TRIO Best Practice articles are brief, structured reviews designed to provide the busy clinician with a handy outline and reference for day-to-day clinical decision making. The ENTtoday summaries below include the Background and Best Practice sections of the original article. To view the complete Laryngoscope articles free of charge, visit Laryngoscope.
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January 2018Background
Postoperative nausea and vomiting (PONV) is an undesirable yet common complication that may delay patient discharge; necessitate unplanned hospital admission; and/or compromise the surgical outcome, in some cases via secondary effects such as hematoma and wound dehiscence. The incidence is estimated to be about 30% or more in higher risk procedures such as otolaryngologic operations. The sensation of nausea and vomiting can be extremely distressing for patients, and some may consider it worse than postoperative pain. Postanesthetic discharge criteria, such as the commonly used postanesthesia discharge scoring system, typically require that patients have minimal PONV to qualify for home discharge. As such, it is advisable to administer antiemetic medications prophylactically. This article reviews the evidence supporting administration of intravenous dexamethasone for prophylaxis of PONV in otolaryngology procedures.
Dexamethasone is a synthetic steroid with primarily glucocorticoid activity that is widely and inexpensively available for perioperative use. Although the pharmacological mechanisms by which dexamethasone works to prevent PONV are not completely understood, it may function through a variety of mechanisms, including interaction with known emetogenic trigger sites such as the chemoreceptor trigger zone, alpha-adrenergic receptors, and the solitary tract nucleus; antiinflammatory effects; inhibition of serotonin expression; normalization of the hypothalamic-pituitary-adrenal axis; and even decreasing the sensation of pain resulting in a lower need for opioids. Dexamethasone may prevent emesis by one or a combination of these mechanisms. In addition to decreasing PONV and modifying postoperative pain levels, dexamethasone reduces airway edema, which can be especially beneficial in otolaryngology procedures. Although this medication generally is well tolerated, hyperglycemia can occur in labile diabetic patients.
Best Practice
The literature supports dexamethasone as an effective agent for prevention of postoperative nausea and vomiting in frequently performed adult and pediatric otolaryngology procedures (Laryngoscope. 2017;127:1493–1495).