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Desai N, Pararajasingham S, Onwochei D, Albrecht E. Comparison of intravenous versus perineural dexamethasone as a local anaesthetic adjunct for peripheral nerve blocks in the lower limb: A meta-analysis and systematic review. Eur J Anaesthesiol 2024:00003643-990000000-00202. [PMID: 38988252 DOI: 10.1097/eja.0000000000002038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/12/2024]
Abstract
BACKGROUND As a local anaesthetic adjunct, the systemic absorption of perineural dexamethasone in the lower limb could be restricted because of decreased vascularity when compared with the upper limb. OBJECTIVES To compare the pharmacodynamic characteristics of intravenous and perineural dexamethasone in the lower limb. DESIGN Systematic review of randomised controlled trials with meta-analysis. DATA SOURCES Systematic search of Central, Google Scholar, Ovid Embase and Ovid Medline to 18 July 2023. ELIGIBILITY CRITERIA Randomised controlled trials, which compared the intravenous with perineural administration of dexamethasone as a local anaesthetic adjunct in peripheral nerve blocks for surgery of the lower limb. RESULTS The most common peripheral nerve blocks were femoral, sciatic and ankle block. The local anaesthetic was long acting in all trials and the dose of dexamethasone was 8 mg in most trials. The primary outcome, the duration of analgesia, was investigated by all nine trials (n = 546 patients). Overall, compared with intravenous dexamethasone, perineural dexamethasone increased the duration of analgesia from 19.54 to 22.27 h, a mean difference [95% confidence interval (CI) of 2.73 (1.07 to 4.38) h; P = 0.001, I2 = 87]. The quality of evidence was moderate owing to serious inconsistency. However, analysis based on the location of the peripheral nerve block, the type of local anaesthetic or the use of perineural adrenaline showed no difference in duration between intravenous and perineural dexamethasone. No differences were shown for any of the secondary outcomes related to efficacy and side effects. CONCLUSION In summary, moderate evidence supports the superiority of perineural dexamethasone over intravenous dexamethasone in prolonging the duration of analgesia. However, this difference is unlikely to be clinically relevant. Consideration of the perineural use of dexamethasone should recognise that this route of administration remains off label.
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Affiliation(s)
- Neel Desai
- From the Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom (ND, SP, DO) and Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland (EA)
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Albrecht E, Renard Y, Desai N. Intravenous versus perineural dexamethasone to prolong analgesia after interscalene brachial plexus block: a systematic review with meta-analysis and trial sequential analysis. Br J Anaesth 2024; 133:135-145. [PMID: 38782616 PMCID: PMC11213995 DOI: 10.1016/j.bja.2024.03.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 03/15/2024] [Accepted: 03/22/2024] [Indexed: 05/25/2024] Open
Abstract
BACKGROUND The efficacy of perineural vs intravenous dexamethasone as a local anaesthetic adjunct to increase duration of analgesia could be particular to specific peripheral nerve blocks because of differences in systemic absorption depending on the injection site. Given this uncertainty, we performed a systematic review with meta-analysis and trial sequential analysis comparing dexamethasone administered perineurally or intravenously combined with local anaesthetic for interscalene brachial plexus block. METHODS Following a search of various electronic databases, we included 11 trials (1145 patients). The primary outcome was the duration of analgesia defined as the time between peripheral nerve block or onset of sensory blockade and the time to first analgesic request or initial report of pain. RESULTS The primary outcome, duration of analgesia, was greater in the perineural dexamethasone group, with a mean difference (95% confidence interval) of 122 (62-183) min, I2=73%, P<0.0001. Trial sequential analysis indicated that firm evidence had been reached. The quality of evidence was downgraded to low, mainly because of moderate inconsistency and serious publication bias. No significant differences were present for any of the secondary outcomes, except for onset time of sensory and motor blockade and resting pain score at 12 h, but the magnitude of differences was not clinically relevant. CONCLUSIONS There is low-quality evidence that perineural administration of dexamethasone as a local anaesthetic adjunct increases duration of analgesia by an average of 2 h compared with intravenous injection for interscalene brachial plexus block. Given the limited clinical relevance of this difference, the off-label use of perineural administration, and the risk of drug crystallisation, we recommend intravenous dexamethasone administration. SYSTEMATIC REVIEW PROTOCOL PROSPERO (CRD42023466147).
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Affiliation(s)
- Eric Albrecht
- Department of Anaesthesia, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.
| | - Yves Renard
- Department of Anaesthesia, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Neel Desai
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, UK; King's College London, London, UK
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Mojica JJ, Ocker A, Barrata J, Schwenk ES. Anesthesia for the Patient Undergoing Shoulder Surgery. Anesthesiol Clin 2024; 42:219-231. [PMID: 38705672 DOI: 10.1016/j.anclin.2023.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2024]
Abstract
Shoulder surgery introduces important anesthesia considerations. The interscalene nerve block is considered the gold standard regional anesthetic technique and can serve as the primary anesthetic or can be used for postoperative analgesia. Phrenic nerve blockade is a limitation of the interscalene block and various phrenic-sparing strategies and techniques have been described. Patient positioning is another important anesthetic consideration and can be associated with significant hemodynamic effects and position-related injuries.
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Affiliation(s)
- Jeffrey J Mojica
- Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, 111 South 11th Street, Suite 8290 Gibbon Building, Philadelphia, PA 19107, USA.
| | - Aaron Ocker
- Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, 111 South 11th Street, Suite 8290 Gibbon Building, Philadelphia, PA 19107, USA
| | - Jaime Barrata
- Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, 111 South 11th Street, Suite 8290 Gibbon Building, Philadelphia, PA 19107, USA
| | - Eric S Schwenk
- Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, 111 South 11th Street, Suite 8290 Gibbon Building, Philadelphia, PA 19107, USA
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YaDeau JT, Cushner FD, Westrich G, Lauzadis J, Kahn RL, Lin Y, Goytizolo EA, Mayman DJ, Jules-Elysee KM, Gbaje E, Padgett DE. What Is the Role of a Periarticular Injection for Knee Arthroplasty Patients Receiving a Multimodal Analgesia Regimen Incorporating Adductor Canal and Infiltration Between the Popliteal Artery and Capsule of the Knee Blocks? A Randomized Blinded Placebo-Controlled Noninferiority Trial. Anesth Analg 2024; 138:1163-1172. [PMID: 38190339 DOI: 10.1213/ane.0000000000006805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2024]
Abstract
BACKGROUND Optimal analgesic protocols for total knee arthroplasty (TKA) patients remain controversial. Multimodal analgesia is advocated, often including peripheral nerve blocks and/or periarticular injections (PAIs). If 2 blocks (adductor canal block [ACB] plus infiltration between the popliteal artery and capsule of the knee [IPACK]) are used, also performing PAI may not be necessary. This noninferiority trial hypothesized that TKA patients with ACB + IPACK + saline PAI (sham infiltration) would have pain scores that were no worse than those of patients with ACB + IPACK + active PAI with local anesthetic. METHODS A multimodal analgesic protocol of spinal anesthesia, ACB and IPACK blocks, intraoperative ketamine and ketorolac, postoperative ketorolac followed by meloxicam, acetaminophen, duloxetine, and oral opioids was used. Patients undergoing primary unilateral TKA were randomized to receive either active PAI or control PAI. The active PAI included a deep injection, performed before cementation, of bupivacaine 0.25% with epinephrine, 30 mL; morphine; methylprednisolone; cefazolin; with normal saline to bring total volume to 64 mL. A superficial injection of 20 mL bupivacaine, 0.25%, was administered before closure. Control injections were normal saline injected with the same injection technique and volumes. The primary outcome was numeric rating scale pain with ambulation on postoperative day 1. A noninferiority margin of 1.0 was used. RESULTS Ninety-four patients were randomized. NRS pain with ambulation at POD1 in the ACB + IPACK + saline PAI group was not found to be noninferior to that of the ACB + IPACK + active PAI group (difference = 0.3, 95% confidence interval [CI], [-0.9 to 1.5], P = .120). Pain scores at rest did not differ significantly among groups. No significant difference was observed in opioid consumption between groups. Cumulative oral morphine equivalents through postoperative day 2 were 89 ± 40 mg (mean ± standard deviation), saline PAI, vs 73 ± 52, active PAI, P = .1. No significant differences were observed for worst pain, fraction of time in severe pain, pain interference, side-effects (nausea, drowsiness, itching, dizziness), quality of recovery, satisfaction, length of stay, chronic pain, and orthopedic outcomes. CONCLUSIONS For TKA patients given a comprehensive analgesic protocol, use of saline PAI did not demonstrate noninferiority compared to active PAI. Neither the primary nor any secondary outcomes demonstrated superiority for active PAI, however. As we cannot claim either technique to be better or worse, there remains flexibility for use of either technique.
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Affiliation(s)
- Jacques T YaDeau
- From the Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York
| | - Fred D Cushner
- Department of Orthopaedic Surgery (Adult Reconstruction and Joint Replacement Service), Hospital for Special Surgery, New York, New York
| | - Geoffrey Westrich
- Department of Orthopaedic Surgery (Adult Reconstruction and Joint Replacement Service), Hospital for Special Surgery, New York, New York
| | - Justas Lauzadis
- From the Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York
| | - Richard L Kahn
- From the Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York
| | - Yi Lin
- From the Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York
| | - Enrique A Goytizolo
- From the Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York
| | - David J Mayman
- Department of Orthopaedic Surgery (Adult Reconstruction and Joint Replacement Service), Hospital for Special Surgery, New York, New York
| | - Kethy M Jules-Elysee
- From the Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York
| | - Ejiro Gbaje
- From the Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York
| | - Douglas E Padgett
- Department of Orthopaedic Surgery (Adult Reconstruction and Joint Replacement Service), Hospital for Special Surgery, New York, New York
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5
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Joe YE, Lee JH, Eum D, Kim JH, Lee JR. Intravenous dexamethasone does not prolong the duration of pudendal nerve block in infants and children undergoing hypospadias surgery: A randomized clinical trial. Paediatr Anaesth 2024; 34:259-266. [PMID: 38037830 DOI: 10.1111/pan.14805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 10/27/2023] [Accepted: 11/19/2023] [Indexed: 12/02/2023]
Abstract
BACKGROUND The administration of intravenous dexamethasone increases the duration of neuraxial block and improves the quality of analgesia. However, little is known about these effects of dexamethasone on peripheral nerve blocks in children. AIMS In this study, we aimed to investigate the benefit of intravenous dexamethasone for enhancing the effect of pudendal block on postoperative analgesia in children who underwent hypospadias surgery. METHODS In total, 46 children aged 6-36 months who underwent hypospadias surgery were randomly allocated to either a control group (normal saline, group C) or dexamethasone group (0.5 mg/kg, group D). Pudendal block was performed before the surgery using 0.3 mL/kg of 0.225% ropivacaine on both sides. Parents were instructed to press the patient-controlled analgesia bolus button when their children's pain score was >4 points. The primary outcome measure was the time at which the first patient-controlled analgesia by proxy bolus dose was administered. The secondary outcome measures were pain score, number of patient-controlled analgesia administration by proxy bolus attempts, number of rescue analgesics required, total amount of fentanyl administered, and overall parental satisfaction. RESULTS The time of first patient-controlled analgesia bolus administration by proxy was not different between the control and dexamethasone groups (5.6 [5.2, 8.8] h versus 6.5 [5.4, 8.1] h, hazard ratio 0.8, 95% confidence intervals 0.43 to 1.47, p = .46). There were no statistically significant differences among the secondary outcomes. CONCLUSIONS Administration of intravenous dexamethasone did not enhance the duration of pudendal nerve block in infants and children aged 6-36 months who underwent hypospadias surgery.
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Affiliation(s)
- Young-Eun Joe
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Jae-Hoon Lee
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Darhae Eum
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Ji-Ho Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Jeong-Rim Lee
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, South Korea
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Maagaard M, Plambech MZ, Funder KS, Schou NK, Mølgaard AK, Stormholt ER, Leth MF, Bukhari S, Mortensen A, Lunn TH, Tryggedsson I, Nørskov AK, Zamany C, Toquer P, Jaeger P, Andersen JH, Mathiesen O. The effect of oral dexamethasone on duration of analgesia after upper limb surgery under infraclavicular brachial plexus block: a randomised controlled trial. Anaesthesia 2023; 78:1465-1471. [PMID: 37864459 DOI: 10.1111/anae.16149] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/09/2023] [Indexed: 10/22/2023]
Abstract
The effects of oral dexamethasone on peripheral nerve blocks have not been investigated. We randomly allocated adults scheduled for forearm or hand surgery to oral placebo (n = 61), dexamethasone 12 mg (n = 61) or dexamethasone 24 mg (n = 57) about 45 min before lateral infraclavicular block. Mean (SD) time until first pain after block were: 841 (327) min; 1171 (318) min; and 1256 (395) min, respectively. Mean (98.3%CI) differences in time until first postoperative pain for dexamethasone 24 mg vs. placebo and vs. dexamethasone 12 mg were: 412 (248-577) min, p < 0.001; and 85 (-78 to 249) min, p = 0.21, respectively. Mean (98.3%CI) difference in time until first postoperative pain for dexamethasone 12 mg vs. placebo was 330 (186-474) min, p < 0.001. Both 24 mg and 12 mg of oral dexamethasone increased the time until first postoperative pain compared with placebo in patients having upper limb surgery under infraclavicular brachial plexus block.
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Affiliation(s)
- M Maagaard
- Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Køge, Denmark
| | - M Z Plambech
- Department of Anaesthesiology, Naestved, Slagelse and Ringsted Hospitals, Slagelse, Denmark
| | - K S Funder
- Department of Anaesthesia and Intensive Care, Bispebjerg and Frederiksberg Hospital, Copenhagen University Hospital, Denmark
| | - N K Schou
- Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Køge, Denmark
| | - A K Mølgaard
- Department of Anaesthesiology, Naestved, Slagelse and Ringsted Hospitals, Slagelse, Denmark
| | - E R Stormholt
- Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Køge, Denmark
| | - M F Leth
- Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Køge, Denmark
| | - S Bukhari
- Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Køge, Denmark
| | - A Mortensen
- Department of Anaesthesiology, Naestved, Slagelse and Ringsted Hospitals, Slagelse, Denmark
| | - T H Lunn
- Department of Anaesthesia and Intensive Care, Bispebjerg and Frederiksberg Hospital, Copenhagen University Hospital, Denmark
| | - I Tryggedsson
- Department of Orthopaedic Surgery and Traumatology, Bispebjerg and Frederiksberg Hospital, Copenhagen University Hospital, Denmark
| | - A K Nørskov
- Department of Anaesthesiology, Copenhagen University Hospital, North Zealand Hospital, Hillerød, Denmark
| | - C Zamany
- Department of Orthopaedic Surgery, Trauma Unit, Zealand University Hospital, Køge, Denmark
| | - P Toquer
- Department of Orthopaedic Surgery, Trauma Unit, Zealand University Hospital, Køge, Denmark
| | - P Jaeger
- Department of Anaesthesia, The Juliane Marie Centre, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - J H Andersen
- Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Køge, Denmark
| | - O Mathiesen
- Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Køge, Denmark
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Vietor R, Kiendrebeogo R, Tracy E, Plunkett AR. Peripheral nerve block adjuncts: which medication to choose? A narrative review of the current literature. Pain Manag 2023; 13:655-665. [PMID: 37937437 DOI: 10.2217/pmt-2023-0049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2023] Open
Abstract
Enhancing the effect of peripheral nerve blockade by adding other classes of medications has long history of trial and error. Studies have identified multiple potentially beneficial adjuncts that work to either speed the onset of analgesia or prolong its duration. The benefits of these adjuncts must be weighed against the risks of systemic negative side effects. To date, the most commonly used adjuncts, and ones with the most robust scientific efficacy are, dexamethasone, dexmedetomidine and buprenorphine. This narrative review will discuss several classes of local anesthetic adjuncts and provide evidence for the clinical efficacy and side effect profile of the most commonly studied medications.
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Affiliation(s)
- Robert Vietor
- Department of Anesthesiology, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Roland Kiendrebeogo
- Department of Anesthesiology, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Erin Tracy
- Department of Anesthesiology, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Anthony R Plunkett
- Department of Anesthesia & Operative Services. Womack Army Medical Center. Ft. Liberty, NC 28310, USA
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Hannig KE, Hauritz RW, Bjørn S, Jensen HI, Henriksen CW, Jessen C, Bendtsen TF. Pain relief after major ankle and hindfoot surgery with repetitive peripheral nerve blocks: A feasibility study. Acta Anaesthesiol Scand 2023; 67:1266-1272. [PMID: 37280182 DOI: 10.1111/aas.14289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 05/12/2023] [Accepted: 05/23/2023] [Indexed: 06/08/2023]
Abstract
BACKGROUND Major ankle and hindfoot surgery (e.g., ankle, triple and subtalar arthrodesis) typically causes severe postoperative pain, especially the first two postoperative days. Current modalities of postoperative analgesic treatment often include continuous peripheral nerve blocks of the saphenous and sciatic nerves via catheters in order to extend the duration of pain- and opioid-free nerve blockade to 48 h. Unfortunately, the 48 h-efficacy of continuous infusion via a catheter is reduced by a high displacement rate. We hypothesised that one-time repetition of the single injection peripheral nerve blocks would provide effective analgesia with a low opioid consumption the first 48 postoperative hours. METHODS Eleven subjects preoperatively received a popliteal sciatic and a saphenous single injection nerve block with a protracted local anaesthetic mixture. Surgery was performed under general anaesthesia. The one-time repetition of the single injection nerve block was carried out approximately 24 h after the primary nerve block. The main outcomes were pain and cumulative opioid consumption during the first 48 postoperative hours. RESULTS Nine of the 11 (82%) patients had effective analgesia without opioids during the first 48 postoperative hours. Two patients each required a single dose of 7.5 mg of oral morphine equivalents after 43 h. CONCLUSION One-time repetition of single injection saphenous and sciatic nerve blocks consistently provided effective analgesia practically without opioids for 48 h after major elective ankle and hindfoot surgery.
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Affiliation(s)
- Kjartan E Hannig
- Department of Anaesthesiology, Kolding Hospital, a part of Lillebaelt Hospital, University Hospital of Southern Denmark, Denmark
- Department of Anaesthesiology, Vejle Hospital, a part of Lillebaelt Hospital, University Hospital of Southern Denmark, Denmark
| | - Rasmus W Hauritz
- Department of Anaesthesiology, Kolding Hospital, a part of Lillebaelt Hospital, University Hospital of Southern Denmark, Denmark
| | - Siska Bjørn
- Institute of Clinical Medicine, Health, Aarhus University, Aarhus, Denmark
| | - Hanne Irene Jensen
- Department of Anaesthesiology, Kolding Hospital, a part of Lillebaelt Hospital, University Hospital of Southern Denmark, Denmark
- Department of Anaesthesiology, Vejle Hospital, a part of Lillebaelt Hospital, University Hospital of Southern Denmark, Denmark
| | - Claus W Henriksen
- Department of Orthopaedic Surgery, Kolding Hospital, a part of Lillebaelt Hospital, University Hospital of Southern Denmark, Denmark
| | | | - Thomas F Bendtsen
- Department of Anaesthesiology, Aarhus University Hospital, Aarhus, Denmark
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Nijs K, Ruette J, Van de Velde M, Stessel B. Regional anaesthesia for ambulatory surgery. Best Pract Res Clin Anaesthesiol 2023; 37:397-408. [PMID: 37938085 DOI: 10.1016/j.bpa.2022.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 12/05/2022] [Accepted: 12/12/2022] [Indexed: 12/23/2022]
Abstract
Regional anaesthesia (RA) has an important and ever-expanding role in ambulatory surgery. Specific practices vary depending on the preferences and resources of the anaesthesia team and hospital setting. It is used for various purposes, including as primary anaesthetic technique for surgery but also as postoperative analgesic modality. The limited duration of action of currently available local anaesthetics limits their application in postoperative pain control and enhanced recovery. The search for the holy grail of regional anaesthetics continues. Current evidence suggests that a peripheral nerve block performed with long-acting local anaesthetics in combination with intravenous or perineural dexamethasone gives the longest and most optimal sensory block. In this review, we outline some possible blocks for ambulatory surgery and additives to perform RA. Moreover, we give an update on local anaesthesia drugs and adjuvants, paediatric RA in ambulatory care and discuss the impact of RA by COVID-19.
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Affiliation(s)
- Kristof Nijs
- Department of Anaesthesiology and Pain Medicine, Jessa Hospital, Hasselt, Belgium; UHasselt, Faculty of Medicine and Life Sciences, Diepenbeek, Belgium; KULeuven, Department of Cardiovascular Sciences, Leuven, Belgium; Department of Anaesthesiology and Pain Medicine, University Hospitals Leuven, Leuven, Belgium.
| | - Joke Ruette
- Department of Anaesthesiology and Pain Medicine, Jessa Hospital, Hasselt, Belgium; Department of Anaesthesiology and Pain Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Marc Van de Velde
- KULeuven, Department of Cardiovascular Sciences, Leuven, Belgium; Department of Anaesthesiology and Pain Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Björn Stessel
- Department of Anaesthesiology and Pain Medicine, Jessa Hospital, Hasselt, Belgium; UHasselt, Faculty of Medicine and Life Sciences, Diepenbeek, Belgium
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10
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Hui H, Miao H, Qiu F, Lin Y, Li H, Zhang Y, Jiang B. Adjunctive dexamethasone palmitate use for intercostal nerve block after video-assisted thoracoscopic surgery: A prospective, randomized control trial. Heliyon 2023; 9:e19156. [PMID: 37662806 PMCID: PMC10474424 DOI: 10.1016/j.heliyon.2023.e19156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 08/12/2023] [Accepted: 08/14/2023] [Indexed: 09/05/2023] Open
Abstract
Objectives The efficacy of dexamethasone palmitate in extending durations of local anesthetic blocks is uncertain. In a randomized, double-blind study of patients undergoing video-assisted thoracoscopic surgery, we tested whether intravenous or perineural dexamethasone palmitate caused prolonged analgesia after intercostal nerve block. Methods A total of 90 patients subjected to video-assisted thoracoscopic surgery between May and December 2022 were randomly assigned to one of three intercostal nerve blocks study arms (n = 30 each), requiring the addition of 0.5% ropivacaine (23 ml) as follows: controls (C group), 2 ml saline; IV-DXP group, 2 ml saline + 2 ml (8 mg) intravenous dexamethasone palmitate; and PN-DXP group, 2 ml (8 mg) perineural dexamethasone palmitate. Time to first postoperative remedial analgesia served as primary outcome measure. Secondary endpoints included postoperative opioid consumption, pain scores by Visual Analog Scale, analgesia satisfaction, and related adverse effects. Results Compared with controls or the IV-DXP group, time to first postoperative remedial analgesia was longer and postoperative opioid consumption for rescue analgesia was lower in the PN-DXP group (p < 0.01). Similarly, the Visual Analog Scale scores in patients at 8, 12, 18, and 24 h postoperatively were lower in the PN-DXP group than in controls and the IV-DXP group (p < 0.01). Patient satisfaction was statistically lower in the PN-DXP group, compared with either the control or IV-DXP group (p < 0.05). Clinically, the three groups did not differ significantly in occurrences of adverse effects during the 48-h postoperative monitoring period (p > 0.05). Conclusions Perineural dexamethasone palmitate is a promising adjunct to ropivacaine intercostal nerve block by prolonging analgesia with almost no related adverse effects.
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Affiliation(s)
| | | | | | - Yangui Lin
- Department of Thoracic Cardiovascular Surgery, The Eighth Affiliated Hospital of Sun Yat-sen University, Shenzhen, Guangdong, China
| | - Huaming Li
- Department of Thoracic Cardiovascular Surgery, The Eighth Affiliated Hospital of Sun Yat-sen University, Shenzhen, Guangdong, China
| | - Yiqian Zhang
- Department of Thoracic Cardiovascular Surgery, The Eighth Affiliated Hospital of Sun Yat-sen University, Shenzhen, Guangdong, China
| | - Bo Jiang
- Department of Thoracic Cardiovascular Surgery, The Eighth Affiliated Hospital of Sun Yat-sen University, Shenzhen, Guangdong, China
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11
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Bloc S, Alfonsi P, Belbachir A, Beaussier M, Bouvet L, Campard S, Campion S, Cazenave L, Diemunsch P, Di Maria S, Dufour G, Fabri S, Fletcher D, Garnier M, Godier A, Grillo P, Huet O, Joosten A, Lasocki S, Le Guen M, Le Saché F, Macquer I, Marquis C, de Montblanc J, Maurice-Szamburski A, Nguyen YL, Ruscio L, Zieleskiewicz L, Caillard A, Weiss E. Guidelines on perioperative optimization protocol for the adult patient 2023. Anaesth Crit Care Pain Med 2023; 42:101264. [PMID: 37295649 DOI: 10.1016/j.accpm.2023.101264] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
OBJECTIVE The French Society of Anesthesiology and Intensive Care Medicine [Société Française d'Anesthésie et de Réanimation (SFAR)] aimed at providing guidelines for the implementation of perioperative optimization programs. DESIGN A consensus committee of 29 experts from the SFAR was convened. A formal conflict-of-interest policy was developed at the outset of the process and enforced throughout. The entire guidelines process was conducted independently of any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence. METHODS Four fields were defined: 1) Generalities on perioperative optimization programs; 2) Preoperative measures; 3) Intraoperative measures and; 4) Postoperative measures. For each field, the objective of the recommendations was to answer a number of questions formulated according to the PICO model (population, intervention, comparison, and outcomes). Based on these questions, an extensive bibliographic search was carried out using predefined keywords according to PRISMA guidelines and analyzed using the GRADE® methodology. The recommendations were formulated according to the GRADE® methodology and then voted on by all the experts according to the GRADE grid method. As the GRADE® methodology could have been fully applied for the vast majority of questions, the recommendations were formulated using a "formalized expert recommendations" format. RESULTS The experts' work on synthesis and application of the GRADE® method resulted in 30 recommendations. Among the formalized recommendations, 19 were found to have a high level of evidence (GRADE 1±) and ten a low level of evidence (GRADE 2±). For one recommendation, the GRADE methodology could not be fully applied, resulting in an expert opinion. Two questions did not find any response in the literature. After two rounds of rating and several amendments, strong agreement was reached for all the recommendations. CONCLUSIONS Strong agreement among the experts was obtained to provide 30 recommendations for the elaboration and/or implementation of perioperative optimization programs in the highest number of surgical fields.
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Affiliation(s)
- Sébastien Bloc
- Clinical Research Department, Ambroise Pare Hospital Group, Neuilly-sur-Seine, France; Department of Anesthesiology, Clinique Drouot Sport, Paris, France.
| | - Pascal Alfonsi
- Department of Anesthesia, University of Paris Descartes, Groupe Hospitalier Paris Saint-Joseph, 185 rue Raymond Losserand, F-75674 Paris Cedex 14, France
| | - Anissa Belbachir
- Service d'Anesthésie Réanimation, UF Douleur, Assistance Publique Hôpitaux de Paris, APHP.Centre, Site Cochin, Paris, France
| | - Marc Beaussier
- Department of Digestive, Oncologic and Metabolic Surgery, Institut Mutualiste Montsouris, Université de Paris, 42 Boulevard Jourdan, 75014, Paris, France
| | - Lionel Bouvet
- Department of Anaesthesia and Intensive Care, Hospices Civils de Lyon, Hôpital Femme Mère Enfant, Lyon, France
| | | | - Sébastien Campion
- AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Département d'Anesthésie-Réanimation, F-75013 Paris, France; Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, F-75005 Paris, France
| | - Laure Cazenave
- Department of Anaesthesia and Critical Care, Hospices Civils de Lyon, Lyon, France; Groupe Jeunes, French Society of Anaesthesia and Intensive Care Medicine (SFAR), 75016 Paris, France
| | - Pierre Diemunsch
- Unité de Réanimation Chirurgicale, Service d'Anesthésie-réanimation Chirurgicale, Pôle Anesthésie-Réanimations Chirurgicales, Samu-Smur, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, 1, Avenue Molière, 67098 Strasbourg Cedex, France
| | - Sophie Di Maria
- Department of Anaesthesiology and Critical Care, AP-HP, Hôpital Pitié-Salpêtrière, Paris, France
| | - Guillaume Dufour
- Service d'Anesthésie-Réanimation, CHU de Pitié-Salpêtrière, 47-83, Boulevard de l'Hôpital, 75013 Paris, France
| | - Stéphanie Fabri
- Faculty of Economics, Management & Accountancy, University of Malta, Malta
| | - Dominique Fletcher
- Université de Versailles-Saint-Quentin-en-Yvelines, Assistance Publique-Hôpitaux de Paris, Hôpital Ambroise-Paré, Service d'Anesthésie, 9, Avenue Charles-de-Gaulle, 92100 Boulogne-Billancourt, France
| | - Marc Garnier
- Sorbonne Université, GRC 29, DMU DREAM, Service d'Anesthésie-Réanimation et Médecine Périopératoire Rive Droite, Paris, France
| | - Anne Godier
- Department of Anaesthesiology and Critical Care, European Georges Pompidou Hospital, Assistance Publique-Hôpitaux de Paris, France
| | | | - Olivier Huet
- CHU de Brest, Anesthesia and Intensive Care Unit, Brest, France
| | - Alexandre Joosten
- Department of Anesthesiology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium; Department of Anesthesiology and Intensive Care, Hôpitaux Universitaires Paris-Sud, Université Paris-Sud, Université Paris-Saclay, Paul Brousse Hospital, Assistance Publique Hôpitaux de Paris (APHP), Villejuif, France
| | | | - Morgan Le Guen
- Paris Saclay University, Department of Anaesthesia and Pain Medicine, Foch Hospital, 92150 Suresnes, France
| | - Frédéric Le Saché
- Department of Anesthesiology, Clinique Drouot Sport, Paris, France; DMU DREAM Department of Anesthesiology and Critical Care, Pitié-Salpêtrière Hospital, Paris, France
| | - Isabelle Macquer
- Bordeaux University Hospitals, Bordeaux, Anaesthesia and Intensive Care Medicine Department, Bordeaux, France
| | - Constance Marquis
- Clinique du Sport, Département d'Anesthésie et Réanimation, Médipole Garonne, 45 rue de Gironis - CS 13 624, 31036 Toulouse Cedex 1, France
| | - Jacques de Montblanc
- Departments of Anesthesiology and Intensive Care Paris-Saclay University, Bicêtre Hospital, Assistance Publique Hôpitaux de Paris, Le Kremlin-Bicêtre, France
| | | | - Yên-Lan Nguyen
- Anesthesiology and Critical Care Medicine Department, Cochin Academic Hospital, APHP, Université de Paris, 75014 Paris, France
| | - Laura Ruscio
- Departments of Anesthesiology and Intensive Care Paris-Saclay University, Bicêtre Hospital, Assistance Publique Hôpitaux de Paris, Le Kremlin-Bicêtre, France; INSERM U 1195, Université Paris-Saclay, Saint-Aubin, Île-de-France, France
| | - Laurent Zieleskiewicz
- Service d'Anesthésie Réanimation, Hôpital Nord, AP-HM, Marseille, Aix Marseille Université, C2VN, France
| | - Anaîs Caillard
- Centre Hospitalier Universitaire La Cavale Blanche Université de Bretagne Ouest, Anaesthesiology, Critical Care and Perioperative Medicine Department, Brest, France
| | - Emmanuel Weiss
- Department of Anaesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP, Nord, Clichy, France; University of Paris, Paris, France; Inserm UMR_S1149, Centre for Research on Inflammation, Paris, France
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Lee HJ, Woo JH, Chae JS, Kim YJ, Shin SJ. Intravenous Versus Perineural Dexamethasone for Reducing Rebound Pain After Interscalene Brachial Plexus Block: A Randomized Controlled Trial. J Korean Med Sci 2023; 38:e183. [PMID: 37337808 DOI: 10.3346/jkms.2023.38.e183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 02/24/2023] [Indexed: 06/21/2023] Open
Abstract
BACKGROUND Interscalene brachial plexus block (ISB) is a common regional technique to manage acute postoperative pain for arthroscopic rotator cuff tear repair. However, rebound pain may compromise its overall benefit. Our aim was to investigate the primary hypothesis that perineural and intravenous dexamethasone have different effects on rebound pain after resolution of ISB for arthroscopic rotator cuff tear repair. METHODS Patients aged ≥ 20 years scheduled for elective arthroscopic rotator cuff tear repair under general anesthesia with preoperative ISB were included. The participants were randomized to receive dexamethasone either perineurally (perineural group) or intravenously (intravenous group). In the perineural group, patients received ISB with 12 mL of 0.5% ropivacaine containing 5 mg of dexamethasone; simultaneously, 1 mL of 0.9% normal saline was administered intravenously. In the intravenous group, patients received ISB with 12 mL of 0.5% ropivacaine; simultaneously, 1 mL of dexamethasone 5 mg was administered intravenously. The primary outcome was the difference in the pain score (0-10 on numeric rating scale) between before and after ISB resolution. The secondary outcomes were the incidence of rebound pain; onset, duration, and intensity of rebound pain; time to the first analgesic request; and pain-related sleep disturbance. RESULTS A total of 71 patients were randomized to either perineural group (n = 36) or intravenous group (n = 35). After block resolution, pain scores increased significantly more in the perineural group (mean ± standard deviation, 4.9 ± 2.1) compared to the intravenous group (4.0 ± 1.7, P = 0.043). The duration of ISB was more prolonged in the perineural group (median [interquartile range], 19.9 [17.2-23.1] hours) than the intravenous group (15.1 [13.7-15.9] hours, P < 0.001). The incidence of rebound pain and pain-related sleep disturbance during the first postoperative week was significantly higher in the perineural group than in the intravenous group (rebound pain: 44.4% vs. 20.0%, P = 0.028; sleep disturbance: 55.6% vs. 25.7%, P = 0.011). The duration and intensity of rebound pain were similar between the two groups. CONCLUSION Although perineural dexamethasone provided longer postoperative analgesia, intravenous dexamethasone was more beneficial in reducing pain increase after ISB resolution, incidence of rebound pain, and pain-related sleep disturbance. TRIAL REGISTRATION Clinical Research Information Service Identifier: KCT0006795.
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Affiliation(s)
- Hyun Jung Lee
- Department of Anesthesiology and Pain Medicine, College of Medicine, Ewha Womans University Seoul Hospital, Seoul, Korea
| | - Jae Hee Woo
- Department of Anesthesiology and Pain Medicine, College of Medicine, Ewha Womans University Seoul Hospital, Seoul, Korea.
| | - Ji Seon Chae
- Department of Anesthesiology and Pain Medicine, College of Medicine, Ewha Womans University Seoul Hospital, Seoul, Korea
| | - Youn Jin Kim
- Department of Anesthesiology and Pain Medicine, College of Medicine, Ewha Womans University Seoul Hospital, Seoul, Korea
| | - Sang-Jin Shin
- Department of Orthopedic Surgery, College of Medicine, Ewha Womans University Seoul Hospital, Seoul, Korea
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Akaravinek P, Kampitak W, Tanavalee A, Ngarmukos S, Tanavalee C, Limsakul K. Effect of Adding Perineural Methylprednisolone to Peripheral Nerve Blocks Combined With Intravenous Dexamethasone for Prolonged Postdischarge Analgesia After Fast-track Total Knee Arthroplasty: A Randomized Controlled Trial. Clin J Pain 2023; 39:180-187. [PMID: 36943162 DOI: 10.1097/ajp.0000000000001098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 01/19/2023] [Indexed: 03/23/2023]
Abstract
OBJECTIVES Patients undergoing total knee arthroplasty (TKA) may experience moderate-to-severe subacute pain after hospital discharge that may be undermanaged. We aimed to evaluate the effect of methylprednisolone added to ultrasound-guided peripheral nerve blocks (PNBs) combined with multimodal analgesia including intravenous dexamethasone for prolonged analgesia after early discharge. MATERIALS AND METHODS We randomized 80 patients who underwent fast-track TKA into 2 groups. All patients received a periarticular injection, PNBs, and multiple doses of intravenous dexamethasone. The methylprednisolone group received 140 mg methylprednisolone in PNBs, while the nonmethylprednisolone group did not. The primary outcome was the incidence of moderate-to-severe pain (Numerical Rating Scale ≥4) during the first 12 postdischarge days. The secondary outcomes included pain scores until 3 postoperative months, incidence of rebound pain, functional performances, patient satisfaction, and adverse events. RESULTS No significant between-group differences were noted in the incidence of moderate-to-severe pain during the first 12 postdischarge days (nonmethylprednisolone vs. methylprednisolone groups: 70% vs. 69.2%, P=0.941). However, this incidence was significantly higher in the methylprednisolone group between 2 weeks and 1 month (P=0.015) and between 1 and 3 months (P=0.004) postoperatively. No between-group differences in the Numerical Rating Scale scores at the postdischarge time points, incidence of rebound pain, and functional performance results were noted. DISCUSSION Adding perineural methylprednisolone to ultrasound-guided PNBs for multimodal analgesia with intravenous dexamethasone did not prolong analgesia and improved the functional ability after fast-track TKA within 12 postdischarge days. However, the incidence moderate-to-severe pain may increase between the 2-week and 3-month follow-up.
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Affiliation(s)
- Piraya Akaravinek
- Department of Anesthesiology, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society and Faculty of Medicine, Chulalongkorn University
| | - Wirinaree Kampitak
- Department of Anesthesiology, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society and Faculty of Medicine, Chulalongkorn University
| | - Aree Tanavalee
- Department of Orthopedics, King Chulalongkorn Memorial Hospital and Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Srihatach Ngarmukos
- Department of Orthopedics, King Chulalongkorn Memorial Hospital and Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Chotetawan Tanavalee
- Department of Orthopedics, King Chulalongkorn Memorial Hospital and Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Kamonwan Limsakul
- Department of Anesthesiology, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society and Faculty of Medicine, Chulalongkorn University
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Liposomal Bupivacaine versus Dexamethasone: Reply. Anesthesiology 2023; 138:229. [PMID: 36629460 DOI: 10.1097/aln.0000000000004410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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Fernández Martin MT, Alvarez Lopez S, Aldecoa Alvarez-Santullano C. Role of adjuvants in regional anesthesia: A systematic review. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2023; 70:97-107. [PMID: 36813032 DOI: 10.1016/j.redare.2021.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Accepted: 06/16/2021] [Indexed: 02/22/2023]
Abstract
The combination of drugs and routes of administration produces a synergistic effect, and one of the most important components of multimodal analgesic strategies are, therefore, nerve blocks for pain management. The effect of a local anaesthetic can be prolonged by administering an adjuvant. In this systematic review, we included studies on adjuvants associated with local anaesthetics in peripheral nerve blocks published in the last 5 years in order to evaluate their effectiveness. The results were reported according to the PRISMA guidelines. The 79 studies selected using our criteria showed a clear prevalence of dexamethasone (n=24) and dexmedetomidine (n=33) over other adjuvants. Different meta-analyses comparing adjuvants suggest that dexamethasone administered perineurally achieves superior blockade with fewer side effects than dexmedetomidine. Based on the studies reviewed, we found moderate evidence to recommend the use of dexamethasone as an adjuvant to peripheral regional anaesthesia in surgeries that can cause moderate to severe pain.
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Affiliation(s)
- M T Fernández Martin
- Servicio de Anestesiología y Reanimación, Hospital Universitario Río Hortega, Valladolid, Spain.
| | - S Alvarez Lopez
- Servicio de Anestesiología y Reanimación, Hospital Abente y Lago, A Coruña, Spain
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Guna Pratheep K, Sonawane K, Rajasekaran S, Shetty AP, Subramanian BJ, Kanna RM. Transient paraplegia in lumbar spine surgery-a potential complication following erector spinae plane block. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2022; 31:3719-3723. [PMID: 34787688 DOI: 10.1007/s00586-021-07059-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 09/14/2021] [Accepted: 11/09/2021] [Indexed: 12/14/2022]
Abstract
PURPOSE Erector spinae plane block (ESPB) has gained popularity over recent years and is being increasingly used in spine surgery for pain management. To date, no major neurological complications have been reported. We present here two patients who developed transient postoperative paraplegia and discuss the possible causes of this phenomenon. METHODS Patients, who underwent preoperative bilateral ESPB as an adjunct to general anesthesia for elective lumbar spine surgery at our institution between January 2017 and December 2020, were retrospectively identified. Among them, only patients who developed postoperative motor and sensory deficits were finally included. RESULTS Overall, two patients [of 316 who underwent ESPB (0.6%)] developed complete motor and sensory deficits in bilateral lower limbs postoperatively. In both patients, the surgery was uncomplicated. Ninety minutes following recovery from general anesthesia, both patients showed gradual neurological recovery in a distal-to-proximal pattern, with complete motor recovery preceding the sensory improvement. Since the surgical procedure was performed at the cauda equine level, transient paraplegia in these patients could only attributed to ESPB. CONCLUSION Transient paraplegia following ESPB (due to anterior spread of the local anesthetic agent into the epidural space) has never been reported, and both anesthetists and surgeons must be aware of this possible complication.
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Affiliation(s)
- K Guna Pratheep
- Department of Orthopedics and Spine Surgery, Ganga Hospital, Ganga Medical Center and Hospital, Coimbatore, Tamil Nadu, India
| | - Kartik Sonawane
- Department of Anaesthesiology, Ganga Medical Center and Hospital, Coimbatore, Tamil Nadu, India
| | - Shanmuganathan Rajasekaran
- Department of Orthopedics and Spine Surgery, Ganga Hospital, Ganga Medical Center and Hospital, Coimbatore, Tamil Nadu, India
| | - Ajoy Prasad Shetty
- Department of Orthopedics and Spine Surgery, Traumatology and Spine Surgery, Ganga Hospital, Ganga Medical Center and Hospital, 313, Mettupalayam Road, Coimbatore, 641043, Tamil Nadu, India.
| | | | - Rishi Mugesh Kanna
- Department of Orthopedics and Spine Surgery, Ganga Hospital, Ganga Medical Center and Hospital, Coimbatore, Tamil Nadu, India
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Termpornlert S, Vijitpavan A, Ngodngamthaweesuk M, Sangkum L, Saeaeh L, Pipatpongsa B, Leurcharusmee P, Wanishpongpan S, Sakura S. Analgesic Efficacy of Intravenous Dexamethasone as an Adjunct to Ultrasound-Guided Paravertebral Block with Bupivacaine in Video-Assisted Thoracoscopic Surgery. J Pain Res 2022; 15:2351-2361. [PMID: 35996452 PMCID: PMC9391992 DOI: 10.2147/jpr.s372780] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Accepted: 07/29/2022] [Indexed: 12/03/2022] Open
Abstract
Purpose Thoracic paravertebral block (TPVB) is a recommended regional analgesia during video-assisted thoracoscopic surgery (VATS). However, single-injection TPVB does not last long enough to provide sufficient acute postoperative pain relief. Continuous TPVB through a catheter is technically challenging and often unreliable. Intravenous dexamethasone extends the analgesic duration with some peripheral nerve blocks. However, data on the effect of intravenous dexamethasone on pain relief with TPVB are limited. This study aimed to assess the analgesic efficacy of intravenous dexamethasone in patients who received TPVB for VATS. Patients and Methods In this multicenter prospective randomized controlled trial, we recruited patients aged between 18 and 80 years with the American Society of Anesthesiologists of physical status class 1–3 and underwent elective VATS. Patients under general anesthesia randomly received 8 mg of intravenous dexamethasone (group D) or normal saline (group C). Ultrasound-guided TPVB (USG-TPVB) was performed at the T4–T5 and T6-T7 spaces. Multimodal analgesia was achieved via paracetamol, tramadol and intravenous morphine for both study groups. The primary outcome was time for the first analgesic requirement. Postoperative pain in terms of numeric rating score (NRS), total morphine consumption and postoperative nausea and vomiting (PONV) were assessed. Results After excluding one patient, 59 patients were analyzed. There were no intergroup differences in baseline characteristics. The time to first analgesic requirement was longer in group D (305 [240, 510] minutes) than in group C (270 [180, 300] minutes) (P value = 0.02). The NRS at rest and on movement was lower in group D than in group C at 12 hours but did not differ at other time points. Postoperative morphine consumption was significantly lower in group D than in group C at 6,12,24 and 48 hours. Incidences of PONV were comparable between the groups. Conclusion Intravenous dexamethasone, used as an adjunct to a single-injection USG-TPVB prolonged analgesic duration, had an opioid-sparing effect and provided better postoperative pain relief after VATS.
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Affiliation(s)
- Sivaporn Termpornlert
- Department of Anesthesiology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Amorn Vijitpavan
- Department of Anesthesiology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Montien Ngodngamthaweesuk
- Department of Cardiovascular Thoracic Surgery, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Lisa Sangkum
- Department of Anesthesiology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Lalisa Saeaeh
- Department of Anesthesiology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Benjaporn Pipatpongsa
- Department of Anesthesiology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Prangmalee Leurcharusmee
- Department of Anesthesiology, Faculty of Medicine Maharaj Nakorn Chiang Mai Hospital, Chiang Mai University, Chiang Mai, Thailand
| | - Samon Wanishpongpan
- Department of Anesthesiology, Faculty of Medicine Maharaj Nakorn Chiang Mai Hospital, Chiang Mai University, Chiang Mai, Thailand
| | - Shinichi Sakura
- Department of Anesthesiology, University Hospital Shimane University Faculty of Medicine, Izumo, Japan
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Multimodal Analgesia in the Aesthetic Plastic Surgery: Concepts and Strategies. Plast Reconstr Surg Glob Open 2022; 10:e4310. [PMID: 35572190 PMCID: PMC9094416 DOI: 10.1097/gox.0000000000004310] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 03/17/2022] [Indexed: 12/13/2022]
Abstract
Postoperative pain management is crucial for aesthetic plastic surgery procedures. Poorly controlled postoperative pain results in negative physiologic effects and can affect length of stay and patient satisfaction. In light of the growing opioid epidemic, plastic surgeons must be keenly familiar with opioid-sparing multimodal analgesia regimens to optimize postoperative pain control. Methods A review study based on multimodal analgesia was conducted. Results We present an overview of pain management strategies pertaining to aesthetic plastic surgery and offer a multimodal analgesia model for outpatient aesthetic surgery practices. Conclusion This review article presents an evidence-based approach to multimodal pain management for aesthetic plastic surgery.
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Mojica JJ, Ocker A, Barrata J, Schwenk ES. Anesthesia for the Patient Undergoing Shoulder Surgery. Clin Sports Med 2022; 41:219-231. [PMID: 35300836 DOI: 10.1016/j.csm.2021.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Shoulder surgery introduces important anesthesia considerations. The interscalene nerve block is considered the gold standard regional anesthetic technique and can serve as the primary anesthetic or can be used for postoperative analgesia. Phrenic nerve blockade is a limitation of the interscalene block and various phrenic-sparing strategies and techniques have been described. Patient positioning is another important anesthetic consideration and can be associated with significant hemodynamic effects and position-related injuries.
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Affiliation(s)
- Jeffrey J Mojica
- Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, 111 South 11th Street, Suite 8290 Gibbon Building, Philadelphia, PA 19107, USA.
| | - Aaron Ocker
- Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, 111 South 11th Street, Suite 8290 Gibbon Building, Philadelphia, PA 19107, USA
| | - Jaime Barrata
- Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, 111 South 11th Street, Suite 8290 Gibbon Building, Philadelphia, PA 19107, USA
| | - Eric S Schwenk
- Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, 111 South 11th Street, Suite 8290 Gibbon Building, Philadelphia, PA 19107, USA
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Interscalene Brachial Plexus Block with Liposomal Bupivacaine versus Standard Bupivacaine with Perineural Dexamethasone: A Noninferiority Trial. Anesthesiology 2022; 136:434-447. [PMID: 35041742 DOI: 10.1097/aln.0000000000004111] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND The interscalene nerve block provides analgesia for shoulder surgery. To extend block duration, provide adequate analgesia, and minimize opioid consumption, the use of adjuvants such as dexamethasone as well as the application of perineural liposomal bupivacaine have been proposed. This randomized, double-blinded, noninferiority trial hypothesized that perineural liposomal bupivacaine is noninferior to standard bupivacaine with perineural dexamethasone in respect to average pain scores in the first 72 h after surgery. METHODS A total of 112 patients undergoing ambulatory shoulder surgery were randomized into two groups. The liposomal bupivacaine group received a 15-ml premixed admixture of 10 ml of 133 mg liposomal bupivacaine and 5 ml of 0.5% bupivacaine (n = 55), while the bupivacaine with dexamethasone group received an admixture of 15 ml of 0.5% standard bupivacaine with 4 mg dexamethasone (n = 56), respectively. The primary outcome was the average numerical rating scale pain scores at rest over 72 h. The mean difference between the two groups was compared against a noninferiority margin of 1.3. Secondary outcomes were analgesic block duration, motor and sensory resolution, opioid consumption, numerical rating scale pain scores at rest and movement on postoperative days 1 to 4 and again on postoperative day 7, patient satisfaction, readiness for postanesthesia care unit discharge, and adverse events. RESULTS A liposomal bupivacaine group average numerical rating scale pain score over 72 h was not inferior to the bupivacaine with dexamethasone group (mean [SD], 2.4 [1.9] vs. 3.4 [1.9]; mean difference [95% CI], -1.1 [-1.8, -0.4]; P < 0.001 for noninferiority). There was no significant difference in duration of analgesia between the groups (26 [20, 42] h vs. 27 [20, 39] h; P = 0.851). Motor and sensory resolutions were similar in both groups: 27 (21, 48) h versus 27 (19, 40) h (P = 0.436) and 27 [21, 44] h versus 31 (20, 42) h (P = 0.862), respectively. There was no difference in opioid consumption, readiness for postanesthesia care unit discharge, or adverse events. CONCLUSIONS Interscalene nerve blocks with perineural liposomal bupivacaine provided effective analgesia similar to the perineural standard bupivacaine with dexamethasone. The results show that bupivacaine with dexamethasone can be used interchangeably with liposomal bupivacaine for analgesia after shoulder surgery. EDITOR’S PERSPECTIVE
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Hoerner E, Gasteiger L, Ortler M, Pustilnik V, Mathis S, Brunner C, Neururer S, Schlager A, Egle D, Putz G. The impact of dexamethasone as a perineural additive to ropivacaine for PECS II blockade in patients undergoing unilateral radical mastectomy - A prospective, randomized, controlled and double-blinded trial. J Clin Anesth 2021; 77:110622. [PMID: 34872040 DOI: 10.1016/j.jclinane.2021.110622] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 11/25/2021] [Accepted: 11/26/2021] [Indexed: 01/31/2023]
Abstract
STUDY OBJECTIVE Dexamethasone is commonly used as an adjuvant to local anesthetics to prolong duration of peripheral nerve blocks with minimal side-effects. The present study investigates the efficacy of dexamethasone added to ropivacaine 0.2% as compared to ropivacaine 0.2% alone for pectoral nerves block II (PECS II) in unilateral radical mastectomy. DESIGN A prospective, randomized, controlled and double-blinded trial. SETTING The study was performed at Innsbruck Medical University Hospital, Austria, between January 2019 and October 2020. PATIENTS Sixty female patients with an American Society of Anesthesiologists Score I-II (18-90 years, BMI 18-35) scheduled for unilateral radical mastectomy without one-stage immediate autologous breast reconstruction were randomly assigned to receive PECS II block with ropivacaine 0.2% with or without dexamethasone 8 mg. INTERVENTIONS Patients were randomly assigned to receive PECS II block with ropivacaine 0.2% with or without dexamethasone 8 mg. MEASUREMENTS Primary outcome parameter was the cumulative opioid consumption during the first 72 postoperative hours. Secondary outcome parameters were the duration of analgesia and the course of the visual analogue scale (VAS) and the area under the curve VAS (AUC-VAS). MAIN RESULTS There was no difference in cumulative opioid consumption after 72 h between the ropivacaine 0.2% plus dexamethasone group and the ropivacaine 0.2% plus placebo group (11.89 vs 11.90 morphine milligram equivalent, respectively; p 0.831). Duration of analgesia also did not differ significantly between the ropivacaine 0.2% plus dexamethasone group and the ropivacaine 0.2% plus placebo group (12.75 versus 8.75 h, respectively; p 0.680). There also was no difference in the course of VAS and AUC-VAS. CONCLUSIONS Dexamethasone 8 mg when added to ropivacaine 0.2% for PECS II block in unilateral radical mastectomy was not found to reduce total opioid consumption over 72 postoperative hours or to prolong duration of analgesia as compared to pure ropivacaine 0.2%.
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Affiliation(s)
- Elisabeth Hoerner
- Department of Anaesthesiology and Intensive Care Medicine, Medical University of Innsbruck, Austria
| | - Lukas Gasteiger
- Department of Anaesthesiology and Intensive Care Medicine, Medical University of Innsbruck, Austria.
| | - Michael Ortler
- Department of Anaesthesiology and Intensive Care Medicine, Medical University of Innsbruck, Austria
| | - Vitaliy Pustilnik
- Department of Anaesthesiology and Intensive Care Medicine, Medical University of Innsbruck, Austria
| | - Simon Mathis
- Department of Anaesthesiology and Intensive Care Medicine, Medical University of Innsbruck, Austria
| | - Christine Brunner
- Department of Obstetrics and Gynaecology, Medical University of Innsbruck, Austria
| | - Sabrina Neururer
- Department of Medical Statistics, Informatics and Health Economics, Medical University of Innsbruck, Austria
| | - Andreas Schlager
- Department of Anaesthesiology and Intensive Care Medicine, Medical University of Innsbruck, Austria
| | - Daniel Egle
- Department of Obstetrics and Gynaecology, Medical University of Innsbruck, Austria
| | - Guenther Putz
- Department of Anaesthesiology and Intensive Care Medicine, Medical University of Innsbruck, Austria
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Hong B, Oh C, Jo Y, Chung W, Park E, Park H, Yoon S. The Effect of Intravenous Dexamethasone and Dexmedetomidine on Analgesia Duration of Supraclavicular Brachial Plexus Block: A Randomized, Four-Arm, Triple-Blinded, Placebo-Controlled Trial. J Pers Med 2021; 11:jpm11121267. [PMID: 34945739 PMCID: PMC8703270 DOI: 10.3390/jpm11121267] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Revised: 11/16/2021] [Accepted: 11/28/2021] [Indexed: 12/25/2022] Open
Abstract
Intravenous dexamethasone and dexmedetomidine, in conjunction with peripheral nerve blockade, have each been reported to prolong the duration of analgesia. This study tested whether combined use further prolongs analgesia duration after supraclavicular brachial plexus block (BPB) in patients undergoing orthopedic upper extremity surgery. One hundred twenty patients were randomized 1:1:1:1 to Control (saline bolus and midazolam infusion [0.05 mg/kg loading, 20 µg/kg/h thereafter]); DMED (saline bolus and dexmedetomidine infusion [1 μg/kg loading, 0.4 μg/kg/h thereafter]); DEXA (dexamethasone [10 mg] bolus and midazolam infusion); and DMED-DEXA (dexmedetomidine infusion and dexamethasone bolus) groups. The primary outcome was the duration of postoperative analgesia, defined as the time from the end of the BPB to the first dose of analgesia via a patient-controlled device. Median (interquartile range) times to first dose of analgesia in the Control, DMED, DEXA, and DMED-DEXA groups were 8.1 (6.2–11.6), 9.0 (8.1–11.3), 10.7 (8.1–20.5), and 13.2 (11.5–19.1) hours, respectively (p < 0.001). Pairwise comparisons showed significant prolongation of analgesia in the DEXA included groups compared with the non-DEXA included groups (DEXA vs. control, p = 0.045; DEXA vs. DMED, p = 0.045; DMED-DEXA vs. control, p < 0.001; DMED-DEXA vs. DMED, p < 0.001). A mixed effect model showed that dexamethasone was the only significant factor for the prolongation of analgesia (p < 0.001). Intravenous dexamethasone prolonged the analgesia duration of supraclavicular BPB after orthopedic upper extremity surgery. The concurrent use of mild to moderate sedation dose of intravenous dexmedetomidine in addition to intravenous dexamethasone showed no additional benefit to the prolongation of analgesia.
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Affiliation(s)
- Boohwi Hong
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, 282 Munhwa-ro, Jung-gu, Daejeon 35015, Korea; (B.H.); (C.O.); (Y.J.); (W.C.); (E.P.); (H.P.)
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chungnam National University, 266 Munhwa-ro, Jung-gu, Daejeon 35015, Korea
- Big Data Center, Biomedical Research Institute, Chungnam National University Hospital, 282 Munhwa-ro, Jung-gu, Daejeon 35015, Korea
| | - Chahyun Oh
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, 282 Munhwa-ro, Jung-gu, Daejeon 35015, Korea; (B.H.); (C.O.); (Y.J.); (W.C.); (E.P.); (H.P.)
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chungnam National University, 266 Munhwa-ro, Jung-gu, Daejeon 35015, Korea
| | - Yumin Jo
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, 282 Munhwa-ro, Jung-gu, Daejeon 35015, Korea; (B.H.); (C.O.); (Y.J.); (W.C.); (E.P.); (H.P.)
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chungnam National University, 266 Munhwa-ro, Jung-gu, Daejeon 35015, Korea
| | - Woosuk Chung
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, 282 Munhwa-ro, Jung-gu, Daejeon 35015, Korea; (B.H.); (C.O.); (Y.J.); (W.C.); (E.P.); (H.P.)
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chungnam National University, 266 Munhwa-ro, Jung-gu, Daejeon 35015, Korea
| | - Eunhye Park
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, 282 Munhwa-ro, Jung-gu, Daejeon 35015, Korea; (B.H.); (C.O.); (Y.J.); (W.C.); (E.P.); (H.P.)
| | - Hanmi Park
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, 282 Munhwa-ro, Jung-gu, Daejeon 35015, Korea; (B.H.); (C.O.); (Y.J.); (W.C.); (E.P.); (H.P.)
| | - Seokhwa Yoon
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, 282 Munhwa-ro, Jung-gu, Daejeon 35015, Korea; (B.H.); (C.O.); (Y.J.); (W.C.); (E.P.); (H.P.)
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chungnam National University, 266 Munhwa-ro, Jung-gu, Daejeon 35015, Korea
- Correspondence:
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23
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Sirivanasandha B, Sutthivaiyakit K, Kerdchan T, Poolsuppasit S, Tangwiwat S, Halilamien P. Adding a low-concentration sciatic nerve block to total knee arthroplasty in patients susceptible to the adverse effects of non-steroidal anti-inflammatory drugs (NSAIDs): a randomized controlled trial. BMC Anesthesiol 2021; 21:282. [PMID: 34773995 PMCID: PMC8590368 DOI: 10.1186/s12871-021-01491-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 10/27/2021] [Indexed: 11/25/2022] Open
Abstract
Background This study compared the effects of adductor canal blocks with those of a low concentration of popliteal-sciatic nerve block (SNB) and dexamethasone as an adjunctive technique for total knee arthroplasties (TKA) in patients susceptible to the adverse effects of NSAIDs. Methods A prospective, double-blinded, randomized controlled trial was performed in 50 patients susceptible to the adverse effects of NSAIDs undergoing unilateral TKAs. All patients received spinal anesthesia, adductor canal blocks, and periarticular infiltration. The 25 patients in the intervention group received SNB (0.125% bupivacaine [20 ml] and dexamethasone [5 mg]). Results The SNB group significantly had lower median resting pain scores at 6, 12, and 18 h: the control group, 1 (0–4.5), 3 (0–5), and 3 (2–5); the intervention group, 0 (0–0), 0 (0–3), and 1 (0–3); p-values, 0.012, 0.021, and 0.010, respectively. Movement-evoked pain scores at 6, 12, and 18 h were also lower: control group, 3 (0–5.5), 5 (2.5–6.5), and 7 (4–9); intervention group, 0 (0–1.5), 2 (0–4), and 3 (2–5); p-values, 0.019, 0.005, and 0.001, respectively. There were no differences in motor function. Moreover, the mean morphine consumption 24 h was also reduced in the SNB group: control group, 3.80 ± 2.48 mg; intervention group, 1.96 ± 2 mg; p-value, 0.005. Conclusion For patients susceptible to the adverse effects of NSAIDs, a low concentration of SNB and dexamethasone is an effective adjunctive technique for early postoperative pain control (especially on movement) following TKAs, without an increase in motor weakness. Trial registration ClinicalTrials.gov, NCT03486548, Registered 3 April 2018.
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Affiliation(s)
- Busara Sirivanasandha
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkok Noi, Bangkok, 10700, Thailand.
| | - Kulwadee Sutthivaiyakit
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkok Noi, Bangkok, 10700, Thailand
| | - Thippatai Kerdchan
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkok Noi, Bangkok, 10700, Thailand
| | - Suppachai Poolsuppasit
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkok Noi, Bangkok, 10700, Thailand
| | - Suwimon Tangwiwat
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkok Noi, Bangkok, 10700, Thailand
| | - Pathom Halilamien
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkok Noi, Bangkok, 10700, Thailand
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Veena G, Pangotra A, Kumar S, Prakash J, Rao NS, Priye S. Comparison of Perineural and Intravenous Dexamethasone as an Adjuvant to Levobupivacaine in Ultrasound-Guided Infraclavicular Brachial Plexus Block: A prospective Randomized Trial. Anesth Essays Res 2021; 15:45-50. [PMID: 34667347 PMCID: PMC8462415 DOI: 10.4103/aer.aer_69_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 06/18/2021] [Accepted: 06/18/2021] [Indexed: 12/04/2022] Open
Abstract
Background: The effect of perineural versus intravenous (i.v.) dexamethasone (4 mg) when added to levobupivacaine as an adjuvant has not been well studied. Aims: This study was conducted to compare the analgesic efficacy of perineural and i.v. dexamethasone as an adjuvant to levobupivacaine in infraclavicular brachial plexus (ICBP) block. Settings and Design: This was a prospective, randomized, double-blind study. Materials and Methods: This study was conducted on 68 patients with the ultrasound-guided ICBP block, randomly allocated into two groups (34 each). Four patients had failed block (2 in each group) that was excluded from the study. Group A received 25 mL of levobupivacaine 0.5% and 1 mL of normal saline for the block and i.v. dexamethasone 4 mg. Group B received 25 mL of levobupivacaine 0.5% with 4 mg of perineural dexamethasone for the block. Postoperative vitals and different block characteristics were assessed. Statistical Analysis Used: Student's independent sample t-test and Chi-square test were used for statistical analysis. Results: The duration of motor block and analgesia in Group A was 1245.94 ± 153.22 min and 1310.16 ± 151.68 min, respectively. However, in Group B, the duration of motor block and analgesia was 1768.13 ± 309.86 min and 1743.59 ± 231.39 min, respectively, which was more when compared to Group A (P < 0.001). The Visual Analog Scale score of ≥3 in Group A was 37% and in Group B was 9% (P = 0.008). Four cases had delayed regression of motor block in the perineural group. Conclusions: Perineural dexamethasone significantly prolonged the duration of motor block promoted by levobupivacaine in infraclavicular brachial plexus block, reduced pain intensity and rescue analgesia needs in the postoperative period when compared with the intravenous dexamethasone.
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Affiliation(s)
- G Veena
- Department of Anaesthesia, Vydehi Institute of Medical Sciences and Research Centre, Bengaluru, Karnataka, India
| | - Anshu Pangotra
- Department of Superspeciality Anaesthesia, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India
| | - Shailesh Kumar
- Department of Anaesthesia, MVJ Medical College and Research Hospital, Bengaluru, Karnataka, India
| | - Jay Prakash
- Department of Critical Care Medicine, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India
| | - Natesh S Rao
- Department of Anaesthesia, Vydehi Institute of Medical Sciences and Research Centre, Bengaluru, Karnataka, India
| | - Shio Priye
- Department of Superspeciality Anaesthesia, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India
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25
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Woo JH, Lee HJ, Oh HW, Lee JW, Baik HJ, Kim YJ. Perineural dexamethasone reduces rebound pain after ropivacaine single injection interscalene block for arthroscopic shoulder surgery: a randomized controlled trial. Reg Anesth Pain Med 2021; 46:965-970. [PMID: 34535548 DOI: 10.1136/rapm-2021-102795] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 08/25/2021] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND OBJECTIVES A single injection interscalene block (ISB) is a common regional analgesic technique in patients undergoing arthroscopic shoulder surgery. However, rebound pain after ISB resolution may reduce its overall benefit. Our primary aim was to assess whether perineural dexamethasone reduces the intensity and incidence of rebound pain in patients undergoing arthroscopic shoulder surgery under general anesthesia combined with a preoperative single injection ISB. METHODS The patients were randomly assigned to receive single injection ISB using either 0.5% ropivacaine (control) or 0.5% ropivacaine containing 5 mg of dexamethasone. The primary outcomes were the pain score difference before and after ISB resolution, and the incidence of rebound pain. The secondary outcomes were the onset and duration of rebound pain, the presence of sleep disturbances due to postoperative pain, the first time when an analgesic was requested, and pain scores at various predefined time points. RESULTS Pain increase following ISB resolution was lower in the dexamethasone group compared with the control group (4.5±2.4 and 6.9±2.2, respectively, p<0.001). The incidence of rebound pain was significantly lower in the dexamethasone group compared with the control group (37.1% and 82.9%, respectively, p<0.001). The controls experienced greater sleep disturbance during the postoperative period compared with those who received ISB with perineural dexamethasone. CONCLUSIONS Perineural dexamethasone added to ISB using ropivacaine led to a much smoother resolution of ISB, reflected in a significantly smaller increase in pain after block resolution, a lower incidence of rebound pain and a lower sleep disturbance during the first postoperative week. TRIAL REGISTRATION NUMBER Clinical Trial Registry of Korea (KCT0004418).
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Affiliation(s)
- Jae Hee Woo
- Department of Anesthesiology and Pain Medicine, College of Medicine, Ewha Womans University, Seoul, South Korea
| | - Hyun Jung Lee
- Department of Anesthesiology and Pain Medicine, College of Medicine, Ewha Womans University, Seoul, South Korea
| | - Hye-Won Oh
- Department of Anesthesiology and Pain Medicine, College of Medicine, Ewha Womans University, Seoul, South Korea
| | - Jong Wha Lee
- Department of Anesthesiology and Pain Medicine, College of Medicine, Ewha Womans University, Seoul, South Korea
| | - Hee Jung Baik
- Department of Anesthesiology and Pain Medicine, College of Medicine, Ewha Womans University, Seoul, South Korea
| | - Youn Jin Kim
- Department of Anesthesiology and Pain Medicine, College of Medicine, Ewha Womans University, Seoul, South Korea
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26
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Aoyama Y, Sakura S, Abe S, Uchimura E, Saito Y. Effects of the addition of dexamethasone on postoperative analgesia after anterior cruciate ligament reconstruction surgery under quadruple nerve blocks. BMC Anesthesiol 2021; 21:218. [PMID: 34496755 PMCID: PMC8425164 DOI: 10.1186/s12871-021-01440-4] [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] [Received: 05/19/2021] [Accepted: 08/28/2021] [Indexed: 11/13/2022] Open
Abstract
Background Anterior cruciate ligament (ACL) reconstruction is an invasive surgical procedure for the knee. Quadruple nerve blocks including continuous femoral nerve block and single-injection sciatic, obturator, and lateral femoral cutaneous nerve blocks can provide effective intraoperative anesthesia and analgesia in the early postoperative period. However, severe pain often appears after the effect of single-injection nerve blocks resolves and that is why we conducted two studies. The first study was to determine whether dexamethasone administered along with local anesthetic for sciatic nerve block could prolong the duration of analgesia in patients given quadruple nerve blocks, including continuous femoral nerve block, for ACL reconstruction using a hamstring tendon autograft. The second study was designed to evaluate any difference in effects from dexamethasone administered perineurally versus intravenously. Methods Patients undergoing unilateral arthroscopic ACL reconstruction using a hamstring tendon autograft were enrolled into two studies. The first study was prospectively conducted to see if dexamethasone 4 mg could prolong the duration of analgesia when administered perineurally to the subgluteal sciatic nerve with 0.5% ropivacaine. In the second study, we retrospectively evaluated the effects of intravenous dexamethasone 4 mg as compared with those of perineural dexamethasone to the sciatic nerve block and effects with no dexamethasone. Results In the first study, perineural dexamethasone prolonged the duration of analgesia by 9.5 h (median duration: 22.5 and 13.0 h with and without perineural dexamethasone, respectively, P = 0.011). In the second study, the duration of analgesia was similarly prolonged for intravenous and perineural dexamethasone compared with no dexamethasone. Conclusion Perineural dexamethasone administered along with local anesthetic for single sciatic nerve block prolonged the duration of analgesia of quadruple nerve blocks for ACL reconstruction, however the effects were not different from those of intravenous dexamethasone. Trial registration The protocols of both studies were approved by the Institutional Review Board of Shimane University Hospital, Japan (study number 2821 and 3390 for study 1 and study 2, respectively). Study 1 was registered in University Hospital Medical Information Network Clinical Trials Registry (UMIN000028930). Study 2, which was a retrospective study, was not registered.
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Affiliation(s)
- Yuki Aoyama
- Department of Anesthesiology, Faculty of Medicine, Shimane University, 89-1 Enya-cho, Izumo City, Shimane, 693-8501, Japan
| | - Shinichi Sakura
- Department of Anesthesiology, Faculty of Medicine, Shimane University, 89-1 Enya-cho, Izumo City, Shimane, 693-8501, Japan.
| | - Shoko Abe
- Department of Anesthesiology, Faculty of Medicine, Shimane University, 89-1 Enya-cho, Izumo City, Shimane, 693-8501, Japan
| | - Erika Uchimura
- Department of Anesthesiology, Faculty of Medicine, Shimane University, 89-1 Enya-cho, Izumo City, Shimane, 693-8501, Japan
| | - Yoji Saito
- Department of Anesthesiology, Faculty of Medicine, Shimane University, 89-1 Enya-cho, Izumo City, Shimane, 693-8501, Japan
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27
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Barad M, Ailani J, Hakim SM, Kissoon NR, Schuster NM. Percutaneous Interventional Strategies for Migraine Prevention: A Systematic Review and Practice Guideline. PAIN MEDICINE 2021; 23:164-188. [PMID: 34382092 DOI: 10.1093/pm/pnab236] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To systematically evaluate the efficacy and effectiveness of percutaneous interventional treatments for prevention of migraine through a qualitative and (when possible) quantitative analysis. METHODS An expert panel was asked to develop recommendations for the multidisciplinary preventive treatment of migraine, including interventional strategies. The committee conducted a systematic review and (when evidence was sufficient) a meta-analytic review using GRADE criteria and the modified Cochrane risk of bias analysis available in the Covidence data management program. Clinical questions addressed adults with migraine who should be offered prevention. Examined outcomes included headache days, acute medication use, and functional impairment. Acute management of migraine was outside the scope of this guideline. RESULTS The committee screened 1195 studies and assessed 352 by full text, yielding 16 randomized controlled trials that met inclusion criteria. RECOMMENDATIONS/CONCLUSIONS As informed by evidence related to the preselected outcomes, adverse event profile, cost, and values and preferences of patients, onabotulinumtoxinA received a strong recommendation for chronic migraine prevention and a weak recommendation against use for episodic migraine prevention. Greater occipital nerve blocks received a weak recommendation for chronic migraine prevention. For greater occipital nerve block, steroid received a weak recommendation against use vs local anesthetic alone. Occipital nerve with supraorbital nerve blocks, sphenopalatine ganglion blocks, cervical spine percutaneous interventions, and implantable stimulation all received weak recommendations for chronic migraine prevention. The committee found insufficient evidence to assess trigger point injections in migraine prevention and highly discouraged use of intrathecal medication.
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Affiliation(s)
- Meredith Barad
- Anesthesia (Pain Management) and Neurology and Neurological Sciences, Stanford Hospital and Clinics, Stanford, California, USA
| | - Jessica Ailani
- Neurology, Medstar Georgetown University, Washington, DC, USA
| | - Sameh M Hakim
- Anesthesiology, Intensive Care, and Pain Management, Ain Shams University Faculty of Medicine, Cairo, Egypt
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Hanson NA, Lavallee MB, Thiele RH. Apophenia and anesthesia: how we sometimes change our practice prematurely. Can J Anaesth 2021; 68:1185-1196. [PMID: 33963519 PMCID: PMC8104920 DOI: 10.1007/s12630-021-02005-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 02/08/2021] [Accepted: 02/16/2021] [Indexed: 12/21/2022] Open
Abstract
Human beings are predisposed to identifying false patterns in statistical noise, a likely survival advantage during our evolutionary development. Moreover, humans seem to prefer "positive" results over "negative" ones. These two cognitive features lay a framework for premature adoption of falsely positive studies. Added to this predisposition is the tendency of journals to "overbid" for exciting or newsworthy manuscripts, incentives in both the academic and publishing industries that value change over truth and scientific rigour, and a growing dependence on complex statistical techniques that some reviewers do not understand. The purpose of this article is to describe the underlying causes of premature adoption and provide recommendations that may improve the quality of published science.
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Affiliation(s)
- Neil A Hanson
- Department of Anesthesiology, University of Virginia Health System, PO Box 800710, ville, VA, 22908-0710, USA.
| | - Matthew B Lavallee
- Department of Anesthesiology, University of Virginia Health System, PO Box 800710, ville, VA, 22908-0710, USA
| | - Robert H Thiele
- Department of Anesthesiology, University of Virginia Health System, PO Box 800710, ville, VA, 22908-0710, USA
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29
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Xuan C, Yan W, Wang D, Li C, Ma H, Mueller A, Wang J. The Facilitatory Effects of Adjuvant Pharmaceutics to Prolong the Duration of Local Anesthetic for Peripheral Nerve Block: A Systematic Review and Network Meta-analysis. Anesth Analg 2021; 133:620-629. [PMID: 34153021 DOI: 10.1213/ane.0000000000005640] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Peripheral nerve block (PNB) with perineural local anesthetic is used for anesthesia or analgesia with many benefits. To extend these benefits, various adjuvant drugs have been used to prolong the duration of analgesia. We aimed to evaluate the effectiveness of various adjuvants at prolonging the duration of sensory and motor blockade for PNB. METHODS A network meta-analysis of placebo-controlled and active randomized controlled trials was performed comparing 10 adjuvants. Embase, PubMed, Web of Science, and Cochrane library were searched, with articles before May 21, 2020 included. Two authors independently selected studies and extracted data. The primary outcomes were sensory block (SB) and motor block (MB) time, and the secondary outcome was time of first analgesia rescue (FAR). Effect size measures were described as mean differences (MD) with 95% confidence intervals (CIs). Confidence in evidence was assessed using Confidence in Network Meta-Analysis (CINeMA). The study protocol was preregistered with the prospectively registered systematic reviews in health and social care international database (PROSPERO), as number CRD42020187866. RESULTS Overall 16,364 citations were identified, of which 53 studies were included with data for 3649 patients. In network meta-analyses, 4 of 7 included treatment strategies were associated with more efficacious analgesia compared with placebo therapy, including dexamethasone (SB time: 5.73 hours, 95% CI, 4.16-7.30; MB time: 4.20 hours, 95% CI, 2.51-5.89; time of FAR: 8.71 hours, 95% CI, 6.63-10.79), dexmedetomidine (SB time: 4.51 hours, 95% CI, 3.52-5.50; MB time: 4.04 hours, 95% CI, 2.98-5.11; time of FAR: 5.25 hours, 95% CI, 4.08-6.43), fentanyl (SB time: 3.59 hours, 95% CI, 0.11-7.06; MB time: 4.42 hours, 95% CI, 0.78-8.06), and clonidine (SB time: 2.75 hours, 95% CI, 1.46-4.04; MB time: 2.93 hours, 95% CI, 1.69-4.16; time of FAR: 3.35 hours, 95% CI, 1.82-4.87). In a subgroup analysis, addition of dexamethasone to ropivacaine significantly increased the time of FAR when compared to dexmedetomidine (time of FAR: 5.23 hours, 95% CI, 2.92-7.54) or clonidine (time of FAR: 6.61 hours, 95% CI, 4.29-8.92) with ropivacaine. CONCLUSIONS These findings provide evidence for the consideration of dexmedetomidine, dexamethasone, and clonidine as adjuvants to prolong the duration of PNB. The addition of dexamethasone to ropivacaine has a longer time of FAR compared with clonidine or dexmedetomidine.
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Affiliation(s)
- Chengluan Xuan
- From the Department of Anesthesia, The First Hospital of Jilin University, Jilin, China
| | - Wen Yan
- Department of Anesthesia, The Second Hospital of Jilin University, Jilin, China
| | - Dan Wang
- From the Department of Anesthesia, The First Hospital of Jilin University, Jilin, China
| | - Cong Li
- From the Department of Anesthesia, The First Hospital of Jilin University, Jilin, China
| | - Haichun Ma
- From the Department of Anesthesia, The First Hospital of Jilin University, Jilin, China
| | - Ariel Mueller
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jingping Wang
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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Margulis R, Francis J, Tischenkel B, Bromberg A, Pedulla D, Grtisenko K, Cornett EM, Kaye AD, Imani F, Imani F, Shaparin N, Vydyanathan A. Comparison of Dexmedetomidine and Dexamethasone as Adjuvants to Ultra-Sound Guided Interscalene Block in Arthroscopic Shoulder Surgery: A Double-Blinded Randomized Placebo-Controlled Study. Anesth Pain Med 2021; 11:e117020. [PMID: 34540645 PMCID: PMC8438728 DOI: 10.5812/aapm.117020] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Revised: 06/22/2021] [Accepted: 06/22/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Interscalene block is one of the popular methods for decreasing pain and analgesic consumption after shoulder arthroscopic surgeries. OBJECTIVES The objective is to compare the analgesic duration of effects of dexmedetomidine and dexamethasone as adjuvants to 0.5% ropivacaine in ultrasound-guided interscalene blocks for arthroscopic shoulder surgery in an ambulatory setting. METHODS In this randomized controlled trial, 117 adult patients candidate for ambulatory arthroscopic shoulder surgery under general anesthesia were divided into three groups to perform an ultra-sound guided interscalene block before the surgery. The ropivacaine (control) group received ropivacaine 0.5% 20 mL, group Dexamethasone received ropivacaine 0.5% 20 mL plus 4mg dexamethasone, and group dexmedetomidine received ropivacaine 0.5% 20 mL plus 75 mcg of dexmedetomidine. Time to return of sensory function, of motor function, of first pain sensation, amount of opioid medication consumed at 24 hours and 48 hours post-operatively were measured. RESULTS The 24-hour median (25th- 75th percentile) opioid consumption in morphine equivalents was similar between groups 22.5 mg (10 - 30), 15 mg (0 - 30), and 15 mg (0 - 20.6) in the ropivacaine, dexmedetomidine, and dexamethasone groups, respectively (P = 0.130). The median (25th- 75th percentile) 48 hours post-operatively, the median opioid consumption in morphine equivalents was 40 mg (25 - 67.5) in the ropivacaine group, 30 mg (22 - 50.6) in the dexamethasone group, and 52.5 mg (30 - 75) in the dexmedetomidine group (P = 0.278). The median 24-hour pain scores were 6 (5 - 8) in the ropivacaine control group, 7 (5.5 - 8) in the dexamethasone group, and 7 (4 - 9) in the dexmedetomidine group (P = 0.573). CONCLUSIONS There was no statistical difference in opioid consumption at 24 and 48 hours post-operatively when comparing dexmedetomidine, dexamethasone, and no adjuvant. However, intraoperative opioid use was significantly lower with dexmedetomidine compared to dexamethasone and plain 0.5% ropivacaine. The safe side effect profile of dexmedetomidine makes it a reasonable alternative as an adjuvant for peripheral nerve blockade when dexamethasone use may be contraindicated.
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Affiliation(s)
- Roman Margulis
- Department of Anesthesiology, Montefiore Medical Center, Bronx, NY, USA
| | - Jacquelyn Francis
- Department of Anesthesiology, Montefiore Medical Center, Bronx, NY, USA
| | - Bryan Tischenkel
- Department of Anesthesiology, Montefiore Medical Center, Bronx, NY, USA
| | - Adam Bromberg
- Department of Anesthesiology, Montefiore Medical Center, Bronx, NY, USA
| | | | | | - Elyse M. Cornett
- Louisiana State University Health Shreveport, Department of Anesthesiology, Shreveport, LA, USA
| | - Alan D. Kaye
- Louisiana State University Health Shreveport, Department of Anesthesiology, Shreveport, LA, USA
| | - Farnad Imani
- Pain Research Center, Department of Anesthesiology and Pain Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Farsad Imani
- Department of Anesthesiology, Tehran University of Medical Sciences, Tehran, Iran
| | - Naum Shaparin
- Department of Anesthesiology, Montefiore Medical Center, Bronx, NY, USA
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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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Fang J, Shi Y, Du F, Xue Z, Cang J, Miao C, Zhang X. The effect of perineural dexamethasone on rebound pain after ropivacaine single-injection nerve block: a randomized controlled trial. BMC Anesthesiol 2021; 21:47. [PMID: 33579199 PMCID: PMC7879628 DOI: 10.1186/s12871-021-01267-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 02/04/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Rebound pain after a single-shot nerve block challenges the real benefit of this technique. We aimed to investigate whether perineural dexamethasone addition decreased the incidence of rebound pain after a single-shot nerve block. METHODS We randomly allocated 132 patients scheduled for open reduction internal fixation of an upper extremity closed fracture under single-shot peripheral nerve block and sedation into two groups. Patients in the dexamethasone group received nerve block with 0.375% ropivacaine and 8 mg dexamethasone, while those in the control group received ropivacaine only. Sixty-three patients in the dexamethasone group and 60 patients in the control group were analyzed for the incidence of rebound pain 48 h after block administration, which was the primary outcome. The secondary outcomes included the highest self-reported numeric rating scale (NRS) pain score, and NRS at 8, 12, 24, and 48 h after the block, sufentanil consumption, sleep quality on the night of surgery, patient satisfaction with the pain therapy, blood glucose at 6 h after the block, pain and paresthesia at 30 days after surgery. RESULTS The incidence of rebound pain was significantly lower in the dexamethasone group (7 [11.1%] of 63 patients) than in the control group (28 [48.8%] of 60 patients [RR = 0.238, 95% CI (0.113-0.504), p = 0.001]. Dexamethasone decreased opioid consumption in 24 h after surgery (p < 0.001) and improved the sleep quality score on the night of surgery (p = 0.01) and satisfaction with pain therapy (p = 0.001). Multivariate logistic regression analysis showed that only group allocation was associated with the occurrence of rebound pain [OR = 0.062, 95% CI (0.015-0.256)]. Patients in the dexamethasone group reported later onset pain (19.7 ± 6.6 h vs 14.7 ± 4.8 h since block administration, mean ± SD, p < 0.001) and lower peak NRS scores [5 (3, 6) vs 8 (5, 9), median (IQR), p < 0.001] than those in the control group. CONCLUSIONS The perineural administration of 8 mg dexamethasone reduces rebound pain after a single-shot nerve block in patients receiving ORIF for an upper limb fracture. TRIAL REGISTRATION This study was retrospectively registered in the Chinese Clinical Trial Registry ( ChiCTR-IPR-17011365 ) on May 11th, 2017.
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Affiliation(s)
- Jie Fang
- Department of Anesthesiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yuncen Shi
- Department of Anesthesiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Fang Du
- Department of Anesthesiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zhanggang Xue
- Department of Anesthesiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jing Cang
- Department of Anesthesiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Changhong Miao
- Department of Anesthesiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xiaoguang Zhang
- Department of Anesthesiology, Zhongshan Hospital, Fudan University, Shanghai, China. .,Department of Anesthesiology, Jinshan Hospital of Fudan University, Shanghai, China.
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Chazapi A, Lepetsos P, Gambopoulou Z, Siafaka I, Argyra E, Vadalouka A. Analgesic Effect of the Topical Use of Dexamethasone in Ultrasound-Guided Axillary Brachial Plexus Blockade: A Prospective, Randomized, Double-Blind, Placebo-Controlled Study. Cureus 2021; 13:e12971. [PMID: 33654632 PMCID: PMC7913892 DOI: 10.7759/cureus.12971] [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: 11/10/2022] Open
Abstract
Introduction Increasing the duration of regional anesthesia in orthopedic surgery is of vital importance, as it prolongs postoperative analgesia, allowing faster rehabilitation of patients. Dexamethasone has been found to extend the block duration in animal and human studies. The aim of this study is the assessment of the effect of the addition of dexamethasone to ropivacaine on the onset and duration of axillary brachial plexus block, along with the intensity of postoperative pain. Methods Forty patients undergoing below-elbow surgery under ultrasound-guided axillary brachial plexus block were randomly allocated to receive either 30 mL ropivacaine 0.75% with 2 mL of saline (Group A, n = 20) or 30 mL ropivacaine 0.75% with 2 mL of dexamethasone (4 mg) (Group B, n = 20). Sensory and motor blockade were assessed, with the use of the pinprick test and the modified Bromage scale, at five, 10, 15, and 20 min after the block. The duration of analgesia, intensity of postoperative pain, postoperative opioid consumption, overall satisfaction, and perioperative complications were compared between the two groups. Results We found no difference at the mean onset time of the sensory and motor block between the two groups. The mean duration of postoperative analgesia was three hours higher in the dexamethasone group (15.85 ± 4.82 versus 11.75 ± 6.81, p-value = 0.035). Pain intensity was lower in the dexamethasone group, at six and 12 hours after surgery (3.45 ± 1.79 versus 4.65 ± 1.79, p-value = 0.040). Postoperative opioid consumption, patient overall satisfaction, and perioperative complications were not significantly different between groups. Conclusions Dexamethasone prolongs the duration of ropivacaine in an axillary brachial plexus block and decreases postoperative pain in patients subjected to below-elbow surgery.
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Affiliation(s)
| | | | | | - Ioanna Siafaka
- 1st Department of Anaesthesiology, University of Athens Medical School, Athens, GRC
| | - Erifylli Argyra
- 1st Department of Anaesthesiology, University of Athens Medical School, Athens, GRC
| | - Athina Vadalouka
- 1st Department of Anaesthesiology, University of Athens Medical School, Athens, GRC
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Desai N, Kirkham KR, Albrecht E. Local anaesthetic adjuncts for peripheral regional anaesthesia: a narrative review. Anaesthesia 2021; 76 Suppl 1:100-109. [PMID: 33426668 DOI: 10.1111/anae.15245] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/29/2020] [Indexed: 12/13/2022]
Abstract
Moderate-to-severe postoperative pain persists for longer than the duration of single-shot peripheral nerve blocks and hence continues to be a problem even with the routine use of regional anaesthesia techniques. The administration of local anaesthetic adjuncts, defined as the concomitant intravenous or perineural injection of one or more pharmacological agents, is an attractive and technically simple strategy to potentially extend the benefits of peripheral nerve blockade beyond the conventional maximum of 8-14 hours. Historical local anaesthetic adjuncts include perineural adrenaline that has been demonstrated to increase the mean duration of analgesia by as little as just over 1 hour. Of the novel local anaesthetic adjuncts, dexmedetomidine and dexamethasone have best demonstrated the capacity to considerably improve the duration of blocks. Perineural dexmedetomidine and dexamethasone increase the mean duration of analgesia by up to 6 hour and 8 hour, respectively, when combined with long-acting local anaesthetics. The evidence for the safety of these local anaesthetic adjuncts continues to accumulate, although the findings of a neurotoxic effect with perineural dexmedetomidine during in-vitro studies are conflicting. Neither perineural dexmedetomidine nor dexamethasone fulfils all the criteria of the ideal local anaesthetic adjunct. Dexmedetomidine is limited by side-effects such as bradycardia, hypotension and sedation, and dexamethasone slightly increases glycaemia. In view of the concerns related to localised nerve and muscle injury and the lack of consistent evidence for the superiority of the perineural vs. systemic route of administration, we recommend the off-label use of systemic dexamethasone as a local anaesthetic adjunct in a dose of 0.1-0.2 mg.kg-1 for all patients undergoing surgery associated with significant postoperative pain.
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Affiliation(s)
- N Desai
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, UK.,King's College London, London, UK
| | - K R Kirkham
- Department of Anaesthesia and Pain Management, Toronto Western Hospital, University of Toronto, ON, Canada
| | - E Albrecht
- Department of Anaesthesia, University Hospital of Lausanne and University of Lausanne, Lausanne, Switzerland
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Santonastaso DP, DE Chiara A, Magnoni S, Martino C, Russo E, Agnoletti V. Single shot erector spinae plane block for intra and postoperative pain control in open nephroureterectomy: a nice surprise. Minerva Anestesiol 2020; 87:492-494. [PMID: 33331749 DOI: 10.23736/s0375-9393.20.15134-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Domenico P Santonastaso
- Anesthesiology and Intensive Care Unit, Azienda Romagna, M. Bufalini Hospital, Cesena, Forlì-Cesena, Italy -
| | - Annabella DE Chiara
- Anesthesiology and Intensive Care Unit, Azienda Romagna, M. Bufalini Hospital, Cesena, Forlì-Cesena, Italy
| | - Stefania Magnoni
- Specialization School in Anesthesiology, Resuscitation and Intensive Care, University of Bologna, Bologna, Italy
| | - Costanza Martino
- Anesthesiology and Intensive Care Unit, Azienda Romagna, M. Bufalini Hospital, Cesena, Forlì-Cesena, Italy
| | - Emanuele Russo
- Anesthesiology and Intensive Care Unit, Azienda Romagna, M. Bufalini Hospital, Cesena, Forlì-Cesena, Italy
| | - Vanni Agnoletti
- Anesthesiology and Intensive Care Unit, Azienda Romagna, M. Bufalini Hospital, Cesena, Forlì-Cesena, Italy
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Sehmbi H, Brull R, Ceballos KR, Shah UJ, Martin J, Tobias A, Solo K, Abdallah FW. Perineural and intravenous dexamethasone and dexmedetomidine: network meta-analysis of adjunctive effects on supraclavicular brachial plexus block. Anaesthesia 2020; 76:974-990. [PMID: 33118163 DOI: 10.1111/anae.15288] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/05/2020] [Indexed: 12/11/2022]
Abstract
Both perineural and intravenous dexamethasone and dexmedetomidine are used as local anaesthetic adjuncts to enhance peripheral nerve block characteristics. However, the effects of dexamethasone and dexmedetomidine based on their administration routes have not been directly compared, and the relative extent to which each adjunct prolongs sensory blockade remains unclear. This network meta-analysis sought to compare and rank the effects of perineural and intravenous dexamethasone and dexmedetomidine as supraclavicular block adjuncts. We sought randomised trials investigating the effects of adding perineural and intravenous dexamethasone or dexmedetomidine to long-acting local anaesthetics on supraclavicular block characteristics, including time to block onset and durations of sensory, motor and analgesic blockade. Data were compared and ranked according to relative effectiveness for each outcome. Our primary outcome was sensory block duration, with a 2-h difference considered clinically important. We performed a frequentist analysis, using the GRADE framework to appraise evidence. One-hundred trials (5728 patients) were included. Expressed as mean (95%CI), the control group (local anaesthetic alone) had a duration of sensory block of 401 (366-435) min, motor block duration of 369 (330-408) min and analgesic duration of 435 (386-483) min. Compared with control, sensory block was prolonged most by intravenous dexamethasone [mean difference (95%CI) 477 (160-795) min], followed by perineural dexamethasone [411 (343-480) min] and perineural dexmedetomidine [284 (235-333) min]. Motor block was prolonged most by perineural dexamethasone [mean difference (95%CI) 294 (236-352) min], followed by intravenous dexamethasone [289 (129-448)min] and perineural dexmedetomidine [258 (212-304)min]. Analgesic duration was prolonged most by perineural dexamethasone [mean difference (95%CI) 518 (448-589) min], followed by intravenous dexamethasone [478 (277-679) min] and perineural dexmedetomidine [318 (266-371) min]. Intravenous dexmedetomidine did not prolong sensory, motor or analgesic block durations. No major network inconsistencies were found. The quality of evidence for intravenous dexamethasone, perineural dexamethasone and perineural dexmedetomidine for prolongation of supraclavicular sensory block duration was 'low', 'very low' and 'low', respectively. Regardless of route, dexamethasone as an adjunct prolonged the durations of sensory and analgesic blockade to a greater extent than dexmedetomidine. Differences in block characteristics between perineural and intravenous dexamethasone were not clinically important. Intravenous dexmedetomidine did not affect block characteristics.
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Affiliation(s)
- H Sehmbi
- Department of Anesthesia and Peri-operative Medicine, London Health Sciences Centre, University of Western Ontario, London, ON, Canada
| | - R Brull
- Department of Anesthesia, Toronto Western Hospital, University of Toronto, Toronto, ON, Canada
| | - K R Ceballos
- Department of Anesthesia, University of Ottawa, ON, Canada
| | - U J Shah
- Department of Anesthesia and Peri-operative Medicine, London Health Sciences Centre, University of Western Ontario, London, ON, Canada
| | - J Martin
- Department of Anesthesia and Peri-operative Medicine, London Health Sciences Centre, University of Western Ontario, London, ON, Canada
| | - A Tobias
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - K Solo
- London Health Sciences Centre, University of Western Ontario, London, ON, Canada
| | - F W Abdallah
- Department of Anesthesiology and Pain Medicine, Ottawa Hospital Research Institute, University of Ottawa, ON, Canada
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Abstract
Trends in pediatric pain management are moving toward thinking beyond opioids. Regional anesthetic techniques, such as quadratus lumborum and erector spinae plane blocks, demonstrate efficacy and safety in pediatric populations. Extremity blocks with motor-sparing characteristics also are used. Adjuvants may be added to pediatric peripheral nerve blocks to increase duration of action and improve block efficacy. For medical management, pediatric pain management frequently uses nonopioid medications. These opioid-sparing medications and regional techniques are used to facilitate enhanced recovery after surgery in pediatric surgical patients. Virtual reality is a field where technology can aid in managing acute pain in pediatric patients.
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Affiliation(s)
- Charlotte M Walter
- Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2001, Cincinnati, OH 45229-3026, USA.
| | - Niekoo Abbasian
- Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2001, Cincinnati, OH 45229-3026, USA
| | - Vanessa A Olbrecht
- Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2001, Cincinnati, OH 45229-3026, USA
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Singariya G, Choudhary S, Kamal M, Seervi SN, Bihani P, Kumar M. Analgesic sparing effect of dexamethasone with levobupivacaine in quadratus lumborum block in patients undergoing unilateral inguinal hernia repair: A prospective randomised controlled trial. Indian J Anaesth 2020; 64:668-674. [PMID: 32934400 PMCID: PMC7457994 DOI: 10.4103/ija.ija_159_20] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 04/21/2020] [Accepted: 05/19/2020] [Indexed: 11/04/2022] Open
Abstract
Background Quadratus lumborum block (QLB) provides somatic and visceral analgesia to the lower thoracic and abdominal wall. The aim was to investigate the analgesic effect of dexamethasone with levobupivacaine in QLB in patients undergoing unilateral inguinal hernia repair surgery. Methods A total of 90 patients of American Society of Anaesthesiologists (ASA) I/II were randomly divided into two groups. Group L received 0.25% levobupivacaine (20 ml) + normal saline (1 ml) and group D received 0.25% levobupivacaine (20 ml) + 4 mg dexamethasone (1 ml) in QL plane on the operated side using ultrasound, after completion of surgery under spinal anaesthesia. The primary objective was to compare time for first rescue analgesia. The secondary objectives were total rescue analgesic consumption and numeric rating scale (NRS) in the first 24 h. Results The demographic data age, sex, height, weight and ASA were comparable in both groups. The mean time to request for first rescue analgesia was longer in group D compared to group L (1016.02 ± 205.97 min versus 640 ± 132.96 min; P < 0.0001). The mean total tramadol consumption in the first 24 h was lower in group D compared to group L (233.55 ± 86.92 mg versus 328.22 ± 78.74 mg; P < 0.0001). Patients in group D had significantly lower NRS scores at rest and on movement as compared to group L. Conclusions The addition of dexamethasone to levobupivacaine in QLB results in prolonged duration of postoperative analgesia, less rescue analgesic requirements and better quality of analgesia as compared to levobupivacaine in unilateral inguinal hernia repair surgery.
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Affiliation(s)
- Geeta Singariya
- Department of Anaesthesiology and Critical Care, Dr S N Medical College, Jodhpur, Rajasthan, India
| | - Sangeeta Choudhary
- Department of Anaesthesiology and Critical Care, Dr S N Medical College, Jodhpur, Rajasthan, India
| | - Manoj Kamal
- Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Satya Narayan Seervi
- Department of Anaesthesiology and Critical Care, Government Medical College, Pali, Rajasthan, India
| | - Pooja Bihani
- Department of Anaesthesiology and Critical Care, Dr S N Medical College, Jodhpur, Rajasthan, India
| | - Mritunjay Kumar
- Department of Anaesthesiology, Critical Care and Pain Medicine, All India Institute of Medical Sciences, New Delhi, India
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Peng C, Li C, Yuan B, Jiao J. The efficacy of dexamethasone on pain management for knee arthroscopy: A meta-analysis of randomized controlled trials. Medicine (Baltimore) 2020; 99:e19417. [PMID: 32311920 PMCID: PMC7220723 DOI: 10.1097/md.0000000000019417] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION The impact of dexamethasone on pain management for knee arthroscopy remains controversial. We conduct a systematic review and meta-analysis to explore the influence of dexamethasone for knee arthroscopy. METHODS We search PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases through October 2018 for randomized controlled trials (RCTs) assessing the effect of dexamethasone on pain intensity for patients with dental implant. This meta-analysis is performed using the random-effect model. RESULTS Four RCTs involving 228 patients are included in the meta-analysis. Overall, compared with control group for knee arthroscopy, dexamethasone supplementation has no notable effect on pain scores at 4 to 6 hours (Std. MD = 0.99; 95% CI = -2.97 to 4.95; P = .62), but exerts significantly favorable promotion to pain scores at 12 hours (Std. MD = -1.06; 95% CI = -1.43 to -0.69; P < .00001), duration of block (Std. MD = 1.87; 95% CI = 0.65 to 3.10; P = .003), time to first analgesic requirement (Std. MD = 0.90; 95% CI = 0.51 to 1.29; P < .00001), analgesic consumption (Std. MD = -1.62; 95% CI = -2.31 to -0.93; P < .00001), and patient satisfaction (Std. MD = 1.15; 95% CI = 0.73 to 1.58; P < .00001). CONCLUSIONS Dexamethasone supplementation has importantly positive influence on pain control for knee arthroscopy.
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Targeted Ultrasound-Guided Perineural Hydrodissection of the Sciatic Nerve for the Treatment of Piriformis Syndrome. Ultrasound Q 2020; 35:125-129. [PMID: 29727344 DOI: 10.1097/ruq.0000000000000360] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Piriformis syndrome is a common cause of lumbar, gluteal, and thigh pain, frequently associated with sciatic nerve symptoms. Potential etiologies include muscle injury or chronic muscle stretching associated with gait disturbances. There is a common pathological end pathway involving hypertrophy, spasm, contracture, inflammation, and scarring of the piriformis muscle, leading to impingement of the sciatic nerve. Ultrasound-guided piriformis injections are frequently used in the treatment of these pain syndromes, with most of the published literature describing injection of the muscle. We describe a safe, effective ultrasound-guided injection technique for the treatment of piriformis syndrome using targeted sciatic perineural hydrodissection followed by therapeutic corticosteroid injection.
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Nasr YM, Waly SH, Morsy AA. Scalp block for awake craniotomy: Lidocaine-bupivacaine versus lidocaine-bupivacaine with adjuvants. EGYPTIAN JOURNAL OF ANAESTHESIA 2020. [DOI: 10.1080/11101849.2020.1719301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Affiliation(s)
- Yasser M. Nasr
- Department of Anesthesia and Surgical Intensive Care, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Salwa H. Waly
- Department of Anesthesia and Surgical Intensive Care, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Ahmed A. Morsy
- Department of Neurosurgery, Faculty of Medicine, Zagazig University, Zagazig, Egypt
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Short A, El-Boghdadly K, Clarke H, Komaba T, Jin R, Chin KJ, Chan V. Effect of intravenous dexamethasone on the anaesthetic characteristics of peripheral nerve block: a double-blind, randomised controlled, dose–response volunteer study. Br J Anaesth 2020; 124:92-100. [DOI: 10.1016/j.bja.2019.08.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2019] [Revised: 08/12/2019] [Accepted: 08/28/2019] [Indexed: 11/29/2022] Open
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Hauritz RW, Hannig KE, Balocco AL, Peeters G, Hadzic A, Børglum J, Bendtsen TF. Peripheral nerve catheters: A critical review of the efficacy. Best Pract Res Clin Anaesthesiol 2019; 33:325-339. [PMID: 31785718 DOI: 10.1016/j.bpa.2019.07.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Accepted: 07/11/2019] [Indexed: 10/26/2022]
Abstract
Continuous peripheral nerve blocks are commonly used for postoperative analgesia after surgery. However, catheter failure may occur due to either primary (incorrect insertion) or secondary reasons (displacement, obstruction, disconnection). Catheter failure results in unanticipated pain, need for opioid use, and risk of readmission or delay in hospital discharge. This review aimed to assess definition and frequency of catheter failure, and discuss the alternatives to prolong duration of single-shot nerve blocks. A literature search was performed on peripheral catheters reporting failure as the main outcome measure. Thirty-three studies met the selection criteria, comprising 2711 catheters. Literature review suggests that peripheral nerve catheters have clinically significant failure rate when the assessment is performed using an objective (imaging) method. Subjective methods of assessment (without imaging) may underestimate the incidence of catheter failure.
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Affiliation(s)
- Rasmus W Hauritz
- Department of Anesthesia and Intensive Care Medicine, Kolding Hospital, Denmark
| | - Kjartan E Hannig
- Department of Anesthesia and Intensive Care Medicine, Kolding Hospital, Denmark
| | - Angela Lucia Balocco
- Department of Anesthesiology, Ziekenhuis Oost-Limburg, Schiepse Bos 6, 3600, Genk, Belgium.
| | - Gwendolyne Peeters
- Department of Anesthesiology, Ziekenhuis Oost-Limburg, Schiepse Bos 6, 3600, Genk, Belgium.
| | - Admir Hadzic
- Department of Anesthesiology, Ziekenhuis Oost-Limburg, Schiepse Bos 6, 3600, Genk, Belgium.
| | - Jens Børglum
- Department of Anesthesia and Intensive Care Medicine, Zealand University Hospital, Denmark
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Seering MS, Bayman EO, Wong CA, Ranganath YS, Marian AA. Comparison of the effect of three different adjuvants on the analgesic duration of single injection interscalene brachial plexus block: a prospective, randomized, triple blinded clinical trial. Reg Anesth Pain Med 2019; 44:rapm-2018-100201. [PMID: 31308262 DOI: 10.1136/rapm-2018-100201] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 06/12/2019] [Accepted: 06/17/2019] [Indexed: 11/03/2022]
Abstract
BACKGROUND AND OBJECTIVES Use of regional anesthesia can result in faster recovery and better patient satisfaction. Addition of perineural adjuncts to local anesthetics may improve the duration of analgesia, but there is a paucity of data comparing them in a single randomized trial. We compared the effects of three adjuncts clonidine, dexamethasone, and buprenorphine, on the duration of analgesia of interscalene brachial plexus block. METHODS 160 patients, undergoing elective shoulder surgery, were randomized to four groups to receive an interscalene block with one of the following solutions: ropivacaine alone, ropivacaine with clonidine 75 µg, ropivacaine with dexamethasone 8 mg, or ropivacaine with buprenorphine 300 µg. The primary outcome variable was the duration of analgesia; secondary outcome measures were time to onset of the block, and the duration of sensory and motor blocks. RESULTS There was no statistically significant difference in the total analgesia time among the four groups; p=0.11. The pairwise comparison in analgesic time and 99% CI were: control versus clonidine (-1.94 hours (-7.33 to 3.12)), control versus dexamethasone (-4.16 hours (-9.50 to 0.58)) and control versus buprenorphine (-1.1 hours (-5.34 to 3.23)). There was no differences in block set-up time, or total sensory and motor block duration among the groups. CONCLUSION There was no significant improvement in the duration of analgesia with addition of any of the three adjuncts to interscalene blocks. However, there was a larger than expected variability in patient response, hence the study may have been underpowered for the primary outcome.
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Affiliation(s)
- Melinda S Seering
- Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Emine O Bayman
- Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Cynthia A Wong
- Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | | | - Anil A Marian
- Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
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Tafelski S, Mohamed D, Shaqura M, Assaf C, Beyer A, Treskatsch S, Schäfer M, Mousa SA. Identification of mineralocorticoid and glucocorticoid receptors on peripheral nociceptors: Translation of experimental findings from animal to human biology. Brain Res 2019; 1712:180-187. [DOI: 10.1016/j.brainres.2019.02.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 02/04/2019] [Accepted: 02/12/2019] [Indexed: 11/30/2022]
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Abstract
A 79-year-old woman with primary erythromelalgia underwent a left reverse total shoulder arthroplasty with a left interscalene nerve block, a superficial cervical plexus block, and a general endotracheal anesthetic, with no residual neurological deficits. Herein, we discuss the classification and pathophysiology of erythromelalgia along with the anesthetic considerations of peripheral nerve blockade in patients with primary erythromelalgia.
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Kot P, Rodriguez P, Granell M, Cano B, Rovira L, Morales J, Broseta A, Andrés JD. The erector spinae plane block: a narrative review. Korean J Anesthesiol 2019; 72:209-220. [PMID: 30886130 PMCID: PMC6547235 DOI: 10.4097/kja.d.19.00012] [Citation(s) in RCA: 132] [Impact Index Per Article: 26.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Accepted: 03/13/2019] [Indexed: 11/17/2022] Open
Abstract
Regional anesthesia and pain management have experienced advances in recent years, especially with the advent of fascial plane blocks. The erector spinae plane block is one of the newest techniques to be described. In the past two years, publications referring to ESP block have increased significantly. The objective of this review is to analyze the articles about ESP block that have been published to date. We performed a search in the main databases and identified 368 articles. After a selection of the relevant articles, 125 studies were found eligible and were included in the review. The ESP block is performed by depositing the local anesthetic in the fascial plane, deeper than the erector spinae muscle at the tip of the transverse process of the vertebra. Many cases of its use have been described with satisfactory results in the treatment of both acute pain and chronic pain. The applicability of the technique covers many clinical scenarios. Of the 98 case reports reviewed, 12 and 87 articles, respectively described the technique as a treatment for chronic pain and acute pain. The single-shot was the most frequently used technique. As described in the articles published to date, the technique is easy to perform and has a low rate of complications. However, despite the effectiveness of the technique, further studies are necessary to obtain more evidence of its actions.
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Affiliation(s)
- Pablo Kot
- Department of Anesthesia, Critical Care and Pain Medicine, University General Hospital Consortium of Valencia, Spain
| | - Pablo Rodriguez
- Department of Anesthesia, Critical Care and Pain Medicine, University General Hospital Consortium of Valencia, Spain
| | - Manuel Granell
- Department of Anesthesia, Critical Care and Pain Medicine, University General Hospital Consortium of Valencia, Spain
| | - Beatriz Cano
- Department of Hospital Nursing, University General Hospital Consortium of Valencia, Valencia, Spain
| | - Lucas Rovira
- Department of Anesthesia, Critical Care and Pain Medicine, University General Hospital Consortium of Valencia, Spain
| | - Javier Morales
- Department of Anesthesia, Critical Care and Pain Medicine, University General Hospital Consortium of Valencia, Spain
| | - Ana Broseta
- Department of Anesthesia, Critical Care and Pain Medicine, University General Hospital Consortium of Valencia, Spain
| | - Jose De Andrés
- Department of Anesthesia, Critical Care and Pain Medicine, University General Hospital Consortium of Valencia, Spain
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Coppens SJ, Zawodny Z, Dewinter G, Neyrinck A, Balocco AL, Rex S. In search of the Holy Grail: Poisons and extended release local anesthetics. Best Pract Res Clin Anaesthesiol 2019; 33:3-21. [DOI: 10.1016/j.bpa.2019.03.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 03/12/2019] [Indexed: 11/17/2022]
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Marty P, Rontes O, Chassery C, Bataille B, Ferre F, Delbos A. Blinded by certainties. Reg Anesth Pain Med 2019; 44:419-420. [PMID: 30777906 DOI: 10.1136/rapm-2018-100319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 12/27/2018] [Indexed: 11/04/2022]
Affiliation(s)
- Philippe Marty
- Department of Anesthesia, Clinique Medipole Garonne, Toulouse, France
| | - Olivier Rontes
- Department of Anesthesia, Clinique Medipole Garonne, Toulouse, France
| | - Clement Chassery
- Department of Anesthesia, Clinique Medipole Garonne, Toulouse, France
| | - Benoit Bataille
- Department of Anesthesia and Intensive Care, Narbonne general Hospital, Narbonne, France
| | - Fabrice Ferre
- Department of Anesthesia, CHU Purpan, Toulouse, France
| | - Alain Delbos
- Department of Anesthesia, Clinique Medipole Garonne, Toulouse, France
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Clement JC, Besch G, Puyraveau M, Grelet T, Ferreira D, Vettoretti L, Pili-Floury S, Samain E, Berthier F. Clinical effectiveness of single dose of intravenous dexamethasone on the duration of ropivacaine axillary brachial plexus block: the randomized placebo-controlled ADEXA trial. Reg Anesth Pain Med 2019; 44:rapm-2018-100035. [DOI: 10.1136/rapm-2018-100035] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 08/20/2018] [Indexed: 11/04/2022]
Abstract
Background and objectivesThe effect of intravenous dexamethasone on the duration of axillary plexus block performed using ropivacaine is not described. The aim of this study is to assess the effect of intravenous dexamethasone on the duration of axillary plexus block analgesia after distal upper arm surgery.MethodsIn this prospective, randomized, placebo-controlled, double-blinded trial, consenting patients scheduled for hand or forearm surgery under ultrasound-guided axillary plexus block performed using 0.5 mL/kg of 0.475% ropivacaine, were randomized to receive an intravenous injection of either 8 mg/2 mL of dexamethasone (Dexa group) or 2 mL of saline (Control). The primary outcome was the time of first analgesic intake after axillary block. Secondary outcomes included motor or sensory block duration, total use of postoperative analgesics, and block-related complications.ResultsAmong the 98 patients included, 6 and 2 patients did not require postoperative analgesic intake in Dexa and Control groups, respectively (p=0.06). The time of first analgesic intake was significantly longer in the Dexa (20.9±9.3 hours) than in the Control group (14.7±6.6 hours, p<0.0004). Motor and sensory recovery occurred significantly later, and total analgesic consumption was lower in the Dexa than in the Control group. No nerve complication related to intravenous dexamethasone injection was recorded.ConclusionsThis study showed that intravenous dexamethasone delayed for 6 hours the time to first analgesic intake after upper arm surgery under axillary plexus block performed with the long-lasting local anesthetic ropivacaine. This suggests that intravenous dexamethasone could be an interesting adjuvant to axillary plexus block.Trial registration numberNCT02862327
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