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@example.com 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 .
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.
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
. 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 .
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 . 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 , 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 . 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
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 . In conclusion, our study suggests that 5 mg dexamethasone given to
patients undergoing a wide spectrum of surgery might reduce the
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