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Betamethasone Reduces Postoperative Pain and Nausea
After Ambulatory Surgery
Vidar Aasboe,
MD*,
Johan C. Raeder,
PhD, MD*,
and Bjarne Groegaard,
rhD, MDt
Departments of *Anesthesia and tsurgery, Ullevaal University Hospital, Oslo, Norway
The aims of this study were to evaluate the effects of a
single-dose glucocort icoid on the incidence andseverity
of pain and nausea and vomiting (PONV) after ambula-
tory surgery. Seventy-eight ASA physical status I-III pa-
tients scheduled for hemorrhoidectomy or hallux valgus
correction were studied using a randomized, double-
blind, placebo-controlled protocol. One group received
12 mg of betametbasone lM 30 min before the start of sur-
gery (Group B), whereas the placebo group (Group I) re-
ceived saline. General anesthesia was induced with
propofol and fentanyl and maintained with isoflurane in
both groups. Pain (measured using a visual analog scale,
verbal score, and analgesic requirements), PONV, and
other side effects were evaluated postoperatively. Pa-
tients in Group B experienced significantly less postoper-
ative pain, less PONV, and better pat ient satisfaction dur-
ing the first 24 h after surgery. ln conclusion, a single dose
of betametbasone (12 mg) seemed to produce analgesic
and antiemetic effects after day-case surgery. Implica-
tions:
ln aplacebo-controlled tudy, the useof corticoste-
roid prophylaxis (betamethasone)roduceda significant
reduction n both postoperativepainand nausean outpa-
tientswho received he corticosteroid njectionbefoream-
bulatory foot or hemorrhoidoperations.
(Anesth Analg 1998;87:319-23)
rostaglandins are important mediators of pain.
P
y inhibiting the phospholipase enzyme, the
glucocorticoids block both the cyclooxygenase
and the lipooxygenase pathway in the inflammatory
chain reaction. Thus, these compounds may be effec-
tive in reducing pain and may have a different side-
effect profile than the nonsteroidal antiinflammatory
drugs (NSAIDs).
Corticosteroids have been studied for postoperative
pain relief in oral surgery (l-3). Skjelbred and L&ken
(1) found that 9 mg of betamethasone after dental
surgery alleviated postoperative pain and swelling
effectively. Although analgesic effects have also been
reported after general surgery (4), orthopedic surgery
(5), or back surgery (6,7), others studies have not cor-
roborated these reports (8-11).
The aim of the present study was to evaluate the
postoperative effects of betamethasone 12 mg IM after
proctologic or orthopedic ambulatory surgery.
Financial upportwasprovidedasa research rantbeforestudy
start from Shering-Plough, orway, the distributor of Celeston
Chronodosebetamethasone).
Accepted or publicationMay 5, 1998.
Addresscorrespondencend reprint requestso Vidar Aasboe,
MD, Department f Anesthesia, estfoldCentralHospital,N-1603
Fredrikstad, orway.
01998 by the International Anesthesia Research Society
0003-2999/98/$5.00
Methods
The study was approved by our regional ethics com-
mittee and was performed according to the Helsinki II
Declaration. Eighty patients scheduled for ambulatory
surgery involving either hallux valgus (Mitchells op-
eration) or hemorrhoids (Milligans operation) were
included after giving their informed consent. The in-
clusion criteria included age >18 yr, ASA physical
status I-III, and no corticosteroids during last week or
NSAIDs during the 2 days before the operation. The
exclusion criteria included known allergy or contrain-
dications to any of the test drugs or pregnancy.
All the patients were instructed in the use of the
visual analog scale (VAS) for pain, with an unmarked
line of 100 mm from 0 = no pain to 100 = most
extreme pain, before surgery. The patients were ran-
domly assigned to double-blind administration, from
coded ampules, of 2 mL of the test drug IM 30 min
before the start of surgery. Group B received beta-
methasone 12 mg, containing 50 betamethasone di-
sodiumphosphate with fast onset and 50 betametha-
sone acetate with slower onset and longer duration.
Group I received 2 mL of saline in lipid solution,
which was prepared by the hospital pharmacy to ap-
pear identical to the test drug.
The patients received midazolam 0.04 mg/kg IV
on arrival in the operating room. General anesthesia
was induced with fentanyl 2 pg/kg and propofol
Anesth Analg 1998;87:319-23 319
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320
AMBULATORY ANESTHESIA AASBOE ET AL.
EFFEC T OF BETAMETHASO NE ON PONV
ANESTH ANALG
1998;87:319-23
2.0 mg/kg IV. Anesthesia was maintained with isoflu-
rane 0.5 -1.5 and nitrous oxide 66 in oxygen
without opioid supplementation. Isoflurane was ad-
justed to maintain the mean arterial pressure and
heart rate within 30 of preoperative values. The
patients breathed spontaneously through a laryngeal
mask airway and were monitored with end-tidal cap-
nography and gas monitor, pulse oximeter, electrocar-
diogram, and noninvasive blood pressure device.
The postoperative pain was evaluated 0, 1,2,3, and
4 h after surgery using the loo-mm VAS, a verbal
score of O-3 (0 = no pain, 1 = slight pain, 2 = mod-
erate pain, 3 = severe pain), and opioid requirements
(meperidine 10 mg IV when requested or VAS
>40 mm). Side effects such as postoperative nausea
and vomiting (PONV), dyspepsia, bleeding, and seda-
tion were subjectively evaluated. Any episode of
PONV (including retching) during the preceding hour
was noted. Metoclopramide 10 mg was given IV for
PONV when requested by the patient. After the first 4
postoperative hours, the patients received acetamino-
phen 500 mg + codeine 30 mg tablets for pain when
needed. Times to eligibility for discharge were evalu-
ated regularly according to the criteria of Korttila (12),
and the actual discharge time was noted.
The day after surgery, the patients were contacted
by telephone and asked to evaluate their pain using
the verbal score during rest, ambulation, sitting in a
chair (for hemorrhoid patients), and leg movement
(for hallux valgus patients). They were also asked
about analgesic consumption and the occurrence of
PONV. The patients were asked to evaluate their over-
all experience during the postoperative period as ei-
ther unacceptable, adequate, or good. A similar tele-
phone interview was performed 7 days after the
surgery.
To detect a reduction in moderate to severe postop-
erative pain from 60 to 30 with a power of 0.8 and
a P value of 0.05, 80 patients were studied. The data
were analyzed by using Students t-test for parametric
data and the Mann-Whitney U-test or 2 test for non-
parametric data, with a P value ~0.05 regarded as
significant.
Results
Eighty patients were included in the study. Two pa-
tients were excluded because the surgical procedure
was changed after inclusion. There were no significant
differences between the two groups in demographic
data (Table 1) or vital signs in the perioperative pe-
riod. The postoperative data for the two groups dis-
tributed as a function of the surgical procedure are
shown in Table 2. Because data for hallux valgus
correction and hemorrhoid extirpation were similar,
these data were pooled. On admission to the recovery
Table 1. Demographic Data
Group P Group B
(placebo, = 40) (betamethasone,= 38)
Age (ye=4
45 + 14 44 ? 13
Height (cm) 168 6.8 169 c 13
Weight (kg) 64? 11 65 ? 10
Male/female 5 /35 10 28
Hemorrhoids/ 18 22
24 /14
hallux valgus
Duration of surgery
e-4
Hemorrhoids
16? 6 15+ 6
Hallux valgus 25-c5 26 ? 9
Propofoldose mg)
135+26
135 2 27
room, 58 of the patients in Group I complained of
moderate or severe pain, significantly more than in
Group B (32 ). In the 4-h postoperative observation
period, significantly more pain was reported by the
patients in Group P 3 and 4 h postoperatively (Fig. 1).
In the 4-h postoperative observation period, there was
no significant difference in PONV or in the need for
antiemetics between the groups, with 11 patients
(28 ) in Group I receiving metoclopramide versus 7
(18 ) in Group B. There were no differences in other
side effects, time to eligibility for discharge, or actual
discharge time between the two groups.
In the 5- to 24-h postoperative observation period,
significantly more PONV and pain occurred in the
placebo group. Only 4 (11 ) patients experienced any
nausea or vomiting in Group B, versus 15 (38 ) in
Group P (P < 0.01). Only nine patients in Group B
(24 ) experienced moderate or severe pain, compared
with 25 (63 ) in Group P (P < 0.001) (Fig. 2). In the
patients undergoing hemorrhoidectomy, there was
also significantly more pain in Group P while sitting
(P < 0.05). In the hallux valgus patients, pain was
significantly more severe in Group P during leg move-
ment (P < 0.05).
When the patients were asked for overall postoper-
ative satisfaction at 24 h, significantly more patients
had a good experience in Group B (Table 3) (P
