The Steroid Controversy: Where Are We?

Abstract

Dexamethasone is widely administered to children during elective tonsillectomy to reduce the rate of postoperative nausea and vomiting, as well as decrease postoperative use of pain medications. Over the past two decades, there has been a wealth of literature advocating the practice that has led to endorsement by a variety of anesthesia and otolaryngology professional associations. However, the publication of a trial that was halted due to a potential dose-dependent association between postoperative hemorrhage and dexamethasone raised significant scrutiny regarding the practice in 2008. As a result, significant re-evaluation of existing data as well as the development and execution of additional trials have been pursued in recent years. Ultimately, the body of evidence that currently exists appears to support the concept that a single dose of perioperative dexamethasone is not associated with undue risk. A decision to withdraw dexamethasone from use in pediatric tonsillectomy needs to be weighed against the potential of causing increased postoperative nausea, vomiting, pain, and resultant hospital readmission. At this point, surgeons and anesthesiologists should feel comfortable giving perioperative dexamethasone but must remain vigilant for bleeding complications.

Association of National Guidelines With Tonsillectomy Perioperative Care and Outcomes

“…18 Subsequent safety evidence published during or after the postguideline period in this study has been conflicting, and thus the use of dexamethasone has been a point of controversy. 19 A noninferiority trial found that there was no increased risk of bleeding associated with dexamethasone; however, this trial has been criticized as having set an inappropriately large noninferiority margin for bleeding that necessitated reoperation (ie, 5%). 20,21 A meta-analysis and a large observational study concluded that there is no clinically important risk of bleeding associated with dexamethasone use.…”

Dexamethasone and Risk of Bleeding in Children Undergoing Tonsillectomy

“…Our large observational study combined with this body of evidence from small RCTs supports the safety of dexamethasone and these recommendations for the routine use of dexamethasone in children. 3,8 …”

“…There has been controversy on whether dexamethasone increases bleeding risk. 8 It has been hypothesized that dexamethasone inhibits postoperative healing processes resulting in increased risk of bleeding. 9 Analysis of bleeding as a secondary outcome in several small trials found postoperative bleeding to be increased with dexamethasone use.…”

A new analgesic paradigm for pediatric tonsillectomy: Are we dragging our heels?

“…17 That 2008 study was an outlier in the dexamethasone literature, and its statistical analyses have been extensively questioned. 18 Ibuprofen and other nonselective NSAIDs face precisely the same challenge if a bleeding risk rationale-however unproven-is also considered to be true.…”

“…17 Cette étude fait figure d'anomalie dans la littérature portant sur la dexaméthasone, et ses analyses statistiques ont depuis été considérablement remises en question. 18 L'ibuprofène et les autres AINS non sélectifs seront confrontés aux mêmes difficultés d'adoption s'il existe la moindre croyance-qu'elle soit avérée ou non-qu'il y a un risque de saignement. À la lumière de cet exemple édifiant, et malgré les directives 13,15 préconisant son utilisation, nous ne pouvons pas nous attendre à ce que l'ibuprofène soit adopté de façon universelle par les médecins dans un avenir proche.…”