RCT: In TKA, dexamethasone given 24 h after surgery decreased pain and nausea at 48 h after surgery vs saline or dexamethasone given 1 h before surgery.
Kim JK, Ro DH, Lee HJ, et al. Efficacy of Systemic Steroid Use Given One Day After Total Knee Arthroplasty for Pain and Nausea: A Randomized Controlled Study. J Arthroplasty. 2019 Aug 19. pii: S0883-5403(19)30757-0. doi: 10.1016/j.arth.2019.08.026.

BACKGROUND: Systemic steroid has been used to control pain and nausea in total knee arthroplasty (TKA), but most studies recommend a single dose administration prior to, or during, surgery. This study aimed to determine the efficacy of administration on 1 day postoperatively.

METHODS: Patients who were scheduled to undergo TKA were randomly assigned to the following groups: control group, receiving normal saline injection; group 1, receiving 10 mg dexamethasone intravenously (IV) 1 hour before surgery; group 2, receiving 0.1 mg/kg dexamethasone (IV) 24 hours after surgery; or group 3, receiving 0.2 mg/kg dexamethasone (IV) 24 hours after surgery (n = 44-46 per group). Primary outcomes were pain and nausea visual analogue scale (VAS). Secondary outcomes were analgesic administration, rescue antiemetic administration, C-reactive protein, range of motion, and complications.

RESULTS: Postoperative pain and nausea remained high for 48 hours post-TKA. Group 1 had lower pain and nausea VAS scores than did the control group (P < .01) for only 24 hours post-TKA. Groups 2 and 3 had lower pain and nausea VAS scores than did the control group and group 1 (P < .01) 48 hours post-TKA. Analgesic and antiemetic administration were significantly lower in groups 2 and 3 than in the control group during 48 hours after TKA. There were no differences in C-reactive protein level and range of motion, and complications were not detected.

CONCLUSION: The effect of preoperative and postoperative administration of dexamethasone for controlling pain and nausea was observed only for 24 hours. Considering that severe pain and nausea persisted for more than 48 hours after TKA, additional administration of dexamethasone at 1 day postoperatively is suggested.

LEVEL OF EVIDENCE: Level I.

Ratings
Specialty Area Score
Special Interest - Pain -- Physician
Hospital Doctor/Hospitalists
Internal Medicine
Comments from MORE raters

Hospital Doctor/Hospitalists

Fairly minimal differences in clinical outcomes. The most interesting result has to do with the secondary outcome of safety, confirming it is safe to use single-dose corticosteroids after arthroplasty.

Special Interest - Pain -- Physician

Interesting results in favor of the prolongation of systemic corticosteroid use after knee replacement, despite the absence of reduction of opioid and antiemetic consumption compared with a single preoperative intravenous administration. This study also confirms the low interest of methylprednisolone intra-articular (control group) without coupling with an associated intravenous administration. NOTE: All patients in this study were at high risk for PONV (PCA with opioid combined with tramadol and nefopam and an absence of antiemetic prophylaxis in the intraoperative period).

The positive effects of single dose intravenous dexamethasone on early postoperative pain and PONV is well-acknowledged. The optimal timing, before start of surgery, during surgery or postoperatively is a matter of discussion. There may be benefits in dosing after surgery prolonging the effects.

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