July FY 19 Journal Club

[katevaughn]

This month’s journal club is presented by LarSharVeA to kick off fiscal year 2019!
With the ongoing discussions surrounding the opioid crisis we currently face, multimodal analgesia is at the forefront. One drug in particular, dexamethasone, is often administered to combat PONV but has also been linked as an opioid-sparing adjunct. This article reviews the use of dexamethasone and whether it reduces postoperative pain. It is a very interesting read and another helpful tool for our toolbox!


Here is a link to the article. 

The two questions to encompass within your response:



1. After reading the article, what is your opinion on the use of dexamethasone, in recommended doses, as an adjunct?



2. What patient/surgical population might this adjunct benefit greatly? What population could this do more harm than good?

[kty67]

1.My opinion on dexamethasone as an adjunct is positive. I think in a future we will see more studies to evaluate this drug and so far it has good results with intermediate doses for nausea and pain control without significant side effects.
2. The patient that have airway procedures and have potential for swelling (swelling will create more pain) do benefit from administration of dexamethasone. I am not sure if I would give it to patients that have ERAS protocols and potential for DM after surgery.

[cvelard1]

After reading this article it has made the concept of multi-modal pain reduction an important topic for all anesthesia providers. There has been a push to decrease the use of opioids in the post-op surgical phase. The use of dexamethasone in intermediate-range dose has shown some promise in decreasing opioid requirements. The push to eliminate opioids post-op can help decrease the potential for opioid dependence and the potential for habitual use of opioids. This opioid crisis is a daunting societal problem this country is experiencing.

Potential patients that may be harmed by this intermediate dosing may be the diabetic population or the patients that are borderline diabetics. Increase serum glucose may cause problems for the maintenance of normal glucose levels, increasing insulin doses or starting sliding insulin scales on patients who have not used insulin in the past.

[KJ]

Really wonderful article. I think more research is definitely needed on this topic like so many other topics. I do think dexamethasone is a good drug to use especially with intermediate dosing and as sated by others the benefit of using it as an adjunct is so very important especially now during our nation wide opioid crisis.

I do think dexamethasone is a drug most of us think about after a difficult intubation that required multiple attempts . Thinking about our ABCs getting that airway selling down for future extubation is critical and could benefit the patient . Like most of the other posts I do think twice about giving dexamethasone to the diabetic population .

[LarSharVeA Bennett]

Opioid administration is not without consequence. Whether it be an increase in healthcare cost due to prolonged hospital stay secondary to decreased mobility leading to pneumonia or skin breakdown, decreased gastric motility and its effects, or even poor pain tolerance secondary to upregulation of the pain receptors (wind up theory), our patients can deal with the choices we make for them for the rest of their lives although we often make those choices in a split second. Needless to say, I am an advocate for any effective narcotic sparing adjunct.

I would not administer decadron 0.1mg/kg to type I diabetics. The risk of diabetic ketoacidosis, poor wound healing, stroke, and coronary events are too great. We routinely administer the recommended doses to neurosurgery and ENT patients and then we monitor their glucose levels and maintain tight control to ensure we circumvent global injury. I also give 0.1mg/kg of decadron to women younger than 40 that are undergoing general anesthesia. This population often emerge from anesthesia with a "scrambled" amygdala presenting with crying, nausea, physical hyperactivity, et cetera, thus decadron is a useful component of the cocktail to facilitate a smooth emergence and recovery.

[Jackie Howell]

I really enjoyed reading this article and all of the responses. I think with the current opioid epidemic that our society is struggling with, every attempt to manage pain using multimodal approaches should be a priority. I would be more hesitant to administer dexamethasone in the patient with poorly controlled diabetes and patients concerned with having healing abnormalities in the acute postoperative phase. I was interested to read that preoperative administration of dexamethasone appeared to to produce more consistent analgesic effects compared with intraoperative administration. Its's important to remember that IV dexamethasone causes severe perianal burning in the awake or minimally sedated patient. Furthermore, I think oral dexamethasone could be an area of further study.

[Ben Waldbaum]

1. Interesting article. I've always been a strong proponent of multi-modal balanced technique of providing anesthesia. I never knew about this before, but it does at least make intuitive sense. Single dose steroids are safe with little downside. Unless there is a contraindication, this is another reason to administer dexamethasone.

2. I think most surgical populations would benefit besides diabetics and those have pancreatic surgery.

[khall]

In my opinion the use of Dexamethasone, in appropriate doses, is a great opioid sparing adjunct. Since I often use it to prevent PONV it is great to learn of the benefits as part of a multimodal approach to manage pain. I agree that most surgical populations would benefit except for diabetics and those who tight glucose control is not possible.

[nanci]

Interesting to use dexamethasone as part of a non-opioid
Adjunct to improve recovery and reducing pain. Maybe combine that with multimodal preop P.O. meds or even intraop IV magnesium for Read something similar about use of Esmolol for pain reduction as well- but not the same PONV reduction that dexamethasone would also provide. The .1-.2 mg/kg dose is a lot more than I have seen typically given and although that dosing is listed as an intermediate dose I would hesitate administering for patients with Diabetes or that have risks for poor wound healing / infections, GI bleeds. However, short term side effect profile is better than long term so a one time dose may be advantageous and with proper pain management postoperative may be impactful to help limit opioids.

[jswitzman]

After reading this article I am more apt to use Dexamethasone as a part of multimodal anesthetic. A great benefit is reduction of PONV and inflammation. I agree that a large surgical population could benefit from Dexamethasone as an adjunct but would not use with Diabetics or immunosuppressed patients.

[krechti1]

Good to know that dexamethasone has another added benefit of reducing postoperative pain. Since many of us routinely give it for PONV and for any ENT cases, we now know there is the added benefit of adding to the multimodal approach to pain management. Especially now, during the opioid crisis, anything we can do to reduce the opioid we give while reducing postoperative pain is beneficial to the patient. As mentioned above, we must still be aware of contraindications such as diabetic or immunocompromised patients. Also, some surgeons prefer we do not give dexamethasone (due to theoretical increased risk of infection or interference with immunotherapy, for example).... so we should always check before giving.

[belinda]

Interesting article! I have heard this use of Dexamethasone at recent conferences but not seen it in clinical use for this purpose at this dosage. The research thus far seems like it would be a great addition to our multimodal non-narcotic armamentarium at the intermediate dosing at least as it seems to have little downside especially since we already use it frequently as antiemetic (unless we are concerned for hyperglycemia). I look forward to it's use in the future.

 

[Kristen Praesel Lang]

1. After reading the article, what is your opinion on the use of dexamethasone, in recommended doses, as an adjunct? I am in fan of using dexamethasone as an antiemetic. Additionally, I am in favor of using dexamethasone in recommended doses as an adjunct in multimodal pain management to spare opiod use and optimize recovery.

2. What patient/surgical population might this adjunct benefit greatly? What population could this do more harm than good? Generally, I think most surgical patients would benefit from adjunct use of dexamethasone. However, this therapy could cause more harm than benefit in the diabetic population.

[Chuck Eder]

1. The use of dexamethasone to help decrease the amount of opioid needed seems to be great news in the battle against opioid abuse. It seems like the intermediate (0.1 mg/kg) and high dose (0.11-0.22 mg/kg) ranges have the best effect and can help benefit the right patient population.

2. I would think most surgical procedures could benefit from dexamethasone use in order to decrease the amount of opioids used, particularly those that typically have increased pain scores post op. One challenge could be with some Ortho surgeons and their stance that the use of dexamethasone leads to poor healing. This is a double edged sword, since ortho patients typically have a fair amount of post op pain. I would be less likely to use intermediate or high dose dexamethasone in the diabetic, immunocompromised, or Whipple patient population.

[emedina1]

After reading the article, made me aware that dexamethasone helps to curb the amount of opioid use. I do think that more study should be done to confirm this positive effect. I routinely use this drug to combat nausea
especilally in eye cases with adult and pediatric