(05011 he American Laryngoogiea hinelopiest and Otel Society, Toe Ania Best Practice Is Dexamethasone Effective in Preventing Nausea and Vomiting After Common Otolaryngology Procedures? Risa L. Wolk, MD; Anil K. Lalwani, MD; Parwane P. Pagano, MD BACKGROUND Postoperative nausea and vomiting (PONV) is an undesirable yot common complication that may delay patient discharge; necessitate unplanned hospital admis sion; and/or compromise the surgical outcome, in some eases via secondary effects such as hematoma and wouund dehiscence. The incidence is estimated to be about 30% or more in higher risk procedures such as otolaryngologie operations. The sensation of nausea and vomiting can be extremely distressing for patients, and some may consider it worse than postoperative pain, Postanesthetic discharge criteria, such as the commonly used postanesthesia discharge scoring system, typically require that patients have minimal PONV to qualify for hhome discharge. As such, it is advisable to administer antiemetic medications prophylactically. This article reviews the evidence supporting administration of intra- venous dexamethasone for prophylaxis of PONV in oto- laryngology procedures. ‘Dexamethasone is a synthetic steroid with primarily slucocorticoid activity that is widely and inexpensively available for perioperative use. Although the pharmaco- logical mechanisms by which dexamethasone works to prevent PONV aro not completely understood, it may function through a variety of mechanisms, including interaction with known emetogenic trigger sites such as, the chemoreceptor trigger zone, alpha-adrenergic recep- tors, and the solitary tract nucleus; antiinflammatory effects; inhibition of serotonin expression; normalization of the hypothalamic-pituitary-adrenal axis; and even From the Department of Anesthesiology (ai, rae); and the Department of Otaaryagology-Head and Neck "Surgery (ae Colubin Univeraty College ef Physicians and Surgeons, New York New Yor, USA, Tutitation where weck was performed: Columbia, University C lege of Bilan aa Surgeons, New York, New York, USA thos have ne funding” Graal Felatvonahipe, or confcte cf interen fo dao, ‘end sormapemdene Ye Parwane P. Pagans, Departznnt of Anes thesiloy, Celumbia University Calee of Phpncans and Surgeons, 622 Wert 166th St, PHS, New York. New York, USA Bra pppolosecume DOE 1010020926548, Laryngoscope 127: July 2017 docreasing the sensation of pain resulting in a lower need, for opivids* Dexamethasone may prevent emesis by one or ‘8 combination of these mechanisms. In addition to decreas ing PONV and modifying postoperative pain levels, dexa- ‘methasone reduces airway edema, which can be especially beneficial in otolaryngology procedures. Although this ‘medication generally is well tolerated, hyperglycemia ean, ‘ceur in labile diabetic patients, LITERATURE REVIEW Several studies have evaluated the role of dexa- ‘methasone in patients undergoing common otolaryngolo- gy procedures (Table 1). Without prophylaxis, a majority of pediatric patients undergoing tonsillectomy will expe- rience postoperative vomiting (POV), causing patient distress, parental concern, dehydration, prolongation of postanesthesia care unit (PACU) stay, and possible ‘unplanned hospital admission. Bolton et al? performed ‘2 meta-analysis of nine randomized, double-blind place- bo-controlled studies evaluating intravenous dexametha- sone for prevention of postoperative vomiting in pediatric patients undergoing tonsillectomy with or without adenoi- ectomy, The dose of dexamethasone evaluated in these studies ranged from 0.15 mglkg to 1 mg/kg. The authors reported that vomiting was much less likely in pediatric patients who reesived dexamethasone (relative risk 0.48), ‘Adults presenting for tonsillectomy benefit similarly from the administration of dexamethasone. Diskos et al.” conducted a meta-analysis, which included three random- ied, controlled double-blinded trials with a total of 231 adults (patients >16 years of age) undergoing elective ton~ sillectomy. Patients received either 10 mg dexamethasone intraoperatively, 8 mg dexamethasone intraoperatively fol- lowed by dexamethasone 2 mg twice a day postoperatively, or a 24-hour course of dexamethasone 6 mg every 8 hours Intraoperative dosing of dexamethasone correlated with a significant decrease in PONV in the first 24 hours after, surgery (relative risk 0.52). ‘To examine the relative efficacy of specific medica- tions in emesis prophylaxis, Gunter et al“ enrolled 240 pediatric patients having adenotonsillectomy in a factorial study of ondansetron, dexamethasone, and metoclopramide. The study included patients 3 to 10 years old who received dexamethasone at one of five Wolk et al: Dexamethasone for Nausea/Vomiting Prevention 1493TABLET Ettectveness of Dexamethasone for PONY Prophylaxis in Otolaryngology Procedures. ‘Sugieal Procedure we 55 rae Ecciam — Chartnin “SBR ‘double-blind ienerermnely ‘antiemetics Decreased incidence N= 80 (no POV or need for 4 FOV eplesdios vet oi Meta-analysis of ® RCT ‘dose range 0.15~1.0 0.40-0.57) oe he Metaanaiis of RCT rere PON eatated for eros Naa amg To days eee mg dexamett 2weeks: ry Sei Fst come SETS fence somoraton nth ous 680 amas) N61 mg) In combination O.18-0.41) I ~ 86% cowideneeaewal N ~ iavenous: OR ratte nic ROT = randornzed cntolea Wa PACU. doses (0, 125, 250, 375 or 500 megikg), along with ondan- ssetron (0, 15, 30, 45, or 60 megikg) and metoclopramide (0, 100, 200, 800, or 400 meg/kg), in a total of 15 drug. combinations. The investigators recorded postoperative ‘emesis taking place in the PACU before discharge, emesis, after discharge, and any episodes of emesis in the first 24 hhours after surgery. Dexamethasone had a significant beneficial effect in reducing postdischarge emesis (odds rratio (OR] 0.87 per 125 meg dose), as well as decreasing overall episodes of emesis in the first 24 hours after sur- ery (OR 0.74), The investigators also demonstrated a vir- tually linear decrease in the probability of emesis, with tan increase in the dose of dexamethasone. Only 10 study participants reported minor aide effects that may have been related to the antiemetics administered. In addition to those requiring tonsillectomies, the eff- cacy of dexamethasone administration has been studied in patients presenting for other otolaryngologic operations. Li Laryngoscope 127: July 2017 1494 ‘6 ati; PONY postaestres.a care nt osoperaive nausea ard versing, POV = postoperative vomiting, AR and Wang® performed a meta-analysis of even randomized, placebo-controlled studies involving 611 patients to investi- gate whether dexamethasone reduced the incidence and severity of postoperative nausea and vomiting after thy- roidectomy. In addition to patient distress, uncontrolled postoperative emesis after thyroidectomy may be a risk factor for hematoma formation. The seven studies included, in the meta-analysis evaluated a total of 10 dose levels of intravenous dexamethasone (5-10 mg) compared to place- bo. In each study, general anesthesia was maintained with, inhalation agents, and patients also received one other antiemetic or antacid medication (ondansetron, droperidol, ranitidine, or metoclopramide). The analysis revealed strong evidence that dexamethasone decreases the inci- dence of postoperative nausea and vomiting (OR 0.23). With the exclusion of one trial of moderate methodological, quality, the reeults were similar. Among the thyroidectomy studies included in the meta-analysis, four trials included Wolk et al: Dexamethasone for Nausea/Vomiting Preventiondata on the severity of PONV with administration of six dose levels of dexamethasone. A significant decrease in the level of severity of PONV was found in patients receiving dexamethasone. Liu et al! performed a randomized double-blinded placebo-controlled study examining the effect of prophy- lactic dexamethasone on the incidence of PONV in adult, patients undergoing tympanomastoidectomy. They stud- ied 80 patients age 31 to 44 years old undergoing gener- al endotracheal anesthesia. Forty participants received 10-mg intravenous dexamethasone following intubation, whereas the remaining 40 patients received the equiva lent volume of saline intravenously. Patients were observed for 24 hours after surgery. Outcome measures included PONV; number of episodes of POV (04 and > 4); requirement for rescue antiemetic medication; and achievement of a complete response, which was defined tas having no PONV or antiemetic medication require- ment for 24 hours postoperatively. The primary efficacy ‘endpoint was the incidence of a complete response, Their data revealed that 65% of patients undergoing tympano- mastoid surgery experience PONV; with dexamethasone prophylaxis, the incidence decreased to 20%. Dexameth- gone administration was found to significantly decrease the number of patients who experienced more than four episodes of POY, decrease the requirement for rescue ‘antiemetics, and increase the number of complete responders (number needed to treat was 2.2). This data suggests that dexamethasone is a simple and effective Laryngoscope 127: July 2017 way to prevent PONV associated with tympanomastoid surgery BEST PRACTICE ‘The literature supports dexamethasone as an effective agent for prevention of postoperative nausea and vomiting in frequently performed adult and pediat- rie otolaryngology procedures. LEVEL OF EVIDENCE ‘The studies reviewed indicate treatment benefit ased on meta-analyses of randomized controlled trials and randomized double-blind placebo controlled studies, levels 14 and 1B evidence, BIBLIOGRAPHY 6. UB Wang H, Denman rede Wolk et al: Dexamethasone for Nausea/Vomiting Prevention 1495