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Berger AA, Syed Z, Ryan L, Lee C, Hasoon J, Urits I, Viswanath O, Cornett EM, Kaye AD, Eskander JP. Superior Block Length and Reduced Opioid Use with Dexmedetomidine and Dexamethasone regional block versus plain Ropivacaine: a retrospective trial. Orthop Rev (Pavia) 2022; 14:31921. [DOI: 10.52965/001c.31921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Amnon A Berger
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Zuby Syed
- Georgetown University School of Medicine, Washington DC
| | | | - Christopher Lee
- Creighton University School Of Medicine—Phoenix Regional Campus, Phoenix, AZ
| | - Jamal Hasoon
- Baylor College of Medicine, Department of Anesthesiology, Houston, TX
| | - Ivan Urits
- Louisiana State University Health Shreveport, Shreveport, LA
| | - Omar Viswanath
- Louisiana State University Health Shreveport, Shreveport, LA
| | - Elyse M Cornett
- Louisiana State University Health Shreveport, Shreveport, LA
| | - Alan D Kaye
- Louisiana State University Health Shreveport, Shreveport, LA
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Zhang JP, Zhang N, Chen X, Zhou Y, Jiang Z, Gao C, Xie YH, Wang S, Zhang W. Efficacy of dexmedetomidine as an adjunct to ropivacaine in bilateral dual-transversus abdominis plane blocks in patients with ovarian cancer who underwent cytoreductive surgery. BMC Anesthesiol 2022; 22:20. [PMID: 35021994 PMCID: PMC8753880 DOI: 10.1186/s12871-021-01542-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 12/08/2021] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE We sought to evaluate the postoperative control of pain and recovery in patients with ovarian cancer who underwent cytoreductive surgery by adding dexmedetomidine to ropivacaine in bilateral dual-transversus abdominis plane (Bd-TAP) blocks. METHODS We enrolled 90 patients with an American Society of Anesthesiologists physical status I to III undergoing open abdominal cytoreductive surgery in this study. Patients were randomized and assigned into three groups (TAP-R, TAP-DR, or CON) of 30 participants each. All of the patients received standardized general anesthesia, and postoperative Bd-TAP blocks were performed. The TAP-R, TAP-DR, and CON groups received Bd-TAP blocks with 0.3% ropivacaine, 0.3% ropivacaine and 0.5 μg/kg of dexmedetomidine, and 0.9% normal saline, respectively. All of the patients received patient-controlled analgesia (PCA) (formula, 100 μg of sufentanil and 16 mg of ondansetron diluted with normal saline to 100 mL). Flurbiprofen axetil was used as a rescue drug if the visual analog scale (VAS) score was more than four points. The first request time for PCA bolus; the VAS scores at 0, 6, 12, 24, and 48 h after operation; and the cumulative sufentanil consumption within 24 and 48 h, respectively, were compared. Pulmonary function was evaluated preoperatively and at 24 h after the operation. The use of the rescue drug was recorded. Postoperative functional recovery, including time to stand, time to walk, time to return of bowel function, time to readiness for discharge, and postoperative complications, were recorded. RESULTS Median values of the first request time for PCA of the TAP-R group was significantly prolonged compared to that of the CON group (median [interquartile range], 7.3 [6.5-8.0] hours vs. 3.0 [2.3-3.5] hours) (P < .001), while the TAP-DR group has the longest request time among the three groups (median [interquartile range], 13.5 [12.4-14.5] hours) (P < .001). The VAS scores at rest and upon coughing of the TAP-R group in the first 12 h were significantly lower than those of the CON group (P < 0.05), but showed no significant difference compared to those of the TAP-DR group. The VAS scores at rest and upon coughing were lower in the TAP-DR group at each time point compared to those of the CON group (P < .05). The cumulative sufentanil consumption in the TAP-DR group was significantly lower at 48 h (P = .04) after surgery than in the CON group, while there was no significant difference compared to that in the TAP-R group (P > .05). Less rescue analgesic was required by patients in the TAP-DR group than in the CON group (P < .05). Postoperative mean measured forced expiratory volume in 1 s (FEV1) and FEV1/forced vital capacity values in the TAP-DR group were significantly higher than those of the CON group (P = .009), while there was no significant difference compared to those of the TAP-R group (P = .10). There was no significantly difference in postoperative functional recovery between TAP-DR and CON group (P > 0.05). CONCLUSION TAP blocks can provide effective pain relief up to 12 h postoperatively without a significant improvement in postoperative pulmonary function. The addition of dexmedetomidine to ropivacaine for Bd-TAP block prolonged the first bolus time of PCA when compared to that in the TAP-R group and decreased sufentanil consumption and the need of rescue analgesia relative to in the CON group at 48 h postoperative. The procedure provided better postoperative analgesia and improved postoperative pulmonary function relative to the CON group. Our results indicate that dexmedetomidine as an adjuvant of Bd-TAP can provide effective pain relief up to 48 h.
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Affiliation(s)
- Jian-Ping Zhang
- Department of Anesthesiology, Pain Clinic, First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, 230001, Anhui, China
| | - Na Zhang
- Department of Anesthesiology, Pain Clinic, First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, 230001, Anhui, China
| | - Xu Chen
- Department of Anesthesiology, Pain Clinic, First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, 230001, Anhui, China
| | - Yin Zhou
- Department of Obstetrics and Gynaecology, First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, 230001, Anhui, China
| | - Zhen Jiang
- Department of Anesthesiology, Pain Clinic, First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, 230001, Anhui, China
| | - Chen Gao
- Department of Anesthesiology, Pain Clinic, First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, 230001, Anhui, China
| | - Yan-Hu Xie
- Department of Anesthesiology, Pain Clinic, First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, 230001, Anhui, China
| | - Sheng Wang
- Department of Anesthesiology, Pain Clinic, First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, 230001, Anhui, China
| | - Wei Zhang
- Department of Anesthesiology, Pain Clinic, First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, 230001, Anhui, China.
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Southerland WA, Gillis J, Urits I, Kaye AD, Eskander J. Intraoperative Administration of Dexmedetomidine and Dexamethasone in Local Anesthetic Infiltration to Improve Postoperative Pain Control After Posterior Cervical Fusion. Cureus 2021; 13:e14699. [PMID: 34055542 PMCID: PMC8153515 DOI: 10.7759/cureus.14699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Dexmedetomidine, a selective and potent α2-adrenoceptor agonist, is used for its anxiolytic, sedative, and analgesic properties. Dexamethasone is a high-potency, long-acting glucocorticoid that has been shown to provide analgesic and anti-inflammatory effects. At present, little has been published with regard to the effectiveness of these drugs as dual agents with local anesthetics for analgesia. In this report, a case of a 50-year-old man who underwent a cervical spine orthopedic procedure is described, in which an intraoperative injection of ropivacaine was administered with the adjuvants dexmedetomidine and dexamethasone, providing extended postoperative pain relief. In summary, we present a patient who had an injection of ropivacaine with dexmedetomidine and dexamethasone into the erector spinae muscles in the cervical region, which provided improvement in postoperative pain and reduced opioid consumption for five days post-surgery, demonstrating additive and/or synergistic effects beyond the normal local anesthetic duration.
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Affiliation(s)
- Warren A Southerland
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | - Justin Gillis
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | - Ivan Urits
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | - Alan D Kaye
- Department of Anesthesiology, Louisiana State University Shreveport, Shreveport, USA
| | - Jonathan Eskander
- Anesthesiology and Pain Medicine, Portsmouth Anesthesia Associates, Portsmouth, USA
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Ma H, Wachtendorf LJ, Santer P, Schaefer MS, Friedrich S, Nabel S, Ramachandran SK, Shen C, Sundar E, Eikermann M. The effect of intraoperative dexmedetomidine administration on length of stay in the post-anesthesia care unit in ambulatory surgery: A hospital registry study. J Clin Anesth 2021; 72:110284. [PMID: 33831766 DOI: 10.1016/j.jclinane.2021.110284] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Revised: 03/13/2021] [Accepted: 03/14/2021] [Indexed: 12/30/2022]
Abstract
STUDY OBJECTIVE Dexmedetomidine, which is commonly used for procedural sedation and as adjunct to general anesthesia for ambulatory procedures, may affect patient discharge from the post-anesthesia care unit (PACU). We hypothesized that intraoperative dexmedetomidine use in ambulatory surgery is associated with delayed discharge from the PACU and that this is modified by surgical duration and anesthesia type. DESIGN Retrospective cohort study. SETTING Academic medical center. PATIENTS 130,854 adult patients undergoing ambulatory surgery between 2008 and 2018. INTERVENTIONS Intraoperative administration of dexmedetomidine. MEASUREMENTS The primary outcome was PACU length of stay. In secondary and exploratory analyses, we examined dose-dependency, effect modification by duration of surgery and anesthesia type, effects of timing of dexmedetomidine administration, and PACU discharge delays. MAIN RESULTS Dexmedetomidine was associated with a prolonged PACU length of stay (adjusted absolute difference [ADadj] 15.0 min; 95%CI 12.7-17.3; p < 0.001). This effect was dose-dependent (p-for-trend < 0.001), magnified in surgeries of less than one hour (ADadj 20.7 min; 95%CI 16.7-24.7; p < 0.001) and in patients undergoing monitored anesthesia care compared to general anesthesia (ADadj 16.8 min; 95%CI 14.1-19.6; p < 0.001). The effect was more pronounced if dexmedetomidine was administered within the last 60 min of surgery (ADadj 18.7 min; 95%CI 15.7-21.7; p < 0.001). Dexmedetomidine was associated with discharge delays due to cardiovascular complications (ORadj 2.27; 95%CI 1.59-3.24; p < 0.001) and over-sedation (ORadj 1.28; 95%CI 1.11-1.48; p < 0.001). In patients who received dexmedetomidine (n = 2901), the use of bolus doses only versus the combination of bolus and infusions, magnified the effects on PACU length of stay (ADadj 29.5 min per μg/kg; 95%CI 17.3-41.8 versus 18.1 min per μg/kg; 95%CI 11.4-24.8; p < 0.001). CONCLUSIONS The intraoperative administration of dexmedetomidine was dose-dependently associated with a prolonged PACU length of stay. Clinicians should judiciously titrate dexmedetomidine, especially when using this long-acting drug for monitored anesthesia care for shorter procedures.
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Affiliation(s)
- Haobo Ma
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
| | - Luca J Wachtendorf
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
| | - Peter Santer
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
| | - Maximilian S Schaefer
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Department of Anesthesia, Duesseldorf University Hospital, Duesseldorf, Germany.
| | - Sabine Friedrich
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Sarah Nabel
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
| | - Satya Krishna Ramachandran
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
| | - Changyu Shen
- Medical Data Science and Analytics, Biogen Inc, Cambridge, MA, USA.
| | - Eswar Sundar
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
| | - Matthias Eikermann
- Klinik für Anästhesiologie und Intensivmedizin, Universität Duisburg-Essen, Essen, Germany; Department of Anesthesiology, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, USA.
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Synergistic Effects of Dexamethasone and Dexmedetomidine in Extending the Effects of Pectoral I and Pectoral II Blocks for Postoperative Analgesia Following Total Mastectomy with Lymph Node Dissection. Clin Pract 2021; 11:190-192. [PMID: 33808063 PMCID: PMC8103239 DOI: 10.3390/clinpract11020027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 02/02/2021] [Accepted: 03/01/2021] [Indexed: 11/16/2022] Open
Abstract
Regional anesthesia is an important aspect of the overall anesthetic plan for patients. It has the potential to offer superior benefits compared to opioid-based treatment and is an important component of Enhanced Recovery after Surgery (ERAS) protocols. The use of the pectoral type I (PECS I) and pectoral type II blocks (PECS II) has been shown to reduce postoperative pain and opioid consumption in patients undergoing complete mastectomy and breast surgery. We describe the use of dexamethasone and dexmedetomidine to prolong the analgesic effects of these regional blocks in a patient undergoing total mastectomy with lymph node dissection.
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Berger AA, Urits I, Hasoon J, Kaye AD, Viswanath O, Eskander J. Pain Alleviation and Opioid Weaning in an 80-Year-Old with Chronic Foot Pain Following Injection Therapy with Perineural Dexmedetomidine and Dexamethasone. Surg J (N Y) 2021; 7:e1-e2. [PMID: 33437869 PMCID: PMC7790527 DOI: 10.1055/s-0040-1722176] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 09/22/2020] [Indexed: 12/03/2022] Open
Abstract
Opiates are routinely used for chronic pain patients, and up to 44% of them will have a prescription for an opiate medication for pain alleviation. However, of the 76 million adults prescribed opiates for pain management, about 12% report misuse, and a large number of these may find themselves addicted to opioid medications. Opioid addiction is an ongoing epidemic, costing many lives. Withdrawal is very difficult. This requires providers to consider alternative analgesic plans and minimize opiate use. Here we report the use of a dexamethasone-dexmedetomidine combination for a regional nerve block in an elderly woman chronically treated with opiate medications who had previously failed opiate weaning. Following her nerve block, she was able to completely wean off of opioids and continues having good pain control with an opioid-free regimen.
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Affiliation(s)
- Amnon A Berger
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Ivan Urits
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Jamal Hasoon
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Alan D Kaye
- Department of Anesthesiology, Louisiana State University Health Shreveport, Shreveport, Louisiana
| | - Omar Viswanath
- Valley Anesthesiology and Pain Consultants - Envision Physician Services, Phoenix, Arizona.,Department of Anesthesiology, University of Arizona College of Medicine - Phoenix, Phoenix, Arizona.,Department of Anesthesiology, Creighton University School of Medicine, Omaha, Nebraska
| | - Jonathan Eskander
- Anesthesiology and Pain Medicine, Portsmouth Anesthesia Associates, Portsmouth, Virginia
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Kassem H, Urits I, Viswanath O, Kaye AD, Eskander JP. Use of Dexmedetomidine With Dexamethasone for Extended Pain Relief in Adductor Canal/Popliteal Nerve Block During Achilles Tendon Repair. Cureus 2020; 12:e11917. [PMID: 33425503 PMCID: PMC7785491 DOI: 10.7759/cureus.11917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The use of regional anesthetic techniques in the peri-operative period has increased as a means to improve analgesia and patient outcomes. Traditionally, various local anesthetics are used and addition of adjuncts such as epinephrine, clonidine, and dexamethasone has shown to prolong the block effect. There has been ongoing research to support the prolongation of a regional block with the addition of dexamethasone and dexmedetomidine (Dex-Dex), providing analgesia for multiple days. We present a case of a 35-year-old female who underwent an Achilles tendon repair with an adductor/popliteal nerve block. Both dexmedetomidine and dexamethasone were added to the local anesthetic mixture with substantial postoperative analgesic control. The patient also did not require any supplemental opioid medication. This case emphasizes the proposed synergistic effect of dexmedetomidine and dexamethasone when added to the local anesthesia injectate for lower extremity peripheral nerve blocks.
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Affiliation(s)
- Hisham Kassem
- Anesthesiology and Perioperative Medicine, Mount Sinai Medical Center, Miami Beach, USA
| | - Ivan Urits
- Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | - Omar Viswanath
- Pain Management, Valley Anesthesiology and Pain Consultants, Phoenix, USA
| | - Alan D Kaye
- Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Jonathan P Eskander
- Anesthesiology and Pain Medicine, Portsmouth Anesthesia Associates, Portsmouth, USA
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Noor NA, Urits I, Viswanath O, Kaye AD, Eskander J. Fascia Iliaca Block Successfully Prolonged With Dexmedetomidine and Dexamethasone for Pain Control in a Patient Undergoing Total Hip Arthroplasty. Cureus 2020; 12:e10897. [PMID: 33194466 PMCID: PMC7654983 DOI: 10.7759/cureus.10897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Regional anesthesia has found many advocates as enhanced recovery after surgery continues to become a more popular option for procedures such as total hip arthroplasty. Among the many benefits is the better pain control with a reduction or complete elimination of the need for opioids for perioperative pain management. With aims to improve the multi-modal approach to pain management, we present a case demonstrating further improvements in the regional anesthetic technique with the addition of a dexamethasone and dexmedetomidine adjuvant to the local anesthetic injectate. Our case is that of a 65-year-old woman with a history of hypertension, hyperlipidemia, and right hip osteoarthritis undergoing a right total hip arthroplasty who received a preoperative ultrasound-guided fascia iliaca block with the adjuvants dexamethasone and dexmedetomidine added to the injectate. The surgery was uneventful. She did not require any postoperative opioid or non-opioid analgesics, denying any pain for the first three postoperative days.
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Affiliation(s)
- Nazir A Noor
- Anesthesiology and Critical Care, Mount Sinai Medical Center, Miami Beach, USA
| | - Ivan Urits
- Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA.,Anesthesiology, Louisiana State University Shreveport, Shreveport, USA
| | - Omar Viswanath
- Pain Management, Valley Pain Consultants, Phoenix, USA.,Anesthesiology, University of Arizona College of Medicine, Phoenix, USA.,Anesthesiology, Creighton University School of Medicine, Omaha, USA.,Anesthesiology, Louisiana State University Shreveport, Shreveport, USA
| | - Alan D Kaye
- Anesthesiology, Louisiana State University Shreveport, Shreveport, USA
| | - Jonathan Eskander
- Anesthesiology and Pain Medicine, Portsmouth Anesthesia Associates, Portsmouth, USA
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Noor NA, Urits I, Viswanath O, Kaye A, Eskander J. Synergistic Effect of Perineural Dexamethasone and Dexmedetomidine (Dex-Dex) Prolong Analgesic Effect of a Preoperative Interscalene Block. Cureus 2020; 12:e9473. [PMID: 32874802 PMCID: PMC7455378 DOI: 10.7759/cureus.9473] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
The brachial plexus is often a target of regional anesthesia for procedures involving the upper extremities. These include the supraclavicular, infraclavicular, interscalene, and axillary blocks. The cases we present involve the use of an ultrasound-guided interscalene block using 20 mL 0.2% ropivacaine with dexamethasone and 25 mcg dexmedetomidine as the injectate. This particular block technique has proven to be a very useful adjunct to the perioperative anesthetic care and enhanced recovery after surgery (ERAS) protocol for these patients. The series of cases we present include patients receiving the dexamethasone and dexmedetomidine (Dex-Dex) combination in their local anesthetic injectate for the ultrasound-guided interscalene block. Two of the patients underwent arthroscopic shoulder procedures and one underwent a shoulder total arthroplasty with biceps tenodesis. None of the patients required any postoperative opioids for analgesia. Though the technique is fairly new, with only a limited number of case studies described its efficacy, the understanding of the benefits of ERAS has helped it gain some traction in the field of regional anesthesia. Conduction of further large clinical trials is the next step in providing a better understanding of the Dex-Dex adjuvant method as it moves towards becoming a commonly used component of ERAS protocols in the perioperative period.
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Affiliation(s)
- Nazir A Noor
- Anesthesiology and Critical Care, Mount Sinai Medical Center, Miami Beach, USA
| | - Ivan Urits
- Anesthesiology, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, USA
| | - Omar Viswanath
- Pain Management, Valley Pain Consultants - Envision Physician Services, Phoenix, USA
| | - Alan Kaye
- Anesthesiology, Louisiana State University Shreveport, Shreveport, USA
| | - Jonathan Eskander
- Anesthesiology and Pain Medicine, Portsmouth Anesthesia Associates, Portsmouth, USA
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