premedication dexamethasone

[Sonny Crocket]

We give a lot of premedication at my hospital. Most patients get 16mg of dexamethasone PO, 2g paracetamol, and depending on the patient, NDAIDS.

Some of the orthopedic surgeons are worried about malunion, nonunion etc with administration of steroids such as dexa. We only give one dose and there is no evidence for their concern with one pre op dose. I know they 'own' the patient so why fight it.
But what do you guys think?

Do your orthopods complain when patient is given steroids ?

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[Doctor4Life1769]

We give a lot of premedication at my hospital. Most patients get 16mg of dexamethasone PO, 2g paracetamol, and depending on the patient, NDAIDS.

Some of the orthopedic surgeons are worried about malunion, nonunion etc with administration of steroids such as dexa. We only give one dose and there is no evidence for their concern with one pre op dose. I know they 'own' the patient so why fight it.
But what do you guys think?

Do your orthopods complain when patient is given steroids ?

Not sure why oral steroids are needed.
They do fine with OxyContin, NSAID or Tylenol, gabapentin and if it's a joint then a respective block under US guidance (with versed, fentanyl prn).

 

[Planktonmd]

What's the indication for such huge dose of Dexamethasone???

 

[jwk]

We give it to almost everyone. Our total joint protocol is dexamethasone 0.15mg/kg.

 

[OB1🤙]

What's the indication for such huge dose of Dexamethasone???

Can't wait to hear the answer to this. WTF.

 

[Doctor4Life1769]

We give it to almost everyone. Our total joint protocol is dexamethasone 0.15mg/kg.

But... Why?

 

[sethco]

We give it to almost everyone. Our total joint protocol is dexamethasone 0.15mg/kg.

Ideal body weight or actual?

 

[Ezekiel2517]

We give it to almost everyone. Our total joint protocol is dexamethasone 0.15mg/kg.

Ours is similar, pretty common practice nowadays

 

[Urzuz]

Giving dexamethasone to joint patients is common practice as its been shown to decrease nausea and pain scores, which leads to patients going home earlier. But as far as I know, none of these studies have studied the optimal dose. I have seen some studies giving 10 mg to patients, and one study that even gave 40 mg IV to patients (!!!), but there hasn't been a study that has attempted to find the optimal dose.

We know from our anesthesia literature that doses as small as 4 mg IV reduce nausea and can help with pain. Giving over 10 mg is insane and unwarranted in my opinion. For a little perspective, giving a patient 16 mg of dexamethasone is equivalent to giving a patient 400 mg of hydrocortisone. Daily hydrocortisone production is around 20 mg. A bit excessive, no?

I really believe many physicians fall into the trap of, "if a little is good more must be better" without realizing that the medicines we give are all potent and have side effect profiles that can lead to morbidity and mortality. Simple examples include giving 30 mL of local anesthetic for an adductor canal block, giving 2 mg of midazolam to everyone regardless of age and anxiety level, and now giving 16 mg of dexamethasone to all joint patients.

 

[jwk]

Ideal body weight or actual?

Actual up to 15mg max dose

 

[Pooh & Annie]

As I recall, there's pretty good data that there's no benefit of 8mg over 4mg in terms of nausea. Why would 0.15 per be any better? Is there some ortho specific data?

Sore throat/inflammation I know more is better.

 

[nimbus]

Just came to my inbox today....

http://www.arthroplastyjournal.org/article/S0883-5403(13)00500-7/fulltext

 

[Urzuz]

Just came to my inbox today....

http://www.arthroplastyjournal.org/article/S0883-5403(13)00500-7/fulltext

Yes, most studies I've seen in the orthopedic literature use 10 mg. As I said above, anything more than that is unnecessary in my opinion since plenty of studies have shown 10 mg being effective.

Additionally, it still doesn't address the fact that no study has looked at the optimal dose. What if 4 mg had the same results? We already know from our literature that as little as 4 mg can decrease nausea.

 

[nimbus]

Yes, most studies I've seen in the orthopedic literature use 10 mg. As I said above, anything more than that is unnecessary in my opinion since plenty of studies have shown 10 mg being effective.

Additionally, it still doesn't address the fact that no study has looked at the optimal dose. What if 4 mg had the same results? We already know from our literature that as little as 4 mg can decrease nausea.

The larger doses are used to treat pain, not nausea.

 

[Urzuz]

The larger doses are used to treat pain, not nausea.

Yes, my point is that we already know 4 mg can treat nausea. We don't know the optimal dose for pain. Blindly giving people a huge whack of steroids without knowing the optimal dose is doing patients a disservice.

 

[nimbus]

Yes, my point is that we already know 4 mg can treat nausea. We don't know the optimal dose for pain. Blindly giving people a huge whack of steroids without knowing the optimal dose is doing patients a disservice.

I vaguely recall some dosing studies showing 8+ mg is better for pain scores.

 

[nimbus]

https://www.researchgate.net/profil...sterectomy/links/0c96052932f3c195b7000000.pdf

https://www.researchgate.net/profil...throplasty/links/00b49532266eddba01000000.pdf

 

[deleted162650]

0.1mg/kg is what I've heard as the dose needed to have an effect on post-op pain scores.

 

[Sonny Crocket]

Am talking about 16mg PO PRE operatively Which Seems like a lot. But it is common practice here in Europe for post op pain. Much bigger on premed here than when I was in the states doing residency. Don't remember giving any premeds in residency actually.

 

[OB1🤙]

So you guys that are doing this think it actually has a discernible clinical effect?

I'd be more worried about the hyperglycemia and sequelae of that in my usual raging diabetic patients than I would be interested in some very marginal analgesic benefit.

But hey, if it's working for you, go nuts.

 

[nimbus]

0.1mg/kg is what I've heard as the dose needed to have an effect on post-op pain scores.

So that's 12mg for our average joint patient

 

[nimbus]

So you guys that are doing this think it actually has a discernible clinical effect?

I'd be more worried about the hyperglycemia and sequelae of that in my usual raging diabetic patients than I would be interested in some very marginal analgesic benefit.

But hey, if it's working for you, go nuts.

In the study by Backes it reduced LOS by over 1day without significant adverse effects even in diabetics. Pain scores went from >4 to <2 with less opioid use. Read it.

 

[turnupthevapor]

There is never a free ride but literature supports not to much increased risk

 

[Sonny Crocket]

So you guys that are doing this think it actually has a discernible clinical effect?

I'd be more worried about the hyperglycemia and sequelae of that in my usual raging diabetic patients than I would be interested in some very marginal analgesic benefit.

But hey, if it's working for you, go nuts.

We don't give it to diabetics. And I thought it was a very high dose when I first started working here. Just to shock you even more. Most patients that don't have contraindications get 2g acetaminophen , 16mg dex, and 100mg diclofenac as premedication in our day surgery center. All PO.

 

[Maverikk]

Where in the EU do you practice?

 

[kazuma]

It's been a while since I looked at the literature but when I was reading about this topic the studies I found used anywhere from 0.1-0.2mg/kg to help with pain and decreased inflammation and showed little downside at this dose. I usually give upwards 10-16mg depending on the case. I avoid dex in IDDM though. I haven't heard of any problems nor have I had any surgeons complain about it.

 

[Ezekiel2517]

So you guys that are doing this think it actually has a discernible clinical effect?

I'd be more worried about the hyperglycemia and sequelae of that in my usual raging diabetic patients than I would be interested in some very marginal analgesic benefit.

But hey, if it's working for you, go nuts.

I don't do anything. Surgeon orders it, preop nurse gives it. It's their patient, they can do whatever they want. Even if I were against it, I'm not gonna waste my time trying to convince an orthopod otherwise. Spent a good half hour the other day trying to explain to one of them how TXA works. He refuses to use it cuz he believes it causes more blood loss.

 

[ZzzPlz]

Time to address the elephant in the room...

If you give a big dose of po dexamethasone in pre op and the patient swallows it too fast, do their genitals start burning?

 

[Random Anesthesiologist]

Time to address the elephant in the room...

If you give a big dose of po dexamethasone in pre op and the patient swallows it too fast, do their genitals start burning?

Hahahaha I wondered who was going to say it.

 

[urge]

Time to address the elephant in the room...

If you give a big dose of po dexamethasone in pre op and the patient swallows it too fast, do their genitals start burning?

But not if they swallow it slowly.

 

[dhb]

But not if they swallow it slowly.

Yes i aways recommend slow swallowing over 2 minutes

 

[deleted171991]

Yes i aways recommend slow swallowing over 2 minutes

It should be over 10. Just ask a nurse.

 

[BLADEMDA]

Our literature supports 0.1 mg/kg of decamethasone to reduce pain. For diabetics I would suggest sticking to the 0.1 mg/kg dose with a maximum of 10 mg. For non diabetics I don't have an issue with 0.15 mg/kg up to 15 mg.

 

[BLADEMDA]

Anesthesiology. 2011 Sep;115(3):575-88. doi: 10.1097/ALN.0b013e31822a24c2.
Perioperative single dose systemic dexamethasone for postoperative pain: a meta-analysis of randomized controlled trials.
De Oliveira GS Jr1, Almeida MD, Benzon HT, McCarthy RJ.
Author information

Abstract
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.

 

[BLADEMDA]

Another interesting tidbit is the decadron IV may prolong your nerve block. Plus, if you use Precedex instead of Propofol for sedation (assuming a regional technique) the block is likely prolonged as well.

 

[CopaceticOne]

Another interesting tidbit is the decadron IV may prolong your nerve block. Plus, if you use Precedex instead of Propofol for sedation (assuming a regional technique) the block is likely prolonged as well.

Do you have a link for the precedex info handy?

 

[BLADEMDA]

Anesthesiology. 2016 Mar;124(3):683-95. doi: 10.1097/ALN.0000000000000983.
IV and Perineural Dexmedetomidine Similarly Prolong the Duration of Analgesia after Interscalene Brachial Plexus Block: A Randomized, Three-arm, Triple-masked, Placebo-controlled Trial.
Abdallah FW1, Dwyer T, Chan VW, Niazi AU, Ogilvie-Harris DJ, Oldfield S, Patel R, Oh J, Brull R.
Author information

Abstract
BACKGROUND:
Perineural and IV dexmedetomidine have each been suggested to prolong the duration of analgesia when administered in conjunction with peripheral nerve blocks. In the first randomized, triple-masked, placebo-controlled trial to date, the authors aimed to define and compare the efficacy of perineural and IV dexmedetomidine in prolonging the analgesic duration of single-injection interscalene brachial plexus block (ISB) for outpatient shoulder surgery.

METHODS:
Ninety-nine patients were randomized to receive ISB using 15 ml ropivacaine, 0.5%, with 0.5 μg/kg dexmedetomidine administered perineurally (DexP group), intravenously (DexIV group), or none (control group). The authors sequentially tested the joint hypothesis that dexmedetomidine prolongs the duration of analgesia and reduces the 24-h cumulative postoperative morphine consumption. Motor blockade, pain severity, hemodynamic variations, opioid-related side effects, postoperative neurologic symptoms, and patient satisfaction were also evaluated.

RESULTS:
Ninety-nine patients were analyzed. The duration of analgesia was 10.9 h (10.0 to 11.8 h) and 9.8 h (9.0 to 10.6 h) for the DexP and DexIV groups, respectively, compared with 6.7 h (5.6 to 7.8) for the control group (P < 0.001). Dexmedetomidine also reduced the 24-h cumulative morphine consumption to 63.9 mg (58.8 to 69.0 mg) and 66.2 mg (60.6 to 71.8 mg) for the DexP and DexIV groups, respectively, compared with 81.9 mg (75.0 to 88.9 mg) for the control group (P < 0.001). DexIV was noninferior to DexP for these outcomes. Both dexmedetomidine routes reduced the pain and opioid consumption up to 8 h postoperatively and did not prolong the duration of motor blockade.

CONCLUSION:
Both perineural and IV dexmedetomidine can effectively prolong the ISB analgesic duration and reduce the opioid consumption without prolonging motor blockade.