Download PDF
J Knee Surg 2023; 36(02): 208-215
DOI: 10.1055/s-0041-1731722
Original Article

Steroids Significantly Decrease Postoperative Postural Hypotension in Total Knee Replacement

Gloria H. M. Cheng
1   Department of Orthopaedic Surgery, Tan Tock Seng Hospital, Singapore, Singapore
,
Gabriel K. Y. Tan
2   Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
,
Muhammad F. B. Kamarudin
1   Department of Orthopaedic Surgery, Tan Tock Seng Hospital, Singapore, Singapore
,
Bryan W. W. Lee
1   Department of Orthopaedic Surgery, Tan Tock Seng Hospital, Singapore, Singapore
,
Yap Yan Mei
3   Department of Physiotherapy, Tan Tock Seng Hospital, Singapore
,
Kelvin G. Tan
1   Department of Orthopaedic Surgery, Tan Tock Seng Hospital, Singapore, Singapore
› Author Affiliations
› Further Information
   Permissions and Reprints

Abstract

Total knee replacement (TKR) is one of the most common orthopaedic procedures performed, and enhanced recovery after surgery (ERAS) has been developed and incorporated into inpatient surgical pathways to improve patient outcomes. Under ERAS recommendations, multimodal prophylaxis has been used to help manage postoperative nausea and vomiting (PONV) following TKR. Dexamethasone is one of the commonly used for this and the anti-inflammatory properties could depress vagal activity, reducing postural hypotension (PH). The hypothesis of this study is that postoperative dexamethasone use is associated with lower rates of early postoperative PH following TKR surgery. In our institution, patients who undergo elective primary TKR are admitted on the day of surgery and follow a standardized ERAS protocol. Data on patients who underwent elective primary TKR under a single adult reconstruction team from September 2017 to March 2020 were reviewed and analyzed. A review of demographic characteristics, surgical data, postoperative medications, and postoperative notes was performed. Binary logistic regression was used to assess the effect of the use of dexamethasone on PH, with an adjusted odds ratio (OR) calculated after accounting for potential confounders. Of the 149 patients were included in the study, 78 had dexamethasone postoperatively, and 71 did not. Patients who had received dexamethasone were statistically less likely to suffer from PH (OR = 0.31, p = 0.03) and less likely to develop PONV (OR = 0.21, p = 0.006). Patients who had received dexamethasone were more likely able to participate in early physiotherapy (OR = 2.42, p = 0.14), and this result was statistically insignificant. The use of postoperative intravenous dexamethasone is significantly associated with lower rates of postoperative PH after TKR. However, more studies are required to assess the optimal dosing amount and frequency, as well as to assess other factors which can enhance early postoperative patient mobilization as part of our goals for ERAS. This therapeutic study reflects level of evidence III.

Keywords

total knee replacement - dexamethasone - postural hypotension


Publication History

Received: 08 February 2021

Accepted: 31 May 2021

Article published online:
08 July 2021

© 2021. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 

  • References

  • 1 Wainwright TW, Gill M, McDonald DA. et al. Consensus statement for perioperative care in total hip replacement and total knee replacement surgery: Enhanced Recovery After Surgery (ERAS) Society recommendations. Acta Orthop 2020; 91 (01) 3-19
    CrossrefPubMedGoogle Scholar
  • 2 Huston JM, Tracey KJ. The pulse of inflammation: heart rate variability, the cholinergic anti-inflammatory pathway and implications for therapy. J Intern Med 2011; 269 (01) 45-53
    CrossrefPubMedGoogle Scholar
  • 3 Jans Ø, Brinth L, Kehlet H, Mehlsen J. Decreased heart rate variability responses during early postoperative mobilization--an observational study. BMC Anesthesiol 2015; 15: 120
    CrossrefPubMedGoogle Scholar
  • 4 Weibel S, Rücker G, Eberhart LH. et al. Drugs for preventing postoperative nausea and vomiting in adults after general anaesthesia: a network meta-analysis. Cochrane Database Syst Rev 2020; 10: CD012859
    PubMedGoogle Scholar
  • 5 Rhen T, Cidlowski JA. Antiinflammatory action of glucocorticoids--new mechanisms for old drugs. N Engl J Med 2005; 353 (16) 1711-1723
    CrossrefPubMedGoogle Scholar
  • 6 Ding BTK, Ng J, Tan KG. Enhanced recovery after surgery for knee arthroplasty in the era of COVID-19. J Knee Surg 2020; (e-pub ahead of print) DOI: 10.1055/s-0040-1715125.
    Article in Thieme ConnectPubMedGoogle Scholar
  • 7 Amirshahi M, Behnamfar N, Badakhsh M. et al. Prevalence of postoperative nausea and vomiting: a systematic review and meta-analysis. Saudi J Anaesth 2020; 14 (01) 48-56
    CrossrefPubMedGoogle Scholar
  • 8 Jans Ø, Bundgaard-Nielsen M, Solgaard S, Johansson PI, Kehlet H. Orthostatic intolerance during early mobilization after fast-track hip arthroplasty. Br J Anaesth 2012; 108 (03) 436-443
    CrossrefPubMedGoogle Scholar
  • 9 Lindberg-Larsen V, Petersen PB, Jans Ø, Beck T, Kehlet H. Effect of pre-operative methylprednisolone on orthostatic hypotension during early mobilization after total hip arthroplasty. Acta Anaesthesiol Scand 2018; 62 (07) 882-892
    CrossrefPubMedGoogle Scholar
  • 10 Zhang Y-M, He J, Zhou C, Li Y, Yi D-K, Zhang X. Acute hypotension after total knee arthroplasty and its nursing strategy. Int J Clin Exp Med 2015; 8 (08) 13946-13953
    PubMedGoogle Scholar
  • 11 Grubb BP. Neurocardiogenic syncope and related disorders of orthostatic intolerance. Circulation 2005; 111 (22) 2997-3006
    CrossrefPubMedGoogle Scholar
  • 12 Cowie DA, Shoemaker JK, Gelb AW. Orthostatic hypotension occurs frequently in the first hour after anesthesia. Anesth Analg 2004; 98 (01) 40-45
    CrossrefPubMedGoogle Scholar
  • 13 Jans Ø, Kehlet H. Postoperative orthostatic intolerance: a common perioperative problem with few available solutions. Can J Anaesth 2017; 64 (01) 10-15
    CrossrefPubMedGoogle Scholar
  • 14 Samona J, Cook C, Krupa K. et al. Effect of intraoperative dexamethasone on pain scores and narcotic consumption in patients undergoing total knee arthroplasty. Orthop Surg 2017; 9 (01) 110-114
    CrossrefPubMedGoogle Scholar
  • 15 Li X, Xu G, Xie W, Ma S. The efficacy and safety of dexamethasone for pain management after total knee arthroplasty: a systematic review and meta-analysis. Int J Surg 2018; 53: 65-71
    CrossrefPubMedGoogle Scholar
  • 16 DREAMS Trial Collaborators and West Midlands Research Collaborative. Dexamethasone versus standard treatment for postoperative nausea and vomiting in gastrointestinal surgery: randomised controlled trial (DREAMS Trial). BMJ 2017; 357: j1455 DOI: 10.1136/bmj.j1455.
    CrossrefPubMedGoogle Scholar
  • 17 Gupta B. Role of dexamethasone in peri-operative anesthesia management: a review of literature. Res Practice Anesth 2017; 2 (02) 33-39
    PubMedGoogle Scholar
  • 18 De Oliveira Jr. GS, Almeida MD, Benzon HT, McCarthy RJ. Perioperative single dose systemic dexamethasone for postoperative pain: a meta-analysis of randomized controlled trials. Anesthesiology 2011; 115 (03) 575-588
    CrossrefPubMedGoogle Scholar
  • 19 Waldron NH, Jones CA, Gan TJ, Allen TK, Habib AS. Impact of perioperative dexamethasone on postoperative analgesia and side-effects: systematic review and meta-analysis. Br J Anaesth 2013; 110 (02) 191-200
    CrossrefPubMedGoogle Scholar
  • 20 Lunn TH, Kristensen BB, Andersen LØ. et al. Effect of high-dose preoperative methylprednisolone on pain and recovery after total knee arthroplasty: a randomized, placebo-controlled trial. Br J Anaesth 2011; 106 (02) 230-238
    CrossrefPubMedGoogle Scholar
  • 21 Chua MJ, Hart AJ, Mittal R, Harris IA, Xuan W, Naylor JM. Early mobilisation after total hip or knee arthroplasty: A multicentre prospective observational study. PLoS One 2017; 12 (06) e0179820
    CrossrefPubMedGoogle Scholar
  • 22 Jans Ø, Mehlsen J, Kjærsgaard-Andersen P. et al. Oral midodrine hydrochloride for prevention of orthostatic hypotension during early mobilization after hip arthroplasty: a randomized, double-blind, placebo-controlled trial. Anesthesiology 2015; 123 (06) 1292-1300
    CrossrefPubMedGoogle Scholar
  • 23 Richardson AB, Bala A, Wellman SS, Attarian DE, Bolognesi MP, Grant SA. Perioperative dexamethasone administration does not increase the incidence of postoperative infection in total hip and knee arthroplasty: a retrospective analysis. J Arthroplasty 2016; 31 (08) 1784-1787
    CrossrefPubMedGoogle Scholar
  • 24 Corcoran T, Kasza J, Short TG. et al; ENIGMA-II investigators. Intraoperative dexamethasone does not increase the risk of postoperative wound infection: a propensity score-matched post hoc analysis of the ENIGMA-II trial (EnDEX). Br J Anaesth 2017; 118 (02) 190-199
    CrossrefPubMedGoogle Scholar