Effect of high-dose preoperative methylprednisolone on pain and recovery after total knee arthroplasty: a randomized, placebo-controlled trial

Lunn, Troels Haxholdt; Kristensen, B.; Andersen, Lea Laird; Husted, Henrik; Otte, Kristian Stahl; Gaarn-Larsen, L.; Kehlet, Henrik

doi:10.1093/bja/aeq333

Cited by 230 publications

(254 citation statements)

References 35 publications

Supporting

Mentioning

225

Contrasting

Unclassified

Order By: Relevance

“…Our findings agree with those of previous small series [15,36,38,40] and reviews of numerous perioperative settings [19,21,22,46] that found no association between corticosteroid use and increased risk for postoperative wound infection. Furthermore, studies using higher corticosteroid doses than that used in our study showed no increase in postoperative wound infection after major orthopaedic surgeries [1,5,19,25,46].…”

Section: Discussionsupporting

confidence: 93%

“…Patients who received dexamethasone experienced lower pain and consumed less opioid during the 6-to 24-hour postoperative period compared with patients who received ramosetron alone. These findings agree with those of two recent studies that showed that 125 mg of methylprednisolone reduced resting pain for 2 to 48 hours and reduced opioid consumption for the first 24 hours in 24 patients who had unilateral TKA [38], and that 300 mg hydrocortisone reduced postoperative pain and epidural medication for the first 24 hours in 17 patients who had bilateral TKAs concurrently treated with a multimodal analgesic regimen [24] (Table 4). Our results and those of previous studies [24,38] suggest that incorporation of corticosteroids in a multimodal analgesic regimen provides synergistic analgesia and opioid-sparing effects.…”

Section: Discussionsupporting

confidence: 91%

“…Previous studies have found that perioperative use of single, lowdose corticosteroids significantly decreased inflammatory markers after TKA [23,24,49]. However, despite the potential benefits and reported efficacy in numerous surgical procedures, only a few small studies involving less than 25 patients per group evaluated the efficacy and safety of corticosteroids after TKA [15,24,38,40]. Moreover, heterogeneity among studies regarding type, dosage, and administration protocol of corticosteroids and concomitant pain control regime make it difficult to judge the practical value of corticosteroid use after TKA.…”

Section: Introductionmentioning

confidence: 99%

See 2 more Smart Citations

Preemptive Low-dose Dexamethasone Reduces Postoperative Emesis and Pain After TKA: A Randomized Controlled Study

Koh

Chang

Lee

et al. 2013

Clinical Orthopaedics &Amp; Related Research

115

147

View full text Add to dashboard Cite

Background Dexamethasone is a potent analgesic and antiemetic. However, the benefit of dexamethasone after TKA is unclear, as is the efficacy in a current multimodal regime. Questions/purposes We determined (1) whether the addition of dexamethasone to a protocol including ramosetron further reduces postoperative emesis compared with ramosetron alone; (2) whether it reduces postoperative pain; and (3) whether it increases the risk for wound complications in a current multimodal regime after TKA. Methods We randomized 269 patients undergoing TKAs to receive dexamethasone (10 mg) 1 hour before surgery and ramosetron immediately after surgery (Dexa-Ra group, n = 135), or ramosetron alone (Ra group, n = 134). We recorded the incidence of postoperative nausea and vomiting (PONV), severity of nausea, incidence of antiemetic requirement, complete response, pain level, and opioid consumption. Patients were assessed 0 to 6, 6 to 24, 24 to 48, and 48 to 72 hours postoperatively. In addition, patients were evaluated for wound complications and periprosthetic joint infections at a minimum of 1 year after surgery. Results The Dexa-Ra group had a lower incidence of PONV during the entire 72-hour evaluation period and experienced less severe nausea for the first 6 hours after TKA, although not between 6 to 72 hours.

show abstract

Section: Discussionsupporting

confidence: 93%

Section: Discussionsupporting

confidence: 91%

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

Preemptive Low-dose Dexamethasone Reduces Postoperative Emesis and Pain After TKA: A Randomized Controlled Study

Koh

Chang

Lee

et al. 2013

Clinical Orthopaedics &Amp; Related Research

115

147

View full text Add to dashboard Cite

show abstract

“…The efficacy of glucocorticoids as part of multimodal postoperative pain treatment in different surgical procedures has recently been reviewed [20] demonstrating reductions in both pain scores and morphine consumption. Likewise, Lunn et al [21] showed that IV methylprednisolone 125 mg after total knee arthroplasty improved analgesia and promoted recovery. Neither of the studies reported on serious complications, especially wound infection, from the use of a single dose of glucocorticoids, but calls for further largescale studies on safety issues.…”

Section: Discussionmentioning

confidence: 99%

A comprehensive multimodal pain treatment reduces opioid consumption after multilevel spine surgery

et al. 2013

View full text Add to dashboard Cite

Purpose Major spine surgery with multilevel instrumentation is followed by large amount of opioid consumption, significant pain and difficult mobilization in a population of predominantly chronic pain patients. This case-control study investigated if a standardized comprehensive pain and postoperative nausea and vomiting (PONV) treatment protocol would improve pain treatment in this population. Methods A new regimen with acetaminophen, NSAIDs, gabapentin, S-ketamine, dexamethasone, ondansetron and epidural local anesthetic infusion or patient controlled analgesia with morphine, was introduced in a post-intervention group of 41 consecutive patients undergoing multilevel (median 10) instrumented spinal fusions and compared with 44 patients in a pre-intervention group. Results Compared to patients in the pre-intervention group, patients treated according to the new protocol consumed less opioid on postoperative day (POD) 1 (P = 0.024) and 2 (P = 0.048), they were mobilized earlier from bed (P = 0.003) and ambulation was earlier both with and without a walking frame (P = 0.027 and P = 0.027, respectively). Finally, patients following the new protocol experienced low intensities of nausea, sedation and dizziness on POD 1-6. Conclusions In this study of patients scheduled for multilevel spine surgery, it was demonstrated that compared to a historic group of patients receiving usual care, a comprehensive and standardized multimodal pain and PONV protocol significantly reduced opioid consumption, improved postoperative mobilization and presented concomitant low levels of nausea, sedation and dizziness.

show abstract

“…Although the prevalence of OI was not significantly reduced with midodrine (risk ratio, 0.63; 95% confidence interval, 0.36 to 1.10; P = 0.10), further studies with higher dosing and earlier premobilization administration may be warranted. Furthermore, targeting the postoperative inflammatory response with high-dose systemic glucocorticoids-which has shown to have some effect on reducing pain, opioid requirements, inflammatory response, and early fatigue after THA, TKA, 18,19 and endovascular aortic aneurism repair-20 could potentially reduce the incidence of OH and OI during early postoperative mobilization. Indeed, this is currently being studied in THA patients (www.…”

Section: Interventions To Reduce Postoperative Oimentioning

confidence: 99%

Postoperative orthostatic intolerance: a common perioperative problem with few available solutions

Jans

Kehlet

2016

Can J Anesth/J Can Anesth

View full text Add to dashboard Cite

Over the past decade or so, several procedure-specific Enhanced Recovery After Surgery (ERAS) programs have been documented to have beneficial effects, including reduced length of stay (and fewer medical complications) without increasing hospital readmission rates. Early mobilization has been a key element in the multimodal concept of fast-track surgery and ERAS programs, with subsequent positive effects on pulmonary and thromboembolic complications and avoidance of loss of muscle function through immobility. Although postoperative orthostatic intolerance (OI), characterized by symptoms of dizziness, nausea, vomiting, blurred vision, or syncope during sitting or standing, 1 is a well-known clinical problem that can delay early mobilization, relatively few data are available on its mechanism and possible treatment. Consequently, the aim of this freestanding editorial is to provide an update and perspective on the current knowledge regarding the pathogenesis and mechanisms of OI and potential future treatment strategies. Prevalence and mechanismsAlthough reports have indicated that OI was not a problem after relatively minor surgery (e.g., mastectomy), 2 prospective studies of major surgery have reported that OI is a common problem during early postoperative mobilization, with a prevalence of 42-50%. 3,4Retrospective studies with less well-defined mobilization protocols have reported an OI prevalence in the range of 12-60% across surgical procedures. 5-7The few existing studies with detailed recordings of hemodynamic changes during early postoperative mobilization and with a preoperative control-i.e., in prostatectomy and total hip arthroplasty (THA)-suggest that orthostatic hypotension (OH) with a concomitant decrease in cerebral perfusion is the main mechanism for the OI symptoms experienced in most cases. 3,4,8 Furthermore, the results from these studies suggest that OH is caused by a postoperative attenuated postural vasopressor response during early mobilization. Thus, in both prostatectomy and THA patients, the normal increase in total peripheral resistance during postural change was impaired compared with a preoperative evaluation.3,4 In a separate study in 42 prostatectomy patients, norepinephrine concentrations were measured during early mobilization, and the increase in norepinephrine during transition from supine to standing was impaired during early postoperative mobilization in OI patients. This suggests an attenuated vasopressor response compared with preoperative levels. Finally, a secondary analysis of heart rate variability between pre-and early postoperative mobilization in 23 THA patients found autonomic dysregulation during early mobilization. When compared with the preoperative evaluation, there was a paradoxical shift towards increased vagal activity with movement from the supine to the standing position in OI patients six and 24 hr postoperatively.9 Thus, a state of impaired cardiovascular regulation and autonomic dysfunction may be present in the early postoperative period with undesirable ...

show abstract

Effect of high-dose preoperative methylprednisolone on pain and recovery after total knee arthroplasty: a randomized, placebo-controlled trial

Abstract: MP 125 mg before surgery improves analgesia and immediate recovery after TKA, even when combined with a multimodal analgesic regime. These findings call for further studies on safety aspects.

Cited by 230 publications

References 35 publications

Preemptive Low-dose Dexamethasone Reduces Postoperative Emesis and Pain After TKA: A Randomized Controlled Study

Preemptive Low-dose Dexamethasone Reduces Postoperative Emesis and Pain After TKA: A Randomized Controlled Study

A comprehensive multimodal pain treatment reduces opioid consumption after multilevel spine surgery

Postoperative orthostatic intolerance: a common perioperative problem with few available solutions

Contact Info

Product

Resources

About