Intravenous Dexamethasone as an Analgesic:

A Literature Review

Sean G. Moore, MSN, CRNA

The management of pain in surgical patients has acknowledged. A review of literature was conducted.
shifted in recent years from a technique grounded Multiple studies were found that demonstrated
in opioid administration, to a multimodal method dexamethasone’s ability to lower postoperative pain
that uses the analgesic properties of many drugs to scores and reduce the amount of opioids required to
minimize required narcotics. Multimodal analgesia has achieve adequate pain scores. Single doses of dexa-
demonstrated a benefit in patient outcomes following methasone have demonstrated safety with minimal
a surgical procedure. Also of consideration is the fact side effects that would be expected from corticosteroid
that multimodal analgesia allows for less opioid to be administration. Although an elevation in blood glu-
administered to achieve acceptable pain scores, in turn cose levels is seen, this is likely of little clinical signifi-
reducing a patient’s exposure to a potentially addicting cance. No difference is seen in wound healing or rates
substance. Dexamethasone is a corticosteroid that has of wound infection compared with control groups.
been widely used in the perioperative setting to pre-
vent postoperative nausea and vomiting. The analgesic Keywords: Analgesic adjunct, dexamethasone, multi-
properties of dexamethasone have not been as widely modal analgesia.

T
he management of acute surgical pain has its postoperative antinausea and antivomiting effects
shifted in recent years from a primarily nar- by reducing surgery-induced inflammation because of
cotic-based technique to a system using drugs its inhibition of prostaglandin synthesis.4 The analgesic
from multiple classifications known as multi- effects of dexamethasone come from inhibition of phos-
modal analgesia. This technique, also known pholipase that is necessary for the inflammatory chain
as balanced analgesia, strives to reduce the number of reaction along both the cyclooxygenase and lipoxygen-
opioids required to reduce side effects as well as obtaining ase pathways. The purpose of this review is to highlight
additional analgesic benefits. Pain is a prevalent reason recent studies that have established dexamethasone as
for delayed recovery and discharge following ambulatory a viable option for multimodal analgesia and to provide
surgery and a common cause for unanticipated hospital guidelines for dosing to achieve optimal effects of this
admissions after what would otherwise be outpatient medication.
procedures.1 Multimodal analgesia has demonstrated
the ability to allow earlier oral intake, ambulation, and Methods
discharge in postoperative patients as well as quicker An electronic search was performed using PubMed,
participation in rehabilitation activities such as physical MEDLINE, Cumulative Index to Nursing & Allied
therapy.2 A reduction in the morbidity and mortality of Health Literature, and Google Scholar. The search terms
surgical patients has also been demonstrated in patients used were intravenous dexamethasone, analgesia, and post-
who receive a balanced analgesic plan.2 operative pain. The search terms were limited to title and
Although the use of ketamine, gabapentin, acetamino- abstract only. The search was also limited to articles that
phen, and nonsteroidal anti-inflammatory drugs has have been published in the last 10 years.
been well established in pain management,3 the role and This search yielded 67 articles, 7 of which were deemed
dosing of dexamethasone as an analgesic is relatively appropriate for this review. Articles included examined the
new. Dexamethasone is a synthetic corticosteroid, a effects of intravenous (IV) dexamethasone on postopera-
fluorinated derivative of prednisolone, and an isomer tive pain scores and analgesic requirements. Articles that
of bethamasone.4 Historically, dexamethasone has been investigated the effects of dexamethasone in combina-
used to treat a number of conditions, and its effective- tion with other nonnarcotic analgesics such as ketamine,
ness has been well established in treating cerebral edema nonsteroidal anti-inflammatory drugs, and gabapentin
and the resultant increases in intracranial pressure due were excluded from this review. Articles that studied the
to tumors and metastatic lesions.4 Also well established effect of IV or perineural dexamethasone on extending the
is dexamethasone’s role as an antiemetic during the peri- effects of regional anesthesia were also excluded, as the
operative period.4,5 Dexamethasone is believed to exhibit purpose of this review was to highlight dexamethasone’s

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analgesic properties, not its ability to extend the effects of treatment group. The treatment group received a single
other anesthetic and analgesic agents. Of the 7 articles that 40-mg dose of dexamethasone before surgery, and after
were deemed appropriate for this review, 2 were a meta- they received an intrathecal dose of 15 mg of plain 0.5%
analysis, 4 were randomized controlled trials (RCTs), and bupivacaine, IV sedation with propofol followed. The
1 was a retrospective chart review. results of this study did not indicate any improvement
with pain at rest between the treatment group and the
Results control group at any time.7 However, pain with move-
• Pain Scores. One of the most accepted ways of assessing ment was significantly lower starting at the 12-hour
a pharmacologic agent’s analgesic effects is by examining mark in the group receiving dexamethasone, and persist-
patient-reported pain scores. Of the studies included in ing through the end of measurement, which occurred at
this review, 6 had a component of pain score assessment the 48-hour mark.7
included in the study. De Oliveira et al3 performed a An RCT performed by Kim et al8 examined the effects
meta-analysis of 24 RCTs that included 2,751 subjects. of dexamethasone on the inflammatory response and
Inclusion into the meta-analysis required an RCT of a pain of women undergoing uterine artery embolization
single perioperative IV dexamethasone injection and a (UAE) for treatment of symptomatic fibroids. The main
placebo control group.3 Trials were excluded if they con- goal of the trial was to evaluate levels of inflammatory
tained more than 1 perioperative dose of dexamethasone, markers, including the white blood cell count, C-reactive
contained concurrent use of an alternative multimodal protein (CRP), interleukin-6 (IL-6), and the stress
analgesic regimen, or if a direct comparison between hormone cortisol in patients undergoing UAE. Secondary
dexamethasone and placebo groups could not be made. goals of the study were to evaluate pain scores on an
Early (0-4 hours) and late (24 hours) pain scores were 11-point numeric rating scale (NRS). The 64 patients
examined, as well as pain at rest and with movement. were randomly assigned to a treatment group receiving
Studies were also classified into 3 groups by the dose of dexamethasone, 10 mg, or a placebo group receiving just
dexamethasone they received; low (0.1 mg/kg or less), saline. Results of the study demonstrated a significantly
intermediate (0.11-0.2 mg/kg), and high (0.2 mg/kg). lower pain score on the NRS at 12 hours (MD −1.1, P <
De Oliveira et al3 determined that a statistically and .05) and 24 hours (MD −1.4, P < .05) postoperatively in
clinically significant reduction in early (mean difference the group that received dexamethasone.8 Of note, the
[MD] −0.32, 95% confidence interval [CI]) and late (MD patients who received dexamethasone demonstrated a
−0.49, 95% CI) pain scores at rest, and early (MD −0.64, significant inhibition of CRP, IL-6, and cortisol levels,
95% CI) and late (MD −0.49, 95% CI ) pain scores with indicating the drug’s effectiveness at reducing inflamma-
movement are seen with intermediate and high dosing of tion and the stress response after UAE.8
dexamethasone. Szucs et al9 evaluated the analgesic effect of dexa-
Waldron et al6 performed a meta-analysis of 45 RCTs methasone on patients undergoing operative fixation
that involved a total of 5,796 patients. Patients in the of a fractured femur neck. A relatively small sample of
studies that were included were randomized into either 37 patients was recruited and randomly assigned into a
a group receiving a perioperative dose of dexamethasone treatment group receiving dexamethasone, 0.1 mg/kg, or
1.25 to 20 mg, or a group receiving a placebo. Five studies a control group receiving a placebo. The results of this
that received multiple doses of dexamethasone were in- study demonstrated a significant reduction of pain scores
cluded. Of those studies, 21 had a comparator other than at rest (MD −3.1, P = .0004) 6 hours after surgery.9
saline, including a 5-HT3 (serotonin) antagonist, dro- A retrospective chart review was performed by Samona
peridol, metoclopramide, midazolam, and haloperidol. et al10 that evaluated the effectiveness of dexamethasone
Pain scores were examined using the Visual Analog Scale at reducing pain scores in patients who underwent a
(VAS), and were reported at 2 hours and 24 hours post- single total knee arthroplasty. A sample of 102 patients
operatively. Results of this meta-analysis demonstrated a were selected from a 6-month period and separated into
statistically significant reduction (MD −0.49, 95% CI) in a treatment group receiving 8 mg of dexamethasone or a
the VAS pain scores, but the clinical significance of this control group that received none. Pain scores were evalu-
was debated because the difference between control and ated using an NRS upon arrival to the postanesthesia care
treatment groups was small.6 Despite this questionable unit (PACU) and 12 hours, 24 hours, and 48 hours post-
clinical significance, the study by Waldron et al is not operatively. Results of this study differ from those previ-
discredited, because of the discovery of opioid-sparing ously presented in that NRS pain scores were only lower
properties of dexamethasone administration that will be in the 24-hour postoperative period, but not on arrival to
covered later in this review. the PACU or at the 12- and 48-hour marks.10
Kardash et al7 performed an RCT of 50 patients un- • Opioid Consumption. Another measure of an effec-
dergoing elective, unilateral, primary total hip arthro- tive analgesic adjunct in multimodal pain management
plasty, randomly assigning them to a control group or a is the effect it has on reducing the amount of opioids

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required to achieve satisfactory pain levels. An estimated pain score in the group receiving dexamethasone.
6% of patients who are prescribed opioids after surgery • Adverse Effects. As with all medications adminis-
will develop new persistent opioid use.11 Among those tered, dexamethasone is not without potentially harmful
who misuse prescription opioids, the National Institute adverse effects. Of the 7 studies included in this review,
on Drug Abuse12 estimates that 4% to 6% will progress only 2 provided any analysis of potentially adverse effects.
to heroin use. Of the studies included in this review, De Oliveira et al5 examined differences in wound healing,
all examined dexamethasone’s opioid-sparing effects wound infection rates, and blood glucose levels between
postoperatively. Jokela et al13 performed an RCT of 129 the 3 treatment groups and control group. Ultimately
women undergoing laparoscopic hysterectomy. Subjects there were no differences in these potential adverse reac-
were randomized into 4 groups: a control group receiving tions between the treatment groups and control group.
a placebo and 3 treatment groups receiving an IV dose of The meta-analysis by Waldron et al6 similarly assessed
5 mg, 10 mg, or 15 mg of dexamethasone. The results of differences in wound healing, wound infection rates,
this study demonstrated that the opioid-sparing ability of and blood glucose levels. Although wound healing and
dexamethasone was dose dependent.13 Patients receiving wound infection rates yielded no difference, alteration in
5 mg of dexamethasone saw no significant reduction in blood sugar levels postoperatively was found. Waldron
postoperative opioid consumption. In the first 2 hours et al6 reported that no difference in blood glucose levels
following surgery, there was a significant (P ≤ .001) could be found 12 hours postoperatively, but 24 hours
reduction in the amount of oxycodone required by the postoperatively a small increase in blood glucose levels
10-mg group (0.17 mg/kg) as well as the 15-mg group was demonstrated. What effect, if any, this has on patient
(0.17 mg/kg) compared with the control group (0.26 outcomes was not discussed.
mg/kg). A significant (P = .027) reduction of total oxy- Dexamethasone, being a corticosteroid, has the poten-
codone dose required 24 hours postoperatively was also tial to increase a patient’s blood glucose levels following
seen in the 15-mg group (0.34 mg/kg) compared with the administration. Of particular concern is the effect that
control group (0.55 mg/kg).13 dexamethasone administration will have on a diabetic
Both the meta-analyses performed by De Oliveira et al3 patient’s blood glucose levels. Hans et al14 performed a
and Waldron et al6 examined the opioid-sparing effects of study in which nondiabetic individuals and patients with
dexamethasone by looking at opioid consumption using type 2 diabetes were administered 10 mg of IV dexameth-
IV morphine equivalents. De Oliveira et al3 found no asone after the induction of anesthesia, and alterations
statistically significant reduction in IV morphine equiva- in blood glucose levels were monitored. Reported results
lents in subjects who received low-dose dexamethasone found that diabetic patients had a larger increase from
(< 0.1 mg/kg). A reduction of required IV morphine baseline blood glucose levels than did nondiabetic pa-
equivalent units was found to be statistically significant tients and that the greatest increases were seen in patients
in the dexamethasone intermediate-dose group (95% CI with higher hemoglobin A1C levels and in those with
= 0.11-0.2 mg/kg) and in the high-dose group (> 0.2 mg/ an elevated body mass index.14 The highest recorded
kg). No reduction difference was noted between the inter- blood glucose level was 232.2 mg/dL, and the authors
mediate- and high-dose group. Waldron et al6 reported a argued that the elevations seen were of debatable clini-
statistically significant (95% CI) reduction in required IV cal significance. Tien et al15 performed a similar study
morphine equivalents at 2 hours (−0.87 mg/kg) and 24 examining the effect of 8 mg of IV dexamethasone on
hours (−2.33 mg/kg) postoperatively in those receiving blood glucose levels of nondiabetic persons and patients
dexamethasone. Unfortunately, no dosing guidelines are with type 2 diabetes. Contrary to the study performed by
outlined because the authors of the meta-analysis did not Hans et al,14 no difference was found in the percentage
separate the dosages given into varying groups. of elevation of blood glucose levels when they compared
In the RCT performed by Szucs et al9 of patients un- patients who have type 2 diabetes with nondiabetic indi-
dergoing operative fixation of a fractured neck of the viduals. Mixed results of reports are available on the role
femur, 24-hour postoperative morphine consumption that dexamethasone has on blood glucose level alteration
was significantly lower in the treatment group that re- in diabetic patients, and if reported alterations are of any
ceived 0.1 mg/kg of IV dexamethasone. A retrospective clinical significance, intuitively it makes sense to exercise
chart review performed by Samona et al10 demonstrated caution when one is administering dexamethasone to
similar results with administration of 8 mg of IV dexa- patients with diabetes. Clinical judgment should be used
methasone resulting in lower oral opioid consumption on a patient-by-patient basis with emphasis placed on
over the 3-day admission following total knee arthro- evaluation of the patient’s preoperative control of blood
plasty. The RCTs performed by Kardash et al7 and Kim glucose levels.
et al8 failed to find any difference in opioid consumption Another well-established concern with the admin-
in treatment groups receiving dexamethasone vs control istration of corticosteroids is the potential for wound
groups despite demonstrating a significant decrease in infections and delayed healing. Three studies were found

490 AANA Journal  December 2018  Vol. 86, No. 6 www.aana.com/aanajournalonline

 Study Sample
Source design size (N) Dexamethasone dose Results
De Oliveira Meta-analysis 2,751 Patients were separated into subgroups Dexamethasone at dosages more than 0.1 mg/kg resulted in lower pain scores at 4 hours
et al,3 2011 receiving dexamethasone at dosages and 24 hours, and resulted in a reduction in the required morphine equivalent units required
< 0.1 mg/kg, 0.11-0.2 mg/kg, or > 0.2 after surgery. No difference was seen in the intermediate-dose group vs the high-dose
mg/kg group.
Jokela et Blinded RCT 129 Patients were randomly assigned to Dexamethasone, 10 mg and 15 mg, results in decreased oxycodone consumption during
al,13 2009 receive a placebo or dexamethasone, the first 2 hours after surgery. Dexamethasone, 15 mg, reduces the amount of oxycodone
5 mg, 10 mg, or 15 mg required for the first 24 hours after laparoscopic hysterectomy
Kardash et Double-blinded 50 Patients received either a placebo or Dexamethasone, 40 mg, has a prolonged suppressive effect on the inflammatory response
al,7 2008 RCT dexamethasone, 40 mg and decreases dynamic pain 24 hours after total hip arthroplasty
Kim et al,8 Blinded RCT 59 Patients received either a placebo or Dexamethasone, 10 mg, resulted in lower pain scores at 12 and 24 hours following uterine
2016 dexamethasone, 10 mg artery embolization

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Samona et Retrospective 102 Patients received either a placebo or Dexamethasone, 8 mg, resulted in decreased pain scores 24 hours after total knee
al,10 2017 chart review dexamethasone, 8 mg arthroplasty, as well as decreased oral narcotic consumption

Szucs et al,9 Double-blinded 30 Patients received either a placebo or Pain scores at rest were lower at 6 hours following operative fixation of a fractured femur
2016 RCT dexamethasone, 0.1 mg/kg neck, and cumulative morphine consumption was lower 24 hours after surgery
Waldron et Meta-analysis 5,796 Patients were separated into subgroups Pain scores were lower in patients who received dexamethasone, 8-10 mg, postoperatively
al,6 2013 receiving dexamethasone, either 4-5 at 2 and 24 hours, and a reduction of morphine equivalent units at 2 and 24 hours
mg or 8-10 mg
Table 1. Study Design, Sample Size, Dexamethasone Dose, and Results for Studies Evaluating Analgesic Effects of Intravenous Dexamethasone
Abbreviation: RCT, randomized controlled trial.

Sample Study
Source Adverse effect examined size (N) design Results

AANA Journal

Bolac et Surgical site infection, wound 431 Retrospective No difference demonstrated in rates of surgical site infection, wound cellulitis, wound
al,16 2013 cellulitis, wound separation, fascial chart review separation, or fascial dehiscence in patients who received dexamethasone compared with
dehiscence those who did not
De Oliveira Wound healing, wound infection rate, 2,751 Meta-analysis No difference found in wound healing, rates of wound infection, or postoperative glucose
et al,3 2011 blood glucose levels levels between the group receiving dexamethasone and the group that did not

Gali et al,17 Wound infection rate 574 Retrospective No difference found in the rate of postoperative wound infection rates in patients who
2012 chart review received dexamethasone compared with patents who did not

December 2018

Hans et al,14 Blood glucose levels in diabetic and 63 Prospective Blood glucose levels were found to be marginally higher postoperatively in diabetic patients
2006 nondiabetic patients nonrandomized who received dexamethasone, although the clinical significance of this is debatable
trial
Richardson Periprosthetic joint infection rate 6,294 Retrospective No difference was found in the rate of periprosthetic joint infections in patients who
et al,18 2016 chart review received an intraoperative dose of dexamethasone compared with those who did not
Tien et al,15 Blood glucose levels in diabetic and 85 Randomized Dexamethasone increases postoperative blood glucose levels, but no difference was found

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2016 nondiabetic patients controlled trial in the level of increase between diabetic and nondiabetic patients
Waldron et Wound healing, wound infection 5,796 Meta-analysis No difference was seen in wound healing or wound infection rates between the control and
al,6 2013 rates, and blood glucose levels treatment groups. Blood glucose levels were found to be higher in the treatment group 24

491
hours postoperatively.
Table 2. Study Design, Sample Size, and Results of Studies Evaluating the Potential Adverse Effects of Dexamethasone Administration
in recent literature that demonstrated the safety of dexa- from 8 to 10 mg of dexamethasone. Although the dose
methasone when given as a single IV dose to surgical pa- administered was not weight based, one can assume that
tients. Bolac et al16 performed a retrospective chart review an appropriately sized adult received a dose equivalent to
of 431 patients who underwent laparotomy for treatment 0.1 mg/kg or higher.
of endometrial cancer, of which 192 patients received a
perioperative dose of IV dexamethasone ranging from 4 Conclusion
to 12 mg. Complications of surgical site infection, wound As shifts in surgical pain management from an opioid-
cellulitis, wound separation, and fascial dehiscence were based technique to a multimodal technique continue to
searched for in the study. The resulting analysis found evolve, IV dexamethasone appears to be a viable adjunct.
no difference in rates of wound complications in patients Although lower doses are effective at preventing post-
who received dexamethasone compared with those who operative nausea and vomiting, intermediate doses of
did not.16 Gali et al17 performed a retrospective chart dexamethasone of at least 0.1 mg/kg appear necessary to
review of 574 patients who underwent urogynecologic observe reduction of pain scores and opioid consump-
procedures, of which 112 received a perioperative dose of tion. Single doses of dexamethasone have no effect on
IV dexamethasone ranging from 4 to 8 mg. The results of rates of surgical site infections or delayed wound healing.
this study found no correlation between dexamethasone Elevations of blood glucose levels do occur following
administration and postoperative wound infection. A ret- administration of dexamethasone, and whereas the clini-
rospective chart review was also performed by Richardson cal significance of this is debatable, caution should be
et al18 examining 6,294 patients who underwent total hip exercised in patients with diabetes.
arthroplasty or total knee arthroplasty, of which 557 pa-
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AUTHOR
and diabetic patients: a prospective randomised controlled study.
Sean G. Moore, MSN, CRNA, is a Certified Registered Nurse Anesthetist
Anaesthesia. 2016;71(9):1037-1043.
at ProMedica Toledo Hospital in Toledo, Ohio, and a DNP student at the
16. Bolac CS, Wallace AH, Broadwater G, Havrilesky LJ, Habib AS. University of Alabama in Tuscaloosa, Alabama. Email: sgmoore@crimson.
The impact of postoperative nausea and vomiting prophylaxis ua.edu.
with dexamethasone on postoperative wound complications in
patients undergoing laparotomy for endometrial cancer. Anesth Analg.
2013;116(5):1041-1047. DISCLOSURES
17. Gali B, Burkle CM, Klingele CJ, Schroeder D, Jankowski CJ. Infec- The author has declared no financial relationships with any commercial
tion after urogynecologic surgery with the use of dexamethasone for entity related to the content of this article. The author did discuss off-label
nausea prophylaxis. J Clin Anesth. 2012;24(7):549-554. use within the article.

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