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Impact of Introducing Routine Dexamethasone for Cesarean Delivery: A Retrospective Quality Improvement Project
Abstract Number: T4A-4
Abstract Type: Original Research
Background: Dexamethasone is an effective analgesic and anti-emetic in general surgical and gynecologic patients (1,2), but its effects on pain after cesarean delivery (CD) under spinal or combined spinal-epidural (CSE) anesthesia with multimodal analgesia (intrathecal morphine and scheduled postoperative acetaminophen plus ibuprofen) are unclear. The aim of this impact study was to evaluate if the introduction of routine intraoperative administration of dexamethasone improved pain and decreased postoperative nausea or vomiting (PONV) after CD.
Methods: An IRB waiver was obtained for this retrospective quality improvement initiative. Electronic medical record data was obtained for 5 months before and 5 months after a practice change that introduced the routine use of intravenous (IV) dexamethasone 4 mg after delivery for all scheduled CD. Our standard spinal or CSE anesthetic is 12 mg hyperbaric bupivacaine, 15 mcg fentanyl, and 150 mcg morphine, with scheduled acetaminophen and ibuprofen postoperatively and oral oxycodone for breakthrough pain. IV opioids are reserved for severe pain or if NPO. The primary outcome was time to first opioid use. Secondary outcomes were 48h postoperative opioid consumption (IV morphine equivalents) as well as between 0-6h, 6-12h, 12-24h, 24-36h, and 36-48h, peak and mean visual pain scores (VPS 0-10), anti-emetic usage, and PONV incidence.
Results: A total of 404 women were evaluated (n=178 no dexamethasone and n=226 receiving dexamethasone). There was no difference in time to first opioid use (11.02 hours before and 11.71 hours after the introduction of dexamethasone; p=0.59). Opioid use was similar in all timeframes; 0-6h (p=0.21), 6-12h (p=0.75), 12-24h (p=0.66), 24-36h (p=0.20), 36-48h (p=0.84) and in total over 48h (40.5 mg before vs. 37.3 mg after; p=0.37). Mean VPS from 0-6h was similar before and after (1.1 vs. 1.0; p=0.28), as were peak (p=0.11) and mean (p=0.87) VPS in the first 48h. The percentage of patients receiving anti-emetic therapy postoperatively was not different in the no dexamethasone and dexamethasone groups (7.9% vs. 7.1%; p=0.77), nor was the percentage of patients who reported having had any PONV at post-operative day 2 follow-up (33.5% vs. 29.2%; p=0.39).
Discussion: This impact study of over 400 patients before and after a practice change of intraoperative dexamethasone administration during CD found no significant improvement of postoperative time to opioid request, opioid consumption, or pain scores. Additionally, we were unable to find any difference in the incidence of or treatment for PONV. Future studies are required to determine if a larger dose or repeated administration influence postoperative analgesia or PONV, and whether a subset of patients may benefit, for example those in whom NSAIDs are contraindicated.
1. Br J Anaesth. 2013;110(2):191-200.
2. Anesth Analg. 2009;109(2):607-615.