Preoperative Dexamethasone Reduces Nausea, Pain After Mastectomy

Norra MacReady

December 29, 2010

December 29, 2010 — Preoperative dexamethasone infusion has been associated with lower rates of pain, nausea, and vomiting in a prospective, double-blind, placebo-controlled study of women undergoing mastectomy and axillary lymph node dissection for breast cancer.

Postoperative nausea and vomiting (PONV) occur in 60% to 80% of women who undergo this procedure without an antiemetic, lead author Jorge Gómez-Hernández, MD, from the Oncologic Institute of Jalisco in Guadalajara, Mexico, and colleagues write in an article published online December 23 in BMC Cancer.

Adverse outcomes associated with PONV include aspiration of gastric contents, wound dehiscence, psychological distress, and delayed recovery and discharge times. Many of the currently used antiemetic medications have occasional serious adverse effects, such as excessive sedation, hypotension, dysphoria, and even hallucinations and extrapyramidal signs. Antiserotonins such as ondansetron have a more benign adverse effect profile but are expensive. Noting the antiemetic and analgesic effect of dexamethasone on patients undergoing cancer surgery observed by other investigators, Dr. Gómez-Hernández and colleagues decided to evaluate its effects in women undergoing breast cancer surgery.

The patients were randomly assigned to receive 8 mg of intravenous dexamethasone or a placebo 60 minutes before skin incision. Women older than 80 years or who had a history of motion sickness or PONV after any previous surgery were excluded. All of the patients underwent standardized general anesthesia with 2% to 3% sevoflurane and 66% nitrous oxidel they received no preanesthetic medication other than the dexamethasone or placebo. Patients were followed up from the time of hospital admission until 30 days after surgery. There were 35 patients in each group.

Pain was assessed immediately on entering the recovery room and at 6, 12, and 24 hours after the operation. The women rated their pain using a visual analogue scale (VAS), which went from 0 (no pain) to 10 (the most severe pain). They received sodium ketorolac as an analgesic, with intravenous tramadol as a back-up when necessary. Similarly, PONV was reported immediately and then at 6, 12, and 24 hours after surgery, using a 4-point scale (0 = none, 1 = nausea, 2 = retching, 3 = vomiting). Intravenous ondansetron was administered on demand.

Patients given dexamethasone preoperatively had a lower incidence of PONV at the immediate postoperative evaluation (28.6% vs 60% in the control group; P = .02) and 6 hours later (17.2% vs 45.8%; P = .03). There were no significant differences in PONV between the groups thereafter, although 8 patients in the dexamethasone group and 21 in the placebo group required antiemetic medication (P = .01).

Dexamethasone also was associated with significantly lower pain scores on the VAS immediately after surgery and at 6 and 12 hours, as shown in the table. All in all, 21 control patients and 10 study patients required analgesics (P = .008).

Median VAS for Pain

  Dexamethasone Group Placebo Group P Value
Immediately after surgery 4.54 5.83 .004
6 hours postoperation 3.03 4.17 .0005
12 hours postoperation 2.09 2.54 .04
24 hours postoperation 1.23 1.43 .09

There were no adverse events, morbidity, or mortality.

These findings suggest that "preoperative dexamethasone at 8 mg ameliorates nausea, vomiting, pain, and reduces the antiemetic and analgesic requirements of women after breast surgery for cancer without apparent side effects," the investigators conclude. "It appears to be a valuable treatment for preventing such adverse postoperative symptoms."

The authors have disclosed no relevant financial relationships.

BMC Cancer. Published online December 23, 2010.

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