Decadron dosing regime for managing post-operative pain, nausea and vomiting after total knee arthroplasty
Peri-operative Dexamethasone for Control of Pain After Total Knee
Adam Rosen, DO*, Pam Pulido, RN, BSN†, Michelle Munro, BS†, Suzanne
Daneshvari, RN, CCRC†, and Steven N. Copp, MD*
*Scripps Clinic Division of Orthopaedics, La Jolla, CA
†Shiley Center for Orthopaedic Research and Education at Scripps Clinic, La
Despite great advances made in TKA implant design and surgical technique, many
patients stil suffer from acute pain in the early postoperative period. This pilot study
examined the administration intraoperative intravenous dexamethasone in combination
with 3 days of postoperative oral dexamethasone for total knee arthroplasty (TKA)
patients in order to reduce postoperative pain, prevent postoperative nausea and
vomiting, and improve early post operative ambulation. We compared opioid use,
numeric rating scale pain scores, and physical functioning in each group. Our results
demonstrated a significant effect in PACU with less time for the dexamethasone group
(97.9 minutes) versus the control (group 135.4 minutes) (p = 0.009), lower reported pain
scores in the dexamethasone group (2.61) than in the control group (4.33) (p = 0.049),
and less opioid usage with a dose equivalent of 0.419 for the dexamethasone group
compared with 0.768 for the control group (p = 0.041). Mean ambulation distance on
the day of discharge was 280 feet in the dexamethasone group compared with 184 feet
in the control group (p = 0.074). From this retrospective pilot study, use of
dexamethasone perioperatively for elective TKA appears to be beneficial without
Total knee arthroplasty (TKA) is a very successful procedure for the treatment of
degenerative joint disease of the knee. Studies have predicted that the number of TKA’s
performed in the United States wil be approximately 3.5 mil ion per year by the year
2030. Despite the great advances made in TKA implant design and surgical technique,
many patients stil suffer from acute pain in the early postoperative period. Many
anesthesia modalities and medications have been used in numerous combinations in an
attempt to reduce pain and limit side effects.
Standard treatment for pain relief after TKA includes opioid pain medication. Although
opioid pain medication is effective in relieving pain, these medications can produce
unwanted side effects, including postoperative nausea and vomiting (PONV), urinary
retention, constipation, respiratory depression, confusion, and drowsiness.
Identification of adjunctive treatments to reduce postoperative pain and the associated
side effects from opioids may improve patient experience in the early postoperative
Corticosteroids are used to decrease pain and inflammation 1 and to prevent PONV 2
after surgery. Inflammation is one source of pain in TKA. The anti-inflammatory effects
of corticosteroids have been known for decades. Corticosteroids are a subgroup of
compounds known as adrenocorticoids that are naturally secreted by the adrenal gland.
Synthetic agents, such as dexamethasone (Decadron, Merck Co., Whitehouse Station,
NJ) are more potent, have longer duration of action, have increased anti-inflammatory
properties, and general y reduce unwanted side effects of opioid consumption.3
Corticosteroids may be given orally, intramuscularly, or intravenously. Factors which
may influence both the therapeutic and adverse effects of corticosteroids include the
pharmacokinetic properties of the steroid, daily dosage, timing of administration, and
Dexamethasone, a corticosteroid, administered to TKA patients intraoperatively and
during the early postoperative period may decrease postoperative pain, opioid
consumption, and the associated side effects of opioid consumption. The addition of
dexamethasone may increase well-being and improve rehabilitation after TKA.
The purpose of this pilot study was to determine whether administration of
dexamethasone intravenously during total knee arthroplasty (TKA), and oral
dexamethasone daily, for the first three post operative days, would reduce
postoperative pain, prevent nausea and vomiting, and increase early rehabilitation
Materials and Methods
We conducted a retrospective chart review of patients identified from our outcomes
database who underwent total knee replacement and whose anesthesia included
general with either femoral or femoral and sciatic nerve blocks. Patients who received
spinal or intraarticular nerve blocks were excluded from the study. The groups were
consecutive with the control group from 2005-2006 and the dexamethasone group from
2007 when we added dexamethasone to the pain treatment regime. Twenty-three
patients (dexamethasone group) were identified who received dexamethasone 10 mg
intravenously during TKA surgery and dexamethasone 4mg orally daily for three days
postoperatively and 23 patients (control group) who did not receive dexamethasone
during TKA surgery or anytime postoperatively. This pilot study was approved by our
We compared the use of opioids for pain relief, postoperative nausea and vomiting, and
physical functioning in each group. Each patient’s opioid intake was monitored in the
operating room, post-anesthesia care unit (PACU), day of surgery and each subsequent
postoperative day for three days or until the day of discharge. Famotidine (Pepcid) 20
mg. was given orally twice a day until discharge for gastrointestinal prophylaxis in the
dexamethasone group. Postoperative nausea and vomiting and respiratory depression
were tracked. The patients were asked prior to surgery, after surgery, and each
postoperative morning while in the hospital to provide their numerical (Numerical Rating
On postoperative day one, and on the day of discharge, knee flexion and distance
ambulated were measured. Our data analysis included demographics, anesthesia type,
dexamethasone dose, surgical data, NRS, total opioid dose equivalents (DE, 1 DE = 10
mg morphine sulfate intravenously), PONV, physical functioning, and 3 month wound
Data were analyzed using SPSS (DEFINE) version 13.0 (Chicago, IL). After checking
for normal distribution of the data, independent t-tests were used to analyze the
differences in NRS pain scores, opioid DEs, and physical functioning data between
groups. Demographic and baseline data were analyzed using independent t-tests for
continuous data and chi-square tests for categorical data to determine if there were any
differences between groups. Al statistical tests were two-tailed and the alpha level was
No significant differences were noted between groups with regard to age, gender,
weight, height, or anesthesia. (Table 1) Our results demonstrated that patients given
dexamethasone spent less time in PACU, 97.87 minutes versus 135.35 minutes in the
control group (p = 0.009). Postoperative NRS pain scores in the PACU were less for the
dexamethasone group (2.61) than in the control group (4.33) (p = 0.049) (Figure 1).
PACU opioid DE of 0.419 were significantly less in the dexamethasone group compared
to the DE of 0.768 in the control group (p = 0.041) (Figure 2). The NRS pain rating and
opioid DE use at all other time points were similar.
Physical functioning findings included a mean ambulation distance on the day of
discharge of 279.6 feet in the dexamethasone group compared with a mean of 184.1
feet in the control group (p = 0.074) (Figure 3). Flexion on the day of discharge was 84°
in the dexamethasone group and 81° in the control group. Nausea was 13% and 8%
lower in the dexamethasone group on the day of surgery and on postoperative day 1.
Incidence of vomiting did not differ between groups. No wound infections were reported
at three months, though one patient in the control group received antibiotics for a
We evaluated dexamethasone as a way to decrease pain, PONV, and increase physical
functioning following TKA. In our pilot study we saw lower NRS pain scores (p=0.049)
and lower DE usage (p=0.041) in the PACU for the dexamethasone group. We also
saw a shorter time spent in the PACU for the dexamethasone group (p=0.009).
Previous authors have found that using corticosteroids can reduce pain and
inflammation.1, 3, 5, 6 Decreasing pain with dexamethasone may allow for less opioid use
and potentially a better rehabilitation effort.
PONV can prolong hospitalizations and delay recovery. Movafegh found that using IV
dexamethasone reduced PONV in their patients undergoing inguinal herniorrhaphy .
Though the nausea was lower in the dexamethasone group, we did not see a statistical
difference in PONV between groups in our study. The opioid usage of the
dexamethasone group in the PACU was significantly less and this could reduce PONV
in some patients. Holte and Kehlet concluded in their study that the positive effects of
corticosteroids on PONV could improve recovery.7
We observed an improvement in the ambulation distance on the day of discharge in the
dexamethasone group, which could be due to decreased pain and/or inflammation.
Vargas and Ross studied ACL reconstruction patients and saw a 38% reduction in time
to ambulation in patients receiving dexamethasone intraoperatively and
A concern of using steroids around the time of joint replacement is a risk of infection.
Vargas and Ross found no difference between groups of ACL patients with regard to
infection or wound healing.5 In our study no deep infections occurred in either group.
One patient in the control group was treated with oral antibiotics for a suspected early
This study is limited by its retrospective nature and the small numbers of patients. The
patients were not matched during the selection process, though the groups were similar
in demographics. The majority of the patients in the dexamethasone group were
operated on in 2007, whereas the majority of the control group were operated on in
2005 and 2006. Though treatments other than dexamethasone did not change during
this period, other factors in time may have had an effect on the groups. The time in
PACU may have been influenced by the variation in the number of blocks that included
sciatic nerve and femoral nerve in the dexamethasone group compared with the control
Based on this pilot study perioperative dexamethasone appears to be a safe modality in
patients undergoing TKA. Dexamethasone does not appear to increase the risk of
infection. The patients who received dexamethasone did show shorter stays, lower
opioid usage and lower NRS pain scores in the PACU. Although no difference in PONV
was noted in our study, dexamethasone is known to reduce the risk of PONV. The
dexamethasone group also demonstrated an improved walking distance on the day of
discharge. Dexamethasone appears to be a safe modality to use to control pain in
patients undergoing TKA but further study with a prospective, randomized, larger
Fleischli JW, Adams WR. Use of postoperative steroids to reduce pain and
inflammation. J Foot Ankle Surg. 1999;38(3):232-237.
Apfel CC, Korttila K, Abdalla M, et al. A factorial trial of six interventions for the
prevention of postoperative nausea and vomiting. N Engl J Med.
Salerno A, Hermann R. Efficacy and safety of steroid use for postoperative pain
relief. Update and review of the medical literature. J Bone Joint Surg Am.
Ogilvy AJ, Smith G, Nimmo WS, Rowbotham DJ, Smith G. Postoperative Pain.
Anaesthesia. Vol 2nd Boston: Blackwell Scientific Publications; 1994:1570-1601.
Vargas JH, III, Ross DG. Corticosteroids and anterior cruciate ligament repair.
Am J Sports Med. 1989;17(4):532-534.
Kizilkaya M, Yildirim OS, Dogan N, Kursad H, Okur A. Analgesic effects of
intraarticular sufentanil and sufentanil plus methylprednisolone after arthroscopic
knee surgery. Anesth Analg 2004;98(4):1062-1065.
Holte K, Kehlet H. Perioperative single-dose glucocorticoid administration:
pathophysiologic effects and clinical implications. J Am Coll Surg.
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