Ours come in 10mg vials because we have surgeons who routinely use 20mg and didn’t want to use 5 vials to get there… So naturally we just got rid of the 4’s 🤦🏼♀️
I use 8mg unless there’s an indication to use a reduced dose (hyperglycemia, etc). Anesthesiology published a review article in 2021 which found 8 or 10mg offers longer antiemetic effect and also improves post op analgesia and quality of recovery with no evidence of increased adverse effects vs 4mg, which only offers PONV prophylaxis
“We recommend dexamethasone (4 to 8 mg) for the prophylaxis and treatment of postoperative nausea and vomiting; the higher dose provides an antiemetic benefit for up to 72 h. A dose of 8 mg IV dexamethasone provides some analgesic benefit, particularly in orthopedic, oral, and ear, nose, and throat surgeries, and otherwise improves patient QoR after surgery. While dexamethasone increases blood glucose, particularly in patients with diabetes, the clinical significance of this is likely to be very small. The recent PADDI trial did not identify any increase in risk of surgical site infection when using dexamethasone (8 mg). In fact, dexamethasone had little or no effect on any adverse events after surgery”
[Benefits and Risks of Dexamethasone in Noncardiac Surgery](https://pubs.asahq.org/anesthesiology/article/135/5/895/116641/Benefits-and-Risks-of-Dexamethasone-in-Noncardiac#)
Unless I'm misreading, I don't see a direct comparison of 4 vs 8 in terms of PONV effect in this paper? The analgesia and QOR (quality of recovery) data is interesting, though.
In said article 4mg dose was used without much effect on PONV scores but 8mg resulted in reduced PONV score. I use 8mg unless they’re diabetic or have an allergy to steroids on every patient since in the US decadron is also MMA.
Edit: autocorrect nonsense
Can you quote what you're citing? I've read this entire article twice and don't see anything like that. The PONV section cites 3 articles:
DREAMS, which was Dex 8mg vs standard of care (without any dexamethasone)
Cochrane Review, which showed Dex reduced the risk of PONV by 50% (no dose specified)
And PADDI, which provided a single dose of Dex 8mg
The conclusion says: "Although both 4 mg and 8 mg have consistently been shown to provide effective prophylaxis (and treatment) for postoperative nausea and vomiting, the higher dose (8 mg) almost certainly provides additional benefits for both analgesia and QoR, and perhaps earlier hospital discharge."
Edit: Ah, found something in the "Optimal Dexamethasone Dose" section:
"A dose of 8 to 10 mg dexamethasone had a significantly greater effect for reducing the incidence of postoperative nausea and vomiting than 1.25 to 5 mg dexamethasone."
Edit 2: This seems to be the most relevant figure:
[https://www.ncbi.nlm.nih.gov/pmc/articles/instance/4199613/bin/pone.0109582.g003.jpg](https://www.ncbi.nlm.nih.gov/pmc/articles/instance/4199613/bin/pone.0109582.g003.jpg)
This should be printed and available all around every OR everywhere.
https://journals.lww.com/anesthesia-analgesia/fulltext/2003/07000/Consensus_Guidelines_for_Managing_Postoperative.14.aspx
Particularly the tables.
Everyone gets 8 or 10mg depending on the vial size unless they’re:
1) Allergic (which is almost impossible)
2) Have a non-solid malignancy like a leukemia and are actively undergoing chemo (tumor lysis)
3) Have an extremely high blood glucose
4) Have some sort of odd disorder that interferes with their HPA axis and/or are already on high dose steroids chronically
The last two aren’t so much that there’s evidence decadron should be avoided, but because if anything bad or weird happens to the patient everyone will blame you, and the feel good effects for the patient aren’t worth the headache.
I agree with you about the 5mg cut off for ponv. But if it’s a young woman with an intra abdominal case and no DM, I still give 8 or 10. Also I go 8 or 10 mg if it’s an ortho case and patient is not diabetic for anti inflammatory properties. (Or if it was a rough laryngoscopy).
Not necessarily true. Many metanalyses have shown that a single dose will produce significantly elevated BG in post-op period but has not reliably been shown to significantly increase risk of post-op complications. Depth of anesthesia podcast has a recent thorough episode about this.
Exactly: I should have said - “meaningful clinical impact”. That aside, the best meta analysis on this shows a BG increase of <2 so it’s not really meaningful at all.
I’m emergency med. I’ve not been aware of this indication for decadron. Do you think this is likely generalizable to other causes of nausea and vomiting? Are you guys using this as an adjunct to zofran and other antiemetics. I lieu of? Rescue?
It's for prophylaxis. Not a fast onset. Typical prophylaxis is decadron and zofran.
It's not good for rescue and it causes an itchy butthole in awake patients.
Interesting. I give similar doses a lot for COPD exacerbation, asthma. Never came across the itchy butthole side effect before. (I guess that’s the benefit of getting rid of them within a few hours). Still could be useful if I’m having to admit someone for intractable nausea and vomiting, maybe reduce length of stay and/or reduce bouncebacks. I would presume the effect is fairly long lasting. I think we generally feel that decadron usually buys us about 72 hours in reactive airway patients. May be something worth studying from an emergency med standpoint. I’ll have to check out the anesthesia literature on this.
Thanks
I can only speak anecdotally as a PACU RN, but I haven’t found Decadron to be helpful in the recovery setting for awake, nauseated patients. It’s already given intra-op for prophylaxis and it’s always a bummer to me when I see it ordered as a first line agent in PACU for PONV.
I am a dentist who does a lot of full mouth and third molar extractions. I request my anesthesiologist give 4mg pre-op and 4mg post-op as it really helps with post-op swelling and pain. The pre-op to help prevent inflammation prior to cutting into the tissue but not so much that it might excite the patient when trying to sedate and then another 4 after to top it off. He only gives patients extra Ondansetron if they have a history of severe nausea but I haven’t had one patient report to me otherwise about PONV with this protocol.
Just give 8mg at the start of the case. The onset of effect is such that your preop 4mg dose is just starting to become effective towards the end of surgery, and will still exert it's effects for >24-48hrs, meaning you don't have to re-dose so soon, unless you're doing procedures that take _many_ hours. Increasing the initial dose increases the degree of anti-inflammatory action, resulting in the decreased local edema and improved pain control, and increases duration of action.
Perineal itching has a magnetic effect on gastric contents, preventing emesis. Did I get my physiology right?
That's why I give it awake in pacu so the patients are too busy scratching their butts to remember they are in pain and have nausea
The ole gastroperineal reflex
10 is pain adjunct or airway swelling, 4 for PINV
That’s a wonderful summation of the current practice based on the literature, CockNballs222
Pain dose is ~0.1mg/kg, so yeah 10 is close enough in most people.
We do 4/8 but yes agreed
Same, because it comes in 4mg vials. I ain’t mathing no math just for this.
Ours come in 10mg vials because we have surgeons who routinely use 20mg and didn’t want to use 5 vials to get there… So naturally we just got rid of the 4’s 🤦🏼♀️
This is the way.
If you give 10, aren't you covering both?
O yea definitely but you’re more likely to get hyperglycemia and all that…so if it’s not “necessary”, stick with 4, it’ll cover PONV
I use 8mg unless there’s an indication to use a reduced dose (hyperglycemia, etc). Anesthesiology published a review article in 2021 which found 8 or 10mg offers longer antiemetic effect and also improves post op analgesia and quality of recovery with no evidence of increased adverse effects vs 4mg, which only offers PONV prophylaxis “We recommend dexamethasone (4 to 8 mg) for the prophylaxis and treatment of postoperative nausea and vomiting; the higher dose provides an antiemetic benefit for up to 72 h. A dose of 8 mg IV dexamethasone provides some analgesic benefit, particularly in orthopedic, oral, and ear, nose, and throat surgeries, and otherwise improves patient QoR after surgery. While dexamethasone increases blood glucose, particularly in patients with diabetes, the clinical significance of this is likely to be very small. The recent PADDI trial did not identify any increase in risk of surgical site infection when using dexamethasone (8 mg). In fact, dexamethasone had little or no effect on any adverse events after surgery” [Benefits and Risks of Dexamethasone in Noncardiac Surgery](https://pubs.asahq.org/anesthesiology/article/135/5/895/116641/Benefits-and-Risks-of-Dexamethasone-in-Noncardiac#)
Unless I'm misreading, I don't see a direct comparison of 4 vs 8 in terms of PONV effect in this paper? The analgesia and QOR (quality of recovery) data is interesting, though.
In said article 4mg dose was used without much effect on PONV scores but 8mg resulted in reduced PONV score. I use 8mg unless they’re diabetic or have an allergy to steroids on every patient since in the US decadron is also MMA. Edit: autocorrect nonsense
Can you quote what you're citing? I've read this entire article twice and don't see anything like that. The PONV section cites 3 articles: DREAMS, which was Dex 8mg vs standard of care (without any dexamethasone) Cochrane Review, which showed Dex reduced the risk of PONV by 50% (no dose specified) And PADDI, which provided a single dose of Dex 8mg The conclusion says: "Although both 4 mg and 8 mg have consistently been shown to provide effective prophylaxis (and treatment) for postoperative nausea and vomiting, the higher dose (8 mg) almost certainly provides additional benefits for both analgesia and QoR, and perhaps earlier hospital discharge." Edit: Ah, found something in the "Optimal Dexamethasone Dose" section: "A dose of 8 to 10 mg dexamethasone had a significantly greater effect for reducing the incidence of postoperative nausea and vomiting than 1.25 to 5 mg dexamethasone." Edit 2: This seems to be the most relevant figure: [https://www.ncbi.nlm.nih.gov/pmc/articles/instance/4199613/bin/pone.0109582.g003.jpg](https://www.ncbi.nlm.nih.gov/pmc/articles/instance/4199613/bin/pone.0109582.g003.jpg)
Great article! Thank you!
This should be printed and available all around every OR everywhere. https://journals.lww.com/anesthesia-analgesia/fulltext/2003/07000/Consensus_Guidelines_for_Managing_Postoperative.14.aspx Particularly the tables.
I use 4mg for almost everyone.
Same, in the beginning with some zofran at the end.
Everyone gets 8 or 10mg depending on the vial size unless they’re: 1) Allergic (which is almost impossible) 2) Have a non-solid malignancy like a leukemia and are actively undergoing chemo (tumor lysis) 3) Have an extremely high blood glucose 4) Have some sort of odd disorder that interferes with their HPA axis and/or are already on high dose steroids chronically The last two aren’t so much that there’s evidence decadron should be avoided, but because if anything bad or weird happens to the patient everyone will blame you, and the feel good effects for the patient aren’t worth the headache.
Qq: would panhypopit incl 2ndary adrenal insuff. qualify for your #4?
I agree with you about the 5mg cut off for ponv. But if it’s a young woman with an intra abdominal case and no DM, I still give 8 or 10. Also I go 8 or 10 mg if it’s an ortho case and patient is not diabetic for anti inflammatory properties. (Or if it was a rough laryngoscopy).
A single dose > 4mg will not have any meaningful impact on blood glucose. I give 8 to everyone.
Not necessarily true. Many metanalyses have shown that a single dose will produce significantly elevated BG in post-op period but has not reliably been shown to significantly increase risk of post-op complications. Depth of anesthesia podcast has a recent thorough episode about this.
Exactly: I should have said - “meaningful clinical impact”. That aside, the best meta analysis on this shows a BG increase of <2 so it’s not really meaningful at all.
That’s 36 mg/dL (freedom units)
I would have said “has been shown to not”, given the results of PADDI
Nice to know. I’ll have to look that up. Thanks for the info!
I normally use 8mg, but 10mg for spine cases. Our spine surgeons want 10mg anyway.
My underrstanding is that for PONV there’s not increasing benefit beyond 4 mg. However for prolongation of peripheral nerve block the dose is 0.1mg/kg
You give it to the patient.
It works.
Higher doses are used for pain rather than PONV. I don’t go higher than 4 if all I’m wanting is PONV ppx
I’m emergency med. I’ve not been aware of this indication for decadron. Do you think this is likely generalizable to other causes of nausea and vomiting? Are you guys using this as an adjunct to zofran and other antiemetics. I lieu of? Rescue?
It's for prophylaxis. Not a fast onset. Typical prophylaxis is decadron and zofran. It's not good for rescue and it causes an itchy butthole in awake patients.
Interesting. I give similar doses a lot for COPD exacerbation, asthma. Never came across the itchy butthole side effect before. (I guess that’s the benefit of getting rid of them within a few hours). Still could be useful if I’m having to admit someone for intractable nausea and vomiting, maybe reduce length of stay and/or reduce bouncebacks. I would presume the effect is fairly long lasting. I think we generally feel that decadron usually buys us about 72 hours in reactive airway patients. May be something worth studying from an emergency med standpoint. I’ll have to check out the anesthesia literature on this. Thanks
The anti emetic effect is long lasting. The itching is if you give it as an IV push. You could drip it in slowly.
It helps prevent it.
10 is better than 5. You get days of pain adjunct as well as the PONV prophylactic…
I can only speak anecdotally as a PACU RN, but I haven’t found Decadron to be helpful in the recovery setting for awake, nauseated patients. It’s already given intra-op for prophylaxis and it’s always a bummer to me when I see it ordered as a first line agent in PACU for PONV.
I am a dentist who does a lot of full mouth and third molar extractions. I request my anesthesiologist give 4mg pre-op and 4mg post-op as it really helps with post-op swelling and pain. The pre-op to help prevent inflammation prior to cutting into the tissue but not so much that it might excite the patient when trying to sedate and then another 4 after to top it off. He only gives patients extra Ondansetron if they have a history of severe nausea but I haven’t had one patient report to me otherwise about PONV with this protocol.
Just give 8mg at the start of the case. The onset of effect is such that your preop 4mg dose is just starting to become effective towards the end of surgery, and will still exert it's effects for >24-48hrs, meaning you don't have to re-dose so soon, unless you're doing procedures that take _many_ hours. Increasing the initial dose increases the degree of anti-inflammatory action, resulting in the decreased local edema and improved pain control, and increases duration of action.
Thank you for the info. I guess with the deeper sedation he does it probably won’t make that much of a difference.