Risks and benefits of preoperative high dose methylprednisolone in surgical patients: a systematic review

Methylprednisolone taper is an effective addition to multimodal pain regimens after total shoulder arthroplasty: results of a randomized controlled trial: 2022 Neer Award winner

BACKGROUND

Perioperative corticosteroids have shown potential as nonopioid analgesic adjuncts for various orthopedic pathologies, but there is a lack of research on their use in the postoperative setting after total shoulder arthroplasty (TSA). The purpose of this study was to assess the effect of a methylprednisolone taper on a multimodal pain regimen after TSA.

METHODS

This study was a randomized controlled trial (clinicaltrials.gov NCT03661645) of opioid-naive patients undergoing TSA. Patients were randomly assigned to receive intraoperative dexamethasone only (control group) or intraoperative dexamethasone followed by a 6-day oral methylprednisolone (Medrol) taper course (treatment group). All patients received the same standardized perioperative pain management protocol. Standardized pain journal entries were used to record visual analog pain scores (VAS-pain), VAS-nausea scores, and quantity of opioid tablet consumption during the first 7 postoperative days (POD). Patients were followed for at least one year postoperatively for clinical evaluation, collection of patient-reported outcomes, and observation of complications.

RESULTS

A total of 67 patients were enrolled in the study; 32 in the control group and 35 in the treatment group. The groups had similar demographics and comorbidities. The treatment group demonstrated a reduction in mean VAS pain scores over the first 7 POD. Between POD 1 and POD 7, patients in the control group consumed an average of 17.6 oxycodone tablets while those in the treatment group consumed an average of 5.5 tablets. This equated to oral morphine equivalents of 132.1 and 41.1 for the control and treatment groups, respectively. There were fewer opioid-related side effects during the first postoperative week in the treatment group. The treatment group reported improved VAS pain scores at 2-week, 6-week, and 12-week postoperatively. There were no differences in Europe Quality of Life, shoulder subjective value (SSV), at any time point between groups, although American Shoulder and Elbow Surgeons questionnaire scores showed a slight improvement at 6-weeks in the treatment group. At mean follow-up, (control group: 23.4 months; treatment group:19.4 months), there was 1 infection in the control group and 1 postoperative cubital tunnel syndrome in the treatment group. No other complications were reported.

CONCLUSIONS

A methylprednisolone taper course shows promise in reducing acute pain and opioid consumption as part of a multimodal regimen following TSA. As a result of this study, we have included this 6-day methylprednisolone taper course in our multimodal regimen for all primary shoulder arthroplasties. We hope this trial serves as a foundation for future studies on the use of low-dose oral corticosteroids and other nonnarcotic modalities to control pain after shoulder surgeries.

Enhanced recovery pathways for head and neck surgery with free tissue transfer reconstruction

The enhanced recovery after surgery (ERAS) pathway is designed to facilitate recovery after surgery by packaging evidence-based protocols specific to each aspect of the perioperative period, including the preoperative, intraoperative, postoperative, and post-discharge periods. The ERAS pathway, which was originally developed for use with colonic resection, is now being expanded to include a variety of surgical procedures, and the ERAS Society has published a consensus review of the ERAS pathway for head and neck surgery with free tissue transfer reconstruction (HNS-FTTR). The ERAS pathway for HNS-FTTR consists of various important protocols, including early postoperative mobilization, early postoperative enteral nutrition, abolition of preoperative fasting, preoperative enteral fluid loading, multimodal pain management, and prevention of postoperative nausea and vomiting. In recent years, meta-analyses investigating the utility of the ERAS pathway in head and neck cancer surgery have also been presented, and all reports showed that the length of the postoperative hospital stay was reduced by the implementation of the ERAS pathway. The ERAS pathway is now gaining traction in the field of head and neck surgery; however, the details of its efficacy remain uncertain. We believe the future direction will require research focused on improving the quality of postoperative patient recovery and patient satisfaction. It will be important to use patient-reported outcomes to determine whether the ERAS pathway is actually beneficial.

Effect of dexamethasone and ramosetron on the prevention of postoperative nausea and vomiting in low-risk patients: a randomized, double-blind, placebo-controlled, multicenter trial

BACKGROUND

Several studies have investigated the effect of antiemetics on postoperative nausea and vomiting (PONV) in high-risk groups. However, few studies have investigated the effect of antiemetics in patients at low risk of developing PONV.

METHODS

In this prospective, randomized, double-blinded trial, 177 patients undergoing surgery under general anesthesia were randomly allocated to three groups. Patients allocated to group C (control group) received 2 mL of intravenous 0.9% saline, those allocated to group R (ramosetron group) received 0.3 mg of intravenous ramosetron, and those allocated to group DR (ramosetron plus dexamethasone group) received 5 mg of intravenous dexamethasone and 0.3 mg of intravenous ramosetron.

RESULTS

Finally, 174 patients completed the study, and the types of surgeries were orthopedic (n = 80), rhinologic (n = 47), urologic (n = 29), and others (n = 18). The incidence of PONV up to 48 h postoperatively was significantly lower in group DR than in group C. The incidence of PONV up to 0-1 h postoperatively was significantly lower in groups R and DR than in group C. The usage pattern of rescue antiemetics was consistent with the incidence of PONV. The percentage of patients requiring rescue analgesics 0-1 h postoperatively was significantly lower in groups R and DR than in group C.

CONCLUSIONS

The combination of dexamethasone and ramosetron demonstrated a superior effect in preventing PONV for 48 h after surgery under general anesthesia than saline in patients at low risk of developing PONV. Compared with saline injections, ramosetron injections yielded better outcomes for the incidence of PONV and the use of rescue antiemetics and rescue analgesics 0-1 h postoperatively.

TRIAL REGISTRATION

Clinical trial registration number: criskorea@korea.kr, KCT0006749.

Effect of Perioperative Corticosteroid Administration on Early Postoperative Range of Motion and Functional Outcomes Following Dupuytren's Fasciectomy

BACKGROUND

The purpose of the study was to evaluate whether perioperative corticosteroid (CS) administration improves early postoperative range of motion (ROM) and function in patients undergoing Dupuytren's fasciectomy.

METHODS

We retrospectively identified 58 patients who underwent Dupuytren's fasciectomy by a single fellowship-trained orthopedic hand surgeon from 2016 to 2020. During this time period, 51 digits in 34 patients received a single intraoperative dose of 10 mg of intravenous dexamethasone followed by a 6-day oral methylprednisolone taper course (CS group), and 37 digits in 24 patients did not (control group). Postoperatively, all patients started hand therapy within 1 week of surgery. At 2 and 6 weeks, patients had ROM data and Disabilities of the Arm, Shoulder, and Hand (DASH) scores collected by a blinded hand therapist. Paired t tests were used to compare the change in ROM and DASH scores at weeks 2 and 6.

RESULTS

The 2 cohorts had similar preoperative ROM. At 2 weeks postoperatively, the CS group had greater metacarpophalangeal (MP), proximal interphalangeal (PIP), and distal interphalangeal (DIP) flexion. There was no difference in MP, PIP, or DIP extension. At 6 weeks postoperatively, the CS group had greater PIP flexion. There was no difference between the groups in MP extension, MP flexion, PIP extension, DIP extension, or DIP flexion. Mean DASH scores were significantly lower in the CS group at weeks 2 and 6. There were no postoperative deep infections or complications requiring surgery in either group.

CONCLUSION

Perioperative CS administration appears to be safe and to improve early ROM and DASH scores following Dupuytren's fasciectomy.

A single preoperative low-dose dexamethasone may reduce the incidence and severity of postoperative delirium in the geriatric intertrochanteric fracture patients with internal fixation surgery: an exploratory analysis of a randomized, placebo-controlled trial

OBJECTIVE

Postoperative delirium (POD) is a common complication along with poor prognosis in geriatric intertrochanteric fracture (ITF) patients. However, the prevention and treatment of POD remain unclear. Previous studies have confirmed that POD is essentially a consequence of neuro-inflammatory responses. Dexamethasone is a glucocorticoid with comprehensive anti-inflammatory effects, while a high dose of dexamethasone correlates with many side effects or even adverse consequences. Thus, this prospective study aims to discuss whether a single preoperative low-dose dexamethasone can reduce the impact of POD on geriatric ITF patients with internal fixation surgery.

METHODS

Between June 2020 and October 2022, there were 219 consecutive ITF patients assessed in our department. Of the 219 ITF patients, 160 cases who met the inclusion and exclusion criteria were finally enrolled and randomly allocated to the dexamethasone group and the placebo group (80 geriatric ITF patients in each group) in this prospective study. The patients in the dexamethasone group received intravenous 10 mg (2 ml) dexamethasone while the patients in the placebo group received intravenous 2 ml saline in 30 min before being sent to the operating room, respectively. The baseline characteristics, surgical information, incidence and severity of POD as the efficacy-related outcomes, and infection events and hyperglycemia as safety-related outcomes (adverse events), were collected and analyzed between the two groups. The severity of POD was evaluated by Memorial Delirium Assessment Scale (MDAS) score.

RESULTS

There were no differences in baseline characteristics and surgical information between the dexamethasone group and the placebo group. The dexamethasone group had a lower incidence of POD than the placebo group within the first 5 days after surgery [(9/80, 11.3% vs. 21/80, 26.3%, RR = 0.83, 95% CI 0.71-0.97, P = 0.015]. The dexamethasone group had lower MDAS scores (Mean ± SD) than the placebo group [13.2 ± 1.0 (range 11 to 15) vs. 15.48 ± 2.9 (range 9 to 20), P = 0.011, effect size = 0.514]. There were no differences in infection events and hyperglycemia between the two groups.

CONCLUSIONS

A single preoperative low-dose dexamethasone may reduce the incidence and severity of POD in geriatric ITF patients with internal fixation surgery.

TRIAL REGISTRATION

ChiCTR2200055281.

Efficacy and Safety of Methylprednisolone for Lung Surgery: a Systematic Review and Meta-analysis of Randomized Controlled Trials

INTRODUCTION

The administration of methylprednisolone (MP) is a component of perioperative multimodal analgesia that mitigates the potentially deleterious effects of postoperative pain and opioid consumption. However, a systematic evaluation of the efficacy and safety of MP is lacking. The present systematic review and meta-analysis was performed to quantify the potential clinical benefits and risks of perioperative MP in lung surgery.

METHODS

We searched seven electronic databases for randomized controlled trials (RCTs) comparing MP with placebo. Coprimary outcomes were rest pain scores, dynamic pain scores, and cumulative morphine equivalent consumption within 24 h postoperatively.

RESULTS

A total of 11 trials including 643 participants were selected for our meta-analysis. The results demonstrated that the MP group had a significant difference in coprimary outcomes (rest pain scores, dynamic pain scores, and cumulative morphine equivalent consumption) compared with the placebo group; nevertheless, the improvement was not clinically meaningful based on minimum clinically important differences (MCID). Notably, MP administration reduced serum levels of interleukin (IL)-6 at 6 h (weighted mean difference -20.49 pg/mL; 95% CI -29.94 to -11.04), and decreased the incidence rate of acute lung injury (rate ratio 0.18; 95% CI 0.03-0.98) and cognitive dysfunction (rate ratio 0.43; 95% CI 0.21-0.88) compared with the placebo group.

CONCLUSIONS

Our findings suggest that the administration of MP contributed to an insignificant relief in acute postoperative pain for lung surgery in a clinical setting. Future studies should focus on exploring the role of MP in reducing pulmonary and surgical-related complications after lung surgery.

CLINICAL TRIAL NUMBER

PROSPERO registration number CRD42022314224.

The efficacy and safety of glucocorticoid for perioperative patients with hepatectomy: a systematic review and meta-analysis

OBJECTIVE

Glucocorticoids have been used in patients undergoing perioperative hepatectomy, however their safety and efficacy remain controversial. This meta-analysis was conducted to investigate this issue and further provide reference for clinical practice.

METHODS

PubMed/MEDLINE, Embase, and Cochrane Library were searched for randomized controlled trials (RCTs) from database inception to December 2022. Literature screening and data extraction were performed independently by two reviewers. The methodological quality of the RCTs was assessed using the Jadad scale. RevMan 5.4 was used for the meta-analysis.

RESULTS

A total of 11 RCTs involving 905 patients were included. Compared with the control group, we found perioperative glucocorticoid administration significantly lowered overall complication rate [RR = 0.67; 95% CI (0.55, 0.83); P = 0.0003], infectious complication rate [RR = 0.41; 95% CI (0.21, 0.82); P = 0.01] and postoperative liver failure [RR = 0.63; 95% CI (0.41, 0.97); P = 0.03]. In addition, glucocorticoids appear to improve liver function (TBil) [MD = -0.36, 95% CI (-0.59, -0.14), P = 0.001] and reduce the release of certain inflammatory cytokines (IL-6) [MD = -48.52, 95% CI (-56.88, -40.16), P < 0.00001].

CONCLUSION

Based on the available evidence, glucocorticoids appear to be safe and effective in patients undergoing hepatectomy, but further research is needed.

Promising Advances in Pharmacotherapy for Patients with Spinal Cord Injury-A Review of Studies Performed In Vivo with Modern Drugs

Spinal cord injury (SCI) is a pathological neurological condition that leads to significant motor dysfunction. It is a condition that occurs as a result of tragic accidents, violent acts, or as a consequence of chronic diseases or degenerative changes. The current treatments for patients with SCI have moderate efficacy. They improve the quality of life of patients, but they are still doomed to long-term disability. In response to the modern directions of research on possible therapeutic methods that allow for the recovery of patients with SCI, a scientific review publication is needed to summarize the recent developments in this topic. The following review is focused on the available pharmacological treatments for SCIs and the problems that patients face depending on the location of the injury. In the following review, the research team describes problems related to spasticity and neuropathic pain; possible therapeutic pathways are also described for neuroprotection and the improvement of neurotransmission within the injured spinal cord, and the review focuses on issues related to oxidative stress.

A Prospective Randomized Controlled Trial of Methylprednisolone for Postoperative Pain Management of Surgically Treated Distal Radius Fractures

PURPOSE

Perioperative glucocorticoids have been effectively used as a pain management regimen for reducing pain after hand surgery. We hypothesize that a methylprednisolone taper (MPT) course following surgery will reduce pain and opioid consumption in the early postoperative period.

METHODS

This study was a randomized controlled trial of patients undergoing surgical fixation for distal radius fracture. Before surgery, patients were randomly assigned to receive preoperative dexamethasone only or preoperative dexamethasone followed by a 6-day oral MPT. Patient pain and opioid consumption data were collected for 7 days after surgery using a patient-reported pain journal.

RESULTS

Our study consisted of 56 patients enrolled from November 2018 to March 2020. Twenty-eight patients each were assigned to the control and treatment groups. Demographic characteristics such as age, body mass index, the dominant side affected, smoking status, diabetes status, and current narcotic use were similar between the control and treatment groups. With a noticeable, significant reduction starting on postoperative day 2, patients who received an MPT course consumed substantially less opioids during the first 7 days (7.8 ± 7.2 pills compared with 15.5 ± 11.5 pills, a 50% reduction). These patients also consumed significantly fewer oral morphine equivalents than the control group (81.2 vs 41.2). A significant difference in the pain visual analog scale scores between the 2 groups was noted starting on postoperative day 2, with 48% of the treatment group reporting no pain by postoperative day 6. No adverse events, including infection or complications of wound or bone healing, were seen in either group.

CONCLUSIONS

There was an early improvement in pain and reduction in early opioid consumption with a 6-day MPT following surgical fixation for distal radius fracture. With no increased risk of adverse events in our sample, MPT may be a safe and effective way to reduce postoperative pain.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic II.

Benefit of a flash dose of corticosteroids in digestive surgical oncology: a multicenter, randomized, double blind, placebo-controlled trial (CORTIFRENCH)

Background

The modulation of perioperative inflammation seems crucial to improve postoperative morbidity and cancer-related outcomes in patients undergoing oncological surgery. Data from the literature suggest that perioperative corticosteroids decrease inflammatory markers and might be associated with fewer complications in esophageal, liver, pancreatic and colorectal surgery. Their benefit on cancer-related outcomes has not been assessed.

Methods

The CORTIFRENCH trial is a phase III multicenter randomized double-blind placebo-controlled trial to assess the impact of a flash dose of preoperative corticosteroids versus placebo on postoperative morbidity and cancer-related outcomes after elective curative-intent surgery for digestive cancer. The primary endpoint is the frequency of patients with postoperative major complications occurring within 30 days after surgery (defined as all complications with Clavien-Dindo grade > 2). The secondary endpoints are the overall survival at 3 years, the disease-free survival at 3 years, the frequency of patients with intraabdominal infections and postoperative infections within 30 days after surgery and the hospital length of stay. We hypothesize a reduced risk of major complications and a better disease-survival at 3 years in the experimental group. Allowing for 5% of drop-out, 1 200 patients (600 per arm) should be included.

Discussion

This will be the first trial focusing on the impact of perioperative corticosteroids on cancer related outcomes. If significant, it might be a strong improvement on oncological outcomes for patients undergoing surgery for digestive cancers.

Trial registration

ClinicalTrials.gov, NCT03875690, Registered on March 15, 2019, URL: https://clinicaltrials.gov/ct2/show/NCT03875690.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-022-09998-z.

Perioperative administration of methylprednisolone was associated with postoperative pulmonary complications in elderly patients undergoing hip fracture surgery

BACKGROUND

Postoperative pulmonary complications (PPCs) seriously affect the postoperative prognosis of elderly patients underwent hip fracture surgery. Although methylprednisolone is increasingly used, the association between perioperative methylprednisolone and PPCs is still controversial. The study aims to determine whether perioperative administration of methylprednisolone is associated with PPCs in elderly patients during hip fracture surgery.

PATIENTS AND METHODS

In this retrospective cohort study, records of 584 patients (≥ 65 years) who underwent hip fracture surgery between January 2013 and October 2020 were extracted. Univariate and multivariate regression analysis were performed to identify the risk factors for PPCs. To further explore the association between administration of methylprednisolone and PPCs, 53 patients received methylprednisolone and 53 patients without methylprednisolone were matched for the confounding factors using propensity score matching (PSM) analysis. The odds ratios (OR) and 95% confidence intervals (CI) for the above variables were analyzed.

RESULTS

The incidence of PPCs during postoperative hospitalization was 6.83% (38/556) among the elderly patients following hip fracture surgery. Patients with PPCs had higher postoperative mortality rate, longer hospital stay, more hospitalization cost, and higher incidence of cardiac arrest (all P < 0.05). Multivariate logistic regression analysis showed that age, hypertension, hypoglycemia, hypoproteinemia and perioperative methylprednisolone were independent risk factors for PPCs. Moreover, administration of methylprednisolone was significantly correlated with PPCs both before PSM adjustment (OR = 3.25; 95% CI, 1.67 to 6.33; P = 0.001) and after PSM adjustment (OR = 6.68; 95% CI, 1.40 to 31.82; P = 0.017).

CONCLUSION

Perioperative administration of methylprednisolone is a risk factor for PPCs in elderly patients undergoing hip fracture surgery.

Single High-Dose Systemic Methylprednisolone Administered Preoperatively Improves Pain Control and Sleep Quality After Total Hip Arthroplasty: A Double-Blind, Randomized Controlled Trial

Background

This study was performed to evaluate the efficacy of preoperative high-dose methylprednisolone on pain levels and sleep quality following primary total hip arthroplasty.

Material and methods

A double-blind, randomized controlled trial was performed in adults underdoing total hip arthroplasty. A computer-generated, permuted-block randomization scheme with a 1:1 ratio between the intervention (125 mg methylprednisolone) and control groups (normal saline) was utilized. Patients underwent a similar preoperative and postoperative protocol. Pain was assessed using the visual analog scale (VAS). Sleep quality was assessed at the 2-week postoperative visit using the Pittsburgh Sleep Quality Index (PSQI).

Results

With a total of 70 patients, 35 patients were included in the intervention and placebo groups. Hospital stay was significantly shorter in the intervention group (1.5 ± 0.7 vs 2.0 ± 0.5 days, P = .03). Preoperative pain levels were similar between groups, while satisfactory pain control was achieved in a significantly larger number of patients in the intervention group (18 vs 8 patients, P = .009). The intervention group was significantly more likely to have a good sleep quality than the placebo groups (74% vs 31%, P = .001). No significant differences were found between preoperative and postoperative blood sugar levels. We did not observe any cases of early postoperative wound complication, infection, or deep vein thrombosis among our patients.

Conclusion

In this randomized controlled trial, preoperative administration of 125 mg of methylprednisolone was found to improve pain control, as measured by VAS, 24 hours after surgery, and sleep quality, as measured by PSQI, 2 weeks following surgery.

AHA STEROID trial, dexamethasone in acute high-risk abdominal surgery, the protocol for a randomized controlled trial

INTRODUCTION

Existing multimodal pathways for patients undergoing acute high-risk abdominal surgery for intestinal obstruction (IO) and perforated viscus (PV) have focused on rescue in the immediate perioperative period. However, there is little focus on the peri-operative pathophysiology of recovery in this patient group, as done to develop enhanced recovery pathways in elective care. Acute inflammation is the main driver of the perioperative pathophysiology leading to adverse outcomes. Pre-operative high-dose of glucocorticoids provides a reduction in the inflammatory response after surgery, effective pain relief in several major surgical procedures, as well as reduce fatigue and improving endothelial dysfunction.

AIM

To evaluate the effect of high-dose glucocorticoid on the inflammatory response, fluid distribution and recovery after acute high-risk abdominal surgery in patients with IO and PV.

METHODS

AHA STEROID trial is a sponsor-initiated single-center, randomized, double-blind placebo-controlled trial, assessing preoperative high-dose dexamethasone (1 mg/kg) versus placebo (normal saline) in patients undergoing emergency high-risk abdominal surgery. We plan to enroll 120 patients. Primary outcome is the reduction in C-reactive protein on postoperative day 1 as a marker of successful attenuation of the acute stress response. Secondary outcomes include perioperative changes in endothelial and other inflammatory markers, fluid distribution, pulmonary function, pain, fatigue, and mobilization. The statistical plan is outlined in the protocol.

DISCUSSION

The AHA STEROID trial will provide important evidence to guide the potential use of high-dose glucocorticoids in emergency high-risk abdominal surgery, with respect to different pathophysiologies.

Single-dose premedication enhances multimodal analgesia after knee arthroplasty

BACKGROUND

With the current trend to reduce postoperative opioid use to enhance recovery and address perioperative opioid addiction concerns, the challenge of managing pain after total knee arthroplasty has increased. This study examined the effect of adding a preoperative medication regime to a multimodal postoperative analgesia protocol that included regional anaesthesia.

MATERIALS AND METHODS

Sixty patients undergoing elective first-time unilateral knee arthroplasty received celecoxib 100mg, gabapentin 600mg and dexamethasone 10mg po one hour before skin incision. They were compared to a sequential retrospective cohort of 49 patients. All patients routinely received acetaminophen 650mg po q6h, ibuprofen 400mg po q8h, patient-controlled opioid analgesia and continuous adductor canal blocks postoperatively. Pain scores and opioid consumption were recorded at 4, 8, 12, 24 and 48h.

RESULTS

Pain scores and cumulative opioid use were statistically and clinically significantly reduced at all time points up to 48h.

CONCLUSIONS

Combining preoperative oral celecoxib, gabapentin and dexamethasone had a clinically significantly effect in reducing pain scores and opioid use for at least 48h. Most of this effect is probably due to dexamethasone.

Modifying the Stress Response - Perioperative Considerations and Controversies

The idea that perioperative outcomes may be improved through the implementation of measures that modify the surgical stress response has been around for several decades. Many techniques have been trialled with varying success. In addition, how the response to modification is measured, what constitutes a positive result and how this translates into clinical practice is the subject of debate. Modification of the stress response is the principal tenet behind the enhanced recovery after surgery (ERAS) movement which has seen the development of guidelines for perioperative care across a variety of surgical specialties bringing with them significant improvements in outcomes.

Traumatic optic neuropathy: a review of current studies

Traumatic optic neuropathy (TON) is a serious complication of craniofacial trauma that directly or indirectly damages the optic nerve and can cause severe vision loss. The incidence of TON has been gradually increasing in recent years. Research on the protection and regeneration of the optic nerve after the onset of TON is still at the level of laboratory studies and which is insufficient to support clinical treatment of TON. And, due to without clear guidelines, there is much ambiguity regarding its diagnosis and management. Clinical interventions for TON include observation only, treatment with corticosteroids alone, or optic canal (OC) decompression (with or without steroids). There is controversy in clinical practice concerning which treatment is the best. A review of available studies shows that the visual acuity of patients with TON can be significantly improved after OC decompression surgery (especially endoscopic transnasal/transseptal optic canal decompression (ETOCD)) with or without the use of corticosteroids. And new findings of laboratory studies such as mitochondrial therapy, lipid change studies, and other studies in favor of TON therapy have also been identified. In this review, we discuss the evolving perspective of surgical treatment and experimental study.

Optic nerve injury in preoperative imaging is associated with visual improvement outcome in endoscopic optic nerve decompression

Objective

To evaluate potential clinical parameters having an impact on visual outcome after endoscopic optic nerve decompression in acute optic neuropathy patients.

Methods

A retrospective chart review of patients with acute optic neuropathy, who underwent endoscopic optic nerve decompression between June 2001 and November 2018 at an academic center was performed. Patients were divided into groups according to visual improvement after surgical treatment (yes/no). Following clinical parameters were compared between groups: perioperative steroid use, evidence of optic nerve affection in preoperative neuroimaging, additional optic nerve sheath incision, surgery delay and preoperative C-reactive protein (CRP) levels. Further subgroups analyses were conducted based on etiology (trauma/tumor).

Results

Among 32 included cases, 16 patients (50%) reported visual improvement after endoscopic optic nerve decompression. There was no significant difference in visual improvement between etiology subgroups (trauma: n = 9/20 (45%) vs. tumor: n = 7/12 (58.3%), p = 0.465). Tumor subgroup patients with visual improvement had a significantly higher prevalence of optic nerve affection in preoperative neuroimaging than those without visual improvement (p = 0.018, φ = 0.683). Perioperative steroid administration was negatively associated with visual outcome (p = 0.034, φ = 0.375). Nerve sheath incision, surgery delay and preoperative CRP levels did not have a significant impact on visual outcome (p > 0.05).

Conclusion

Radiological findings can help as an indicator for surgical treatment since an affected optic nerve in preoperative neuroimaging resulted in better visual outcome after surgery. The use of steroids should be considered more carefully since it did not show any beneficial effect.

Preoperative dexamethasone for pain relief after total knee arthroplasty: A randomised controlled trial

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.

Efficacy of Periarticular Cocktail Injection in Rheumatoid Patients Undergoing Total Knee Replacement

BACKGROUND

Pain control after total knee replacement (TKR) is of primary importance to joint replacement surgeons to achieve good functional outcome post-surgery. This becomes even more challenging when these major procedures are done in immunocompromised patients like rheumatoid arthritis. Good peri-operative analgesia facilitates early rehabilitation, improves patient satisfaction, and reduces the hospital stay. The adverse effects caused by epidural analgesia or parenteral opioids can be avoided by replacing it with an analgesic cocktail locally. Our prospective study was to evaluate the benefits of a periarticular cocktail injection which was given in rheumatoid patients undergoing bilateral TKR in single sitting with respect to pain and knee motion recovery.

METHODS

Sixty-four rheumatoid arthritis patients undergoing simultaneous primary total knee replacement were included in the study. A total of 128 knees were randomized either to receive a periarticular intra-operative injection containing ropivacaine, fentanyl, clonidine, cefuroxime and epinephrine (Group A) on one knee and to receive plain ropivacaine (Group B) on the opposite knee. The perioperative and post-operative analgesic regimens were standardized. All patients received the same standard analgesia protocol. Visual analog scores for pain, knee range of motion and quadriceps function were recorded on the day of surgery, first post-operative day, second post-operative day, day of discharge, and 2 weeks and 6 weeks during follow-up. The need for rescue analgesic requirement and adverse effects to the cocktail injection were also noted during the study period.

RESULTS

The patients who received the periarticular cocktail fared better in terms of pain scores and functional recovery. Additional rescue agents used were significantly less at 6 h, at 12 h, and over the first 24 h after the surgery in group A when compared with group B. No cardiac or central nervous system toxicity was observed.

CONCLUSIONS

Periarticular cocktail injection significantly reduces the requirements for post-operative analgesia and also improves patient satisfaction, with no apparent risks, following total knee arthroplasty in rheumatoid arthritis.

Enhanced recovery after surgery program involving preoperative dexamethasone administration for head and neck surgery with free tissue transfer reconstruction: Single-center prospective observational study

BACKGROUND

There are few reports on Enhanced Recovery After Surgery (ERAS)-based perioperative management following head and neck surgery with free tissue transfer reconstruction (HNS-FTTR). Here, we prospectively evaluated our ERAS program involving preoperative glucocorticoid administration in HNS-FTTR.

METHODS

This prospective study included 60 patients who underwent HNS-FTTR at the Miyagi Cancer Center from June 2017 to December 2018. Their treatment plan included receiving perioperative management in accordance with our head and neck ERAS program. Major outcomes of hospitalization periods, early mobilization, early enteral nutrition, and patient satisfaction were assessed, and blood date and vital signs were compared with control patients who underwent HNS-FTTR from January 2014 to September 2016 at our institution before ERAS was implemented.

RESULTS

The duration of hospital stay and the duration until completion of the discharge criteria was a median of 25 days and 17 days, respectively. Early mobilization was achieved in 86.0% of the patients at postoperative-day (POD)1 and 96.5% at POD2. Enteral nutrition was started in 80.1% at POD1 and 100% at POD2. Postoperative pain was controlled at mean VAS scores of 1.51-3.13. Clavien-Dindo grade II or higher postoperative complications were evident in 27.6% of the patients. The mean QOR40 score was 179.6 preoperatively, 146.1 at POD3, and 167.8 at POD7. Compared with the control group, there were significantly lower C-reactive protein levels, higher albumin levels, a lower body temperature, a lower neutrophil-to-lymphocyte ratio, less body weight fluctuation, and fewer incidences of decreased blood pressure in the ERAS group.

CONCLUSION

Patients who underwent HNS-FTTR with ERAS-based perioperative management achieved early mobilization, early enteral nutrition, favorable pain control, remarkable recovery of patient satisfaction at POD7, and there was evidence of better hemodynamic stability and less inflammatory response compared with control patients.

Dexamethasone Dose and Early Postoperative Recovery after Mastectomy

Background

Pain and nausea are the most common challenges in postoperative recovery after mastectomy. Preventive measures include multimodal analgesia with preoperative glucocorticoid. The aim of this study was to investigate whether 24 mg of preoperative dexamethasone was superior to 8 mg on early recovery after mastectomy in addition to a simple analgesic protocol.

Methods

In a randomized, double-blind trial, patients 18 yr of age or older having mastectomy were randomized 1:1 to 24 mg or 8 mg dexamethasone, and all received a standardized anesthetic and surgical protocol with preoperative acetaminophen, total intravenous anesthesia, and local anesthetic wound infiltration. The primary endpoint was number of patients transferred to the postanesthesia care unit according to standardized discharge criteria (modified Aldrete score). Secondary endpoints included pain and nausea at extubation, transfer from the operating room and upon arrival at the ward, length of stay, seroma occurrence, and wound infections.

Results

One hundred thirty patients (65 in each group) were included and analyzed for the primary outcome. Twenty-three (35%) in each group met the primary outcome, without significant differences in standardized discharge scores (odds ratio, 1.00 [95% CI, 0.49 to 2.05], P &gt; 0.999). More patients had seroma requiring drainage in the 24 mg versus 8 mg group, 94% versus 81%, respectively (odds ratio, 3.53 [95% CI, 1.07 to 11.6], P = 0.030). Median pain scores were low at all measured time points, numeric rating scale less than or equal to 2 versus less than or equal to 1 in the 24 mg versus 8 mg group, respectively. Six patients in each group (9%) experienced nausea at any time during hospital stay (P &gt; 0.999). Length of stay was median 11 and 9.2 h in the 24 and 8 mg group, respectively (P = 0.217).

Conclusions

The authors found no evidence of 24 mg versus 8 mg of dexamethasone affecting the primary outcome regarding immediate recovery after mastectomy. The authors observed a short length of stay and low pain scores despite a simple analgesic protocol.

Editor’s Perspective

What We Already Know about This Topic

What This Article Tells Us That Is New

Postoperative Considerations in the Management of Hallux Valgus

Postoperative management of hallux valgus varies widely. Setting preoperative expectations is an important aspect of attaining a successful outcome, but this is not routinely reviewed in the literature. This chapter offers suggestions on successfully navigating this area of patient care. Current concepts focus on pain control, immobilization, and return to activities. This chapter also reviews the current literature in these areas and sets out the authors' preferred management in the postoperative setting.

Modifiable, Postoperative Risk Factors for Delayed Discharge Following Total Knee Arthroplasty: The Influence of Hypotension and Opioid Use

BACKGROUND

We sought to identify independent modifiable risk factors for delayed discharge after total knee arthroplasty (TKA) that have been previously underrepresented in the literature, particularly postoperative opioid use, postoperative laboratory abnormalities, and the frequency of hypotensive events.

METHODS

Data from 1033 patients undergoing TKA for primary osteoarthritis of the knee between June 2012 and August 2014 at an academic orthopedic specialty hospital were reviewed. Patient demographics, comorbidities, inpatient opioid medication, postoperative hypotensive events, and abnormalities in laboratory values, all occurring on postoperative day 0 or 1, were collected. Multivariate logistic regression analysis was performed to identify independent risk factors for a prolonged length of stay (LOS) >3 days.

RESULTS

The average age of patients undergoing primary TKA in our cohort was 65.9 (standard deviation, 9.1) years, and 61.7% were women. The mean LOS for all patients was 2.64 days (standard deviation, 1.14; range, 1-9). And 15.3% of patients had a LOS >3 days. On multivariate logistic regression analysis, nonmodifiable risk factors associated with a prolonged LOS included nonwhite race (odds ratio [OR], 2.01), single marital status (OR, 1.53), and increasing age (OR, 1.47). Modifiable risk factors included every 5 postoperative hypotensive events (OR, 1.31), 10-mg increases in oral morphine equivalent consumption (OR, 1.04), and postoperative laboratory abnormalities (hypocalcemia: OR, 2.15; low hemoglobin: OR, 2.63).

CONCLUSION

This study identifies potentially modifiable factors that are associated with increased LOS after TKA. Doubling down on efforts to control the narcotic use and to use opioid alternatives when possible will likely have efficacy in reducing LOS. Attempts should be made to correct laboratory abnormalities and to be cognizant of patient opioid use, age, and race when considering potential avenues to reduce LOS.

Efficacy of Systemic Steroid Use Given One Day After Total Knee Arthroplasty for Pain and Nausea: A Randomized Controlled Study

BACKGROUND

Systemic steroid has been used to control pain and nausea in total knee arthroplasty (TKA), but most studies recommend a single dose administration prior to, or during, surgery. This study aimed to determine the efficacy of administration on 1 day postoperatively.

METHODS

Patients who were scheduled to undergo TKA were randomly assigned to the following groups: control group, receiving normal saline injection; group 1, receiving 10 mg dexamethasone intravenously (IV) 1 hour before surgery; group 2, receiving 0.1 mg/kg dexamethasone (IV) 24 hours after surgery; or group 3, receiving 0.2 mg/kg dexamethasone (IV) 24 hours after surgery (n = 44-46 per group). Primary outcomes were pain and nausea visual analogue scale (VAS). Secondary outcomes were analgesic administration, rescue antiemetic administration, C-reactive protein, range of motion, and complications.

RESULTS

Postoperative pain and nausea remained high for 48 hours post-TKA. Group 1 had lower pain and nausea VAS scores than did the control group (P < .01) for only 24 hours post-TKA. Groups 2 and 3 had lower pain and nausea VAS scores than did the control group and group 1 (P < .01) 48 hours post-TKA. Analgesic and antiemetic administration were significantly lower in groups 2 and 3 than in the control group during 48 hours after TKA. There were no differences in C-reactive protein level and range of motion, and complications were not detected.

CONCLUSION

The effect of preoperative and postoperative administration of dexamethasone for controlling pain and nausea was observed only for 24 hours. Considering that severe pain and nausea persisted for more than 48 hours after TKA, additional administration of dexamethasone at 1 day postoperatively is suggested.

LEVEL OF EVIDENCE

Level I.

Long-Term Outcomes after Use of Perioperative Glucocorticoids in Patients Undergoing Cancer Surgery: A Systematic Review and Meta-Analysis

The surgical stress response can accelerate clinical metastasis formation. Perioperative glucocorticoids might modulate this response and the metastatic process. We aimed to describe associations between perioperative glucocorticoids and long-term outcomes after cancer surgery. We searched four databases for eligible trials and performed meta-analyses on frequency and time-to-event data. We included sixteen studies that evaluated eight different cancer types. No association was found between perioperative glucocorticoids and recurrence in either the frequency meta-analysis, risk ratio (RR) 1.04, 95% confidence interval (CI) (0.87-1.25), or in the time-to-event meta-analysis, hazard ratio (HR) 1.18, 95% CI (0.78-1.79). Increased 1-year overall survival, RR 0.70, 95% (0.51-0.97), and disease-free survival, RR 0.77, 95% CI (0.60-0.97), was found for the glucocorticoid group, but five years after surgery, overall survival was reduced for the glucocorticoid group, RR 1.64, 95% CI (1.00-2.71). An exploratory subgroup analysis revealed decreased overall survival, HR 1.78, 95% CI (1.57-2.03), for patients undergoing colorectal cancer surgery while receiving glucocorticoids. Perioperative glucocorticoids were not associated with recurrence after cancer surgery. We found neither beneficial or deleterious associations between glucocorticoids and overall survival or disease-free survival. The available evidence remains heterogenous; low in quality and amount; and cancer-specific at present.

Effect of Methylprednisolone on Pain Management in Total Knee or Hip Arthroplasty: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Total joint arthroplasty (TJA) has been reported to be a successful strategy for patients with advanced osteoarthritis; however, early postoperative pain has become an unresolved issue. Perioperative methylprednisolone (MP) administration in TJA is an important and controversial topic. This study was conducted to assess the efficacy and safety of MP for pain management after total knee or hip arthroplasty (TKA/THA).

MATERIALS AND METHODS

PubMed, Embase, and the Cochrane Library were searched for randomized controlled trials comparing MP versus placebo for patients undergoing TKA/THA. Related indicators that reflected the efficacy and safety for pain management were evaluated by meta-analysis.

RESULTS

Six randomized controlled trials involving a total of 350 patients met the inclusion criteria. The outcomes showed that intravenous MP significantly reduced pain scores at 6 and 24 hours during activity after TKA and THA but local use of MP had no clear benefit in reducing pain scores compared with the control group. There was no significant difference in VAS at 24 hours at rest and 48 hours during activity after TKA and THA. In addition, MP was associated with a reduction of morphine consumption at 24 hours after TKA. Furthermore, patients receiving MP had an obvious inflammatory control and improving postoperative nausea and vomiting and the use of MP was not associated with a significant increase in the risk of complications. There was no significant difference in the range of knee motion and length of hospital stay in both groups.

CONCLUSIONS

This study showed that intravenous MP significantly alleviated early postoperative pain and the incidence of postoperative nausea and vomiting after TKA and THA. For safety, intravenous MP as a promising strategy in rapid recovery to TJA.

Redefining the perioperative stress response: a narrative review

The systemic stress response triggered by surgical trauma is characterised by sterile inflammation preceding metabolic and neuroendocrine dysregulation. However, the relevance of the classically described 'stress response' is now highly questionable in an era where profound physiological deconditioning is common in older, frail surgical patients. Commonly used assessment techniques do not accurately reflect hypothalamic-pituitary-adrenal axis integrity after major surgery. Clinical interpretation of plasma concentrations of cortisol, the prototypical stress hormone, is rarely accurate, because of study heterogeneity, the inherently dynamic characteristics of cortisol production, and assay variability. Before surgery, chronic psychosocial stress and common cardiorespiratory co-morbidities are clinically relevant modifiers of neuroendocrine activation to acute stress/inflammation. The frequent development of multi-morbidity after major surgery further clouds the compartmentalised, discrete model of neuroendocrine activation after initial tissue injury. Starvation, impaired mobility, and sepsis after surgery generate distinct neuroendocrine profiles that challenge the conventional model of neuroendocrine activation. Basic science studies suggest that high circulating levels of cortisol may directly cause organ injury. Conversely, randomised controlled clinical trials investigating glucocorticoid supplementation have delivered contrasting results, with some suggesting a protective effect in the perioperative period. Here, we consider many of the confounding factors that have emerged to challenge the conventional model of the surgical stress response, and suggest that a more nuanced understanding of changes in hypothalamic-pituitary-adrenal axis physiology is warranted to advance perioperative medicine. Re-examining the perioperative stress response presents opportunities for improving outcomes through enhancing the understanding of the neuroendocrine aspects of preparation for and recovery from surgery.

Effectiveness of intraoperative periarticular cocktail injection for pain control and knee motion recovery after total knee replacement

Background

Pain control after total knee replacement (TKR) is pivotal in postoperative rehabilitation. Usage of epidural analgesia or parenteral opioids can cause undesirable side effects hampering early recovery and rehabilitation. These side effects can be avoided by infiltration of an analgesic cocktail locally. Our study was performed to evaluate the benefits of a particular cocktail combination in patients undergoing TKR with respect to pain and knee motion recovery.

Methods

One hundred consecutive patients who underwent simultaneous bilateral TKR were enrolled and received an intraoperative periarticular cocktail injection in the right knee (intervention) and normal saline in the left knee (control). Postoperative pain was recorded using the visual analog scale for each knee, and the time taken to achieve 90° of knee flexion was noted for each side.

Results

The cocktail injected knee had significantly less pain when compared with the control knee during the first 48 hours and significantly shorter period to achieve 90° of knee flexion.

Conclusions

The use of intraoperative periarticular cocktail injection significantly reduces early postoperative pain and provides better early knee motion.

Parecoxib Shortens the Duration of Acute Postoperative Pain After Laparoscopic-Assisted Vaginal Hysterectomy

The effect of parecoxib sodium on the duration and severity of acute postoperative pain after laparoscopic-assisted vaginal hysterectomy has been inadequately studied. This randomized, controlled trial compared the effects of parecoxib, methylprednisolone, and placebo on the duration of acute postoperative pain after elective laparoscopic-assisted vaginal hysterectomy. Ninety-four eligible patients were randomized to three groups [parecoxib sodium 40 mg (Group P), methylprednisolone 1 mg/kg (Group M), and saline (Group S)]. The duration of pain during coughing [median (interquartile range)] was significantly lower in Group P than in Group M or Group S [26.0 (5.8–48.0) vs. 48.0 (30.0–55.5) vs. 48.0 (36.0–58.5) h; p = 0.025]. The duration of pain during rest was also significantly lower in Group P than in Group M or Group S [5.5 (3.8–21.0) vs. 24.0 (6.0–28.0) vs. 22.0 (5.8–36.0) h; p = 0.009]. Compared with those in Group M and Group S, the patients in Group P reported less intense visceral pain during coughing at 12 (p = 0.050) and 24 h (p = 0.009) as well as at rest at 12 h (p = 0.008). Compared with those in Group P and Group S, the patients in Group M showed lower serum C-reactive protein levels and higher blood glucose levels after surgery. No differences were noted in nausea, vomiting, length of hospital stay, wound infection, and delayed wound healing among the groups. Thus, parecoxib sodium reduces the duration and intensity of acute postoperative pain after laparoscopic-assisted vaginal hysterectomy.

The efficiency and safety of steroid addition to multimodal cocktail periarticular injection in knee joint arthroplasty: a meta-analysis of randomized controlled trials

Steroids are frequently used for postoperative pain relief without definite evidence. This study was conducted to assess the pain management effect of the addition of steroids to a multimodal cocktail periarticular injection (MCPI) in patients undergoing knee arthroplasty and evaluate their safety. Pubmed, Embase, and Cochrane Library were searched through April, 2018. A total of 918 patients from ten randomized controlled trials (RCTs) were ultimately included. Compared with placebo groups, steroids application could effectively relieve pain on postoperative day (POD)1; decrease C-Reactive protein (CRP) level on POD3; improve range of motion (ROM) in postoperative 5 days; reduce morphine consumption, achieve earlier straight leg raising (SLR), and shorten the length of stay (LOS) in hospital. With regards to adverse effects, it did not increase the risk of postoperative infection, postoperative nausea and vomiting (PONV), or other complications. However, no significant difference in pain relief, ROM, or increased Knee Society Knee Function Scores were found during long-term follow up. Overall, this meta-analysis ensured the efficiency and safety of steroids with MCPI in knee arthroplasty patients during the early postoperative period.

Can Preoperative Intravenous Corticosteroids Administration Reduce Postoperative Pain Scores Following Spinal Fusion?: A Meta-Analysis

Objective: This meta-analysis aimed to assess whether preoperative intravenous corticosteroids reduced postoperative pain in patients undergoing spinal fusion surgery. Methods: We systematically searched PubMed, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science and Google databases, from inception to March 29, 2018. Randomized controlled trials (RCTs) that compared preoperative intravenous glucocorticoids against a control treatment for the effect on pain following spinal fusion surgery were included. A meta-analysis was performed to generate a pooled risk ratio (RR) and weighted mean difference (WMD) with corresponding 95% confidence interval (CI) for discontinuous outcomes (the occurrence of postoperative nausea and vomiting [PONV] as well as surgical-site infections) and continuous outcomes (visual analog scale [VAS] scores at 12 h, 24 h, 48 h, and 72 h; total morphine consumption and the length of hospital stay), respectively. Results: Ten RCTs that compared intravenous corticosteroids versus placebo were included in our final meta-analysis. Compared with controls, intravenous corticosteroids were associated with a statistically significant reduction in pain VAS scores at 12 h, 24 h, 48 h, and 72 h. Additionally, intravenous corticosteroids decreased total morphine consumption, PONV, and the length of hospital stay. There was no significant difference between intravenous corticosteroids and controls, regarding the occurrence of infection (p > 0.05). Conclusions: In summary, our results indicated that intravenous corticosteroids not only reduce pain but also have anti-emetic effects. More studies should focus on the adverse effects of administering intravenous corticosteroids.

Association of preoperative systemic corticosteroid therapy with surgical outcomes in chronic obstructive pulmonary disease patients

BACKGROUND:

Chronic obstructive pulmonary disease (COPD) patients are at an increased risk of postoperative pulmonary complications (PPCs). The purpose of this study is to evaluate the risks and benefits associated with preoperative steroids in COPD patients.

METHODS:

The National Surgical Quality Improved Program database was used to identify 92 COPD patients who underwent surgery at the American University of Beirut Medical Center between 2009 and 2013. COPD was diagnosed based on postbronchodilator forced expiratory volume in 1 s to forced vital capacity ratio <0.7 and a history of smoking. The exposure of interest was preoperative systemic corticosteroid therapy. The primary outcomes were PPCs and wound complications. Cardiac and urinary complications along with unplanned readmission or reoperation and death were also evaluated.

RESULTS:

Overall 42.4% of patients received preoperative systemic corticosteroids. Postoperative wound complications were significantly more frequent in COPD patients who received preoperative systemic corticosteroids compared to patients who did not (10.3% vs. none, respectively, P = 0.03). However, PPCs were not significantly different between patients who received preoperative systemic corticosteroids and patients who did not (17.9% vs. 13.2%, respectively, P = 0.53). There were no significant differences in the secondary outcomes.

CONCLUSIONS:

This study suggests that preoperative administration of systemic corticosteroids in stable COPD patients is associated with an increased risk of postoperative wound complications but may not reduce PPCs.

Intraoperative dexamethasone does not increase the risk of postoperative wound infection: a propensity score-matched post hoc analysis of the ENIGMA-II trial (EnDEX)

BACKGROUND

In a post hoc analysis of the ENIGMA-II trial, we sought to determine whether intraoperative dexamethasone was associated with adverse safety outcomes.

METHODS

Inverse probability weighting with estimated propensity scores was used to determine the association of dexamethasone administration with postoperative infection, quality of recovery, and adverse safety outcomes for 5499 of the 7112 non-cardiac surgery subjects enrolled in ENIGMA-II.

RESULTS

Dexamethasone was administered to 2178 (40%) of the 5499 subjects included in this analysis and was not associated with wound infection [189 (8.7%) vs 275 (8.3%); propensity score-adjusted relative risk (RR) 1.10; 95% confidence interval (CI) 0.89-1.34; P=0.38], severe postoperative nausea and vomiting on day 1 [242 (7.3%) vs 189 (8.7%); propensity score-adjusted RR 1.06; 95% CI 0.86-1.30; P=0.59], quality of recovery score [median 14, interquartile range (IQR) 12-15, vs median 14, IQR 12-16, P=0.10), length of stay in the postanaesthesia care unit [propensity score-adjusted median (IQR) 2.0 (1.3, 2.9) vs 1.9 (1.3, 3.1), P=0.60], or the primary outcome of the main trial. Dexamethasone administration was associated with a decrease in fever on days 1-3 [182 (8.4%) vs 488 (14.7%); RR 0.61; 95% CI 0.5-0.74; P<0.001] and shorter lengths of stay in hospital [propensity score-adjusted median (IQR) 5.0 (2.9, 8.2) vs 5.3 (3.1, 9.1), P<0.001]. Neither diabetes mellitus nor surgical wound contamination status altered these outcomes.

CONCLUSION

Dexamethasone administration to high-risk non-cardiac surgical patients did not increase the risk of postoperative wound infection or other adverse events up to day 30, and appears to be safe in patients either with or without diabetes mellitus.

CLINICAL TRIAL REGISTRATION

NCT00430989.

Effects of anaesthesia and analgesia on long-term outcome after total knee replacement: A prospective, observational, multicentre study

BACKGROUND

Perioperative regional anaesthesia may protect from persistent postsurgical pain (PPSP) and improve outcome after total knee arthroplasty (TKA).

OBJECTIVES

Aim of this study was to evaluate the impact of regional anaesthesia on PPSP and long-term functional outcome after TKA.

DESIGN

A web-based prospective observational registry.

SETTING

Five Italian Private and University Hospitals from 2012 to 2015.

PATIENTS

Undergoing primary unilateral TKA, aged more than 18 years, informed consent, American Society of Anesthesiologists (ASA) physical status classes 1 to 3, no previous knee surgery.

INTERVENTION(S)

Personal data (age, sex, BMI and ASA class), preoperative pain assessed by numerical rating scale (NRS) score, and risk factors for PPSP were registered preoperatively. Data on anaesthetic and analgesic techniques were collected. Postoperative pain (NRS), analgesic consumption, major complications and patient satisfaction were registered up to the time of discharge. PPSP was assessed by a blinded investigator during a phone call after 1, 3 and 6 months, together with patient satisfaction, quality of life (QOL) and walking ability.

MAIN OUTCOME MEASURES

Experience of PPSP according to the type of peri-operative analgesia.

RESULTS

Five hundred sixty-three patients completed the follow-up. At 6 months, 21.6% of patients experienced PPSP, whereas autonomy was improved only in 56.3%; QOL was worsened or unchanged in 30.7% of patients and improved in 69.3%. Patients receiving continuous regional anaesthesia (epidural or peripheral nerve block) showed a lower NRS through the whole peri-operative period up to 1 month compared with both single shot peripheral nerve block and those who did not receive any type of regional anaesthesia. No difference was found between these latter two groups. Differences in PPSP at 3 or 6 months were not significantly affected by the type of anaesthesia or postoperative analgesia. A higher NRS score at 1 month, younger age, history of anxiety or depression, pro-inflammatory status, higher BMI and a lower ASA physical status were associated with a higher incidence of PPSP and worsened QOL at 6 months.

CONCLUSION

Continuous regional anaesthesia provides analgesic benefit for up to 1 month after surgery, but did not influence PPSP at 6 months. Better pain control at 1 month was associated with reduced PPSP. Patients with higher expectations from surgery, enhanced basal inflammation and a pessimistic outlook are more prone to develop PPSP.

TRIAL REGISTRATION

Clinicaltrials.gov identifier: NCT02147730.

The efficacy of dexamethasone on pain and recovery after total hip arthroplasty: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Total hip arthroplasty (THA) perioperative dexamethasone treatment is still a controversial subject. We write this systematic review and meta-analysis to evaluate the efficacy of dexamethasone on pain and recovery after THA.

METHODS

Two researchers searched the relevant studies from Pubmed, Cochrane, and Embase. The research was reported according to the preferred reporting items for systematic reviews and meta-analysis (PRISMA) guidelines. Randomized controlled trials (RCTs) were included in our meta-analysis. At the same time, the assessment of the risk of bias was conducted according to the Cochrane Handbook for Systematic Reviews of Interventions version. The pooled data are processed by software RevMan 5.3.

RESULT

In accordance with inclusion and exclusion, 3 studies with 207 patients were eligible and accepted into this meta-analysis. For RCTs, the risk of bias was evaluated by Cochrane Collaboration tool. Only one study did not have detection bias. Our study demonstrated that the dexamethasone group was more effective than the placebo group in term of visual analogue scale (VAS) score at 24 hours (P < .001), 48 hours (P = .04); opioid consumption (P < .001); length of stay (LOS, P < .001); and postoperative nausea (P = .001).

CONCLUSION

Dexamethasone not only reduces postoperative pain scores and postoperative opioids consumption within 48 hours, but also reduces postoperative vomiting and effectively reduces LOS. However, we still need large sample size and high quality studies to explore the relationship between complications and dose response to give the final conclusion.

Impact of duloxetine and dexamethasone for improving postoperative pain after laparoscopic gynecological surgeries: A randomized clinical trial

Background

Patients' surgical experiences are influenced by their perception of pain management. Duloxetine (Dulox) and dexamethasone (Dex) are used in multimodal analgesia to reduce opioid use and side effects. Dulox is a selective serotonin and norepinephrine reuptake inhibitor and has efficacy in chronic pain conditions. Dex enhances postoperative (PO) analgesia and reduces PO nausea and vomiting (PONV).

Methods

Seventy-five female patients were randomly allocated into one of three equal groups. GI received Dulox 60 mg orally and 100 ml 0.9% sodium chloride (normal saline [NS]) intravenous infusion (IVI) over 15 min, GII: received as GI except Dex 0.1 mg/kg was mixed with NS and GIII received identical placebo for Dulox capsule and Dex IVI, 2 h preoperatively. Patients' vitals, visual analog scale (VAS), and sedation score were assessed at 30 min, 1 h, 2 h, 6 h, and 12 h postoperatively. Total pethidine requirements, plasma cortisol, PONV, and patients satisfaction were recorded.

Results

PO time for 1^st rescue analgesic was significantly high in GI and GII compared to GIII and in GII compared to GI. There was a significant less VAS score, heart rate, mean arterial pressure, and a high sedation score in GI and GII compared to GIII at 30 min, 1, 2, and 6 h postoperatively. Total pethidine requirements were significantly less in GI and GII compared to GIII 12 h postoperatively. There was a significant reduction in the 2 h PO serum cortisol (μg/dl) and a significant increase in the PO patients satisfaction score in GI and GII compared to GIII. PONV was decreased significantly in GII compared to GI and GIII.

Conclusion

The use of oral Dulox 60 mg combined with Dex 0.1 mg/kg IVI is more effective than oral Dulox 60 mg alone, 2 h preoperatively, for improving PO pain by reducing the requirements for rescue analgesia and PONV.

Mechanism of Neuroprotection Against Experimental Spinal Cord Injury by Riluzole or Methylprednisolone

Any spinal cord injury carries the potential for persistent disability affecting motor, sensory and autonomic functions. To prevent this outcome, it is highly desirable to block a chain of deleterious reactions developing in the spinal areas immediately around the primary lesion. Thus, early timing of pharmacological neuroprotection should be one major strategy whose impact may be first studied with preclinical models. Using a simple in vitro model of the rat spinal cord it is possible to mimic pathological processes like excitotoxicity that damages neurons because of excessive glutamate receptor activation due to injury, or hypoxic/dysmetabolic insult that preferentially affects glia following vascular dysfunction. While ongoing research is exploring the various components of pathways leading to cell death, current treatment principally relies on the off-label use of riluzole (RLZ) or methylprednisolone sodium succinate (MPSS). The mechanism of action of these drugs is diverse as RLZ targets mainly neurons and MPSS targets glia. Even when applied after a transient excitotoxic stimulus, RLZ can provide effective prevention of secondary excitotoxic damage to premotoneurons, although not to motoneurons that remain very vulnerable. This observation indicates persistent inability to express locomotor activity despite pharmacological treatment conferring some histological protection. MPSS can protect glia from dysmetabolic insult, yet it remains poorly effective to prevent neuronal death. In summary, it appears that these pharmacological agents can produce delayed protection for certain cell types only, and that their combined administration does not provide additional benefit. The search should continue for better, mechanism-based neuroprotective agents.

Comparison of cortisol and inflammatory response between aged and middle-aged patients undergoing total hip arthroplasty: a prospective observational study

Background

To investigate the differences in the perioperative serum cortisol, C-reactive protein (CRP) and interleukin-6 (IL-6) levels between aged and middle-aged patients undergoing total hip arthroplasty (THA).

Methods

Sixty patients (30 aged and 30 middle-aged) undergoing THA for osteoarthritis between August 2016 and January 2017 participated in this study. Blood samples were collected preoperatively and at 6 hours, 24 hours and 3 days after surgery to measure the cortisol, CRP and IL-6 concentrations. The clinical outcomes were assessed using the visual analogue scale (VAS) pain score and Harris hip score (HHS).

Results

No significant differences were found between the two groups before the operation in the cortisol, IL-6 and CRP levels; the VAS score; or the HHS. Cortisol was significantly lower at 6 hours after surgery in the aged group than in the middle-aged group (P < 0.05). IL-6 at 6 and 24 hours after surgery, CRP at 3 days after surgery and the VAS score at 6 and 24 hours after surgery in the aged group were significantly higher than those in the middle-aged group (P < 0.05). In the aged group, weak correlations were found between the cortisol concentration 6 hours after THA and the IL-6 level 24 hours after THA (r = −0.37, P = 0.04) and between the IL-6 level 6 hours after THA and the VAS score 24 hours after THA (r = 0.42, P = 0.02).

Conclusion

Aged patients showed lower cortisol levels at 6 hours after surgery and higher IL-6 levels at 6 and 24 hours after surgery than middle-aged patients undergoing THA.

Guidelines for Perioperative Care in Bariatric Surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations

BACKGROUND

During the last two decades, an increasing number of bariatric surgical procedures have been performed worldwide. There is no consensus regarding optimal perioperative care in bariatric surgery. This review aims to present such a consensus and to provide graded recommendations for elements in an evidence-based "enhanced" perioperative protocol.

METHODS

The English-language literature between January 1966 and January 2015 was searched, with particular attention paid to meta-analyses, randomised controlled trials and large prospective cohort studies. Selected studies were examined, reviewed and graded. After critical appraisal of these studies, the group of authors reached a consensus recommendation.

RESULTS

Although for some elements, recommendations are extrapolated from non-bariatric settings (mainly colorectal), most recommendations are based on good-quality trials or meta-analyses of good-quality trials.

CONCLUSIONS

A comprehensive evidence-based consensus was reached and is presented in this review by the enhanced recovery after surgery (ERAS) Society. The guidelines were endorsed by the International Association for Surgical Metabolism and Nutrition (IASMEN) and based on the evidence available in the literature for each of the elements of the multimodal perioperative care pathway for patients undergoing bariatric surgery.

Multimodal Analgesia in Foot and Ankle Surgery

Progress in surgical acute pain management has allowed most foot and ankle surgery to be performed in ambulatory outpatient surgical centers. Multimodal analgesia focuses on improving postoperative pain by combining pharmacologic and other modalities, addressing multiple pain mechanisms and receptor pathways while reducing adverse effects through lower doses of oral medications. Local anesthesia techniques provide excellent pain relief with few adverse events. Multimodal analgesia in foot and ankle surgery provides superior pain relief, and reduced opioid dependence and opioid-related side effects, improving patient satisfaction, safety, and timely return to function.

Effects of methylprednisolone on the duration of rocuronium-induced neuromuscular block: A randomized double-blind trial

BACKGROUND

We aim to investigate whether intraoperative use of methylprednisolone could affect the duration of rocuronium-induced neuromuscular blockade.

METHODS

A double blind, randomized, placebo-controlled trial was conducted. A total of 136 patients underwent gynecologic laparoscopic surgery were randomly divided into 3 groups: pregroup, receiving intravenous injection of methylprednisolone (40 mg) 30 minutes before induction of anesthesia; postgroup, receiving intravenous injection of methylprednisolone (40 mg) immediately after induction of anesthesia and intubation; and control group, receiving intravenous injection of normal saline. Patients were intravenously administrated with rocuronium 0.6 mg/kg, and changes in adductor policies evoked twitch responses were measured by ulnar nerve stimulator.

RESULTS

We found that all patients achieved maximum blockade effects, and there was no difference in onset time among the 2 groups. For time required to achieve train-of-four ratio (TOFR) 90%, pregroup (64.50 ± 10.52 minutes) and postgroup (65.29 ± 11.64 minutes) were significantly shorter than that of the control group (71.04 ± 10.55 minutes, P = .027), whereas clinical duration and total duration were significantly shorter in the 2 groups received methylprednisolone than the control group. However, there was no significant difference between the 2 treatment groups either in clinical duration and total duration of muscle relaxants, or time required to achieve TOFR 90%. No significant difference was found in recovery index among the 3 groups.

CONCLUSION

Our findings suggest that a single intravenous injection of methylprednisolone, no matter preoperatively or intraoperatively, could shorten the duration of rocuronium-induced neuromuscular blockade.

A Comparative Randomized Trial on the Optimal Timing of Dexamethasone for Pain Relief after Endoscopic Submucosal Dissection for Early Gastric Neoplasm

Background/Aims

The aim of this study was to compare the clinical effects of preoperative and postoperative dexamethasone on pain after endoscopic submucosal dissection (ESD) for early gastric neoplasm.

Methods

Forty patients with early gastric neoplasm who were scheduled for ESD were randomized into two groups according to the timing of steroid administration: preoperative (“pre”, n=20) and postoperative (“post”, n=20) steroid administration. The pre group received 0.15 mg/kg dexamethasone before ESD and placebo after, and the post group received pre-ESD placebo and post-ESD dexamethasone. The present pain intensity (PPI) index and the short-form McGill pain (SF-MP) questionnaire were evaluated.

Results

The primary outcome was PPI score at 6 hours after ESD. There was a greater reduction in 6-hour PPI in the pre group than in the post group (2.1±0.8 vs 3.0±1.1, respectively; p=0.006). The immediate PPI was also significantly lower in the pre group than in the post group (1.6±0.6 vs 2.9±0.6, respectively; p<0.001), and the total SF-MP scores were significantly lower in the pre group than in the post group both immediately and at 6 hours after the operation.

Conclusions

Preoperative administration of dexamethasone may produce a superior analgesic effect in patients who undergo ESD compared with the postoperative administration of dexamethasone.