Nausea and vomiting are common complications after anaesthesia, and anaesthetists routinely give medications to prevent them. Dexamethasone and ondansetron are the two most commonly used agents and have a long safety record. However, their effects on sleep, behaviour, and overall recovery are not well studied. Understanding these will guide future care. The aim of this study is to determine if dexamethasone or ondansetron given during an anaesthetic affect post-operative sleep, behaviour and recovery in children. Patients enrolled in the study will be randomised to receive either dexamethasone or ondansetron during their procedure. This randomisation will be blinded to patients, their families and their treating anaesthetist. Information about the patient's pain, recovery and sleep will be collected over 7 days post-operatively using online surveys. A subset of patients will also be asked to complete additional pre-operative non-invasive monitoring using an oximeter and an actigraph to measure their sleep quality before and after surgery. In addition to the postoperative surveys, these patients will be asked to wear the oximeter and actigraph for 3 nights before and immediatey after surgery. Patients who are admitted overnight postoperatively will also have additional transcutaneous carbon dioxide monitoring on the night of their surgery.
Postoperative nausea and vomiting (PONV) are a common complication after anaesthesia. Therefore, it is standard practice to administer either ondansetron and/or dexamethasone intraoperatively as prophylaxis. PONV affects up to 30-40% of the general surgical population and up to 80% of high-risk patients, making it one of the most distressing complications of the perioperative period.Uncontrolled PONV prolongs recovery room stay, increases unplanned hospital re-admissions, and is consistently identified by patients and families as one of the most undesirable aspects of the surgical experience. It was ranked in the top 10 research priorities in perioperative medicine in a recent large consumer engagement study involving over 350 children. Ondansetron, a 5-HT3 receptor antagonist, and dexamethasone, a corticosteroid, are the two most widely used agents for PONV prophylaxis in paediatric anaesthesia, often administered in combination.Dexamethasone exerts well-documented glucocorticoid effects, including modulation of the hypothalamic-pituitary-adrenal (HPA) axis, suppression of endogenous cortisol secretion, and direct actions on brain structures involved in arousal and sleep regulation, including the hippocampus, hypothalamus, and limbic system.a single intraoperative dose of dexamethasone (0.1-0.5 mg/kg) has been shown to produce measurable HPA axis suppression lasting 24-48 hours postoperatively in children, as well as transient elevations in blood glucose and behavioural changes including hyperactivity, irritability, and emotional lability. Sleep is a critical component of paediatric postoperative recovery. Disrupted postoperative sleep has been associated with increased pain perception, impaired immune function, heightened parental anxiety, and prolonged behavioural disturbance following surgery. Glucocorticoids are known to disrupt sleep architecture, including fragmentation of sleep, suppression of slow-wave sleep, and reductions in total sleep time. In children, the effects of a single perioperative dose of dexamethasone on sleep remain poorly characterised. In contrast, ondansetron does not directly affect the HPA axis or glucocorticoid receptors, and its central effects are limited primarily to 5-HT3 receptor blockade, with no established direct mechanism for sleep disruption. Postoperative negative behavioural changes (PNBC) in children, sometimes referred to as "new-onset behavioural problems", are a recognised sequela of paediatric anaesthesia and surgery, affecting up to 54% of children in the first 2 weeks following surgery. The potential role of perioperative dexamethasone in exacerbating these changes through glucocorticoid-mediated effects on the developing brain has not been systematically examined. Understanding whether the choice of PONV prophylaxis agent influences postoperative sleep quality and behaviour could have important implications for anaesthetic practice and family-centred postoperative care. This study aims to investigate the impact of intraoperative intravenous dexamethasone vs ondansetron administered for prophylaxis of postoperative nausea and vomiting (PONV) on postoperative sleep, behaviour and recovery in children undergoing general anaesthesia.
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
PREVENTION
Masking
QUADRUPLE
Enrollment
500
Dexamethasone (0.2 mg/kg, maximum 8 mg) will be diluted to 2mL with normal saline and administered intravenously at the start of procedure.
Ondansetron (0.15mg/kg, maximum 4mg) will be diluted to 2mL with normal saline and administered intravenously 15-30 minutes before the end of surgery
Perth Children's Hospital
Perth, Western Australia, Australia
Hospital das Clinicas
São Paulo, São Paulo, Brazil
Santa Casa de Misericórdia de Ribeirão Preto
São Paulo, São Paulo, Brazil
Compare parent-reported sleep quality on day 1 post-op between children receiving intravenous dexamethasone and children receiving intravenous ondansetron during their anaesthetic.
Parent-reported sleep quality will be measured on a 0 - 10 point scale, where 0 is terrible sleep and 10 is excellent sleep.
Time frame: Sleep quality will be assessed on day 1 post-surgery
Compare parent-reported sleep quality preoperatively and on postoperative days 2,3,5 and 7 between children who received dexamethasone and children who received ondansetron intraoperatively.
Sleep quality is measured on a 0 -10 point scale, where 0 is terrible sleep and 10 is excellent sleep.
Time frame: Parent-reported preoperative sleep quality will be collected on the day of surgery and postoperatively on days 2,3,5 and 7.
Compare child-reported (if child is aged over 8 years) sleep quality on postoperative days 1, 2, and 7 between children receiving intravenous dexamethasone and children receiving intravenous ondansetron during their anaesthetic.
Child reported sleep quality will be measured on a 0 - 10 point scale, where 0 is terrible sleep and 10 is excellent sleep
Time frame: child reported sleep quality will be measure don days 1, 2, and 7 postoperatively
Compare parent reported postoperative recovery on postoperative days 1, 2, 3, 5, and 7 between children in the dexamethasone group and children in the ondasetron group
Postoperative recovery will be measured using the Pediatric Scale for Quality of Recovery (PedSQoR). The overall score will range from 20 to 100, higher scores indicate a better quality of recovery or a more complete recovery.
Time frame: Postoperative recovery will be measured postoperative days 1, 2, 3, 5, and 7
Compare parent reported postoperative behaviour on postoperative days 1, 2, 3, 5, and 7 between children in the dexamethasone group and children in the ondasetron group
Postoperative behaviour will be measured using the the Post-Hospitalisation Behaviour Questionnaire for Ambulatory Surgery (PHBQ-AS). The scores range from 11 - 55. Higher scores indicate increased behavioural changes post-surgery,
Time frame: postoperative behaviour will be measured on postoperative days 1, 2, 3, 5, and 7
Compare parent reported average and maximum pain score on postoperative days 1, 2, 3, 5, and 7 or until the child has returned to normal function between children in the dexamethasone group and children in the ondasetron group
Parent reported post-operative pain will be measured using the Verbal Rating Scale 0 - 10 \[VRS\] where 0 is no pain and 10 is the worst possible pain.
Time frame: postoperative pain will be measured on days 1, 2, 3, 5 and 7 or until the child returns to normal function.
Comparison of sleep disturbances at baseline and 7 days post-surgery between children in the dexamethasone group and children in the ondasetron group
Sleep disturbance will be measured using the Patient Reported Outcomes Information System (PROMIS) Parent Proxy Sleep Disturbance - Short Form 8a. Higher scores indicate more severe sleep disturbances as reported by the parent
Time frame: Sleep disturbance will be measured at baseline on the day of surgery in the pre-operative holding area and on postoperative day 7
Comparison of the incidence of early postoperative nausea and vomiting between children in the dexamethasone group and children in the ondansetron group
Postoperative nausea and vomiting will as self-reported by the patient or parent reported
Time frame: From PACU arrival until 6 hours postoperatively or hospital discharge, whichever comes first.
Comparison of the use of rescue medication for postoperative nausea and vomiting between children in the dexamethasone group and children in the ondansetron group
Rescue medications given will be as recorded on the patient's medication chart
Time frame: from PACU arrival until 6 hours postoperatively or hospital discharge, whichever comes first
Determine the impact of the Snoring, Trouble Breathing and Unrefreshed (STUBR) questionnaire on postoperative recovery
postoperative recovery will be measured using the Pediatric Scale for Quality of Recovery (PedSQoR)
Time frame: STUBR questionnaire will be administered preoperatively and recovery will be assessed on postoperative days 1,2,3,5, and 7
Determine the impact of the Snoring, Trouble Breathing and Unrefreshed (STUBR) questionnaire on postoperative sleep
Parent-reported and child-reported sleep quality will be measured on a 0 - 10 point scale, where 0 is terrible sleep and 10 is excellent sleep.
Time frame: Parent reported sleep quality will be measured on postopeative days 1,2,3,5, and 7. Child reported sleep quality (if the child is older than 8 years) will be measured on postoperative days 1,2, and 7.
Impact of sedative premedication on postoperative delirium
Emergence delirium will be assessed by the post-operative recovery nurse using the WATCHA Scale. The WATCHA Scale is scored from 0 (asleep) to 4 (thrashing around). Scores greater than or equal to 2 on this scale are indicative of emergence delirium.
Time frame: Delirium will be assessed from PACU arrival until PACU discharge criteria met
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