DECADRON & Totals? Saftey?

[turnupthevapor]

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Hello my people

We have started giving our non-DM totals (Knees and Hips) 0.1 mg/kg of dexamethasone in the hopes that it will improve their dynamic pain scores as it has in the literature with the added bonus effect it will have on the nerve blocks. Pretty accepted to use this medication for antiemesis but this is a touch of a higher dose than used for that.

I know the literature doesn't suggest anymore than a theoretical risk of increasing wound infection but I ask all of you your thoughts? One thing I have already noticed is the patients are having a bump in their WBC post op day 1&2. Although I don't know the clinical significance of this it could cloud the diagnostic picture etc.

 

[turnupthevapor]

food for thought


The antiinflammatory effects of glucocorticoids in the postoperative period are well known [5, 10, 23]. A small single dose of dexamethasone reduces C-reactive protein (CRP) levels by 50% three days following total knee replacement [23]. There exist various synthetic glucocorticoids that have few mineralocorticoid properties responsible for modulating water and electrolyte balance. Dexamethasone is a high-potency and long-acting glucocorticoid with few mineralocorticoid side effects [20]. A single preoperative glucocorticoid dose has commonly been used to prevent postoperative nausea and vomiting and reduce pain and inflammation after surgery [1, 8, 12, 14, 19]. The immediate analgesic and antiemetic benefits in the perioperative period have clearly been demonstrated although glucocorticoids have yet to gain widespread acceptance because of potential side effects. The risk of femoral head osteonecrosis is negligible and has rarely been associated with a short course of corticosteroid therapy [17]. The onset of symptoms is typically within 18 months after treatment and only a few cases have been documented up until 3 years following corticosteroid therapy.

We recently reported the short-term effect on dynamic pain of a single dexamethasone dose compared to placebo after THA [11]. Dynamic pain scores at 24 hours were lower in the dexamethasone group compared to placebo. However, the functional effects of dexamethasone administration at longer term remain unknown. Lower levels of acute phase reactants, such as CRP and interleukin 6 (IL-6), reportedly independently predict pain and the ability to walk following elective THA

 

[deleted162650]

I think 0.1mg/kg is widely considered safe barring any specific contraindications. Where I trained there was an old timer ENT at the children's hospital who requested his T&A pts receive 1mg/kg dexamethasone 😱😵.

 

[soorg]

Ya, one ENT I used to work with always wanted 1 mg/kg as well. Made me cringe. Never did it. Afterwards read some study that showed that dose had a higher re-bleed rate. 0.1 mg/kg is what I always use.

 

[IlDestriero]

We give all the T&As 0.5mg/kg up to 10mg.

 

[pgg]

Ya, one ENT I used to work with always wanted 1 mg/kg as well. Made me cringe. Never did it. Afterwards read some study that showed that dose had a higher re-bleed rate. 0.1 mg/kg is what I always use.

We have one who wants 50 mg for his adult tonsils. Weird.

 

[deleted162650]

We have one who wants 50 mg for his adult tonsils. Weird.

Next time tell him "I'm running low on Decadron, you OK if I give 1562mg of cortisone?

See what he says.

Then say "Hey circulator, can you bring me 16 vials of Cortisone"

I think these surgeons are a little ignorant on just how potent dexamethasone is.

 

[CodeBlu]

I usually give average sized folks 8-10 mg. And I almost always use Decadron. Unless it's a pain in the ass ortho who thinks it's gonna interfere with their surgery.
Or a naysayer ENT post T&A doesn't want any NSAIDs what so ever (Which btw was a HORRIBLY done study)

If it's a long surgery, I don't give it until an hour after induction.
Surgery goes off without a hitch. They're 10 minutes from closing. They get Ondansetron 4 mg. If I'm running any infusions, I stop them. I give Gravol 25 mg IV. Turn down the vapour to 0.5-0.6 MAC on super low flows. Get them breathing spontaneously if possible. Surgery is done? Vapour off. Flows up. And reversal. They're starting to make respiratory I usually give 20-40 mg of propofol. And then extubate deep. I'm a huge fan of extubating deep. Especially smokers and young adults. They always wake up like it's the apocalypse.

I did have a patient who required frequent bladder distentions. She always had super wicked PONV, requiring hospital admission numerous times. My attending and I decided to try a complete TIVA with propofol. Induce with a remifentanil infusion... bolus initially. Keep that on during induction at 0.12 mcg/kg/min. Turn up the propofol to 200-300 mcg/kg/min. Turn down remi to 0.o8 mcg/kg. Give decadron at start of case, 10 mg. Ondansetron 4 mg IV. Remi off. Propofol down to 50 mcg/kg/min. Turn off the propofol when the drapes come down. And boom, smooth wake up... no dirty nasty vapour on board. She now requests this attending, because she doesn't want the PONV to happen ever again.

What do you guys think about Decadron? I've found it almost always seems to lower PONV and pain post op.

 

[deleted171991]

What do you guys think about Decadron? I've found it almost always seems to lower PONV and pain post op.

You should write a paper about it. 🙂

 

[CodeBlu]

You should write a paper about it. 🙂

Apfel beat me to it... sort of 🙁

 

[Urzuz]

I know the literature doesn't suggest anymore than a theoretical risk of increasing wound infection but I ask all of you your thoughts? One thing I have already noticed is the patients are having a bump in their WBC post op day 1&2. Although I don't know the clinical significance of this it could cloud the diagnostic picture etc.

In regards to the clinical significance, there isn't much. Steroids lead to demargination of white blood cells from the endothelial lining and an increased release from the bone marrow. None of these actually signify infection. This acute increase in absolute WBC count can be distinguished from infection usually by a left-shift on the differential during infection but not after steroid administration.

This is what I remember from intern year anyway...