European Journal of Cardiovascular Medicine

Print ISSN: 2042-4884 | E-ISSN: 2042-4892

Language: Multilingual
Origin: United Kingdom
Website: https://www.healthcare-bulletin.co.uk/ Volume 13 Issue: 2 - 2023
Open Access
Dexamethasone is Effective in Improving Post-Operative Outcomes in Paediatric
Patients Undergoing Tonsillectomy
Dr. Vithal Kulkarni1, Dr. Roopashree N2, Dr. Lakshmi B R3, Dr. Nataraj M S4
Abstract: Background: To determine the effect of single dose of intravenous dexamethasone AFFILIATIONS
1
(0.15 mg/kg) given at the time of induction of general anaesthesia for tonsillectomy in paediatric M D Specialist, Department of
patients on post-operative nausea vomiting, pain and quality of oral intake. Materials And Anesthesia, Jayanagar General
Methods: After ethical committee approval and parental consent, 64 children of ASA physical Hospital
status I or II, aged 6 –16 years, scheduled for elective tonsillectomy with or without Bangalore, India.
2
adenoidectomy, were randomly assigned to one of two groups to receive, at the time of induction Assistant Professor, Department
of anaesthesia, either a single dose of intravenous dexamethasone (0.15 mg/kg) diluted in normal of Physiology, BGS Global
saline to total volume of 5 ml or an equal amount of normal saline. The post-operative pain scores Institute of Medical Sciences
were assessed at different time intervals post-operatively using objective pain scale and visual Kengeri, Bangalore, India.
3
analogue score. Post-operative nausea and vomiting scores were assessed 30 mins, 3 hours, 6 Senior Resident, ESIC Medical
hours, 12 hours, 24 hours post-operatively using Bellville PONV score. Quality of oral intake was College, Bangalore, India.
4
assessed 3 hours post-operatively. Results: The demographic data were comparable between two Professor, Department of
Anesthesiology, ESIC Medical
groups. Post-operative pain scores and post-operative nausea and vomiting scores were College, Bangalore, India..
significantly less in the dexamethasone group (study group) at different time intervals (p
value<0.05). The number of patients who received rescue analgesia in study group and control
group were 5 out of 32 and 13 out of 32 respectively (p=0.034). The need of rescue anti emetic in CORRESPONDING AUTHOR
study group and control group were 25% and 46.9% respectively (p=0.048). At 3 hours post Dr. Roopashree N, Assistant
operatively, 21.9% in study group and 6.3% in control group had excellent quality of oral intake Professor, Department of
(p=0.022). Conclusion: Single intravenous dose of 0.15 mg/kg of dexamethasone given following Physiology, BGS Global Institute
of Medical Sciences Kengeri,
induction of general anaesthesia in paediatric patients undergoing elective tonsillectomy with or Bangalore, India.
without adenoidectomy reduces incidence of post-operative nausea and vomiting, provides better
and prolonged post-operative pain relief and results in better quality of oral intake without side
effects.
Keywords: Dexamethasone; Post-operative nausea and vomiting, Pain, Tonsillectomy.

INTRODUCTION
Tonsillectomy is one of the most routinely performed surgical procedures in children.[1] It is associated with higher
morbidity in relation to post-operative nausea and vomiting (PONV), pain, risk of bleeding and dehydration due to impaired
oral intake.[2] PONV is of multifactorial origin with a reported incidence ranging from 23 to 73%.[3]

Non-steroidal anti-inflammatory drugs have been widely used because of their prolonged analgesic efficacy and a lack of
the emetogenic effect inherent to opioids. However, classic NSAIDs through reversible platelet inhibition may further increase
the risk of bleeding after tonsillectomy.[4] Steroids can have beneficial effects on post-tonsillectomy morbidity due to their anti-
emetic and anti-inflammatory properties. The most used steroid for this purpose is dexamethasone, which is inexpensive and
largely devoid of side effects.

The mechanism of dexamethasone-induced antiemesis is not completely understood, but central inhibition of prostaglandin
synthesis and decrease of 5 hydroxy tryptamine turn-over in the central nervous system may be involved.[5]
We studied to find out the effect of a single intravenous dose of dexamethasone in a dose of 0.15 mg/kg on postoperative
pain, nausea and vomiting and quality of oral intake.

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 Article Title: Dexamethasone is Effective in Improving Post-Operative Outcomes in Paediatric Patients Undergoing
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METHODS
Institutional ethical committee approval was obtained prior to the study. A prospective randomized controlled study was
done from December 2018 to March 2020. Data was collected from all paediatric patients who were scheduled for elective
tonsillectomy under general anaesthesia with endotracheal intubation.Written informed consent was taken from the parents of
all patients included in the study, following which a detailed pre-anaesthetic evaluation was done. Adequate NPO status was
ensured,on the day of surgery, after arrival at the operation theatre the patient was shifted to the anaesthetic preparation room. A
total of 64 patients (32 in each group) were randomized into either group D or group C by a computer-generated random
number table. Children with chronic tonsillitis, aged between 6 to 16 years of ASA I or II were included in the study. Children
with known coagulopathy, hypersensitivity reaction to dexamethasone, congenital heart disease and mental retardation were
excluded from the study. Group D received a single dose of intravenous dexamethasone (0.15mg/kg) diluted in saline to the
total volume of 5 ml prior to induction of anaesthesia and group Creceived 5ml normal saline study drug was prepared and
coded in a 5 ml syringe by anaesthesiology resident (observer 1) who was not involved further in the study.

Tonsillectomy was performed by dissection and snare method. A standard anaesthetic technique was used in all children.
Once the patient was shifted inside the operation theatre, routine monitoring such as ECG, NIBP and pulse oximetry were
connected and monitored during and after anaesthesia, until the patient recovered from anaesthesia. After the insertion of the
intravenous line, all the patients were premedicated with injection glycopyrrolate 0.005 (mg/kg) and midazolam (0.05mg/kg).
All the patients were pre oxygenated for 3 mins and anaesthesia was induced with propofol (2mg/kg) and fentanyl (2 mcg/kg).
Neuromuscular blockade was achieved with inj atracurium (0.5mg /kg). All patients received inj paracetamol intravenous
15mg/kg. Once adequate depth was achieved, the trachea was intubated with an appropriate sized endotracheal tube. An
effective airway was confirmed with symmetrical bilateral chest expansion on manual ventilation, the square waveform on the
capnograph, stable oxygen saturation and no audible leaks of the gases. Before the commencement of surgery, the
anaesthesiology resident (observer 2) administered the study drug based on a computer-generated random number table.

Anaesthesia was maintained with sevoflurane (0.5 to 2 % MAC), nitrous oxide (50%) and oxygen (50%) and atracurium
(0.1mg/kg). Intra-operatively Ringer’s lactate with 1% dextrose was infused at a rate of 5ml/kg/hr. In addition, extra fluid
2ml/kg/hr of the starvation period was administered. Blood loss was replaced with three times the volume by crystalloid. After
surgery, residual secretions and blood were removed with gentle suction. Neuromuscular blockade was reversed with inj.
neostigmine (0.05 mg/kg) and inj glycopyrrolate (0.01 mg/kg). Patients were extubated when they had satisfactory motor
recovery and were fully awake. Observer 2, who was unaware of the drug administered monitored the patients in PACU and
evaluated the patients post-operatively at 30min, 3hr, 6hr, 12hr and 24 hours for pain, nausea, vomiting and oral intake. The
pain was assessed using an objective pain scale[6] in patients below 8 years and it was graded as (Significant pain = >6 Mild
pain = 4-5 Pain-free = 0-3) and visual analogue scale (VAS, 0-10) above 8 years of age and it was graded as (No pain= <2
Moderate = <4 >2, Severe = >4). Pain scores of more than 4 were treated with bolus dose of tramadol 1 mg/kg and
recorded.Post-operative nausea and vomiting (PONV) was assessed by using Bellville PONV scale.[7]

Which was graded as Grade 1: No symptoms, Grade 2: Subjective unpleasant sensation with awareness of the urge to vomit,
Grade 3: Retching, spasmodic contraction of abdominal wall and diaphragm muscles without expulsion of gastric contents and
Grade 4: Vomiting, same as the retching but with forceful expulsion of gastric contents.
PONV scores of 3 and above were treated with inj ondansetron 0.15mg/kg and recorded.
The quality of oral intake was graded as excellent = when the patient requested, good = the patient accepted when it offered,
fair = the patient accepted it when coaxed and Poor = when the patient refused it.

Statistical analysis
Sample size: A total sample of 64 patients (32 in each group) were required to detectincidence of PONV and pain for a
difference of 20%, to get 90% statistical power and 5% level of significance.
The data was presented as mean values with standard deviations, medians with range, or as a proportion with a 95 % confidence
interval (CI).Student’s t-test was used to compare normally distributed continuous variables between the two groups.
Categorical data was analysed by a Chi-square test or Fisher’s exact test. A p-value of < 0.05 was considered to be statistically
significant.Data were analysed using SPSS software v.23.0. and Microsoft office 2007.

RESULTS
This study comprised of 64 paediatric patients undergoing elective tonsillectomy in our institute from December 2018 to
March 2020. Chronic tonsillitis patients were selected randomly. In this study, 32 of the patients received intravenous
dexamethasone and the other 32 patients received normal saline.

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All the patients completed the study without any dropouts or major complications. Sixty-four paediatric patients were allocated
into two equal groups. The patients in the two groups were comparable regarding their demographic characteristics and duration
of surgery table (1)
Table 1: Demographic data and baseline characteristics in the two studied groups
Variables Study group Control group C p-value
(n=32) (n=32)
Age (years) 9.88 9.47 0.586
Weight (kg) 25.31 25.66 0.825
Gender Male 18 (56.3%) 17 (53.1%) 0.671
Female 14 (43.8%) 15 (46.9%)
ASA grading I 27 (84.4%) 26 (81.3%) 0.74
II 05 (60.0%) 06 (66.7%)
Duration of surgery (mins) 37.75 39.75 0.045

At 30 mins postoperatively 53.1% in the study group and 15.6 %in the control group had no pain, 31.3% in the study group
and 62.5% in the control group had moderate pain, 15.6% in the study group and 21.9% in the control group had severe pain. At
3 hours postoperatively 50.0% in the study group and 18.8 % in the control group had no pain, 40.6% in the study group and
62.5% in the control group had moderate pain, 9.4% in the study group and 18.8% in the control group had severe pain. At 6
hours postoperatively 68.8% in the study group and 50 %in the control group had no pain, 31.3% in the study group and 40.6%
in the control group had moderate pain, none of the patients in the study group and 9.4% in the control group had severe pain.
At 12 hours postoperatively 84.4% in the study group and 53.6% in the control group had no pain, 12.5% in the study group
and 37.5% in the control group had moderate pain, 3.1% in the study group and 6.3% in the control group had severe pain. At
24 hours postoperatively 87.5% in the study group and 53.1 % in the control group had no pain, 9.4% in the study group and
37.5% in the control group had moderate pain, 3.1% in the study group and 9.4% in the control group had severe pain (Figure
1).

Figure 1: Comparison of postoperative pain percentage between two groups

Table 2: Comparison of postoperative nausea and vomiting score between two groups
Post-operative nausea and Study group Control group p value
vomiting score (n=32) (n=32)
Duration Score
1 8 7 0.050*
30 min 2 18 9
3 3 6
4 3 10
1 17 6 0.040*
3 hours 2 9 16
3 4 6
4 2 4
1 20 9 0.049*
6 hours 2 7 13
3 3 7
4 2 3

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1 22 13 0.022*
12 hours 2 8 7
3 1 8
4 1 4
1 24 16 0.014*
24 hours 2 8 7
3 0 6
4 0 3
There was a statistically significant difference between both the groups with respect to postoperative nausea and vomiting
scores, at different time intervals of 30 mins, 3, 6, 12 and 24 hours (p-value< 0.05) (Table 2).

Table 3: Comparison of quality of oral intake, need for rescue analgesics and anti-emetics among the study group and
control group
Variable Study group Control group (n=32) P value
(n=32)
Quality of oral Excellent 7(21.9%) 2(6.3%)
intake Fair 16(50.0%) 9(28.1%)
Good 6(18.8%) 13(40.6%) 0.022
Poor 3(9.4%) 8(25.0%)
Need of rescue Yes 8(25.0%) 15(46.9%)
anti-emetic No 24(75.0%) 17(53.1%) 0.048
Need of rescue Yes 5(15.6%) 13(40.6%)
analgesics No 27(84.4%) 19(59.4%) 0.034

At 3 hours postoperatively, the quality of oral intake was excellent in the study group compared to the control group(p=0.022).
The needfor rescue anti-emetic and rescue analgesics were less in the study group compared to the control group.

DISCUSSION
Intravenous administration of dexamethasone in a dose of 0.15mg/kg at the time of induction of anaesthesia in children
undergoing tonsillectomy with or without adenoidectomy was associated with reduced post-operative pain, reduced post-
operative nausea and vomiting and improved quality of oral intake. We administered intravenous dexamethasone at the time of
induction of anaesthesia. In a study conducted by Wang et al., it was shown that administration of intravenous dexamethasone
at the time of induction of anaesthesia was more effective than when administered at the end of the procedure. [8] Tonsillectomy
is one of the most frequently performed surgical procedures in children.Tissue injury-induced acute inflammation, nerve
irritation and spasm of exposed pharyngeal muscle is known to play a role in the genesis of post-tonsillectomy pain.
Oropharyngeal pain and irritation of gastric mucosa by swallowed blood are two main contributors towards the high incidence
of postoperative nausea and vomiting following tonsillectomy. [9]

Steroids have a multiplicity of physiological actions, effects on metabolism, electrolyte and water metabolism, the central
nervous system and anti-inflammatory and immuno- suppressive actions. They exert their action by inhibiting phospholipase
enzyme, which block the cyclo-oxygenase and lipo-oxygenase pathway and thus prostaglandin production and thereby leading
to pain relief.[9] Dexamethasone is also known to have an anti-inflammatory effect.[10] We selected dexamethasone as it is
highly potent and has a prolonged half-life (36-72 hours) for glucocorticoid activity so that the effect would remain even after
the discharge of the patient. We used a single intravenous dose, as it is devoid of side effects like gastritis, adrenal suppression
etc.[11]
we observed that there was a significant reduction in post-operative pain in the study group compared to the control group
at different time intervals which is consistent with the study conducted by Elhakim et al. in which they observed that pain score
30 min after extubation were lower (p<0.05) in the dexamethasone group. Pain at 12 and 24 hours post- operatively were still
significantly less in the dexamethasone group than in the control group (p<0.01).[12] A similar study conducted by Hermans et
al. observed that the incidence of severe pain was reduced in the dexamethasone groups on the second postoperative day
(p=0.001).[13]

Some studies failed to demonstrate any beneficial effect of dexamethasone on the incidence of postoperative vomiting or the
degree of pain after tonsillectomy in children. These studies included a limited number of children and were not standardized
for both the anesthetic technique and other perioperative factors.[14]

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We selected the dose of intravenous dexamethasone as 0.15 mg/kg. A similar study by Steward et al. observed that doses
ranging from 0.15 mg/kg to 1 mg/kg with maximum doses ranging from 8 to 25 mg have been used in children15.Ohlms et al.,
used a higher dose of dexamethasone 0.5 mg/kg versus placebo at the start of the surgery and found no effect on postoperative
pain in the hospital or at home.[16]

We used two different pain scores for the evaluation of pain as we had selected patients between six and sixteen years. We
had chosen OPS (Objective Pain Scale) score of 6 or more or a VAS (Visual analogue scale) score of 4 or more as significant
pain.[17]

The number of patients requiring rescue analgesics and the doses needed was less in the dexamethasone group, which
indicates the prolonged analgesic effect of dexamethasone.

Postoperative nausea and vomiting are less in the dexamethasone group compared to the control group (p<0.05). Our results
are similar to the meta-analysis of eight published studies by Steward et al. in which they reported that in patients undergoing
tonsillectomy, pre-operative dexamethasone decreased vomiting incidence two times and improved oral intake of clear fluids
within the first 24 h when compared with the placebo group.[15]

The incidence of post-operative emesis is more frequent in paediatric patients than in adults.We included children between 6
to 16 years who are undergoing tonsillectomy. In a study conducted by Watcha et al. they observed that age was a cofactor for
the increased incidence of postoperative vomiting with a peak incidence at the pre-adolescent age.[18]

Post-operative vomiting depends on the type of surgery; the incidence is increased after strabismus, tonsillectomy or
orchiopexy than it is after extremity or orthopaedic surgery.Dexamethasone was first reported to be an effective anti-emetic
drug in patients receiving cancer chemotherapy.[19] In our study, the number of patients requiring rescue antiemeticswas less in
the study group compared to the control group (p= 0.048). Our results are similar to the study conducted by Henzi. I et al. in
their meta-analysis of 17 trials involving the use of intravenous dexamethasone for the prevention of postoperative nausea and
vomiting in surgical patients. The number needed to treat to prevent early and late vomiting compared with placebo in adults
and children were 7.1 (95% CI 4.5 to 18) and 3.8 (2.9 to 5) respectively, they concluded that when there is a high risk of
postoperative nausea and vomiting, a single prophylactic dose of dexamethasone is anti-emetic compared with placebo, without
evidence of any clinically relevant toxicity in otherwise healthy patients.[20]

William et al. in their study found that dexamethasone reduced the overall incidence of vomiting from 72% (placebo) to
40% (p<0.001). Vomiting, both in hospital and post-discharge, was decreased by the prophylactic administration of
dexamethasone.[21]

Time to first liquid intake was similar between the groups, but the first solid intake was earlier in the dexamethasone group
compared to the placebo group (6 hours vs 10 hours; p <0.05). Our results are consistent with a study conducted by Pappas et
al. in which they observed a decrease in the overall incidence of postoperative vomiting, especially during the 24 hours after
discharge, as well as an improvement in the post-operative quality of oral intake in children undergoing tonsillectomy who
received dexamethasone 1 mg/kg after the induction of anaesthesia as compared with those in a control group.[22] A prospective,
randomized, double-blind study by Volk et al. observed no differences in postoperative recovery variables, such as oral intake,
level of activity, and analgesic use, in children who received a single dose of dexamethasone 10 mg IV versus placebo,
although they did not specifically examine PONV.[23]

Aouad et al. in their study found that the vomiting incidence in patients undergoing tonsillectomy or adenotonsillectomy
was 10% in the dexamethasone group and in the placebo group it was 30% (p<0.05).[24] The decrease in vomiting in the study
group might also be attributed to the potentiation of the effect of the analgesic combination used. Also, the late efficacy of
dexamethasone is consistent with its biological half-life of 36 to 48 hours.

In a similar study conducted by April MM et al. involving 80 children who received 0.1 mg/kg of intravenous
dexamethasone or placebo prior to adenotonsillectomy and measured post-operative oral intake, pain, vomiting, and
complications during the first 24 hours. The dexamethasone group had significantly less trismus and vomiting in the first 6
hours post-operatively, and more oral intake (including earlier solid food) than the control group.[25]

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We allowed oral feeding three hours after the operation. The amount of oral intake was higher in the study group compared
to the control group (p=0.022). Our results are consistent with the study conducted by Pappas et al. Their observation found that
there was no significant difference in the pain scores and quality of oral intake within the first three hours between the two
groups postoperatively; however, when examining the 24 h quality of oral intake, the dexamethasone group showed significant
improvement. Additionally, the number of children who returned to the hospital due to dehydration and poor oral intake was
higher in the placebo group.[24] Complications from corticosteroid therapy, such as an increased rate of infection, peptic
ulceration, and adrenal suppression, are usually related to its long-term use. The risks of steroid therapy of <24 hours are
negligible.[11]

CONCLUSION
A single intravenous dose of 0.15 mg/kg of dexamethasone given at induction of general anaesthesia in paediatric patients
undergoing elective tonsillectomy with or without adenoidectomy results in a reduced incidence of postoperative nausea and
vomiting. Provides better and prolonged post-operative pain relief resulting in an earlier and better quality of oral intake and
reduces the requirement of rescue analgesics and anti-emetics.

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