Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA.
RFU Center for Interprofessional Evidence Based Practice: A JBI Centre of Excellence, Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA.
JBI Evid Synth. 2023 Nov 1;21(11):2156-2187. doi: 10.11124/JBIES-22-00300.
The objective of this review was to evaluate the effect of intravenous dexamethasone given intraoperatively for postoperative nausea and vomiting prophylaxis on maximal blood glucose level within the initial 24 hours following elective surgery for patients with diabetes.
Postoperative nausea and vomiting is a prevalent adverse effect of anesthesia that leads to morbidity, increased health care costs, and unanticipated hospital admissions. Dexamethasone is an effective prophylactic agent that confers secondary analgesic and anti-inflammatory benefits. However, its use in patients with diabetes remains controversial due to the potential for increased postoperative blood glucose levels.
This review considered studies with participants 18 years of age or older with type 1 or 2 diabetes undergoing an elective surgical procedure. Eligible studies reported postoperative blood glucose levels in adults with diabetes after receiving a single 4-10 mg prophylactic dose of intravenous dexamethasone intraoperatively for postoperative nausea and vomiting. The primary outcome was maximum blood glucose level in the first 24 hours after surgery. All study designs were eligible for inclusion. Studies were excluded if they lacked a control group with diabetes or if they did not report maximum blood glucose values in both groups.
A search of MEDLINE, CINAHL Complete, Embase, Web of Science, TRIP database, and the Cochrane Database of Systematic Reviews was completed in October 2021. Gray literature resources were also searched. No date or language restrictions were applied. Methodological quality was assessed using JBI appraisal tools for randomized controlled trials, cohort studies, and case-control studies. A meta-analysis of maximal postoperative blood glucose level within 24 hours of surgery was performed, as well as subgroup analyses by dexamethasone dose, insulin treatment, and study design type.
Eleven studies (4 randomized controlled trials, 6 cohort studies, and 1 case-control study) were included in this review, with 1 study excluded from meta-analysis and results reported narratively. The total sample size of studies included in meta-analysis was 2567. The administration of dexamethasone significantly increased maximal blood glucose levels in the 24 hours immediately following surgery compared with control groups with diabetes, as demonstrated by randomized controlled trials (mean difference [MD] 39.56 mg/dL; 95% CI 16.18 to 62.94; P < 0.001; I2 = 87%) and observational studies (MD 26.31 mg/dL; 95% CI 7.10 to 45.52; P = 0.007; I2 = 92%). This increase in blood glucose was significant for all doses of dexamethasone: 4 mg (MD 40.81 mg/dL; 95% CI 2.42 to 79.19; P = 0.001; I2 = 91%), 8 mg (randomized controlled trials only; MD 39.45 mg/dL; 95% CI 15.32 to 63.58; P = 0.001; I2 = 86%), and mixed 4-10 mg dose (MD 30.82 mg/dL; 95% CI 6.75 to 54.88; P < 0.012; I2 = 93%). Postoperative hyperglycemia persisted in studies using insulin treatment as well as those not using insulin protocols. The overall certainty of the findings ranged from very low for outcomes that included cohort studies to moderate when outcomes from randomized controlled trials were analyzed separately. However, the quantitative findings of the experimental and observational studies were clinically similar. Risk of bias presented minimal concerns in all included studies.
Dexamethasone leads to transient postoperative hyperglycemia in patients with diabetes undergoing elective surgery when given as a single 4-10 mg intravenous dose for postoperative nausea and vomiting prophylaxis. The clinical relevance of hyperglycemia is debatable given its small magnitude and transient nature. Without more tightly controlled data, methodological consistency, and baseline blood glucose values, it is impossible to test causal links between hyperglycemia and pre-existing patient factors (eg, hemoglobin A1C levels) or postoperative complications.
PROSPERO CRD42020185607.
本综述旨在评估术中给予静脉内地塞米松预防术后恶心和呕吐对糖尿病患者择期手术后 24 小时内最大血糖水平的影响。
术后恶心和呕吐是麻醉的一种常见不良反应，可导致发病率增加、医疗保健成本增加和意外住院。地塞米松是一种有效的预防药物，具有辅助镇痛和抗炎作用。然而，由于其可能导致术后血糖水平升高，其在糖尿病患者中的使用仍存在争议。
本综述考虑了年龄在 18 岁或以上的 1 型或 2 型糖尿病患者进行择期手术的研究。符合条件的研究报告了接受单次 4-10mg 预防性静脉内地塞米松预防术后恶心和呕吐的成人糖尿病患者手术后 24 小时内的术后血糖水平。主要结局是手术后 24 小时内的最大血糖水平。所有研究设计均符合纳入标准。如果研究没有糖尿病对照组或没有报告两组的最大血糖值，则排除该研究。
2021 年 10 月，对 MEDLINE、CINAHL Complete、Embase、Web of Science、TRIP 数据库和 Cochrane 系统评价数据库进行了检索。还搜索了灰色文献资源。没有应用日期或语言限制。使用 JBI 评估工具对随机对照试验、队列研究和病例对照研究进行了方法学质量评估。对手术后 24 小时内最大术后血糖水平进行了荟萃分析，并按地塞米松剂量、胰岛素治疗和研究设计类型进行了亚组分析。
共纳入 11 项研究（4 项随机对照试验、6 项队列研究和 1 项病例对照研究），其中 1 项研究被排除在荟萃分析之外，结果以叙述性报告呈现。荟萃分析纳入的研究总样本量为 2567 例。与糖尿病对照组相比，地塞米松的给药显著增加了术后 24 小时内的最大血糖水平，这在随机对照试验（平均差异[MD]39.56mg/dL；95%CI16.18 至 62.94；P<0.001；I2=87%）和观察性研究（MD26.31mg/dL；95%CI7.10 至 45.52；P=0.007；I2=92%）中均得到证实。所有剂量的地塞米松均显著增加了血糖：4mg（MD40.81mg/dL；95%CI2.42 至 79.19；P=0.001；I2=91%）、8mg（仅随机对照试验；MD39.45mg/dL；95%CI15.32 至 63.58；P=0.001；I2=86%）和混合 4-10mg 剂量（MD30.82mg/dL；95%CI6.75 至 54.88；P<0.012；I2=93%）。在使用胰岛素治疗的研究以及未使用胰岛素方案的研究中，术后高血糖仍然存在。包括队列研究在内的结局的总体确定性为极低，而单独分析随机对照试验的结局的确定性为中度。然而，实验和观察性研究的定量发现具有临床相似性。所有纳入的研究都存在最小的偏倚风险。
当术中给予 4-10mg 静脉内地塞米松预防术后恶心和呕吐时，糖尿病患者在择期手术后会出现短暂的术后高血糖。鉴于其幅度较小且短暂，高血糖的临床相关性存在争议。在没有更严格控制的数据、方法一致性和基线血糖值的情况下，无法检验高血糖与患者固有因素（例如血红蛋白 A1C 水平）或术后并发症之间的因果关系。
PROSPERO CRD42020185607。
