Steroids and postoperative analgesia

The Effect of a Single Intravenous Corticosteroid Administration on Pain after Knee Arthroscopy: A Prospective, Double-Blind, Non-Randomized Controlled Clinical Trial

BACKGROUND

Knee arthroscopy is a standard surgical procedure that is nowadays widely performed as day-case surgery. The aim of the study was to observe the effect of a single dose of intravenous corticosteroid on pain after undergoing knee arthroscopy for non-bony procedures.

METHODS

A prospective, double-blind study design was adopted. Patients undergoing knee arthroscopy for non-bony procedures were prospectively assigned into two equal groups: control (those who were not given steroids) and treatment (those who were given eight milligrams of dexamethasone intravenously 15 min prior to the inflation of the tourniquet). The pain was assessed pre-operatively on admission and on the first post-operative day during the morning round in five different movements using a visual analogue scale (VAS).

RESULTS

A total of 60 patients were included in the study. There was no significant difference in the pre-and post-operatively scores between both groups. The treatment group experienced a significant reduction in post-operative morphine requirements, with 80% of patients who did not receive dexamethasone requiring post-operative morphine compared to only 53.3% of patients who did (p = 0.027).

CONCLUSIONS

Pre-operative intravenous administration of a single dose of dexamethasone may decrease opioid requirements for adequate pain control after knee arthroscopy.

Single-Shot Liposomal Bupivacaine Reduces Postoperative Narcotic Use Following Outpatient Rotator Cuff Repair: A Prospective, Double-Blinded, Randomized Controlled Trial

BACKGROUND

Liposomal bupivacaine (LB) theoretically is longer-acting compared with conventional bupivacaine. The purpose of this study was to compare conventional bupivacaine combined with dexamethasone (control group), LB combined with conventional bupivacaine (LB group), and LB combined with dexamethasone and conventional bupivacaine (LBD group) in a perineural interscalene nerve block during ambulatory arthroscopic rotator cuff repair to determine if LB decreased postoperative narcotic consumption and pain. The effect of supplemental dexamethasone on prolonging the analgesic effect of LB was also assessed.

METHODS

This was a prospective, double-blinded, randomized controlled trial of 76 consecutive patients who underwent outpatient arthroscopic rotator cuff repair. Patients were randomized into the 3 interscalene-block treatment groups: control group (n = 26), LB group (n = 24), and LBD group (n = 26). Outcome measures included pain measured with a visual analog scale (VAS; 0 to 10) and narcotic consumption measured in oral morphine milligram equivalents (MME). Both were measured daily on postoperative day 0 through postoperative day 4.

RESULTS

Generalized estimating equation modeling revealed that narcotic consumption across all time points (postoperative days 0 to 4) was significantly lower in the LB group compared with the control group (mean difference, -8.5 MME; 95% confidence interval, -15.4 to -1.6; p = 0.015). Narcotic consumption was significantly higher in the control group on postoperative days 2 and 3 compared with the LB group (p = 0.004 and p = 0.02, respectively) and the LBD group (p = 0.01 and p = 0.003, respectively). There was no difference in narcotic consumption between the LBD and LB groups on any postoperative day. VAS pain scores in all groups were similar across all postoperative days.

CONCLUSIONS

Among patients undergoing outpatient arthroscopic rotator cuff repair, the addition of LB to conventional bupivacaine in interscalene nerve blocks appeared to be effective in controlling postoperative pain. Because LB with and without dexamethasone decreased postoperative narcotic use, LB should be considered for use in preoperative interscalene nerve blocks to reduce the reliance on narcotics for pain management.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Local injection of liposomal bupivacaine combined with intravenous dexamethasone reduces postoperative pain and hospital stay after shoulder arthroplasty

BACKGROUND

Alternative techniques have been developed to address pain after shoulder arthroplasty and are well documented. We evaluated the effect of adding intraoperative liposomal bupivacaine and intravenous dexamethasone during shoulder arthroplasty.

METHODS

We retrospectively reviewed 2 consecutive cohorts undergoing elective shoulder arthroplasty. The 24 patients in cohort 1 and the 31 patients in cohort 2 received perioperative multimodal management with preoperative and postoperative intravenous and oral narcotics, gabapentin, nonsteroidal anti-inflammatory drugs, acetaminophen, and single-injection interscalene block. Cohort 2 also received 8 to 10 mg of intravenous dexamethasone intraoperatively after the skin incision and liposomal bupivacaine injected at surgery. Patients who did and did not use preoperative narcotics were analyzed together and separately. We evaluated hospitalization length of stay, narcotic use, and visual analog scale pain before and after the change in the perioperative protocol.

RESULTS

Cohort 1 was hospitalized longer (2 vs. 1 day; P < .001), required more narcotics on postoperative day 1 (21.0 vs. 10.0 mg; P < .001) and days 0 and 1 cumulatively (30.5 vs. 17.5 mg; P = .001), and had more pain on postoperative days 0 (6.5 vs. 3.5; P < .001) and 1 (7.5 vs. 3.5; P < .001) than cohort 2. In patients using preoperative narcotics, cohort 2 had less pain on postoperative day 1 (3.5 vs. 7.0; P = .006), less cumulative narcotic use (20 vs. 58.5 mg; P = .03), and shorter hospitalization (1 vs. 2 days; P = .052) than cohort 1.

CONCLUSION

These changes to the perioperative shoulder arthroplasty protocol decreased hospitalization length of stay, narcotic requirement, and pain.

The cellular mechanisms of the antiemetic action of dexamethasone and related glucocorticoids against vomiting

Glucocorticoids, used primarily as anti-allergic and anti-inflammatory drugs, are also effective, alone or combined with other antiemetics, for preventing nausea and vomiting. Dexamethasone, one of the glucocorticoids, has been suggested as a first-line drug for preventing low-level emetogenic chemotherapy- and radiotherapy-induced nausea and vomiting, and in patients with only one or two risks for postoperative nausea and vomiting (PONV). Dexamethasone combined with 5-HT3 or tachykinin NK1 antagonists is also suggested for higher-level emetogenic chemotherapy and radiotherapy and for patients at high risk for PONV. Glucocorticoids may act via the following mechanisms: (1) anti-inflammatory effect; (2) direct central action at the solitary tract nucleus, (3) interaction with the neurotransmitter serotonin, and receptor proteins tachykinin NK1 and NK2, alpha-adrenaline, etc.; (4) maintaining the normal physiological functions of organs and systems; (5) regulation of the hypothalamic-pituitary-adrenal axis; and (6) reducing pain and the concomitant use of opioids, which in turn reduces opioid-related nausea and vomiting.

Dexamethasone reduces pain after tonsillectomy in adults

The aim of this study was to assess the effect of a course of dexamethasone on postoperative pain and morbidity after adult tonsillectomy. We report the results of a double-blind, randomized, placebo-controlled trial of 200 adult patients undergoing elective tonsillectomy. Patients were randomized to three groups: one group received the non-steroidal anti-inflammatory drug piroxicam for 8 days postoperatively, one group received dexamethasone for the same period and the third group received both drugs. Patients recorded their pain scores and analgesic requirements daily for 10 days. Patients treated with a combination of piroxicam and dexamethasone recorded consistently lower pain scores than those treated with either drug alone. This difference was statistically significant (P < 0.05) on all days except the day of surgery and the second postoperative day. Patients treated with piroxicam alone had significantly higher analgesic requirements than in either of the other groups. Dexamethasone given in this regime reduces postoperative pain and analgesic requirements after adult tonsillectomy.

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

BACKGROUND

A single preoperative high dose of methylprednisolone (15 to 30 mg/kg) has been advocated in surgery, because it may inhibit the surgical stress response and thereby improve postoperative outcome and convalescence. However, these potential clinical benefits must be weighed against possible adverse effects.

OBJECTIVE

To conduct a risk-benefit analysis using a meta-analysis, to compare complication rates and clinical advantages associated with the use of high dose methylprednisolone in surgical patients.

METHODS

Randomised controlled trials of high dose methylprednisolone in elective and trauma surgery were systematically searched for in various literature databases. Outcome data on adverse effects, postoperative pain and hospital stay were extracted and statistically pooled in fixed-effects meta-analyses.

RESULTS

We located 51 studies in elective cardiac and noncardiac surgery, as well as traumatology. Pooled data failed to show any significant increase in complication rates. In patients treated with corticosteroids, nonsignificantly more gastrointestinal bleeding and wound complications were observed; the 95% confidence interval boundaries of the numbers-needed-to-harm were 59 and 38, respectively. The only significant finding was a reduction of pulmonary complications (risk difference -3.5%; 95% confidence interval -1.0 to -6.1), mainly in trauma patients.

CONCLUSION

For patients undergoing surgical procedures, a perioperative single-shot administration of high dose methylprednisolone is not associated with a significant increase in the incidence of adverse effects. In patients with multiple fractures, limited evidence suggests promising benefits of glucocorticoids on pulmonary complications.

Management of pain in the critically ill patient

In spite of growing evidence that effective pain management of critically ill human beings decreases their morbidity and mortality, pain is often undertreated in critically ill animals. Reasons for withholding analgesics in these animals have included fear of contributing to cardiopulmonary instability and difficulty in monitoring response to therapy. Appropriately used, analgesics improve the status of critically ill animals. Opioids are the most widely used analgesics but other options exist. Newer methods of analgesic administration include continuous infusions, epidural, local, regional, and transdermal administration.

The risks and benefits of corticosteroids in advanced cancer

Corticosteroids are extensively prescribed in advanced cancer for various specific indications (e.g. spinal cord compression), for pain relief, as hormone therapy and to stimulate appetite and wellbeing. Choice of corticosteroid is dictated largely by local fashion, and times of administration are more traditional than pharmacological. Corticosteroids have many potential disadvantages, some life-threatening (e.g. masked septicaemia). Others are seriously debilitating (e.g. myopathy, avascular bone necrosis). Oropharyngeal candidiasis is a common complication. Corticosteroids are withdrawn in about 5% of patients because of unacceptable adverse effects, including moon-face and diabetes mellitus. Corticosteroid hypersensitivity occurs, and the succinate salts have been associated with bronchospasm. Steroid pseudorheumatism may occur with high dose therapy or when tailing off after a prolonged course. Important drug interactions with corticosteroids relate to salt and water retention, and decreased glucose tolerance. Some anticonvulsants cause an increased clearance of corticosteroids and, with dexamethasone, up to a 50% reduction in the anticipated effect. The benefit of corticosteroids in terms of increased appetite, mood and activity has been demonstrated in several controlled trials. The effect may well be time-limited in most patients. In several studies, corticosteroids have resulted in an analgesic-sparing effect. Some centres use very high doses of dexamethasone in cases of spinal cord compression, although the justification for these is not obvious. Corticosteroids are used to help relieve nerve compression pain and in symptomatic raised intracranial pressure. Corticosteroids are also injected locally into or around bone metastases, particularly ribs and the sacro-iliac joints. Epidural injections are used for patients with troublesome intractable low back pain. Corticosteroids are now used less often in hypercalcaemia because of poor response rates. More benefit is obtained, however, if high dosages are used, e.g. prednisolone 60 to 80 mg/day. Dexamethasone is widely used as an antiemetic in association with chemotherapy. Some centres use dexamethasone by continuous subcutaneous infusion in selected patients when the oral route is not feasible. The choice of starting dose of a corticosteroid is largely arbitrary. It is important, however, not to miss a possible treatment benefit by prescribing too low a dose. For most patients, an initial dosage of prednisolone of 30 to 60 mg/day (dexamethasone 4 to 8 mg/day) is appropriate. In patients with anorexia, there are several alternative options that should be considered. There is evidence to suggest that patients with advanced cancer receiving a corticosteroid are not as closely monitored as other patients. There is a need to state clearly in writing the reason(s) for prescription and to review after 1 or 2 weeks.(ABSTRACT TRUNCATED AT 400 WORDS)

Management of postoperative pain: influence of anesthetic and analgesic choice

Improved control of postoperative pain is being increasingly scrutinized yet concomitantly demanded by patients, physicians, and even the federal government. Our ever-increasing subspecialization in medicine has compartmentalized much of perioperative care and has created substantial difficulty for physicians in understanding the overall influence of other physicians' perioperative decisions, including control of pain. Clearly, intraoperative anesthetic management can affect patients' pain and perioperative course remote from the surgical procedure through modulation of analgesic and perioperative stress responses. Additionally, outcome studies show that provision of improved analgesia and minimization of the perioperative stress response enhance clinical outcome in both low- and high-risk patients. This article highlights new information on how anesthetic and analgesic management influences perioperative pain and decreases the incidence of complications in surgical patients.