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Background and Objectives: Perioperative modulation of the surgical inflammatory response has been hypothesized as a viable pharmacological preventive target for the development of chronic pain after surgery. The objective of the current investigation was to evaluate an association between intravenous dexamethasone 4 to 20 mg on the day of surgery with self-reported pain in the breast or axilla 3 months or more after mastectomy., Methods: The study was a secondary data analysis of a prospective cohort investigation. Subjects who have undergone mastectomy surgery were evaluated at least 3 months after the surgical procedure for the presence of chronic postsurgical pain using validated pain questionnaires. Binary logistic regression analysis was used to determine the odds of development of chronic postsurgical pain in subjects who did and did not receive perioperative dexamethasone., Results: Three hundred ten patients were included in the study. Fifty-two patients (17%) met the IMMPACT (Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials) criteria for chronic pain in the breast and/or axillary region. Two hundred eleven (68%) of 310 subjects received perioperative dexamethasone on doses varying from 4 to 20 mg. The incidence of chronic pain in the mastectomy group who received perioperative dexamethasone was not different, 15 (15.2%) of 84 compared with 37 (17.5%) of 211 in the group who did not receive perioperative dexamethasone, difference -2% (95% confidence interval, -10 to 7; P = 0.75)., Conclusions: Perioperative dexamethasone is not associated with a reduction in the incidence and/or severity of chronic postmastectomy pain. In addition, we did not detect a dose-response effect of dexamethasone on the incidence of chronic postsurgical pain.

Background: Basic science studies suggest that perioperative immune impairment may augment the risk of cancer recurrence after otherwise potentially curative surgery. Despite its immunosuppressant properties, dexamethasone is commonly given to oncologic patients in an effort to reduce postoperative nausea and vomiting. We therefore tested the hypothesis that perioperative dexamethasone administration increases the risk of ovarian cancer recurrence., Methods: Women who had primary ovarian cytoreductive surgery between January 1997 and October 2007 were identified using a database maintained by the division of Gynecologic Oncology at Northwestern University. Tumor recurrence in women given perioperative systemic dexamethasone (4-10 mg) was compared with those who did not receive dexamethasone. The primary outcome was the propensity-matched time to cancer recurrence. Recurrence was defined by a carcinoantigen 125 >21 U/mL or computerized tomography evidence of the disease followed by tissue confirmation. Median difference and 95% confidence interval between the propensity-matched groups were calculated using a 10,000 sample bootstrap., Results: Among 260 women having primary cytoreductive surgery for ovarian cancer that met our inclusion criteria, 102 subjects were given perioperative systemic dexamethasone. Cancer recurrence was observed in 178 subjects, and the overall unadjusted median (IQR) time to recurrence was 18 (7-50) months. Eighty-seven cases and 87 controls were propensity matched to adjust for confounding covariates. After propensity matching the groups for confounding covariates, the median (IQR) time to recurrence in the dexamethasone group was 23 (6-46) compared with 18 (8-53) months in the control group (P = 0.63) with a median (95% confidence interval) difference of time to recurrence between the dexamethasone and the control group of 5 (-8 to 17) months., Conclusion: We could not find evidence for an association between perioperative systemic dexamethasone administration and ovarian cancer recurrence after primary cytoreductive surgery. Our results do not support avoiding low-dose perioperative dexamethasone for prevention of postoperative nausea, vomiting, and pain in ovarian cancer patients.

Background: Perineural dexamethasone has been investigated as an adjuvant for brachial plexus nerve blocks, but it is not known whether the beneficial effect of perineural dexamethasone on analgesia duration leads to a better quality of surgical recovery. We hypothesized that patients receiving dexamethasone would have a better quality of recovery than patients not receiving dexamethasone. We also sought to compare the effect of perineural with that of IV dexamethasone on block characteristics., Methods: Patients undergoing elective ankle and foot surgery were recruited over a 9-month period. Patients received ultrasound-guided sciatic nerve blocks by using 0.5% bupivacaine with epinephrine 1:300,000 (0.45 mL/kg) and were randomized into 3 groups: group 1 = perineural dexamethasone 8 mg/2 mL with 50 mL IV normal saline, group 2 = perineural saline/2 mL with IV 8 mg dexamethasone in 50 mL normal saline, and group 3 = perineural saline/2 mL with 50 mL normal saline. The primary outcome was the global score in the quality of recovery (QoR-40). The secondary outcomes included analgesia duration, opioid consumption, patient satisfaction, numeric pain rating scores, and postoperative neurologic symptoms., Results: Eighty patients were randomized, and 78 patients completed the study protocol. There was no improvement in the global QoR-40 score at 24 hours between the perineural dexamethasone and saline, median (97.5% CI) difference of -3 (-7 to 3); IV dexamethasone and saline, median difference of -1 (-8 to 5); or perineural dexamethasone and IV dexamethasone median difference of -2 (-6 to 5). Analgesia duration (P < 0.001) and time to first toe movement (P < 0.001) were prolonged by perineural dexamethasone compared with saline. IV dexamethasone prolonged time to first toe movement compared with saline (P = 0.008) but not analgesia duration (P = 0.18). There was no significant difference in the time to first toe movement or analgesia duration between the perineural and IV dexamethasone groups. Postoperative opioid consumption was not different among study groups. Self-reported neurologic symptoms at 24 hours were not different among perineural dexamethasone (17, 63%), IV dexamethasone (10, 42%), or normal saline (8, 30%) (P = 0.31). All postoperative neurologic sequelae were resolved by 8 weeks., Conclusions: Preoperative administration of IV and perineural dexamethasone compared with saline did not improve overall QoR-40 or decrease opioid consumption but did prolong analgesic duration in patients undergoing elective foot and ankle surgery and receiving sciatic nerve block. Given the lack of clinical benefit and the concern of dexamethasone neurotoxicity as demonstrated in animal studies, the practice of perineural dexamethasone administration needs to be further evaluated.

Background: Dexamethasone has an established role in decreasing postoperative nausea and vomiting (PONV); however, the optimal dexamethasone dose for reducing PONV when it is used as a single or combination prophylactic strategy has not been clearly defined. In this study, we evaluated the use of 4 mg to 5 mg and 8 mg to 10 mg IV doses of dexamethasone to prevent PONV when used as a single drug or as part of a combination preventive therapy., Methods: A wide search was performed to identify randomized clinical trials that evaluated systemic dexamethasone as a prophylactic drug to reduce postoperative nausea and/or vomiting. The effects of dexamethasone dose were evaluated by pooling studies into 2 groups: 4 mg to 5 mg and 8 mg to 10 mg. The first group represents the suggested dexamethasone dose to prevent PONV by the Society for Ambulatory Anesthesia (SAMBA) guidelines, and the second group represents twice the dose range recommended by the guidelines. The SAMBA guidelines were developed in response to studies, which have been performed to examine different dosages of dexamethasone., Results: Sixty randomized clinical trials with 6696 subjects were included. The 4-mg to 5-mg dose dexamethasone group experienced reduced 24-hour PONV compared with control, odds ratio (OR, 0.31; 95% confidence interval [CI], 0.23-0.41), and number needed to treat (NNT, 3.7; 95% CI, 3.0-4.7). When used together with a second antiemetic, the 4-mg to 5-mg dexamethasone group also experienced reduced 24-hour PONV compared with control (OR, 0.50; 95% CI, 0.35-0.72; NNT, 6.6; 95% CI, 4.3-12.8). The 8-mg to 10-mg dose dexamethasone group experienced decreased 24-hour PONV compared with control (OR, 0.26; 95% CI, 0.20-0.32; NNT, 3.8; 95% CI, 3.0-4.3). Asymmetric funnel plots were observed in the 8-mg to 10-mg dose analysis, suggesting the possibility of publication bias. When used together with a second antiemetic, the 8-mg to 10-mg dose group also experienced reduced incidence of 24-hour PONV (OR, 0.35; 95% CI, 0.22-0.53; NNT, 6.2; 95% CI, 4.5-10). In studies that provided a direct comparison between groups, there was no clinical advantage of the 8-mg to 10-mg dexamethasone dose compared with the 4-mg to 5-mg dose on the incidence of postoperative nausea and/or vomiting., Conclusions: Our results showed that a 4-mg to 5-mg dose of dexamethasone seems to have similar clinical effects in the reduction of PONV as the 8-mg to 10-mg dose when dexamethasone was used as a single drug or as a combination therapy. These findings support the current recommendation of the SAMBA guidelines for PONV, which favors the 4-mg to 5-mg dose regimen of systemic dexamethasone.

Background: Glucocorticoids are commonly administered before ambulatory surgery, although their effects on quality of recovery are not well characterized. The purpose of this study was to evaluate the dose-dependent effects of dexamethasone on patient recovery using the Quality of Recovery 40 questionnaire (QoR-40) after ambulatory surgery., Methods: This prospective, double-blind trial studied 106 female subjects undergoing outpatient gynaecological laparoscopy. Subjects were randomized to receive saline, dexamethasone 0.05 mg kg(-1) or dexamethasone 0.1 mg kg(-1) before induction. The primary outcome was global QoR-40 at 24 h. Postoperative pain, analgesic consumption, side-effects, and discharge time were also evaluated., Results: Global median (IQR) QoR-40 after dexamethasone 0.1 mg kg(-1) 193 (192-195) was greater than dexamethasone 0.05 mg kg(-1) 179 (175-185) (P=0.004) or saline, 171 (160-182) (P<0.005). Median (IQR) morphine equivalents administered before discharge were 2.7 (0-6.3) mg after dexamethasone 0.1 mg kg(-1) compared with 5.3 (2.4-8.8) mg and 5.3 (2.7-7.8) mg after dexamethasone 0.05 mg kg(-1) and saline (P=0.02). Time to meet discharge criteria was 30 min shorter after dexamethasone 0.1 mg kg(-1) compared with saline (P=0.005). At 24 h, subjects receiving dexamethasone 0.1 mg kg(-1) had consumed less opioid analgesics, reported less sore throat, muscle pain, confusion, difficulty in falling asleep, and nausea compared with dexamethasone 0.05 mg kg(-1) and saline., Conclusions: Dexamethasone demonstrated dose-dependent effects on quality of recovery. Dexamethasone 0.1 mg kg(-1) reduced opioid consumption compared with dexamethasone 0.05 mg kg(-1), which may be beneficial for improving recovery after ambulatory gynaecological surgery.

Background: Dexamethasone is frequently administered in the perioperative period to reduce postoperative nausea and vomiting. In contrast, the analgesic effects of dexamethasone are not well defined. The authors performed a meta-analysis to evaluate the dose-dependent analgesic effects of perioperative dexamethasone., Methods: We followed the PRISMA statement guidelines. A wide search was performed to identify randomized controlled trials that evaluated the effects of a single dose systemic dexamethasone on postoperative pain and opioid consumption. Meta-analysis was performed using a random-effect model. Effects of dexamethasone dose were evaluated by pooling studies into three dosage groups: low (less than 0.1 mg/kg), intermediate (0.11-0.2 mg/kg) and high (≥ 0.21 mg/kg)., Results: Twenty-four randomized clinical trials with 2,751 subjects were included. The mean (95% CI) combined effects favored dexamethasone over placebo for pain at rest (≤ 4 h, -0.32 [0.47 to -0.18], 24 h, -0.49 [-0.67 to -0.31]) and with movement (≤ 4 h, -0.64 [-0.86 to -0.41], 24 h, -0.47 [-0.71 to -0.24]). Opioid consumption was decreased to a similar extent with moderate -0.82 (-1.30 to -0.42) and high -0.85 (-1.24 to -0.46) dexamethasone, but not decreased with low-dose dexamethasone -0.18 (-0.39-0.03). No increase in analgesic effectiveness or reduction in opioid use could be demonstrated between the high- and intermediate-dose dexamethasone. Preoperative administration of dexamethasone appears to produce a more consistent analgesic effect compared with intraoperative administration., Conclusion: Dexamethasone at doses more than 0.1 mg/kg is an effective adjunct in multimodal strategies to reduce postoperative pain and opioid consumption after surgery. The preoperative administration of the drug produces less variation of effects on pain outcomes.