Objectives To determine whether preoperative dexamethasone reduces postoperative vomiting in patients undergoing elective bowel surgery and whether it is associated with other measurable benefits during recovery from surgery, including quicker return to oral diet and reduced length of stay. Design Pragmatic two arm parallel group randomised trial with blinded postoperative care and outcome assessment. Setting 45 UK hospitals. Participants 1350 patients aged 18 or over undergoing elective open or laparoscopic bowel surgery for malignant or benign pathology. Interventions Addition of a single dose of 8 mg intravenous dexamethasone at induction of anaesthesia compared with standard care. Main outcome measures Primary outcome: reported vomiting within 24 hours reported by patient or clinician. Secondary outcomes: vomiting with 72 and 120 hours reported by patient or clinician; use of antiemetics and postoperative nausea and vomiting at 24, 72, and 120 hours rated by patient; fatigue and quality of life at 120 hours or discharge and at 30 days; time to return to fluid and food intake; length of hospital stay; adverse events. Results 1350 participants were recruited and randomly allocated to additional dexamethasone (n=674) or standard care (n=676) at induction of anaesthesia. Vomiting within 24 hours of surgery occurred in 172 (25.5%) participants in the dexamethasone arm and 223 (33.0%) allocated standard care (number needed to treat (NNT) 13, 95% confidence interval 5 to 22; P=0.003). Additional postoperative antiemetics were given (on demand) to 265 (39.3%) participants allocated dexamethasone and 351 (51.9%) allocated standard care (NNT 8, 5 to 11; P<0.001). Reduction in on demand antiemetics remained up to 72 hours. There was no increase in complications. Conclusions Addition of a single dose of 8 mg intravenous dexamethasone at induction of anaesthesia significantly reduces both the incidence of postoperative nausea and vomiting at 24 hours and the need for rescue antiemetics for up to 72 hours in patients undergoing large and small bowel surgery, with no increase in adverse events. Trial registration EudraCT (2010-022894-32) and ISRCTN (ISRCTN21973627).

SummaryA patient undergoing minor orthopaedic surgery suffered from unexpected arterial and venous gas embolism caused by hydrogen peroxide. We describe our management of the case and emphasise the need for continued vigilance during the use of hydrogen peroxide. Key wordsComplications; embolism, oxygen. Pharmacology; hydrogen peroxide.The use of hydrogen peroxide has been associated with a variety of potentially fatal complications such as surgical emphysema and oxygen embolism to various vascular beds of the body [I]. We report the unexpected occurrence of arterial and subsequent venous, oxygen embolism during a case of minor orthopaedic surgery in which the first sign of danger was the visualisation of gas in the vascular tree. Case historyA 22-year-old female patient (55 kg) presented for excision of an infected sinus in the left tibia. Six months previously a Denham pin had been inserted 2cm below the tibia1 tubercle to apply traction for an acetabular fracture following a road traffic accident. The pin was removed after 7 weeks and the patient discharged a few days later.The patient was fit, with no previous medical problems and an ASA 1 status. After oral premedication with metoclopramide 10 mg, ranitidine 150 mg and temazepam 10 mg anaesthesia was induced with midazolam 2 mg, fentanyl 50 pg and propofol 120 mg followed by insertion of a laryngeal mask airway. Arterial oxygen saturation (Spo,), inspiratory oxygen concentration (Ro2), end-tidal carbon dioxide concentration (Fk'co,), noninvasive blood pressure and electrocardiograph (mode V5) monitoring was started in the anaesthetic room and continued throughout the operation. Anaesthesia was maintained with isoflurane 0.7-1.2% in 60% nitrous oxide in oxygen, the patient breathing spontaneously from a Mapleson A breathing system. Morphine analgesia was administered in increments up to 5 mg in total. A tourniquet was applied (250 mmHg pressure) and the surgeon excised infected granulation tissue which was superficial as well as deep inside the former pin tract. The bony wound canal was irrigated with 10 ml of hydrogen peroxide 6% followed by 10 ml of 0.9% saline. After insertion of a Kaltostat wick the wound was closed and a dressing applied. Throughout the operation the patient remained normocapnoeic (Fk'co, 4.9-5.2 kPa), the systolic blood pressure between 95 and 110 mmHg and the pulse rate between 55 and 65 beat.min-I. After 26min operation time the tourniquet was deflated and the drapes removed.Within a few seconds of releasing the tourniquet the surgeon noted that the first and second toe of the foot were white, whereas the rest of the foot was pink. Gas bubbles were then noticed in the veins of the dorsum of the foot followed by a decrease in the end-tidal CO, concentration from 4.9 to 3.6 kPa. Auscultation of the heart revealed a classic 'mill-wheel' murmur. There was no evidence of haemodynamic instability shown by alterations in heart rate, rhythm or blood pressure.The tourniquet was immediately reapplied, the patient put in a left-lateral position...

A patient undergoing minor orthopaedic surgery suffered from unexpected arterial and venous gas embolism caused by hydrogen peroxide. We describe our management of the case and emphasise the need for continued vigilance during the use of hydrogenperoxide.

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