Citation
Sharma, A., Dai, F., Tseng, L., Effraim, P. R., Zhou, B., Schonberger, R. B., & Li, J. (2023). Systemic Effects of Perineural Glucocorticoids on Fasting Serum Glucose, Potassium, and White Blood Cell Count in Total Hip Arthroplasty. Journal of Pain Research, 16, 553–561.
Context and Motivation
This study aimed to investigate the systemic effects of perineural glucocorticoids—specifically dexamethasone and methylprednisolone acetate—on fasting serum glucose, potassium, and white blood cell (WBC) count following total hip arthroplasty (THA). The use of these drugs as adjuvants to improve the quality and duration of regional anesthesia is common, but there is limited data on their potential systemic impacts. Understanding these effects is critical for patient safety and could impact postoperative care and discharge protocols.
Key Concepts and Definitions
- Perineural Glucocorticoids: Steroids administered around a nerve to prolong the effect of anesthetic and provide pain relief without the systemic effects of steroids.
- Total Hip Arthroplasty (THA): A type of surgery that involves replacing the hip joint with a prosthetic implant.
- Fasting Serum Glucose (FSG): The levels of glucose in the blood after fasting, an important measure for patients with diabetes.
Main Findings
The study observed that perineural glucocorticoids result in a statistically significant but clinically insignificant increase in serum glucose on the first two postoperative days compared to a control group. There were also marginal effects on serum potassium and WBC on some postoperative days, but these were again not clinically significant. The findings suggest that while systemic effects can be detected, they do not necessarily alter clinical decisions about the use of glucocorticoids in nerve blocks.
Data Sources
Data were collected from electronic health records of 210 patients who underwent THA between July 2017 and July 2019 at a single academic teaching hospital.
Methodological Approach
The research was a retrospective cohort study comparing patients who received periarticular local anesthetic injection alone (PAI, N=132) or with additional peripheral nerve blocks containing glucocorticoids (PAI+PNB, N=78). Primary and secondary outcomes measured changes in serum glucose, potassium, and WBC from preoperative baseline on postoperative days 1, 2, and 3, analyzed using mixed effect models for repeated measures.
Evaluation of the Study
Strengths
- Robust Patient Data: The use of electronic health records from a well-defined patient cohort adds to the reliability of the findings.
- Relevant Clinical Outcomes: Examining fasting serum glucose, potassium, and WBC count provided relevant clinical markers that are routinely measured postoperatively.
- Statistical Analysis: Employing mixed effect models for repeated measures is a methodological strength as it accounts for individual variations over time and provides a nuanced view of the data.
Weaknesses
- Retrospective Nature: The study’s retrospective design is less robust than prospective studies and may be prone to biases inherent in retrospective analyses.
- Single-Center Study: Being conducted at a single academic teaching hospital may limit the generalizability of the results to other settings or populations.
- Diabetes Status Imbalance: There was a significant difference in the distribution of diabetes status between the two groups, which could influence the study’s outcomes concerning serum glucose levels.
- Missing Data: Some data points were missing due to reasons like patient discharge, which could potentially impact the study’s conclusions.
Potential Biases
- Selection Bias: Clinician hesitancy to administer glucocorticoids to patients with preexisting glycemic control issues may have influenced the composition of the study groups.
- Incomplete Data: Missing follow-up data due to early discharge could introduce bias in the outcome measures, especially if such occurrences were not distributed evenly across the study groups.
Overall Impact
The study contributes to the understanding of the systemic effects of perineural glucocorticoids in a postoperative setting, particularly for THA patients. These findings are important as they suggest that the use of glucocorticoids in nerve blocks does not significantly alter systemic markers to a clinically significant degree. This can reassure clinicians concerning the metabolic and immune impacts of such practices and aid in the decision-making process for postoperative care.
While the study does not indicate a need to alter current clinical practices, it highlights the importance of careful monitoring and individualized patient assessment postoperatively, especially for those with preexisting conditions like diabetes. It also serves as a reminder of the nuanced understanding required when interpreting statistically significant findings in clinical research, stressing the difference between statistical significance and clinical relevance.
Furthermore, the research identifies areas for further study, such as the need for prospective trials to confirm these findings and to understand better the potential long-term impacts of perineural glucocorticoid use. It paves the way for more nuanced research into the perioperative management of patients undergoing THA, potentially influencing future guidelines and protocols for the use of adjuvants in regional anesthesia.
Future Directions and Recommendations
1. Prospective Studies:
To build on the findings of this retrospective study, prospective randomized controlled trials are recommended to establish causality and further assess the clinical significance of perineural glucocorticoids.
2. Broader Population Sampling:
Future research should involve multiple centers and include a more diverse patient population to increase the generalizability of the results.
3. Longitudinal Follow-Up:
Extending the follow-up period would help to understand any delayed systemic effects of perineural glucocorticoids, particularly any late-onset hyperglycemia, electrolyte imbalances, or immune system effects.
4. More Granular Data Collection:
Including more detailed patient information, such as the exact timing of preoperative fasting and the specifics of diabetes management, could offer deeper insights into the glucose management challenges following THA.
5. Subgroup Analyses:
Examining subgroups, such as patients with different types of diabetes or other comorbidities, could provide tailored recommendations for these populations.
6. Comparative Efficacy Studies:
Comparing the effectiveness of different types and dosages of glucocorticoids used in regional anesthesia could optimize postoperative pain management while minimizing systemic effects.
7. Mechanistic Studies:
Investigating the mechanisms by which glucocorticoids exert their systemic effects when used perineurally could inform safer and more effective clinical use.
8. Patient-Centered Outcomes Research:
Incorporating patient-reported outcomes, such as quality of life and satisfaction with pain management, would provide a more comprehensive evaluation of the clinical significance of these interventions.
9. Policy and Guidelines Review:
Based on accumulating evidence, healthcare institutions may need to revisit their guidelines and policies regarding the use of perineural glucocorticoids, to ensure they align with the latest research findings.
By addressing these areas, the medical community can enhance its understanding of the implications of perineural glucocorticoids in THA and refine patient care strategies to optimize outcomes while minimizing potential risks. These recommendations strive to advance patient care quality through evidence-based practice and meticulous consideration of drug effects beyond the immediate surgical context.