|Year : 2008 | Volume
| Issue : 3 | Page : 305-310
Dexamethasone As Prophylaxis! is it Effective in Reducing Postoperative Extubation Blues in Paediatric Age Group? A RetrospectiveReview of 331 Patients
Pramod Patra1, Debasish Nayak2
1 Consultant, Anesthesiology and Critical Care, Sun Hospital, Cuttack, India
2 Consultant, Pediatrics and neonatology, Sun Hospital, Cuttack, India
|Date of Acceptance||11-Apr-2008|
|Date of Web Publication||19-Mar-2010|
Anesthesiology and Critical Care, Sun Hospital, Cuttack, Orissa
Source of Support: None, Conflict of Interest: None
Use of steroids for different airway morbidities is common. This retrospective analysis was aimed at justifying the use of dexamethasone in preventing postoperative airway morbidities during extubation in paediatric age group. Recorded data of all paediatric surgeries in a particular institute was analyzed for incidences of post extubation airway problems in patients who received dexamethasone and compared with those who did not receive any steroid perioperatively. Three hundred and thirty one patients were considered out of which 226 received intravenous dexamethasone preoperatively, and 105 did not receive any steroids peri-operatively. Out of 52 children (15.7%) who had post-extubation airway problems, only 14 (6.1%) belonged to the dexamethasone group while 38 (36.1%) belonged to the non-dexa group. The difference noted in the incidence between the two groups was statistically significant (p< 0.05).There was no significant incidence of any systemic adverse effects while a large number of children developed severe perianal and vulval pruritus immediately after the bolus dexamethasone injection. There was no significant difference in the incidence of subglottic or supraglottic airway morbidities when compared between both the groups. In conclusion, a single bolus preoperative intravenous dose of dexamethasone, in paediatric patients, is of immense help in reducing the airway morbidities faced at the time of extubation in the post operative period.
Keywords: Dexamethasone, Preoperative, Postextubation Stridor, Airway morbidity, Perianal pruritus, Paediatric surgeries
|How to cite this article:|
Patra P, Nayak D. Dexamethasone As Prophylaxis! is it Effective in Reducing Postoperative Extubation Blues in Paediatric Age Group? A RetrospectiveReview of 331 Patients. Indian J Anaesth 2008;52:305-10
|How to cite this URL:|
Patra P, Nayak D. Dexamethasone As Prophylaxis! is it Effective in Reducing Postoperative Extubation Blues in Paediatric Age Group? A RetrospectiveReview of 331 Patients. Indian J Anaesth [serial online] 2008 [cited 2019 Sep 21];52:305-10. Available from: http://www.ijaweb.org/text.asp?2008/52/3/305/60639
| Introduction|| |
General anaesthesia for paediatric surgery has been an area of concern for all anaesthesiologists. There is a high prevalence of undetected upper respiratory tract infections during elective surgery, which often gets missed during preoperative assessment. Moreover, in this part of our country, where freelancing anaesthesiologists often don't have time for a detailed previous day pre-anaesthetic assessment, a hurried preoperative assessment is made at the operation room just before induction. Postoperative adverse airway events are therefore known to be very common in this age group, more so, when intubation for general anaesthesia is required. Most experienced paediatric anaesthesiologists adopt some technique or the other to counter this adverse situation during the surgery. Use of steroids as a treatment for postoperative laryngeal edema and bronchospasm is a well known technique. Hydrocortisone as prophylaxis for bronchial asthma has been in routine use. It is also a common practice to use steroids in adult patients to manage postoperative airway morbidities by most anaesthesiologists. Since the incidence of postoperative airway morbidity is high, in paediatric age group it is essential to justify the use of premedications like dexamethasone preoperatively.
A lot has been published on the efficacy of dexamethasone as a prophylactic for post operative nausea and vomiting in tonsillectomies, ,2,, strabismus surgeries,  thyroidectomy , and total abdominal hysterectomies  . Its use in the prevention of post extubation stridor in ICU patients has also been adequately published ,, . However, nothing so far has been done to prove its efficacy in preventing airway morbidities and stridor on extubation in children after surgery under general anaesthesia.
In hospitals where multiple anaesthesiologists are involved, different techniques are used to prevent post extubation airway morbidities. One such technique frequently used in our setup is preoperative dexamethasone single bolus intravenous dose in paediatric surgeries. Since many anaesthesiologists are involved, and most of them use dexamethasone as a prophylaxis, a retrospective analysis was made to establish whether this technique actually helps in reducing the incidence of postoperative airway events .The data was also used to establish if any adverse reactions could be attributed to the use of dexamethasone in a single bolus IV dosage.
| Methods|| |
After hospital ethics committee approval, all paediatric surgeries done under general anaesthesia at this particular institute carried out by various anaesthesiologists were considered for the retrospective review. All post-anaesthesia notes and the operation room records during the six month period from 1st January to 31 st June 2007 were analyzed. As per the hospital protocol, all drugs used and all events that occurred in the peri-operative period, was required to be recorded by the operation room assistant in the computerized and manual record books of the hospital. As a matter of policy it is also mandatory to preserve a copy of the preoperative assessment and the post-anesthesia notes written by the concerned anaesthesiologists, in the hospital records.
At the time of the surgery, neither the patient nor the anaesthesiologists involved were aware that these notes would be used in future for analysis in the study. Therefore the analysis qualifies as a double blinded retrospective study.
All paediatric surgeries in patients aged from neonates to 14 years done during this period at this Hospital were considered for the analysis.
Those which were done under GA but not intubated and those who received regional anaesthesia were excluded from the study. In cases where the data was incomplete or incomprehensible were also excluded .The cases were divided into two groups based on whether dexamethasone was administered preoperatively (Dexa group) or not (Non-dexa group). Those which received steroids other than dexamethasone during the preoperative period were excluded from the study. Any pre-existing co-morbidities as pointed out in the PAC notes were also recorded and analyzed for any correlation. Comparison between both groups were done for incidences of postoperative airway morbidities like subglottic airway obstruction (laryngospasm, bronchospasm), and supra glottic airway obstruction (inspiratory stridor, prolonged apnoea, breath holding, in drawing of soft tissues of the chest wall, etc). Any mention of acute adverse effects of dexamethasone during the perioperative period was also looked for from the notes. Chi-square analysis was applied for comparison of both groups and P-value of < 0.05 was considered significant.
| Results|| |
A total of 376 operated paediatric cases were recorded during this period. Out of which 45 cases were excluded from the study as they were done either under general anaesthesia with facemask/ regional anaesthesia or the data was incomplete. Most of the surgical procedures involved correction of congenital cleft lips and palates. However 5 patients underwent surgeries that involved parts other than the head and neck.
There were 331 cases, which qualified for the analysis where tracheal intubation had been done during general anaesthesia. All the cases done under general anaesthesia followed a standard anaesthesia technique. Patients received intravenous midazolam and glycopyrrolate as premedication.Two hundred twenty six patients received dexamethasone IV preoperatively. Immediate pre-induction pentazocin and post-induction rectal diclofenac were used for preemptive analgesia. All cases were induced intravenously with either thiopentone or propofol. Mask induction by halothane inhalation was done in few cases where IV access was difficult. Intubation was facilitated either by suxamethonium or atracurium or vecuronium as per the choice of different anaesthesiologists. Anesthesia was maintained by titrating halothane along with nitrous oxide and oxygen mixture in all cases. Reversal of muscle activity was done in all cases with neostigmine and either glycopyrrolate or atropine at the end of surgery. Other rescue drugs like atropine, theophylline , and salbutamol inhaler were used when situation warranted.
A total of 226 children in the Dexa group had received dexamethasone 0.3 to 0.5 mg per kg as a single bolus IV dose just before induction of anaesthesia. Another 105 children belonging to the Non-Dexa group did not receive any steroids during the perioperative period .The demographic distribution in both the groups were proportionate [Table 1] and [Table 2]. It was seen that most number of cases comprised of children in the age group of 4 to 10 years of age n=188, [Table 2]. Pre-existing co morbidities were found in equal proportions in both the groups while the number of respiratory tract related co morbidities like coryza, eosinophilia, chronic suppurative otitismedia (CSOM) and upper or lower respiratory tract infections (URTI/ LRTI) (n=63) were seen more in the Dexa group (n=51) than the Non dexa group (n=12). This could be attributed to the general tendency of anesthesiologists to premedicate such children with steroids. It was also seen that a considerable number of children presented with congenital complex syndromes, cardiac anomalies, malnutrition, cerebral palsy and mental retardation. [Table 3].
From the 331 cases 15.7 %( n=52) cases developed some form of airway problems in the post operative period. Out of the 226 cases in the Dexa group only 14 developed airway problems, while 38 in the Non Dexa group were found to have airway difficulties. The difference observed in the development of airway morbidities among the Dexa and the Non Dexa groups was found to be statistically highly significant with a P-value of less than 0.0001.
Thirty six of the 52 cases had sub glottic airway obstruction which included either bronchospasm or laryngospasm (11 %, n=36) while the remaining 5% (n=16) were seen to have supraglottic airway obstruction as evident by either inspiratory stridor or prolonged breath holding.
Although a higher number of patients in the Non Dexa group had subglottic airway obstructions, as compared to the Dexa groups, statistically it is not significant, with a chi square value of 3.326 and a P-value of > 0.05. Eleven of these 52 children required to be reintubated following significant drop in blood oxygen saturation levels .Even though more patients who were reintubated belonged to the Non Dexa group, statistically it is not significant when compared with that of Dexa group (P> 0.05). Dexa group had a high incidence of perianal or vulvul prurities(12.8%)
| Discussions|| |
Although a lot has been published on the efficacy of dexamethasone as a prophylactic for nausea and vomiting in other surgeries like tonsillectomy ,,, , strabismus  , thyroidectomy , abdominal hysterectomies  and in the prevention of post extubation stridor in ICU patients, nothing so far has been done to prove its efficacy in preventing postoperative stridor in children after extubation. In this retrospective analysis, for the first time the role of preoperative single bolus intravenous dose of dexamethasone in preventing postoperative airway morbidity is being reported.
Post extubation laryngeal edema results from fibrinous exudates and polymorph nuclear infiltration to the area traumatized by the ETT  . These cells (mast cell) release histamine and other chemical mediators like leukotrienes, bradykinin at the site of inflammation which can cause severe contractions of the laryngeal and bronchial smooth muscles after the anaesthetic drugs are withdrawn and the patient comes to a lighter plane of anaesthesia. Despite its ability to inhibit the early stages of inflammation, evidences justifying the efficacy of corticosteroids in the setting of laryngeal edema are conflicting  . Goddard et al  compared both subjective and objective symptoms of laryngeal edema between groups receiving placebo and betamethasone, and reported no significant difference. Even Dorman in his mega study  of 700 adult patients found no beneficial effect of 8 mg dexamethasone on limiting onset of stridor, dyspnoea, or need for reintubation. However, in paediatric age group the evidence is more supportive. Anne et al  studied 66 children below 5 years of age in a paediatric ICU and concluded that pretreatment with dexamethasone decreases the frequency of postextubation airway obstruction in children. Similarly, Lukkassen IM  et al in their study concluded that the risk of postextubation stridor is relatively high in the group of children aged between 4 weeks and 6 years with intubation more than 24 hours in an ICU setup. They found that dexamethasone was effective in preventing reintubation due to postextubation stridor in this paediatric high-risk group. A similar study conducted by Markovitz et al  on paediatric patients in an ICU setup also concluded that prophylactic administration of dexamethasone before elective extubation reduces the prevalence of postextubation stridor in neonates and children and may reduce the rate of reintubation. Freezer N et al  also suggested that steroids significantly increased the incidences of successful extubations. However Tellez D W et al  in their double blinded prospective trial assessed dexamethasones role in preventing postextubation stridor and concluded that routine use of corticosteroids for prevention of postextubation stridor during uncomplicated paediatric intensive care airway management is unwarranted.
Acute perioperative complications associated with single bolus dose of dexamethasone preoperatively is negligible as found in this analysis and this has been supported by previous publications by Melby  . Systemic adverse effects of dexamethasone, like suppression of hypothalamic pituitary axis, gastritis, osteoporosis, etc is not seen when the drug is used in a single bolus dose 17 . It is also seen that dexamethasone group has a high incidence of perianal and vulval pruritus in this study (12.8%).This has also been reported in earlier studies ,,,, . From this study sample it is also evident that quite a large number of patients (63 out of 331 patients in this case) are likely to have pre-existing airway related co morbidities just before surgery. Therefore a detailed preoperative previous day assessment would be the best prophylactic measure to prevent any untoward incident perioperatively.
This analysis suggests that preoperative single bolus intravenous dexamethasone in the dose range of 0.20.5 mg per kg body weight significantly reduces the incidences of postoperative airway morbidity like laryngospasm, bronchospasm, breathholding, etc. The added advantage of preoperative steroid is that it is known to reduce postoperative inflammation and pain . However, the effect of reducing postoperative subglottic spasms more than the supraglottic effects cannot be conclusively attributed to dexamethasone premedication. Therefore, to conclude, a single preoperative intravenous bolus dose of dexamethasone, in paediatric patients undergoing general anaesthesia would be of immense help in reducing the airway morbidities faced at the time of extubation in the post operative period.[Table 4]
| References|| |
|1.||Malde AD, Vinod SS, Sheetal R J. Effect of dexamethasone on post tonsillectomy morbidities. Indian J Anaesth 2005; 49: 202 - 207. |
|2.||Pappas ALS, Sukhani R, Hotaling AJ, Mikat-Stevens M Javorski JJ, Donzelli J. The effect of preoperative dexamethasone on the immediate and delayed postoperative morbidity in children undergoing adenotonsillectomy. Anesth Analg 1998; 87: 57-61. |
|3.||Splinter WM, Roberts DJ. Dexamethasone decreases vomiting by children after tonsillectomy. Anesth Analg 1996; 83: 913-6. [PUBMED] [FULLTEXT] |
|4.||Giannoni C, White S, Enneking FK. Does dexamethasone with preemptive analgesic improve pediatric tonsillectomy pain? Otolaryngol Head Neck Surg 2002; 126: 307315. [PUBMED] [FULLTEXT] |
|5.||Splinter WM, Rhine EJ. Low-dose ondansetron with dexamethasone more effectively decreases vomiting after strabismus surgery in children than does high-dose ondansetron. Anesthesiology 1998; 88: 72-5. [PUBMED] [FULLTEXT] |
|6.||Wang JJ, Ho ST, Lee SC, Liu YC, Liu YH, Lia YC. The Prophylactic Effect of Dexamethasone on postoperative nausea and vomiting in women undergoing thyroidectomy: A Comparison of droperidol with saline. Anesth Analg 1999; 89:200-3. |
|7.||Wang JJ, Ho ST, Lee SC, Liu YC, Ho CM. The use of dexamethasone for preventing postoperative nausea and vomiting in females undergoing thyroidectomy: a doseranging study. Anesth Analg 2000; 91: 1404-7. |
|8.||Wang JJ, Ho ST, Tzeng JI, Tang CS. The effect of timing of dexamethasone administration on its efficacy as a prophylactic antiemetic for postoperative nausea and vomiting.AnesthAnalg 2000;91:136-139. |
|9.||Anene O, Meert KL, Uy H, et al. Dexamethasone for the prevention of postextubation airway obstruction: a prospective, randomized, double-blind, placebo-controlled trial. Crit Care Med 1996;24:1666-9. [PUBMED] [FULLTEXT] |
|10.||Lukkasseen IM, Hassing MB, Markhorst DG. Dexamethasone reduces reintubation rate due to postextubation stridor in a high risk pediatric population. Acta Paediatr 2006; 95:74-6. |
|11.||Markovitz BP, Randolph AGl.Corticosteroids for the prevention of reintubation and postextubation stridor in pediatric patients: A meta-analysis. Pediatric Critical Care Medicine 2002;3:223-226. |
|12.||Darmon JY, Rauss A, Dreyfuss D, et al. Evaluation of risk factors for laryngeal edema after tracheal extubation in adults and its prevention by dexamethasone: a placebocontrolled, double-blind, multicenter study. Anesthesiology 1992; 77:245-51. |
|13.||Meade MO, Guyatt GH, Cook DJ, et al. Trials of corticosteroids to prevent postextubation airway complications. Chest 2001; 120:464S-8. [PUBMED] [FULLTEXT] |
|14.||Goddard JE Jr., Phillips OC, Marcy JH. Betamethasone for prophylaxis of postintubation inflammation: a doubleblind study. Anesth Analg 1967; 46:348-53. |
|15.||Freezer N, Butt W, Phelan P. Steroids in croup: do they increase the incidence of successful extubation? Anaesth Intensive Care 1990; 18: 224-8. [PUBMED] |
|16.||Tellez DW,Galvis AG, Storgion SA, Amer HN, Hoseyni M, Deakers TW. Dexamethasone in the prevention of postextubation stridor in children. J Pediatr 1991;118:28994. [PUBMED] |
|17.||Melby JC. Drug spotlight program: systemic corticosteroid therapy- pharmacology and endocrinologic considerations. Ann Intern Med 1974; 81: 505-12. [PUBMED] |
|18.||Neff SP, Stapelberg E, Warmington A. Excruciating perineal pain after intravenous dexamethasone. Anaesth Intensive Care 2002; 30:370-1. |
|19.||Thomas VL. More on dexamethasone - induced perineal irritation (Letter). N Eng J Med 1986; 314:1643-4. |
|20.||Klygis LM. Dexamethasone induced perineal irritation in head injury (Letter). Am J Emerg Med 1992;10:268. [PUBMED] |
|21.||Andrews D, Grunau VJ. An uncommon adverse effect following bolus administration of intravenous dexamethasone. J Can Dent Assoc 1986; 52:309-11. [PUBMED] |
|22.||Taleb N, Geahchan N, Ghosn M, Brihi E, Sacre P. Vulvar Pruritus after high-dose dexamethasone (Letter). Eur J Cancer Clin Oncol 1988; 24: 495. [PUBMED] |
|23.||Skjelbred P, Lt kken P. Post-operative pain and inflammatory reaction reduced by injection of a corticosteroid. European journal of Clinical Pharmacology 1982;21:391-396. |
[Table 1], [Table 2], [Table 3], [Table 4]