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Zhang N, Feng D, Wu W, Liu J, Shi H. Influence of higher body mass index on postoperative nausea and vomiting in patients following thoracic surgery for lung cancer: a propensity score-matched cohort study. Sci Rep 2024; 14:13873. [PMID: 38880825 PMCID: PMC11180656 DOI: 10.1038/s41598-024-64686-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Accepted: 06/12/2024] [Indexed: 06/18/2024] Open
Abstract
This study aimed to quantify the association between body mass index (BMI) and postoperative nausea and vomiting (PONV) within the initial 48 h following thoracic surgery for lung cancer. We then explored whether changes in serum inflammatory factor concentrations were related to BMI during the early postoperative period. We conducted a propensity score-matched (PSM), retrospective cohort study at a specialized tertiary medical center. A total of 194 patients aged 18-80 years who underwent thoracic surgery for lung cancer at Shanghai Pulmonary Hospital between January and June 2021 were enrolled. The primary outcome was the incidence of PONV during the first 48 h after surgery. Nausea, vomiting or retching at different time periods, severe pain, and concentrations of perioperative serum inflammatory factors including CRP, IL-6, IL-12, and IFN-γ were also assessed. Patients in the high BMI group (BMI ≥ 25 kg/m2) had a lower incidence of PONV than those in the normal BMI group (18.5-25 kg/m2) within the first 48 h after surgery (22 vs. 50%, p = 0.004). The incidence of nausea was lower at 0-12 h (14.5 vs. 37.1%, p = 0.004) and 12-24 h (8.1 vs. 22.6%, p = 0.025) in the high BMI group after surgery, and the incidence of vomiting was lower at 0-12 h (12.9 vs. 30.6%, p = 0.017) in higher BMI after surgery. We found no significant difference in the incidence of severe pain [severe static pain (p = 0.697) and severe dynamic pain (p = 0.158)]. Moreover, higher concentrations of IL-12 (2.24 ± 2.67 pg/ml vs. 1.48 ± 1.14 pg/ml, p = 0.048) and IFN-γ [1.55 (1.00) pg/ml vs. 1.30 (0.89) pg/ml, p = 0.041] were observed in patients with normal BMI on the first day after surgery. Given this finding, patients with a normal BMI should receive more attention for the prevention of PONV than those with a high BMI following thoracic surgery for lung cancer.Trial registration: http://www.chictr.org.cn and ChiCTR2100052380 (24/10/2021).
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Affiliation(s)
- Nan Zhang
- Department of Anesthesiology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, 200433, China
| | - Di Feng
- Department of Anesthesiology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, 200433, China
| | - Wei Wu
- Department of Anesthesiology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, 200433, China
| | - Ji Liu
- Department of Anesthesiology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, 200433, China.
| | - Hong Shi
- Department of Anesthesiology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, 200433, China.
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Gettleman BS, Liu KC, Yoshida B, Vega AN, Kusnezov N, Lieberman JR, Heckmann ND. Perioperative Dexamethasone is Associated with a Decreased Risk of Pulmonary Embolism and Deep Vein Thrombosis Following Total Joint Arthroplasty: An Analysis of 70,000 High-Risk Patients. J Arthroplasty 2024:S0883-5403(24)00453-4. [PMID: 38735549 DOI: 10.1016/j.arth.2024.05.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Revised: 05/02/2024] [Accepted: 05/03/2024] [Indexed: 05/14/2024] Open
Abstract
BACKGROUND Dexamethasone (DEX) has demonstrated promise with respect to decreasing postoperative thromboembolic complications following total joint arthroplasty (TJA). Therefore, the aim of this study was to investigate the effects of perioperative intravenous DEX on rates of pulmonary embolism (PE) and deep vein thrombosis (DVT) after primary TJA in patients who have a history of venous thromboembolism (VTE). METHODS Patients who have a history of VTE who underwent primary, elective TJA from 2015 to 2021 were identified using a commercial healthcare database. Patients were divided based on receipt of perioperative intravenous DEX [DEX(+) versus DEX(-)] on the day of index TJA. Patient demographics and hospital factors were collected. The 90-day risk of postoperative complications, readmission, and in-hospital mortality were compared. RESULTS Overall, 70,147 patients who had a history of VTE underwent TJA, of which 40,607 (57.89%) received DEX and 29,540 (42.11%) did not. The DEX(+) patients were younger (67 ± 9.8 versus 68 ± 9.9 years, P < 0.001) and had a significantly shorter length of stay compared to the DEX(-) patients (1.8 ± 1.6 versus 2.2 ± 1.8 days, P < 0.001). The DEX(+) patients demonstrated lower rates of PE (1.37 versus 1.75%, P < 0.001) and DVT (2.37 versus 3.01%, P < 0.001) compared to DEX(-) patients. The DEX(+) patients experienced a lower risk of PE (adjusted odds ratio [aOR] 0.78, 95% confidence interval [95%-CI]: 0.66 to 0.93, P = 0.006) and DVT (aOR: 0.84, 95%-CI: 0.74 to 0.95, P = 0.006) compared to DEX(-) patients. The DEX(+) patients demonstrated no differences in the odds of surgical site infection, periprosthetic joint infection, or sepsis compared to the DEX(-) patients (P > 0.05). CONCLUSION The administration of DEX was associated with a decreased risk of PE and DVT in patients who have a history of VTE who underwent TJA. These data warrant further study investigating the postoperative benefits of perioperative DEX administration for high-risk patients undergoing TJA.
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Affiliation(s)
- Brandon S Gettleman
- 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
| | - Brandon Yoshida
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Andrew N Vega
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Nicholas Kusnezov
- 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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Liu F, Duan M, Fu H, Wang T. The efficacy and safety of perioperative glucocorticoid for total knee arthroplasty: a systematic review and meta-analysis. BMC Anesthesiol 2024; 24:144. [PMID: 38622510 PMCID: PMC11017604 DOI: 10.1186/s12871-024-02530-9] [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: 07/30/2023] [Accepted: 04/08/2024] [Indexed: 04/17/2024] Open
Abstract
BACKGROUND An increasing number of individuals undergo total knee arthroplasty (TKA), which can result in pain, limited motor function and adverse complications such as infection, nausea and vomiting. Glucocorticoids have been shown anti-inflammatory and antiemetic effects, but can also elevate blood glucose levels and increase the risk of wound infection. Thus, it is essential to investigate the efficacy and safety of glucocorticoid usage in TKA. METHOD A comprehensive systematic search of PubMed, Medline, EMBASE, Cochrane databases, to identify relevant randomized controlled trials (RCTs) of glucocorticoid application in TKA. The primary outcomes assessed were the postoperative pain assessment. Secondary outcomes included the range of motion in knee joint, levels of inflammatory cytokines, adverse complications, and the length of hospital stay. RESULTS Thirty-six randomized controlled trials were included in the final analysis. The glucocorticoid group exhibited significant reduction in the resting VAS scores on postoperative days 1, 2 (POD1, 2)and postoperative 3 months (POM3), as well as decreased morphine consumption on POD1 and increased range of motion (ROM) in knee joint on POD1, 3. Additionally, the glucocorticoid group exhibited decreased levels of postoperative inflammatory cytokines and the incidence of PONV along with a shorter length of hospital stay. The blood glucose concentration was significantly increased in the glucocorticoid group on POD1 compared with the control group. While the blood glucose on POD2 and occurrence of postoperative adverse complications were similar between two groups including wound infection and venous thrombosis. The periarticular injection analgesia (PIA) group demonstrated lower VAS scores on POD2 comparing to the systemic administration (SA) group according to two studies. However, there was no significant difference of the resting VAS on POD1 and POD2 between PIA and SA group across all studies. CONCLUSION Perioperative glucocorticoids treatment in TKA significantly reduced short-term pain score and opioid-use which was probably not patient relevant. The application of glucocorticoids in TKA implied a beneficial trend in analgesic, anti-inflammatory, and antiemetic effects, as well as improved range of motion and shortened hospital stay. While it will not increase the risk of continued high glucose, postoperative wound infection and venous thrombosis.
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Affiliation(s)
- Fangyan Liu
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Xicheng District, Beijing, 100053, China
| | - Mei Duan
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Xicheng District, Beijing, 100053, China
| | - Huiqun Fu
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Xicheng District, Beijing, 100053, China
| | - Tianlong Wang
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Xicheng District, Beijing, 100053, China.
- National Clinical Research Center for Geriatric Diseases, Beijing, China.
- Beijing Institute for Brain Disorders, Beijing, China.
- Center for Sleep and Consciousness Disorders, Collaborative Innovation Center for Brain Disorders, Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China.
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Liu XY, Mou P, Cao J, Wang HY, Zeng WN, Zhou ZK. Effects of Dexamethasone on Postoperative Glycemic Control in Patients After Primary Total Joint Arthroplasty: A Randomized Double-Blind Controlled Trial. J Arthroplasty 2024:S0883-5403(24)00342-5. [PMID: 38614358 DOI: 10.1016/j.arth.2024.04.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 04/07/2024] [Accepted: 04/08/2024] [Indexed: 04/15/2024] Open
Abstract
BACKGROUND In patients undergoing total joint arthroplasty, the use of dexamethasone (DEX) may cause perioperative blood glucose (BG) disorders, leading to complications even in patients who do not have diabetes. We aimed to evaluate the effects of different DEX doses on perioperative BG levels. METHODS A total of 135 patients who do not have diabetes were randomized into three groups: preoperative intravenous (IV) injection of normal saline (Group A, the placebo group), preoperative IV injection of 10 mg DEX (Group B), and preoperative IV injection of 20 mg DEX (Group C). Postoperative fasting BG (FBG) levels were designated as the primary outcome, while postoperative postprandial BG (PBG) levels were assigned as the secondary outcome. The incidence of complications was recorded. We also investigated the risk factors for FBG ≥ 140 mg/dL and PBG ≥ 180 mg/dL. RESULTS The FBG levels were higher in Groups B and C than in Group A on postoperative days (PODs) 0 and 1. The PBG levels were lower for Groups A and B compared to Group C on POD 1. No differences in FBG or PBG were detected beyond POD 1. Elevated preoperative glycosylated hemoglobin A1c levels increased the risk of FBG ≥ 140 mg/dL and PBG ≥ 180 mg/dL, respectively. However, preoperative IV injection of DEX was not associated with FBG ≥ 140 mg/dL or PBG ≥ 180 mg/dL. No differences were found in postoperative complications among the three groups. CONCLUSIONS The preoperative IV administration of 10 or 20 mg DEX in patients who do not have diabetes showed transient effects on postoperative BG after total joint arthroplasty. The preoperative glycosylated hemoglobin A1c level threshold (regardless of the administration or dosage of DEX) that increased the risk for the occurrence of FBG ≥ 140 mg/dL and PBG ≥ 180 mg/dL was 5.75 and 5.85%, respectively.
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Affiliation(s)
- Xiao-Yang Liu
- Department of Orthopedics, Orthopaedic Research Institute, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Ping Mou
- Department of Rehabilitation Medicine, West China Hospital, Sichuan University, Chengdu, People's Republic of China; Key Laboratory of Rehabilitation Medicine in Sichuan Province, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Jian Cao
- Department of Orthopedics, Orthopaedic Research Institute, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Hao-Yang Wang
- Department of Orthopedics, Orthopaedic Research Institute, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Wei-Nan Zeng
- Department of Orthopedics, Orthopaedic Research Institute, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Zong-Ke Zhou
- Department of Orthopedics, Orthopaedic Research Institute, West China Hospital, Sichuan University, Chengdu, People's Republic of China
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Ilyas AM, Sundaram P, Plusch K, Kasper A, Jones CM. Multimodal Pain Management After Outpatient Orthopedic Hand Surgery: A Prospective Randomized Trial. JOURNAL OF HAND SURGERY GLOBAL ONLINE 2024; 6:16-20. [PMID: 38313605 PMCID: PMC10837162 DOI: 10.1016/j.jhsg.2023.07.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 07/29/2023] [Indexed: 02/06/2024] Open
Abstract
Purpose Opioid stewardship ensures effective pain management while avoiding overprescribing of opioids after surgery. This prospective randomized study investigates the efficacy of a multimodal postoperative pain regimen compared to a traditional opioid-only pain regimen following elective outpatient orthopedic hand surgery. We hypothesized that patients receiving multimodal pain management would consume fewer opioids and report greater satisfaction than patients receiving only opioids. Methods Consecutive patients undergoing outpatient hand and upper extremity surgery performed by two board-certified fellowship-trained orthopedic hand surgeons at one institution were recruited and randomized into either a study or control group. The study group received a standing multimodal postoperative regimen consisting of scheduled oral acetaminophen and naproxen as well as oxycodone to be taken as needed. The control group received only oxycodone to be taken as needed. Postoperatively, daily pain levels, medication usage, refills, satisfaction, and adverse events were recorded. Descriptive statistics were performed. Results Of the 112 patients enrolled, 54 were randomized to the control group, and 58 were randomized to the study group. Study and control group patients did not differ significantly based on daily average pain scores or daily worst pain scores. However, study group patients reported fewer average daily oxycodone intake and total oxycodone pill count (7.0 vs 2.4 total pills, P <.005). In addition, the study group patients were more likely to report satisfaction with their postoperative pain control than control regimen patient's and were more likely to use the same pain regimen again if required. Conclusion A multimodal postoperative pain regimen reduces opioid usage and has higher patient satisfaction rates in comparison to traditional opioid-only regimens. Use of multimodal pain regimens that use nonopioids, such as acetaminophen and naproxen, over an opioid should be considered for postoperative pain after orthopedic hand surgery. Level of Evidence Therapeutic II.
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Affiliation(s)
- Asif M Ilyas
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA USA
| | - Padmaja Sundaram
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA USA
| | - Kyle Plusch
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA USA
| | - Alexis Kasper
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA USA
| | - Christopher M Jones
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA USA
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Mølgaard AK, Gasbjerg KS, Skou ST, Mathiesen O, Hägi-Pedersen D. Chronic Pain and Functional Outcome 3 years After Total Knee Arthroplasty and Perioperative Dexamethasone: A Follow-Up of the Randomized, Clinical DEX-2-TKA Trial. J Arthroplasty 2023; 38:2592-2598.e2. [PMID: 37286048 DOI: 10.1016/j.arth.2023.05.060] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 05/22/2023] [Accepted: 05/24/2023] [Indexed: 06/09/2023] Open
Abstract
BACKGROUND Perioperative dexamethasone as an adjunct to multimodal analgesia, has an opioid-sparing and pain alleviating effect after total knee arthroplasty (TKA), however, the 3-year effects are unknown. We aimed to investigate the 3-year effect of 1 (DX1) or 2 (DX2) intravenous doses of 24 mg dexamethasone or placebo on pain, physical function, and health-related quality of life after TKA. METHODS Patients who participated in the Dexamethasone Twice for Pain Treatment after TKA (DEX-2-TKA) were invited to physical tests and questionnaires (self-reported characteristics, Oxford Knee Score, EuroQol-5Dimensions-5Levels (EQ5D5L), and PainDetect). The tests were 40-meter Fast Paced Walk (40FPW) test, Timed Up and Go (TUG), 30 Second Chair Stand test (30CST), Stair Climb Test (SCT), bilateral knee Range of Motion, and knee extension torque. For each test the peak pain intensity was registered on a 0 to 100 mm Visual Analogue Scale. Primary outcome was average peak pain intensity during the 40FPW, TUG, 30CST and SCT. Secondary outcomes were the tests and questionnaires. Out of 252 eligible patients, 133 (52.8%) underwent the tests and 160 (63.5%) answered the questionnaires. Mean follow-up time was 33 months (range, 23 to 40). RESULTS Median (interquartile range) peak pain intensity was 0 (0 to 65) for the DX2 group, 0 (0 to 51) for DX1 group and 0 (0 to 70) for the placebo group (P = .72). No differences in secondary outcomes were identified. CONCLUSION One or 2 intravenous doses of 24 mg dexamethasone did not impact chronic pain development or physical function 3 years after TKA.
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Affiliation(s)
- Asger K Mølgaard
- Research Centre of Anaesthesiology and Intensive Care Medicine, Department of Anaesthesiology, Næstved, Slagelse and Ringsted Hospitals, Slagelse, Denmark
| | - Kasper S Gasbjerg
- Research Centre of Anaesthesiology and Intensive Care Medicine, Department of Anaesthesiology, Næstved, Slagelse and Ringsted Hospitals, Slagelse, Denmark
| | - Søren T Skou
- The Research Unit PROgrez, Department of Physiotherapy and Occupational Therapy, Næstved, Slagelse and Ringsted Hospitals, Slagelse, Denmark; Research Unit for Musculoskeletal Function and Physiotherapy, Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense M, Denmark
| | - Ole Mathiesen
- Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Køge, Denmark; Department of Clinical Medicine, Copenhagen University, Copenhagen N, Denmark
| | - Daniel Hägi-Pedersen
- Research Centre of Anaesthesiology and Intensive Care Medicine, Department of Anaesthesiology, Næstved, Slagelse and Ringsted Hospitals, Slagelse, Denmark; Department of Clinical Medicine, Copenhagen University, Copenhagen N, Denmark
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Wu C, Luo D, Zhu Y, Zhao Q, Wang J, Dai Y. Efficacy of combining intravenous and topical dexamethasone against postoperative pain and function recovery after total knee arthroplasty: A prospective, double-blind, randomized controlled trial. J Orthop Surg (Hong Kong) 2023; 31:10225536231189782. [PMID: 37437069 DOI: 10.1177/10225536231189782] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/14/2023] Open
Abstract
BACKGROUND Dexamethasone is a corticosteroid with powerful anti-inflammatory effects. This study aimed to explore whether combining intravenous and topical dexamethasone could improve postoperative pain, swelling, and function recovery after total knee arthroplasty (TKA). METHODS In this prospective, double-blind, randomized controlled study, 90 patients undergoing primary unilateral TKA were randomized into a dexamethasone group, which received dexamethasone (10 mg) by periarticular infiltration during surgery, as well as intravenous dexamethasone (10 mg) before tourniquet release and at 12 h postoperatively; or a control group, which received equal volumes of isotonic saline instead of dexamethasone. The primary outcome was postoperative pain, as assessed on the visual analogue scale (VAS). Secondary outcomes were postoperative consumption of morphine hydrochloride for rescue analgesia, postoperative swelling ratio of the thigh, knee, and tibia; functional recovery in terms of total range of motion (ROM) of knee and daily ambulation distance; postoperative inflammation biomarkers levels of C-reactive protein and interleukin-6; and postoperative complications. RESULTS Resting VAS scores at postoperative 6, 12, and 24 h, and VAS scores during motion at postoperative 2, 6, 12, and 24 h were significantly lower in the dexamethasone group. The dexamethasone group also showed significantly less morphine consumption during the first 24 h after surgery and cumulatively during hospitalization, milder limb swelling at 24 and 48 h postoperatively, greater flexion and total ROM on postoperative day 1, and longer ambulation distance on postoperative days 1 and 2, and lower levels of inflammatory biomarkers on postoperative days 1 and 2. The dexamethasone group had significantly lower incidence of postoperative nausea and vomiting. CONCLUSION Compared with placebo, the combination of intravenous and topical dexamethasone can reduce pain, swelling, and inflammation after TKA, it also can improve functional recovery and reduce the incidence of postoperative nausea and vomiting.
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Affiliation(s)
- Changjun Wu
- Department of Orthopaedics Surgery, Dafang County People's Hospital, Bijie, China
| | - Defa Luo
- Department of Orthopaedics Surgery, Dafang County People's Hospital, Bijie, China
| | - Yu Zhu
- Department of Orthopaedics Surgery, Dafang County People's Hospital, Bijie, China
| | - Qingyuan Zhao
- Department of Orthopaedics Surgery, Dafang County People's Hospital, Bijie, China
| | - Jian Wang
- Department of Orthopaedics Surgery, Dafang County People's Hospital, Bijie, China
| | - Yunlei Dai
- Department of Orthopaedics Surgery, Dafang County People's Hospital, Bijie, China
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Systemic glucocorticoids as an adjunct to treatment of postoperative pain after total hip and knee arthroplasty: A systematic review with meta-analysis and trial sequential analysis. Ugeskr Laeger 2023; 40:155-170. [PMID: 36325886 DOI: 10.1097/eja.0000000000001768] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Postoperative analgesic effects of systemic glucocorticoids given as an adjunct to treatment are largely undetermined in alloplastic procedures. OBJECTIVES To investigate the beneficial and harmful effects of peri-operative systemic glucocorticoid treatment for pain after total hip arthroplasty (THA) or total knee arthroplasty (TKA). DESIGN A systematic review of randomised clinical trials (RCTs) with meta-analyses, trial sequential analyses and GRADE. Primary outcome was 24 h intravenous (i.v.) morphine (or equivalent) consumption with a predefined minimal important difference (MID) of 5 mg. Secondary outcomes included pain at rest and during mobilisation (MID, VAS 10 mm), adverse and serious adverse events (SAEs). DATA SOURCES We searched EMBASE, Cochrane CENTRAL, PubMed and Google Scholar up to October 2021. ELIGIBILITY CRITERIA RCTs investigating peri-operative systemic glucocorticoid versus placebo or no intervention, for analgesic pain management of patients at least 18 years undergoing planned THA or TKA, irrespective of publication date and language. RESULTS We included 32 RCTs with 3521 patients. Nine trials were at a low risk of bias. Meta-analyses showed evidence of a reduction in 24 h cumulative morphine consumption with glucocorticoids by 5.0 mg (95% CI 2.2 to 7.7; P = 0.0004). Pain at rest was reduced at 6 h by 7.8 mm (95% CI 5.5 to 10.2; P < 0.00001), and at 24 h by 6.3 mm (95% CI 3.8 to 8.8; P < 0.00001). Pain during mobilisation was reduced at 6 h by 9.8 mm (95% CI 6.9 to 12.8; P < 0.00001), and at 24 h by 9.0 mm (95% CI 5.5 to 12.4, P < 0.00001). Incidence of adverse events was generally lower in the glucocorticoid treatment group. SAEs were rarely reported. The GRADE rated quality of evidence was low to very low. CONCLUSION Peri-operative systemic glucocorticoid treatment reduced postoperative morphine consumption to an individually relevant level following hip and knee arthroplasty. Pain levels were reduced but were below the predefined MID. The quality of evidence was generally low. REGISTRATION PROSPERO ID: CRD42019135034.
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Heckmann ND, Wang JC, Piple AS, Marshall GA, Mills ES, Liu KC, Lieberman JR, Christ AB. Is Intraoperative Dexamethasone Utilization Associated With Increased Rates of Periprosthetic Joint Infection Following Total Joint Arthroplasty? J Arthroplasty 2023; 38:224-231.e1. [PMID: 36031084 DOI: 10.1016/j.arth.2022.08.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 08/11/2022] [Accepted: 08/15/2022] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Intraoperative dexamethasone can reduce postoperative pain and nausea following total knee (TKA) and total hip arthroplasty (THA). To the best of our knowledge, no study to date has been adequately powered to detect the risk of periprosthetic joint infection (PJI) from early dexamethasone exposure. This study aimed to assess PJI rates and complications in patients undergoing primary elective TKA and THA who received intraoperative dexamethasone. METHODS A national database was used to identify adults undergoing primary elective TKA and THA between 2015 and 2020. Patients who received intraoperative dexamethasone and those who did not were identified. The primary endpoint was 90-day risk of infectious complications. Secondary end points included thromboembolic, pulmonary, renal, and wound complications. Multivariate analyses were performed to assess the risk of all endpoints between cohorts. Between 2015 and 2020, 1,322,025 patients underwent primary elective TJA, of which 857,496 (64.1%) underwent TKA and 474,707 (35.9%) underwent TKA. RESULTS In patients who underwent TKA, dexamethasone was associated with lower risk of PJI (adjusted odds ratio: 0.87, 95% CI: 0.82-0.93, P < .001) as well as other secondary endpoints such as pulmonary embolism, deep vein thrombosis, and acute kidney injury. In patients who underwent THA, dexamethasone was associated with a lower risk of PJI (adjusted odds ratio: 0.80, 95% CI: 0.73-0.86, P < .001) as well as other secondary endpoints such as pulmonary embolism, deep vein thrombosis, acute kidney injury, and pneumonia. CONCLUSION Intraoperative dexamethasone was not associated with increased risk of infectious complications. The data presented here provide evidence in support of intraoperative dexamethasone utilization during primary TKA or THA.
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Affiliation(s)
- Nathanael D Heckmann
- Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, California
| | - Jennifer C Wang
- Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, California
| | - Amit S Piple
- Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, California
| | - Glenda A Marshall
- Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, California
| | - Emily S Mills
- Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, California
| | - Kevin C Liu
- Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, California
| | - Jay R Lieberman
- Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, California
| | - Alexander B Christ
- Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, California
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Perioperative Intravenous Glucocorticoids in Total Joint Arthroplasty: A Systematic Review. J Am Acad Orthop Surg 2023; 31:e94-e106. [PMID: 36580055 DOI: 10.5435/jaaos-d-22-00232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 08/10/2022] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Total joint arthroplasties (TJAs) of the hip and knee are common orthopaedic procedures. Postoperative pain in TJA is managed with opioids, which carry notable adverse effects and are associated with high dependency rates. With newer multimodal pain control regimens, perioperative glucocorticoid administration has shown promise as a means of mitigating postoperative pain. The objective of this review was to identify the effects of perioperative intravenous glucocorticoid administration on postoperative outcomes in TJA. MATERIALS AND METHODS A systematic review was done. The EMBASE database was searched from inception through September 1, 2020, to identify studies of perioperative glucocorticoids in TJA. Primary outcomes were postoperative pain, nausea, and vomiting. Secondary outcomes included hospital length of stay, postoperative opioid utilization, antiemetic rescue medication use, and postoperative surgical complications. RESULTS Our search yielded 429 publications; 14 studies were ultimately included, incorporating 1704 patients. In 13 of 14 studies, pain scores improved with perioperative steroid administration. Regarding postoperative nausea and vomiting, most of the studies found a notable association between steroids and improved VAS-N (visual analogue scale for nausea) and decreased postoperative nausea and vomiting incidence. There were inconclusive data on the effects of perioperative steroids regarding postoperative length of stay, fatigue, and range of motion of the affected joint. In all 14 studies, no notable difference was found between study groups regarding postoperative surgical complications. CONCLUSION This systematic review supports the use of perioperative steroids in TJA for mitigating postoperative pain, nausea, and systemic inflammation. Additional randomized trials are needed to form a consensus on optimal dosing, delivery method, and timing of perioperative glucocorticoids in TJA.
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11
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Komatsu DE, Uddin SMZ, Gordon C, Kanjiya MP, Bogdan D, Achonu J, DiBua A, Iftikhar H, Ackermann A, Shah RJ, Shieh J, Bialkowska AB, Kaczocha M. Acute postoperative pain and dorsal root ganglia transcriptomic signatures following total knee arthroplasty (TKA) in rats: An experimental study. PLoS One 2022; 17:e0278632. [PMID: 36473007 PMCID: PMC9725137 DOI: 10.1371/journal.pone.0278632] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 11/19/2022] [Indexed: 12/12/2022] Open
Abstract
Total knee arthroplasty (TKA) is the final treatment option for patients with advanced knee osteoarthritis (OA). Unfortunately, TKA surgery is accompanied by acute postoperative pain that is more severe than arthroplasty performed in other joints. Elucidating the molecular mechanisms specific to post-TKA pain necessitates an animal model that replicates clinical TKA procedures, induces acute postoperative pain, and leads to complete functional recovery. Here, we present a new preclinical TKA model in rats and report on functional and behavioral outcomes indicative of pain, analgesic efficacy, serum cytokine levels, and dorsal root ganglia (DRG) transcriptomes during the acute postoperative period. Following TKA, rats exhibited marked deficits in weight bearing that persisted for 28 days. Home cage locomotion, rearing, and gait were similarly impacted and recovered by day 14. Cytokine levels were elevated on postoperative days one and/or two. Treatment with morphine, ketorolac, or their combination improved weight bearing while gabapentin lacked efficacy. When TKA was performed in rats with OA, similar functional deficits and comparable recovery time courses were observed. Analysis of DRG transcriptomes revealed upregulation of transcripts linked to multiple molecular pathways including inflammation, MAPK signaling, and cytokine signaling and production. In summary, we developed a clinically relevant rat TKA model characterized by resolution of pain and functional recovery within five weeks and with pain-associated behavioral deficits that are partially alleviated by clinically administered analgesics, mirroring the postoperative experience of TKA patients.
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Affiliation(s)
- David E. Komatsu
- Department of Orthopaedics and Rehabilitation, Renaissance School of Medicine, Stony Brook University, Stony Brook, NY, United States of America
- * E-mail: (DEK); (MK)
| | - Sardar M. Z. Uddin
- Department of Orthopaedics and Rehabilitation, Renaissance School of Medicine, Stony Brook University, Stony Brook, NY, United States of America
| | - Chris Gordon
- Department of Anesthesiology, Renaissance School of Medicine, Stony Brook University, Stony Brook, NY, United States of America
| | - Martha P. Kanjiya
- Department of Anesthesiology, Renaissance School of Medicine, Stony Brook University, Stony Brook, NY, United States of America
| | - Diane Bogdan
- Department of Anesthesiology, Renaissance School of Medicine, Stony Brook University, Stony Brook, NY, United States of America
| | - Justice Achonu
- Department of Orthopaedics and Rehabilitation, Renaissance School of Medicine, Stony Brook University, Stony Brook, NY, United States of America
| | - Adriana DiBua
- Department of Anesthesiology, Renaissance School of Medicine, Stony Brook University, Stony Brook, NY, United States of America
| | - Hira Iftikhar
- Department of Anesthesiology, Renaissance School of Medicine, Stony Brook University, Stony Brook, NY, United States of America
| | - Amanda Ackermann
- Department of Anesthesiology, Renaissance School of Medicine, Stony Brook University, Stony Brook, NY, United States of America
| | - Rohan J. Shah
- Department of Anesthesiology, Renaissance School of Medicine, Stony Brook University, Stony Brook, NY, United States of America
| | - Jason Shieh
- Department of Medicine, Renaissance School of Medicine, Stony Brook University, Stony Brook, NY, United States of America
| | - Agnieszka B. Bialkowska
- Department of Medicine, Renaissance School of Medicine, Stony Brook University, Stony Brook, NY, United States of America
| | - Martin Kaczocha
- Department of Anesthesiology, Renaissance School of Medicine, Stony Brook University, Stony Brook, NY, United States of America
- Stony Brook University Pain and Analgesia Research Center, Renaissance School of Medicine, Stony Brook University, Stony Brook, NY, United States of America
- * E-mail: (DEK); (MK)
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12
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Hannon CP, Fillingham YA, Mason JB, Sterling RS, Casambre FD, Verity TJ, Woznica A, Nelson N, Hamilton WG, Della Valle CJ. The Efficacy and Safety of Corticosteroids in Total Joint Arthroplasty: A Direct Meta-Analysis. J Arthroplasty 2022; 37:1898-1905.e7. [PMID: 36162922 DOI: 10.1016/j.arth.2022.03.084] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 03/09/2022] [Accepted: 03/31/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Corticosteroids are commonly used intraoperatively to treat pain and reduce opioid consumption and nausea associated with primary total joint arthroplasty (TJA). The purpose of this study was to evaluate the efficacy and safety of corticosteroids in primary TJA to support the combined clinical practice guidelines of the American Association of Hip and Knee Surgeons, American Academy of Orthopaedic Surgeons, Hip Society, Knee Society, and the American Society of Regional Anesthesia and Pain Management. METHODS The MEDLINE, Embase, and Cochrane Central Register of Controlled Trials databases were searched for studies published before February 2020 on corticosteroids in TJA. All included studies underwent qualitative and quantitative homogeneity testing followed by a systematic review and direct comparison meta-analysis to assess the efficacy and safety of corticosteroids. RESULTS Critical appraisal of 1,581 publications revealed 23 studies regarded as the best available evidence for analysis. Intraoperative dexamethasone reduces postoperative pain, opioid consumption, and nausea and vomiting. Multiple doses lead to further reduction in pain, opioid consumption, nausea and vomiting. There is insufficient evidence on the risk of adverse events with perioperative dexamethasone in TJA. CONCLUSION Strong evidence supports the use of a single dose or multiple doses of intravenous dexamethasone to reduce postoperative pain, opioid consumption, nausea and vomiting after primary TJA. There is insufficient evidence on perioperative dexamethasone in primary TJA to determine the optimal dose, number of doses, or risk of postoperative adverse events.
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Affiliation(s)
- Charles P Hannon
- Department of Orthopedic Surgery, Washington University in St. Louis, St. Louis, Missouri
| | - Yale A Fillingham
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | | | - Robert S Sterling
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Francisco D Casambre
- Department of Clinical Quality and Value, American Academy of Orthopaedic Surgeons, Rosemont, Illinois
| | - Tyler J Verity
- Department of Clinical Quality and Value, American Academy of Orthopaedic Surgeons, Rosemont, Illinois
| | - Anne Woznica
- Department of Clinical Quality and Value, American Academy of Orthopaedic Surgeons, Rosemont, Illinois
| | - Nicole Nelson
- Department of Clinical Quality and Value, American Academy of Orthopaedic Surgeons, Rosemont, Illinois
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Hannon CP, Fillingham YA, Mason JB, Sterling RS, Hamilton WG, Della Valle CJ. Corticosteroids in Total Joint Arthroplasty: The Clinical Practice Guidelines of the American Association of Hip and Knee Surgeons, American Society of Regional Anesthesia and Pain Medicine, American Academy of Orthopaedic Surgeons, Hip Society, and Knee Society. J Arthroplasty 2022; 37:1684-1687. [PMID: 35970568 DOI: 10.1016/j.arth.2022.03.043] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 02/23/2022] [Accepted: 03/07/2022] [Indexed: 02/02/2023] Open
Affiliation(s)
- Charles P Hannon
- Department of Orthopedic Surgery, Washington University in St. Louis, St. Louis, MO
| | | | | | - Robert S Sterling
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | | | - Craig J Della Valle
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
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14
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No Benefits of Adding Dexmedetomidine, Ketamine, Dexamethasone and Nerve Blocks to an Established Multimodal Analgesic Regimen after Total Knee Arthroplasty. Anesthesiology 2022; 137:459-470. [PMID: 35867857 DOI: 10.1097/aln.0000000000004326] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND. An optimal opioid-sparing multimodal analgesic regimen to treat severe pain can enhance recovery after total knee arthroplasty. We hypothesized that adding 5 recently described IV and regional interventions to multimodal analgesic regimen can further reduce opioid consumption. METHODS. In a double-blinded fashion, seventy-eight patients undergoing elective total knee arthroplasty were randomized to either (1) a control group (n=39) that received spinal anesthesia with intrathecal morphine, periarticular local anesthesia infiltration, IV dexamethasone and a single injection adductor canal block or (2) a study group (n=39) that received the same set of analgesic treatments plus 5 additional interventions - local anesthetic infiltration between the popliteal artery and capsule of the posterior knee, intraoperative IV dexmedetomidine and ketamine, and postoperatively, 1 additional IV dexamethasone bolus, and 2 additional adductor canal block injections. The primary outcome measure was 24-hour cumulative opioid consumption after surgery and secondary outcomes were other analgesic, patient recovery and functional outcomes and adverse events. RESULTS. Opioid consumption was not different between groups at 24 hours (oral morphine equivalents, mean ± SD), study: 23.7 ± 18.0 mg vs. control: 29.3 ± 18.7 mg; mean difference [95% CI], -5.6 mg [-2.7, 13.9]; P = 0.189) and all other time points after surgery. There were no major differences in pain scores, quality of recovery, or time to reach rehabilitation milestones. Hypotensive episodes occurred more frequently in the study group (25/39 (64.1%) vs. 13/39 (33.3%), p= 0.010). CONCLUSIONS. In the presence of periarticular local anesthesia infiltration, intrathecal morphine, single shot adductor canal block and dexamethasone, the addition of 5 analgesic interventions - local anesthetic infiltration between the popliteal artery and capsule of the posterior knee, IV dexmedetomidine, IV ketamine, an additional IV dexamethasone dose and repeated adductor canal block injections - failed to further reduce opioid consumption, pain scores or improve functional outcomes after total knee arthroplasty.
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15
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Tan TK, Lee JY, Tay A, Kuster M. Intra-articular versus intravenous administration of tranexamic acid in lower limb total arthroplasty: a systematic review and meta-analysis of randomised clinical trials. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2022; 33:709-738. [PMID: 35377071 DOI: 10.1007/s00590-022-03241-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Accepted: 02/28/2022] [Indexed: 11/30/2022]
Abstract
AIM The ideal route of tranexamic acid (TXA) administration in total hip arthroplasty (THA) or total knee arthroplasty (TKA) remains controversial. This study aims to identify the optima route of TXA administration in THA or TKA. METHODS PUBMED, EMBASE, MEDLINE and CENTRAL database were systematically searched until 4 August 2021 for randomised studies that compared intravenous (IV) or intra-articular (IA) administration of TXA in THA or TKA. RESULTS Sixty-seven studies enrolling 8335 patients (IA: 4162; IV: 4173) were eligible for quantitative and qualitative analysis. Comparable results were demonstrated in the incidence of venous thromboembolisation (OR:0.96, p = 0.84), total blood loss (MD: - 9.05, p = 0.36), drain output (MD: - 7.36, p = 0.54), hidden blood loss (MD: - 6.85, p = 0.47), postoperative haemoglobin level (MD: 0.01, p = 0.91), haemoglobin drop (MD: - 0.10, p = 0.22), blood transfusion rate (OR: 0.99, p = 0.87), total adverse events (OR: 1.12, p = 0.28), postoperative range of motion (MD: 1.08, p = 0.36), postoperative VAS pain score (MD: 0.13, p = 0.24) and postoperative D-dimer level (MD: 0.61, p = 0.64). IV route of TXA administration was associated with significantly longer length of hospital stay compared to IA route of administration (MD: - 0.22, p = 0.01). CONCLUSION In this meta-analysis, both IV and IA route of TXA administration were equally effective in managing blood loss and postoperative outcomes in lower limb joints arthroplasty. LEVEL OF EVIDENCE Level 1. PROSPERO Registration CRD42021271355.
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Affiliation(s)
- Tze Khiang Tan
- Department of Orthopaedic Surgery, Sir Charles Gairdner Hospital, Perth, WA, Australia.
| | | | - Aaron Tay
- Department of Orthopaedic Surgery, Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Markus Kuster
- Department of Orthopaedic Surgery, Sir Charles Gairdner Hospital, Perth, WA, Australia
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16
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Steroid Use in Palatoplasty: A Single Surgeon Comparative Retrospective Cohort Study. J Craniofac Surg 2022; 33:526-529. [PMID: 35013068 DOI: 10.1097/scs.0000000000008305] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Fistula rates in cleft palate repair vary by technique, surgeon, and institution. Although steroids are commonly used in airway surgery, many plastic surgeons are reluctant to use steroids because of concerns with wound healing. This study aims to assess outcomes and safety of steroid use in Furlow palatoplasty and determine its impact on fistula formation. METHODS A retrospective cohort study was done of all cleft palate surgeries performed by a single surgeon between 2010 and 2014. Data reviewed included demographics, type of cleft, steroid use, length of surgery, length of stay, and fistula formation rate. RESULTS One hundred thirty-five patients underwent palatoplasty, of which 101 received steroids and 34 did not. The mean age was 4.6 years. A total of 42.2% of patients underwent primary palatoplasty, 48.1% underwent submucous cleft palatoplasty, and 9.7% underwent conversion palatoplasty. The overall fistula rate was 1.5% and was comparable between the 2 groups (steroids = 2.0%, no steroids = 0.0%, P = 0.558), and all occurred in primary palatoplasty patients. The average length of stay in the hospital was shorter among patients receiving steroids (steroids = 2.0 days, no steroids = 2.5 days, P < 0.05). CONCLUSIONS Steroid use in cleft palate surgery appears to be safe and likely not associated with impaired wound healing or increased fistula formation. It may also shorten length of hospitalization.
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Gasbjerg KS, Hägi-Pedersen D, Lunn TH, Laursen CC, Holmqvist M, Vinstrup LØ, Ammitzboell M, Jakobsen K, Jensen MS, Pallesen MJ, Bagger J, Lindholm P, Pedersen NA, Schrøder HM, Lindberg-Larsen M, Nørskov AK, Thybo KH, Brorson S, Overgaard S, Jakobsen JC, Mathiesen O. Effect of dexamethasone as an analgesic adjuvant to multimodal pain treatment after total knee arthroplasty: randomised clinical trial. BMJ 2022; 376:e067325. [PMID: 34983775 PMCID: PMC8724786 DOI: 10.1136/bmj-2021-067325] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To investigate the effects of one and two doses of intravenous dexamethasone in patients after total knee arthroplasty. DESIGN Randomised, blinded, placebo controlled trial with follow-up at 90 days. SETTING Five Danish hospitals, September 2018 to March 2020. PARTICIPANTS 485 adult participants undergoing total knee arthroplasty. INTERVENTION A computer generated randomised sequence stratified for site was used to allocate participants to one of three groups: DX1 (dexamethasone (24 mg)+placebo); DX2 (dexamethasone (24 mg)+dexamethasone (24 mg)); or placebo (placebo+placebo). The intervention was given preoperatively and after 24 hours. Participants, investigators, and outcome assessors were blinded. All participants received paracetamol, ibuprofen, and local infiltration analgesia. MAIN OUTCOME MEASURES The primary outcome was total intravenous morphine consumption 0 to 48 hours postoperatively. Multiplicity adjusted threshold for statistical significance was P<0.017 and minimal important difference was 10 mg morphine. Secondary outcomes included postoperative pain. RESULTS 485 participants were randomised: 161 to DX1, 162 to DX2, and 162 to placebo. Data from 472 participants (97.3%) were included in the primary outcome analysis. The median (interquartile range) morphine consumptions at 0-48 hours were: DX1 37.9 mg (20.7 to 56.7); DX2 35.0 mg (20.6 to 52.0); and placebo 43.0 mg (28.7 to 64.0). Hodges-Lehmann median differences between groups were: -2.7 mg (98.3% confidence interval -9.3 to 3.7), P=0.30 between DX1 and DX2; 7.8 mg (0.7 to 14.7), P=0.008 between DX1 and placebo; and 10.7 mg (4.0 to 17.3), P<0.001 between DX2 and placebo. Postoperative pain was reduced at 24 hours with one dose, and at 48 hours with two doses, of dexamethasone. CONCLUSION Two doses of dexamethasone reduced morphine consumption during 48 hours after total knee arthroplasty and reduced postoperative pain. TRIAL REGISTRATION Clinicaltrials.gov NCT03506789.
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Affiliation(s)
- Kasper Smidt Gasbjerg
- Department of Anaesthesiology, Næstved, Slagelse and Ringsted Hospitals, Næstved, Denmark
| | - Daniel Hägi-Pedersen
- Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
- Department of Regional Health Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- Department of Anaesthesiology, Næstved, Slagelse and Ringsted Hospitals, Slagelse, Denmark
| | - Troels Haxholdt Lunn
- Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
- Department of Anaesthesia and Intensive Care, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Christina Cleveland Laursen
- Department of Anaesthesia and Intensive Care, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
- Copenhagen Centre for Translational Research, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Majken Holmqvist
- Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Køge, Denmark
| | - Louise Ørts Vinstrup
- Department of Anaesthesia and Intensive Care, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
- Copenhagen Centre for Translational Research, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Mette Ammitzboell
- Department of Orthopaedic Surgery and Traumatology, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Karina Jakobsen
- Department of Anaesthesiology, Næstved, Slagelse and Ringsted Hospitals, Næstved, Denmark
| | - Mette Skov Jensen
- Department of Anaesthesiology, Næstved, Slagelse and Ringsted Hospitals, Næstved, Denmark
| | - Marie Jøhnk Pallesen
- Department of Orthopaedic Surgery and Traumatology, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Jens Bagger
- Department of Orthopaedic Surgery and Traumatology, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Peter Lindholm
- Department of Anaesthesiology and Intensive Care, Odense University Hospital, Odense, Denmark
| | | | | | - Martin Lindberg-Larsen
- Orthopaedic Research Unit, Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Anders Kehlet Nørskov
- Department of Anaesthesiology, Nordsjællands University Hospital, Hillerød, Denmark Anders
- Copenhagen Trial Unit Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Capital Region of Denmark, Copenhagen, Denmark
| | - Kasper Højgaard Thybo
- Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Køge, Denmark
| | - Stig Brorson
- Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
- Department of Orthopaedic Surgery, Zealand University Hospital, Køge, Denmark
| | - Søren Overgaard
- Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
- Department of Orthopaedic Surgery and Traumatology, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
- Orthopaedic Research Unit, Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Janus Christian Jakobsen
- Department of Regional Health Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- Copenhagen Trial Unit Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Capital Region of Denmark, Copenhagen, Denmark
| | - Ole Mathiesen
- Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
- Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Køge, Denmark
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Effects of Intravenous Dexamethasone on Glycemic Control in Patients With Type 2 Diabetes Mellitus After Total Knee Arthroplasty. J Arthroplasty 2021; 36:3909-3914. [PMID: 34446328 DOI: 10.1016/j.arth.2021.07.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Revised: 07/28/2021] [Accepted: 07/31/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND We sought to determine whether administrations of intravenous (IV) dexamethasone jeopardize blood glycemic control, increase rates of postoperative complications, and diabetic medication change after TKA. METHODS This retrospective study included 427 patients with DM who underwent TKA. Patients were divided into two groups according to the use of IV dexamethasone (Dexa and No Dexa). For the Dexa, IV dexamethasone (5mg) was administered twice (surgery day, postoperative day 1). Blood glucose level until postoperative day 5, whether the mean blood glucose level was ≥200 mg/dL or not, the rate of a diabetic medication change, and postoperative complications (surgical site infection, delayed wound healing) were analyzed. RESULTS The adverse effects of IV dexamethasone on glycemic control were limited to the day of injection. The mean blood glucose level was 168.8 mg/dL and 204.4 mg/dL on operation day and 193.0 mg/dL and 210.5 mg/dL on postoperative day 1 in the No Dexa and the Dexa, respectively. High preoperative glycated hemoglobin (HbA1c) levels, but not IV dexamethasone administration, increased the risk of postoperative blood glucose level ≥200 mg/dL (odds ratio [OR], 2.810) and diabetic medication change (OR, 3.635, P < .001). A preoperative HbA1c level of >7.05% was associated with the risk of diabetic medication change. There was increase of postoperative complications (OR, 0.693, P = .552). CONCLUSIONS IV dexamethasone have transient effects on increasing the blood glucose level after TKA in patients with DM. However, patients with a preoperative HbA1c level of ≥7.05% may need to change their diabetic medication after TKA, regardless of IV dexamethasone administration.
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Chaturvedi R, Tram J, Chakravarthy K. Reducing opioid usage in total knee arthroplasty postoperative pain management: a literature review and future directions. Pain Manag 2021; 12:105-116. [PMID: 34551582 DOI: 10.2217/pmt-2020-0107] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Total knee arthroplasty (TKA) is a common orthopedic surgery performed with a projected 3.5 million procedures to be done by 2030. Current postoperative pain management for TKA is insufficient, as it results in extensive opioid consumption and functional decline postoperatively. This study identifies the best practices for postoperative TKA pain management through a literature review of the last three years. Studies utilizing interventional techniques (local infiltration analgesia, nerve blocks) and pharmacologic options were reviewed on PubMed, Embase, Ovid Medline and Scopus. Primary outcomes analyzed were the effect of different analgesic approaches on pain reduction, opioid use reduction and improvements in functional mobility or quadriceps strength postoperatively. Additionally, this paper explores the use of cooled radiofrequency ablation, a minimally invasive therapy, for preoperative and postoperative TKA pain management.
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Affiliation(s)
- Rahul Chaturvedi
- Department of Anesthesiology, Division of Pain Medicine, University of California San Diego, 9400 Campus Point Dr, La Jolla, CA 92037, USA
| | - Jennifer Tram
- Department of Anesthesiology, Division of Pain Medicine, University of California San Diego, 9400 Campus Point Dr, La Jolla, CA 92037, USA
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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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Zhuo Y, Yu R, Wu C, Huang Y, Ye J, Zhang Y. The role of perioperative intravenous low-dose dexamethasone in rapid recovery after total knee arthroplasty: a meta-analysis. J Int Med Res 2021; 49:300060521998220. [PMID: 33685282 PMCID: PMC7952853 DOI: 10.1177/0300060521998220] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 02/02/2021] [Indexed: 12/25/2022] Open
Abstract
PURPOSE The purpose of this meta-analysis was to evaluate the overall safety and effectiveness of perioperative intravenous dexamethasone to facilitate postoperative rehabilitation in patients after total knee arthroplasty (TKA). METHODS A comprehensive literature search was performed using the Embase, PubMed, Cochrane Library, and China National Knowledge Infrastructure (CNKI) databases for relevant randomized controlled trials (RCTs) from inception to 2020. Methodological quality of the trials was assessed using the Cochrane Risk of Bias Tool, and the relevant data were extracted using a predefined data extraction form. RESULTS Ten RCTs with 1100 knees were included. Our study showed a significant reduction in pain using a postoperative pain visual analog scale (VAS) at 24 hours and 48 hours, total opioid consumption at 24 hours and 48 hours, postoperative nausea and vomiting (PONV), active range of motion (ROM) limitation, and passive ROM limitation at 72 hours in dexamethasone-treated groups compared with controls. CONCLUSION Intravenous low-dose dexamethasone is potentially useful in the perioperative setting for reducing postsurgical immediate ROM limitations, pain, opioid consumption, and PONV. There are no data that directly attribute an increase in postoperative complications to intravenous dexamethasone. More high-quality studies are necessary to draw these conclusions.
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Affiliation(s)
| | | | - Chunling Wu
- Department of Orthopedics, Fuzhou Second Hospital Affiliated to Xiamen University, Fuzhou, Fujian, People’s Republic of China
| | - Yuting Huang
- Department of Orthopedics, Fuzhou Second Hospital Affiliated to Xiamen University, Fuzhou, Fujian, People’s Republic of China
| | - Jie Ye
- Department of Orthopedics, Fuzhou Second Hospital Affiliated to Xiamen University, Fuzhou, Fujian, People’s Republic of China
| | - Yiyuan Zhang
- Department of Orthopedics, Fuzhou Second Hospital Affiliated to Xiamen University, Fuzhou, Fujian, People’s Republic of China
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Lex JR, Edwards TC, Packer TW, Jones GG, Ravi B. Perioperative Systemic Dexamethasone Reduces Length of Stay in Total Joint Arthroplasty: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. J Arthroplasty 2021; 36:1168-1186. [PMID: 33190999 DOI: 10.1016/j.arth.2020.10.010] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 10/06/2020] [Accepted: 10/08/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The objective of this review is to examine the effect of perioperative systemic corticosteroids at varying doses and timings on early postoperative recovery outcomes following unilateral total knee and total hip arthroplasty. The primary outcome was length of stay (LOS). METHODS A systematic review and meta-analysis of randomized controlled trials was performed. MEDLINE, EMBASE, and Cochrane Library databases were searched from inception to June 1, 2020. Studies comparing the outcome of adult patients receiving a systemic steroid to patients who did not receive steroids were included. RESULTS Seventeen studies were included, incorporating 1957 patients. Perioperative corticosteroids reduced hospital LOS (mean difference [MD] = -0.39 days, 95% confidence interval [CI] -0.61 to -0.18). A subsequent dose of corticosteroid at 24 hours further reduced LOS (MD = -0.33, 95% CI -0.55 to -0.11). Corticosteroids resulted in reduced levels of pain on postoperative day (POD) 0 (MD = -1.99, 95% CI -3.30 to -0.69), POD1 (MD = -1.47, 95% CI -2.15 to -0.79), and POD2. Higher doses were more effective in reducing pain with activity on POD0 (P = .006) and 1 (P = .023). Steroids reduced the incidence of PONV on POD1 (log odds ratio [OR] = -1.05, 95% CI -1.26 to -0.84) and POD2, with greater effect at higher doses (P = .046). Corticosteroids did not increase the incidence of infection (P = 1.000), venous thromboembolism (P = 1.000), or gastrointestinal hemorrhage (P = 1.000) but were associated with an increase in blood glucose (MD = 5.30 mg/dL, 95% CI 2.69-7.90). CONCLUSION Perioperative corticosteroids are safe, facilitate earlier discharge, and improve patient recovery following unilateral total knee arthroplasty and total hip arthroplasty. Higher doses (15-20 mg of dexamethasone) are associated with further reductions in dynamic pain and PONV, and repeat dosing may further reduce LOS.
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Affiliation(s)
- Johnathan R Lex
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | | | - Timothy W Packer
- St Mary's Hospital, Imperial Healthcare Trust, London, United Kingdom
| | - Gareth G Jones
- MSk Lab, Imperial College London, London, United Kingdom
| | - Bheeshma Ravi
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Sunnybrook Health Sciences Centre, Division of Orthopaedic Surgery, Toronto, Ontario, Canada
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Previtali D, Di Laura Frattura G, Filardo G, Delcogliano M, Deabate L, Candrian C. Peri-operative steroids reduce pain, inflammatory response and hospitalisation length following knee arthroplasty without increased risk of acute complications: a meta-analysis. Knee Surg Sports Traumatol Arthrosc 2021; 29:59-81. [PMID: 31494685 DOI: 10.1007/s00167-019-05700-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Accepted: 08/28/2019] [Indexed: 12/27/2022]
Abstract
PURPOSE There is no consensus regarding the risks and benefits of peri-operative steroid supplementation in total knee arthroplasty (TKA). The aim of this meta-analysis is to compare TKA protocols implemented with or without steroids in terms of pain, inflammatory response, hospitalisation length, and complications. METHODS A systematic literature search was performed on July 2019 in PubMed, Medline, Embase, Web of Science, Cochrane library, and the grey literature for a meta-analysis of RCTs comparing peri-operative analgesia protocols implemented with or without steroids. Sub-analyses considering the administration route, steroid type, and dosage were performed. The inverse variance method and the Mantel-Haenszel test were used for pooling continuous variables and for dichotomous variables, respectively. Risk of bias and quality of evidence were defined according to the Cochrane guidelines. RESULTS Twenty articles were included. Steroid supplementation provides significantly lower post-operative pain from day 1 to day 4 (p < 0.05), with less opioid consumption (p = 0.05), less nausea and vomiting (p < 0.05), and greater knee range of motion (p < 0.001), thus resulting in a shorter hospitalisation length (p = 0.01). Moreover, lower C-reactive protein (p < 0.05), and IL-6 (p < 0.05) levels, but a higher blood glucose level at day 1 (p = 0.004), were documented. No significant differences were documented in all the outcomes after 4 days of follow-up. These results were achieved without an increased incidence of complications. According to the results of the sub-analyses, the intravenous administration of 200 steroid equivalents of a long-acting steroid was associated with better results. CONCLUSION Steroid supplementation of peri-operative drug protocols is effective in decreasing post-operative pain, opioid consumption, nausea and vomiting, range of motion limitation, and inflammatory markers without increasing short- and mid-term complications. Although these benefits last only the peri-operative period, steroid supplementation can reduce the length of hospitalisation after TKA. LEVEL OF EVIDENCE Systematic review and meta-analysis, level II.
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Affiliation(s)
- Davide Previtali
- Orthopaedic and Traumatology Unit, Ospedale Regionale di Lugano, EOC, Via Tesserete 46, 6900, Lugano, Switzerland
| | - Giorgio Di Laura Frattura
- Orthopaedic and Traumatology Unit, Ospedale Regionale di Lugano, EOC, Via Tesserete 46, 6900, Lugano, Switzerland.
| | - Giuseppe Filardo
- Orthopaedic and Traumatology Unit, Ospedale Regionale di Lugano, EOC, Via Tesserete 46, 6900, Lugano, Switzerland
- ATRC, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Marco Delcogliano
- Orthopaedic and Traumatology Unit, Ospedale Regionale di Lugano, EOC, Via Tesserete 46, 6900, Lugano, Switzerland
| | - Luca Deabate
- Orthopaedic and Traumatology Unit, Ospedale Regionale di Lugano, EOC, Via Tesserete 46, 6900, Lugano, Switzerland
| | - Christian Candrian
- Orthopaedic and Traumatology Unit, Ospedale Regionale di Lugano, EOC, Via Tesserete 46, 6900, Lugano, Switzerland
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Thompson KA, Klein D, Alaia MJ, Strauss EJ, Jazrawi LM, Campbell KA. Opioid Use Is Reduced in Patients Treated with NSAIDs After Arthroscopic Bankart Repair: A Randomized Controlled Study. Arthrosc Sports Med Rehabil 2020; 3:e15-e22. [PMID: 33615243 PMCID: PMC7879172 DOI: 10.1016/j.asmr.2020.08.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 08/07/2020] [Indexed: 11/29/2022] Open
Abstract
Purpose To evaluate the efficacy of oral nonsteroidal anti-inflammatory drugs (NSAIDs) as the primary postoperative pain medication compared with standard oral opioids after arthroscopic shoulder capsulolabral (Bankart) repair for recurrent anterior shoulder instability. Methods This was a single-center, prospective, randomized controlled study. Patients aged 18 to 65 years indicated for arthroscopic shoulder capsulolabral repair for recurrent anterior shoulder instability were included. Postoperatively, patients were prescribed 1 of 2 analgesic regimens: (1) 30 ibuprofen (600 mg every 6 to 8 hours as needed) and 10 tablets of oxycodone/acetaminophen (5/325 mg every 6 hours as needed for breakthrough pain) or (2) 30 tablets oxycodone/acetaminophen (5/325 mg every 6 hours as needed). Subjects completed questionnaires at 24, 48, and 96 hours and 1 week after surgery, which included questions about analgesic medication usage, visual analog scale (VAS) pain score, incidence of adverse events, and patient satisfaction. Results Between December 2017 and May 2019, 80 patients (mean age 31.3 ± 10.4 years) were enrolled. Overall there were no significant differences in VAS pain score or patient satisfaction between the 2 groups. Patients in the opioid-only group had a significantly higher mean opioid consumption on postoperative days (PODs) 2 to 4 (5.5 versus 2.9, P = .05) and after 1 week (11.7 versus 7.9 tablets, P = .05) compared with patients in the NSAID group. Of patients in the NSAID group, 17.5% experienced adverse effects, compared with 35% in the opioid-only group. Conclusions Use of oral NSAIDs with limited breakthrough opioids results in significantly less opioid use after arthroscopic Bankart repair in the first postoperative week compared with opioids only. Both groups used limited amounts of opioids to control postoperative pain. There were no differences in pain levels at any time point postoperatively or satisfaction between patient groups. Level of Evidence II, nonblinded randomized control trial.
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Affiliation(s)
- Kamali A Thompson
- Division of Sports Medicine, Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, New York
| | - David Klein
- Division of Sports Medicine, Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, New York
| | - Michael J Alaia
- Division of Sports Medicine, Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, New York
| | - Eric J Strauss
- Division of Sports Medicine, Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, New York
| | - Laith M Jazrawi
- Division of Sports Medicine, Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, New York
| | - Kirk A Campbell
- Division of Sports Medicine, Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, New York
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Preoperative dexamethasone for pain relief after total knee arthroplasty: A randomised controlled trial. Eur J Anaesthesiol 2020; 37:1157-1167. [PMID: 33105245 DOI: 10.1097/eja.0000000000001372] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Corticosteroids can reduce pain but the optimal dose and safety profiles are still uncertain. OBJECTIVE This study aimed to evaluate two different doses of dexamethasone for pain management and their side effects after total knee arthroplasty. DESIGN A prospective randomised, controlled trial. SETTING A tertiary teaching hospital in Hong Kong. PATIENTS One hundred and forty-six patients were randomly allocated to one of three study groups. INTERVENTIONS Before operation, patients in group D8, D16 and P received dexamethasone 8 mg, dexamethasone 16 mg and placebo (0.9% saline), respectively. MAIN OUTCOME MEASURES The primary outcome was postoperative pain score. Secondary outcomes were opioid consumption, physical parameters of the knees and side effects of dexamethasone. RESULTS Compared with placebo, group D16 patients had significantly less pain during maximal active flexion on postoperative day 3 [-1.3 (95% CI, -2.2 to -0.31), P = 0.005]. There was also a significant dose-dependent trend between pain scores and dexamethasone dose (P = 0.002). Compared with placebo, patients in group D16 consumed significantly less opioid [-6.4 mg (95% CI, -11.6 to -1.2), P = 0.025] and had stronger quadriceps power on the first three postoperative days (all P < 0.05). They also had significantly longer walking distance on postoperative day 1 [7.8 m ([95% CI, 0.85 to 14.7), P = 0.023] with less assistance during walking on the first two postoperative days (all P < 0.029) and significantly better quality-of-recovery scores on postoperative day 1 (P = 0.018). There were significant dose-dependent trends between all the above parameters and dexamethasone dose (all P < 0.05). No significant differences were found in the incidence of chronic pain or knee function 3, 6 and 12 months postoperatively. CONCLUSION Dexamethasone 16 mg given before total knee arthroplasty led to a reduction in postoperative pain, less opioid consumption, stronger quadriceps muscle power, better mobilisation and better overall quality-of-recovery after operation. No long-term improvement in reduction in pain and function of the knee was found. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT02767882.
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Weibel S, Rücker G, Eberhart LH, Pace NL, Hartl HM, Jordan OL, Mayer D, Riemer M, Schaefer MS, Raj D, Backhaus I, Helf A, Schlesinger T, Kienbaum P, Kranke P. Drugs for preventing postoperative nausea and vomiting in adults after general anaesthesia: a network meta-analysis. Cochrane Database Syst Rev 2020; 10:CD012859. [PMID: 33075160 PMCID: PMC8094506 DOI: 10.1002/14651858.cd012859.pub2] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Postoperative nausea and vomiting (PONV) is a common adverse effect of anaesthesia and surgery. Up to 80% of patients may be affected. These outcomes are a major cause of patient dissatisfaction and may lead to prolonged hospital stay and higher costs of care along with more severe complications. Many antiemetic drugs are available for prophylaxis. They have various mechanisms of action and side effects, but there is still uncertainty about which drugs are most effective with the fewest side effects. OBJECTIVES • To compare the efficacy and safety of different prophylactic pharmacologic interventions (antiemetic drugs) against no treatment, against placebo, or against each other (as monotherapy or combination prophylaxis) for prevention of postoperative nausea and vomiting in adults undergoing any type of surgery under general anaesthesia • To generate a clinically useful ranking of antiemetic drugs (monotherapy and combination prophylaxis) based on efficacy and safety • To identify the best dose or dose range of antiemetic drugs in terms of efficacy and safety SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP), ClinicalTrials.gov, and reference lists of relevant systematic reviews. The first search was performed in November 2017 and was updated in April 2020. In the update of the search, 39 eligible studies were found that were not included in the analysis (listed as awaiting classification). SELECTION CRITERIA Randomized controlled trials (RCTs) comparing effectiveness or side effects of single antiemetic drugs in any dose or combination against each other or against an inactive control in adults undergoing any type of surgery under general anaesthesia. All antiemetic drugs belonged to one of the following substance classes: 5-HT₃ receptor antagonists, D₂ receptor antagonists, NK₁ receptor antagonists, corticosteroids, antihistamines, and anticholinergics. No language restrictions were applied. Abstract publications were excluded. DATA COLLECTION AND ANALYSIS A review team of 11 authors independently assessed trials for inclusion and risk of bias and subsequently extracted data. We performed pair-wise meta-analyses for drugs of direct interest (amisulpride, aprepitant, casopitant, dexamethasone, dimenhydrinate, dolasetron, droperidol, fosaprepitant, granisetron, haloperidol, meclizine, methylprednisolone, metoclopramide, ondansetron, palonosetron, perphenazine, promethazine, ramosetron, rolapitant, scopolamine, and tropisetron) compared to placebo (inactive control). We performed network meta-analyses (NMAs) to estimate the relative effects and ranking (with placebo as reference) of all available single drugs and combinations. Primary outcomes were vomiting within 24 hours postoperatively, serious adverse events (SAEs), and any adverse event (AE). Secondary outcomes were drug class-specific side effects (e.g. headache), mortality, early and late vomiting, nausea, and complete response. We performed subgroup network meta-analysis with dose of drugs as a moderator variable using dose ranges based on previous consensus recommendations. We assessed certainty of evidence of NMA treatment effects for all primary outcomes and drug class-specific side effects according to GRADE (CINeMA, Confidence in Network Meta-Analysis). We restricted GRADE assessment to single drugs of direct interest compared to placebo. MAIN RESULTS We included 585 studies (97,516 randomized participants). Most of these studies were small (median sample size of 100); they were published between 1965 and 2017 and were primarily conducted in Asia (51%), Europe (25%), and North America (16%). Mean age of the overall population was 42 years. Most participants were women (83%), had American Society of Anesthesiologists (ASA) physical status I and II (70%), received perioperative opioids (88%), and underwent gynaecologic (32%) or gastrointestinal surgery (19%) under general anaesthesia using volatile anaesthetics (88%). In this review, 44 single drugs and 51 drug combinations were compared. Most studies investigated only single drugs (72%) and included an inactive control arm (66%). The three most investigated single drugs in this review were ondansetron (246 studies), dexamethasone (120 studies), and droperidol (97 studies). Almost all studies (89%) reported at least one efficacy outcome relevant for this review. However, only 56% reported at least one relevant safety outcome. Altogether, 157 studies (27%) were assessed as having overall low risk of bias, 101 studies (17%) overall high risk of bias, and 327 studies (56%) overall unclear risk of bias. Vomiting within 24 hours postoperatively Relative effects from NMA for vomiting within 24 hours (282 RCTs, 50,812 participants, 28 single drugs, and 36 drug combinations) suggest that 29 out of 36 drug combinations and 10 out of 28 single drugs showed a clinically important benefit (defined as the upper end of the 95% confidence interval (CI) below a risk ratio (RR) of 0.8) compared to placebo. Combinations of drugs were generally more effective than single drugs in preventing vomiting. However, single NK₁ receptor antagonists showed treatment effects similar to most of the drug combinations. High-certainty evidence suggests that the following single drugs reduce vomiting (ordered by decreasing efficacy): aprepitant (RR 0.26, 95% CI 0.18 to 0.38, high certainty, rank 3/28 of single drugs); ramosetron (RR 0.44, 95% CI 0.32 to 0.59, high certainty, rank 5/28); granisetron (RR 0.45, 95% CI 0.38 to 0.54, high certainty, rank 6/28); dexamethasone (RR 0.51, 95% CI 0.44 to 0.57, high certainty, rank 8/28); and ondansetron (RR 0.55, 95% CI 0.51 to 0.60, high certainty, rank 13/28). Moderate-certainty evidence suggests that the following single drugs probably reduce vomiting: fosaprepitant (RR 0.06, 95% CI 0.02 to 0.21, moderate certainty, rank 1/28) and droperidol (RR 0.61, 95% CI 0.54 to 0.69, moderate certainty, rank 20/28). Recommended and high doses of granisetron, dexamethasone, ondansetron, and droperidol showed clinically important benefit, but low doses showed no clinically important benefit. Aprepitant was used mainly at high doses, ramosetron at recommended doses, and fosaprepitant at doses of 150 mg (with no dose recommendation available). Frequency of SAEs Twenty-eight RCTs were included in the NMA for SAEs (10,766 participants, 13 single drugs, and eight drug combinations). The certainty of evidence for SAEs when using one of the best and most reliable anti-vomiting drugs (aprepitant, ramosetron, granisetron, dexamethasone, ondansetron, and droperidol compared to placebo) ranged from very low to low. Droperidol (RR 0.88, 95% CI 0.08 to 9.71, low certainty, rank 6/13) may reduce SAEs. We are uncertain about the effects of aprepitant (RR 1.39, 95% CI 0.26 to 7.36, very low certainty, rank 11/13), ramosetron (RR 0.89, 95% CI 0.05 to 15.74, very low certainty, rank 7/13), granisetron (RR 1.21, 95% CI 0.11 to 13.15, very low certainty, rank 10/13), dexamethasone (RR 1.16, 95% CI 0.28 to 4.85, very low certainty, rank 9/13), and ondansetron (RR 1.62, 95% CI 0.32 to 8.10, very low certainty, rank 12/13). No studies reporting SAEs were available for fosaprepitant. Frequency of any AE Sixty-one RCTs were included in the NMA for any AE (19,423 participants, 15 single drugs, and 11 drug combinations). The certainty of evidence for any AE when using one of the best and most reliable anti-vomiting drugs (aprepitant, ramosetron, granisetron, dexamethasone, ondansetron, and droperidol compared to placebo) ranged from very low to moderate. Granisetron (RR 0.92, 95% CI 0.80 to 1.05, moderate certainty, rank 7/15) probably has no or little effect on any AE. Dexamethasone (RR 0.77, 95% CI 0.55 to 1.08, low certainty, rank 2/15) and droperidol (RR 0.89, 95% CI 0.81 to 0.98, low certainty, rank 6/15) may reduce any AE. Ondansetron (RR 0.95, 95% CI 0.88 to 1.01, low certainty, rank 9/15) may have little or no effect on any AE. We are uncertain about the effects of aprepitant (RR 0.87, 95% CI 0.78 to 0.97, very low certainty, rank 3/15) and ramosetron (RR 1.00, 95% CI 0.65 to 1.54, very low certainty, rank 11/15) on any AE. No studies reporting any AE were available for fosaprepitant. Class-specific side effects For class-specific side effects (headache, constipation, wound infection, extrapyramidal symptoms, sedation, arrhythmia, and QT prolongation) of relevant substances, the certainty of evidence for the best and most reliable anti-vomiting drugs mostly ranged from very low to low. Exceptions were that ondansetron probably increases headache (RR 1.16, 95% CI 1.06 to 1.28, moderate certainty, rank 18/23) and probably reduces sedation (RR 0.87, 95% CI 0.79 to 0.96, moderate certainty, rank 5/24) compared to placebo. The latter effect is limited to recommended and high doses of ondansetron. Droperidol probably reduces headache (RR 0.76, 95% CI 0.67 to 0.86, moderate certainty, rank 5/23) compared to placebo. We have high-certainty evidence that dexamethasone (RR 1.00, 95% CI 0.91 to 1.09, high certainty, rank 16/24) has no effect on sedation compared to placebo. No studies assessed substance class-specific side effects for fosaprepitant. Direction and magnitude of network effect estimates together with level of evidence certainty are graphically summarized for all pre-defined GRADE-relevant outcomes and all drugs of direct interest compared to placebo in http://doi.org/10.5281/zenodo.4066353. AUTHORS' CONCLUSIONS We found high-certainty evidence that five single drugs (aprepitant, ramosetron, granisetron, dexamethasone, and ondansetron) reduce vomiting, and moderate-certainty evidence that two other single drugs (fosaprepitant and droperidol) probably reduce vomiting, compared to placebo. Four of the six substance classes (5-HT₃ receptor antagonists, D₂ receptor antagonists, NK₁ receptor antagonists, and corticosteroids) were thus represented by at least one drug with important benefit for prevention of vomiting. Combinations of drugs were generally more effective than the corresponding single drugs in preventing vomiting. NK₁ receptor antagonists were the most effective drug class and had comparable efficacy to most of the drug combinations. 5-HT₃ receptor antagonists were the best studied substance class. For most of the single drugs of direct interest, we found only very low to low certainty evidence for safety outcomes such as occurrence of SAEs, any AE, and substance class-specific side effects. Recommended and high doses of granisetron, dexamethasone, ondansetron, and droperidol were more effective than low doses for prevention of vomiting. Dose dependency of side effects was rarely found due to the limited number of studies, except for the less sedating effect of recommended and high doses of ondansetron. The results of the review are transferable mainly to patients at higher risk of nausea and vomiting (i.e. healthy women undergoing inhalational anaesthesia and receiving perioperative opioids). Overall study quality was limited, but certainty assessments of effect estimates consider this limitation. No further efficacy studies are needed as there is evidence of moderate to high certainty for seven single drugs with relevant benefit for prevention of vomiting. However, additional studies are needed to investigate potential side effects of these drugs and to examine higher-risk patient populations (e.g. individuals with diabetes and heart disease).
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Affiliation(s)
- Stephanie Weibel
- Department of Anesthesiology and Critical Care, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Gerta Rücker
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center - University of Freiburg, Freiburg, Germany
| | - Leopold Hj Eberhart
- Department of Anaesthesiology & Intensive Care Medicine, Philipps-University Marburg, Marburg, Germany
| | - Nathan L Pace
- Department of Anesthesiology, University of Utah, Salt Lake City, UT, USA
| | - Hannah M Hartl
- Department of Anesthesiology and Critical Care, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Olivia L Jordan
- Department of Anesthesiology and Critical Care, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Debora Mayer
- Department of Anesthesiology and Critical Care, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Manuel Riemer
- Department of Anesthesiology and Critical Care, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Maximilian S Schaefer
- Department of Anaesthesiology, University Hospital Düsseldorf, Düsseldorf, Germany
- Department of Anesthesia, Critical Care & Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Diana Raj
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Queen Elizabeth University Hospital, Glasgow, UK
| | - Insa Backhaus
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Antonia Helf
- Department of Anesthesiology and Critical Care, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Tobias Schlesinger
- Department of Anesthesiology and Critical Care, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Peter Kienbaum
- Department of Anaesthesiology, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Peter Kranke
- Department of Anesthesiology and Critical Care, University Hospital Wuerzburg, Wuerzburg, Germany
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Wu L, Si H, Li M, Zeng Y, Wu Y, Liu Y, Shen B. The optimal dosage, route and timing of glucocorticoids administration for improving knee function, pain and inflammation in primary total knee arthroplasty: A systematic review and network meta-analysis of 34 randomized trials. Int J Surg 2020; 82:182-191. [PMID: 32877755 DOI: 10.1016/j.ijsu.2020.07.065] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Accepted: 07/31/2020] [Indexed: 02/08/2023]
Abstract
PURPOSE Glucocorticoids are a mainstay to control postoperative pain, inflammation, nausea and vomiting (PONV) in total knee arthroplasty (TKA). Understanding the optimal dose and route of glucocorticoids administration in TKA is of great significance in speedy functional recovery. We aimed to summarize, evaluate and rank order the efficacy of glucocorticoids regimens in TKA. METHODS Electronic databases (PubMed et al.) were systematically searched from inception up to April 30, 2020. The primary outcomes were visual analogue scale (VAS), range of motion (ROM) and knee society score (KSS). C-reactive Protein (CRP) and PONV were also evaluated. Multivariable Bayesian random effects models were used to synthesize and rank the comparative efficacy of glucocorticoids regimens. RESULTS A total of 34 eligible randomized controlled trials with 11 different glucocorticoids regimens were assessed. Overall inconsistency and heterogeneity were acceptable. Multiple medium dose perioperative intravenous injection (IV) ranked first in the analgesia network and a single high doses of preoperative IV ranked first in the inflammation and PONV network. There was no statistically significant increase in ROM or KSS in all the glucocorticoid formulations and doses compared with controls on postoperative day 30. CONCLUSIONS Glucocorticoid multiple intravenous injection was preferable to a single intravenous injection (preoperative and postoperative), periarticular injection and intra-articular injection in analgesia. Based on the available evidence, a medium dose of hydrocortisone of 2-4 mg/kg is optimal.
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Affiliation(s)
- Limin Wu
- Department of Orthopaedic Surgery, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province, 610041, China.
| | - Haibo Si
- Department of Orthopaedic Surgery, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province, 610041, China.
| | - Mingyang Li
- Department of Orthopaedic Surgery, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province, 610041, China.
| | - Yi Zeng
- Department of Orthopaedic Surgery and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, Sichuan Province, 610041, China.
| | - Yuangang Wu
- Department of Orthopaedic Surgery, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province, 610041, China.
| | - Yuan Liu
- Department of Orthopaedic Surgery, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province, 610041, China.
| | - Bin Shen
- Department of Orthopaedic Surgery, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province, 610041, China.
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