Dexamethasone combined with other antiemetics for prophylaxis after laparoscopic cholecystectomy

Beyond the Operating Room: A Narrative Review of Enhanced Recovery Strategies in Colorectal Surgery

Enhanced Recovery After Surgery (ERAS) protocols have significantly transformed the management of patients undergoing colorectal surgery. This comprehensive review explores the key components and benefits of ERAS in colorectal procedures, focusing on preoperative, perioperative, and postoperative strategies aimed at improving patient outcomes. These strategies include preoperative patient education, multimodal analgesia, minimally invasive surgical techniques, and early mobilization. ERAS protocols reduce postoperative complications, shorten hospital stays, and enhance overall recovery, leading to better patient satisfaction and decreased healthcare costs. However, challenges such as patient adherence and managing high-risk patients remain critical areas for further research. Additionally, future research should focus on refining ERAS protocols, integrating novel technologies such as minimally invasive techniques, and evaluating long-term outcomes to further enhance the recovery process.

Impact of intravenous steroids on subjective recovery quality after surgery: A meta-analysis of randomized clinical trials

STUDY OBJECTIVE

Quality of postoperative recovery is a crucial aspect of perioperative care. This meta-analysis aimed to evaluate the efficacy of intravenous steroids in improving the quality of recovery (QoR) after surgery, as measured by validated QoR scales.

DESIGN

Meta-analysis of randomized controlled trials (RCTs).

SETTING

Operating room.

INTERVENTION

The use of a single dose of intravenous steroids as a supplement to general anesthesia.

PATIENTS

Adult patients undergoing surgery.

MEASUREMENTS

A literature search was conducted using electronic databases (e.g., MEDLINE and Embase) from their inception to June 2024. Randomized controlled trials (RCTs) comparing intravenous steroids with placebo or no treatment in adult patients undergoing surgery under general anesthesia were included. The primary outcome was the QoR scores on postoperative days (POD) 1 and 2-3, as assessed by validated QoR scales (QoR-15 and QoR-40). Secondary outcomes included QoR dimensions, analgesic rescue, pain scores, and postoperative nausea and vomiting (PONV).

MAIN RESULTS

Eleven RCTs involving 951 patients were included in this study. The steroid group showed significant improvements in global QoR scores on POD 1 (standardized mean difference [SMD]: 0.52; 95 % confidence interval[CI]: 0.22 to 0.82; P = 0.0007) and POD 2-3 (SMD: 0.50; 95 % CI: 0.19 to 0.81; P = 0.001) compared to the control group. Significant improvements were also observed in all QoR dimensions on POD 1, with the effect sizes ranging from small to moderate. Intravenous steroids also significantly reduced the analgesic rescue requirements (RR: 0.77; 95 % CI: 0.67 to 0.88; P = 0.0003), postoperative pain scores (SMD: -0.41; 95 % CI: -0.68 to -0.14; P = 0.003), and PONV incidence (RR: 0.73; 95 % CI: 0.56 to 0.95; P = 0.02).

CONCLUSIONS

Intravenous administration of steroids significantly improved QoR after surgery. The benefits of steroids extend to all dimensions of QoR and important clinical outcomes such as analgesic requirements, pain scores, and PONV. These findings support the use of steroids as an effective strategy to enhance the postoperative recovery quality.

The effect of dexamethasone and bupivacaine on postoperative pain and nausea and vomiting by preperitoneal nerve blocking in laparoscopic cholecystectomy: a randomized clinical trial

Background

This study aims to examine the effects of preperitoneal administration of dexamethasone and bupivacaine surrounding laparoscopic trocars on postoperative pain (POP) and nausea and vomiting (PONV) in patients undergoing laparoscopic cholecystectomy (LC).

Method

In this randomized triple-blinded trial with a 1:1 randomization ratio, 104 patients with chronic cholecystitis were candidates for elective LC. A total of 40 mg (8 ml) of bupivacaine was mixed with 8 mg (2 ml) of dexamethasone or normal saline. The solution was injected preperitoneally via an 18G needle parallel and lateral to trocars until a bulge in the interior surface of the parietal peritoneum was observed by the camera. Primary outcomes were the severity of POP based on 0-10 Likert visual analog scale (VAS) and rates of PONV and secondary outcomes were rate of postoperative opioid usage and any side-effects.

Result

The mean VAS score was significantly lower in the dexamethasone group (3.5 vs. 6.2, P<0.001). The dexamethasone group had 46.2% and 26.9% lower rates of nausea and vomiting after LC compared to the other group (P=0.001 and 0.015, respectively). Postoperative opioid use was lower in the dexamethasone group, but its difference was insignificant (P=0.3).

Conclusions

Preperitoneal dexamethasone injection around laparoscopic trocars may lower the intensity of POP and PONV rates. Perioperative local corticosteroids can be used as an effective, available, and inexpensive analgesic and antiemetic prevention for laparoscopic procedures.

Comparison of Nausea and Vomiting Incidence After Laparoscopic Cholecystectomy With Pretreatment With Haloperidol and Ondansetron: A Randomization Clinical Trial Study

OBJECTIVE

Nausea and vomiting after surgery are the most common complications. Therefore, we performed this study to compare the effect of ondansetron and haloperidol on nausea and vomiting after laparoscopic cholecystectomy.

PATIENTS AND METHODS

In this randomized clinical trial, 60 patients candidates for elective laparoscopic cholecystectomy were allocated to haloperidol (0.05 mg/kg, n = 30) and ondansetron (0.15 mg/kg, n = 30) groups. An Ocular Analog Scale was used to assess postoperative nausea and vomiting. Every 15 minutes in the recovery room, heart rate and blood pressure were measured up to 6 hours after surgery. In addition, patient satisfaction was assessed postoperatively.

RESULTS

Haloperidol and ondansetron have the same effect on postoperative nausea and vomiting in the recovery room and ward. It was found that the trend of Visual Analog Scale variable changes in the recovery room was similar in the haloperidol and ondansetron group ( P = 0.58); it was also true for the ward ( P = 0.79). Comparing the length of stay in a recovery room in the 2 groups was not statistically significant ( P = 0.19). In addition, the 2 groups did not differ in satisfaction postoperatively ( P = 0.82).

CONCLUSION

Haloperidol and ondansetron had an equal effect on reducing nausea and vomiting in the recovery room and ward after laparoscopic cholecystectomy. Patient satisfaction and length of stay in the recovery room did not differ between groups.

Perioperative intravenous dexamethasone for patients undergoing colorectal surgery: a systematic review and meta-analysis

PURPOSE

Dexamethasone is a glucocorticoid that is often administered intraoperatively as prophylaxis for postoperative nausea and vomiting (PONV). Several randomized controlled trials (RCTs) have examined its use in colorectal surgery. This systematic review aims to assess the postoperative impacts of dexamethasone use in colorectal surgery.

METHODS

MEDLINE, Embase, and CENTRAL were searched from database inception to January 2023. Articles were included if they compared perioperative intravenous dexamethasone to a control group in patients undergoing elective colorectal surgery in terms of postoperative morbidity. The primary outcomes were prolonged postoperative ileus (PPOI) and PONV. Secondary outcomes included postoperative infectious morbidity and return of bowel function. A pair-wise meta-analysis and GRADE assessment of the quality of evidence were performed.

RESULTS

After reviewing 3476 relevant citations, seven articles (five RCTs, two retrospective cohorts) met the inclusion criteria. Overall, 1568 patients received perioperative dexamethasone and 1459 patients received a control. Patients receiving perioperative dexamethasone experienced significantly less PPOI based on moderate-quality evidence (three studies, OR 0.46, 95%CI 0.28-0.74, p < 0.01). Time to first flatus was significantly reduced with intravenous dexamethasone. There was no difference between groups in terms of PONV (four studies, OR 0.90, 95%CI 0.64-1.27, p = 0.55), postoperative morbidity (OR 0.93, 95%CI 0.63-1.39, p = 0.74), or rate of postoperative infectious complications (seven studies, OR 0.74, 95%CI 0.55-1.01, p = 0.06).

CONCLUSION

This review presents moderate-quality evidence that perioperative intravenous dexamethasone may reduce PPOI and enhance the return of bowel function following elective colorectal surgery. There was no significant observed effect on PONV or postoperative infectious complications.

Clinical practice guidelines for enhanced recovery after colon and rectal surgery from the American Society of Colon and Rectal Surgeons and the Society of American Gastrointestinal and Endoscopic Surgeons

The American Society of Colon and Rectal Surgeons (ASCRS) and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) are dedicated to ensuring high-quality innovative patient care for surgical patients by advancing the science, prevention, and management of disorders and diseases of the colon, rectum, and anus as well as minimally invasive surgery. The ASCRS and SAGES society members involved in the creation of these guidelines were chosen because they have demonstrated expertise in the specialty of colon and rectal surgery and enhanced recovery. This consensus document was created to lead international efforts in defining quality care for conditions related to the colon, rectum, and anus and develop clinical practice guidelines based on the best available evidence. While not proscriptive, these guidelines provide information on which decisions can be made and do not dictate a specific form of treatment. These guidelines are intended for the use of all practitioners, healthcare workers, and patients who desire information about the management of the conditions addressed by the topics covered in these guidelines. These guidelines should not be deemed inclusive of all proper methods of care nor exclusive of methods of care reasonably directed toward obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all the circumstances presented by the individual patient. This clinical practice guideline represents a collaborative effort between the American Society of Colon and Rectal Surgeons (ASCRS) and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and was approved by both societies.

Comparison of Intraperitoneal Versus Intravenous Dexamethasone on Postoperative Pain, Nausea, and Vomiting After Laparoscopic Cholecystectomy

Background

Despite all of the benefits provided by laparoscopic cholecystectomy, such as rapid recovery and shorter hospital stay for patients, the incidence of postoperative nausea and vomiting (PONV) and postoperative pain (POP) still remains high.

Objectives

This study was designed to compare the effects of intraperitoneal (IP) and intravenous (IV) dexamethasone on the reduction of PONV and POP.

Methods

This prospective, randomized, double-blind clinical trial was conducted on a study population of 86 adult patients who were scheduled for laparoscopic cholecystectomy with the American Society of Anesthesiologists class I-II. The patients were randomized into three groups, namely IP dexamethasone (n = 29), IV dexamethasone (n = 29), and control (n = 28) groups. The patients were followed for clinical outcomes, including PONV, POP, and consumption of antiemetics, and their hemodynamic status during the first 24 hours after the surgery.

Results

In the first 24 hours after the operation, no significant differences were observed in nausea (P = 0.41) and vomiting (P = 0.38) between the IP and IV dexamethasone groups. However, there was a lower severity of nausea in the IP group (P = 0.001). Additionally, the visual analog scale score representing POP was significantly reduced in the IP group (P = 0.02). No significant differences in the hemodynamic status were observed after the operation between all the three groups.

Conclusions

The administration of 8 mg IP dexamethasone was associated with significantly reduced pain and severity of nausea, but not PONV, after laparoscopic cholecystectomy.

What is the ideal combination antiemetic regimen?

Postoperative nausea and vomiting (PONV) and post-discharge nausea and vomiting (PDNV) are frequent unpleasant complaints that patients and clinicians report after surgery. PONV and PDNV have been associated with postoperative complications and hospital discharge delays. Despite the extensive evidence describing the use of several regimens in different surgical populations, the ideal regimen has not been established. Several antiemetic drugs have been evaluated in more than 1000 clinical controlled trials for management of this complex emetogenic pathway, including the 5-hydroxytryptamine (5-HT₃) receptor antagonists, dopamine receptor antagonists, neurokinin-type receptor antagonists, antihistaminics, anticholinergics, and corticosteroids, with the 5-HT₃ receptor antagonists being the most commonly used for PONV prophylaxis. Because of the complex emetogenic pathway and multifactorial etiology of PONV, a multimodal approach using two or more drugs that act at different neuro-receptor sites is suggested in patients with one or more risk factors to successfully address PONV and reduce its incidence. Nevertheless, the most studied regimens in randomized clinical trials (RCTs) are the combination of serotonin 5-HT3 receptor antagonists with dexamethasone or dopamine receptor antagonists (droperidol). Therefore, the safest and more effective combination regimen appears to be the use of serotonin 5-HT3 receptor antagonist antiemetic drugs with dexamethasone.

Comparison of intraperitoneal versus intravenous dexamethasone on postoperative nausea and vomiting after gynecological laparoscopy: a randomized clinical trial

Background

Postoperative nausea and vomiting (PONV) is a common complication following laparascopic surgery. This study compared the effect of intraperitoneal versus intravenous dexamethasone for reducing PONV after gynecological laparoscopic surgeries.

Methods

Eighty adult female patients, American Society of Anesthesiologists physical status I–II, scheduled for gynecological laparoscopic surgery were randomized to receive 8 mg dexamethasone intravenously (IV) (n = 40) or intraperitoneally (IP) (n = 40). The primary outcome was the PONV incidence during the first 24 h after laparoscopy. Secondary outcomes included visual analogue scale (VAS) pain scores, total rescue analgesic consumption during the first 24 h postoperatively, the need for rescue antiemetic drugs, and the incidence of complications that may accompany these medications.

Results

Eleven women (27.5%) in the IV group, versus only 3 (7.5%) women in the IP group, experienced nausea during the first 24 h postlaparoscopy (P = 0.037). However, 5 patients (12.5%) in the IV group, versus only 2 patients (5.0%) in the IP group, experienced vomiting (P = 0.424). No statistically significant differences were seen in the severity of nausea or the need for rescue antiemetics. The IV group had a higher rate of side-effects than the IP group (27.5% vs. 7.5%, P = 0.037). Headache and dizziness were common side effects in the IV dexamethasone group. The groups did not differ significantly in terms of mean VAS score for pain and total meperidine consumption during the first 24 h postoperatively.

Conclusions

Intraperitoneal dexamethasone at a dose of 8 mg at the end of gynecological laparoscopy reduces the incidence of postoperative nausea.

Dexamethasone combined with other antiemetics versus single antiemetics for prevention of postoperative nausea and vomiting after laparoscopic cholecystectomy: An updated systematic review and meta-analysis

OBJECTIVE

A systematic review and meta-analysis of published randomized controlled trials was performed to update the present evidence about the safety and efficacy of dexamethasone combined with other antiemetics versus single antiemetics for the prevention of postoperative nausea and vomiting after laparoscopic cholecystectomy.

METHODS

A computer literature search of PubMed, Scopus, Web of Science and Embase was conducted to identify the relevant randomized controlled trials. In addition, a manual search of reference lists of the retrieved articles was conducted. Relevant outcomes were pooled as odds ratio (OR) by RevMan version 5.3 for windows.

RESULTS

Pooled data from 14 RCTs (1542 patients) favored dexamethasone combined with other antiemetics over single antiemetics as a prophylaxis against postoperative nausea and vomiting after laparoscopic cholecystectomy in the early postoperative period (OR = 0.39, 95% CI [0.27 to 0.54], p < 0.00001), late postoperative period (OR = 0.36, 95% CI [0.23 to 0.56], p < 0.00001), and overall postoperative period (OR = 0.34, 95% CI [0.23 to 0.51], p < 0.00001). Subsequently, rescue antiemetic usage was significantly lower in the combination group (OR = 0.25, 95% CI [0.16 to 0.41], p < 0.00001). Subgroup analysis showed that all combinations of dexamethasone and other antiemetics were superior to corresponding singel antiemetics except for the combination of dexamethasone and ramosetron which was not superior to ramosetron alone in all postoperative periods and the combination of dexamethasone and granisetron which was not superior to granisetron alone in the early postoperative period (OR = 0.26, 95% CI [0.07 to 1.01], p = 0.05). For all adverse events, there was no significant difference between the two groups.

CONCLUSION

Dexamethasone combined with other antiemetics provided better prophylaxis than single antiemetics against postoperative nausea and vomiting after laparoscopic cholecystectomy. The underlying mechanism of dexamethasone action and its optimal dose should be further investigated.

Effects of dexamethasone on quality of recovery following vaginal surgery: a randomized trial

OBJECTIVE

Dexamethasone is a corticosteroid with minimal side effects that may improve quality of recovery. We sought to evaluate standard use of this medication prior to vaginal reconstructive surgery.

STUDY DESIGN

This was a double-blind, randomized, placebo-controlled trial of women undergoing vaginal reconstructive surgery for pelvic organ prolapse. Patients scheduled for an intraperitoneal vaginal vault suspension, with general anesthesia and an overnight stay, were enrolled. The intervention arm received dexamethasone 60 minutes prior to surgery, and controls received placebo. Postoperative pain medications, antiemetics, and voiding trials were standardized. Our primary outcome was the difference in Quality of Recovery (QoR-40) scores on postoperative day 1. Secondary measures included Postoperative Nausea and Vomiting Intensity scores, and visual analog scales for nausea/vomiting, and pain. Our power calculation demonstrated 31 subjects in each group would be necessary to document difference in QoR-40 scores; to allow for attrition, a goal of 74 subjects was set.

RESULTS

Seventy-four women were enrolled and randomized. Two withdrew, 9 were excluded, and 63 were analyzed (36 placebo, 27 dexamethasone). The mean age was 63 years. No significant differences were noted among demographics other than American Society for Anesthesiologists class; there were greater numbers of dexamethasone subjects that were class 3 (5 vs 11; P = .030). Postoperatively, more patients in the placebo group required promethazine as a rescue antiemetic for control of their nausea/vomiting (11 vs 2; P = .029). Placebo subjects also failed their voiding trials more frequently, which remained following a logistic regression controlling for suburethral sling (30 vs 15; P = .037). Regarding the QoR-40 following surgery, the emotional state domain declined less in dexamethasone patients (-14.3, interquartile range [IQR], 16.8 vs -4.6, IQR, 20.1; P = .042), indicating better symptoms. Whereas pain scales were similar, the visual analog scales for nausea/vomiting was lower in dexamethasone subjects (0.7; IQR, 4.1 vs 0.4; IQR, 1.4; P = .042). Postoperative Nausea and Vomiting Intensity scores were not significantly different; nevertheless, twice as many placebo subjects had severe range symptoms (4 vs 2; P = .47). No adverse effects from the dexamethasone were noted.

CONCLUSION

Use of dexamethasone prior to vaginal reconstructive surgery was associated with less nausea/vomiting and need for antiemetics as well as greater success with voiding trials. Furthermore, quality of recovery was enhanced, suggesting use of dexamethasone should be considered for these patients.