January 2001

The use of Dexamethasone for preventing Postoperative Nausea and Vomiting in Females Undergoing Thyrodiectomy: A Dose Ranging Study
Wang JJ, Ho ST, Lee SC, Liu YC, Ho CM.
Anesth Analg 2000 Dec;91(6):1404-7

Commentary by David Lubarsky, M.D.

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[see abstract below]

When was the last time you thought about giving steroids for PONV prophylaxis? Was there a first time? Many of us are familiar with the raging debate of low dose droperidol versus ondansetron. Some still espouse the occasional use of phenergan and other sleep inducing anti-emetics, but very few of us routinely consider dexamethasone. However, it is quite efficacious and has a limited side effect profile as a single dose.

Wang et al. (from Taipei, Taiwan) bring us a well conducted study to address a global problem — how best to administer drugs to prevent PONV. The authors administered dexamethasone to five groups chosen from a homogeneous patient population (225 women undergoing thyroidectomy). They studied four doses - 10, 5, 2.5, and 1.25 mg - and a fifth group received saline in a double blind randomized placebo controlled trial. (i.e. a good and valid study design). There were several appropriate exclusion criteria applied in order to isolate the effect of varying the dose of dexamethasone. The primary clinical endpoint was "complete response," defined as no vomiting and no anti-emetic drugs needed in the first 24 hours postop. Other endpoints included the total incidence of PONV, incidence of >4 episodes of vomiting, percentage of patients who required rescue anti-emetics (i.e. a dose of ondansetron). Concerns about serious side effects were addressed by following delayed wound healing and wound infection. This is a key issue in the use of steroids. In my opinion (which has minimal scientific backing), I would not expect significant problems of this sort to manifest with a single dose. No patients reported problems with wound healing. However, I would want to test this hypothesis on patients having intestinal surgery via an abdominal approach as those patients are at higher risk, and a difference might be detectable. This study was underpowered as regards detecting outcome differences due to wound complications.

Patients received a standard anesthetic — propofol, fentanyl, isoflurane, and vecuronium. Dexamethasone was administered shortly after induction.

The results — PONV was reduced from about 50% in the control group to 20% for the groups receiving 5 and 10 mg dexamethasone. This is as good an effect as one expects from the best anti-emetics we currently employ.

The bottom line — literally. Give 5 mg of dexamethasone. Less is progressively less efficacious, more does not improve outcome. Oh — and its cost???? VERY VERY VERY cheap. At Duke, our generic version costs 51 CENTS for 20 mg/5ml, or 13 cents per dose. A bargain if I ever saw one!

Your last question might be — well, where does this fit into my practice exactly? What happens if I combine zofran and dexamethasone and droperidol? Hmmmmm. An excellent question. Stay tuned for my next review — Multimodal Antiemetic Management, by Scuderi et al.!!!!