Article Notes
- Does peri-operative intravenous dexamethasone reduce pain and opioid consumption after caesarean delivery? YES
- Are the effects statistically significant? YES
- Are the effects clinically significant? Possibly, though pain scores are only modestly improved and the reduction in opioid use is only small.
- Are the findings applicable to my patient population? Possibly, though the majority of studies were performed in Middle East, Asian & South Asian hospitals, and with diverse post-operative analgesic regimes.
- Is peri-operative dexamethasone safe? Probably, though few studies were adequately powered to identify less-common potential side effects, such as infection or delayed wound healing.
- Quality of evidence is low to modest. Notably, the primary outcome for most studies was PONV reduction, not post-operative pain.
- Should this evidence result in routine practice change? Probably not at this stage. IV dexamethasone may however be an appropriate intervention in select patient groups.
Note this is a systemic review of a small number of RCTs published very early in the COVID-19 pandemic, and notably only one of the four RCTs included coronarvirus, Loeb (2009), the others mainly focusing on influenza [MacIntyre (2011), MacIntyre (2013), Radonovich (2019)]. Obviously none of the studies specifically looked at SARS-CoV-2.
Subsequent N95/P2 mask studies since this have shown significant benefit of high-quality masks in reducing COVID-19 transmission.
As of February 28th 2023, pholcodine has FINALLY been banned in Australia by the Therapeutic Goods Administration (TGA).
Press release here: TGA - Pholcodine
It's very sad that it took 14 years after Florvaag & Johansson's landmark 2009 paper describing the connection between pholcodine and NMBD anaphylaxis, for this problem to be addressed.
How many patients were exposed to avoidable harm?
The pressure to practice truly patient-focused, evidence-based medicine weighs on every anaesthetist and anaesthesiologist. Yet as the volume of evidence has grown, so has the expectation to always provide the highest quality care.
There is a trap of unknown knowns: evidence known in the greater medical-knowledge body but that we are naively ignorant of.
Bastardising William Gibson (1993), we risk that the evidence:
“…is already here – it's just not very evenly distributed.”
The greatest challenge for evidence-based anaesthesia continues to be the translation of research findings into actual practice change. The key to this is the intersection between quality, personal relevance, general significance, and credibility. But how can we achieve this?
Carlisle investigated the distribution of independent variables between study groups in Fujii's fraudulent research:
"The published distributions of 28/33 variables (85%) were inconsistent with the expected distributions, such that the likelihood of their occurring ranged from 1 in 25 to less than 1 in 1 000 000 000 000 000 000 000 000 000 000 000 (1 in 1033), equivalent to p values of 0.04 to < 1 × 10-33 , respectively."
See the more recent 2022 article, Return to exercise post-COVID-19 infection: A pragmatic approach in mid-2022, which also sets out a graduated return to exercise, though is perhaps even more pragmatic.
This editorial from authors working in elite sport, exercise medicine and sports cardiology, contextualises the best current advice on returning to exercise after COVID infection, specifically acknowledging the Omicron variant and its potential differences.
"...with over 6 million cases recorded in Australia & NZ in the first 4 months of 2022, and few reports of serious adverse outcomes with exercise, the approach to return to exercise has become more pragmatic."
The author's experience has been that most vaccinated elite athletes achieve pre-morbid fitness levels after COVID recovery by day 7-14. Recreational athletes are recommended to pursue a more conservative course, but nonetheless they suggest:
"...a quick return to moderate exercise with a more cautious return to higher intensity exercise."
For those with no or minimal symptoms, the authors describe a graduated approach of exercise return over 6 days (days 1-3, 50% intensity for 15-30 min, then days 4-6, 75% intensity for 30 min), culminating in return to normal activity on day 7 if the graduation is well tolerated.
Elite athletes with close medical and training supervision may be able to undertake an accelerated progression of training intensity.
The full-text article includes a useful decision flowchart.