Perineural versus intravenous dexamethasone as an adjuvant in regional anesthesia: a systematic review and meta-analysis

Wen-Ling Zhao, Xiao-Feng Ou, Jin Liu, Wen-Sheng Zhang, Wen-Ling Zhao, Xiao-Feng Ou, Jin Liu, Wen-Sheng Zhang

Abstract

Background: Dexamethasone is a common adjuvant for local anesthetics in regional anesthesia, but the optimal route of administration is controversial. Therefore, we did a systematic review and meta-analysis of randomized controlled trials to assess the effect of perineural versus intravenous dexamethasone on local anesthetic regional nerve-blockade outcomes.

Materials and methods: Medline (through PubMed), Embase, Cochrane, Web of Science, and Biosis Previews databases were systematically searched (published from inception of each database to January 1, 2017) to identify randomized controlled trials. The data of the selected trials were statistically analyzed to find any significant differences between the two modalities. The primary outcome was the duration of analgesia. Secondary outcomes included duration of motor block, postoperative nausea and vomiting, and postoperative analgesic dose at 24 hours. We conducted a planned subgroup analysis to compare the effects between adding epinephrine or not.

Results: Ten randomized controlled trials met the inclusion criteria of our analysis, with a total of 749 patients. Without the addition of epinephrine, the effects of perineural and intravenous dexamethasone were equivalent concerning the duration of analgesia (mean difference 0.03 hours, 95% CI -0.17 to 0.24). However, with the addition of epinephrine, the analgesic duration of perineural dexamethasone versus intravenous dexamethasone was prolonged (mean difference 3.96 hours, 95% CI 2.66-5.27). Likewise, the impact of epinephrine was the same on the duration of motor block. The two routes of administration did not show any significant differences in the incidence of postoperative nausea and vomiting, nor on postoperative analgesic consumption at 24 hours.

Conclusion: Our results show that perineural dexamethasone can prolong the effects of analgesic duration when compared to the intravenous route, only when epinephrine is coadministered. Without epinephrine, the two modalities show equivalent effect as adjuvants on regional anesthesia.

Keywords: anesthesia adjuvants; dexamethasone; regional anesthesia.

Conflict of interest statement

Disclosure The authors report no conflicts of interest in this work.

Figures

Figure 1
Figure 1
Flowchart of the search strategy. Abbreviation: RCTs, randomized controlled trials.
Figure 2
Figure 2
Forest plots showing the duration of analgesia. Notes: Analysis of all data in the associated studies (A); subgroup analysis by differentiating addition or not of epinephrine (B).
Figure 3
Figure 3
Forest plots showing the duration of motor block. Notes: Analysis of four studies (A) and subgroup analysis by differentiating addition or not of epinephrine (B).
Figure 4
Figure 4
Forest plots comparing perineural and intravenous groups at 24 hours. Notes: Incidence of postoperative nausea and vomiting (A); postoperative analgesic consumption (B).

References

    1. Abdelmonem A, Rizk SN. Comparative study between intravenous and local dexamethasone as adjuvant to bupivacaine in perianal block. Egypt J Anaesth. 2011;27(3):163–168.
    1. Desmet M, Braems H, Reynvoet M, et al. I.V. and perineural dexamethasone are equivalent in increasing the analgesic duration of a single-shot interscalene block with ropivacaine for shoulder surgery: a prospective, randomized, placebo-controlled study. Br J Anaesth. 2013;111(3):445–452.
    1. Kawanishi R, Yamamoto K, Tobetto Y, et al. Perineural but not systemic low-dose dexamethasone prolongs the duration of interscalene block with ropivacaine: a prospective randomized trial. Local Reg Anesth. 2014;7:5–9.
    1. Rahangdale R, Kendall MC, McCarthy RJ, et al. The effects of perineural versus intravenous dexamethasone on sciatic nerve blockade outcomes: a randomized, double-blind, placebo-controlled study. Anesth Analg. 2014;118(5):1113–1119.
    1. Abdallah FW, Johnson J, Chan V, et al. Intravenous dexamethasone and perineural dexamethasone similarly prolong the duration of analgesia after supraclavicular brachial plexus block: a randomized, triple-arm, double-blind, placebo-controlled trial. Reg Anesth Pain Med. 2015;40(2):125–132.
    1. Rosenfeld DM, Ivancic MG, Hattrup SJ, et al. Perineural versus intra-venous dexamethasone as adjuncts to local anaesthetic brachial plexus block for shoulder surgery. Anaesthesia. 2016;71(4):380–388.
    1. Chun EH, Kim YJ, Woo JH. Which is your choice for prolonging the analgesic duration of single-shot interscalene brachial blocks for arthroscopic shoulder surgery? Intravenous dexamethasone 5 mg vs. perineural dexamethasone 5 mg randomized, controlled, clinical trial. Medicine (Baltimore) 2016;95(23):e3828.
    1. Aliste J, Leurcharusmee P, Engsusophon P, et al. A randomized comparison between intravenous and perineural dexamethasone for ultrasound-guided axillary block. Can J Anaesth. 2017;64(1):29–36.
    1. Dawson RL, McLeod DH, Koerber JP, Plummer JL, Dracopoulos GC. A randomised controlled trial of perineural vs intravenous dexamethasone for foot surgery. Anaesthesia. 2016;71(3):285–290.
    1. Leurcharusmee P, Aliste J, Van Zundert TC, et al. A multicenter randomized comparison between intravenous and perineural dexamethasone for ultrasound-guided infraclavicular block. Reg Anesth Pain Med. 2016;41(3):328–333.
    1. Chun EH, Kim YJ, Woo JH. Which is your choice for prolonging the analgesic duration of single-shot interscalene brachial blocks for arthroscopic shoulder surgery? Intravenous dexamethasone 5 mg vs. perineural dexamethasone 5 mg randomized, controlled, clinical trial. Medicine (Baltimore) 2016;95(23):e3828.
    1. Miller RD. Miller’s Anesthesia. 7th ed. Philadelphia: Churchill Livingstone; 2009.
    1. Candido KD, Knezevic NN. All adjuvants to local anesthetics were not created equal: animal data evaluating neurotoxicity, thermal hyperalgesia, and relevance to human application. Reg Anesth Pain Med. 2011;36(3):211–212.
    1. Kirksey MA, Haskins SC, Cheng J, Liu SS. Local anesthetic peripheral nerve block adjuvants for prolongation of analgesia: a systematic qualitative review. PloS One. 2015;10(9):e0137312.
    1. Arulkumar S, Elnagar I, Hamilton C, Fox C. Dexamethasone as an adjunct for brachial plexus blockade: meta-analysis. 2014. [Accessed June 13, 2017]. Available from: .
    1. Huynh TM, Marret E, Bonnet F. Combination of dexamethasone and local anaesthetic solution in peripheral nerve blocks: A meta-analysis of randomised controlled trials. Eur J Anaesthesiol. 2015;32(11):751–758.
    1. Choi S, Rodseth R, McCartney CJ. Effects of dexamethasone as a local anaesthetic adjuvant for brachial plexus block: a systematic review and meta-analysis of randomized trials. Br J Anaesth. 2014;112(3):427–439.
    1. De Oliveira GS, Jr, Almeida MD, Benzon HT, McCarthy RJ. Perioperative single dose systemic dexamethasone for postoperative pain: a meta-analysis of randomized controlled trials. Anesthesiology. 2011;115(3):575–588.
    1. Lee S, Choi S. Intravenous and perineural dexamethasone in peripheral nerve block: are they truly equivalent? Anesth Analg. 2015;121(1):251.
    1. Sondekoppam RV, Uppal V, Ganapathy S. Intravenous or perineural dexamethasone for interscalene brachial plexus block: the equivalence not yet proven. Br J Anaesth. 2014;112(1):175–176.
    1. Tighe SQ. Perineural or intravenous dexamethasone: do we still need catheters? Anaesthesia. 2016;71(8):983–984.
    1. Bolin ED, Wilson S. Perineural versus systemic dexamethasone: questions remain unanswered. Reg Anesth Pain Med. 2015;40(4):393–394.
    1. Albrecht E, Kern C, Kirkham KR. Perineural vs intravenous administration of dexamethasone: more data are available. Br J Anaesth. 2015;114(1):160.
    1. Hozo SP, Djulbegovic B, Hozo I. Estimating the mean and variance from the median, range, and the size of a sample. BMC Med Res Methodol. 2005;5:13.
    1. Abdelmonem A, Rizk SN. Comparative study between intravenous and local dexamethasone as adjuvant to bupivacaine in perianal block. Egypt J Anaesth. 2011;27(3):163–168.
    1. Desmet M, Braems H, Reynvoet M, et al. I.V. and perineural dexamethasone are equivalent in increasing the analgesic duration of a single-shot interscalene block with ropivacaine for shoulder surgery: a prospective, randomized, placebo-controlled study. Br J Anaesth. 2013;111(3):445–452.
    1. Kawanishi R, Yamamoto K, Tobetto Y, et al. Perineural but not systemic low-dose dexamethasone prolongs the duration of interscalene block with ropivacaine: a prospective randomized trial. Local Reg Anesth. 2014;7:5–9.
    1. Rahangdale R, Kendall MC, McCarthy RJ, et al. The effects of perineural versus intravenous dexamethasone on sciatic nerve blockade outcomes: a randomized, double-blind, placebo-controlled study. Anesth Analg. 2014;118(5):1113–1119.
    1. Abdallah FW, Johnson J, Chan V, et al. Intravenous dexamethasone and perineural dexamethasone similarly prolong the duration of analgesia after supraclavicular brachial plexus block: a randomized, triple-arm, double-blind, placebo-controlled trial. Reg Anesth Pain Med. 2015;40(2):125–132.
    1. Chun EH, Kim YJ, Woo JH. Which is your choice for prolonging the analgesic duration of single-shot interscalene brachial blocks for arthroscopic shoulder surgery? Intravenous dexamethasone 5 mg vs. perineural dexamethasone 5 mg randomized, controlled, clinical trial. Medicine (Baltimore) 2016;95(23):e3828.
    1. Dawson RL, McLeod DH, Koerber JP, Plummer JL, Dracopoulos GC. A randomised controlled trial of perineural vs intravenous dexamethasone for foot surgery. Anaesthesia. 2016;71(3):285–290.
    1. Leurcharusmee P, Aliste J, Van Zundert TC, et al. A multicenter randomized comparison between intravenous and perineural dexamethasone for ultrasound-guided infraclavicular block. Reg Anesth Pain Med. 2016;41(3):328–333.
    1. Rosenfeld DM, Ivancic MG, Hattrup SJ, et al. Perineural versus intravenous dexamethasone as adjuncts to local anaesthetic brachial plexus block for shoulder surgery. Anaesthesia. 2016;71(4):380–388.
    1. Aliste J, Leurcharusmee P, Engsusophon P, et al. A randomized comparison between intravenous and perineural dexamethasone for ultrasound-guided axillary block. Can J Anaesth. 2017;64(1):29–36.
    1. Morales-Muñoz C, Sánchez-Ramos JL, Diaz-Lara MD, González-González J, Gallego-Alonso I, Hernández-del-Castillo MS. Analgesic effect of a single-dose of perineural dexamethasone on ultrasound-guided femoral nerve block after total knee replacement. Rev Esp Anestesiol Reanim. 2017;64(1):19–26.
    1. Rücker G, Carpenter JR, Schwarzer G. Detecting and adjusting for small-study effects in meta-analysis. Biom J. 2011;53(2):351–368.
    1. Niemi G, Breivik H. Adrenaline markedly improves thoracic epidural analgesia produced by a low-dose infusion of bupivacaine, fentanyl and adrenaline after major surgery: a randomised, double-blind, crossover study with and without adrenaline. Acta Anaesthesiol Scand. 1998;42(8):897–909.
    1. Sakaguchi Y, Sakura S, Shinzawa M, Saito Y. Does adrenaline improve epidural bupivacaine and fentanyl analgesia after abdominal surgery? Anaesth Intensive Care. 2000;28(5):522–526.
    1. Boussofara M, Carles M, Raucoules-Aime M, Sellam MR, Horn JL. Effects of intrathecal midazolam on postoperative analgesia when added to a bupivacaine-clonidine mixture. Reg Anesth Pain Med. 2006;31(6):501–505.
    1. Kazemeini A, Rahimi M, Fazeli MS, et al. The effect of local injections of bupivacaine plus ketamine, bupivacaine alone, and placebo on reducing postoperative anal fistula pain: a randomized clinical trial. ScientificWorldJournal. 2014;2014:424152.
    1. Trifa M, Engelhardt T, Khalifa SB. The addition of clonidine to bupivacaine in saphenous/sciatic nerve blocks in children. Paediatr Anaesth. 2016;26(3):321–322.
    1. Xiang Q, Huang DY, Zhao YL, et al. Caudal dexmedetomidine combined with bupivacaine inhibit the response to hernial sac traction in children undergoing inguinal hernia repair. Br J Anaesth. 2013;110(3):420–424.
    1. Martinez V, Fletcher D. Dexamethasone and peripheral nerve blocks: on the nerve or intravenous? Br J Anaesth. 2014;113(3):338–340.
    1. Yilmaz-Rastoder E, Gold MS, Hough KA, Gebhart GF, Williams BA. Effect of adjuvant drugs on the action of local anesthetics in isolated rat sciatic nerves. Reg Anesth Pain Med. 2012;37(4):403–409.
    1. Buvanendran A, Kroin JS, Li J, Moric M, Tuman KJ. Relative contribution of adjuvants to local anesthetic for prolonging the duration of peripheral nerve blocks in rats. Reg Anesth Pain Med. 2016;41(5):589–592.
    1. An K, Elkassabany NM, Liu J. Dexamethasone as adjuvant to bupivacaine prolongs the duration of thermal antinociception and prevents bupivacaine-induced rebound hyperalgesia via regional mechanism in a mouse sciatic nerve block model. PloS One. 2015;10(4):e0123459.
    1. Barnes PJ. Anti-inflammatory actions of glucocorticoids: molecular mechanisms. Clin Sci (Lond) 1998;94(6):557–572.
    1. Williams BA, Hough KA, Tsui BY, Ibinson JW, Gold MS, Gebhart GF. Neurotoxicity of adjuvants used in perineural anesthesia and analgesia in comparison with ropivacaine. Reg Anesth Pain Med. 2011;36(3):225–230.
    1. Watkins TW, Dupre S, Coucher JR. Ropivacaine and dexamethasone: a potentially dangerous combination for therapeutic pain injections. J Med Imaging Radiat Oncol. 2015;59(5):571–577.
    1. Hwang H, Park J, Lee WK, et al. Crystallization of local anesthetics when mixed with corticosteroid solutions. Ann Rehabil Med. 2016;40(1):21–27.
    1. Awad K, Ahmed H, Abushouk AI, et al. Dexamethasone combined with other antiemetics versus single antiemetics for prevention of postoperative nausea and vomiting after laparoscopic cholecystectomy: an updated systematic review and meta-analysis. Int J Surg. 2016;36(Pt A):152–163.
    1. Albrecht E, Kern C, Kirkham KR. A systematic review and meta-analysis of perineural dexamethasone for peripheral nerve blocks. Anaesthesia. 2015;70(1):71–83.

Source: PubMed

Sponsors et collaborateurs

Les conditions médicales

Interventions en matière de drogue

3
S'abonner