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From the Department of Anesthesia, Faculty of Medicine, Ain-Shams University, Cairo, Egypt.
Address correspondence to: Dr. Mokhtar Elhakim, Al Horreya Heliopolis, Code No: 11361, P.O. Box: 2361, Cairo, Egypt. Phone: 202-271-6141; Fax: 202-271-6141; E-mail: mokhtare_h{at}hotmail.com
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Abstract |
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Methods: In a double-blinded study, 120 patients were randomly allocated to receive either dexamethasone 0.5 mg•kg-1 (maximum dose 8 mg) iv or an equivalent volume of saline preoperatively. The incidence of early and late vomiting, need for rescue antiemetics, time to first oral intake, time to first demand of analgesia and analgesic consumption were compared in both groups. Pain scores used included Children’s Hospital Eastern Ontario Pain Scale, "faces", and a 0–10 visual analogue pain scale.
Results: Compared with placebo, dexamethasone significantly decreased the incidence of early and late vomiting (P < 0.05, P < 0.001 respectively). Fewer patients in the dexamethasone group needed antiemetic rescue (P < 0.01). The time to first oral intake was shorter, and the time to first dose of analgesic was longer in the dexamethasone group (P < 0.01). Pain scores 30 min after extubation were lower (P < 0.05) in the dexamethasone group. At 12 and 24 hr postoperative swallowing was still significantly less painful in the dexamethasone group than in the control group (P < 0.01).
Conclusion: Preoperative dexamethasone 0.5 mg•kg-1 iv reduced both postoperative vomiting and pain in children after electrocautery tonsillectomy.
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Introduction |
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Dexamethasone has been used as an antiemetic drug in patients undergoing chemotherapy with limited side effects.5 Recently, it has been found to have a prophylactic effect on postoperative vomiting in children undergoing tonsillectomy.6 Dexamethasone has combined antiemetic and anti-inflammatory effects that may decrease postoperative tissue injury, edema and pain after electrocautery tonsillectomy.
The aim of this study was to assess the effect of a single dose of dexamethasone on postoperative vomiting and pain in children undergoing tonsillectomy using a standardized anesthetic technique.
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Methods |
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The study design was randomized, double-blind, and placebo-controlled. Patients were prospectively randomized to receive either dexamethasone 0.5 mg•kg-1 iv (maximum dose 8 mg) or an equivalent volume of saline. Study drugs were marked only with a coded number label. A computer-generated table of numbers guided randomization. Study drugs were given immediately after iv access was established by the anesthesiologist, who was unaware of drug identity.
Patients were not allowed solid food for eight hours before operation; clear liquids were permitted until three hours before surgery. A standard anesthetic technique was used. Premedication with oral midazolam 0.5 mg•kg-1 (maximal dose 20 mg) was given 20 min preoperatively. Anesthesia was induced with sevoflurane and 60% nitrous oxide in oxygen via mask followed by insertion of an iv cannula. Suxamethonium 1 mg•kg-1 was used to facilitate intubation. A mixture of sevoflurane in nitrous oxide and oxygen (FIO2 = 0.4) was administered via a T-piece or Bain system for maintenance of anesthesia. All children received fentanyl 1 µg•kg-1 before surgery started and 20 mL•kg-1 lactated Ringer’s solution during operation. All patients breathed with gentle hand-assisted ventilation. The heart rate (ECG), arterial oxygen saturation (SpO2), blood pressure, temperature and end-tidal CO2 were monitored. The same surgeon, using an electrodissection technique, performed all operations. At the end of surgery, gastric contents were suctioned via an orogastric tube before extubation. The trachea was extubated when the child was awake. All children were transferred to the postanesthesia care unit (PACU). The criteria for discharge from PACU to ward included stable vital signs, adequate pain control, and absence of vomiting for one hour.
Pain was assessed in the PACU by an independent observer, using both a five point ‘faces’ scale (1 = no pain, 5 = highest pain score), and the Children’s Hospital Eastern Ontario Pain Scale (CHEOPS; range of score 4–13), at 30 min, one, two, and four hours after extubation. Pain was assessed in the ward by children on a visual analogue toy at six, 12 and, 24 hr postoperatively. All children were shown the visual analogue toy during the preoperative visit, and its use was explained. This instrument is in the form of a chart, containing different animal figures increasing in size from bird (0, bottom = no pain) to elephant (10, top = worst pain), in ten steps. One nurse blinded to treatment group also assessed the patients’ pain with a standard visual analogue scale at six-hour intervals postoperatively at rest and while drinking 50 mL of water. Pain assessment by the nurse was based on six main components: i) direct questioning of pain at rest and during swallowing; ii) moisture and colour of the skin; iii) vocalization; iv) movements; v) response to handling; and vi) measurement of cardiovascular variables,7 respiratory rate and pulse oxymetry. Parents were instructed to assist the nurse in her assessment because they knew their child’s behaviour best. The time and dosage of postoperative analgesics received was also recorded.
Time to awaken (from the end of anesthesia until the patients opened their eyes on command) and time to the first administration of postoperative analgesia were recorded. Postoperative pain relief was obtained with rectal paracetamol 30 mg•kg-1 repeated every six hours as necessary (maximum dose 90 mg•kg-1•day-1). Pethidine in a titrated dose (total 1 mg•kg-1) was administered iv for rapid pain relief to patients with a CHEOPS score > 7 or who were crying during two consecutive five-minute observation periods until the child was comfortable. Water was offered to children one hour after arrival in the PACU and at the child’s request. Intravenous fluid infusion was continued until adequate oral intake (oral ingestion of 100 mL of fluids and 100 mL of soft food within four hours). Duration of PACU stay, time to first oral intake and volume of iv fluid infusion were recorded. The quality of oral intake was assessed by the child if aged over seven years or the parent using the following scale: 1 = child requests food, 2 = child accepts food when offered, 3 = child accepts food when coaxed, 4 = child refuses food. The nurse recorded the incidence of vomiting. Repeated vomiting within a one- to two-minute period was recorded as a single emesis. Nausea was not recorded because it is difficult to assess in children. Vomiting occurring more than twice was treated with metoclopramide 0.15 mg•kg-1 iv The presence or absence of any side effect such as bleeding, fever, flushing or headache was noted.
A sample size calculation performed before the commencement of the study revealed that 55 patients per group would be required to detect a 50% reduction in the incidence of postoperative vomiting, assuming a 50% baseline incidence of vomiting after tonsillectomy in the control group (
= 0.05 and ß = 0.20). Groups were compared using Student’s t test or Chi-squared test for contingency tables as appropriate. Visual analogue scores, time to awaken and time to first postoperative analgesia were analyzed using Mann-Whitney U test. Differences within groups were subjected to the Wilcoxon signed rank test. A P value < 0.05 was considered statistically significant.
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) and ‘faces’ (Figure 2) pain scores were lower (P < 0.05) in the dexamethasone group at 30 min and up to four hours after extubation. All children properly understood the visual analogue toy. At six hours postoperatively, children in the dexamethasone group had lower pain scores at rest and during drinking compared to the control group (P < 0.05). At 12 and 24 hr postoperative swallowing was still significantly less painful in the dexamethasone group than in the control group (P < 0.01). Mean pain scores during drinking in the dexamethasone group was lower in the late postoperative period (24 hr) than at six hours after surgery (P < 0.05). Mean pain scores reported by the nurse at six hour intervals were similar to those reported by the child. No child in the dexamethasone group required postoperative pethidine supplementation compared to nine children in the control group (Table II).
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). The severity of late vomiting (requirement for a rescue antiemetic) was significantly less in the dexamethasone group (0%) than in the saline group (11%; P < 0.05). There were no children in the dexamethasone group who required antiemetic rescue on the ward while two (4%) patients required treatment with metoclopramide in the PACU. The time to the first oral intake was significantly shorter and the quality of intake was significantly better in the dexamethasone group (P < 0.01, and P < 0.05 respectively; Table IV).
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Discussion |
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Several studies failed to demonstrate any beneficial effect of dexamethasone on the incidence of postoperative vomiting or pain after tonsillectomy in children.8–10 These studies included a limited number of patients and anesthetic and antiemetic protocols were not standardized. Postoperative nausea and vomiting are a multifactorial problem and several anesthetic and nonanesthetic factors must be controlled to obtain meaningful results. In the present study, sample size was predetermined and anesthetic technique, amount of iv hydration, dose of narcotic analgesic, antiemetic therapy and duration of hospital stay were standardized. We found that dexamethasone 0.5 mg•kg-1 up to 8 mg administered before tonsillectomy markedly decreased vomiting in children both in the PACU (early vomiting) and on the ward up to 24 hr after surgery (late vomiting). Dexamethasone may exert an antiemetic action via prostaglandin antagonism,11 serotonin inhibition in the gut,12 and release of endorphins.13
Aouad et al.14 and Pappas et al.15 have reported a significant decrease in the incidence of vomiting in dexamethasone treated children only during delayed recovery. In Splinter and Roberts’ study,16 dexamethasone decreased vomiting in children after tonsillectomy both during early PACU recovery and delayed (24 hr) recovery. The children who received propofol on induction of anesthesia in the previous study had a decreased incidence of early vomiting when compared to those who had an inhaled induction. This may be due to an interaction between dexamethasone and propofol. In the present study, the decrease in the incidence of early vomiting and pain might be attributed to potentiation of opioid analgesia by dexamethasone. The analgesic and antiemetic effects of dexamethasone were more pronounced in the late postoperative period, which is consistent with its prolonged biological half-life of 36 to 48 hr.
The dose of dexamethasone used in the present study was similar to that reported in a recent study of patients undergoing tonsillectomy.14 Complete antiemetic response was reported to be 60% with dexamethasone 0.15 mg•kg-1 (maximum dose, 8 mg),16 76% with dexamethasone 1 mg•kg-1 (maximum dose, 25 mg),15 77% with dexamethasone 0.5 mg•kg-1 (maximum dose, 8 mg)14 and 80% with our regimen. There was a remarkably low incidence of postoperative vomiting of 5%, with the combination of dexamethasone plus a low dose of ondansetron after strabismus surgery in children when compared with dexamethasone alone.17 To minimize the incidence of postoperative vomiting and improve oral intake after tonsillectomy, anesthesiologists have focused primarily on anesthetic technique and other perioperative factors with minimal emetogenic potential and on preoperative dexamethasone administration (0.5 mg•kg-1 iv up to 8 mg).
The clinical evaluation of postoperative pain in children is difficult. We used both the faces and CHEOPS pain scales to cross-validate the results, especially in the PACU.18 We used a visual analogue scale on the ward as it is more sensitive than simple descriptive scales and can be used in children four to five years old. We found that preoperative dexamethasone administration improves pain scores, reduces analgesic requirements, allows earlier oral fluid intake, and improves postoperative swallowing and the quality of oral intake. These results may be attributed to the anti-inflammatory effect produced by dexamethasone, which may reduce local edema and pain. These results on the analgesic effect of dexamethasone are in agreement with previous studies of dental19,20 and ambulatory surgery.21 Inconclusive results in other studies may be due to difficulties in standardizing perioperative clinical condition, the use of analgesics in the control groups and insensitive methods to assess pain. We limited our study to standardized surgical and anesthetic procedures and perioperative analgesics were adjusted to reveal any differences in analgesic consumption. Combined assessment by child, nurse, and parents as applied in our study may be a valid means of improving the validity of pain scoring in children.22
The long-term administration of corticosteroids is associated with adverse events, such as increased risk of infection, delayed wound healing, glucose intolerance, adrenal suppression, and a vascular necrosis of the hip or other joints. Although a single dose of dexamethasone is considered safe, further studies with longer follow-ups are indicated.
In conclusion, a prophylactic intraoperative single dose (0.5 mg•kg-1 iv up to 8 mg) of dexamethasone decreases the incidence of early and late postoperative vomiting, reduces pain scores at rest as well as during swallowing and improves the quality of oral intake in children during the first 24 hr after electrodissection tonsillectomy without apparent side effects.
Revision received December 13, 2002. Accepted for publication September 30, 2002.
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2 Furst SR, Rodarte A. Prophylactic antiemetic treatment with ondansetron in children undergoing tonsillectomy. Anesthesiology 1994; 81: 799–803.[Medline]
3 Ferrari LR, Donlon JV. Metoclopramide reduces the incidence of vomiting after tonsillectomy in children. Anesth Analg 1992; 75: 351–4.
4 Weimert TA, Babyak JW, Richter HJ. Electrodissection tonsillectomy. Arch Otolaryngol Head Neck Surg 1990; 116: 186–8.[Abstract]
5 Jones AL, Hill AS, Soukop M, et al. Comparison of dexamethasone and ondansetron in the prophylaxis of emesis induced by moderately emetogenic chemotherapy. Lancet 1991; 338: 483–7.[Medline]
6 April MM, Callan ND, Nowak DM, Hausdorff MA. The effect of intravenous dexamethasone in pediatric adenotonsillectomy. Arch Otolaryngol Head Neck Surg 1996; 122: 117–20.[Abstract]
7 Maunuksela EL, Olkkola KT, Korpela R. Measurement of pain in children with self-reporting and behavioral assessment. Clin Pharmacol Ther 1987; 42: 137–41.[Medline]
8 Ohlms LA, Wilder RT, Weston B. Use of intraoperative corticosteroids in pediatric tonsillectomy. Arch Otolaryngol Head Neck Surg 1995; 121: 737–42.[Abstract]
9 Catlin FI, Grimes WJ. The effect of steroid therapy on recovery from tonsillectomy in children. Arch Otolaryngol Head Neck Surg 1991; 117: 649–52.[Abstract]
10 Volk MS, Martin P, Brodsky L, Stanievich JF, Ballou M. The effects of preoperative steroids on tonsillectomy patients. Otolaryngol Head Neck Surg 1993; 109: 726–30.[Medline]
11 Rich WM, Abdulhayoglu G, DiSaia PJ. Methylprednisolone as an antiemetic during cancer chemotherapy – a pilot study. Gynecol Oncol 1980; 9: 193–8.[Medline]
12 Fredrikson M, Hursti T, Furst CJ, et al. Nausea in cancer chemotherapy is inversely related to urinary cortisol excretion. Br J Cancer 1992; 65: 779–80.[Medline]
13 Harris AL. Cytotoxic-therapy-induced vomiting is mediated via enkephalin pathways. Lancet 1982; 1: 714–6.[Medline]
14 Aouad MT, Siddik SS, Rizk LB, Zaytoun GM, Baraka AS. The effect of dexamethasone on postoperative vomiting after tonsillectomy. Anesth Analg 2001; 92: 636–40.
15 Pappas ALS, Sukhani R, Hotaling AJ, et al. The effect of preoperative dexamethasone on the immediate and delayed postoperative morbidity in children undergoing adenotonsillectomy. Anesth Analg 1998; 87: 57–61.
16 Splinter WM, Roberts DJ. Dexamethasone decreases vomiting by children after tonsillectomy. Anesth Analg 1996; 83: 913–6.[Abstract]
17 Splinter WM. Prevention of vomiting after strabismus surgery in children: dexamethasone alone versus dexamethasone plus low-dose ondansetron. Paediatr Anaesth 2001; 11: 591–5.[Medline]
18 Suraseranivongse S, Santawat U, Kraiprasit K, Petcharatana S, Prakkamodom S, Muntraporn N. Cross-validation of a composite pain scale for preschool children within 24 hours of surgery. Br J Anaesth 2001; 87: 400–5.
19 Baxendale BR, Vater M, Lavery KM. Dexamethasone reduces pain and swelling following extraction of third molar teeth. Anaesthesia 1993; 48: 961–4.[Medline]
20 Skjelbred P, Lokken P. Post-operative pain and inflammatory reaction reduced by injection of a corticosteroid. Eur J Clin Pharmacol 1982; 21: 391–6.[Medline]
21 Aasboe V, Raeder JC, Groegaard B. Betamethasone reduces postoperative pain and nausea after ambulatory surgery. Anesth Analg 1998; 87: 319–23.
22 Elhakim M, Abdul Salam AY, Eid A, Kaschef N, Mostafa BE. Inclusion of pethidine in lidocaine for infiltration improves analgesia following tonsillectomy in children. Acta Anaesthesiol Scand 1997; 41: 214–7.[Medline]
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