Preoperative intravenous glucocorticoids can reduce postoperative acute pain following total knee arthroplasty

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Abstract

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Abstract

Background:

The ability of preoperative intravenous glucocorticoids to control pain after total knee arthroplasty (TKA) has been examined in many studies, but it remains controversial. Therefore, we undertook a meta-analysis of randomized controlled trials (RCTs) to evaluate the efficacy and safety of preoperative intravenous glucocorticoids for postoperative pain management after TKA.

Methods:

We systematically searched RCTs from electronic databases, including PubMed, Embase, Web of Science, the Cochrane Library, the Chinese Wanfang Database, and the China National Knowledge Infrastructure database. The outcomes included visual analogue scale (VAS) scores at 6, 12, 24, 48, and 72 hours after TKA; the occurrence of postoperative nausea and vomiting (PONV); blood glucose at 6 and 24 hours after TKA; and the occurrence of infection.

Results:

Of the identified studies, a total of 11 RCTs involving 1000 patients (glucocorticoids = 501, control = 499) were included in this meta-analysis. Compared with a placebo, preoperative intravenous glucocorticoids significantly reduced VAS scores at 6, 12, 24, and 48 hours, with decreases of 3.63 points, 6.81 points, 10.40 points, and 3.15 points, respectively, on a 110-point VAS. Moreover, intravenous glucocorticoids were associated with significant decreases of 19.4% and 16.8% in the occurrence of nausea and vomiting, respectively. However, intravenous glucocorticoids were also associated with increased blood glucose with no clinical importance at 6 hours after TKA. No significant difference was found in the occurrence of infection or in blood glucose at 24 hours after TKA.

Conclusion:

Preoperative intravenous glucocorticoids are an effective and safe method to reduce postoperative pain and PONV in patients following TKA. More studies are necessary to identify the optimal dose and type of glucocorticoids for maximal pain control.

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Most cited references 21

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A simplified risk score for predicting postoperative nausea and vomiting: conclusions from cross-validations between two centers.

C. C. Apfel, E Läärä, M Koivuranta … (1999)

Recently, two centers have independently developed a risk score for predicting postoperative nausea and vomiting (PONV). This study investigated (1) whether risk scores are valid across centers and (2) whether risk scores based on logistic regression coefficients can be simplified without loss of discriminating power. Adult patients from two centers (Oulu, Finland: n = 520, and Wuerzburg, Germany: n = 2202) received inhalational anesthesia (without antiemetic prophylaxis) for various types of surgery. PONV was defined as nausea or vomiting within 24 h of surgery. Risk scores to estimate the probability of PONV were obtained by fitting logistic regression models. Simplified risk scores were constructed based on the number of risk factors that were found significant in the logistic regression analyses. Original and simplified scores were cross-validated. A combined data set was created to estimate a potential center effect and to construct a final risk score. The discriminating power of each score was assessed using the area under the receiver operating characteristic curves. Risk scores derived from one center were able to predict PONV from the other center (area under the curve = 0.65-0.75). Simplification did not essentially weaken the discriminating power (area under the curve = 0.63-0.73). No center effect could be detected in a combined data set (odds ratio = 1.06, 95% confidence interval = 0.71-1.59). The final score consisted of four predictors: female gender, history of motion sickness (MS) or PONV, nonsmoking, and the use of postoperative opioids. If none, one, two, three, or four of these risk factors were present, the incidences of PONV were 10%, 21%, 39%, 61% and 79%. The risk scores derived from one center proved valid in the other and could be simplified without significant loss of discriminating power. Therefore, it appears that this risk score has broad applicability in predicting PONV in adult patients undergoing inhalational anesthesia for various types of surgery. For patients with at least two out of these four identified predictors a prophylactic antiemetic strategy should be considered.

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

H Kehlet, Troels Lunn, Niels Kristensen … (2011)

Total knee arthroplasty (TKA) is associated with severe pain and inflammation despite an extensive multimodal analgesic approach, but the effect of high-dose glucocorticoid administration has not been studied. Forty-eight patients undergoing unilateral TKA were included in a randomized, double-blind, placebo-controlled trial receiving preoperative methylprednisolone (MP) 125 mg i.v. or saline. All surgery was performed under lumbar spinal anaesthesia and patients received a standardized, multimodal analgesic regime. The primary endpoint was pain during walking 24 h after surgery, and secondary endpoints were pain at rest, pain upon hip flexion, and pain upon knee flexion. Pain assessments were performed repeatedly for the first 48 h after surgery, in a questionnaire from days 2 to 10, and at follow-up on days 21 and 30. Tertiary endpoints were postoperative nausea and vomiting (PONV), plasma C-reactive protein (CRP) concentrations, fatigue, sleep quality, and rescue analgesic and antiemetic requirements. Pain during walking was significantly lower in the MP group up to 32 h after operation. Overall pain and cumulative pain scores (2-48 h) were lower for all pain assessments (P<0.04). Consumption of rescue oxycodone was lower from 0 to 24 h (P=0.02) and PONV, consumption of ondansetron reduced (P<0.05), and CRP concentrations were lower at 24 h (P<0.000001). Fatigue throughout the day of surgery was lower (P=0.02), but sleep quality was worse on the first night (P=0.002). No side-effects or complications were observed in other respects. 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.

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Pain Management Modalities after Total Knee Arthroplasty: A Network Meta-analysis of 170 Randomized Controlled Trials.

Abdullah Terkawi, Dimitris Mavridis, Daniel Sessler … (2017)

Optimal analgesia for total knee arthroplasty remains challenging. Many modalities have been used, including peripheral nerve block, periarticular infiltration, and epidural analgesia. However, the relative efficacy of various modalities remains unknown. The authors aimed to quantify and rank order the efficacy of available analgesic modalities for various clinically important outcomes.

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Author and article information

Journal

Journal ID (nlm-ta): Medicine (Baltimore)

Journal ID (iso-abbrev): Medicine (Baltimore)

Journal ID (publisher-id): MEDI

Title: Medicine

Publisher: Wolters Kluwer Health

ISSN (Print): 0025-7974

ISSN (Electronic): 1536-5964

Publication date Collection: September 2017

Publication date (Electronic): 01 September 2017

Volume: 96

Issue: 35

Electronic Location Identifier: e7836

Affiliations

Department of Orthopaedics, The Eighty-Ninth Hospital of PLA, Weifang, Shandong Province, China.

Author notes

[∗ ]Correspondence: Xiangcheng Liu, Department of Orthopaedics, The Eighty-Ninth Hospital of PLA, No. 256, North Palace West St, Weifang City, Shandong Province 261021, China (e-mail: liuxiangcheng@ 123456163.com ).

Article

Publisher ID: MD-D-17-03261 Accession ID: 07836

DOI: 10.1097/MD.0000000000007836

PMC ID: 5585486

PubMed ID: 28858092

SO-VID: 02f0adff-cb76-4b44-b9de-cab4859d87af

License:

This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial License 4.0 (CCBY-NC), where it is permissible to download, share, remix, transform, and buildup the work provided it is properly cited. The work cannot be used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc/4.0

History

Date received : 25 May 2017

Date revision received : 17 June 2017

Date accepted : 1 July 2017

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Keywords: glucocorticoids,meta-analysis,pain control,total knee replacement

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Keywords: glucocorticoids, meta-analysis, pain control, total knee replacement

Preoperative intravenous glucocorticoids can reduce postoperative acute pain following total knee arthroplasty : A meta-analysis

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Most cited references 21

A simplified risk score for predicting postoperative nausea and vomiting: conclusions from cross-validations between two centers.

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

Pain Management Modalities after Total Knee Arthroplasty: A Network Meta-analysis of 170 Randomized Controlled Trials.

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