This Paper of the Month report looks at evidence for reducing postoperative vomiting with preoperative dexamethasone [1] published in a BMJ article in April 2017.
What is known on the subject?
Post-operative nausea and vomiting (PONV) affects around 30% -35% of patients undergoing surgery involving the gastrointestinal tract, and there is evidence that this occurs even after the introduction of an enhanced recovery protocol. These symptoms are highly undesirable for patients, and they can adversely affect post-operative nutritional intake, cause complications such as pneumonia and also lengthen hospital stay.
What this study adds
The DREAMS trial recruited 1350 participants from 45 UK centres to assess the effect of adding a one-off 8mg dose of dexamethasone (versus no dexamethasone), after induction of anaesthesia. The trial had a pragmatic design, with all patients receiving one anti-emetic chosen by the anaesthetist prior to randomisation. All anti-emetics were administered after induction of anaesthesia. The only important exclusion in the trial was of patients with diabetes (because of the recognised rise in blood sugar associated with intravenous steroids).
The trial found that the addition of a single dose of 8 mg intravenous dexamethasone significantly reduces the incidence of post-operative vomiting from 33.2% of patients being affected, to 25.5% at 24 hours, thus indicating that 13 patients need to receive dexamethasone to prevent one patient from experiencing vomiting in this time period. Without dexamethasone 50% of patients reported nausea in the first 24 hours, versus 40% when dexamethasone was given. Although there was no reduction in nausea and vomiting after 24 hours, the need for rescue antiemetics was reduced in the treatment group for up to 72 hours in patients undergoing either large or small bowel surgery. Patients receiving dexamethasone also restarted oral diet earlier. The dietary and PONV benefits were seen for patients undergoing open and laparoscopic procedures.
There was no disparity in the incidence of adverse events between the two groups.
Implications for colorectal practice
In the current era of minimally invasive colorectal surgery combined with enhanced recovery, reducing the incidence and severity of PONV may be particularly important. The benefits of dexamethasone to reduce PONV had not been previously established in patients undergoing bowel surgery. DREAMS provides this evidence as well as reassuring surgeons that risks of wound infection and anastomotic leak are not increased. The pragmatic design avoided the use of a placebo or a specific anaesthetic or post-operative recovery protocol. Thus results provide evidence for the use of dexamethasone across various anaesthetic protocols and gastrointestinal surgical procedures.
- DREAMS Trial Collaborators and West Midlands Research Collaborative, Dexamethasone versus standard treatment for postoperative nausea and vomiting in gastrointestinal surgery: randomised controlled trial (DREAMS Trial), BMJ. 2017 Apr 18;357:j1455. doi: 10.1136/bmj.j1455.
- http://www.bmj.com/content/357/bmj.j1455http://www.bmj.com/content/357/bmj.j1455