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CLINICAL INVESTIGATION
Year : 2008  |  Volume : 52  |  Issue : 3  |  Page : 305-310 Table of Contents     

Dexamethasone As Prophylaxis! is it Effective in Reducing Postoperative Extubation Blues in Paediatric Age Group? A RetrospectiveReview of 331 Patients


1 Consultant, Anesthesiology and Critical Care, Sun Hospital, Cuttack, India
2 Consultant, Pediatrics and neonatology, Sun Hospital, Cuttack, India

Date of Acceptance11-Apr-2008
Date of Web Publication19-Mar-2010

Correspondence Address:
Pramod Patra
Anesthesiology and Critical Care, Sun Hospital, Cuttack, Orissa
India
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Source of Support: None, Conflict of Interest: None


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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 Aug 25];52:305-10. Available from: http://www.ijaweb.org/text.asp?2008/52/3/305/60639


   Introduction Top


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, [1],2[],[3],[4] strabismus sur­geries, [5] thyroidectomy [6],[7] and total abdominal hyster­ectomies [8] . Its use in the prevention of post extubation stridor in ICU patients has also been adequately pub­lished [9],[10],[11] . 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 Top


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 Top


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 Top


Although a lot has been published on the efficacy of dexamethasone as a prophylactic for nausea and vomiting in other surgeries like tonsillectomy [1],[2],[3],[4] , stra­bismus [5] , thyroidectomy [6],[7] abdominal hysterectomies [8] 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 [12] . 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 [13] . Goddard et al [14] 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 [9] 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 [9] 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 [10] 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 [11] 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 [15] also suggested that steroids signifi­cantly increased the incidences of successful extubations. However Tellez D W et al [16] 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 [17] . 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 [18],[19],[20],[21],[22] . 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 [23]. 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 Top

1.Malde AD, Vinod SS, Sheetal R J. Effect of dexametha­sone on post tonsillectomy morbidities. Indian J Anaesth 2005; 49: 202 - 207.  Back to cited text no. 1    Medknow Journal  
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.  Back to cited text no. 2      
3.Splinter WM, Roberts DJ. Dexamethasone decreases vomiting by children after tonsillectomy. Anesth Analg 1996; 83: 913-6.  Back to cited text no. 3  [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.  Back to cited text no. 4  [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.  Back to cited text no. 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.  Back to cited text no. 6      
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.  Back to cited text no. 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.  Back to cited text no. 8      
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.  Back to cited text no. 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.  Back to cited text no. 10      
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.  Back to cited text no. 11      
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.  Back to cited text no. 12      
13.Meade MO, Guyatt GH, Cook DJ, et al. Trials of corticos­teroids to prevent postextubation airway complications. Chest 2001; 120:464S-8.  Back to cited text no. 13  [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.  Back to cited text no. 14      
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.  Back to cited text no. 15  [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.  Back to cited text no. 16  [PUBMED]    
17.Melby JC. Drug spotlight program: systemic corticoster­oid therapy- pharmacology and endocrinologic consid­erations. Ann Intern Med 1974; 81: 505-12.  Back to cited text no. 17  [PUBMED]    
18.Neff SP, Stapelberg E, Warmington A. Excruciating perineal pain after intravenous dexamethasone. Anaesth Intensive Care 2002; 30:370-1.  Back to cited text no. 18      
19.Thomas VL. More on dexamethasone - induced perineal irritation (Letter). N Eng J Med 1986; 314:1643-4.  Back to cited text no. 19      
20.Klygis LM. Dexamethasone induced perineal irritation in head injury (Letter). Am J Emerg Med 1992;10:268.  Back to cited text no. 20  [PUBMED]    
21.Andrews D, Grunau VJ. An uncommon adverse effect following bolus administration of intravenous dexametha­sone. J Can Dent Assoc 1986; 52:309-11.  Back to cited text no. 21  [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.  Back to cited text no. 22  [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.  Back to cited text no. 23      



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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