The Effect of Preoperative Oral Dexamethasone Supplementation on the Outcome of Thyroidectomised Patients.
キーワード
概要
説明
Recovery time after thyroid surgery may depend on several factors, such as postoperative pain, nausea and vomiting, postoperative sore throat, phonation disorders associated with recurrent laryngeal nerve palsy, and symptomatic postoperative hypocalcaemia associated with postoperative hypoparathyroidism.
Glucocorticoids are well known for their analgesic, anti-inflammatory, immunomodulatory and anti-emetic effects. However, there is little information in the literature on the prophylactic use of glucocorticosteroids in patients undergoing thyroid surgery. In some previous studies, preoperative intravenous dexamethasone supplementation was associated with a reduced incidence of postoperative laryngeal nerve palsy, postoperative hypoparathyroidism, and with less severe postoperative pain, postoperative sore throat, nausea and vomiting. Patients receiving supplementation also had decreased levels of inflammatory biochemical parameters and proinflammatory cytokines.
Vitamin D deficiency is widespread in Poland. Vitamin D status has an impact on the postoperative complications in surgical patients. In previous study serum 25-hydroxyvitamin D is also suggested as a negative acute phase reactant, which has implications for acute and chronic inflammatory diseases. According to the authors, serum 25-hydroxyvitamin D level is an unreliable biomarker of vitamin D status after acute inflammatory insult.
In the early stages of inflammation, phagocytic cells and endothelium secrete proinflammatory cytokines, which include: interleukins: IL-1 α / β, IL-6, IL-8, TNF. The antagonistic group is anti-inflammatory cytokines, which include interleukins: IL-4, -5, -10, -13, produced by Th2 lymphocytes. These cytokines reduce the amount of interleukins secreted by Th1 lymphocytes.
Changes in the levels of proinflammatory and anti-inflammatory cytokines in the postoperative period were found in studies related to the assessment of surgical trauma. Pro-inflammatory interleukin 1 and interleukin 6 play an important role in many biological processes such as inflammation, sepsis and wound healing. Interleukin 6 expression is proportional to the extent of the surgical trauma. In turn, interleukin 10 is known as a cytokine that inhibits cytokine synthesis. Is one of the strongest immunosuppressive agents.
The aim of my study is to evaluate the impact of preoperative oral dexamethasone supplementation on the biochemical parameters and results of surgical treatment in patients with nontoxic multinodular goiter undergoing total thyroidectomy.
Patients admitted to the Department of General and Oncological Surgery, Medical University of Lodz with preoperative diagnosis of nontoxic multinodular goitre undergoing total thyroidectomy will be inculded to the study.
After obtaining written informed consent from all participants during a preoperative visit, they will be randomized to the supplementation group and the placebo group. The study will be a prospective, placebo-controlled and double-blind (for patient and surgeon) research.
Intervention: In the supplementation group a single dose of 8mg of dexamethasone will be given orally one hour before surgery (Dexamethasone Krka tablets (8mg), Warsaw, Poland). In the placebo group patients will receive a single tablet of sweetener one hour before operation (Clio tablets, sweetener with a dispenser, Instantina GES, Vienna, Austria).
Preoperatively in the group of all enrolled patients (in the supplementation group and in the placebo group) following tests will be measured in serum: blood count, calcium, inorganic phosphates, albumin, alkaline phosphatase, C reactive protein, procalcitonin, 25-hydroxyvitamin D, fibrinogen, parathormone, magnesium, interleukin 1β, interleukin 6, interleukin 10, thyroid stimulating hormone, free thyroxine, free triiodothyronine.
Total thyroidectomies with routine identification of the recurrent laryngeal nerves and parathyroid glands via a transverse cervicotomy under general anaesthesia will be performed by 3 experienced surgeons.
During the total thyroidectomy the number of parathyroid glands found intraoperatively will be registered.
At 6 hour after surgery in the group of all enrolled patients following tests will be measured in serum: blood count, calcium, inorganic phosphates, albumin, alkaline phosphatase, C reactive protein, procalcitonin, 25-hydroxyvitamin D, fibrinogen, parathormone, magnesium. In addiction, at 6 hour after surgery the incidence and intensity of symptomatic hypocalcaemia, postoperative pain (according to VAS scale), postoperative nausea and vomiting, postoperative sore throat and hoarseness will be evaluated.
At 24 hour after surgery in the group of all enrolled patients following tests will be measured in serum: blood count, calcium, inorganic phosphates, albumin, alkaline phosphatase, C reactive protein, procalcitonin, 25-hydroxyvitamin D, fibrinogen, parathormone, magnesium, interleukin 1β, interleukin 6, interleukin 10. Additionally, the level of interleukin 1β, interleukin 6 and interleukin 10 will be evaluated in drainage fluid. In addiction, at 24 hour after surgery the incidence and intensity of symptomatic hypocalcaemia, postoperative pain (according to Visual Analogue Scale - VAS scale), postoperative nausea and vomiting, postoperative sore throat and hoarseness will be evaluated.
The laboratory parameters will be determined by electrochemiluminescence on the Cobas E411 analyzer and spectrophotometric method on the AU680, Beckman Coulter analyzer. 25-hydroxyvitamin D levels will be measured using the chemiluminescent microparticle immunoassay (CMIA) (Architect 25-OHD). Interleukins levels will be determined by enzyme immunoassay method (EIA) (DGR Medtek) on ElizaMat 2 X analyzer.
Hypocalcemic symptoms will be categorized as mild (a tingling sensation and numbness of the hands or feet and perioral numbness) or severe (a positive Chvostek sign, Trousseau sign, tetany, and carpopedal spasms).
Postoperative hypocalcaemia will be defined as corrected calcium levels <2.0 mmol/l, even if recorded in one measurement only.
In both groups participants who will develop postoperative hypoparathyroidism (parathormone level <1.6 pmol/l at 6 or 24 hour after surgery) or symptomatic hypocalcaemia during hospitalisation will be treated with oral calcium (3 g/d - taken 1 g every 8 hours) and vitamin D derivatives (1 ug/d alfacalcidol taken once).
Intravenous calcium gluconate will be administered if symptoms persist despite oral supplementation.
Patients with symptomatic hypocalcaemia will receive supplementation until the symptoms subside. The treatment will be extended to 6 weeks in patients with hypoparathyroidism on the day of discharge.
The data will be statistically analysed. The main hypothesis of the study is that in patients with supplementation postoperative discomfort and decrease in serum calcium and parathormone level and hypocalcemic symptoms will be less severe and the levels of proinflammatory substances will be decreased. Vitamin D deficiency is probably common in operated patients and postoperative 25-hydroxyvitamin D levels are lower than those measured preoperatively.
The use of oral dexamethasone might be an effective strategy of prevention of complications after total thyroidectomy.
To the best of our knowledge, this is a pioneering study assessing the usefulness of preventive oral dexamethasone supplementation before total thyroidectomy in homogeneous group of patients with nontoxic multinodular goiter undergoing total thyroidectomy.
日付
| 最終確認済み: | 04/30/2020 |
| 最初に提出された: | 05/22/2020 |
| 提出された推定登録数: | 05/28/2020 |
| 最初の投稿: | 06/01/2020 |
| 最終更新が送信されました: | 05/28/2020 |
| 最終更新日: | 06/01/2020 |
| 実際の研究開始日: | 06/30/2020 |
| 一次完了予定日: | 11/30/2020 |
| 研究完了予定日: | 02/28/2021 |
状態または病気
介入/治療
Drug: supplementation group
Drug: placebo group
Diagnostic Test: Preoparative blood laboratory tests
Diagnostic Test: Postoperative laboratory blood tests at 6 hour
Diagnostic Test: Postoperative laboratory blood tests at 24 hour
Diagnostic Test: Postoperative laboratory drainage fluid tests at 24 hour
Procedure: Total thyroidectomy
Other: Symptomatic hypocalcaemia at 6 hour
Other: Symptomatic hypocalcaemia at 24 hour
Other: Postoperative pain at 6 hour
Other: Postoperative pain at 24 hour
Other: Postoperative nausea and vomiting at 6 hour
Other: Postoperative nausea and vomiting at 24 hour
Other: Postoperative sore throat and hoarseness at 6 hour
Other: placebo group
段階
アームグループ
| 腕 | 介入/治療 |
|---|---|
| Experimental: supplementation group Patients will receive preoperative oral supplementation of 8mg of dexamethasone (Dexamethasone Krka tablets (8mg), Warsaw, Poland) in a single dose taken once one hour before surgery. At 6 and 24 hour after surgery, clinical and laboratory parameters will be measured and evaluated. | Drug: supplementation group Preoperative oral dexamathasone supplementation in a single dose of 8mg. |
| Placebo Comparator: placebo group Patients will receive preoperative oral supplementation of sweetener (Clio tablets, sweetener with a dispenser, Instantina GES, Vienna, Austria) taken once in a single dose one hour before surgery. At 6 and 24 hour after surgery, clinical and laboratory parameters will be measured and evaluated. | Drug: placebo group Preoperative oral supplementation of sweetener in a single dose. |
適格基準
| 研究の対象となる年齢 | 18 Years に 18 Years |
| 研究に適格な性別 | All |
| 健康なボランティアを受け入れる | はい |
| 基準 | Inclusion Criteria: - patient's consent - adult patients - preoperative diagnosis of nontoxic multinodular goiter - total thyroidectomy Exclusion Criteria: - lack of patient's consent - hyperthyroidism currently or in the past - retrosternal goiter - thyroid malignanacy or suspected malignant thyroid tumor - parathyroids disease - malingant tumor in any location currently or in the past - state after neck surgery - state after radiotherapy - bone diseases, osteoporosis - sarcoidosis - liver failure, hepatitis - kidney stones, kidney failure (eGFR<60ml/min/1.73m2) - taking nonsteroidal anti-inflammatory drugs - steroid treatment - stomach and duodenal ulcer disease currently or in the past - active infection at the time of the study - history of tuberculosis - a period of 8 weeks before and 2 weeks after administration of the live vaccine - unregulated hypertension - diabetes - psychiatric disorders - glaucoma - corneal ulcers or corneal injuries - severe heart failure - pheochromocytoma - myasthenia gravis - epilepsy - head injury - ulcerative colitis - diverticulitis - pregnancy - breast-feeding - hypokalaemia - galactose intolerance - lactase deficiency - dexamethasone allergy, allergic to lactose, allergic to gelatinized starch, allergic to corn starch, allergic to colloidal anhydrous silica, allergic to magnesium stearate - allergic reaction to substances contained in the sweetener: sodium cyclamate, sodium saccharin, sodium bicarbonate, sodium citrate. - taking medications that affect calcium metabolism: anti-resorptive drugs, anabolic drugs, bisphosphonates, systemic glucocorticosteroids, thiazide diuretics, furosemide, proton pump inhibitors, antacids containing magnesium or aluminum salts, cholestyramine, colestipol, paraffin oil, salicylates, estrogen-containing oral contraceptives (hormonal contraceptives) , preparations containing calcium salts (regular intake), preparations of vitamin D or its analogues (regular intake) - taking medications that increase the side effect of dexamethasone or enter into drug interactions with dexamethasone: acetazolamide, loop diuretics, thiazide diuretics, diuretics, amphotericin B, glucocorticosteroids, mineralocorticosteroids, tetracosactide and laxatives, carbenoxolone, chlorokine, hydroxychlorokine and meflocin, angiotensin converting enzyme inhibitors, thalidomide, cholinesterase inhibitors in patients with myasthenia gravis, fluorochonolones, ephedrine, barbiturates, rifabutin, rifampicin, phenytoin and carbamazepine, aminoglutethimide, bile acid binding resins, such as cholestyramine, antacids,activated carbon, antifungal azoles, ketoconazole, HIV protease inhibitors, macrolide antibiotics, estrogens, anti-tuberculosis drugs (isoniazid), cyclosporin, praziquantel, oral anticoagulants (coumarin), atropine and other anticholinergic drugs, somatotropin, protirel. |
結果
主な結果の測定
1. Postoperative hypocalcaemia [preoperatively and at 6 and 24 hour after surgery]
2. Postoperative hypoparathyroidism [preoperatively and at 6 and 24 hour after surgery]
二次的な結果の測定
1. Postoperative pain [at 6 and 24 hour after surgery]
2. Postoperative nausea on a verbal rating scale [at 6 and 24 hour after surgery]
3. Postoperative vomiting on a verbal rating scale [at 6 and 24 hour after surgery]
4. Postoperative sore throat on a verbal rating scale [at 6 and 24 hour after surgery]
5. Postoperative hoarseness on a verbal rating scale [at 6 and 24 hour after surgery]
その他の成果対策
1. Cytokines in serum [preoperatively and at 6 and 24 hour after surgery]
2. Cytokines in drain fluid [at 24 hour after surgery]
3. Calcium phosphate homeostasis [preoperatively and at 6 and 24 hour after surgery]
4. Vitamin D [preoperatively and at 6 and 24 hour after surgery]
5. Acute phase proteins [preoperatively and at 6 and 24 hour after surgery]
