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Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 12  |  Issue : 3  |  Page : 630-635  

Comparison of postoperative quality of recovery and pain relief with preoperative single-dose dexamethasone and lignocaine after laparoscopic cholecystectomy


1 Department of Anesthesiology, Himalayan Institute of Medical Sciences, Swami Rama Himalayan University, Dehradun, Uttarakhand, India
2 Department of Surgery, Himalayan Institute of Medical Sciences, Swami Rama Himalayan University, Dehradun, Uttarakhand, India

Date of Web Publication11-Sep-2018

Correspondence Address:
Dr. Poonam Arora
Department of Anesthesiology, Himalayan Institute of Medical Sciences, Swami Rama Himalayan University, Jolly Grant, P. O. Doiwala, Dehradun - 248 140, Uttarakhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aer.AER_82_18

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   Abstract 

Aim: To compare the role of single intravenous (IV) bolus of lignocaine and dexamethasone on pain score and quality of recovery score (QoR40) after laparoscopic cholecystectomy. Setting and Design: The study was conducted at the postoperative recovery area, This was a double-blind randomized controlled study Materials and Methods: Seventy patients 18–60 years of age, American Society of Anesthesiologists physical status Class I and II, who underwent elective laparoscopic cholecystectomy, were enrolled in this study after approval from the Institutional Ethics Committee. Patients were randomly allocated to two groups. Group 1 received: 2 mg/kg lignocaine diluted to 10 ml with normal saline, and Group 2 received 0.1 mg/kg IV dexamethasone diluted to 10 ml with normal saline. Global QoR-40 is a 40-item questionnaire that provides a global score and subscores across five dimensions: psychological support, comfort, independence, pain, and emotions. It was assessed on a preoperative day as baseline to assess patient's basic quality of life and at 24 h postoperative. Visual analog scale (VAS) static and dynamic, total analgesic consumption in a day, nausea and vomiting, and antiemetic per day were assessed. Statistical Analysis Used: Student's t-test, Chi-square test, Fisher's exact, Levene's test were used for statistical analysis. Results: Dexamethasone group had higher Global QoR-40 than lignocaine group 187.94 versus 182.85. Among dimensions of QoR-40, dexamethasone had statistically better physical comfort, physical independence, and pain relief as compared to lignocaine. Dexamethasone group had lower VAS compared to lignocaine group. Similarly, there was less fentanyl consumption in dexamethasone group (364.08 ± 127.31) in the postoperative period when compared to the lignocaine group (412.31 ± 147.8). Conclusions: Preoperative administration of a single dose of dexamethasone enhanced QoR after laparoscopic cholecystectomy as compared to lignocaine bolus dose.

Keywords: Dexamethasone, lignocaine, quality of recovery-40 questionnaire, quality of recovery


How to cite this article:
Surender, Arora P, Khurana G, Sachan PK. Comparison of postoperative quality of recovery and pain relief with preoperative single-dose dexamethasone and lignocaine after laparoscopic cholecystectomy. Anesth Essays Res 2018;12:630-5

How to cite this URL:
Surender, Arora P, Khurana G, Sachan PK. Comparison of postoperative quality of recovery and pain relief with preoperative single-dose dexamethasone and lignocaine after laparoscopic cholecystectomy. Anesth Essays Res [serial online] 2018 [cited 2018 Sep 21];12:630-5. Available from: http://www.aeronline.org/text.asp?2018/12/3/630/240876


   Introduction Top


Postoperative pain is a common complaint after laparoscopic cholecystectomy. Pain can not only prolong hospital stay but may lead to postoperative ileus, nausea, vomiting, and urinary retention, thus increasing morbidity. The cause of postoperative pain in laparoscopy is inflammation of peritoneum or the presence of gas. The postoperative pain management aims to eliminate pain and discomfort with minimum of side effects.[1],[2],[3],[4]

Corticosteroids have long been known to modulate the inflammatory response and have been shown to decrease inflammation and provide postoperative analgesia in various surgeries. Injecting single-dose dexamethasone may prevent postoperative nausea and vomiting (PONV), most effective when administered before induction of anesthesia. The role of intravenous (IV) infusion of lignocaine on postoperative pain is seen in various studies. None has compared the role of dexamethasone and lignocaine in laparoscopic cholecystectomy patients under general anesthesia.[5],[6],[7]

Due to recent advances in surgical and anesthetic techniques, traditional outcome measures such as morbidity and mortality are no longer sufficient markers of quality of care. Patient-centered outcomes, such as patient satisfaction and postoperative recovery, are increasingly recognized as important indicators of quality of care.

Quality of recovery (QoR) is a high-quality tool to assess patient perception for recovery after anesthesia and surgery. Poor-quality recovery frequently prolongs the duration of stay in recovery or delays discharge from the hospital, both of which have significant implication for resource utilization. Negative association is demonstrated between the QoR-40 score and duration of hospital stay.[8],[9],[10]

The primary aim of this study was to compare the role of single IV bolus of lignocaine and dexamethasone on pain score and QoR40. Secondary objectives were timing of first rescue analgesia, total postoperative analgesic consumption, incidence of nausea and vomiting, antiemetic consumption, and other side effects.


   Materials and Methods Top


The randomized, double-blind experimental study was approved by the institutional, departmental, and ethics committee, conducted on patients with a primary diagnosis of cholelithiasis after obtaining written informed consent.

The study included a total of 70 patients, American Society of Anesthesiologists (ASA) physical status Class I and II, aged between 18 and 60 years, who underwent elective laparoscopic cholecystectomy under general anesthesia [Figure 1].
Figure 1: CONSORT flow diagram of participants through each stage of the randomized trial

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Patients with hepatic insufficiency (liver enzyme more than two times normal value), renal insufficiency (i.e., serum creatinine more than two times normal value), history of corticosteroid hypersensitivity/lignocaine hypersensitivity, previous gastric ulcer, diabetes mellitus, already on opioid medication, pregnancy, psychiatric/central nervous system disturbance, if surgical procedure is changed from laparoscopic to open approach were excluded.

After exclusion, eligible patients were randomly allocated according to computer-generated number into two groups.

  • Group 1: 2 mg/kg lignocaine diluted to 10 ml with normal saline
  • Group 2: 0.1 mg/kg IV dexamethasone diluted to 10 ml with normal saline.


After exclusion, eligible patients were assessed in the preanesthetic checkup 1 day before surgery. They were explained visual analog scale (VAS) and the use of patient-controlled analgesia (PCA) pump for the postoperative pain relief. Baseline QoR40 was assessed. They were advised to stay nil per oral 6 h before surgery.

On arrival to the operative room, IV line was established. All monitors were attached and the vitals were noted. Treatment assignment was based on computer-generated randomization that was maintained in sequentially numbered sealed envelope. Study medications were prepared by anesthesiologist who was not involved in further patient care or data collection. The anesthesiologist and postanesthesia care unit staff nurse involved in data collection were not aware of groups. Patient received drug according to group allocated.

The patient was preoxygenated with 100% O2 for 3 min; induction was done with injection fentanyl 2 μg/kg and injection propofol 2.0–2.5 mg/kg. Ventilation was assessed and neuromuscular blockade was done with injection vecuronium bromide 0.08–0.1 mg/kg.

After ventilation for 3 min, the patient was intubated under direct laryngoscopy with appropriate size endotracheal tube. Cuff pressure was maintained between 20 and 30 cm H2O.

After tracheal intubation, nasogastric tube was placed to promote emptying the stomach contents and was removed immediately before extubation.

Anesthesia was maintained with 60% nitrous oxide in O2 and sevoflurane with MAC 1.6 and injection vecuronium 0.02 mg/kg. Additional fentanyl 1 μg/kg was administered intraoperatively to maintain mean arterial blood pressure and pulse rate within 20% of the baseline. Ventilation was controlled mechanically to maintain an end-tidal carbon dioxide (EtCO2) concentration of 30–34 mmHg.

Forced air warming device (Bair-Hugger) was used to maintain core body temperature of 36°C. Intraoperative vitals were recorded every 5 min. During laparoscopy, intra-abdominal pressure was maintained ≤15 mmHg.

CO2 was carefully evacuated at the end of surgery by manual compression of abdomen with open trocars. 2 ml of 0.25% bupivacaine was infiltrated in each port site.

Injection paracetamol 1 g was administered intravenously 20 min before extubation. Injection ondansetron 0.08 mg/kg was given10 min before extubation. Neuromuscular blockade was reversed with 0.05 mg/kg neostigmine and 0.01 mg/kg glycopyrrolate before tracheal extubation. The patient was again oxygenated for 5 min with 100% O2 by face mask.

The patient was shifted to recovery room and was asked to rate pain at rest and on movement upon arrival and at 30 min, and 1, 2, 4, 8, 12 and 24 h after the procedure on a 0–10 VAS score for pain, where 0 means no pain and 10 is the worst pain imaginable. Nausea and vomiting, shoulder pain, return of bowel function, and rescue antiemetic used were also assessed at the same interval and recorded as present or absent. Injection metoclopramide 10 mg intravenously was prescribed for persistent nausea (lasting >5 min) or vomiting.

When the patient complained of pain with VAS ≥4, injection fentanyl 1 μg/kg was injected IV and PCA pump was attached with bolus dose of 0.25 μg/kg, with lockout time of 10 min. Total consumption of fentanyl and antiemetic per day was assessed.

Study tools

  • QoR questionnaire-40 (QoR-40)
  • VAS score.


Primary outcome

Global QoR-40-QoR-40 was assessed on a preoperative day as baseline to assess patient basic quality of life and again QoR-40 was assessed at 24 h postoperatively.

Postoperative pain-VAS static and dynamic was used for the assessment of pain. The patient was asked to rate his/her pain as a number out of 10. For example, a score of 0/10 indicates no pain while a score of 10/10 indicates worst pain.

Secondary outcomes

  • Total analgesic consumption in a day
  • Random blood sugar (RBS)
  • Shoulder pain
  • Nausea and vomiting
  • Antiemetic per day
  • Return of bowel function
  • Side effects.


Sample size

Considering QoR-40 scores from previous study,[11],[12] power (1− β) = 80%, and level of significance = 5%, the sample size is calculated by n-master software. As per null hypothesis – detecting no difference, estimating the difference of 10 points, number of patients required was 30 in each group. To account for dropouts, if the questionnaires were incomplete 70 patients were enrolled, each group having 35 patients.

Statistical analysis

The statistical analysis of baseline characteristics of experimental study groups was conducted with the Statistical Package for the Social Sciences System Version SPSS 17.0. (IBM, SPSS Statistical base:SPSS South Asia Pvt Ltd, Bengluru, India). Continuous variables are presented as mean ± standard deviation, and categorical variables are presented as absolute numbers and percentage. The comparison of normally distributed continuous variables between the groups was performed using Student's t-test. Within the groups, the comparison of mean change from preoperative to postoperative was done using paired t-test. Nominal categorical data between the groups were compared using Chi-square test or Fisher's exact test or Levene's test as appropriate. P < 0.05 was considered statistically significant.


   Results Top


The study completed in 67 patients of laparoscopic cholecystectomy; three patients were excluded from the study. The two groups were comparable in terms of demographic variables such as age, sex, weight, height, ASA class, smoking, duration of surgery, and anesthesia (P > 0.05) [Table 1].
Table 1: Demographic characteristics of the study population

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The mean RBS at 0hr was 104.09±26.681mg/dl in group 1, 98.09±14.740mg/dl in group 2. At 4hrs, mean RBS was 134.76±37.710mg/dl in group 1, 141.67±23.792mg/dl in group 2. At 24 hrs, mean RBS was 125.00±29.018 in group 1 and 128.03±20.166mg/dl in group 2.

Rise in blood sugar from baseline value was observed more in Group 2. RBS at 4th h and 24th h was found to be more in Group 2 as compared to Group 1 though it was statistically insignificant [Table 1].

The mean blood pressure, heart rate, SpO2, and respiratory rate were similar in both groups at all measurement times (P > 0.05) [Table 2].
Table 2: Comparison of baseline and postoperative dimensions of quality of recovery-40 between two groups

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On comparing preoperative QoR40 domains of physical comfort, emotional state, independence, pain and psychological support were comparable in both the groups.

There was statistically significant difference in postoperative global QoR-40 of dexamethasone (187.94) and lignocaine group (182.85) (P = 0.000).

While comparing postoperative QoR-40, both groups were comparable in dimensions of emotional state and psychological support. Dexamethasone group was significantly better in domains of physical comfort, physical independence, and pain.

P value of VAS static and dynamic was not statistically significantly difference in both groups. VAS dynamic is more than VAS static in both groups. Postoperative mean VAS static as well as dynamic values are >4 immediately after extubation, which decreased progressively after 1 h of extubation [Table 3].
Table 3: Postoperative visual analogue scale static/dynamic and total analgesic consumption

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Total analgesic consumption was less in Group 2 (364.0819 ± 127.3188) as compared to Group 1 (412.3132 ± 147.7742), but statistically significant difference was not seen in both the groups (P > 0.05). Mean postoperative VAS values at all time intervals as well as analgesic consumption was more in Group 1 than Group 2, but difference is not statistically significant. Postoperative VAS static as well as dynamic values are more immediately after extubation, which decreased progressively after 1 h of extubation.

Total episodes of PONV were 18 in Group 1 and 7 in Group 2. Statistically significant difference was seen between two groups (P = 0.007). Use of antiemetic was more in Group 1 as compared to Group 2 at all the times, though it was not significant statistically at different time intervals. Use of antiemetic was 18 times in Group 1 and 5 times in Group 2 during 24 h of postoperative period. Statistically, significant difference (P = 0.011) was seen in total antiemetic consumption [Table 4].
Table 4: Total frequency of postoperative nausea and vomiting, antiemetic use, shoulder pain, improved appetite in first 24 h

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Lesser episodes of shoulder pain in Group 2 (6) were noted as compared to Group 1 (21). The difference was statistically significant. Improvement in appetite was more in Group 2 (36.36%) as compared to Group 1 (17.64%).

No statistically significant difference was observed between two groups in terms of return of bowel function. None of the patients had IV-site irritation, perioral numbness, blurry vision, arrhythmia, and convulsion in both the groups. Rest of the side effects were more in Group 1 as compared to Group 2, though statistically insignificant (P > 0.05).


   Discussion Top


QoR after anesthesia and surgery is an important measure of the early postoperative health status of patients. Reducing postoperative discomfort and complications, optimizing early feeding and ambulation, and facilitating early hospital discharge, and improving quality outcomes are the important goals for anesthesiologists and health-care systems.

Our findings suggested that QoR outcome with single preoperative dose is enhanced with dexamethasone as compared to single bolus dose of lignocaine. The beneficial effects of dexamethasone on interrelated symptoms resulted in better overall QoR 40 score. The most significant difference between the groups was observed in dimensions of physical comfort, independence, and pain and their subscores.

Global QoR-40 scores on the postoperative day 1 were higher in the dexamethasone group, 178 as compared with the control group, 161. Postoperative QoR-40 scores in the dimensions of emotional state, physical comfort, and pain were all improved in the dexamethasone group compared with the control group (P< 0.001). Nausea, fatigue, and pain scores were all reduced in the dexamethasone group during the hospitalization as were postoperative analgesic requirements. Total hospital length of stay was also reduced in patients administered steroids.[11]

Positive domains such as good sleep, enjoying food, and well rested in the physical comfort were better in dexamethasone as compared to lignocaine.Among negative dimensions of physical comfort, incidence of postoperative nausea vomiting was more in lignocaine group but rest of the negative dimensions improved because of pain relief with opioids.

Among the groups in physical independence domain, the positive items mainly able to wash hand, speech, and look after appearance were more in dexamethasone group as compared to lignocaine.

Among the negative items in the physical comfort domain, episodes of nausea and vomiting decreased more with dexamethasone, which improved the patient comfort.The antiemetic effect of dexamethasone improved appetite, prevented anorexia, indirectly contributing to comfort and convalescence.

Prophylactically, dexamethasone has been seen to reduce sore throat significantly following laryngoscopy and tracheal intubation.[12] In our study, after administration of dexamethasone, the remaining items in subgroup of pain such as sore throat, headache, and backache were seen reduced as compared to the lignocaine group.

Rise in RBS level in both groups without any significant difference might be due to surgical stress and not due to steroid administration. Murphy et al. suggested that since blood sugar concentrations did not differ much between dexamethasone and saline group during first 24 h, use of dexamethasone should not be avoided out of concerns related to hyperglycemia.[13] While hyperglycemia needs to be carefully monitored and treated, particularly in patients at risk for glucose-mediated exacerbation of brain injury mentioned in a report from Pasternak et al.[14]

In 17%–41% of the patients, pain is the main reason for staying overnight in the hospital on the day of surgery, and pain is the dominating complaint and the primary reason for prolonged convalescence after laparoscopic cholecystectomy.[15]

VAS decreased in both groups after 90–120 min of drug administration. This finding is consistent with time of peak effect of dexamethasone. Dexamethasone group had lower VAS compared to lignocaine group. Similarly, there was less fentanyl consumption in dexamethasone group in the postoperative period when compared to the lignocaine group. Bisgaard et al. reported that when 8 mg of dexamethasone was IV injected 90 min before laparoscopic cholecystectomy, the postoperative pain and required amount of opioids were reduced approximately 50% compared to the placebo group due to decrease in postoperative inflammatory response supported by less increase in C-reactive protein levels.[16]

In our study, slightly lower VAS score and opioid consumption were revealed in lignocaine group than previous studies in which patients received lignocaine infusion. This might be influenced by the fact that in previous studies, IV infusion of lidocaine was used as against single bolus dose used in our study.

In a study by Tauzin-Fin et al., IV infusion of lignocaine significantly reduced morphine consumption by about 66% as well as pain score at rest and during coughing, during the first 2 postoperative days.[17] However, no significant difference was observed in VAS; fentanyl consumption between single preoperative bolus of dexamethasone and lignocaine. This may be due to the fact that we used PCA fentanyl as rescue analgesia, causing a steady state concentration in both the groups.

Reduction in VAS and fentanyl requirement in both groups might be due to anti-inflammatory property of the drugs. The intensity of postoperative pain is lesser after steroid administration since the biological onset of action is 1–2 h.

In a meta-analysis by De Oliveira et al., preoperative administration of dexamethasone appears to produce a more consistent analgesic effect compared with intraoperative administration; the finding is consistent with the time to peak effect of dexamethasone (45 min to 1 h). Dexamethasone at doses >0.1 mg/kg is an effective adjunct in multimodal strategies to reduce postoperative pain and opioid consumption after surgery.[18]

Dexamethasone group patients had lesser incidence of shoulder pain when compared to lignocaine group. Anti-inflammatory effect of steroid might be having some role in relieving this pain which is mostly due to peritoneal irritation as mentioned in previous studies. In a study by Asgari Z et al., intraperitoneal dexamethasone relieved postoperative pain, shoulder pain, and need for opioids after gynecological laparoscopic surgery due to direct instillation of drug to inflamed location.[7]

The incidence of PONV in laparoscopic cholecystectomy is estimated to be 50%–75%. We observed that preoperative administration of dexamethasone (24.24%) has less episodes of nausea and vomiting as compared to lignocaine group (52.5%). In a meta-analysis by Henzi et al., who reviewed data from 17 trials, preoperative administration of 8–10 mg of dexamethasone reduces local inflammatory reactions after surgery; this may reduce the inflammation triggered by afferent stimulation of parasympathetic nervous system to the vomiting center, thereby reducing PONV.[19]

Similarly, Murphy et al. also found lower incidence of nausea in dexamethasone group 12.5%, versus 37.3% control group.[20] Elhakim et al. suggested that dexamethasone might act as a serotonin receptor antagonist in the gastrointestinal tract.[21]

Improvement in appetite and lesser incidence of nausea and vomiting with improved pain scores helped patients to return to normal activities. In a study by Tauzin-Fin et al., none of the patients in lidocaine infusion group experienced nausea in comparison to control, probably in relation to 66% reduction in opioid consumption.[17]

In our study, dexamethasone group had improvement in appetite more than lignocaine group, which may be due to anabolic effect of corticosteroids. Early oral feeding should facilitate recovery and rehabilitation. Vardy et al. found that patient receiving dexamethasone for prophylaxis of emesis had increased appetite (19%).[22] Ho et al. in their study mentioned that dexamethasone increases synthesis of endorphins in the body, which uplifts the mood and appetite.[23]

Limitation of our study is that we assessed VAS, QoR-40 score only at 24 h. It is uncertain whether beneficial effects of single dose of dexamethasone and lignocaine extend into long-term outcome. Hence, we should have followed patients to observe their role in chronic pain. We could have assessed levels of pro-inflammatory cytokines, to determine whether bolus dose of dexamethasone and lignocaine has any potential association with pain and QoR.


   Conclusions Top


Our study demonstrated that preoperative administration of a single bolus dose of dexamethasone enhanced recovery after laparoscopic cholecystectomy as compared to lignocaine bolus dose. After 24 h, patient-perceived QoR was enhanced among patients receiving dexamethasone. Physical comfort, pain, and physical independence domains of QoR were more improved with dexamethasone as compared to lidocaine. Pain scores and fentanyl consumption were reduced with dexamethasone. These improvements in recovery translated into better outcomes postoperatively.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

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Boddy AP, Mehta S, Rhodes M. The effect of intraperitoneal local anesthesia in laparoscopic cholecystectomy: A systematic review and meta-analysis. Anesth Analg 2006;103:682-8.  Back to cited text no. 1
    
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Karst M, Kegel T, Lukas A, Lüdemann W, Hussein S, Piepenbrock S, et al. Effect of celecoxib and dexamethasone on postoperative pain after lumbar disc surgery. Neurosurgery 2003;53:331-6.  Back to cited text no. 6
    
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11.
Murphy GS, Szokol JW, Greenberg SB, Avram MJ, Vender JS, Nisman M, et al. Preoperative dexamethasone enhances quality of recovery after laparoscopic cholecystectomy: Effect on in-hospital and postdischarge recovery outcomes. Anesthesiology 2011;114:882-90.  Back to cited text no. 11
    
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De Oliveira GS Jr., Ahmad S, Fitzgerald PC, Marcus RJ, Altman CS, Panjwani AS, et al. Dose ranging study on the effect of preoperative dexamethasone on postoperative quality of recovery and opioid consumption after ambulatory gynaecological surgery. Br J Anaesth 2011;107:362-71.  Back to cited text no. 12
    
13.
Murphy GS, Szokol JW, Avram MJ, Greenberg SB, Shear T, Vender JS, et al. The effect of single low-dose dexamethasone on blood glucose concentrations in the perioperative period: A randomized, placebo-controlled investigation in gynecologic surgical patients. Anesth Analg 2014;118:1204-12.  Back to cited text no. 13
    
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Pasternak JJ, McGregor DG, Lanier WL. Effect of single-dose dexamethasone on blood glucose concentration in patients undergoing craniotomy. J Neurosurg Anesthesiol 2004;16:122-5.  Back to cited text no. 14
    
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Bisgaard T. Analgesic treatment after laparoscopic cholecystectomy: A critical assessment of the evidence. Anesthesiology 2006;104:835-46.  Back to cited text no. 15
    
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[PUBMED]  [Full text]  
18.
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20.
Murphy GS, Sherwani SS, Szokol JW, Avram MJ, Greenberg SB, Patel KM, et al. Small-dose dexamethasone improves quality of recovery scores after elective cardiac surgery: A randomized, double-blind, placebo-controlled study. J Cardiothorac Vasc Anesth 2011;25:950-60.  Back to cited text no. 20
    
21.
Elhakim M, Ali NM, Rashed I, Riad MK, Refat M. Dexamethasone reduces postoperative vomiting and pain after pediatric tonsillectomy. Can J Anaesth 2003;50:392-7.  Back to cited text no. 21
    
22.
Vardy J, Chiew KS, Galica J, Pond GR, Tannock IF. Side effects associated with the use of dexamethasone for prophylaxis of delayed emesis after moderately emetogenic chemotherapy. Br J Cancer 2006;94:1011-5.  Back to cited text no. 22
    
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Ho CM, Wu HL, Ho ST, Wang JJ. Dexamethasone prevents postoperative nausea and vomiting: Benefit versus risk. Acta Anaesthesiol Taiwan 2011;49:100-4.  Back to cited text no. 23
    


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  [Table 1], [Table 2], [Table 3], [Table 4]



 

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