Analgesic effect of intravenous dexamethasone after volar plate surgery for distal radius fracture with brachial plexus block anaesthesia: a prospective, double-blind randomised clinical trial

A Holmberg, S S Hassellund, T Draegni, A Nordby, F S Ottesen, A Gulestøl, J Raeder, A Holmberg, S S Hassellund, T Draegni, A Nordby, F S Ottesen, A Gulestøl, J Raeder

Abstract

Rebound pain after brachial plexus block resolution and development of long-lasting pain are problems associated with volar plate fixation for distal radius fractures. The aim of this double-blind study was to evaluate the effect of a single prophylactic intravenous dose of dexamethasone in this setting. The primary endpoint was highest pain score during the first 24 hours after surgery. We included 51 adults of ASA physical status 1-2 due to undergo planned acute fixation of the radius. All received premedication with oral paracetamol and etoricoxib, and a pre-operative brachial plexus block with ropivacaine. Patients were randomly allocated into two groups: a dexamethasone group receiving 16 mg dexamethasone intravenously at start of surgery and a control group receiving 4 ml saline. After surgery, all patients received fixed doses of paracetamol, etoricoxib and oxycodone, with further oxycodone added as needed in the first 48 hours. Pain, analgesic consumption and daily function were registered at predefined times up to 1 year after surgery. Median (IQR [range]) worst pain score in the first 24 hours, as assessed by verbal numeric rating scale (0-10), was 4 (2-6 [0-7]) in the dexamethasone group compared with 8 (5-8 [2-10]) in the placebo group (p < 0.001). Average pain score, 2 (1-4 [0-5]) vs. 5 (3-6 [0-8]), p = 0.001 and rescue oxycodone consumption, 5 (0-10 [0-35]) mg vs. 10 (5-15 [0-50]) mg, p = 0.037), respectively, were both significantly lower in the dexamethasone group compared with control from 8 to 24 hours. Brachial plexus block duration was 69% longer in the dexamethasone group, 21.5 (19.1-23.4 [12.9-24.1]) hours vs. 12.7 (11.9-15.3 [7.4-26.6]) hours, p < 0.001. Two patients (9%) in the dexamethasone group compared with 12 (50%) in the placebo group experienced worst pain scores of 8-10 during the first 36 hours (p = 0.002). At 3 and 7 days postoperatively, there were no significant differences between groups for pain scores or opioid consumption. At 6 months, 27 patients (57%) reported pain at the site of surgery, with significantly higher average pain score (p = 0.024) in the placebo group. At 1 year, two patients in the dexamethasone group reported pain compared with 10 in the placebo group (p = 0.015), and worst pain score was significantly higher in the placebo group (p = 0.018). We conclude that intravenous dexamethasone improves early postoperative analgesia and may also improve clinical outcomes after 6 and 12 months.

Trial registration: ClinicalTrials.gov NCT03011905.

Keywords: brachial plexus block; dexamethasone; distal radius fractures; infraclavicular block; rebound pain.

© 2020 Association of Anaesthetists.

References

    1. Galos DK, Taormina DP, Crespo A, et al. Does Brachial plexus blockade result in improved pain scores after distal radius fracture fixation? a randomized trial. Clinical Orthopaedics and Related Research 2016; 474: 1247-54.
    1. Egol KA, Soojian MG, Walsh M, Katz J, Rosenberg AD, Paksima N. Regional anesthesia improves outcome after distal radius fracture fixation over general anesthesia. Journal of Orthopaedic Trauma 2012; 26: 545-9.
    1. Williams BA, Bottegal MT, Kentor ML, Irrgang JJ, Williams JP. Rebound pain scores as a function of femoral nerve block duration after anterior cruciate ligament reconstruction: retrospective analysis of a prospective, randomized clinical trial. Regional Anesthesia and Pain Medicine 2007; 32: 186-92.
    1. Goldstein RY, Montero N, Jain SK, Egol KA, Tejwani NC. Efficacy of popliteal block in postoperative pain control after ankle fracture fixation: a prospective randomized study. Journal of Orthopaedic Trauma 2012; 26: 557-61.
    1. DeMarco JR, Componovo R, Barfield WR, Liles L, Nietert P. Efficacy of augmenting a subacromial continuous-infusion pump with a preoperative interscalene block in outpatient arthroscopic shoulder surgery: a prospective, randomized, blinded, and placebo-controlled study. Arthroscopy 2011; 27: 603-10.
    1. Sunderland S, Yarnold CH, Head SJ, et al. Regional versus general anesthesia and the incidence of unplanned health care resource utilization for postoperative pain after wrist fracture surgery results from a retrospective quality improvement project. Regional Anesthesia and Pain Medicine 2016; 41: 22-7.
    1. Lavand'homme P. Rebound pain after regional anesthesia in the ambulatory patient. Current Opinion in Anaesthesiology 2018; 31: 679-84.
    1. Holmberg A, Sauter AR, Klaastad O, Draegni T, Raeder JC. Pre-operative brachial plexus block compared with an identical block performed at the end of surgery: a prospective, double-blind, randomised clinical trial. Anaesthesia 2017; 72: 967-77.
    1. Desmet M, Braems H, Reynvoet M, et al. 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. British Journal of Anaesthesia 2013; 111: 445-52.
    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: e0137312.
    1. Schnepper GD, Kightlinger BI, Jiang Y, Wolf BJ, Bolin ED, Wilson SH. A retrospective study evaluating the effect of low doses of perineural dexamethasone on ropivacaine brachial plexus peripheral nerve block analgesic duration. Pain Medicine 2018; 19: 1485-93.
    1. Baeriswyl M, Kirkham KR, Jacot-Guillarmod A, Albrecht E. Efficacy of perineural vs systemic dexamethasone to prolong analgesia after peripheral nerve block: a systematic review and meta-analysis. British Journal of Anaesthesia 2017; 119: 183-91.
    1. Clarke R, Derry S, Moore RA. Single dose oral etoricoxib for acute postoperative pain in adults. Cochrane Database of Systematic Reviews 2014; (5): CD004309.
    1. Shahraki A, Feizi A, Jabalameli M, Nouri S. The effect of intravenous Dexamethasone on post-cesarean section pain and vital signs: a double-blind randomized clinical trial. Journal of Research in Pharmacy Practice 2013; 2: 99-104.
    1. De Oliveira GS, Almeida MD, Benzon HT, McCarthy RJ. Perioperative single dose systemic dexamethasone for postoperative pain: a meta-analysis of randomized controlled trials. Anesthesiology 2011; 115: 575-88.
    1. Hval K, Thagaard KS, Schlichting E, Raeder J. The prolonged postoperative analgesic effect when dexamethasone is added to a nonsteroidal antiinflammatory drug (rofecoxib) before breast surgery. Anesthesia and Analgesia 2008; 106: 958.
    1. Sauter AR, Dodgson MS, Stubhaug A, Halstensen AM, Klaastad O. Electrical nerve stimulation or ultrasound guidance for lateral sagittal infraclavicular blocks: a randomized, controlled, observer-blinded, comparative study. Anesthesia and Analgesia 2008; 106: 1910-5.
    1. Sauter AR, Smith HJ, Stubhaug A, Dodgson MS, Klaastad O. Use of magnetic resonance imaging to define the anatomical location closest to all three cords of the infraclavicular brachial plexus. Anesthesia and Analgesia 2006; 103: 1574-6.
    1. Schnider TW, Minto CF, Shafer SL, et al. The influence of age on propofol pharmacodynamics. Anesthesiology 1999; 90: 1502-16.
    1. Raeder JC, Drosdahl S, Klaastad O, et al. Axillary brachial plexus block with ropivacaine 7.5 mg/ml - a comparative study with bupivacaine 5 mg/ml. Acta Anaesthesiologica Scandinavica 1999; 43: 794-8.
    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: 380-8.
    1. Woo JH, Kim YJ, Kim DY, Cho S. Dose-dependency of dexamethasone on the analgesic effect of interscalene block for arthroscopic shoulder surgery using ropivacaine 0.5%: a randomised controlled trial. European Journal of Anaesthesiology 2015; 32: 650-5.
    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 2016; 95: e3828.
    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 Regional Anesthesia 2014; 7: 5-9.
    1. Hewson D, Bedforth N, McCartney C, Hardman J. Dexamethasone and peripheral nerve blocks: back to basic (science). British Journal of Anaesthesia 2019; 122: 411-2.
    1. Auyong DB, Cantor DA, Green C, Hanson NA. The effect of fixation technique on continuous interscalene nerve block catheter success: a randomized, double-blind trial. Anesthesia and Analgesia 2017; 124: 959-65.
    1. Cruz FF, Rocco PR, Pelosi P. Anti-inflammatory properties of anesthetic agents. Critical Care 2017; 21: 67.
    1. Perniola A, Magnuson A, Axelsson K, Gupta A. Intraperitoneal local anesthetics have predominant local analgesic effect: a randomized, double-blind study. Anesthesiology 2014; 121: 352-61.
    1. DeGeorge BR Jr, Van Houten HK, Mwangi R, Sangaralingham LR, Larson AN, Kakar S. Outcomes and complications in the management of distal radial fractures in the elderly. Journal of Bone and Joint Surgery 2020; 102(1): 37-44.
    1. McCartney CJ, Brull R, Chan VW, et al. Early but no long-term benefit of regional compared with general anesthesia for ambulatory hand surgery. Anesthesiology 2004; 101: 461-7.
    1. Lei Y, Huang Q, Xu B, Zhang S, Cao G, Pei F. Multiple low-dose dexamethasone further improves clinical outcomes following total hip arthroplasty. Journal of Arthroplasty 2018; 33: 1426-31.
    1. Paiva-Oliveira JG, Bastos PR, Cury Pontes ER, da Silva JC, Delgado JA, Oshiro-Filho NT. Comparison of the anti-inflammatory effect of dexamethasone and ketorolac in the extractions of third molars. Oral and Maxillofacial Surgery 2016; 20: 123-33.
    1. Ruau D, Liu LY, Clark JD, Angst MS, Butte AJ. Sex differences in reported pain across 11,000 patients captured in electronic medical records. Journal of Pain 2012; 13: 228-34.
    1. Quartana PJ, Campbell CM, Edwards RR. Pain catastrophizing: a critical review. Expert Review of Neurotherapeutics 2009; 9: 745-58.
    1. Vuorinen MA, Palanne RA, Makinen TJ, Leskinen JT, Huhtala H, Huotari KA. Infection safety of dexamethasone in total hip and total knee arthroplasty: a study of eighteen thousand, eight hundred and seventy two operations. International Orthopaedics 2019; 43: 1787-92.

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