Perioperative intravenous glucocorticoids can decrease postoperative nausea and vomiting and pain in total joint arthroplasty: A meta-analysis and trial sequence analysis

Abstract

Background: This meta-analysis aimed to demonstrate the efficacy and safety of intravenous glucocorticoids for reducing pain intensity and postoperative nausea and vomiting (PONV) in patients undergoing total joint arthroplasty (TJA).

Methods: PubMed, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, and Google databases were searched for randomized controlled trials (RCTs) comparing intravenous glucocorticoids versus no intravenous glucocorticoids or sham for patients undergoing TJA. Outcomes included visual analogue scale (VAS) pain at 12, 24, and 48 hours; the occurrence of PONV; length of hospital stay; the occurrence of infection; and blood glucose levels after surgery. We calculated risk ratios (RR) with a 95% confidence interval (CI) for dichotomous outcomes and the weighted mean difference (WMD) with a 95% CI for continuous outcomes. Trial sequential analysis was also used to verify the pooled results.

Results: Thirteen clinical trials involving 821 patients were ultimately included in this meta-analysis. The pooled results indicated that intravenous steroids can decrease VAS at 12 hours (WMD = -8.54, 95% CI -11.55 to -5.53, P = 0.000; I = 35.1%), 24 hours (WMD = -7.48, 95% CI -13.38 to -1.59, P = 0.013; I = 91.8%), and 48 hours (WMD = -1.90, 95% CI -3.75 to -0.05, P = 0.044; I = 84.5%). Intravenous steroids can decrease the occurrence of PONV (RR = 0.56, 95% CI 0.44-0.73, P = 0.000; I = 33.1%). There was no significant difference in the length of hospital stay, occurrence of infection, and blood glucose levels after surgery.

Conclusion: Intravenous glucocorticoids not only alleviate early pain intensity but also decrease PONV after TJA. More high-quality RCTs are required to determine the safety of glucocorticoids before making final recommendations.

Conflict of interest statement

The authors have no conflicts of interest to disclose.

Figures

Figure 1

Flowchart of the study search and inclusion criteria.

Figure 2

A, The risk of bias graph. BA = risk of bias of included in randomized controlled trials. + = no bias, − = bias, ? = bias unknown. B, The risk of bias summary of the included studies.

Figure 3

A, Forest plots of the included studies comparing the VAS at 12 h. B, A trial sequential analysis (TSA) showed that the pooled results (Z curve; blue lines) at all 3 time points crossed the conventional boundary of benefit (jacinth lines). VAS = visual analogue scale.

Figure 4

A, Forest plots of the included studies comparing the VAS at 24 h. B, Z curve crossed the trial sequential monitoring boundary for benefit (red curve) but did not reach the required sample size based on TSA (n = 735), entering the area of benefit (above the upper red line). TSA = trial sequence analysis, VAS = visual analogue scale.

Figure 5

A, Forest plots of the included studies comparing the VAS at 48 h. B, Z curve crossed the trial sequential monitoring boundary for benefit (red curve) but did not reach the required sample size based on TSA (n = 1510), entering the area of benefit (above the upper red line).

Figure 6

A, Forest plots of the included studies comparing the occurrence of PONV. PONV = postoperative nausea and vomiting; B, Z curve crossed the trial sequential monitoring boundary for benefit (red curve) but did not reach the required sample size based on TSA (n = 1510), entering the area of benefit (above the upper red line).

Figure 7

Scatter plot showing the relationship between the changing of glucocorticoid dose and the occurrence of PONV.

Figure 8

Forest plots of the included studies comparing the occurrence of infection.

Figure 9

Forest plots of the included studies comparing the length of hospital stay.

Figure 10

Forest plots of the included studies comparing the blood glucose levels.