Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Køge, Denmark.
Department of Anaesthesiology, Naestved Hospital, Naestved, Denmark.
Acta Anaesthesiol Scand. 2023 Jul;67(6):688-702. doi: 10.1111/aas.14237. Epub 2023 Mar 23.
Paracetamol and non-steroidal anti-inflammatory drugs (NSAIDs) are recommended as the basic pain treatment regimen for most surgeries. Glucocorticoids have well-known anti-inflammatory and anti-emetic properties and may also demonstrate analgesic effects. We assessed benefit and harm of adding glucocorticoids to a combination of paracetamol and NSAIDs for post-operative pain management.
We searched Embase, Medline and CENTRAL for randomised clinical trials investigating the addition of glucocorticoids versus placebo/no intervention to paracetamol and an NSAID in adults undergoing any type of surgery. We assessed three primary outcomes: cumulative opioid consumption at 24 h postoperatively, serious adverse events and pain at rest at 24 h postoperatively. We performed meta-analysis and trial sequential analysis (TSA), assessed risk of bias using the Risk of Bias 2 tool and used the Grading of Recommendations Assessment, Development and Evaluation approach to evaluate the certainty of the evidence.
We identified 12 relevant trials of which nine trials randomising 804 participants were included in quantitative analysis. When added to paracetamol and NSAIDs, we found no evidence of a difference of glucocorticoids versus placebo/no intervention in cumulative opioid consumption at 24 h postoperatively (mean difference [MD] -0.28, TSA-adjusted 95% confidence interval [CI] -1.90 to 1.33, p = .68, moderate certainty of evidence), serious adverse events (risk ratio (RR) 0.99, TSA-adjusted 95% CI 0.27-3.63, p = .93, very low certainty of evidence) or pain on the Numeric Rating Scale at 24 h postoperatively (MD -0.39, TSA-adjusted 95% CI -0.84 to 0.17, p = .10, moderate certainty of evidence). All outcomes were assessed to be at high risk of bias and TSA showed that we had insufficient information for most outcomes.
Glucocorticoids added to a baseline therapy of paracetamol and an NSAID likely result in little to no difference in cumulative opioid consumption and pain at rest at 24 h postoperatively. In addition, the evidence is very uncertain about the effect on serious adverse events. For most outcomes we did not have sufficient information to draw firm conclusions and the certainty of the evidence varied from moderate to very low.
Multimodal approaches for post-operative analgesia are favoured, including paracetamol and nonsteroidal anti-inflammatory drugs. In this meta-analysis, pooled results from clinical trials are assessed to describe possible benefit of addition of glucocorticoid treatment for analgesia. The findings did not identify additional benefit, though the certainty of the evidence was not high.
扑热息痛和非甾体抗炎药（NSAIDs）被推荐作为大多数手术的基本止痛治疗方案。糖皮质激素具有众所周知的抗炎和止吐作用，也可能具有镇痛作用。我们评估了在扑热息痛和 NSAIDs 联合治疗的基础上加用糖皮质激素对术后疼痛管理的益处和危害。
我们在 Embase、Medline 和 CENTRAL 中检索了随机临床试验，以评估在接受任何类型手术的成年人中，加用糖皮质激素与安慰剂/不干预相比，对术后 24 小时内累积阿片类药物消耗、严重不良事件和术后 24 小时静息时疼痛的影响。我们进行了荟萃分析和试验序贯分析（TSA），使用风险偏倚 2 工具评估风险偏倚，并使用推荐评估、制定和评估方法评估证据的确定性。
我们确定了 12 项相关试验，其中 9 项随机分配 804 名参与者的试验纳入了定量分析。当与扑热息痛和 NSAIDs 联合使用时，我们发现糖皮质激素与安慰剂/不干预相比，在术后 24 小时内的累积阿片类药物消耗方面没有差异（平均差值[MD]-0.28，TSA 调整后的 95%置信区间[CI]-1.90 至 1.33，p=0.68，中等确定性证据），严重不良事件（风险比[RR]0.99，TSA 调整后的 95%CI 0.27-3.63，p=0.93，极低确定性证据）或术后 24 小时静息时的数字评分量表疼痛（MD-0.39，TSA 调整后的 95%CI-0.84 至 0.17，p=0.10，中等确定性证据）。所有结局均被评估为高偏倚风险，TSA 表明我们对大多数结局的信息不足。
在扑热息痛和 NSAID 的基础治疗上加用糖皮质激素可能对术后 24 小时内的累积阿片类药物消耗和静息时疼痛几乎没有影响。此外，关于严重不良事件的影响，证据非常不确定。对于大多数结局，我们没有足够的信息来得出明确的结论，证据的确定性从中等到极低不等。
术后镇痛采用多模式方法，包括扑热息痛和非甾体抗炎药。在这项荟萃分析中，汇总了临床试验的结果，以描述加用糖皮质激素治疗对镇痛的可能益处。研究结果并未发现额外的益处，尽管证据的确定性不高。
