Department of Anesthesiology, Xiangya Hospital, Central South University, Changsha, Hunan, China; National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, China.
Pain Physician. 2022 Mar;25(2):E169-E183.
Postoperative pain after total knee arthroplasty (TKA) is intense and remains an unsolved problem. Some studies show that perioperative, multimodal analgesia, including intravenous dexamethasone, can provide a better analgesic effect; however, the validity of studies has raised concerns and questions remain around the efficacy, dosing, and safety of dexamethasone in patients undergoing total knee arthroplasty.
The purpose of this systematic review and meta-analysis was to evaluate the impact of intravenous dexamethasone on postoperative pain among patients undergoing TKA.
Systematic review and meta-analysis.
Web of Science, Embase, PubMed, and the Cochrane Central Register of Controlled Trials were searched to identify relevant randomized controlled trials. The last search was in August 2021.
The risk of bias of the included trials was assessed by the Cochrane Risk of Bias Tool. The primary outcome was postoperative visual analog scale (VAS) pain scores and secondary outcomes included cumulative equivalent intravenous morphine consumption, number of patients requiring rescue analgesic, length of hospital stay, and adverse events. We assessed the certainty of evidence according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach.
Eleven studies with 1,671 patients were included. The pooled results indicated that patients receiving dexamethasone had lower VAS pain scores at rest (24 h, MD = -0.68, [95% CI: -0.87 to -0.49]; 48 h, MD = -0.33, [95% CI: -0.46 to -0.21]) and at movement (24 h, MD = -0.74, [95% CI: -1.10 to -0.37]; 48 h, MD = -0.46, [95% CI: -0.66 to -0.26]), required less morphine (24 h, MD = -2.84 mg, [95% CI: -5.13 to -0.54]; 48 h, MD= -4.16 mg, [95% CI: -5.55 to -2.78]) and rescue analgesics, and had shorter hospitalization. There was no increase in infection, gastrointestinal hemorrhage, wound healing problems, or blood glucose levels with dexamethasone. Subgroup analysis did not observe difference between single dose and repeat dose groups.
The perioperative multimodal analgesia measures were varied throughout the studies. The sample size was small for some outcomes and high heterogeneity was observed.
Our results supported the addition of perioperative intravenous dexamethasone to multimodal analgesia in total knee arthroplasty to reduce postoperative pain, opioids consumption, and length of hospital stay. Current evidence did not support the superiority of repeated-dose dexamethasone over single-dose dexamethasone; thus, we recommended perioperative 8-10 mg intravenous dexamethasone to be used based on adequate basic analgesia; however, the results may have been affected by small sample sizes and heterogeneity.
全膝关节置换术后（TKA）的疼痛剧烈，仍然是一个未解决的问题。一些研究表明，围手术期多模式镇痛，包括静脉注射地塞米松，可以提供更好的镇痛效果；然而，研究的有效性引起了关注，并且对地塞米松在接受全膝关节置换术的患者中的疗效、剂量和安全性仍存在疑问。
本系统评价和荟萃分析的目的是评估静脉注射地塞米松对 TKA 患者术后疼痛的影响。
系统评价和荟萃分析。
在 Web of Science、Embase、PubMed 和 Cochrane 对照试验中心注册库中搜索相关的随机对照试验。最后一次搜索是在 2021 年 8 月。
采用 Cochrane 偏倚风险工具评估纳入试验的偏倚风险。主要结局是术后视觉模拟评分（VAS）疼痛评分，次要结局包括累积等效静脉吗啡消耗量、需要解救镇痛的患者人数、住院时间和不良事件。我们根据推荐评估、制定和评估（GRADE）方法评估证据的确定性。
纳入了 11 项研究，共 1671 名患者。汇总结果表明，接受地塞米松治疗的患者在休息时（24 小时，MD = -0.68，[95%CI：-0.87 至 -0.49]；48 小时，MD = -0.33，[95%CI：-0.46 至 -0.21]）和运动时（24 小时，MD = -0.74，[95%CI：-1.10 至 -0.37]；48 小时，MD = -0.46，[95%CI：-0.66 至 -0.26]）的 VAS 疼痛评分较低，需要较少的吗啡（24 小时，MD = -2.84 毫克，[95%CI：-5.13 至 -0.54]；48 小时，MD= -4.16 毫克，[95%CI：-5.55 至 -2.78]）和解救镇痛药，住院时间较短。地塞米松并未增加感染、胃肠道出血、伤口愈合问题或血糖水平的发生。亚组分析未观察到单剂量组和重复剂量组之间的差异。
研究中的围手术期多模式镇痛措施各不相同。一些结局的样本量较小，存在高度异质性。
我们的结果支持在全膝关节置换术的多模式镇痛中加入围手术期静脉注射地塞米松，以减轻术后疼痛、阿片类药物消耗和住院时间。目前的证据并不支持重复剂量地塞米松优于单剂量地塞米松；因此，我们建议根据充分的基础镇痛使用围手术期 8-10 毫克静脉地塞米松；然而，结果可能受到样本量小和异质性的影响。
