Prophylactic Corticosteroid Administration Research Articles

STEROIDS IN CARDIAC SURGERY: A SYSTEMATIC REVIEW

Since there has been considerable research on the prophylactic administration of corticosteroids in adult patients undergoing cardiac surgery with cardiopulmonary bypass (CPB), there is limited evidence to suggest that steroid therapy substantially affects patient outcomes.
 Objective: This study aims to investigate the effects of administering steroids during cardiac surgery.
 Aim: This study complied with the PRISMA 2020 guidelines for systematic review and meta-analysis. The researchers verified the study's similarity to become feasible. Publications from 2015 to 2023 were searched using online reference databases, including Pubmed and SagePub. Review articles, previously published works, and incomplete articles were dismissed.
 Methods: The search identified 9,316 articles in PubMed and 7,654 articles in SagePub. In 2015, a search on PubMed identified 238 articles, and a search on SagePub yielded 121 articles. At last, 27 papers were selected, with 15 sourced from PubMed and 12 from SagePub. We included five studies that met the criteria.
 Conclusion: The relationship between prescribing steroids and surgical site infections is still debated. Corticosteroid therapy has been found to reduce the incidence of postoperative delirium.

Development and Internal Validation of a Recursive Partitioning Analysis–Based Model Predictive of Pain Flare Incidence After Spine Stereotactic Body Radiation Therapy

PurposePain flares are a common acute toxic effect after stereotactic body radiation therapy (SBRT) for spine metastasis. We aimed to identify a subset of patients with the highest rate of pain flare after spine SBRT to optimize prophylactic corticosteroid administration. Methods and MaterialsThe data set included 428 patients with 610 treatments. We defined pain flare as acute worsening of pain at the treatment site requiring new or higher dose therapy with corticosteroids, opiates, and/or hospitalization. Data were split into 70% training and 30% validation sets using a random number generator. After feature importance testing and generation of a correlation heatmap, feature extraction was performed via recursive partitioning analysis. ResultsWe identified 125 total pain flares (20%). Five variables met significance (P < .02) for model inclusion: renal primary, soft tissue involvement, Bilsky >0, spinal instability neoplastic score >6, and gross tumor volume >8 cc. One point was assigned for each variable. The low-risk group (score = 0, n = 159) had pain flare rates of 7.0% and 13.6% in the training and validation sets; the intermediate-risk group (score = 1, n = 150) had rates of 14.0% and 16.3%; and the high-risk group (score >1, n = 301) had rates of 28.8% and 31.3%. Patients in the high-risk group had higher rates of flare (odds ratio, 3.50; 95% confidence interval, 2.06-5.92) and accumulated health care costs 3 and 6 months post-SBRT, relative to intermediate- and low-risk patients (P < .001). ConclusionsOur internally validated model identifies a high-risk group of patients more likely to develop a pain flare after spine SBRT, for whom prophylactic steroids may be considered. Evaluation in a clinical trial is warranted.

Antenatal corticosteroids prior to planned caesarean at term for improving neonatal outcomes.

Antenatal corticosteroids prior to planned caesarean at term for improving neonatal outcomes.

Outcomes of pregnancies in women with extremely high ratio of sFlt-1 / PlGF: a series of clinical cases

Preeclampsia as one of the manifestations of placental dysfunction associated with dysregulation of pro- and antiangiogenic factors. During normal pregnancy, the concentration of antiangiogenic factor sFlt-1 remains low, which allows accurate transmission of signals induced by proangiogenic factors VEGF and PlGF. This balance is crucial to maintain physiological vasodilation. Under hypoperfusion, the placenta increases the synthesis of sFlt-1, trying to increase maternal pressure and increase placental perfusion.The objective: to study the clinical outcomes of pregnancies in a group with extremely high ratios of sFlt-1 and PlGF.Materials and methods. The results of determining the levels of placental growth factor (PlGF) and soluble fms-like tyrosine kinase (sfLT-1), which were performed during 2017-2020 in the serum of 128 pregnant women at 18–39 weeks, were analyzed.Results. The mean age of pregnant women was 28,4±4 years. The average gestational age during the study was 26±5 weeks. The majority of pregnant women had signs of IUGR (62,5%) and/or preeclampsia (50%) during the study. The average level of the sFlt/PIGF ratio was 1747 pg/ml. In 100% of cases with a digital ratio of more than 850, signs of an obstetric angiogenic catastrophe that required immediate delivery developed during the nearest future. The average time from analysis to delivery was 10 days. In 50% of pregnant women, urgent delivery was required within 48 hours after analysis. Favorable neonatal results were observed in 37,5% of women.Conclusion. We found a tendency for worsening perinatal outcomes in women with extremely high sFlt-1/PlGF ratios after reaching 850. Careful monitoring of the pregnant woman and consideration of need for prophylactic administration of corticosteroids to accelerate fetal lung maturation in this group is rational.

EFFICACY OF PROPHYLACTIC CORTICOSTEROIDS PRIOR TO CESAREAN SECTION TO PREVENT RESPIRATORY COMPLICATION

Background: Cesarean section (CS) is a risk factor for the development of neonatal respiratory complications, mostly respiratory distress syndrome (RDS) and transient tachypnea of the new-born, both in term and preterm infants. Infants born at term by elective cesarean delivery are more likely to develop respiratory morbidity than infants born vaginally. Objective: To assess the effect of prophylactic corticosteroid administration before elective cesarean section at term, as compared to usual management without corticosteroids, in reducing neonatal respiratory morbidity and admission to special care with respiratory complications. Patients and methods: This was a prospective study that was conducted on 200 women from the Out-Patient Clinic at Al-Hussein Hospital, Al-Azhar University from September 2018 to November 2019. Randomized controlled trials comparing prophylactic antenatal corticosteroid administration (dexamethasone) with placebo or with no treatment, given before elective cesarean section at term (at or after 37 weeks of gestation). Results: PG represented 60% of 1st group while represented 50% of 2nd group without significant difference between them. There was no significant difference between groups as regard co-morbidity. There was no significant difference between groups regard causes of CS, and the major causes were previous CS and placenta previa. There was no significant difference between groups as regard postpartum hemorrhage or maternal complication in general. APGAR1 was significantly higher among corticosteroid group. Overall respiratory complication was significantly lower among corticosteroid group, respiratory distress (RD), need of neonatal intensive care unit (NICU) and mechanical ventilation and mortality were lower among the same group than control but not significantly. Conclusion: A single course of corticosteroids (four 6mg doses of dexamethasone administered intramuscular every 12 hours) should be considered for women undergoing planned cesarean at 37 or more weeks’ gestation.

EFFICACY OF PROPHYLACTIC CORTICOSTEROIDS PRIOR TO CESAREAN SECTION TO PREVENT RESPIRATORY COMPLICATION

Background: Cesarean section (CS) is a risk factor for the development of neonatal respiratory complications, mostly respiratory distress syndrome (RDS) and transient tachypnea of the new-born, both in term and preterm infants. Infants born at term by elective cesarean delivery are more likely to develop respiratory morbidity than infants born vaginally. Objective: To assess the effect of prophylactic corticosteroid administration before elective cesarean section at term, as compared to usual management without corticosteroids, in reducing neonatal respiratory morbidity and admission to special care with respiratory complications. Patients and methods: This was a prospective study that was conducted on 200 women from the Out-Patient Clinic at Al-Hussein Hospital, Al-Azhar University from September 2018 to November 2019. Randomized controlled trials comparing prophylactic antenatal corticosteroid administration (dexamethasone) with placebo or with no treatment, given before elective cesarean section at term (at or after 37 weeks of gestation). Results: PG represented 60% of 1st group while represented 50% of 2nd group without significant difference between them. There was no significant difference between groups as regard co-morbidity. There was no significant difference between groups regard causes of CS, and the major causes were previous CS and placenta previa. There was no significant difference between groups as regard postpartum hemorrhage or maternal complication in general. APGAR1 was significantly higher among corticosteroid group. Overall respiratory complication was significantly lower among corticosteroid group, respiratory distress (RD), need of neonatal intensive care unit (NICU) and mechanical ventilation and mortality were lower among the same group than control but not significantly. Conclusion: A single course of corticosteroids (four 6mg doses of dexamethasone administered intramuscular every 12 hours) should be considered for women undergoing planned cesarean at 37 or more weeks’ gestation.

Prophylactic corticosteroids for paediatric heart surgery with cardiopulmonary bypass.

Prophylactic corticosteroids for paediatric heart surgery with cardiopulmonary bypass.

The Potential Role of Corticosteroid Prophylaxis for the Prevention of Microscopic Fat Embolism Syndrome in Gluteal Augmentations.

Microscopic fat embolism syndrome (micro-FES) has been recently identified as a potentially fatal complication following gluteal augmentation utilizing autologous fat grafts; safety recommendations advocating for subcutaneous lipo-injections may be insufficient for its prevention. The authors of this systematic review evaluated the potential role of corticosteroid prophylaxis for the prevention of micro-FES in gluteal augmentation procedures. The authors performed a systematic search employing the National Library of Medicine (PubMed), Medline, and Embase databases. Search terms were those pertaining to studies reporting the efficacy of prophylactic corticosteroid administration on micro-FES incidence in a high-risk surrogate population. Thirteen articles met the inclusion criteria for review, comprising 2 studies reporting on the efficacy of a single intravenous (IV) corticosteroid dose for the prophylaxis of micro-FES, 9 studies reporting on multiple prophylactic IV doses, and 2 additional studies reporting on the efficacy of inhaled corticosteroids in this context. All studies were identified from the orthopedic literature given that none were available directly from within plastic surgery. The prophylactic efficacy of multiple IV doses of methylprednisolone, or a single larger dose, was established, whereas the efficacy of inhaled corticosteroids remains elusive. A single perioperative IV dose of methylprednisolone may be most appropriate for utilization by plastic surgeons; the safety and implication of this therapy on wound healing and fat graft survival are discussed. Further studies directly evaluating the efficacy of corticosteroid prophylaxis in the gluteal augmentation population are indicated. Finally, recommendations pertaining to the prevention, timely recognition, and effective management of micro-FES are discussed.

Corticosteroids for preventing neonatal respiratory morbidity after elective caesarean section at term.

Infants born at term by elective caesarean section are more likely to develop respiratory morbidity than infants born vaginally. Prophylactic corticosteroids in singleton preterm pregnancies accelerate lung maturation and reduce the incidence of respiratory complications. The objective of this review was to assess the effect of prophylactic corticosteroid administration before elective caesarean section at term, as compared to usual management without corticosteroids, in reducing neonatal respiratory morbidity and admission to special care with respiratory complications. We searched Cochrane Pregnancy and Childbirth's Trials Register (14 June 2017), and reference lists of retrieved studies. Randomised controlled trials comparing prophylactic antenatal corticosteroid administration (betamethasone or dexamethasone) with placebo or with no treatment, given before elective caesarean section at term (at or after 37 weeks of gestation). Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. We assessed the quality of the evidence using the GRADE approach. We included four trials (3956 women and 3893 neonates) at a moderate risk of bias, comparing prophylactic administration of betamethasone or dexamethasone versus placebo or usual treatment without steroids in term elective caesarean section. Women randomised to treatment group received either two intramuscular doses of betamethasone in the 48 hours before delivery, or intramuscular dexamethasone (two or four doses) prior to delivery (at 37 weeks' gestation or 48 hours before delivery), and were compared to the control group who received a saline placebo or treatment as usual.Prophylactic antenatal corticosteroid administration appeared to decrease the risk of respiratory distress syndrome (RDS) (risk ratio (RR) 0.48; 95% confidence interval (CI) 0.27 to 0.87; 4 studies; 3817 participants; low-quality evidence), transient tachypnoea of the neonate (TTN) (RR 0.43; 95% CI 0.29 to 0.65; 4 studies; 3821 participants; low-quality evidence), admission to the neonatal intensive care unit (NICU) for respiratory morbidity (RR 0.42; 95% CI 0.22 to 0.79; 3 studies; 3441 participants), and admission to neonatal special care (all levels) for respiratory complications (RR 0.45; 95% CI 0.22 to 0.90; 1 study; 942 participants; low-quality evidence). Administration of antenatal corticosteroids also appeared to reduce admission to neonatal special care (RR 0.62; 95% CI 0.43 to 0.89; 2 studies; 2169 participants) and neonatal intensive care (RR 0.14; 95% CI 0.03 to 0.61; 1 study; 452 participants) for any indication, compared to placebo or usual care. Finally, prophylactic antenatal corticosteroids also appeared to reduce the length of stay in NICU by 2.70 days (mean difference (MD) -2.70; 95% CI -2.76 to -2.64; 2 studies; 32 participants).No reduction was found in the need for mechanical ventilation (RR 0.67; 95% CI 0.27 to 1.68; 3 studies; 3441 participants; very-low quality), perinatal death (RR 0.67; 95% CI 0.11 to 4.10; 4 studies; 3893 participants) or neonatal sepsis (RR 1.00; 95% CI 0.06 to 15.95; 2 studies; 2214 participants) .There were no reported events of neonatal respiratory complications (other than RDS and tachypnoea of the newborn (TTN)), chronic lung disease, duration of mechanical ventilation or maternal postpartum infection, therefore results on these outcomes are non-estimable. The studies did not provide data on other pre-defined outcomes.The quality of evidence, as assessed using GRADE was low for the outcomes of RDS, TTN and admission to NICU for respiratory morbidity, indicating that the true effect could potentially be substantially different from our estimate of effect. The results from the four trials are promising, but more high-quality studies with larger sample sizes that are adequately powered to detect the effect of prophylactic antenatal corticosteroids on outcomes of respiratory morbidity are needed, given the potential of the current studies for bias. Consideration should be given to the balance between statistical significance and clinical significance, particularly in view of the low event rates of significant respiratory morbidity (RDS or admission to NICU for respiratory complications) in this population. In addition, further trials on the long-term outcomes of these infants are needed to identify any potential harms and complications of antenatal corticosteroid administration at term.

Trends and Patterns of Corticosteroid Use During Coronary Artery Bypass Grafting Surgery in the United States.

Several clinical trials have documented clinical benefits associated with prophylactic corticosteroid administration at the time of coronary artery bypass graft (CABG) surgery, including a reduction in the risk of atrial fibrillation and hospital length of stay. Despite the published data, the extent to which providers have adopted the perioperative use of corticosteroids remains unknown. To assess temporal trends, between-hospital variation, and determinants of perioperative intravenous corticosteroid use during CABG surgery. We identified all patients admitted for CABG surgery in the Premier Healthcare Database (2003-2014), a large US-based inpatient database. We determined the proportion of patients administered prophylactic corticosteroids on the day of CABG surgery. Linear time-series models were used to estimate the rate and trend of corticosteroid use over time. Separate multivariable generalized estimating equation models were used to quantify the variation in and determinants of perioperative corticosteroid use. Of 401 788 eligible patients who underwent a CABG surgery between 2003 and 2014, 20% (n = 80 681) were administered intravenous prophylactic perioperative corticosteroids (methylprednisolone, dexamethasone, or hydrocortisone). Corticosteroid use increased from 17.5% in 2003 to 22.6% in 2014 (annual rate = 0.42%; P < .001). Individual hospitals accounted for >50% of variation in corticosteroid use. High between-hospital variation was also observed, and the probability of utilization was ≥32.4% in the upper versus ≤3.4% in the bottom quartiles of hospitals. Prophylactic corticosteroid administration during CABG has increased gradually since 2003. To further evaluate the risk-benefit trade-off associated with their use, we believe a large-scale outcomes study is warranted to assess this highly variable practice.

Prophylactic Corticosteroids for Prevention of Postextubation Stridor and Reintubation in Adults: A Systematic Review and Meta-analysis

Corticosteroid administration before elective extubation has been used to prevent postextubation stridor and reintubation. We updated a systematic review to identify which patients would benefit from prophylactic corticosteroid administration before elective extubation. We searched PubMed, EMBASE, the Wanfang Database, the China Academic Journal Network Publishing Database, and the Cochrane Central Register of Controlled Trials for eligible trials from inception through February 29, 2016. All randomized controlled trials were eligible if they examined the efficacy and safety of systemic corticosteroids given prior to elective extubation in mechanically ventilated adults. We pooled data using the DerSimonian and Laird random-effects model. We identified 11 trials involving 2,472 participants for analysis. Use of prophylactic corticosteroids was associated with a reduced incidence of postextubation airway events (risk ratio [RR], 0.43; 95%CI, 0.29-0.66) and reintubation (RR, 0.42; 95%CI, 0.25-0.71) compared with placebo or no treatment. This association was prominent in participants at high risk for the development of postextubation airway complications, defined using the cuff-leak test, with a reduced incidence of postextubation airway events (RR, 0.34; 95%CI, 0.24-0.48) and reintubation (RR, 0.35; 95%CI, 0.20-0.64). This association was not found in trials with unselected participants. Adverse events were rare. Administration of prophylactic corticosteroids before elective extubation was associated with significant reductions in the incidence of postextubation airway events and reintubation, with few adverse events. It is reasonable to select patients at high risk for airway obstruction who may benefit from prophylactic corticosteroids.

Prophylactic Administration of Corticosteroids for Preventing Postoperative Complications Related to Tracheal Intubation: A Systematic Review and Meta-Analysis of 18 Randomized Controlled Trials.

Sore throat, cough, and hoarseness are the common and severe complications after general anesthesia with tracheal intubation. The efficacy of prophylactic administration of corticosteroids in reducing the incidence of postoperative complications is controversial. Thus, we conducted a meta-analysis to assess the effects of corticosteroids in the prevention of postoperative complications. A comprehensive literature search of Pubmed, Embase, and Web of Science was conducted to identify relative trials. Eligible studies were randomized controlled trials (RCTs) that assessed the effect of corticosteroids for preventing postoperative complications. The outcomes included the prevalence of postoperative sore throat, cough, hoarseness, laryngeal edema, and reintubation. A random-effects or fixed-effects model was used to pool the estimates, according to the heterogeneity among the included studies. Eighteen RCTs with a total of 2685 patients were included in this meta-analysis. Pooled estimates showed that corticosteroids significantly reduced the incidence of postoperative sore throat, hoarseness, and cough. Moreover, corticosteroids had a positive effect on the incidence of laryngeal edema and reintubation. Subgroup analysis showed that corticosteroids significantly decreased the incidence of severe sore throat and hoarseness, but not cough. Evidence from this meta-analysis of 18 RCTs indicated that prophylactic administration of corticosteroids is not only effective in reducing the incidence and severity of postoperative sore throat and hoarseness, but also the incidence of laryngeal edema and reintubation.

WITHDRAWN: Prophylactic steroids for pediatric open heart surgery.

The immune response to cardiopulmonary bypass in infants and children can lead to a series of postoperative morbidities and mortality i.e. hemodynamic instability, increased infection and tachyarrhythmias. Administration of prophylactic doses of corticosteroids is sometimes used to try and ameliorate this pro-inflammatory response. However, the clinical benefits and harms of this type of intervention in the pediatric patient remains unclear.To systematically review the beneficial and harmful effects of the prophylactic administration of corticosteroids, compared with placebo, in pediatric open heart surgery.The trials registry of the Cochrane Heart Group, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (Issue 4, 2006), MEDLINE (1966 to January 2007), EMBASE (1980 to January 2007) were searched. An additional handsearch of the EMRO database for Arabic literature was performed. Grey literature was searched and experts in the field were contacted for any unpublished material. No language restrictions were applied.All randomized and quasi-randomized controlled trials of open heart surgery in the pediatric population that received corticosteroids pre-, peri- or post-operatively, with reported clinical outcomes in terms of morbidity and mortality.Eligible studies were abstracted and evaluated by two independent reviewers. All meta-analyses were completed using RevMan4.2.8. Weighted mean difference (WMD) was the primary summary statistic with data pooled using a random-effects model.All cause mortality could not be assessed as the data reports were incomplete. There was weak evidence in favor of prophylactic corticosteroid administration for reducing intensive care unit stay, peak core temperature and duration of ventilation [WMD (95% CI) -0.50 hours (-1.41 to 0.41); -0.20 degrees C (-1.16 to 0.77) and -0.63 hours (-4.02 to 2.75), respectively].The use of prophylactic steroids in pediatric patients to reduce postoperative complications commonly experienced following cardiopulmonary bypass surgery is not supported by the existing evidence. Further well designed and adequately powered randomized controlled trials are needed to more accurately estimate the benefit and harm of this intervention.

Corticosteroids for preventing neonatal respiratory morbidity after elective caesarean section at term

Infants born at term by elective caesarean delivery are more likely to develop respiratory morbidity than infants born vaginally. Prophylactic corticosteroids in singleton preterm pregnancies accelerate lung maturation and reduce the incidence of respiratory complications. The objective of this review was to assess the effect of prophylactic corticosteroid administration before elective caesarean section at term, as compared to usual management without corticosteroids, in reducing neonatal respiratory morbidity and admission to special care with respiratory complications. We searched the Cochrane Pregnancy and Chilbirth Group's Trials Register (30 June 2009). Randomised and quasi-randomised controlled trials comparing prophylactic antenatal corticosteroid administration (betamethasone or dexamethasone) with placebo or with no treatment, given before elective caesarean section at term (at or after 37 weeks of gestation). The co-authors assessed the results of the only available trial independently to retrieve data on perinatal outcomes. Results were expressed as risk ratio (RR) or mean differences (MD), together with their 95% confidence intervals (CI). One study comparing prophylactic administration of betamethasone (N = 467) versus usual treatment without steroids (N = 475) in term elective caesarean section was included in the review. Women randomised to treatment group received two intramuscular doses of betamethasone in the 48 hours before delivery, whereas the control group received treatment as usual.Prophylactic betamethasone appeared to significantly decrease the risk of admission to the neonatal intensive care unit for respiratory morbidity (RR 0.15; 95% CI 0.03 to 0.64). However, no statistically significant reduction was found in the incidence of neonatal respiratory distress syndrome (RR 0.32; 95% CI 0.07 to 1.58), transient tachypnoea of the newborn (RR 0.52; 95% CI 0.25 to 1.11), need for mechanical ventilation (RR 4.07; 95% CI 0.46 to 36.27) and length of stay in neonatal intensive care unit (MD) -2.14 days; 95% CI -5.58 to 1.30).There were no reported events of neonatal sepsis, perinatal deaths or maternal trauma infection, therefore results on these outcomes are non-estimable. The study did not provide data on other pre-defined outcomes. The results from the single trial are promising, but more studies with larger samples are needed to investigate the effect of prophylactic steroids in the incidence of neonatal complications per se. Also more data and longer follow up would be needed for potential harms and complications.

Corticosteroids for the prevention and treatment of post-extubation stridor in neonates, children and adults

Post-extubation stridor may prolong length of stay in the intensive care unit, particularly if airway obstruction is severe and re-intubation proves necessary. Some clinicians use corticosteroids to prevent or treat post-extubation stridor, but corticosteroids may be associated with adverse effects ranging from hypertension to hyperglycaemia, so a systematic assessment of the efficacy of this therapy is indicated. To determine whether corticosteroids are effective in preventing or treating post-extubation stridor in critically ill infants, children, or adults. We searched the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL and reference lists of articles. The most recent searches were conducted in January 2009. Randomized controlled trials comparing administration of corticosteroids by any route with placebo in infants, children, or adults receiving mechanical ventilation via an endotracheal tube in an intensive care unit. Three review authors independently assessed trial quality and extracted data. Eleven trials involving 2301 people were included: six in adults, two in neonates, three in children. All but one examined use of steroids for the prevention of post-extubation stridor; the remaining one concerned treatment of existing post-extubation stridor in children. Patients were drawn from heterogeneous medical/surgical populations. Dexamethasone given intravenously at least once prior to extubation was the most common steroid regimen utilized (uniformly in neonates and children). In neonates the two studies found heterogeneous results, with no overall statistically significant reduction in post extubation stridor (RR 0.42; 95% CI 0.07 to 2.32). One of these studies was on high-risk patients treated with multiple doses of steroids around the time of extubation, and this study showed a significant reduction in stridor. In children, the two studies were clinically heterogeneous. One study included children with underlying airway abnormalities and the other excluded this group. Prophylactic corticosteroids tended to reduce reintubation and significantly reduced post-extubation stridor in the study that included children with underlying airway abnormalities (N = 62) but not in the study that excluded these children (N = 153). In six adult studies (total N = 1953), the use of prophylactic corticosteroid administration did not significantly reduce the risk of re-intubation (RR 0.48; 95% CI 0.19 to 1.22). While there was a significant reduction in the incidence of post extubation stridor (RR 0.47; 95% CI 0.22 to 0.99), there was significant heterogeneity (I(2)=81%, X(2)=26.36, df=5, p<0.0001). Subgroup analysis revealed that post extubation stridor could be reduced in adults with a high likelihood of post extubation stridor when corticosteroids were administered as multiple doses begun 12-24 hours prior to extubation compared to single doses closer to extubation; the test for interaction for multiple versus single doses indicated RRR 0.22 (95% CI 0.10 to 0.47) for stridor with multiple doses. Side effects were uncommon and could not be aggregated. Using corticosteroids to prevent (or treat) stridor after extubation has not proven effective for neonates or children. However, given the consistent trends towards benefit, this intervention does merit further study, particularly for high risk children or neonates. In adults, multiple doses of corticosteroids begun 12-24 hours prior to extubation do appear beneficial for patients with a high likelihood of post extubation stridor.

Cochrane review: Corticosteroids for the prevention and treatment of post‐extubation stridor in neonates, children and adults

AbstractBackgroundPost‐extubation stridor may prolong length of stay in the intensive care unit, particularly if airway obstruction is severe and re‐intubation proves necessary. Corticosteroids, however, may be associated with adverse effects ranging from hypertension to hyperglycemia, and a more systematic assessment of the efficacy of this therapy is indicated prior to widespread adoption of this practice.ObjectivesTo determine whether corticosteroids are effective in preventing or treating post‐extubation stridor in critically ill infants, children, or adults.Search strategyWe searched the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL and reference lists of articles. The most recent searches were conducted in April 2007.Selection criteriaRandomized controlled trial comparing administration of corticosteroids by any route with placebo in infants, children, or adults receiving mechanical ventilation via an endotracheal tube in an intensive care unit.Data collection and analysisThree review authors independently assessed trial quality and extracted data.Main resultsTen trials involving 2230 people were included: five in adults, two in neonates, three in children. All but one examined use of steroids for the prevention of post‐extubation stridor; the remaining one concerned treatment of existing post‐extubation stridor in children. Patients were drawn from heterogeneous medical/surgical populations. Dexamethasone given intravenously at least once prior to extubation was the most common steroid regimen utilized (uniformly in neonates and children). In neonates the two studies found heterogeneous results, but there was an overall non significant reduction in post extubation stridor (RR 0.42; 95% CI 0.07 to 2.32). This decrease was seen only in the study on high‐risk patients treated with multiple doses of steroids around the time of extubation. In children, the two studies were clinically heterogeneous. One study included children with underlying airway abnormalities and the other excluded this group. Prophylactic corticosteroids tended to reduce reintubation and significantly reduced post‐extubation stridor in the study that included children with underlying airway abnormalities (N = 62) but not in the study that excluded these children (N = 153). In five adult studies (total N = 1873), there was a non significant trend for prophylactic corticosteroid administration to reduce the risk of re‐intubation (RR 0.47; 95% CI 0.16 to 1.39) and post extubation stridor (RR 0.49; 95% CI 0.20 to 1.19). These reductions were largely due to two studies that utilized repeated doses of methylprednisolone 12 to 24 hours prior to extubation. Side effects were uncommon and could not be aggregated.Authors' conclusionsUsing corticosteroids to prevent (or treat) stridor after extubation has not proven effective for neonates, children or adults. However, given the consistent trends towards benefit, this intervention does merit further study.Plain Language SummaryCorticosteroids for the prevention and treatment of post‐extubation stridor in neonates, children and adultsWhen people in intensive care need assistance breathing, they may need to have a breathing tube inserted down through their windpipe (trachea or airway ‐ the passage to the lungs). After it is taken out (extubation), the airways can be swollen (inflamed). This swelling can make it hard to breathe, cause stridor (a more severe form of wheezing), and the tube may need to be replaced. Corticosteroids are anti‐inflammatory drugs that might reduce this swelling. The review of 10 trials involving 2230 people found that using corticosteroids to prevent (or treat) stridor after extubation has not been proven overall effective for babies, children, or adults. However, some trials do show benefits and this intervention does merit further study.

Prophylactic steroids for paediatric open-heart surgery: a systematic review

Background The immune response to cardiopulmonary bypass in infants and children can lead to a series of post-operative morbidities and mortality, that is, hemodynamic instability, increased infection and tachyarrhythmias. Administration of prophylactic doses of corticosteroids is sometimes used to try and ameliorate this pro-inflammatory response. However, the clinical benefits and harms of this type of intervention in the paediatric patient remain unclear. Objectives To systematically review the beneficial and harmful effects of the prophylactic administration of corticosteroids, compared with placebo, in paediatric open-heart surgery. Search strategy The trials registry of the Cochrane Heart Group, the Cochrane Central Register of Controlled Trials in The Cochrane Library (Issue 4, 2006), MEDLINE (1966 to January 2007), EMBASE (1980 to January 2007) were searched. An additional hand-search of the EMRO database for Arabic literature was performed. Grey literature was searched, and experts in the field were contacted for any unpublished material. No language restrictions were applied. Selection criteria All randomised and quasi-randomised controlled trials of open-heart surgery in the paediatric population that received corticosteroids pre-, peri- or post-operatively, with reported clinical outcomes in terms of morbidity and mortality. Data collection and analysis Eligible studies were abstracted and evaluated by two independent reviewers. All meta-analyses were completed using RevMan4.2.8. Weighted mean difference (WMD) was the primary summary statistic with data pooled using a random-effects model. Main results All cause mortality could not be assessed as the data reports were incomplete. There was weak evidence in favour of prophylactic corticosteroid administration for reducing intensive care unit stay, peak core temperature and duration of ventilation (WMD (95% confidence intervals) -0.50 h (-1.41 to 0.41); -0.20°C (-1.16 to 0.77) and -0.63 h (-4.02 to 2.75) respectively).

The Impact of Prophylactic Dexamethasone on Nausea and Vomiting After Laparoscopic Cholecystectomy

To determine the impact of prophylactic corticosteroid administration on postoperative nausea, vomiting, pain and complications in patients undergoing laparoscopic cholecystectomy. We searched 4 bibliographic databases, conference proceedings, reference lists of articles and textbooks, and contacted experts in the field of anesthesia and hepatobiliary surgery. We evaluated the methodologic quality of trials and extracted data regarding baseline characteristics, interventions, and outcomes. We pooled results from the studies using a random-effects model, evaluated the degree of heterogeneity, and explored potential explanations for heterogeneity. Seventeen trials met eligibility criteria and provided high quality evidence regarding steroid effectiveness. Irrespective of the co-interventions (other antiemetic medications), dexamethasone reduced the incidence of nausea (RR 0.59, 95% CI, 0.48-0.72), vomiting (RR 0.41, 95% CI, 0.30-0.55), and postoperative nausea or vomiting (RR 0.55, 95% CI, 0.44-0.67) relative to placebo. Dexamethasone also seemed to reduce the severity of postoperative pain (Ratio of Means 0.87, 95% CI, 0.78-0.98), although substantial unexplained heterogeneity was present (I 90.4%). The incidence of headache and dizziness was similar between groups. Prophylactic dexamethasone decreases the incidence of nausea and vomiting after LC relative to placebo and may decrease the severity of postoperative pain. Dexamethasone does not increase the incidence of headaches or dizziness. Surgeons should consider administering prophylactic corticosteroids to patients undergoing laparoscopic cholecystectomy, particularly those at high risk of postoperative nausea and vomiting.

Prophylactic steroids for paediatric open-heart surgery: a systematic review

Background The immune response to cardiopulmonary bypass in infants and children can lead to a series of post-operative morbidities and mortality, that is, hemodynamic instability, increased infection and tachyarrhythmias. Administration of prophylactic doses of corticosteroids is sometimes used to try and ameliorate this pro-inflammatory response. However, the clinical benefits and harms of this type of intervention in the paediatric patient remain unclear. Objectives To systematically review the beneficial and harmful effects of the prophylactic administration of corticosteroids, compared with placebo, in paediatric open-heart surgery. Search strategy The trials registry of the Cochrane Heart Group, the Cochrane Central Register of Controlled Trials in The Cochrane Library (Issue 4, 2006), MEDLINE (1966 to January 2007), EMBASE (1980 to January 2007) were searched. An additional hand-search of the EMRO database for Arabic literature was performed. Grey literature was searched, and experts in the field were contacted for any unpublished material. No language restrictions were applied. Selection criteria All randomised and quasi-randomised controlled trials of open-heart surgery in the paediatric population that received corticosteroids pre-, peri- or post-operatively, with reported clinical outcomes in terms of morbidity and mortality. Data collection and analysis Eligible studies were abstracted and evaluated by two independent reviewers. All meta-analyses were completed using RevMan4.2.8. Weighted mean difference (WMD) was the primary summary statistic with data pooled using a random-effects model. Main results All cause mortality could not be assessed as the data reports were incomplete. There was weak evidence in favour of prophylactic corticosteroid administration for reducing intensive care unit stay, peak core temperature and duration of ventilation (WMD (95% confidence intervals) -0.50 h (-1.41 to 0.41); -0.20°C (-1.16 to 0.77) and -0.63 h (-4.02 to 2.75) respectively).

Prophylactic steroids for paediatric open-heart surgery: a systematic review.

The immune response to cardiopulmonary bypass in infants and children can lead to a series of post-operative morbidities and mortality, that is, hemodynamic instability, increased infection and tachyarrhythmias. Administration of prophylactic doses of corticosteroids is sometimes used to try and ameliorate this pro-inflammatory response. However, the clinical benefits and harms of this type of intervention in the paediatric patient remain unclear. To systematically review the beneficial and harmful effects of the prophylactic administration of corticosteroids, compared with placebo, in paediatric open-heart surgery. The trials registry of the Cochrane Heart Group, the Cochrane Central Register of Controlled Trials in The Cochrane Library (Issue 4, 2006), MEDLINE (1966 to January 2007), EMBASE (1980 to January 2007) were searched. An additional hand-search of the EMRO database for Arabic literature was performed. Grey literature was searched, and experts in the field were contacted for any unpublished material. No language restrictions were applied. All randomised and quasi-randomised controlled trials of open-heart surgery in the paediatric population that received corticosteroids pre-, peri- or post-operatively, with reported clinical outcomes in terms of morbidity and mortality. Eligible studies were abstracted and evaluated by two independent reviewers. All meta-analyses were completed using RevMan4.2.8. Weighted mean difference (WMD) was the primary summary statistic with data pooled using a random-effects model. All cause mortality could not be assessed as the data reports were incomplete. There was weak evidence in favour of prophylactic corticosteroid administration for reducing intensive care unit stay, peak core temperature and duration of ventilation (WMD (95% confidence intervals) -0.50 h (-1.41 to 0.41); -0.20°C (-1.16 to 0.77) and -0.63 h (-4.02 to 2.75) respectively).