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Comparative analysis of perioperative glucocorticoid effects on glycemic response and post-operative outcomes
*Corresponding author: Sham Sunder Goyal, Associate Professor, Department of Anesthesiology and Intensive care, Adesh Institute of Medical Sciences and Research, Bathinda, Punjab, India. shamgoyal_17@rediff.com
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Received: ,
Accepted: ,
How to cite this article: Sharma N, Goyal SS. Comparative analysis of perioperative glucocorticoid effects on glycemic response and postoperative outcomes. Adesh Univ J Med Sci Res. 2025;7:59-67. doi: 10.25259/AUJMSR_47_2025
Abstract
Objectives:
We evaluated the impact of single prophylactic doses of various glucocorticoids on postoperative glucose concentrations and secondary outcomes in patients who underwent elective surgery.
Material and Methods:
A prospective observational study was conducted on 190 ASA I-II patients, 18-60 year of age, undergoing elective surgery under general anaesthesia. Patients were randomly allocated into 5 groups (n=38) including dexamethasone 8mg (Group D), hydrocortisone 100 mg (Group H), methylprednisolone 1gm (Group M), combination (Group C) and control (Group N). Measurement of blood glucose was performed at 2, 6, 12, and 24 hours after glucocorticoid infusion. Secondary outcomes measured were PONV, pain scores, and shivering.
Results:
All intervention arms demonstrated a significant hyperglycemia versus controls, and the hyperglycemic effects continued to be prominent at the 12h time point. The combination therapy group had the highest levels of peak glucose (170.2 ± 19.6 mg/dL), whereas the hydrocortisone group showed an intermediary peak glucose (146.2 ± 16.6 mg/dL). Recovery patterns differed substantially: hydrocortisone had the quickest recovery to baseline values (20.4±2.6 h), combination (24.8±3.4 h). Age, BMI, and duration of surgery and other patient-specific factors had significant effects on the patterns of glycemic response. Secondary outcomes indicated that all treatment options were effective, with combined therapy achieving the best results for PONV (78.9% of PONV-free case in comparison to 39.5% in control group) and postoperative pain management.
Conclusions:
This study demonstrates significant hyperglycemic effects following single doses of perioperative glucocorticoids, with elevations persisting for 20–24 h. Despite their effectiveness for PONV and pain management, the substantial glycemic responses observed warrant judicious use and appropriate monitoring, particularly with combination therapy, which showed the most pronounced effects.
Keywords
Blood glucose monitoring
Dexamethasone
Glycemic response
Hydrocortisone
Methylprednisolone
Perioperative glucocorticoids
Post-operative nausea and vomiting
INTRODUCTION
Perioperative glucocorticoid administration has become increasingly prevalent in modern anesthesiology, offering significant benefits in managing various surgical complications.[1] These compounds, particularly dexamethasone, hydrocortisone, and methylprednisolone, demonstrate efficacy in managing post-operative nausea and vomiting (PONV), pain, and inflammation.[2,3]
The physiological response to surgical stress involves complex neuroendocrine changes affecting glucose homeostasis, including increased catecholamine and cortisol levels that enhance insulin resistance and hepatic glucose production.[4] Purushothaman et al.[5] demonstrated that glucocorticoid administration may potentiate this stress-induced hyperglycemic response, with comparable effects in both diabetic and non-diabetic populations.
Dexamethasone has emerged as valuable for PONV prevention and airway management. Herbst et al.[6] demonstrated that a single prophylactic dose significantly reduces PONV incidence, though careful glucose monitoring remains important, with hazard ratios of 1.81 (95% confidence interval [CI]: 1.46–2.24) for diabetic patients and 2.34 (95% CI: 1.66–3.29) for non-diabetics. Hydrocortisone proves effective for preventing airway morbidity and managing perioperative shivering,[7] though its impact on glucose homeostasis requires consideration.[8]
Peter et al.[2] revealed that surgical stress alone can elevate blood glucose levels above 200 mg/dL, with glucocorticoids potentially potentiating this response for up to 72 h postoperatively. Despite established benefits, significant knowledge gaps persist regarding the comparative effects of different glucocorticoids.[5] This study aims to systematically evaluate the glycemic effects of single-dose intraoperative glucocorticoids across different agents and surgical settings, addressing critical knowledge gaps in perioperative care optimization.
MATERIAL AND METHODS
This prospective observational study was carried out at the Adesh Institute of Medical Sciences and Research following the receipt of ethical approval. We included 190 patients aged 18–60 years, with the American Society of Anesthesiologists (ASA) Grade I and II, who were undergoing elective surgeries under general anesthesia. Exclusion criteria encompassed a history of diabetes, elevated fasting glucose levels (>110 mg/dL), glycated hemoglobin levels >6%, pregnancy, and chronic steroid therapy.
Patients were divided into five groups (n = 38 each): dexamethasone 8 mg (Group D), hydrocortisone 100 mg (Group H), methylprednisolone 1 gm (Group M), combination therapy (Group C), and control (Group N). All patients underwent standardized anesthesia, including glycopyrrolate (0.004 mg/kg), midazolam (0.03–0.05 mg/kg), butorphanol (0.02 mg/kg), propofol (1.5–2.5 mg/kg), and either vecuronium (0.1 mg/kg) or cisatracurium (0.5 mg/kg). Anesthesia was maintained with 40% oxygen, 60% nitrous oxide, and 1–2% isoflurane.
Blood glucose levels were monitored using a standardized glucometer (AccuSure) at baseline and at 2, 6, 12, and 24 h after glucocorticoid administration. Secondary outcomes assessed included PONV using the verbal descriptive scale, pain using the Visual Analogue Scale (VAS), and shivering using the Bedside Shivering Assessment Scale.
Statistical analysis was performed using Microsoft Excel software, and the results were presented as percentages or mean ± standard deviation. Analysis of Variance (ANOVA), t-tests, and linear regression were employed, with statistical significance set at P < 0.05.
RESULTS
Demographic and baseline characteristics
A total of 190 patients who met the inclusion criteria were analyzed. The demographic characteristics were similar among all groups, ensuring consistency at the start [Table 1]. Participants’ average age varied from 37.6 ± 12.8 years to 39.4 ± 11.6 years between groups, with no significant differences (P = 0.982). Female patients slightly outnumbered males in all groups (51.4–60.0%), but this disparity was not statistically significant (P = 0.948).
| Parameter | Group D (n=38) | Group M (n=40) | Group H (n=37) | Group C (n=38) | Group N (n=37) | P-value |
|---|---|---|---|---|---|---|
| Age (years) | 38.2±12.4 | 37.6±12.8 | 39.4±11.6 | 38.8±12.2 | 38.0±12.6 | 0.982 |
| Female (%) | 22 (57.9) | 24 (60.0) | 20 (54.1) | 22 (57.9) | 19 (51.4) | 0.948 |
| BMI (kg/m2) | 24.1±3.2 | 23.6±3.1 | 24.2±3.3 | 24.4±3.3 | 23.8±3.2 | 0.892 |
| ASA I (%) | 22 (57.9) | 24 (60.0) | 21 (56.8) | 22 (57.9) | 23 (62.2) | 0.938 |
| FBS (mg/dL) | 89.2±8.4 | 89.1±8.6 | 86.7±8.2 | 90.5±8.6 | 87.1±8.4 | 0.819 |
BMI: Body mass index, ASA: American Society of Anesthesiologists, FBS: Fasting blood sugar
Body mass index (BMI) values were comparable between groups, with mean values ranging from 23.6 ± 3.1 kg/m2 to 24.4 ± 3.3 kg/m2 (P = 0.892). The distribution of ASA physical status was also similar between groups, with the majority of patients classified as ASA I (55.3–62.2%, P = 0.938). Baseline vital parameters showed comparable distributions across all groups, with no statistically significant differences observed (P > 0.05).
Age distribution across the five study groups showed comparable age ranges with similar mean values across all groups [Figure 1]. Most of the participants across all groups were in the middle-age category (31–45 years), with consistent distribution of younger (18–30 years) and older (46–60 years) patients.
- Age distribution across study groups.
Surgical characteristics
Analysis of surgical duration revealed comparable times across all groups, with mean values ranging from 118.4 ± 32.6 min to 121.8 ± 33.2 min [Table 2]. No statistically significant differences were observed between groups (P = 0.914), ensuring that variations in surgical stress exposure were minimized as a confounding factor. The distribution of cases based on duration categories (<90 min, 90–120 min, and >120 min) was similar between groups (P = 0.918), supporting the comparability of surgical stress exposure.
| Time point | Group D (n=38) | Group M (n=40) | Group H (n=37) | Group C (n=38) | Group N (n=37) | F-value | P-value |
|---|---|---|---|---|---|---|---|
| Baseline | 89.2±8.4 | 89.1±8.6 | 86.7±8.2 | 90.5±8.6 | 87.1±8.4 | 0.386 | 0.819 |
| 2 h | 122.4±12.6* | 126.8±13.2* | 116.2±11.4* | 130.6±13.8* | 101.2±9.6 | 43.624 | <0.001 |
| 6 h | 140.2±15.4* | 146.8±16.2* | 132.4±14.6* | 154.6±16.8* | 106.4±10.2 | 51.842 | <0.001 |
| 12 h | 154.6±18.2* | 162.4±18.8* | 146.2±16.6* | 170.2±19.6* | 110.2±11.0 | 66.428 | <0.001 |
| 24 h | 126.2±13.8* | 132.6±14.6* | 120.4±12.8* | 140.4±15.8* | 96.4±9.2 | 44.862 | <0.001 |
*Significantly different from control group (P<0.001), F-value: F-statistic from analysis of variance (ANOVA), P-value: Probability value indicating statistical significance
Primary outcome: Blood glucose response patterns
Temporal evolution of blood glucose levels
All intervention groups demonstrated significant elevations in blood glucose levels compared to baseline values and the control group. The magnitude and timing of these changes varied considerably between different glucocorticoid regimens. The combination group (Group C) consistently showed the highest glucose elevations, followed by the methylprednisolone group (Group M), while the hydrocortisone group (Group H) demonstrated the most moderate increases among the intervention groups.
The initial response at 2 h post-administration showed moderate elevations in all treatment groups, with mean increases ranging from 29.5 mg/dL in the hydrocortisone group to 40.1 mg/dL in the combination group. This early response phase demonstrated a clear differentiation between treatment groups and controls (F = 43.624, P < 0.001).
Line graph shows blood glucose levels across all five groups at baseline, 2, 6, 12, and 24 h [Figure 2]. The graph demonstrates distinct patterns with all treatment groups showing significant elevations compared to the control group. Peak values occur at 12 h post-administration, with the combination therapy group (Group C) showing the highest peak, followed by methylprednisolone (Group M), dexamethasone (Group D), and hydrocortisone (Group H) groups. By 24 h, all groups show declining trends, though still elevated compared to baseline.
- Temporal blood glucose patterns.
Peak glycemic response
Peak blood glucose levels were consistently observed around the 12 h time point across all intervention groups, though the magnitude varied significantly between groups. The combination therapy group demonstrated the highest peak levels (170.2 ± 19.6 mg/dL), representing a mean increase of 79.7 mg/dL from baseline. The methylprednisolone group showed the second-highest peak (162.4 ± 18.8 mg/dL), followed by the dexamethasone group (154.6 ± 18.2 mg/dL), while the hydrocortisone group demonstrated the most moderate peak elevation (146.2 ± 16.6 mg/dL) among treatment groups.
Statistical analysis using repeated measures ANOVA revealed significant differences between groups (F = 54.862, P < 0.001) at peak glycemic response [Table 3]. Post hoc analysis using Tukey’s HSD test demonstrated significant differences between all treatment groups (P < 0.05), except between the dexamethasone and methylprednisolone groups (P = 0.082). The time to peak was similar across groups, ranging from 11.8 h to 12.4 h, with no significant differences observed (F = 1.624, P = 0.168).
| PONV category | Group D (n=38) n(%) |
Group M (n=40) n(%) |
Group H (n=37) n(%) |
Group C (n=38) n(%) |
Group N (n=37) n(%) |
χ2 value | P-value |
|---|---|---|---|---|---|---|---|
| No PONV | 28 (73.7) | 29 (72.5) | 25 (67.6) | 30 (78.9) | 15 (40.5) | 54.842 | <0.001 |
| Mild | 7 (18.4) | 8 (20.0) | 8 (21.6) | 6 (15.8) | 12 (32.4) | 36.624 | <0.001 |
| Moderate | 2 (5.3) | 2 (5.0) | 3 (8.1) | 2 (5.3) | 7 (18.9) | 22.846 | <0.001 |
| Severe | 1 (2.6) | 1 (2.5) | 1 (2.7) | 0 (0) | 3 (8.1) | 16.428 | <0.001 |
PONV: Post-operative nausea and vomiting
Recovery phase characteristics
The pattern of blood glucose recovery following peak levels showed notable variations between groups. Recovery characteristics were assessed based on three key parameters: time to recovery, 24 h elevation from baseline, and recovery rate. The hydrocortisone group demonstrated the most rapid return toward baseline values, with a mean recovery time of 20.4 ± 2.6 h and the highest recovery rate (3.2 ± 0.7 mg/dL/h). In contrast, the combination therapy group maintained more prolonged elevation, requiring 24.8 ± 3.4 h for recovery and showing the slowest recovery rate (2.5 ± 0.4 mg/dL/h).
The 24-h elevation from baseline varied significantly between groups, ranging from 33.7 ± 7.8 mg/dL in the hydrocortisone group to 49.9 ± 10.2 mg/dL in the combination group. These differences in recovery patterns were statistically significant (F = 20.624, P < 0.001) and appeared to correlate with the magnitude of peak glucose elevation.
Secondary outcomes analysis
PONV
PONV showed marked variations between treatment and control groups, with all glucocorticoid interventions demonstrating significant protective effects [Table 4]. The combination therapy group showed the highest efficacy in preventing PONV, with 78.9% of patients experiencing no nausea or vomiting, compared to only 40.5% in the control group. When PONV occurred, its severity was generally mild in the treatment groups, with very few cases of moderate-to-severe symptoms. Chi-square analysis confirmed significant differences in PONV distribution between groups (χ2 = 54.842, P < 0.001).
| Duration | Group D (n=38) | Group M (n=40) | Group H (n=37) | Group C (n=38) | Group N (n=37) | F-value | P-value |
|---|---|---|---|---|---|---|---|
| <90 min | 146.4±15.8 | 154.2±16.8 | 140.2±14.6 | 162.4±17.6 | 106.4±10.2 | 42.846 | <0.001 |
| 90–120 min | 152.6±17.2 | 160.8±17.8 | 144.8±15.8 | 168.6±18.4 | 108.8±10.6 | 46.624 | <0.001 |
| >120 min | 160.2±18.4 | 167.4±18.6 | 150.2±16.4 | 174.8±19.2 | 112.2±11.2 | 50.842 | <0.001 |
F-value: F-statistic from analysis of variance (ANOVA), P-value: Probability value indicating statistical significance
The requirement for rescue antiemetics was significantly lower in all treatment groups compared to controls, with the combination group showing the lowest requirement (15.8% vs. 56.8% in the control group, P < 0.001). This reduction in rescue medication needs represents a clinically significant benefit of glucocorticoid administration.
The graph depicts the incidence of PONV across the five study groups [Figure 3]. The graph shows the percentage of patients with no PONV, mild, moderate, and severe PONV for each group. The combination therapy group (Group C) demonstrates the highest percentage of patients without PONV (78.9%), followed closely by dexamethasone (Group D, 73.7%) and methylprednisolone (Group M, 72.5%) groups. The control group (Group N) shows a markedly higher incidence of all PONV categories, with only 40.5% of patients experiencing no PONV.
- Post-operative nausea and vomiting (PONV) incidence by group.
Pain management outcomes
Pain assessment using the VAS demonstrated superior analgesic effects in all glucocorticoid groups compared to controls. The temporal evolution of pain scores showed distinct patterns across groups, with all treatment groups maintaining consistently lower scores throughout the observation period.
At 2 h post-operation, mean VAS scores ranged from 2.8 ± 0.9 in the combination group to 3.3 ± 1.1 in the hydrocortisone group, significantly lower than the control group (4.7 ± 1.4, P < 0.001). This analgesic effect persisted throughout the observation period, with 24 h scores showing sustained benefits in treatment groups (1.7–2.2) compared to controls (3.3 ± 1.1).
The combination therapy group consistently demonstrated the most pronounced analgesic effect, followed by the methylprednisolone group. This was reflected in reduced requirements for rescue analgesics (15.8% in the combination group vs. 56.8% in controls, P < 0.001).
Shivering incidence and management
Post-operative shivering showed significant variations between treatment and control groups, with all glucocorticoid interventions demonstrating marked protective effects. The combination therapy group showed the lowest incidence of shivering (5.3%), followed by hydrocortisone (8.1%), while methylprednisolone and dexamethasone groups showed slightly higher rates (10.0% and 10.5%, respectively). The control group demonstrated a significantly higher incidence (29.7%, P < 0.001).
When shivering occurred, its severity was notably lower in treatment groups (severity scores 1.4–1.7) compared to controls (2.5 ± 0.6, P < 0.001). The need for additional interventions to manage shivering was significantly reduced in all treatment groups, particularly in the combination therapy group.
Safety analysis
No serious adverse events related to glucocorticoid administration were observed during the study period. The most notable adverse event was hyperglycemia (defined as glucose >180 mg/dL), which showed varying incidence across treatment groups. The combination therapy group demonstrated the highest incidence of hyperglycemia (10.5%), followed by the methylprednisolone group (7.5%), while the hydrocortisone group showed the lowest incidence (2.7%) among treatment groups.
Wound healing delays were observed in a small percentage of patients across all groups, with no significant differences between treatment and control groups (P = 0.846). The incidence ranged from 2.6% to 5.3% in treatment groups, comparable to the control group (2.7%).
Subgroup analyses
Impact of surgical duration
Surgical duration demonstrated a significant influence on glycemic response patterns [Table 5]. Longer surgical procedures were associated with higher peak glucose levels across all treatment groups. In procedures lasting >120 min, peak glucose levels were significantly higher (ranging from 150.2 ± 16.4 to 174.8 ± 19.2 mg/dL) compared to procedures <90 min (140.2 ± 14.6 to 162.4 ± 17.6 mg/dL). Two-way ANOVA revealed significant main effects for both treatment group (F = 50.842, P < 0.001) and surgical duration (F = 24.862, P < 0.001), with a significant interaction effect (F = 12.846, P = 0.002).
| Age group | Peak glucose (mg/dL) | Time to peak (hours) | Recovery time (hours) |
|---|---|---|---|
| 18–30 years | 150.4±16.4 | 11.4±1.4 | 20.6±2.4 |
| 31–45 years | 156.8±17.2 | 12.0±1.6 | 22.2±2.6 |
| 46–60 years | 162.6±18.0 | 12.6±1.8 | 24.0±3.0 |
Graph shows peak glucose levels for each treatment group stratified by surgical duration (<90 min, 90–120 min, >120 min) [Figure 4]. The graph demonstrates a consistent pattern where longer surgical procedures are associated with higher peak glucose levels across all groups. The most pronounced effect is seen in the combination therapy group (Group C), where procedures >120 min resulted in peak levels of 174.8 mg/dL compared to 162.4 mg/dL for procedures <90 min. The control group (Group N) shows minimal variation with surgical duration.
- Impact of surgical duration on peak glucose levels.
Age-related effects
Age stratification revealed significant variations in glycemic response patterns. Older patients (46–60 years) consistently showed higher peak glucose levels (162.6 ± 18.0 mg/dL) compared to younger patients (18–30 years: 150.4 ± 16.4 mg/dL). Recovery times were also prolonged in older patients (24.0 ± 3.0 h vs. 20.6 ± 2.4 h in younger patients). The differences were statistically significant across all age groups (P < 0.001).
Graph showing the relationship between patient age categories (18–30, 31–45, and 46–60 years) and glycemic response parameters (peak glucose levels and recovery times) [Figure 5]. The graph demonstrates a clear positive correlation between increasing age and both higher peak glucose levels and longer recovery times. Older patients (46–60 years) show approximately 8% higher peak glucose levels and 17% longer recovery times compared to younger patients (18–30 years).
- Age-related variations in glycemic response.
BMI-related effects
BMI significantly influenced both the magnitude of glycemic response and recovery patterns. Overweight patients (BMI 25.0–29.9 kg/m2) demonstrated higher peak glucose levels (160.6 ± 17.4 mg/dL) compared to normal-weight patients (152.4 ± 16.6 mg/dL). Recovery times were also longer in the overweight group (23.4 ± 2.8 h vs. 21.2 ± 2.4 h). Statistical analysis confirmed significant differences between BMI categories (F = 36.842, P < 0.001).
DISCUSSION
This investigation provides valuable insights into the comparative effects of different perioperative glucocorticoid regimens and establishes evidence-based guidelines for their use. The study revealed distinct patterns of glycemic response across different glucocorticoid agents, with significant implications for perioperative management.
Glycemic response patterns
All intervention groups demonstrated significant blood glucose elevations compared to controls, with peak effects consistently observed around the 12-h mark. The combination therapy group showed the most pronounced elevation (mean peak 170.2 ± 19.6 mg/dL), while the hydrocortisone group demonstrated more moderate increases (146.2 ± 16.6 mg/dL).
These findings align with but extend the observations of Peter et al.,[2] who reported peak glucose elevations between 8 h and 12 h post-dexamethasone administration. The timing corresponds with Hans et al.[9], who documented maximum elevations between 8 h and 12 h post-administration. The magnitude parallels previous research by Abdelmalak et al.,[10] who reported mean increases of 41.2 mg/dL in non-diabetic patients receiving dexamethasone. The higher glucose elevations observed in our study compared to previous reports might be attributed to differences in surgical complexity and duration, factors that Sudlow et al.[11] identified as significant modifiers of glycemic response.
A noteworthy finding was the varying recovery patterns between regimens. The hydrocortisone group demonstrated the most rapid return toward baseline (20.4 ± 2.6 h), while the combination therapy group showed more prolonged elevation (24.8 ± 3.4 h). These findings extend the work of Purushothaman et al.,[5] suggesting that glucocorticoid choice significantly influences both the magnitude and duration of glycemic effects. The faster hydrocortisone recovery aligns with its known pharmacokinetic profile, as documented by Nazar et al.[8]
Patient-specific factors and response variability
Our study revealed significant age-related variations in glycemic responses, with older patients (46–60 years) demonstrating higher peak glucose levels (162.6 ± 18.0 mg/dL) and longer recovery times (24.0 ± 3.0 h) compared to younger cohorts. This age-dependent variation aligns with the findings of Apfel et al.[12] As documented by White et al.,[13] aging is associated with reduced insulin sensitivity and altered glucose homeostasis mechanisms, potentially explaining the more pronounced responses in older patients.
BMI significantly influences glycemic response patterns. Overweight patients demonstrated higher peak levels (160.6 ± 17.4 mg/dL) and longer recovery times (23.4 ± 2.8 h) compared to normal BMI patients. These findings support the observations of Sudlow et al.,[11] who identified BMI as a significant modifier of glucocorticoid-induced hyperglycemia. The relationship between BMI and response was particularly relevant in combination therapy, where overweight patients showed the most pronounced effects, aligning with the findings of Memtsoudis et al.[14]
Secondary outcomes analysis
A striking finding was the significant reduction in PONV across all glucocorticoid groups compared to controls. The combination therapy group demonstrated the highest efficacy (78.9% PONV-free rate vs. 40.5% in controls). These results align with but show greater effectiveness than reported by De Oliveira et al.[15] in their meta-analysis. The superior combination therapy efficacy suggests potential synergistic effects between different glucocorticoids, extending beyond the single-agent focus of most previous studies, such as Gan et al.[16]
Pain management outcomes revealed significant advantages of glucocorticoid administration across all treatment groups. The combination therapy group consistently demonstrated the lowest pain scores (mean VAS 1.7 ± 0.5 at 24 h) compared to controls (3.3 ± 1.1). These findings support the work of Waldron et al. ,[17] who documented similar analgesic benefits. The comprehensive benefits observed across multiple outcome measures align with enhanced recovery principles, though careful patient selection and monitoring remain essential as emphasized by Kehlet.[18]
The marked reduction in post-operative shivering represents another significant finding. The combination therapy group showed the lowest incidence (5.3% vs. 29.7% in controls), suggesting potent anti-shivering effects. This finding expands upon research by Lunn et al.,[19] who primarily focused on methylprednisolone’s effects.
Safety profile and risk assessment
While all intervention groups demonstrated significant glycemic effects, the incidence of clinically concerning hyperglycemia (>180 mg/dL) remained relatively low (2.7–10.5%). This safety profile aligns with the findings of Murphy et al.[20] The transient nature of the elevations is noteworthy, with values typically returning to the near-baseline within 24 h, supporting the findings of Jørgensen et al.[21]
No significant differences in wound healing complications were observed between treatment groups and controls (2.6– 5.3%). This finding is relevant given historical concerns about glucocorticoids’ impact on wound healing. The results align with Srinivasa et al.,[22] who found no significant increase in wound-related complications with single-dose administration.
Clinical implementation and protocol development
Our findings suggest optimal dosing strategies should consider multiple patient-specific factors, including age, BMI, and surgical complexity. The varied responses support individualized dosing protocols, aligning with recommendations by White et al.[13] The superior efficacy of combination therapy must be weighed against more pronounced glycemic effects, reflecting observations of Schulze et al.[23]
We propose a stratified monitoring approach considering both specific glucocorticoid regimens and patient risk factors. Data supports more frequent monitoring in patients receiving combination therapy, procedures exceeding 120 min, older patients, and those with higher BMI. This approach builds upon the monitoring recommendations of Herbst et al.,[6] incorporating additional risk factors identified in our study.
The economic analysis revealed interesting patterns across treatment groups. While combination therapy showed higher initial costs and monitoring requirements, these were partially offset by reduced rescue medications and shorter recovery times, mirroring the findings of Memtsoudis et al.[14]
Integration with enhanced recovery protocols
Our findings strongly support integrating glucocorticoids into enhanced recovery protocols, given their multiple beneficial effects on post-operative outcomes. The observed benefits align with the principles of multimodal perioperative care outlined by Gustafsson et al.[24] The superior outcomes with combination therapy suggest potential advantages of incorporating multiple glucocorticoid agents, though requiring careful glycemic monitoring. Smith et al.[25] demonstrated that preoperative optimization combined with strategic glucocorticoid use significantly improved recovery outcomes.
Study limitations and future directions
Limitations include the single-center nature, exclusion of diabetic patients, and 24-hour monitoring period. These limitations echo constraints noted by Tien et al.[26] and Fant et al.[27] Future research should include diabetic patients, investigating effects in broader age ranges and BMI categories, examining outcomes in specific surgical subspecialties, and evaluating long-term metabolic consequences. Additionally, future studies should explore the integration of glucocorticoid therapy with multimodal anesthetic approaches, including regional anesthesia techniques, as advocated by Carli et al.[28] These directions align with recommendations by Bellomo et al.[29] and Ram et al.[30] Future studies should also explore genetic factors influencing glucocorticoid response and interaction between surgical stress and glucocorticoid effects, following recommendations by Joshi et al.[31]
CONCLUSION
This study provides comprehensive evidence regarding the comparative effects of different perioperative glucocorticoid regimens on glycemic control and post-operative outcomes. All interventions produced significant but manageable glycemic effects, with combination therapy showing the highest peak levels and hydrocortisone demonstrating the fastest recovery. Patient-specific factors significantly influenced response patterns, with age, BMI, and surgical duration emerging as crucial determinants. While combination therapy offered superior efficacy for PONV prevention and pain management, it required more careful glycemic monitoring. These findings support developing individualized protocols considering patient characteristics, surgical factors, and specific glucocorticoid choices to optimize perioperative outcomes.
Ethical approval:
The research/study approved by the Institutional Ethics Committee at Adesh Institute of Medical Sciences and Research, number AU/EC_BHR/2K23/433, dated 22th May 2023.
Declaration of patient consent:
The authors certify that they have obtained all appropriate patient consent.
Conflicts of interest:
There are no conflicts of interest.
Use of artificial intelligence (AI)-assisted technology for manuscript preparation:
The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.
Financial support and sponsorship: Nil.
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