Comparative evaluation of ropivacaine and ropivacaine with dexamethasone in supraclavicular brachial plexus block for postoperative analgesia

Santosh Kumar, Urmila Palaria, Ajay K Sinha, D C Punera, Vijita Pandey, Santosh Kumar, Urmila Palaria, Ajay K Sinha, D C Punera, Vijita Pandey

Abstract

Background: Mixing of various adjuvants has been tried with local anesthetics in an attempt to prolong anesthesia from peripheral nerve blocks but have met with inconclusive success. More recent studies indicate that 8 mg dexamethasone added to perineural local anesthetic injections augment the duration of peripheral nerve block analgesia.

Aims: Evaluating the hypothesis that adding dexamethasone to ropivacaine significantly prolongs the duration of analgesia in supraclavicular brachial plexus block compared with ropivacaine alone.

Patients and methods: It was a randomized, prospective, and double-blind clinical trial. Eighty patients of ASA I and II of either sex, aged 16-60 years, undergoing elective upper limb surgeries were equally divided into two groups and given supraclavicular nerve block. Group R patients (n = 40) received 30 ml of 0.5% ropivacaine with distilled water (2 ml)-control group whereas Group D patients (n = 40) received 30 ml of 0.5% ropivacaine with 8 mg dexamethasone (2 ml)-study group. The primary outcome was measured as duration of analgesia that was defined as the interval between the onset of sensory block and the first request for analgesia by the patient. The secondary outcome included maximum visual analogue scale (VAS), total analgesia consumption, surgeon satisfaction, and side effects.

Results: Group R patients required first rescue analgesia earlier (557 ± 58.99 min) than those of Group D patients (1179.4 ± 108.60 min), which was found statistically significant in Group D (P < 0.000). The total dose of rescue analgesia was higher in Group R as compared to Group D, which was statistically significant (P < 0.00).

Conclusion: Addition of dexamethasone (8 mg) to ropivacaine in supraclavicular brachial plexus approach significantly and safely prolongs motor blockade and postoperative analgesia (sensory) that lasted much longer than that produced by local anesthetic alone.

Keywords: Adjuvants; analgesia; dexamethasone; local anesthetics; peripheral nerve blocks.

Conflict of interest statement

Conflict of Interest: None declared.

Figures

Figure 1
Figure 1
Total duration of sensory (analgesia) – motor blockade between two study groups
Figure 2
Figure 2
Visual analog scale for the monitoring and intervention of postoperative analgesia in group D patients
Figure 3
Figure 3
Visual analog scale for the monitoring and intervention of postoperative analgesia in group R patients

References

    1. McCartney CJ, Brull R, Chan VW, Katz J, Abbas S, Graham B, et al. Early but no long-term benefit of regional compared with general anesthesia for ambulatory hand surgery. Anesthesiology. 2004;101:461–7.
    1. Kumar P, Raju BC, David CM. Ultrasound-guided brachial plexus block continuing education in anesthesia. [Last accessed on 2014 Mar 06];Critical Care and Pain Advence Access Published. 2013 Dec 11;
    1. Hansen TG. Ropivacaine: A pharmacological review. Expert Rev Neurother. 2004;4:781–91.
    1. Rose JS, Neal JM, Kopacz DJ. Extended-duration analgesia: Update on microspheres and liposomes. Reg Anesth Pain Med. 2005;30:275–85.
    1. Andan T, Elif AA, Ayse K, Gulnaz A. Clonidine as an adjuvant for lidocaine in axillary brachial plexus block in patients with chronic renal failure. Acta Anaesthesiol Scand. 2005;49:563–8.
    1. Duma A, Urbanek B, Sitzwohl C, Zimpfer M, Kapral S. Clonidine as an adjuvant to local anaesthetic axillary brachial plexus block: A randomized, controlled study. Br J Anaesth. 2005;94:112–6.
    1. Karakaya D, Buyukgoz F, Baris S, Guldogus F, Tur A. Addition of fentanyl to bupivacaine prolongs anesthesia and analgesia in axillary brachial plexus block. Reg Anesth Pain Med. 2001;26:434–8.
    1. Fanelli G, Casati A, Magistris L, Berti M, Albertin A, Scarioni M, et al. Fentanyl does not improve the nerve block characteristics of axillary brachial plexus anesthesia performed with ropivacaine. Acta Anaesthesiol Scand. 2001;45:590–4.
    1. Clerc S, Vuillermier H, Frascarolo P, Spahn DR, Gardaz J. Is the effect of inguinal field block with 0.5% bupivacaine on postoperative pain after hernia repair enhanced by addition of ketorolac or S(+) ketamine? Clin J Pain. 2005;21:101–5.
    1. Noyan A. On effects of ketamine to axillary block in hand surgery. J Reconstr Microsurg. 2002;18:197.
    1. Jarbo K, Batra YK, Panda NB. Brachial plexus block with midazolam and bupivacaine improves analgesia. Can J Anaesth. 2005;52:822–6.
    1. Murphy DB, McCartney CJ, Chan VW. Novel analgesic adjuvants for brachial plexus block, a systemic review. Anesth Analg. 2000;90:1122–8.
    1. Neal JM, Gerancher JC, Hebel JR, Ilfeld BM, McCartney CJ, Franco CD, et al. Upper extremity regional anesthesia-essentials of our current understanding. Reg Anesth Pain Med. 2009;34:134–70.
    1. Colombo G, Padera R, Langer R, Kohane DS. Prolonged duration local anesthesia with lipid-protein-sugar particles containing bupivacaine and dexamethasone. J Biomed Mater Res A. 2005;75:458–64.
    1. Drager C, Benziger D, Gao F, Berde CB. Prolonged intercostal nerve blockade in sheep using controlled-release of bupivacaine and dexamethasone from polymer microspheres. Anesthesiology. 1998;89:969–79.
    1. Movafegh A, Razazian M, Hajimaohamadi F, Meysamie A. Dexamethasone added to lidocaine prolongs axillary brachial plexus blockade. Anesth Analg. 2006;102:263–7.
    1. Parrington SJ, O’Donnell D, Chan VW, Brown-Shreves D, Subramanyam R, Qu M, et al. Dexamethasone added to mepivacaine prolongs the duration of analgesia after supraclavicular brachial plexus blockade. Reg Anesth Pain Med. 2010;35:422–6.
    1. Shrestha BR, Maharjan SK, Tabedar S. Supraclavicular brachial plexus block with and without dexamethasone - A comparative study. Kathmandu Univ Med J. 2003;1:158–60.
    1. Vieira PA, Pulai I, Tsao GC, Manikantan P, Keller B, Connelly NR. Dexamethasone with bupivacaine increases duration of analgesia in ultrasound-guided interscalene brachial plexus blockade. Eur J Anaesthesiol. 2010;27:285–8.
    1. Cummings KC, 3rd, Napierkowski DE, Parra-Sanchez I, Kurz A, Dalton JE, Brems JJ, et al. Effect of dexamethasone on the duration of interscalene nerve blocks with ropivacaine or bupivacaine. Br J Anaesth. 2011;107:446–53.
    1. Pathak RG, Anand PS, Rajendra NK. Supraclavicular brachial plexus block with and without Dexamethasone – A Comparative Study. Int J Sci Res Publ. 2012;12:1–7.
    1. Yasuda I, Hirano T, Ojima T. Supraclavicular brachial plexus block using a nerve stimulator and an insulated needle. Br J Anaesth. 1980;52:409–11.
    1. Golwala M, Swadia V, Dhimar A, Sridahr N. Pain relief by dexamethasone as an adjuvant to local anaesthetics in supraclavicular brachial plexus block. J Anaesth Clin Pharmacol. 2009;25:285–8.
    1. Castillo J, Curley J, Hotz J, Uezono M, Tigner J, Chasin M, et al. Glucocorticoids prolong rat sciatic nerve blockade in vivo from bupivacaine microspheres. Anesthesiology. 1996;85:1157–66.
    1. Kopacz DJ, Lacouture PG, Wu D, Nandy P, Swanton R, Landau C. The dose response and effects of dexamethasone on bupivacaine microcapsules for intercostal blockade (T9 to T11) in healthy volunteers. Anesth Analg. 2003;96:576–82.
    1. McCormack K. The spinal actions of nonsteroidal anti-inflammatory drugs and the dissociation between their anti-inflammatory and analgesic effects. Drugs. 1994;47:28–45.
    1. Ahlgren SC, Wang JF, Levine JD. C-fiber mechanical stimulus response functions are different in inflammatory versus neuropathic hyperalgesia in the rat. Neuroscience. 1997;76:285–90.
    1. Honorio TB. Epidural Steroids: In P. Prithvi Raj. Pain medicine, a comprehensive review. Mosby publications. 1999:259–63.
    1. Attardi B, Takimoto K, Gealy R. Glucocorticoid induced upregulation of a pituitary K+ channel mRNA in vitro and in vivo. Receptors Channels. 1993;1:287–93.
    1. Tan PH, Liu K, Peng CH, Yang LC, Lin CR, Lu CY. The effect of dexamethasone on postoperative pain and emesis after intrathecal neostigmine. Anesth Analg. 2001;92:228–32.
    1. Splinter WM, Rhine EJ. Low-dose ondansetrone with dexamethasone more effectively decreases vomiting after strabismus surgery in children than does high-dose ondansetron. Anesthesiology. 1998;88:72–5.
    1. Neal JM, Rathmell JP, Rowlingson JC. Publishing studies that involve ‘Off-label’ use of drugs: Formalizing regional anesthesia and pain medicine's policy. Reg Anesth Pain Med. 2009;34:391–2.
    1. Benzon HT, Gissen AJ, Strichartz GR, Avram MJ, Covino BG. The effect of polyethylene glycol on mammalian nerve impulses. Anesth Analg. 1987;66:553–9.
    1. Benzon HT, Chew TL, McCarthy RJ, Benzon HA, Walega DR. Comparison of the particle sizes of different steroids and the effect of dilution: A review of the relative neurotoxicities of the steroids. Anesthesiology. 2007;106:331–8.
    1. Aasboe V, Raeder JC, Groegaard B. Betamethasone reduces postoperative pain and nausea after ambulatory surgery. Anesth Analg. 1998;87:913–7.
    1. Baxendale BR, Vater M, Lavery KM. Dexamethasone reduces pain and swelling following extraction of third molar teeth. Anaesthesia. 1993;48:961–4.
    1. Liu K, Hsu CC, Chia YY. Effect of dexamethasone on postoperative pain and emesis. Br J Anaesth. 1998;80:85–6.
    1. Pasternak JJ, McGregor DG, Lanier WL. Effect of single-dose dexamethasone on blood glucose concentration in patients undergoing craniotomy. J Neurosurg Anesthesiol. 2004;16:122–5.
    1. Moore D. Supraclavicular approach for block of the brachial plexus. In: Moore D, editor. Regional block. A handbook for use in the clinical practice of medicine and surgery. 4th ed. Springfield: Charles C Thomas Publisher; 1981. pp. 221–42.
    1. Lanz E, Theiss D, Jankovic D. The extent of blockade following various techniques of brachial plexus block. Anesth Analg. 1983;62:55–8.
    1. Urmey W. Upper extremity blocks. In: Brown D, editor. Regional anesthesia and analgesia. Philadelphia: WB Saunders Company; 1996. pp. 254–78.

Source: PubMed

Sponsorer og samarbeidspartnere

Medisinsk tilstand

Legemiddelintervensjoner

3
Abonnere