Adjuvant IV or epidural dexamethasone in lower limb surgeries among pediatric patients

Study Type: Therapy
OE Level of Evidence: 2
Journal Level of Evidence: N/A
90 pediatric patients undergoing lower-extremity orthopaedic surgery with caudal epidural nerve blocks were randomized to one of three groups: (1) adjuvant intravenous dexamethasone, (2) adjuvant caudal epidural dexamethasone, and (3) placebo (saline). The purpose of this trial was to determine the effect of dexamethasone on postoperative analgesia and vomiting. The results of Please login to view the rest of this report. Please login to view the rest of this report.
Funding: Non-funded
Conflicts: None disclosed
Why was this study needed now?
Analgesia in pediatric patients can be particularly difficult. The use of regional anaesthesia for lower extremity procedures, such as with a single-shot caudal epidural block, is currently quite popular, though drawbacks have been noted with inadequate pain control once the block wears off. Adjuvant dexamethasone has emerged as a possible method to improve and prolong analgesia, though efficacy has not been thoroughly examined in high-quality studies. Additionally, the route of administration of dexamethasone in these cases has been a key topic of debate.
What was the principal research question?
In pediatric patients undergoing lower-extremity orthopaedic surgery, did the administration of intravenous or caudal epidural dexamethasone result in significantly reduced postoperative pain, use of rescue analgesics, postoperative vomiting, and side effects when compared to placebo up to 24 hours post-surgery?
Population: 90 patients aged between 2-12 years undergoing lower-extremity orthopedic procedures. All patients received anaesthesia with sevoflurane and fentanyl 2 mcg/kg.
Intervention: IV group: Patients received intravenous (IV) dexamethasone (0.5 mL/kg, maximum dose 10 mg) mixed in 5 mL saline in addition to caudal epidural block with 0.5mL/kg bupivacaine 0.25% (n=30; mean age= 70.2+/-46.8 months, 13F/17M). Caudal group: Patients received dexamethasone (0.1 mg/kg) in conjunction with caudal epidural block with 0.5mL/kg bupivacaine 0.25%; 5mL intravenous saline was administered to maintain blinding (n=30; mean age= 74.1+/-40.7 months, 15F/15M).
Comparison: Control group: Patients received caudal epidural block with 0.5mL/kg bupivacaine 0.25%, and 5mL intravenous saline (n=30; mean age= 73.8+/-44.2, 14F/16M).
Outcomes: The primary outcome was the postoperative pain on the Paediatric Objective Pain Scale (where a total score less than 5 indicates adequate analgesia). Secondary outcomes included duration of analgesia (time between extubation and requirement of additional analgesia), number of patients who received IV paracetamol as a rescue analgesic, total amount of paracetamol doses (15 mg/kg per dose), blood glucose level at induction of anaesthesia, incidence of postoperative vomiting/emesis, beta-endorphin levels after extubation, and adverse effects.
Methods: RCT: prospective, double-blinded
Time: Outcomes were assessed during a 24-hour postoperative period.
What were the important findings?
What should I remember most?
How will this affect the care of my patients?
The authors responsible for this critical appraisal and ACE Report indicate no potential conflicts of interest relating to the content in the original publication.