Iaas-med.com

Routine Administration of Dexamethasone
in a Day Surgery Protocol might decrease
postoperative vomiting and pain
S Borges*, P Lemos†, M Ramos†, R Maio§, AC Costa†, L Fonseca† & AM Regalado†
Abstract
Results: Both groups were similar in relation to age, gender, physical
Background and Objectives: Postoperative vomiting (POV) remains a
status (ASA), surgical and recovery times; surgical specialty and major problem after ambulatory anaesthesia. In randomised controlled trials dexamethasone has been shown to reduce POV. We have We found a lower incidence of POV with the administration of investigated whether the routine use of corticoid administration can dexamethasone and also a statistical significant inverse relationship decrease the incidence of POV in ambulatory patients. between dexamethasone use and the level of pain (p<0.001). Methods: We analysed retrospectively 2115 patients, divided in two
Conclusions: Our study suggests that 5 mg dexamethasone given to
groups: Group A (n = 737) surgery undertaken between January and patients undergoing a wide spectrum of surgery might reduce the August 2001, without the use of dexamethasone; Group B (n = 1378) surgery undertaken between September 2001 and November 2002 with the administration of dexamethasone. Keywords: Postoperative vomiting; dexamethasone; pain; day surgery.

Authors’ addresses: † Anaesthetic Department of Hospital Geral de Santo António, Largo Prof. Abel Salazar, 4099-001 Porto, Portugal;
§ Epidemiological Department of Instituto de Ciências Biomédicas Abel Salazar, Largo Prof Abel Salazar, 2, P-4099-003, Porto, Portugal
* Anaesthetic and Emergency Department of Centro Hospitalar de Vila Nova de Gaia. Portugal.
Correspondence: Sandra Borges, Rua da Habival 142, 4420-466 Gondomar, Portugal. E-mail: [email protected]
Introduction
A (n = 737) surgery undertaken between January and August 2001, without the use of dexamethasone; Group B (n = 1378) surgery Dexamethasone is a corticosteroid that can decrease postoperative performed between September 2001 and November 2002 with the vomiting after ambulatory surgery. It has been used since 1981 with good results in reducing the incidence of emesis in patients undergoing chemotherapy [1–5]. The proposed mechanism of Patients were excluded from the study if they had active gastric dexamethasone’s anti-emetic effect is related to the inhibition of pathology, hypersensitivity to corticoids or who had received prostaglandin synthesis and an increase in the release of endorphins, resulting in mood elevation, a sense of “well-being” and appetite All patients in the two groups received droperidol in anti-emetic stimulation [6–8]. Dexamethasone is effective in reducing the doses (0.625 mg i.v.), based on our day surgery unit (DSU) protocol. incidence of postoperative vomiting (POV) in patients undergoing different types of surgery by about 26 percent [6,9–13]. In order to Patients in the dexamethasone group B received dexamethasone 5 mg obtain the highest efficacy against POV, prophylactic dexamethasone i.v. Surgery time was determined from skin incision to completion administration should be given during the induction of anaesthesia, of the procedure. Before leaving the operating room, fast-track because the onset time of dexamethasone on antiemesis is eligibility (score > 12) was assessed using standardized criteria [18]. approximately 2 hours, and its biological half-life is 36 to 72 hours Vital signs were registered every 15 minutes in the post-anaesthetic [14,15]. The commonly used dose for the prevention of POV is 8–10 care unit (PACU) and every 30 minutes in the intermediate post- mg i.v. but the minimum effective dose is suggested to be 5 mg in anaesthetic recovery unit (phase II recovery room), til the discharge patients undergoing thyroidectomy and ambulatory laparoscopic time. IV saline (0.9%) was given as maintenance fluid for each patient (minimum of 20 ml/kg). Analgesia was assessed by using a 10-cm In this prospective analysis we tested the hypothesis that linear visual analogue scale (VAS) with 0 corresponding to no pain dexamethasone in the minimum effective dose can reduce the and 10 to the worst pain and analgesics were given according to the incidence of POV in the day surgery programme of our Institution. DSU protocol. For the purpose of data collection, retching (same as vomiting but without expulsion of gastric content) was considered vomiting. Rescue anti-emetics (ondansetron 4 mg i.v.) were given if Materials and Methods
repeated vomiting occurred. Data related to POV was col ected (from 8:00 AM to 8:00 PM) by a We analysed our database that include 2115 patients, with data team of nurses every 1 h, or by spontaneous complaint of the patients. col ected prospectively, between 1st January 2001 and 3rd December 2002, with physical status classification based on the American Society of Anesthesiologists scale (I to VI) and we accepted only patients Statistical analysis was performed, comparing discrete variables between I and III. We divided the patients into two groups: Group by using chi-square test. Metric variables were compared using independent samples t-test. A p value less than 0.05 was considered Moreover, we found an inverse relationship between the statistical y significant. Al values were expressed as mean +/- SD or administration of dexamethasone and the level of pain (p<0.001) We compared statistically the 2 groups with cross-tables and verified The majority of patients reported low VAS pain scores (VAS < 3) in both homogeneity to gender; ASA status; surgical and recovery times; both groups: 95.2% in the dexamethasone group, 87.8% in the non- surgical specialty and anaesthetic technique. dexamethasone group. No significant side effects were found. Discussion
Both baseline and operative characteristics were similar in both Until 5 years ago, the incidence of POV at our DSU was similar to the 20% presented in the literature. It is one of the most annoying side effects after surgery performed under general anaesthesia [19,20]. We found a lower incidence of POV in patients where dexamethasone Between 1998 and 2001 we were able to reduce this incidence to 8% owing to the introduction of low dose of intravenous droperidol Table 1 Patient characteristic, anaesthetic and surgical data. Values are number of patients (%) except age, surgical time and recovery time, which
are given in years and minutes; are presented as mean + standard deviation (SD), and with the 95% confidence interval (CI). ASA = American Society of Anesthesiologists.
Characteristic
difference
t-test p-value
without dexamethasone
dexamethasone
5 mg (n=1378)
Characteristic
chi-square test
without dexamethasone
dexamethasone
5 mg (n=1378)
Table 2 The Evaluation of POV and Level of Pain. Values are number or proportion.
variable
A – without dexamethasone
B - dexamethasone 5 mg
Chi-square test p-value
(n=1378)
In this study, we found that dexamethasone in the minimum effective At the end we found that the dexamethasone group (5 mg) had a dose (5 mg i.v.), could reduce even more the POV incidence, lower incidence of POV (p=0.001) and lower levels of post-operative pain (p<0.001). These results are similar to the ones found by Al data related to POV was col ected every 1 h, until the patient Baxendale et al, who also reported decreased wound pain following discharge. We had no possibility of obtaining information about the extraction of third molar teeth after dexamethasone administration vomiting incidence in the first 24–48 hours after discharge, because [29]. However, Liu et al. showed different results since the influence only recently we have introduced a fol ow-up service by phone to all of dexamethasone on postoperative pain was minimal in patients our patients, during the first 24 hours after operation. undergoing major surgery [30,31], and by Lee at al. who reported that dexamethasone might not alter the intensity of pain after surgery, The presence of risk factors such age, gender, physical status, history nor did it enhance the efficacy of PCA-morphine [28]. of motion sickness or postoperative nausea and vomiting, the duration of anaesthesia and type of surgery and anaesthetic technique, may Probably, the different postoperative pain intensities and different contribute to the episodes of POV [21,22,24–26]. degree of inflammation and oedema associated with different types of surgery can explain these differences, remembering that pain after We found a small difference between the mean ages of both groups, tooth extraction might be related to swel ing and that dexamethasone yet this was statistically significant. However we doubt if this clinical has a potent anti-inflammatory effect. This needs to be studied difference could be strong enough to modify the results obtained, especially because this effect is small, the difference in POV due to an increase of 2 years of age is below 1%, and is not always detected The exact mechanism by which dexamethasone, a corticosteroid, exerts an anti-emetic action is not ful y understood but there have been some suggestions, such as central [6–8] or peripheral Other patients’ characteristics that may have modified the incidence mechanism [7,11,33]. It also has strong anti-inflammatory actions of POV were wel balanced between the two groups, so the and may significantly reduce tissue inflammation around the surgical differences found might be attributed to the use of dexamethasone. sites and thus reduce the ascending parasympathetic impulses (e.g., Nevertheless, we did not assess the history of POV or the non- vagus) to the vomiting centre reducing POV. Final y, theoretical y, as smoking status, as this was a retrospective analysis and this data was dexamethasone has a potent anti-inflammatory not collected. These two factors if present in a higher percentage in one of the groups could influence the results obtained but given that effect, it probably also has the capacity to lower postoperative pain the population was comparable in other aspects it is unlikely that an [30,32,33,34]. However these results are not conclusive and further Another limitation of our study was the fact that it is a non- Long-term corticosteroid therapy causes side effects such as an randomised design. However the effectiveness of dexamethasone in increased risk of infection, glucose intolerance, delayed wound the prevention of POV is well proven [6,9–12] and thus the need for healing, superficial ulceration of gastric mucosa, and adrenal suppression with significant morbidity [34]. However, side effects another placebo-control ed trial can be questioned from an ethical from short corticosteroid therapy (24–48 h), even in a high dose, point of view. Moreover, the aim of this study was to see the impact have been rare. In the current study, no discernible side effect of dexamethasone in our DSU clinical practice and if we could reduce accompanying a single dose of dexamethasone 5 mg was found. Although a single dose of dexamethasone is considered safe The dose often used is 8 to 10 mg and Lee at al. have demonstrated that [6,9,10,29,32], further studies are warranted. the pre-induction administration of 8 mg i.v. was the smallest effective As we used dexamethasone in al our patients in order to prevent dose for the reduction of PCA (patient-controlled analgesia) morphine- POV, we can be criticized because of: i) promoting an increased rate related POV [28], but the minimal effective dose is 5 mg in patients of side effects owing to its corticosteroid properties; i ) giving it to undergoing thyroidectomy and ambulatory laparoscopic surgery patients who probably did not need it; i i) increasing costs related [21,25,26]. Another study by Apfel et al. supports that at least 4 mg of to the administration of this drug. Nevertheless, the authors are dexamethasone i.v. is equally effective to 1,25 mg i.v. droperidol and not aware of any important complication related to this low-dose to 4 mg i.v. ondansetron, al antiemetics can be freely combined, and corticosteroid administration. Moreover, the administration of 5 mg that the type of surgery doesn’t affect the efficacy of antiemetics [13]. In dexamethasone represented an increase in costs of around 0.7 € per this study we wanted to use the minimum dose capable of lowering the patient and when associated with droperidol 0.625 mg an increase incidence of POV with a minimum of side effects. of 1.3 € per patient. Our results have proved that we have been able to reduce POV incidence from around 20% without antiemetics to Acknowledgements
values lower than 3% when we gave a combination of dexamethasone and droperidol to al patients. The question is: Was this a price too high We would like to thank all nursing staff of our DSU for their to pay for the advantages that we got? Gan et al in a way answered this cooperation and Dr. Lino Gonçalves for their invaluable assignments. question when they reported that patients are wil ing to pay between US$56 and US$100 for a completely effective antiemetic [35]. In conclusion, our study suggests that 5 mg dexamethasone given to patients undergoing a wide spectrum of surgery might reduce the References
21. Kovac AL. Prevention and treatment of postoperative nausea and vomiting. Drugs 2000; 59:213–43.
1. Aapro MS, Alberts DS. Dexamethasone as an antiemetic in patients 22. Koivuranta M, Laara E, Snare L, Alahuhta S. A survey of postoperative treated with cisplatin (letter). New Engl J Med 1981; 305: 520.
nausea and vomiting. Anaesthesia 1997: 52; 443–449.
2. Markman M, Sheidler V, Ettinger DS, Quaskey AS, Mellits ED. 23. Apfel CC, at al: A risk score to predict the probability of postoperative Antiemetic efficacy of dexamethasone: randomised, double bind, vomiting in adults. Acta Anaesthesiolo Scand 1998; 42:495–501
crossover study with prochlorperazine in patients receiving cancer 24. Apfel CC, at al: The discriminating power of a risk score for chemotherapy. New Engl J Med 1984; 311: 549–52.
postoperative vomiting in adults undergoing various types of surgery. 3. Sehine I, Nishiwaki Y, Kakinuma R, et al. Phaze II study of high-dose Acta Anaesthesiolo Scand 1998; 42:502–9
dexamethasone-based association in acute and delayed high-dose 25. Bellville JW at al: Factors related to postoperative nausea and cisolatin-induced emesis – JCOG study 9413. Br J Cancer 1997;
vomiting. Anesthesiology 1960; 21:186–93.
76:90–2.
26. Sinclair DR, Chung F, Mezei G. Can postoperative nausea and vomiting 4. Italian Group for Antiemetic Research. Ondansetron versus be predicted? Anesthesiology 1999; 91:109–18.
metoclopramide, both combined with dexamethasone, in the 27. Liu K, at al: Effect of dexamethasone on postoperative emesis and pain. prevention of cisplatin-induced delayed emesis. J Clin Oncol 1997; 15:
Br J Anaesthesia 1998; 80: 85–6.
28. Lee Yi et al. A dose ranging study dexamethasone for preventing 5. Italian Group for Antiemetic Research. Dexamethasone, granisetron, or patient-controlled analgesia-related nausea and vomiting: a comparison both for the prevention of nausea and vomiting during chemotherapy of droperidol with saline. Anesth Analg 2004; 98:1066–71.
for cancer. New Engl J Med 1995; 332: 1–5.
29. Baxendale BR, Vater M, Lavery KM. Dexamethasone reduces pain and 6. Henzi I, Walder B, Tramer MR. Dexamethasone for the prevention of swelling following extraction of third molar teeth. Anaesthesia 1993;
postoperative nausea and vomiting: a quantitative systematic review. 48:961–4.
Anesth Analg 2000; 90: 186–94.
30. Ho CM. Dexamethasone prevents emesis. Taipei, Taiwan: National
7. Rich W, Abdulhayoglu G, Di Saia Pj. Methylprednisolone as antiemetic during cancer chemotherapy: a pilot study. Gynecol Oncol 1980; 9:
31. Wang JJ, HO ST, Liu YH, et al. Dexamethasone reduces nausea and vomiting after laparoscopic cholecystectomy. Br J Anaesth 1999;
8. Harris Al. Cytotoxic-therapy-induced vomiting is mediated via 83:772–5.
enkephalin pathways. Lancet 1982; 1: 714–6.
32. Liu K, at al: The effective dose of Dexamethasone for antiemesis after 9. Pappas ALS, Sukhani R, Hotaling AJ, et al. The effect of preoperative major gynecological surgery. Anesth Analg 1999; 89(5):1316.
dexamethasone on the immediate and delayed postoperative 33. Schimmer BP, Parker KL. Adrenocorticotropic hormone; morbidity in children undergoing adenotonsillectomy. Anesth Analg
adrenocortical steroids and their synthetic analogs; inhibitors of the 1998; 87: 57–61.
synthesis and actions of adrenocorticol hormones. In: Hardman JG, 10. Wang JJ, Ho ST, Lee SC, et al. The use of Dexamethasone for Limbird LE, Molinoff PB, Ruddon RW, eds. Goodman and Gillman’s
preventing postoperative nausea and vomiting in females undergoing the Pharmacological Basis of Therapeutics, 9th edition Edn. NY:
thyroidectomy: a dose-ranging study. Anesth Analg 2000; 91: 1404–7.
11. Wang JJ, Ho ST, Lee SC, et al. Prophylactic antiemetic effect of 34. Skjelbred P, Lokken P. Postoperative pain and inflammatory reaction Dexamethasone in women undergoing ambulatory laparoscopic reduced by injection of a corticosteroid. Eur J Clin Pharmacol 1982;
surgery. Br J Anaesth 2000; 84 (4): 459–62.
12. Lee Y, Lin Y, Chen Y. The effect of dexamethasone upon patient- 35. Gan TJ, Sloan F, Dear GL, et al. How much are patients willing to pay controlled analgesia-related nausea and vomiting. Anaesthesia 2002;
to avoid postoperative nausea and vomiting? Anesth Analg 2001;
57 (7); July; 705–709.
92:393–400.
13. CC Apfel MD, K Korttila PhD, M Abdalla PhD, et al. A factorial trial of six interventions for the prevention of postoperative nausea and
vomiting. New Engl J Med 2004; 350: 2441–2451.
14. Wang JJ, at al. The effect of timing of dexamethasone administration on its efficacy as a prophylactic antiemetic for postoperative nausea
and vomiting. Anesth Analg 2000; 91 (1): 136–139.
15. Haynes R. Adrenocortocotropic hormone: adrenocortical steroids and their synthetic analogs-inhibitors of the synthesis and actions of
adrenocortical hormones. In: Goodman A, Gilman LS, Rall TW, Murad
F, eds. The pharmacological basis of therapeutics. 8th ed. New
York: Pergamon Press, 1990:1447–8.
16. Huang JC, et al. Low-dose dexamethasone effectively prevents postoperative nausea and vomiting after ambulatory laparoscopic surgery. Can J Anaesth 2001; 48: 973–977.
17. Jhi-Joung Wang, et al. Small-dose Dexamethasone reduces nausea and vomiting after laparoscopic cholecystectomy: a comparison of
Tropisetron with saline. Anesth Analg 2002; 95:229–32.
18. White PF. Criteria for fast-tracking outpatients after ambulatory anesthesia. J Clin Anesth 1999; 11: 78–9.
19. Watcha MF, White MF. Postoperative nausea and vomiting; its etiology, treatment and prevention. Anesthesiology 1992; 77: 162–84.
20. Cohen MM, White PG, DeBoer DP, Tweed WA. The postoperative interview: assessing risk factors for nausea and vomiting. Anesth Analg
1994; 78:7–16.

Source: http://www.iaas-med.com/files/Journal/13.1/13.1BORGES.pdf