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Intravenous Dexamethasone As An Analgesic: A Literature Review
Intravenous Dexamethasone As An Analgesic: A Literature Review
A Literature Review
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
www.aana.com/aanajournalonline
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
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-
tients received perioperative dexamethasone ranging from REFERENCES
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