Does dexamethasone actually prevent post-op nausea and vomiting (PONV)?

“I’m sick and tired of being sick and tired” – Fannie Lou Hamer

Dexamethasone versus standard treatment for postoperative nausea and vomiting in gastrointestinal surgery: randomised control trial (DREAMS Trial)  BMJ 2017;357:j1455 doi: https://doi.org/10.1136/bmj.j1455

Background

  • Postoperative nausea and vomiting (PONV) affects more than 30% of patients
  • Gastrointestinal surgery is not traditionally considered high risk for PONV
  • A survey in West Midlands showed that anaesthetists give dexamethasone as an antiemetic to only 25% of colorectal patients
  • Concerns about using dexamethasone in colorectal surgery include complications such as wound infection and anastamotic leak

Methods

  • DREAMS trial: pragmatic blinded randomised control trial carried with 1350 participants carried out at 45 sites
  • Control arm: Standard care – all patients had a general anaesthetic, then received a routine antiemetic (other than dexamethasone) as determined by the anaesthetist
  • Treatment arm: In patients randomised to receive dexamethasone, the anaesthetist then gave dexamethasone 8mg IV before the start of surgery
  • No further anti-emetics were given during the operation
  • The primary outcome measure was vomiting within 24 hours, as reported by either the patient or a clinician.
  • Secondary outcomes measures were; the number of episodes of vomiting postoperatively, use of postoperative anti-emetics, severity of PONV, fatigue and time to toleration of oral diet.

Results

  • Vomiting within 24 hours: 172 (25.5%) participants in the dexamethasone arm and 223 (33%) in the standard care arm (P = 0.003). Number needed to treat (NNT) = 13
  • PONV at 25-72 hours: difference between the two arms was not significant
  • PONV at 73-120 hours: no difference between the two groups
  • Additional postoperative antiemetics: required for 265 (39.3%) participants in the dexamethasone arm and 351 (51.9%) participants in the standard care arm(P <0.001). NNT = 8
  • No increase in complications in patients receiving dexamethasone

Conclusions

  • In patients undergoing small and large bowel surgery, the addition of a single dose of 8 mg intravenous dexamethasone at induction of anaesthesia significantly reduces the incidence of PONV at 24 hours and the need for rescue antiemetics for up to 72 hours
  • There is no increase in adverse events in the dexamethasone group

Summary by Dr Emily Spence

 

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