Methylprednisolone reduces postoperative nausea in total knee and hip arthroplasty

Effect of closed-chain isometric plyometric training combined with palonosetron on postoperative knee function in patients after total knee arthroplasty

Background

Functional training after total knee arthroplasty (TKA) is of great significance for the recovery of knee function. However, the utility of applying an effective training modality, closed-chain isokinetic plyometric training, on top of the drug palonosetron, which is used to prevent nausea and vomiting, is unclear.

Objective

To investigate the effect of closed-chain isokinetic plyometric training combined with palonosetron-on-postoperative-knee-function in patients with TKA, aiming to provide an effective rehabilitation program for patients with TKA.

Methods

The results of the intervention were compared in 47 TKA patients who received closed-chain isokinetic plyometric training combined with palonosetron with 47 TKA patients who received conventional plyometric training combined with palonosetron. Knee function was evaluated using the Hospital for Specialty Surgery Knee (HSS), quadriceps muscle strength was assessed using real-time isometric plyometric testing with the BIODEX-sYs-tem 4-type system, walking ability was evaluated using the Timed Up-and-Go Test (TUGT), and proprioception was determined using the Biodex System 4-type multi-joint isometric system.

Results

After-the intervention,-the-HSS scores-of-the-experimental-group-were-higher-than-those-of-the-control-group-(P < 0.05); the peak moment values of the quadriceps (PT), the total quadriceps work values (STW), and the average power of the quadriceps (AP) were higher than those of the control group (P < 0.05); and the values of the reproduced deviation of the knee joint active joint angle and the TUGT time were lower than those of the control group (P < 0.05).

Conclusion

Closed-chain isokinetic plyometric training combined with palonosetron can strengthen their muscle strength and improve proprioception, which effectively promotes the recovery of postoperative knee function and walking ability in TKA patients.

Perioperative Intravenous Dexamethasone Significantly Reduces Postoperative Opioid Requirement and Nausea After Unilateral Elective Hip Arthroscopy: A Randomized Double-blinded Placebo-controlled Trial

BACKGROUND

Previous studies have shown that dexamethasone has a positive effect on postoperative pain control, opioid consumption, nausea, and vomiting and length of hospital stay after arthroplasty surgery.

PURPOSE/HYPOTHESIS

The purpose of this study was to assess whether adding perioperative dexamethasone to our current pain regimen after hip arthroscopy is more effective than a placebo. It was hypothesized that dexamethasone would reduce postoperative pain, reduce opioid consumption, improve subjective pain and nausea scores, and reduce the number of vomiting events.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

A total of 50 patients requiring unilateral elective hip arthroscopy were randomized to receive intravenous dexamethasone immediately before induction of anesthesia and at 8 am on the first postoperative day (2 ×12 mg) or a placebo (sodium chloride 0.9%). The patient, the surgeons, the treating anesthesiologist, and the involved nursing and physical therapy personnel were blinded to group assignment. The primary outcome was postoperative pain, and secondary outcomes were opioid consumption and nausea scores-assessed using a translated revised version of the American Pain Society Patient Outcome Questionnaire 6 hours postoperatively and on days 1 and 2-and vomiting events. A clinical follow-up was performed 12 weeks postoperatively to assess adverse events.

RESULTS

The mean age at inclusion was 29 years in both groups. Postoperative pain levels did not differ significantly in most instances. Opioid requirements during the hospitalization in the dexamethasone group were significantly lower than those in the placebo group (31.96 ± 20.56 mg vs 51.43 ± 38 mg; P = .014). Significantly fewer vomiting events were noted in the dexamethasone group (0.15 ± 0.59 vs 0.65 ± 0.91; P = .034). Descriptive data and surgical parameters did not differ significantly.

CONCLUSION

Perioperative intravenous dexamethasone significantly reduced postoperative opioid consumption by 40% without compromising pain level and safety, as no corticosteroid-related side effects were observed. Dexamethasone may be a valuable adjuvant to a multimodal systemic pain regimen after hip arthroscopy.

REGISTRATION

NCT04610398 (ClinicalTrials.gov identifier).

A comparative clinical study of methylprednisolone with ondansetron versus ramosetron in preventing postoperative nausea and vomiting in patients undergoing middle-ear surgeries

Background:

One of the most troublesome complications after middle-ear surgeries has been postoperative nausea and vomiting (PONV). A notable decrease in PONV has been observed with the use of 5-hydroxytryptamine type 3 receptor antagonists and glucocorticoids.

Aim:

This study aimed to evaluate the effectiveness of the combination of intravenous methylprednisolone and ondansetron with ramosetron alone in preventing PONV in patients undergoing middle-ear surgeries.

Settings and Design:

This was a prospective, randomized, double-blind study that comprised sixty patients in the age group of 18–60 years belonging to the American Society of Anesthesiologists (ASA) physical status classification I or II and undergoing middle-ear surgery.

Materials and Methods:

With the help of computer-generated randomization table, sixty patients in the age group of 18–60 years belonging to ASA physical status classification I or II and undergoing middle-ear surgery were randomly allotted to receive a combination of methylprednisolone 40 mg (given at the beginning of surgery) and ondansetron 4 mg (given near the end of surgery) (Group MO, n = 30) or ramosetron 0.3 mg (near the end of surgery) (Group R, n = 30). In both the groups, the incidence of PONV was studied.

Statistical Analysis:

Chi-square test or Fisher's exact test was utilized to analogize the categorical variables. Independent t-test was utilized to analogize the continuous variables.

Results:

In the first 2 h after the surgery, the difference between the two groups regarding the incidence of PONV was insignificant. Between 2 h and 24 h, the incidence of nausea was lowered significantly in the group MO compared to the group R (P = 0.01). Between 24 h and 48 h, the incidence of nausea was more in group R compared to the combination therapy group, which was statistically significant.

Conclusion:

The combination therapy is better than ramosetron alone for the prevention of PONV after middle-ear surgery. Therefore, we advocate a combination of methylprednisolone and ondansetron for prophylaxis for PONV in middle-ear surgeries.

Postoperative Infection Risk in Total Joint Arthroplasty After Perioperative IV Corticosteroid Administration: A Systematic Review and Meta-Analysis of Comparative Studies

BACKGROUND

Perioperative corticosteroid administration is associated with reduced postoperative nausea, pain, and enhanced recovery after surgery. However, potential complications including wound and periprosthetic joint infections remain a concern for surgeons after total joint arthroplasty (TJA).

METHODS

A systematic review of the search databases PubMed, Google Scholar, and EMBASE was made in January 2021 to identify comparative studies evaluating infection risk after perioperative corticosteroid administration in TJA. PRISMA guidelines were used for this review. Meta-analysis was used to assess infection risk in accordance with joint and corticosteroid dosing regimen used.

RESULTS

201 studies were returned after initial search strategy, with 29 included for review after application of inclusion and exclusion criteria. Studies were categorized as using low- or high-dose corticosteroid with single or repeat dosing regimens. Single low-dose corticosteroid administration was not associated with an increased risk of infection (P = .4; CI = 0.00-0.00). Single high-dose corticosteroid was not associated with an increased infection risk (P = .3; CI = 0.00-0.01) nor did repeat low-dose regimens result in increased risk of infection (P = .8; CI = -0.02-0.02). Studies assessing repeat high-dosing regimens reported no increased infection, with small numbers of participants included. No significant risk difference in infection risk was noted in hip (P = .59; CI = -0.03-0.02) or knee (P = .2; CI = 0.00-0.01) arthroplasty. Heterogeneity in patient profiles included in studies to date was noted.

CONCLUSION

Use of perioperative corticosteroid in TJA does not appear to be associated with increased risk of postoperative infection in patients with limited comorbidities. Further research is warranted to evaluate postoperative complications after TJA in these at-risk patient populations.

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.

Perioperative multiple low-dose Dexamethasones improves postoperative clinical outcomes after Total knee arthroplasty

Background

The purpose of this study was to investigate the efficacy and safety of multiple low-dose dexamethasones in primary total knee arthroplasty (TKA).

Methods

One hundred fifty patients were equally randomized into 3 groups: Group A (n = 50) received 2 doses of normal saline only; Group B (n = 50) received with 1 dose of intravenous dexamethasone and 1 dose of normal saline; Group C (n = 50) received with 2 doses of intravenous dexamethasone. The clinical outcomes and complications were assessed.

Results

The CRP and IL-6 were significantly lower in Group C and B than Group A at 24, 48, and 72 h postoperatively (P < 0.001 for all). The intensity of postoperative nausea and vomiting (PONV) in Group C was lower than Group A at 24 (P < 0.001, P = 0.002), 48 (P = 0.005, P = 0.041) and 72 h (P = 0.017, P = 0.031) postoperatively and Group B at 24 h (P = 0.027, P = 0.019) postoperatively. Pain were significantly less in Group C than Group A at 24 (P < 0.001), 48 h (P = 0.037) postoperatively and Group B 24 h (P = 0.030) postoperatively. Patients in Group C had better range of motion (ROM) and satisfaction than Group A (P < 0.001, P = 0.002) and B (P = 0.001, P = 0.043). No differences were found in complications.

Conclusions

The administration of 10 mg dexamethasone 1 h before the surgery, and repeated at 6 h postoperatively can significantly reduce the level of postoperative CRP and IL-6 and the incidence of PONV, relieve pain, achieve an additional analgesic effect, and improve the early ROM compared with the other two groups in TKA.

Level of Evidence

Therapeutic Level I.

Trial registration

The Chinese Clinical Trial Registry (ChiCTR1800017036). Registered on July 9, 2018.

What is new in the battle against postoperative nausea and vomiting?

The issue of postoperative nausea and vomiting (PONV) still poses a significant burden on our patients. Although rarely associated with a life-threatening condition, it is consistently considered as one of the most undesirable side effects of surgery and anesthesia. There are well-established risk factors for the development of PONV that include patient-related factors, anesthetic technique, use of volatile anesthetics, use of nitrous oxide, duration of anesthesia, opioid administration, and type of surgery. Because pharmacologic interventions for PONV are not without risks, practitioners must assess patient's risk status from low to high and consider the benefits of treatment. This review summarizes the current state of knowledge related to PONV and provides a practical approach toward risk assessment, prevention, and numerous treatment strategies.

Effects of palonosetron for prophylaxis of postoperative nausea and vomiting in high-risk patients undergoing total knee arthroplasty: A prospective, randomized, double-blind, placebo-controlled study

Background

The preemptive multimodal pain protocols used in total knee arthroplasty (TKA) often cause emesis postoperatively. We investigated whether palonosetron prophylaxis reduces postoperative nausea and vomiting (PONV) in high-risk patients after TKA.

Methods

We randomized 120 female patients undergoing TKA to receive either palonosetron (0.075 mg, intravenous) or no antiemetic prophylaxis (0.9% saline, control group). All patients were given spinal anesthesia, a continuous femoral nerve block, and fentanyl-based intravenous patient controlled analgesia. Patients undergoing staged bilateral TKA were assigned to one group for the first knee and the other group for the second knee. The overall incidence of PONV, the incidences of both nausea and vomiting, severity of nausea, complete response, requirement for rescue antiemetics, pain level, opioid consumption, and satisfaction scores were evaluated during three periods: 0–2, 2–24, and 24–48 h postoperatively. We also compared PONV and pain between the first and second TKA.

Results

The incidence of PONV during the first 48 h was lower in the palonosetron group compared with the controls (22 vs. 41%, p = 0.028), especially 2–24 h after surgery, as was the nausea and vomiting respectively. The severity of nausea was lower in the palonosetron group (p = 0.010). The complete response rate (93 vs. 73%, p = 0.016) and satisfaction score (84 ± 12 vs. 79 ± 15, p = 0.032) were higher in the palonosetron group during 2–24 h after surgery. Patients who underwent a second operation complained of more severe pain, and consumed more opioids than those of the first operation. There was no difference in the incidence of PONV between the first and second operations.

Conclusions

Palonosetron prophylaxis reduced the incidence and severity of PONV in high-risk patients managed with multimodal pain protocol for 48 h, notably 2–24 h after TKA.

Multiple Low-Dose Dexamethasone Further Improves Clinical Outcomes Following Total Hip Arthroplasty

BACKGROUND

The recommended dose regimen of dexamethasone in total hip arthroplasty (THA) has not been determined. This study was performed to assess the effects of multiple low-dose dexamethasone on clinical outcomes after THA.

METHODS

Two hundred ten patients undergoing THA received 3 doses of normal saline (Group A), 2 doses of intravenous dexamethasone and 1 dose of normal saline (Group B), or 3 doses of intravenous dexamethasone (Group C). The primary outcome was the visual analog scale (VAS) score for pain and nausea. The incidence of postoperative nausea and vomiting, use of analgesic and antiemetic rescue, C-reactive protein (CRP) level, range of motion, length of stay (LOS), and complications were also compared.

RESULTS

The VAS score (dynamic pain and nausea) on postoperative day 1 was significantly lower in Groups C and B than Group A. On postoperative day 2, the VAS score (dynamic pain and nausea) was lower in Group C than Groups A and B. In Group C, patients had a lower incidence of postoperative nausea and vomiting and reduced use of analgesic and antiemetic rescue. The CRP level was lower in Group B than Group A. Group C had the lowest CRP level among all 3 groups. LOS was shorter in Group B than Group A, while Group C had an even shorter LOS than Group B. Range of motion was greater in Group C. No complications occurred in any group.

CONCLUSION

The 3-dose dexamethasone regimen can further relieve postoperative pain, ameliorate postoperative nausea, provide additional inflammatory control, enhance mobility, and shorten LOS following THA.

Two doses of low-dose perioperative dexamethasone improve the clinical outcome after total knee arthroplasty: a randomized controlled study

To study the clinical effect and safety of two doses of low-dose perioperative dexamethasone on pain and recovery after total knee arthroplasty. Methods A total of 108 patients were included in this randomized, double-blinded, placebo-controlled study. They received two doses of 10 mg IV dexamethasone (group Dexa) or IV isotonic saline (group Placebo). The CRP, IL-6 and pain levels, postoperative nausea and vomiting (PONV) incidence, nausea severity, postoperative fatigue, range of motion, length of stay, analgesic rescue and antiemetic rescue consumption, and complications were compared. Results The CRP and IL-6 levels in group Dexa were lower than in group Placebo at 24, 48, and 72 h postoperatively (P < 0.001, P < 0.001, and P < 0.001, respectively). In group Dexa, patients had less pain at 24 h postoperatively, at rest (P < 0.001) and during walking (P < 0.001); they also had a lower PONV incidence (P = 0.002) and a lower nausea VAS score (P = 0.008). Postoperative fatigue (P < 0.001) was relieved and the analgesic and antiemetic rescue consumption was reduced. Length of stay (n.s.) and range of motion (n.s.) were similar in both groups. No early surgical wound infection or gastrointestinal haemorrhage occurred in either group. Conclusions Administering two doses of low-dose perioperative dexamethasone for patients receiving total knee arthroplasty reduces postoperative CRP and IL-6 levels, provides additional analgesic effect, and reduces the PONV incidence and postoperative fatigue, without increasing the risk of early surgical wound infection and gastrointestinal haemorrhage. So two doses of low-dose perioperative dexamethasone are effective and safe for patients receiving TKA to decrease the inflammatory response, prevent PONV, relieve postoperative pain and fatigue, and enhance recovery. Level of evidence I.

Postoperative nausea and vomiting: physiopathology, risk factors, prophylaxis and treatment

Recognising the importance of the prevention and early treatment of postoperative nausea and vomiting (PONV) is essential to avoid postoperative complications, improve patient satisfaction and enable the development of major outpatient surgery and fast-track surgery. The topic of PONV might seem to have become stagnant, but we are moving forward. New concepts and problems like post-discharge nausea and vomiting, new risk factors and new drugs are appearing. However, there continue to be mistaken notions about PONV, such as the association between PONV and post-anaesthesia care unit stays, or assuming that it is a risk factore characteristic of the patient, anaesthesia or surgery when it is not. Perhaps, now is the moment to tackle PONV in a different manner, implementing guidelines and going for more aggressive prophylaxis in some groups of patients. We present an extensive review of this topic.

Low-dose dexamethasone during arthroplasty: What do we know about the risks?

Dexamethasone is commonly applied during arthroplasty to control post-operative nausea and vomiting (PONV). However, conflicting views of orthopaedic surgeons and anaesthesiologists regarding the use of dexamethasone raise questions about risks of impaired wound healing and surgical site infections (SSI).

The aim of this systematic review is to determine the level of evidence for the safety of a peri-operative single low dose of dexamethasone in hip and knee arthroplasty.

We systematically reviewed literature in PubMed, EMBASE and Cochrane databases and cited references in articles found in the initial search from 1980 to 2013 based on predefined inclusion criteria. The review was completed with a ‘pro’ and ‘con’ discussion.

After identifying 11 studies out of 104, only eight studies met the inclusion criteria. In total, 1335 patients were studied without any incidence of SSI. Causes of SSI are multifactorial. Therefore, 27 205 patients would be required (power = 90%, alpha = 0.05) to provide substantiated conclusions on safety of a single low dose of dexamethasone.

Positively, many studies demonstrated showed convincing effects of low-dose dexamethasone on prevention of PONV and dose-dependent effects on post-operative pain and quality of recovery. Dexamethasone induces hyperglycaemia, but none of the studies demonstrated a concomitant SSI.

Conversely, animal studies showed that high dose dexamethasone inhibits wound healing.

A team approach of anaesthesiologists and orthopaedic surgeons is mandatory in order to balance the risk–benefit ratio of peri-operatively applied steroids for individual arthroplasty patients.

We did not find evidence that a single low dose of dexamethasone contributes to SSI or wound healing impairment from the current studies.

Cite this article: Wegener JT, Kraal T, Stevens MF, Hollman MW, Kerkhoffs GMMJ, Haverkamp D. Low-dose dexamethasone during arthroplasty: what do we know about the risks? EFORT Open Rev 2016;1:303-309. DOI: 10.1302/2058-5241.1.000039.

Methylprednisolone reduces pain and decreases knee swelling in the first 24 h after fast-track unicompartmental knee arthroplasty

PURPOSE

Unicompartmental knee arthroplasty (UKA) results in less operative trauma and faster patient recovery than after a conventional total knee arthroplasty. Despite an increased focus on multimodal analgesic strategies, there is still a substantial level of patient-reported pain in the early postsurgical period after UKA. The purpose of the study was to evaluate the effect of a single preoperative dose of systemic methylprednisolone on postsurgical pain after fast-track UKA.

METHODS

Seventy-two patients in two consecutive series undergoing unilateral UKA were included in a prospective cohort study. The patients (n = 35) in the treatment group received a single preoperative dose of systemic methylprednisolone 125 mg, whereas the control group (n = 37) did not. Outcome measures were postsurgical pain at rest and during walking, consumption of opioids for pain rescue, knee swelling and knee range of motion, and complications.

RESULTS

In the first 24 h after surgery, the treatment group had less pain at rest (p < 0.001) and during walking (p < 0.001) and less consumption of opioids (p = 0.01) in comparison with the control group. Furthermore, the treatment group had 2.2 cm less knee swelling (p = 0.02) in the first post-operative day, and better knee extension (p = 0.004), whereas knee flexion was similar (n.s.) between groups. No serious complications were associated with the treatment.

CONCLUSION

Addition of a single preoperative dose of 125 mg systemic methylprednisolone to a multimodal analgesic regime significantly reduced postsurgical pain and opioid consumption and decreased knee swelling in the first 24 h after fast-track UKA.

LEVEL OF EVIDENCE

Therapeutic study, Level II.

Postoperative nausea and vomiting: A simple yet complex problem

Postoperative nausea and vomiting (PONV) is one of the complex and significant problems in anesthesia practice, with growing trend toward ambulatory and day care surgeries. This review focuses on pathophysiology, pharmacological prophylaxis, and rescue therapy for PONV. We searched the Medline and PubMed database for articles published in English from 1991 to 2014 while writing this review using “postoperative nausea and vomiting, PONV, nausea-vomiting, PONV prophylaxis, and rescue” as keywords. PONV is influenced by multiple factors which are related to the patient, surgery, and pre-, intra-, and post-operative anesthesia factors. The risk of PONV can be assessed using a scoring system such as Apfel simplified scoring system which is based on four independent risk predictors. PONV prophylaxis is administered to patients with medium and high risks based on this scoring system. Newer drugs such as neurokinin-1 receptor antagonist (aprepitant) are used along with serotonin (5-hydroxytryptamine subtype 3) receptor antagonist, corticosteroids, anticholinergics, antihistaminics, and butyrophenones for PONV prophylaxis. Combination of drugs from different classes with different mechanism of action are administered for optimized efficacy in adults with moderate risk for PONV. Multimodal approach with combination of pharmacological and nonpharmacological prophylaxis along with interventions that reduce baseline risk is employed in patients with high PONV risk.

Postdischarge Nausea and Vomiting Remains Frequent After Le Fort I Osteotomy Despite Implementation of a Multimodal Antiemetic Protocol Effective in Reducing Postoperative Nausea and Vomiting

PURPOSE

To assess the prevalence of postdischarge nausea and vomiting (PDNV) after Le Fort I osteotomy with and without the use of a multimodal antiemetic protocol shown to decrease postoperative nausea and vomiting (PONV).

MATERIALS AND METHODS

Consecutive patients undergoing Le Fort I osteotomy with or without additional procedures at a single academic institution formed the intervention cohort for an institutional review board-approved prospective clinical trial with a retrospective comparison group. The intervention cohort was managed with a multimodal antiemetic protocol. The comparison group consisted of consecutive patients who underwent similar surgical procedures at the same institution before protocol implementation. All patients were asked to complete a postdischarge diary documenting the occurrence of nausea and vomiting. Those who completed the diaries were included in this analysis. Data were analyzed with the Fisher exact test and the Wilcoxon rank sum test. A P value less than .05 was considered significant.

RESULTS

Diaries were completed by 85% of patients in the intervention group (79 of 93) and 75% of patients in the comparison group (103 of 137). Patients in the intervention (n = 79) and comparison (n = 103) groups were similar in the proportion of patients with validated risk factors for PDNV, including female gender, history of PONV, age younger than 50 years, opioid use in the postanesthesia care unit (PACU), and nausea in the PACU (P = .37). The prevalence of PDNV was unaffected by the antiemetic protocol. After discharge, nausea was reported by 72% of patients in the intervention group and 60% of patients in the comparison group (P = .13) and vomiting was reported by 22% of patients in the intervention group and 29% of patients in the comparison group (P = .40).

CONCLUSION

Modalities that successfully address PONV after Le Fort I osteotomy might fail to affect PDNV, which is prevalent in this population. Future investigation will focus on methods to minimize PDNV.

Consensus guidelines for the management of postoperative nausea and vomiting

The present guidelines are the most recent data on postoperative nausea and vomiting (PONV) and an update on the 2 previous sets of guidelines published in 2003 and 2007. These guidelines were compiled by a multidisciplinary international panel of individuals with interest and expertise in PONV under the auspices of the Society for Ambulatory Anesthesia. The panel members critically and systematically evaluated the current medical literature on PONV to provide an evidence-based reference tool for the management of adults and children who are undergoing surgery and are at increased risk for PONV. These guidelines identify patients at risk for PONV in adults and children; recommend approaches for reducing baseline risks for PONV; identify the most effective antiemetic single therapy and combination therapy regimens for PONV prophylaxis, including nonpharmacologic approaches; recommend strategies for treatment of PONV when it occurs; provide an algorithm for the management of individuals at increased risk for PONV as well as steps to ensure PONV prevention and treatment are implemented in the clinical setting.

Preemptive low-dose dexamethasone reduces postoperative emesis and pain after TKA: a randomized controlled study

BACKGROUND

Dexamethasone is a potent analgesic and antiemetic. However, the benefit of dexamethasone after TKA is unclear, as is the efficacy in a current multimodal regime.

QUESTIONS/PURPOSES

We determined (1) whether the addition of dexamethasone to a protocol including ramosetron further reduces postoperative emesis compared with ramosetron alone; (2) whether it reduces postoperative pain; and (3) whether it increases the risk for wound complications in a current multimodal regime after TKA.

METHODS

We randomized 269 patients undergoing TKAs to receive dexamethasone (10 mg) 1 hour before surgery and ramosetron immediately after surgery (Dexa-Ra group, n = 135), or ramosetron alone (Ra group, n = 134). We recorded the incidence of postoperative nausea and vomiting (PONV), severity of nausea, incidence of antiemetic requirement, complete response, pain level, and opioid consumption. Patients were assessed 0 to 6, 6 to 24, 24 to 48, and 48 to 72 hours postoperatively. In addition, patients were evaluated for wound complications and periprosthetic joint infections at a minimum of 1 year after surgery.

RESULTS

The Dexa-Ra group had a lower incidence of PONV during the entire 72-hour evaluation period and experienced less severe nausea for the first 6 hours after TKA, although not between 6 to 72 hours. Overall use of a rescue antiemetic was less frequent, and complete response was more frequent in the Dexa-Ra group. Patients in the Dexa-Ra group experienced lower pain and consumed less opioids during the 6- to 24-hour period and during the overall study period. No differences were found in wound complications between the groups, and each group had one case of periprosthetic joint infection.

CONCLUSIONS

Patients who received prophylactic dexamethasone in addition to ramosetron had reduced postoperative emesis and pain without increased risks for wound complications, compared with patients who received ramosetron alone in patients managed using a multimodal regimen after TKA.

Dexamethasone reduces length of hospitalization and improves postoperative pain and nausea after total joint arthroplasty: a prospective, randomized controlled trial

Controlling postoperative pain and nausea after total joint arthroplasty remains an important challenge. We conducted a prospective, randomized controlled trial with 120 patients to determine if the addition of perioperative dexamethasone to a multimodal regimen improves antiemetic and analgesic control, enhances mobility, and shortens hospital length of stay after total hip and knee arthroplasty. Patients administered 10mg of intravenous dexamethasone intraoperatively consumed less daily rescue anti-emetic and analgesic medication, reported superior VAS nausea and pain scores, ambulated further distances, and had a significantly shorter length of stay compared to the control group (P<0.05). A second, 24-hour postoperative dose of 10mg intravenous dexamethasone provided significant additional pain and nausea control and further reduced length of stay (P<0.05). No adverse events were detected with the administration of the intraoperative and/or postoperative dexamethasone.

Postoperative vomiting in pediatric oncologic patients: prediction by a fuzzy logic model

OBJECTIVE

To report a fuzzy logic mathematical model to predict postoperative vomiting (POV) in pediatric oncologic patients and compare with preexisting scores.

BACKGROUND

Although POV has a high incidence in children and may decrease parental satisfaction after surgeries, there is only one specific score that predicts POV in children: the Eberhart's score. In this study, we report a fuzzy model that intends to predict the probability of POV in pediatric oncologic patients. Fuzzy logic is a mathematical theory that recognizes more than simple true and false values and takes into account levels of continuous variables such as age or duration of the surgery. The fuzzy model tries to account for subjectiveness in the variables.

METHODS

Preoperative potential risk factors for POV in 198 children (0-19 year old) with malignancies were collected and analyzed. Data analysis was performed with the chi-square test and logistic regression to evaluate probable risk factors for POV. A system based on fuzzy logic was developed with the risk factors found in the logistic regression, and a computational interface was created to calculate the probability of POV.

RESULTS

The model showed a good performance in predicting POV. After the analysis, the model was compared with Eberhart's score in the same population and showed a better performance.

CONCLUSIONS

The fuzzy score can predict the chance of POV in children with cancer with good accuracy, allowing better planning for postoperative prophylaxis of vomiting. The computational interface is available for free download at the internet and is very easy to use.