). The rate of nausea in combined group was significantly lower than that of dexamethasone and ondansetron groups. The rate of vomiting in combined group was significantly lower than that of placebo group and less than that of the dexamethasone group (P < 0.05).

CONCLUSION

Based on our study and previous reports, both dexamethasone and ondansetron are efficient and safe in preventing nausea and vomiting in gynecological operations; however, combination of both provides the best results.

Comparing the Effect of Ondansetron-dexamethasone and Metoclopramide-dexamethasone on Postoperative Nausea and Vomiting after Gynecological Laparoscopy: A Randomized Double-blind Clinical Trial

Background

Nausea and vomiting is a common complication after gynecological surgeries, especially laparoscopy, which can lead to discomfort and restlessness in the patients. The aim of the study was to compare the effect of ondansetron-dexamethasone and metoclopramide-dexamethasone on postoperative nausea and vomiting following gynecological laparoscopy.

Materials and Methods

In this double-blind clinical trial, 68 females scheduled for gynecological laparoscopy and age range of 18-40 years were randomly divided into two groups. Group OD received ondansetron 4 mg plus dexamethasone 8 mg and group MD received metoclopramide 10 mg plus dexamethasone 8 mg, 15 min before the end of surgery. The incidence of nausea and vomiting and need for rescue medication was assessed during the recovery period, as well as at 2, 4, 6, 12, and 24 h after surgery. The data were analyzed using STATA software version 12 and a significance level of <0.05 was considered in this research.

Results

The incidence of nausea in ondansetron and metoclopramide groups was 23.3% and 33.3%, respectively, and the frequency of vomiting was 10% and 16.6%, respectively, which showed no significant difference (P > 0.05). The highest incidence of nausea and vomiting in patients belonged to the metoclopramide group inside 4-6 h after surgery.

Conclusion

Our study showed that no significant difference was observed in the incidence of nausea and vomiting between ondansetron-dexamethasone and metoclopramide-dexamethasone groups following laparoscopic gynecological surgery; however, the number of patients with nausea and vomiting was lower in the ondansetron-dexamethasone group.

Effect of combinations of dexamethasone-ondansetron and dexamethasone-ondansetron-aprepitant versus aprepitant alone for early postoperative nausea and vomiting after day care gynaecological laparoscopy: A randomised clinical trial

Background and Aims:

This study was designed to compare the effectiveness of the combination of dexamethasone–ondansetron with oral aprepitant alone and triple combination therapy with all three agents (dexamethasone-ondansetron and oral aprepitant) in the prevention of postoperative nausea and vomiting (PONV) in day care gynaecologic laparoscopy.

Methods:

This was a randomised clinical trial conducted at a university teaching hospital. A total of 105 female patients were randomised into the aprepitant (A), dexamethasone-ondansetron (DO) and aprepitant-dexamethasone-ondansetron (ADO) groups. The patients in the A group received only 80 mg oral aprepitant 1 h before surgery. The patients in the DO group, received dexamethasone 8 mg at induction with ondansetron 4 mg before extubation. Patients in the ADO group received 80 mg oral aprepitant 1 h before surgery, dexamethasone 8 mg at induction and ondansetron 4 mg before extubation. Incidence of nausea and vomiting was compared between groups using the Chi-square test/Fisher's test. Bellville score for severity of PONV was analysed using the Kruskall-Wallis test. P value < 0.05 was regarded as significant.

Results:

The incidence of PONV did not show a statistically significant difference between the three groups, with a P value of 0.13 (12.5%, 30.3% and 32.3% in groups ADO, DO and A, respectively). The severity of PONV measured using Bellville score was also not significantly different among the groups [median values (IQR) of 0 (0-0), 0 (0-1), and 0 (0-1)].

Conclusion:

The combination of aprepitant, dexamethasone and ondansetron failed to demonstrate a statistically significant superiority over the other two antiemetic regimens.

Health Care Professionals' Assessment of Patient Discomfort After Abdominal Surgery

PURPOSE

The purpose of this study was to classify elements of patients' discomfort in the resuscitation room after open or laparoscopic abdominal surgery as per health care professionals' perceptions.

DESIGN

A prospective cross-sectional study at a tertiary hospital in Spain.

METHODS

Resuscitation room nurses administered the Postoperative Discomfort Inventory to physicians and nurses with >1 year experience working closely with patients who had undergone abdominal surgery, asking them to score nine items related to patients' discomfort in the first 8 hours after surgery on an 11-point scale (0 = absent to 10 = very severe). Interobserver agreement among proxy reporters was measured with the Spearman's ρ; correlations >0.35 was considered adequate agreement.

FINDINGS

Of 125 eligible professionals, 116 (93%) participated (63 [54%] nurses and 53 [46%] physicians; mean age, 38 ± 12 years; 86 [74%] women). Professionals' perception of discomfort differed significantly between patients undergoing open surgery and those undergoing laparoscopic surgery; after open surgery, the most common types were pain (7.1 ± 1.8), movement restriction (7 ± 1.75), and dry mouth (6.6 ± 2.6), whereas after laparoscopic surgery, the most common types were dry mouth (5.85 ± 2.8), abdominal bloating (5.3 ± 2.5), and pain (5 ± 2.2). The Spearman's ρ correlations were inadequate for all items except for dry mouth in open surgery (r = 0.40).

CONCLUSIONS

Pain, movement restriction, abdominal bloating, and dry mouth were the main causes of discomfort. Our findings highlight the need to be vigilant for all manifestations of discomfort after abdominal surgery to enable timely treatment.

Comparison of different end-tidal carbon dioxide levels in preventing postoperative nausea and vomiting in gynaecological patients undergoing laparoscopic surgery

The aim of this study was to compare different end-tidal carbon dioxide (EtCO₂) levels to prevent postoperative nausea and vomiting (PONV) caused by increased intracranial pressure due to pneumoperitoneum and Trendelenburg position in gynaecological laparoscopic surgery. A total of 60 female patients aged 25-50 years who would undergo laparoscopic gynaecological surgery under general anaesthesia were randomised into two groups: group A (EtCO₂: 26 - 35 mmHg, n = 30) and group B (EtCO₂: 36 - 45 mmHg, n = 30). In both groups, ONSD and EtCO₂ of the patients were measured at baseline after anaesthesia induction (T_b), at 5 min after pneumoperitoneum (T_PP5), and at 10 min intervals after Trendelenburg position (T_PP10, T_PP20, T_PP30). At 5 (T_D5) and 10 min (T_D10) after deflation, ONSD measurements were repeated. The incidence and severity of PONV of the patients, and antiemetic drugs used in both groups were assessed in the postoperative period. In the intraoperative follow-up periods, T_PP5 and subsequent EtCO₂ values, as well as T_PP10 and subsequent ONSD values, were significantly higher in group B and the incidence of nausea, the PONV scores and the incidence of rescue antiemetic use significantly lower in group A than in group B (p<.001 for all). This result indicates that low EtCO₂ levels have beneficial effects on ICP and PONV in laparoscopic gynaecological operations.Impact statementWhat is already known on this subject? Laparoscopic gynaecologic surgery has been a more preferred technique. The incidence of postoperative nausea and vomiting (PONV) after laparoscopic gynaecologic surgery is remarkably high. In the prevention of PONV after gynaecologic laparoscopic surgery, single and multiple drug therapies and methods have been used.What the results of this study add? Postoperative nausea and vomiting caused by intracranial pressure (ICP) increase due to carbon dioxide pneumoperitoneum and Trendelenburg position in gynaecologic laparoscopic surgeries were decreased in the early postoperative period by low end-tidal carbon dioxide levels in the intraoperative period. It was shown that low end-tidal carbon dioxide levels have beneficial effects on ICP and PONV in laparoscopic gynaecologic operations.What the implications are of these findings for clinical practice and/or further research? This result indicates that low end-tidal carbon dioxide levels have beneficial effects on ICP and PONV in laparoscopic gynaecologic operations.

A Single Prophylactic Dose of Ondansetron Given at Cessation of Postoperative Propofol Sedation Decreases Postoperative Nausea and Vomiting in Cardiac Surgery Patients: A Randomized Controlled Trial

BACKGROUND

Postoperative nausea and vomiting (PONV) is a common occurrence after cardiac surgery. However, in contrast to other surgical populations, routine PONV prophylaxis is not a standard of care in cardiac surgery. We hypothesized that routine administration of a single prophylactic dose of ondansetron (4 mg) at the time of stopping postoperative propofol sedation before extubation in the cardiac surgery intensive care unit would decrease the incidence of PONV.

METHODS

With institutional human ethics board approval and written informed consent, we conducted a randomized controlled trial in patients ≥19 years of age with no history of PONV undergoing elective or urgent cardiac surgery procedures requiring cardiopulmonary bypass. The primary outcome was the incidence of PONV in the first 24 hours postextubation, compared by the χ test. Secondary outcomes included the incidence and times to first dose of rescue antiemetic treatment administration, the incidence of headaches, and the incidence of ventricular arrhythmias.

RESULTS

PONV within the first 24 hours postextubation occurred in 33 of 77 patients (43%) in the ondansetron group versus 50 of 82 patients (61%) in the placebo group (relative risk, 0.70 [95% confidence interval {CI}, 0.51-0.95]; absolute risk difference, -18% [95% CI, -33 to -2]; number needed to treat, 5.5 [95% CI, 3.0-58.4]; χ test, P = .022). Kaplan-Meier "survival" analysis of the times to first rescue antiemetic treatment administration over 24 hours indicated that patients in the ondansetron group fared better than those in the placebo group (log-rank [Mantel-Cox] test; P = .028). Overall, 32 of 77 patients (42%) in the ondansetron group received rescue antiemetic treatment over the first 24 hours postextubation versus 47 of 82 patients (57%) in the placebo group (relative risk, 0.73 [95% CI, 0.52-1.00]; absolute risk difference, -16% [95% CI, -31 to 1]); P = .047. There were no significant differences between the groups in the incidence of postoperative headache (ondansetron group, 5 of 77 patients [6%] versus placebo group, 4 of 82 patients [5%]; Fisher exact test; P = .740) or ventricular arrhythmias (ondansetron group, 2 of 77 patients [3%] versus placebo group, 4 of 82 patients [5%]; P = .68).

CONCLUSIONS

These findings support the routine administration of ondansetron prophylaxis at the time of discontinuation of postoperative propofol sedation before extubation in patients following cardiac surgery. Further research is warranted to optimize PONV prophylaxis in cardiac surgery patients.

Efficacy of Preoperative Usage of Dexamethasone in Diabetic Patients Undergoing Total Hip or Knee Arthroplasty for Control of Nausea and Vomiting

BACKGROUND

Dexamethasone has been used in surgical patients to decrease nausea, vomiting, and postoperative pain. However, it is not well studied how much dexamethasone complicates glucose control in diabetic patients and whether this leads to poor surgical outcomes.

METHODS

We analyzed 256 diabetic patients who underwent elective hip and knee arthroplasty and evaluated the groups that received dexamethasone intraoperatively (201 patients), those who received dexamethasone postoperatively (237 patients), and those who did not receive the steroid intraoperatively (55 patients) and postoperatively (19 patients).

RESULTS

256 diabetic patients were included in the study. The mean age of the group was 68.7 (SD ± 9-10) years. Patients were divided into 123 males (48%) and 133 females (52%). 174 (78%) patients had a total knee replacement operation, and 82 (32%) patients had total hip replacement operation. The mean hemoglobin A1c was 6.728 (SD ± 0.99). The mean ASA score was 2.86 (SD ± 0.38). 201 (78.5%) patients received preoperative or intraoperative dexamethasone, and 237 (92.6%) patients received it postoperatively. The mean blood glucose for all patients raised from 131.9 to 172.2 mg/dL (P = .012) postoperatively, 206.1 mg/dL in the first 24 hours, and 146.2 mg/dL (P = .39) in the second postoperative day. The change was significant in patients who had poorly controlled diabetes (P < .01) preoperatively. There was no significant difference in our study regarding dexamethasone use and effect on postoperative nausea (P = 1.0) and vomiting (P = .52). There was an improvement in pain scores in the patients who received dexamethasone postoperatively which was statistically significant (P = .054).

CONCLUSION

Dexamethasone use in diabetic patients for control of postoperative nausea and vomiting in those undergoing elective total knee and hip arthroplasty had a negative impact on glycemic control specifically in those with poorly controlled diabetes and should be avoided.

Postoperative pain management in children: Guidance from the pain committee of the European Society for Paediatric Anaesthesiology (ESPA Pain Management Ladder Initiative)

The main remit of the European Society for Paediatric Anaesthesiology (ESPA) Pain Committee is to improve the quality of pain management in children. The ESPA Pain Management Ladder is a clinical practice advisory based upon expert consensus to help to ensure a basic standard of perioperative pain management for all children. Further steps are suggested to improve pain management once a basic standard has been achieved. The guidance is grouped by the type of surgical procedure and layered to suggest basic, intermediate, and advanced pain management methods. The committee members are aware that there are marked differences in financial and personal resources in different institutions and countries and also considerable variations in the availability of analgesic drugs across Europe. We recommend that the guidance should be used as a framework to guide best practice.

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.

Dexamethasone alone versus in combination with intra-operative super-hydration for postoperative nausea and vomiting prophylaxis in female patients undergoing laparoscopic cholecystectomy: a randomized clinical trial

Background

Dexamethasone has a prophylactic effect on postoperative nausea and vomiting (PONV) and perioperative hydration is believed to play a role in PONV prophylaxis. This study was performed to examine the combined effects of pre-induction dexamethasone plus super-hydration on PONV and pain following laparoscopic cholecystectomy (LC).

Methods

A total of 100 female patients undergoing LC were enrolled and randomized equally into two groups. Group DF received 5 mg dexamethasone (pre-induction) plus 30 ml/kg Ringer's lactate (intraoperative) and group D received 5 mg dexamethasone (pre-induction) alone. Anesthetic and surgical managements were standardized for all patients. The incidence and severity of PONV, and intra and post-operative analgesic and postoperative antiemetic consumption, were assessed during the first 24 h postoperatively. Post-anesthesia care unit (PACU) stay and aggregated 24 h pain scores were calculated.

Results

Group DF had significantly lower PONV than group D (P = 0.03). The number of patients with the lowest PONV score was significantly increased in group DF (P = 0.03). Ondansetron consumption was significantly lower in group DF (P < 0.0001). The mean accumulated 24 h pain scores were significantly lower in group DF compared to group D (P < 0.0001). The time to first analgesic request was significantly longer in group DF than group D (P < 0.0001). In addition, total meperidine consumption during the first postoperative 24 h was significantly lower in group DF than group D (P = 0.002).

Conclusions

In female patients undergoing LC, pre-induction with 5 mg dexamethasone plus intraoperative 30 ml/kg Ringer's lactate solution decreased PONV and pain during the first 24 h postoperatively compared to 5 mg dexamethasone alone.

Pharmacology of Acetaminophen, Nonsteroidal Antiinflammatory Drugs, and Steroid Medications: Implications for Anesthesia or Unique Associated Risks

Acetaminophen, nonsteroidal antiinflammatory drugs (NSAIDs), and corticosteroids, historically used in perioperative management, are potent analgesic medications. They primarily inhibit the cyclooxygenase (COX) enzyme, decreasing the synthesis of prostaglandins, and modulating pain and temperature. Acetaminophen does not inhibit this synthesis at the inflammatory site. The primary mechanism of action of corticosteroids involves regulation of nuclear expression of genes involved in inflammatory pathways and other systemic effects. Metaanalyses have added purposeful perioperative indications, clarified misconceptions, and established protocols for administering these drugs. Some indications, doses, clinical considerations, and adverse effects need to be further studied.