Dexamethasone versus methylprednisolone for critical asthma: A single center, open-label, parallel-group clinical trial.

BACKGROUND: Evidence for the use of dexamethasone for pediatric critical asthma is limited. We sought to compare the clinical efficacy and safety of dexamethasone versus methylprednisolone among children hospitalized in the pediatric intensive care unit (PICU) for critical asthma. METHODS: A prospective, single center, open-label, two-arm, parallel-group, nonrandomized trial among children ages 5-17 years hospitalized within the PICU from April 2019 to December 2021 for critical asthma consented to receive methylprednisolone (standard care) or dexamethasone (intervention) at a 2:1 allocation ratio, respectively. The intervention arm received intravenous dexamethasone 0.25 mg/kg/dose (max: 15 mg/dose) every 6 h for 48 h and the standard care arm intravenous methylprednisolone 1 mg/kg/dose every 6 h (max dose: 60 mg/dose) for 5 days. Study endpoints were clinical efficacy (i.e., length of stay [LOS], continuous albuterol duration, and a composite of adjunctive asthma interventions) and safety (i.e., corticosteroid-related adverse events). RESULTS: Ninety-two participants were analyzed of whom 31 were allocated to the intervention arm and 61 the standard care arm. No differences in demographics, clinical characteristics, or acute/chronic asthma severity indices were observed. Regarding efficacy and safety endpoints, no differences in hospital LOS, continuous albuterol duration, adjunctive asthma intervention rates, or corticosteroid-related adverse events were noted. Compared to the intervention arm, participants in the standard care arm more frequently were prescribed corticosteroids at discharge (72% vs. 13%, p < 0.001). CONCLUSIONS: Among children hospitalized for critical asthma, dexamethasone appears safe and warrants further investigation to fully assess clinical efficacy and potential advantages over commonly applied agents such as methylprednisolone.

Dexamethasone for Pediatric Critical Asthma: A Multicenter Descriptive Study.

BACKGROUND: Systemic corticosteroids are vital to critical asthma management. While intravenous methylprednisolone is routinely used in the pediatric intensive care unit (PICU) setting, recent data supports dexamethasone as an alternative. Using the Pediatric Health Information System (PHIS) registry, we assessed trends and variation in corticosteroid prescribing among children hospitalized for critical asthma. METHODS: We performed a multicenter retrospective cohort study using PHIS data among children 3-17 years of age admitted for critical asthma from 2011 through 2019. Primary outcomes were corticosteroid prescribing rates by year and participating sites. Exploratory outcomes were corticosteroid-related adverse effects, rates of adjunctive pharmaceutical and respiratory interventions, mortality and length of stay. RESULTS: Of the 49 children's hospitals assessed, 26 907 encounters were included for study. Mean dexamethasone exposure rates were 18.1 ± 2.4% where 2.4 ± 1.2% represented dexamethasone-alone prescribing. Dexamethasone alone prescribing exhibited a linear trend (annual increase of 0.5 ± 0.1% annually R2 = 0.845) without correlation to cumulative site critical asthma admission rates. Compared to encounters prescribed solely methylprednisolone or a combination of dexamethasone and methylprednisolone, subjects provided dexamethasone alone had reduced asthma severity indices, length of stay, and exposure rates to adjunctive asthma interventions. Adverse events were rare and the dexamethasone-alone group less frequently experienced gastritis and hyperglycemia. CONCLUSIONS: In this multicenter retrospective study from 49 children's hospitals, dexamethasone prescribing rates appear increasing for pediatric critical asthma. Observed variability in corticosteroid prescribing implies a continued need for controlled prospective comparative analyses to define ideal corticosteroid regimens for pediatric critical asthma.

Benefits of Thoracic Epidural Analgesia in Patients Undergoing an Open Posterior Component Separation for Abdominal Herniorrhaphy.

An open posterior component separation (PCS) is a commonly utilized surgical approach for repair of complex abdominal wall defects and hernias. Although this approach may improve surgical outcomes, significant postoperative pain can be expected given the required laparotomy and extensive abdominal wall manipulation. Both systemic opioids and thoracic epidural analgesia (TEA) are viable postoperative analgesic options, and both are commonly utilized. Although the benefits of TEA have been investigated following a variety of surgeries, there is a paucity of literature related to its efficacy for this particular surgery. The aim of this study was to evaluate the benefits of TEA following open PCS under the hypothesis that the incorporation of TEA into the postoperative analgesic regimen would hasten bowel recovery. Patients who previously underwent an open PCS were identified through an electronic medical record query. A retrospective chart review was then performed, and patients who had TEA, either alone or combined with systemic opioids, were compared with patients who had only systemic opioids. The primary end point was a comparison of the postoperative day (POD) on which a full diet was started. Secondarily, time to liquid diet, postsurgical length of stay (LOS), intensive care unit (ICU) admission rate, ICU LOS, and the rates of several postoperative adverse events were compared. A post hoc analysis was also performed, using the same end points, to compare the subgroup of TEA patients who avoided systemic opioids with all patients who received systemic opioids, whether alone or combined with TEA. One hundred and one patients were ultimately included for analysis. Time to full diet was not significantly different between patients who had TEA, either with or without systemic opioids, and those who received only systemic opioids (TEA 2.6 ± 1.7 vs. systemic opioids 3.1 ± 2.1 [mean POD ± SD], P = .21). Additionally, no statistically significant differences were found for any secondary outcome. In the post hoc analysis, the subgroup of TEA patients who avoided systemic opioids had a significantly faster time to bowel recovery when compared with all patients who received systemic opioids (2.2 ± 1.0 vs. 3.2 ± 2.2, P = .0033). This subgroup also had a significantly shorter time to liquid diet and a decreased postoperative LOS. In conclusion, for patients undergoing an open PCS, the inclusion of TEA in the postoperative analgesic regimen did not by itself hasten the return of bowel function. However, when TEA was utilized and systemic opioids were avoided, bowel recovery occurred significantly sooner and resulted in a shortened hospital LOS.