The Unseen Helper in the Operating Room
For every patient heading into surgery, the CRNA makes dozens of decisions grounded in core concepts of anesthesia, patient safety, and best practices in CRNA education. But one of the most impactful choices might be a single, inexpensive drug—one that not only prevents the nausea you might fear but also helps you feel more like yourself again, faster. At CRNAeducation.com, believe in staying as up-to-date as possible in the concepts of anesthesia.
That drug is dexamethasone. For decades, it has been a go-to for preventing postoperative nausea and vomiting, an issue that is often of “greater concern to patients than postoperative pain.” It is a type of corticosteroid, routinely administered as a single dose during surgery. But its benefits don’t stop at settling your stomach.
Recent, large-scale clinical trials have shed new light on this workhorse medication, confirming that its benefits are broader than previously understood and that its safety profile is incredibly reassuring. In fact, its full benefits, particularly at the optimal dose, are only now being fully appreciated. Here are three things you should know about this common but surprisingly powerful drug.
Takeaway 1: The Biggest Fear About Steroids in Surgery Appears to Be a Myth
It Doesn’t Increase Your Risk of Infection
One of the most logical and persistent concerns about using corticosteroids like dexamethasone during surgery is their potential to increase the risk of infection. Steroids work by suppressing the immune system, which is great for reducing inflammation but could theoretically make a patient more vulnerable to a surgical site infection. It’s important to distinguish this single, perioperative dose from the chronic steroid therapy used for some medical conditions, which operates very differently and is associated with a different set of risks.
The most compelling data to address this concern comes from a large, international study known as the PADDI trial. This pragmatic trial enrolled 8,725 patients undergoing noncardiac surgery and was specifically designed to answer the question of infection risk. The results were completely reassuring. The study found that a single 8 mg dose of dexamethasone did not increase the risk of surgical site infection.
For emphasis, here are the specific results:
- Surgical site infection occurred in 8.1% of patients who received dexamethasone.
- Surgical site infection occurred in 9.1% of patients who received the placebo.
In simple terms, the results proved with a high degree of confidence (P < 0.001) that dexamethasone was no worse than a placebo when it came to infection risk. This is a powerful and reassuring finding, dismantling one of the primary barriers to the drug’s wider use and providing peace of mind for patients.
Takeaway 2: It Does More Than Stop Nausea—It Helps You Feel Better, Faster
It Improves Your Overall “Quality of Recovery”
While dexamethasone is highly effective against postoperative nausea and vomiting (PONV), its benefits extend far beyond that single symptom. Evidence shows that it improves a patient’s overall “Quality of Recovery” (QoR). This concept is covered extensively in CRNA core modules and CRNA pharmacology articles. Our pharmacology articles count towards your CRNA Class A Credits.
QoR is a measure that captures a patient’s complete postoperative experience. It includes physical factors like pain levels and fatigue, as well as emotional factors like your mood and mental state. A better QoR score means you don’t just feel less sick; you feel better overall, sooner. While a 4 mg dose is effective for nausea, studies show that a slightly higher dose of 8-10 mg is the key to unlocking these broader recovery benefits.
Studies show that patients receiving dexamethasone experience significant improvements across multiple aspects of their recovery:
- Less discomfort: Patients reported less fatigue, muscle pain, confusion, and even less difficulty falling asleep.
- Faster return to normal life: In one study, patients who received dexamethasone resumed their recreational activities in a median of just one day, compared to two days for those who received a placebo.
- Better recovery scores: Higher doses of dexamethasone (around 8-10 mg) led to clinically important improvements in QoR scores and, in one trial, a hospital discharge time that was 30 minutes shorter.
Takeaway 3: It’s Surprisingly Safe, Even for Patients with Diabetes
It’s Considered Safe for Patients with Diabetes
The other major concern associated with steroids is their effect on blood sugar. As a glucocorticosteroid, dexamethasone can and does temporarily increase blood glucose levels. This has historically made clinicians cautious, fearing that even a temporary spike in blood sugar could compromise the body’s ability to heal and increase the risk of infection.
However, crucial new data provides powerful reassurance for this patient group. The PADDI trial, which provided such compelling evidence regarding infection risk, also included 1,149 patients with known diabetes. For concepts of anesthesia, the key finding for this subgroup was clear: patients with diabetes who received dexamethasone were not at an increased risk of surgical site infection.
Furthermore, the trial quantified the drug’s effect on blood sugar and found it to be modest. The median difference in the peak blood glucose level between the dexamethasone and placebo groups in the first 48 hours after surgery was only 1.3 mmol/l. While a small number of patients may require temporary insulin therapy to manage this brief increase, the data suggests the overall clinical significance of this effect is “likely to be very small.” This is vital information that supports the safe use of this beneficial drug in a large patient population that can benefit from a smoother recovery.
Conclusion: A Cheap, Safe, and Effective Tool for Better Recoveries
The evidence is clear in concepts of anesthesia: dexamethasone is a cheap, safe, and effective drug that is a powerful tool in modern surgery. It not only excels at its well-known job of preventing nausea and vomiting but also helps patients feel better faster by improving their overall quality of recovery. Most importantly, large-scale studies have shown that it accomplishes this without increasing key risks like surgical site infection, even in vulnerable groups like patients with diabetes.
The evidence suggests an 8 mg dose is a sweet spot, providing robust anti-nausea effects, enhancing overall recovery, and proven to be exceptionally safe. Given the powerful evidence, the bigger question might be why this simple, inexpensive drug isn’t a standard part of every patient’s surgical plan.
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