Dexamethasone administered for tonsillectomy nausea and vomiting in children also increases post-operative bleeding

Dexamethasone administered for tonsillectomy nausea and vomiting in children also increases post-operative bleeding

Dexamethasone, when administered after tonsillectomies in children, is effective in reducing nausea and vomiting, but is also associated with increased risk of postoperative bleeding, according to a study released on December 9, 2008.

In children, one of the most frequently performed surgical procedures is tonsillectomy. Approximately 186,000 procedures are performed on an outpatient basis every year in the US. The steroid drug dexammethazone is commonly prescribed to relieve postoperative nausea and vomiting (PONV) which are common complications. However, it has not been clearly shown what dosing is effective for and what adverse effects there may be due to this drug, according to the article.

To investigate the most effective does of dexamethasone in children after tonsillectomy, Christoph Czarnetzki, M.D., M.B.A., of the University Hospitals of Geneva, Switzerland, and colleagues performed a randomized controlled trial in 215 children undergoing elective tonsillectomy at a hospital in Switzerland between February 2005 and December 2007. Each child was randomly assigned to receive one of four doses of dexamethasone (0.05, 0.15, or 0.5 milligrams of drug per kilogram of body weight) or placebo intravenously after initiation of anesthesia. Pain relief was provided with acetaminophen-codiene and ibuprofen, and the children were followed up for ten days following the operation.

At least 1 PONV episode occurred within 24 hours in 44% of the children receiving placebo, 38% of the children receiving 0.05 mg/kg dexamethasone, 24% of the children receiving 0.15 mg/kg dexamethasone, 12% of the children receiving 0.5 mg/kg dexamethasone. In the adverse effects after the surger, 26 postoperative bleeding episodes were observed in 22 children. This occurred in 4% of children receiving placebo, 11% receiving 0.05 mg/kg dexamethasone, 4% receiving 0.15 mg/kg dexamethasone, 24% receiving 0.5 mg/kg dexamethasone.

Administration of this highest dose of dexamethasone was associated with 7 times higher risk of bleeding than the placebo. Emergency re-operation was necessary in 8 of the study's children due to post-tonsillectomy hemorrhaging, and all of these children had received the drug. The trial was thus discontinued for safety reasons, and the authors note that this association was unexpected.

The authors write: "In summary, in children undergoing tonsillectomy, dexamethasone has a significant and dose-dependent antiemetic [prevents or alleviates nausea and vomiting] effect and decreases the need for rescue analgesia with nonsteroidal anti-inflammatory drugs [NSAIDs]. However, it cannot be excluded that dexamethasone, possibly through inhibition of wound healing, increases the risk of postoperative bleeding in this specific setting. Randomized trials that are specifically designed to confirm or refute our findings are needed, although it may be difficult to perform such trials in children. Future trials should involve several centers to improve the applicability of the results. In the meantime, and even though dexamethasone is a potent antiemetic drug, it may be prudent to avoid it in children undergoing tonsillectomy."

Dexamethasone and Risk of Nausea and Vomiting and Postoperative Bleeding After Tonsillectomy in Children: A Randomized Trial

Christoph Czarnetzki, MD, MBA; Nadia Elia, MD, MSc; Christopher Lysakowski, MD; Lionel Dumont, MD; Basile N. Landis, MD; Roland Giger, MD; Pavel Dulguerov, MD; Jules Desmeules, MD; Martin R. Tramèr, MD, DPhil

JAMA. 2008;300(22):2621-2630.

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