We would like to thank Dr Andrade for his letter. We would like to clarify that the updated Society for Ambulatory Anesthesia (SAMBA) consensus statement on perioperative blood glucose management in adult patients with diabetes mellitus undergoing ambulatory surgery was based on available evidence at the time of literature serarch. Regarding the use of dexamethasone in patients with diabetes mellitus, the task force did recognize the importance of dexamethasone both for postoperative nausea and vomiting (PONV) prophylaxis and multimodal analgesia. The task force also recognized that dexamethasone 8 mg intravenous would be more appropriate for analgesia. We therefore reiterate that dexamethasone 4 mg intravenous was recommended based on the available evidence at the time of literature search. Thus, it is interesting that Dr Andrade feels that the role of dexamethasone needs to be vindicated, and we believe he inappropriately invokes the name of Alan Turing.
The publications Dr Andrade cites were published after the SAMBA consensus statement was completed, which we are sure he recognizes. In fact, the systematic review and meta-analysis suggesting that perioperative dexamethasone may be given to diabetic patients without increasing the risk of infectious complications was published in the same issue of Anesthesia & Analgesia as the SAMBA consensus statement. Importantly, Jones et al provide no recommendations as to the optimal dose or its use in poorly controlled diabetes. Similarly, the systematic review and meta-analysis assessing the impact of an intraoperative single dose of dexamethasone on blood glucose levels was also published in the same issue of Anesthesia & Analgesia. In the subgroup analysis based on dexamethasone dose the authors found blood glucose levels at 24 hours showed a statistically significant increase in the 8 to 10 mg group compared to 4 to 5 mg group.
In summary, we recognize that higher doses of dexamethasone have not been shown to increase the risk of surgical site infection, however, the effects of higher doses of dexamethasone on glycemic control especially in patients with poorly controlled diabetes and insulin-dependent diabetes, have not been adequately validated. Since lower (4 mg) doses of dexamethasone result in smaller increases in blood glucose levels and have similar efficacy in reducing PONV, the task force recommended the use of 4 mg of intravenous dexamethasone. Finally, it is clear that the task force does not recommend that dexamethasone fall into disuse.