Download Infection Associated With Single-Dose Dexamethasone

Infection Associated With Single-Dose
Dexamethasone for Prevention of Postoperative
Nausea and Vomiting: A Literature Review
Jenna Assante, CRNA, MS
Shawn Collins, CRNA, DNP, PhD
Ian Hewer, CRNA, MSN, MA
Postoperative nausea and vomiting is one of the most
common complications affecting surgical patients. The
glucocorticoid dexamethasone is often used for the
prevention of postoperative nausea and vomiting. This
literature review seeks to summarize research related
to the use of a single perioperative dose of dexamethasone for prophylactic treatment of postoperative nausea and vomiting and its impact on surgical healing.
Although the majority of the literature reviewed found
no association between single-dose intraoperative
P
ostoperative nausea and vomiting (PONV) is
one of the most common complications affecting surgical patients.1 Although mortality rates
are typically not affected, PONV can cause morbidity, including delayed return to diet, electrolyte disturbances, dehydration, and aspiration pneumonia. Delayed return to diet affects nutrition and can lead
to pressure sores, tissue breakdown, wound infection, and
delays in mobilization. As a result, patients can become
predisposed to serious complications, including hospitalacquired pneumonia and thromboembolic events.1
The incidence of PONV ranges from 30% to 70%.1
Many patients fear this outcome more than they fear
postsurgical pain. Emotional distress can result during
future surgical procedures in the patient who has already
experienced PONV.2 Reducing the incidence of PONV
is especially important in lowering costs associated with
extended hospital stays and treatment of complications.1
PONV can result in the unexpected hospitalization of an
ambulatory surgical patient, extend the time required for
patient monitoring postoperatively, increase total hospital stay for an inpatient, and delay recovery in a patient’s
resumption of normal activities.2
Several pharmacologic classifications of drugs are
currently available to assist with the prevention and
treatment of PONV, including antihistamines, phenothiazines, serotonin type 3 receptor antagonists, prokinetic
agents, neurokinin type 1 receptor antagonists, anticholinergic medications, and corticosteroids. Antihistamines
work by blocking the histamine sites located in the
chemoreceptor trigger zone (CTZ), whereas phenothi-
www.aana.com/aanajournalonline
dexamethasone and an increase in surgical site infections, the need for a large-scale randomized controlled
trial is consistently mentioned. Prudent clinicians
should always use the most current evidence with
their best clinical judgment when making medication
decisions for their patients.
Keywords: Corticosteroids, dexamethasone, infection,
postoperative nausea and vomiting, surgical site complications.
azines block the dopamine-2 receptor sites in the CTZ.
Serotonin type 3 receptor antagonists act by blocking
serotonin receptors in the CTZ. Prokinetic agents exert
their effects by antagonizing dopamine and increasing
the release of acetylcholine, whereas neurokinin type 1
receptor antagonists block neurokinin type 1 receptors
in the medulla. The vestibular component of PONV is
blocked by anticholinergic medications by way of the
acetylcholine receptors that innervate the vestibular
input to the CTZ. Unlike most other antiemetics, corticosteroids’ mechanism of action is incompletely understood, although it is known to have both central and
peripheral effects.2
Although each of these pharmacologic classifications
have merits, this literature review will focus on research
related to the use of a single perioperative dose of dexamethasone (a corticosteroid) for prophylactic treatment
of postoperative nausea and vomiting and its impact on
surgical healing outcome in the adult population.
Corticosteroids are steroidal hormones that are produced in the adrenal cortex.3 These hormones result in
the production of mineralocorticoids, androgens, and
glucocorticoids.3 The glucocorticoid dexamethasone is
often used for the prevention of PONV.1 Proposed mechanisms of action of dexamethasone include activation
of glucocorticoid receptors in the medulla, inhibition of
central production of prostaglandins, or inhibition of the
release of endogenous opioids.1
Dexamethasone is effective in reducing nausea and
vomiting when used alone or in conjunction with other
antiemetics. It is one of the most potent glucocorticoids
AANA Journal

August 2015

Vol. 83, No. 4
281
available with a half-life of 36 to 72 hours.4 Advantages
of using dexamethasone compared with other antiemetics include a lower cost and a longer duration of action.5
However, dexamethasone use may not be without
risk. It has long been known that glucocorticoids alter
innate immune responses and may lead to impaired
wound healing. Glucocorticoids in general are known to
inhibit the inflammatory phase of wound healing that is
characterized by cellular migration and increased vascular permeability. In addition, they also reduce concentrations of insulin-like growth factor-1 and growth factor-β,
both of which are important cellular signals for reepithelialization of wounds, collagen deposition, angiogenesis,
and fibrogenesis.6 However, it is unclear whether a single
perioperative dose of dexamethasone increases the risk
of the side effects seen with long-term glucocorticoid
therapy, such as impaired wound healing.7,8
Published editorials on the subject of the routine use
of dexamethasone for PONV and its potential impact on
surgical site healing have found no significant difference
in healing with the use of single-dose dexamethasone.
Many of the articles cited in these editorials are from
sources older than 5 years and are not limited to single,
low-dose intraoperative dexamethasone (4 to 12 mg).9,10
This literature review will focus on the most recent
research regarding the use of dexamethasone in the prevention of PONV and any potential impact on surgical
site healing.
Materials and Methods
A systematic search strategy was used to identify articles pertinent to the literature review. Searches were
conducted in health, social science, and general sciencefocused information resources, including MEDLINE,
Cumulative Index to Nursing & Allied Health Literature
(CINAHL), the Cochrane Database of Systematic Reviews,
SocINDEX, PsycINFO, and Science Citation Index, as
well as multidisciplinary resources such as Academic
Search Complete. Search keywords (used alone and in
combination) included dexamethasone, infection, adverse
outcomes, and wound complications.
The search for evidence included systematic reviews
with or without meta-analysis, human interventional and
observational clinical trials, and clinical practice guidelines. The inclusion criteria included full-text, Englishlanguage articles or clinical practice guidelines published
in peer-reviewed journals. The evidence was appraised
and graded according to the method proposed by Melnyk
and Fineout-Overholt.11
Results
Of the 11 articles examined for this review, 2 were systematic reviews with meta-analysis and are summarized
in Table 1.7,12 The first evaluated the dose-dependent
side effects of a single dose of dexamethasone in the peri-
282
AANA Journal

August 2015

Vol. 83, No. 4
operative period for postoperative pain.12 Comparisons
were stratified by dexamethasone dose into 3 groups;
low-dose (≤ 0.10 mg/kg), intermediate-dose (0.11 mg/kg
to 0.20 mg/kg), and high-dose (≥ 0.21 mg/kg). Adverse
events including postoperative infection, hyperglycemia,
delayed healing, and pruritus were examined.12 It was
found that a single perioperative dose of dexamethasone
did not increase complications such as wound infection or delayed wound healing.12 The second systematic review with meta-analysis evaluated the impact of
a single intravenous dose of dexamethasone (1.25 to 20
mg) on postoperative pain and adverse events associated with this treatment. There was no increase found in
the rates of infection or delayed wound healing.7 There
was a small but statistically significant increase in blood
glucose concentrations 24 hours after surgery, but it was
unclear in this analysis whether the dexamethasoneinduced hyperglycemia had any clinical implications.7 It
was noted that patients at a higher risk of infection such
as diabetics, who could conceivably have adverse effects
from increased blood glucose concentrations, are often
excluded from studies of dexamethasone.7
Four of the 11 articles included in this literature
review were randomized controlled trials and are summarized in Table 2. None of these studies found an increased rate of wound infection associated with the use of
a single dose of dexamethasone. Each study did note the
need for further studies to be conducted on a large-scale
multicenter basis to evaluate the effects of dexamethasone on wound complications as a primary endpoint.
A randomized controlled trial of 269 patients examined the use of dexamethasone (10 mg) in total knee
arthroplasty in combination with ramosetron (0.3 mg)
or ramosetron (0.3 mg) alone.13 There was no difference found in the rate of wound complications between
the 2 groups. This study may be limited by the fact that
all participants were Korean and most were women
(88%).13 Additionally, the sample size of this study was
determined based on the primary outcome of PONV and
had limited power to detect a subtle difference in postoperative wound complications.13 A second randomized
controlled trial studied the use of high-dose dexamethasone (1 mg/kg, maximum 100 mg) vs placebo in cardiac
surgery in a randomized controlled trial of more than
4,000 patients.14 Interestingly, this study found that the
overall risk of developing an infection was lower in the
dexamethasone group, primarily because of a decreased
incidence of pneumonia. High-dose dexamethasone is
commonly used for cardiac surgery in Europe, unlike in
North America where methylprednisolone is more commonly used.
The use of dexamethasone (8 mg) vs placebo in patients undergoing laparoscopic cholecystectomy in an
outpatient setting was examined in a randomized controlled trial.4 None of the patients in this study required
www.aana.com/aanajournalonline
www.aana.com/aanajournalonline
AANA Journal

August 2015

Vol. 83, No. 4
283
• No. of patients
•
•
• Age: ≥ 18 y
• Dexamethasone dose: 1.25-20 mg
•E
xclusion criteria: studies in which
patients received intrathecal or epidural
local anesthetics or opioids, dental/
endodontic procedures
•
•
•
• Type of surgery
• N = 5,796
• Inclusion criteria: full reports of RCTs in
which a single IV dose of dexamethasone
was given perioperatively to adult patients
undergoing surgery under general
anesthesia and compared with either a
placebo or another antiemetic agent
•L
imitations: no minimum sample size required for inclusion in the metaanalysis; dexamethasone administered intraoperatively for all studies in highdose group, limiting ability to investigate influence of drug administration
timing on outcome measures; blood glucose alterations specifically mentioned
in only 2 studies, limiting any safety assessment on this side effect
•4
studies evaluated high-dose dexamethasone: 1 did not comment on side
effects, 2 reported no cases of serious side effects, 1 specifically reported no
cases of wound infection or delayed wound healing
•1
3 studies evaluated intermediate-dose dexamethasone: 2 did not report on
side effects, 2 reported no differences in adverse outcomes, 8 specifically
reported no cases of postop wound infection, 1 reported same incidence of
wound infection in dexamethasone and placebo groups (0.2% incidence)
•7
studies evaluated low-dose dexamethasone: 2 did not comment on adverse
effects, 3 found no difference in adverse effects, 2 specifically reported no
difference in postop wound infection
•S
ingle-dose dexamethasone did not increase complications such as wound
infection or delayed wound healing; conclusion is strongest for intermediatedose, as there are a greater No. of patients at this dosing level
•A
dverse events were examined as secondary outcomes, including postop
infection (wound, urinary tract, and pneumonia), hyperglycemic events,
delayed healing, and pruritus
Results and conclusions
•D
examethasone dose range: 1.25-20 mg, with 8 mg being the most common
dose used
• No increase in infection or delayed wound healing with dexamethasone
Dexamethasone dose
• 14 studies reported incidence of infection: 11 found no infection in either
Comparators
dexamethasone or placebo group, 3 found no increase of infection in patients
receiving dexamethasone
Time of administration
• 9 studies examined incidence of delayed healing: 7 found no delayed healing
Primary outcome measure of
in either dexamethasone or placebo groups, 2 found no increased risk of
study
delayed healing in patients receiving dexamethasone
Outcome measures, including • 3 studies measured perioperative blood glucose levels in nondiabetic
pain scores, analgesic
patients; at 24 h after operation blood glucose in dexamethasone group was
consumption, need for
significantly higher
rescue analgesia, time to
• Limitations: unclear whether hyperglycemia found has clinical implications;
first analgesic request, time
variability in type of surgery, dexamethasone dose and timing; duration of
in PACU, and side effects
most studies limited to 24 h; small sample sizes; many studies did not report
including wound infection,
incidence of adverse events
delayed wound healing,
hyperglycemia, and perineal
pruritus
• Adverse events
• Length of hospital stay
• Time to opioid administration
(min)
• 45 RCTs
•E
xclusion criteria: trials reporting
analgesia after emergency medicine,
dental and nonsurgical pain, studies with
concurrent use of alternative multimodal
analgesia regimen if direct comparison of
dexamethasone and placebo could not be
established
• Cumulative opioid
consumption
• Early (≤ 4 h) and late (24
h) pain scores at rest and
movement
• Type of surgery
Abbreviations: IV, intravenous; PACU, postanesthesia care unit; postop, postoperative; RCT, randomized controlled trial.
Table 1. Summary of Systematic Reviews With Meta-Analysis
Waldron et al,7
2013
• No. of subjects in treatment
groups
• Dexamethasone
dose groups: low-dose: ≤
0.10 mg/kg; intermediate-dose: 0.11-0.20
mg/kg; high-dose: ≥ 0.21 mg/kg
• Follow-up period
• Sample size
• Age: > 18 y
• Inclusion criteria: single-dose
perioperative IV dexamethasone with
control group; studies had to report at
least pain scores or opioid consumption
on postop pain outcomes
• Time of administration
• Dexamethasone dose
Data extraction
• N = 2,751
• 24 RCTs
De Oliveira et al,12
2011
Study design and demographics
Source
284
AANA Journal

August 2015

Vol. 83, No. 4
www.aana.com/aanajournalonline
•E
xclusion criteria: emergent or off-pump procedure,
life expectancy < 6 mo
• Age: ≥ 18 y (mean = 66.2 y)
• N = 4,494
• RCT
•E
xclusion criteria: hx of intolerance/allergy to any
drug in the study, severe impairment of bowel
motility, administration of another antiemetic
or systemic steroid 24 h before surgery, hx of
cardiovascular or respiratory disease, alcohol or
opioid dependence, impairment of renal or hepatic
function
• N = 60
et al,15 2009
•S
urvey of adverse events after discharge showed no patients
requiring readmission due to complications such as wound
infection
•D
examethasone (8 mg, 29
patients) or normal saline (31
patients) at least 90 min before
incision
• Open colonic resection
•T
otal No. of complications were similar in placebo (22) and
dexamethasone (20) groups
• Higher rate of wound infection in placebo (6) vs dexamethasone
(0) group
• Limitations: exclusion criteria of ASA grade ≥ 4 and requirement
of a stoma
• Dexamethasone (8 mg in 2 mL)
or placebo-saline (2 mL) given 60 • Limitations: used a survey response, which could lead to
min before anticipated surgical
response rate bias
incision
• Laparoscopic cholecystectomy
outpatient setting
•W
ound infection: dexamethasone group: 1.5%, placebo group:
1.4%
• Overall risk of developing infection was lower in dexamethasone
group (9.5%) vs placebo group (14.8%) primarily due to
decreased incidence of pneumonia in dexamethasone group
• Limitations: high dose of dexamethasone not routinely used for
PONV prophylaxis
•L
imitations: all participants were female and Korean; sample
size had limited power to detect subtle differences in wound
complications
• Inadequate wound healing: dexamethasone- ramosetron group
1.5% vs ramosetron group 2.2%
• Each group had 1 periprosthetic joint infection (0.7%)
• No differences found in wound complications between groups
Results and conclusions
Abbreviations: CPB, cardiopulmonary bypass; CNS, central nervous system; hx, history; IV, intravenous; PONV, postoperative nausea and vomiting; RCT, randomized controlled trial; TKA,
total knee arthroplasty.
Table 2. Summary of Randomized Controlled Trials
•E
xclusion criteria: ASA grade ≥ 4, requirement
for a stoma, inability to speak English, cognitive
impairment, receiving steroids or other
immunosuppressants
• Age: control group mean = 69 y (range = 34-87 y),
dexamethasone group mean = 71 y (range = 37-92 y)
• RCT
Zargar-Shoshtari,
•E
xclusion criteria: use of steroids or antiemetics
within 1 mo of surgery, chronic pain requiring opioid
treatment, hx of allergy to any study medications,
severe renal or liver disease, pregnancy, poor English
comprehension, or psychiatric/CNS disturbance
•A
ge: control group mean = 49.2 y, dexamethasone
group mean = 51.4 y
• N = 120
• Dexamethasone (49.8%
patients) 1 mg/kg of body
weight (maximum = 100 mg) or
placebo (50.2% of patients) IV
after induction of anesthesia but
before initiation of CPB
• Cardiac surgery
•D
examethasone (10 mg) 1 h
before surgery and ramosetron
(0.3 mg) immediately after
surgery (n = 135) or ramosetron
(0.3 mg) alone (n = 134)
• Age: ≥ 18 y (mean = 72 y)
• TKA
• N = 269
Surgical procedure and
dexamethasone dosages
• RCT
Study design and demographics
Murphy et al,4 2011 • RCT
Dieleman et al,14
2012
Koh et al,13 2013
Source
readmission after surgery because of complications such
as wound infection. This study used a survey of adverse
events after discharge, which may have led to a response
rate bias. An additional randomized controlled trial
studied the use of dexamethasone (8 mg) vs placebo in
60 patients undergoing open colonic resections.15 The researchers found a similar number of total complications
between the dexamethasone and placebo groups, with
a higher rate of wound infection in the placebo group.
Complications included wound infection, urinary tract
infection, ileus, and urinary retention. This randomized
controlled trial was limited by the exclusion criteria.
Patients with a stoma as well as patients with ASA grade
4 and above were excluded.
Five retrospective studies were included in this literature review and are summarized in Table 3. Whereas only
1 study found an association between dexamethasone
administration and wound infection,16 all of the authors
noted the need for a large randomized controlled trial to
study the effects of dexamethasone on wound infection
as a primary endpoint.
In a retrospective chart review of 431 patients undergoing laparotomy, the records of patients who received
dexamethasone (4 to 12 mg) vs no dexamethasone received were examined.6 Dexamethasone did not increase
the rate or severity of wound complications; however,
body mass index and smoking were significant predictors of wound complications. This study examined only
laparotomy, so it has limited generalizability and is also
retrospective in nature. Another retrospective chart
review was conducted of 574 patients who had urogynecologic surgery and received dexamethasone (4 to 8 mg)
vs no dexamethasone received.17 There was no association found between the administration of a single dose
of dexamethasone and perioperative infection. Again,
the use of a single patient group restricts the ability to
generalize across the entire surgical population, and a
lower standard of evidence due to its purely retrospective
nature limits definitive conclusions.
Using a retrospective case-control design, Eberhart
et al18 examined 40 cases and 158 controls of inpatient
gynecologic or obstetric procedures in which patients received dexamethasone (4 to 8 mg) or no dexamethasone.
Each patient identified as having a surgical site infection
was matched to a control patient with comparable surgical intervention and medical history. This study could
not detect any evidence for increased risk of surgical site
infection after a single dose of dexamethasone. As with
previous work, this study was limited to 1 category of
surgical procedure, which restricts generalizability, as
well as having a lower standard of evidence because of its
retrospective nature. Corcoran et al5 used a retrospective
cohort study to examine the safety of dexamethasone.
In a cohort of 439 patients there were 98 cases of documented infection (22.3%). The researchers did not find
www.aana.com/aanajournalonline
any difference with respect to age, weight, body mass
index, tourniquet use, maximum white blood cell count,
or C-reactive protein concentrations between patients
in whom an infection did develop and those in whom it
did not. It was found that patients who experienced an
infection were more likely to be female, have symptomatic reflux or chronic obstructive pulmonary disease, and
to be active smokers. This study was unable to identify
any association between the use of intraoperative dexamethasone and postoperative infections. Limitations of
this study include the retrospective design as well as the
exclusion of more patients than expected, possibly overcorrecting for comorbidities. Because of the diagnostic
criteria of telephone follow-up by the patient’s general
medical practitioner, a component of investigator interpretation was involved.
A 2010 retrospective case-control study identified 63
cases of postoperative infections and 172 controls, then
looked for differences between those who received dexamethasone (4 to 8 mg) and those who did not.16 It was
found that intraoperative administration of dexamethasone might confer an increased risk of postoperative infection. This study is limited by its retrospective design as
well as the exclusion criteria. Exclusion criteria included
postoperative infections involving cardiac surgery, organ
transplantation, and postinfusion infection.
Discussion
Glucocorticoids are known to affect all of the major
steps in the wound healing process. These phases have a
substantial amount of overlap, and one phase can influence the cell growth and differentiation in other phases.
Although long-term use of systemic glucocorticoids is
known to inhibit wound repair, evidence for clinical
decision making regarding single-dose dexamethasone
should ultimately be derived from systematic research.
To date, there is a lack of convincing evidence that a
single dose of a glucocorticoid such as dexamethasone
has this negative effect.4-7,12-15,17,18 Although not specific
to infection related to single-dose dexamethasone for
PONV, several intervention reviews did not find any
adverse effects of single-dose dexamethasone administration.19-21 The first is a general guide for drugs used
to prevent PONV, which found that 8 drugs, including
dexamethasone, reduce PONV by a similar amount.19
The second review article was specific to the use of
antiemetics to treat and prevent chemotherapy-induced
nausea and vomiting in children.20 It was noted that no
clinical studies have found an association between corticosteroids as an antiemetic and worsened outcomes.20
The third review looked at the impact of corticosteroids
on improving recovery in children following tonsillectomy and noted that a single dose of corticosteroid is
considered to be without harmful effects.21
In addition to the theoretical direct effect on wound
AANA Journal

August 2015

Vol. 83, No. 4
285
286
AANA Journal

August 2015

Vol. 83, No. 4
www.aana.com/aanajournalonline
Corcoran et al,5
2010
Eberhart et al,18
2011
Gali et al,17 2012
Bolac et al,6 2013
Source
•D
examethasone (4-12 mg, n
= 192) vs no dexamethasone
received (n = 239)
• N = 431
•D
examethasone (4-8 mg, n
= 108) vs no dexamethasone
received (n = 331)
• Exclusion criteria: surgery performed outside 7
am to 6 pm on weekdays, solid organ transplant,
cardiothoracic surgery, procedures for malignancy,
conditions at high risk of infectious complications,
receiving antibiotics for another infective process,
chronic renal failure, autoimmune disease, receiving
glucocorticoids or disease-modifying agents
• Inclusion criteria: All adult patients undergoing
nonemergency surgery under general anesthesia
• Age: mean = 46.1 y
• All adult surgical specialties
• N = 439
•E
ach patient identified as having
an SSI (n = 40) was matched
to controls with comparable
surgical intervention and medical
hx (n = 158)
•L
imitations: Retrospective nature, exclusion of more patients
than anticipated
•2
2.2% of dexamethasone group had postoperative infections vs
22.3% of nondexamethasone group
•U
nable to identify any association between use of intraoperative
dexamethasone and postoperative infections
•L
imitations: Retrospective nature and limitation to 1 category of
surgical procedure
•T
his case-control study could not detect any evidence of
increased risk of SSI after a single-dose of dexamethasone
•D
examethasone (4-8 mg, n =
1,259) vs no dexamethasone
received (n = 2,190)
•L
imitations: Retrospective nature and limitation to 1 type of
surgical procedure
•4
5% of cases with SSI (n = 40) received dexamethasone vs
49% of controls without SSI (n = 158)
• Retrospective cohort study
• Exclusion criteria: not specified
• Inclusion criteria: inpatients undergoing surgery from
2004 to 2005 with duration of at least 30 min
•M
ean age: cases (n = 40), 52.4 y; controls (n = 158),
53.9 y
• N = 3,449
• Retrospective case-control study
• Exclusion criteria: not specified
• Inclusion criteria: Patients who underwent
urogynecologic surgery from 2004 to 2006
•3
.6% of dexamethasone group had wound infections vs 3% of
nondexamethasone group
•N
o association between single-dose dexamethasone and
perioperative infection
•L
imitations: Retrospective nature and limitation to 1 type of
surgical procedure
•B
MI and smoking were significant predictors of wound
complications
•2
7.6% of dexamethasone group had wound complications vs
33.9% of nondexamethasone group
•D
examethasone does not increase rate or severity of wound
complications.
Results and conclusions
• Inpatient gynecologic or OB
procedures
• Dexamethasone (4-8 mg, n
= 112) vs no dexamethasone
received (n = 462)
• N = 574
• Age: mean ± SD = 60.6 ± 13.0 y
• Urogynecologic surgery
• Retrospective chart review
• Exclusion criteria: Not specified
• Inclusion criteria: Women who underwent
laparotomy for treatment of endometrial cancer from
2002 to 2007 were identified from the university’s
tumor registry
• Age: mean = 60.7 y (range = 18-88 y)
• Laparotomy
Surgical procedure and
dexamethasone dosages
• Retrospective chart review
Study design and demographics
Table 3. Summary of Retrospective Studies
•E
xclusion criteria: postoperative infections involving
cardiac surgery, organ transplant or postinfusion
infections, and initial procedure performed outside
Royal Perth Hospital
• Inclusion criteria: all postoperative infections
•M
ean age: cases (n = 63), 61.5 y; controls (n = 172),
61.6 y
Abbreviations: BMI , body mass index; hx, history; OB, obstetrics; SSI, surgical site infection.
•L
imitations: Retrospective nature, exclusion criteria of specific
infection types
• Intraoperative administration of dexamethasone may confer an
increased risk of postoperative infection. Adjusted odds ratio of
dexamethasone association with postoperative infection = 3.03
(95% CI)16
• Dexamethasone (4-8 mg, cases
n = 19, controls n = 16) vs no
dexamethasone received (cases
n = 44, controls n = 156)
• N = 235 (63 cases, 172 controls)
• Retrospective case-control study
Percival et al,16
2010
www.aana.com/aanajournalonline
healing, another consideration with dexamethasone is its
indirect effect related to hyperglycemia. Hyperglycemia
can slow wound healing for a variety of reasons, such as
impaired neutrophil chemotaxis, as well as by metabolic
alterations that can result in release of inflammatory
mediators. However, although these issues are known to
be of importance in the diabetic patient with chronically
elevated blood glucose, the physiologic effects of temporary hyperglycemia are less certain. It is widely accepted
that dexamethasone increases blood glucose concentrations, especially in diabetic patients, but unfortunately,
the extent of any increase has not been extensively
studied. A recent study looked at administration of 10 mg
of dexamethasone to nondiabetic (n = 32) and diabetic (n
= 31) patients undergoing routine surgery.22 As would
be expected, maximum blood glucose concentrations
remained significantly higher in the group with type 2
diabetes (9.0 mmol/L) than in the nondiabetic group
(7.9 mmol/L). Interestingly, the researchers did not find
any difference in the maximum blood glucose concentration when expressed as a percentage above baseline.
Maximum blood glucose concentration was 19% above
baseline for both the diabetic and nondiabetic groups.
Obesity and poor control of diabetes (as evidenced by
hemoglobin A1c) appeared to be the determining factors
of an exaggerated hyperglycemic response seen after
dexamethasone administration.22 It is important to note
that this study focused on the blood glucose profiles of
study participants and not on specific adverse outcomes.
To date, there have not been any studies showing that a
transient increase in blood glucose concentrations resulting from a single dose of dexamethasone leads to adverse
outcomes in either a diabetic or nondiabetic population;
however, the exclusion of diabetics from multiple studies
has resulted in a limited body of knowledge from which
to draw practice guidelines.7,12 Future research could
address this deficit.
Conclusion
Nearly all of the literature cited shows no relationship
between single-dose dexamethasone administration and
infection complications. However, prudent clinicians
should always use their best clinical judgment when
making decisions for their patients.
As noted in many of the articles included in this
literature review, a large-scale multicenter randomized
controlled trial is still needed to study the effects of a
single intraoperative dose of dexamethasone on surgical site healing and infection. A large-scale trial would
have the scope necessary to include patients at higher
risk of developing postoperative infections, such as
diabetics. These patients are often excluded from
smaller-scale studies, which results in a knowledge gap
in the literature.
AANA Journal

August 2015

Vol. 83, No. 4
287
REFERENCES
1. Hamilton E, Ravikumar R, Bartlett D, et al. Dexamethasone reduces
emesis after major gastrointestinal surgery (DREAMS). Trials.
2013;14(249):2-8.
2. Collins AS. Clinical utility of antiemetics and complementary therapies in the prevention of postoperative nausea and vomiting. Clin
Audit. 2013;5:67-76.
3. Becker DE. Basic and clinical pharmacology of glucocorticosteroids.
Anesth Prog. 2013;60(1):25-32.
4. Murphy GS, Szokol JW, Greenberg SB, et al. Preoperative dexamethasone enhances quality of recovery after laparoscopic cholecystectomy:
effect on in-hospital and postdischarge recovery outcomes. Anesthesiology. 2011;114(4):882-890.
5. Corcoran TB, Truyens EB, Ng A, Moseley N, Doyle AC, Margetts L.
Anti-emetic dexamethasone and postoperative infection risk: a retrospective cohort study. Anaesth Intensive Care. 2010;38(4):654-660.
6.Bolac CS, Wallace AH, Broadwater G, Havrilesky LJ, Habib AS.
The impact of postoperative nausea and vomiting prophylaxis
with dexamethasone on postoperative wound complications in
patients undergoing laparotomy for endometrial cancer. Anesth Analg.
2013;116(5):1041-1047.
7. Waldron NH, Jones CA, Gan TJ, Allen TK, Habib AS. Impact of perioperative dexamethasone on postoperative analgesia and side-effects:
systematic review and meta-analysis. Br J Anaesth. 2013;110(2):191-200.
8. Akca O, Kurz A, Fleischmann E, et al. Hypercapnia and surgical site
infection: a randomized trial. Br J Anaesth. 2013;111(5):759-767.
9. Bartlett R, Hartle AJ. Routine use of dexamethasone for postoperative
nausea and vomiting: the case against. Anaesthesia. 2013;68(9):892-896.
10. Kakodkar PS. Routine use of dexamethasone for postoperative nausea
and vomiting: the case for. Anaesthesia. 2013;68(9):889-891.
11. Melnyk BM, Fineout-Overholt E. Evidence-Based Practice in Nursing
and Healthcare: A Guide to Best Practice. 2nd ed. Philadelphia, PA:
Wolters Kluwer; 2010.
12.De Oliveira GS Jr, Almeida MD, Benzon HT, McCarthy RJ. Perioperative single dose systemic dexamethasone for postoperative
pain: a meta-analysis of randomized controlled trials. Anesthesiology.
2011;115(3):575-588.
13.Koh IJ, Chang CB, Lee JH, Jeon YT, Kim TK. Preemptive lowdose dexamethasone reduces postoperative emesis and pain
after TKA: a randomized controlled study. Clin Orthop Relat Res.
2013;471(9):3010-3020.
14. Dieleman JM, Nierich AP, Rosseel PM, et al. Intraoperative high-dose
dexamethasone for cardiac surgery: a randomized controlled trial.
JAMA. 2012;308(17):1761-1767.
15. Zargar-Shoshtari K, Sammour T, Kahokehr A, Connolly AB, Hill AG.
288
AANA Journal

August 2015

Vol. 83, No. 4
Randomized clinical trial of the effect of glucocorticoids on peritoneal
inflammation and postoperative recovery after colectomy. Br J Surg.
2009;96(11):1253-1261.
16. Percival VG, Riddell J, Corcoran TB. Single dose dexamethasone for
postoperative nausea and vomiting—a matched case-control study of
postoperative infection risk. Anaesth Intensive Care. 2010;38(4):661-666.
17. Gali B, Burkle CM, Klingele CJ, Schroeder D, Jankowski CJ. Infection after urogynecologic surgery with the use of dexamethasone for
nausea prophylaxis. J Clin Anesth. 2012;24(7):549-554.
18. Eberhart LH, Holdorf S, Albert US, et al. Impact of a single perioperative dose of dexamethasone on the incidence of surgical site infections:
a case-control study. J Obstet Gynaecol Res. 2011;37(12):1807-1812.
19. Carlisle JB, Stevenson CA. Drugs for preventing postoperative nausea
and vomiting. Cochrane Database Syst Rev. 2006;(3):CD004125.
20. Phillips RS, et al. Antiemetic medication for prevention and treatment of chemotherapy induced nausea and vomiting in childhood.
Cochrane Database Syst Rev. 2010;(9):CD007786.
21. Steward DL, Grisel J, Meinzen-Derr J. Steroids for improving recovery following tonsillectomy in children. Cochrane Database Syst Rev.
2011;(8):CD003997.
22.Hans P, Vanthuyne A, Dewandre PY, Brichant JF, Bonhomme V.
Blood glucose concentration profile after 10 mg dexamethasone in
non-diabetic and type 2 diabetic patients undergoing abdominal surgery. Br J Anaesth. 2006;97(2):164-170.
AUTHORS
Jenna Assante, CRNA, MS, is nurse anesthetist at Westlake Anesthesia
Group, Austin, Texas.
Shawn Collins, CRNA, DNP, PhD, is the director of the Nurse Anesthesia Program at Western Carolina University, Asheville, North Carolina.
Ian Hewer, CRNA, MSN, MA, is the assistant director in the Nurse
Anesthesia Program at Western Carolina University, Asheville, North
Carolina.
DISCLOSURES
The authors have declared they have no financial relationships with any
commercial interest related to the content of this activity. The authors did
not discuss off-label use within the article.
ACKNOWLEDGMENT
Thank you to Ann Hallyburton, MSLS, MPH, research and instruction services librarian, liaison to the Health Professions, Hunter Library, Western
Carolina University, Asheville, North Carolina.
www.aana.com/aanajournalonline