Re: Dexamethasone versus standard treatment for postoperative nausea and vomiting in gastrointestinal surgery: randomised controlled trial (DREAMS Trial)
To the Editor and Authors,
We read with interest the recent randomised controlled trial (RCT) published in the BMJ by the DREAMS Trial Collaborators . They report that a single dose of 8mg of intravenous dexamethasone, given at the induction of anaesthesia, reduces the incidence of postoperative nausea and vomiting (PONV) and the need for additional anti-emetics following gastrointestinal surgery. The authors conclude that a single dose of 8mg intravenous dexamethasone during anaesthesia should be used routinely to reduce PONV in patients undergoing gastrointestinal surgery. This is in keeping with existing evidence from prior meta-analyses of RCTs on the subject in other areas of surgery [2-3]. The authors suggest that one of the possible mechanisms by which dexamethasone reduces the incidence of PONV is by its anti-inflammatory effects, however no measure of the postoperative systemic inflammatory response was included in the presented paper.
The magnitude of the postoperative systemic inflammatory response is now well recognised to be associated with complications after major gastrointestinal surgery, and in particular colorectal surgery . Serum C-reactive protein (CRP) has been recognised as a marker of the magnitude of the postoperative systemic inflammatory response, and clinically relevant threshold values associated with such complications have already been derived [5-6]. It is therefore of interest that recent observational evidence suggests that intravenous dexamethasone, given during anaesthesia with the aim of reducing PONV, was associated with the attenuation of the postoperative systemic inflammatory response, and a reduction in the rate of complications of any type following surgery for colorectal cancer . Furthermore, a meta-analysis of RCTs of preoperative corticosteroids in surgery for gastrointestinal cancer reported a significant reduction in postoperative CRP and complications . Also, patient factors such as comorbidity, BMI, and the presence of preoperative systemic inflammation act to increase the magnitude of the postoperative systemic inflammatory response whilst it is decreased through the use of minimally invasive surgery . Although the DREAMS Trial was well balanced in its groups in terms of the use of laparoscopic surgery and comorbidity the post-operative measurement of CRP would have informed the efficacy of steroid treatment on the systemic inflammatory response and post-operative nausea and vomiting. In particular, the inclusion of a marker of the postoperative systemic inflammatory response, such as CRP, may have provided useful insight into both the mechanism of action of dexamethasone with regard to its effect on PONV, and also might have shed light as to why there was no observed reduction in postoperative complications.
From the above we would suggest that future trials of corticosteroids with postoperative outcome endpoints, such as PONV and complications, should include measurement of the postoperative systemic inflammatory response using CRP. In particular, this will inform the optimal dose of dexamethasone prior to surgery.
1. Dexamethasone versus standard treatment for postoperative nausea and vomiting in gastrointestinal surgery: a randomised controlled trial (DREAMS Trial). DREAMS Trial Collaborators and West Midlands Research Collaborative. BMJ 2017;357:j1455
2. Karanicolas PJ, Smith SE, Kanbur B, Davies E, Guyatt GH. The impact of prophylactic dexamethasone on nausea and vomiting after laparoscopic cholecystectomy: a systematic review and meta-analysis. Ann Surg 2008;357:751-762
3. De Oliveira GS Jr, Santana Castro-Alves LJ, Ahmad S, Kendall MC, McCarthy RJ. Dexamethasone to prevent postoperative nausea and vomiting: an updated meta-analysis of randomized controlled trials. Anesth Analg 2013;116:58-74
4. Adamina M, Steffen T, Tarantino I, Beutner U, Schmied BM, Warschkow R. Meta-analysis of the predictive value of C-reactive protein for infectious complications in abdominal surgery. Br J Surg 2015;102:590-598
5. Watt DG, Horgan PG, McMillan DC. Routine clinical markers of the magnitude of the systemic inflammatory response after elective operation: a systematic review. Surgery 2015;157(2):362-380
6. McDermott FD, Heeney A, Kelly ME, Steele RJ, Carlson GL, Winter DC. Systematic review of preoperative, intraoperative and postoperative risk factors for colorectal cancer. Br J Surg 2015;102:462-479
7. McSorley ST, Roxburgh CS, Horgan PG, McMillan DC. The Impact of preoperative dexamethasone on the magnitude of the postoperative systemic inflammatory response and complications following surgery for colorectal cancer. Ann Surg Oncol 2017 doi: 10.1245/s10434-017-5817-3. [epub ahead of print]
8. McSorley ST, Horgan PG, McMillan DC. The impact of preoperative corticosteroids on the systemic inflammatory response and postoperative complication following surgery for gastrointestinal cancer: a systematic review and meta-analysis. Crit Rev Oncol Hematol 2016;101:139-150
Competing interests: No competing interests