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Dexamethasone and risk of nausea and vomiting and postoperative bleeding after tonsillectomy in children: a
Christoph Czarnetzki1, Nadia Elia, Christopher Lysakowski
1Division of Anesthesiology, University Hospitals of Geneva, 24 rue Micheli-du-Crest, CH-1211 Geneva 14, Switzerland.
Insights
Dexamethasone reduced postoperative nausea and vomiting (PONV) in pediatric tonsillectomy patients dose-dependently. However, higher doses increased the risk of serious postoperative bleeding, leading to early trial termination.
Area of Science:
- Pediatric Anesthesiology
- Pharmacology
- Surgical Outcomes
Background:
- Dexamethasone is a common prophylactic agent for postoperative nausea and vomiting (PONV) in pediatric tonsillectomy.
- The optimal dose for preventing PONV while minimizing risks remains under investigation.
Purpose of the Study:
- To determine if dexamethasone reduces the risk of PONV at 24 hours post-tonsillectomy in a dose-dependent manner.
- To evaluate the association between dexamethasone dosage and the incidence of adverse events, specifically postoperative bleeding.
Main Methods:
- A randomized, placebo-controlled trial involving 215 children undergoing elective tonsillectomy.
- Participants received intravenous dexamethasone (0.05, 0.15, or 0.5 mg/kg) or placebo post-anesthesia induction.
- Primary endpoint: PONV at 24 hours; Secondary endpoints: analgesic use and adverse effects.
Main Results:
- Dexamethasone significantly reduced PONV in a dose-dependent manner (P<.001).
- The 0.5 mg/kg dose was associated with a significantly increased risk of postoperative bleeding (adjusted relative risk, 6.80; P = .003).
- Eight children required emergency reoperation due to bleeding, all of whom received dexamethasone.
Conclusions:
- Dexamethasone effectively decreases PONV risk after pediatric tonsillectomy in a dose-dependent fashion.
- The highest dose (0.5 mg/kg) significantly elevates the risk of postoperative bleeding, necessitating caution.
- The study was halted early due to safety concerns regarding increased bleeding risk with higher dexamethasone doses.
Context:
Dexamethasone is widely used to prevent postoperative nausea and vomiting (PONV) in pediatric tonsillectomy.
Objective:
To assess whether dexamethasone dose-dependently reduces the risk of PONV at 24 hours after tonsillectomy.
Design, Setting, And Patients:
Randomized placebo-controlled trial conducted among 215 children undergoing elective tonsillectomy at a major public teaching hospital in Switzerland from February 2005 to December 2007.
Interventions:
Children were randomly assigned to receive dexamethasone (0.05, 0.15, or 0.5 mg/kg) or placebo intravenously after induction of anesthesia. Acetaminophen-codeine and ibuprofen were given as postoperative analgesia. Follow-up continued until the 10th postoperative day.
Main Outcome Measures:
The primary end point was prevention of PONV at 24 hours; secondary end points were decrease in the need for ibuprofen at 24 hours and evaluation of adverse effects.
Results:
At 24 hours, 24 of 54 participants who received placebo (44%; 95% confidence interval [CI], 31%-59%) had experienced PONV compared with 20 of 53 (38%; 95% CI, 25%-52%), 13 of 54 (24%; 95% CI, 13%-38%), and 6 of 52 (12%; 95% CI, 4%-23%) who received dexamethasone at 0.05, 0.15, and 0.5 mg/kg, respectively (P<.001 for linear trend). Children who received dexamethasone received significantly less ibuprofen. There were 26 postoperative bleeding episodes in 22 children. Two of 53 (4%; 95% CI, 0.5%-13%) children who received placebo had bleeding compared with 6 of 53 (11%; 95% CI, 4%-23%), 2 of 51 (4%; 95% CI, 0.5%-13%), and 12 of 50 (24%; 95% CI, 13%-38%) who received dexamethasone at 0.05, 0.15, and 0.5 mg/kg, respectively (P = .003). Dexamethasone, 0.5 mg/kg, was associated with the highest bleeding risk (adjusted relative risk, 6.80; 95% CI, 1.77-16.5). Eight children had to undergo emergency reoperation because of bleeding, all of whom had received dexamethasone. The trial was stopped early for safety reasons.
Conclusion:
In this study of children undergoing tonsillectomy, dexamethasone decreased the risk of PONV dose dependently but was associated with an increased risk of postoperative bleeding.
Trial Registration:
clinicaltrials.gov Identifier: NCT00403806.
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