High-dose dexamethasone in low pain responders undergoing total knee arthroplasty: a randomised double-blind trial

Niklas I Nielsen; Henrik Kehlet; Kirill Gromov; Anders Troelsen; Henrik Husted; Claus Varnum; Per Kjærsgaard-Andersen; Lasse E Rasmussen; Lina Pleckaitiene; Nicolai B Foss

doi:10.1016/j.bja.2022.10.038

High-dose dexamethasone in low pain responders undergoing total knee arthroplasty: a randomised double-blind trial

Br J Anaesth. 2023 Mar;130(3):322-330. doi: 10.1016/j.bja.2022.10.038. Epub 2022 Dec 14.

Authors

Affiliations

¹ Department of Anaesthesiology, Copenhagen University, Hvidovre Hospital, Hvidovre, Denmark. Electronic address: Niklas.Ingemann.Nielsen@regionh.dk.
² Section of Surgical Pathophysiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
³ Department of Orthopaedic Surgery, Copenhagen University, Hvidovre Hospital, Hvidovre, Denmark.
⁴ Department of Orthopaedic Surgery, Lillebaelt Hospital, Vejle, Denmark.
⁵ Department of Anaesthesiology, Lillebaelt Hospital, Vejle, Denmark.
⁶ Department of Anaesthesiology, Copenhagen University, Hvidovre Hospital, Hvidovre, Denmark.

PMID: 36526481
DOI: 10.1016/j.bja.2022.10.038

Abstract

Background: Postoperative pain after total knee arthroplasty (TKA) is a continuing problem despite optimised multimodal analgesia. Previous studies have shown preoperative glucocorticoids to reduce postoperative pain, but knowledge about specific doses and effects in specific patient groups is lacking.

Methods: A two-centre, double-blind, two-arm study comparing preoperative dexamethasone (1 mg kg^-1vs 0.3 mg kg^-1 i.v.) on postoperative pain in 160 planned TKA subjects with low preoperative pain catastrophising and no opioid use. Subjects received multimodal analgesia with paracetamol, cyclooxygenase-2 inhibitors, local anaesthetic infiltration analgesia, and rescue opioids. The primary outcome was percentage of subjects experiencing moderate to severe pain (visual analogue scale >30 mm) upon ambulation at 24 h. Secondary outcomes included pain scores, postoperative inflammation (C-reactive protein), opioid and antiemetics use, and 'Quality of Recovery-15' and 'Opioid-Related Symptom Distress Scale', length of stay, readmissions, and complications up to Day 90.

Results: A total of 157 subjects (80 vs 77) were included. No difference was found between groups in the incidence of subjects experiencing visual analogue scale >30 on ambulation 24 h after surgery (56% vs 53%, relative risk =1.07, confidence interval: 0.8-1.4, P=0.65). No differences in other pain outcomes or use of rescue opioids and antiemetics, in Quality of Recovery-15 and Opioid-Related Symptom Distress Scale, length of stay, readmissions, or complications. C-reactive protein values were comparable at 24 h (13 [6-25] mg L^-1vs 16 [9-38] mg L^-1, P = 0.07), but lower at 48 h (26 [9-52] mg L^-1vs 50 [30-72] mg L^-1, P<0.01) in the high-dose group.

Conclusion: Use of 1 mg kg^-1vs 0.3 mg kg^-1 i.v. dexamethasone in low pain responders after TKA did not improve early postoperative pain or other outcomes in contrast to benefits in a high pain responder population.

Clinical trial registration: NCT03758170 (first registration 29-11-2018).

Keywords: anaesthesia; dexamethasone; fast-track surgery; multimodal analgesia; perioperative medicine; postoperative pain; total knee arthroplasty.

Publication types

Randomized Controlled Trial

MeSH terms

Analgesics, Opioid
Anesthetics, Local
Antiemetics* / therapeutic use
Arthroplasty, Replacement, Knee* / adverse effects
C-Reactive Protein
Dexamethasone / therapeutic use
Double-Blind Method
Humans
Pain, Postoperative / diagnosis
Pain, Postoperative / drug therapy
Pain, Postoperative / prevention & control

Substances

Antiemetics
C-Reactive Protein
Analgesics, Opioid
Dexamethasone
Anesthetics, Local

Associated data

ClinicalTrials.gov/NCT03758170