Dexamethasone and dexmedetomidine as adjuvants to local anesthetic mixture in intercostal nerve block for thoracoscopic pneumonectomy: a prospective randomized study

Combination of dexamethasone and dexmedetomidine as adjuvants of transversus abdominis plane block for postoperative analgesia in gastric cancer patients: A double-blinded randomized controlled trial

STUDY OBJECTIVE

We conducted this double-blinded randomized controlled trial to examine whether the combination of dexamethasone and dexmedetomidine as adjuvants of transversus abdominis plane (TAP) block could improve analgesia efficacy and duration for gastric cancer patients.

DESIGN

Randomized controlled trial.

SETTING

The preoperative area, operating room, postanesthesia recovery room and bed ward.

PATIENTS

A total of 312 adult patients (104 per group) with gastric cancer were included.

INTERVENTIONS

Patients received bilateral subcostal TAP block with three different anesthetics (60 ml 0.25% ropivacaine added with 10 mg dexamethasone and 1 μg·kg-1 dexmedetomidine [A] or 10 mg dexamethasone [B] or 1 μg·kg-1 dexmedetomidine [C]).

MEASUREMENTS

The primary outcome was the incidence of moderate-to-severe pain 24 h on movement. Secondary outcomes included incidence of moderate-to-severe pain, pain score, opioids use, recovery quality and adverse events.

MAIN RESULTS

The incidence of moderate-to-severe pain on movement 24 h postoperatively of group A was significantly lower than group B (45.19% vs 63.46%; RR 0.71; 95% CI, 0.55 to 0.92) and group C (45.19% vs 73.08%, RR 0.62; 95% CI, 0.49 to 0.79). The median moving pain scores decreased significantly at 24 h (3.00 [3.00,5.00] vs 4.00 [3.00,6.00] vs 4.00 [3.00,5.00]; P < 0.001). There were significant differences in the opioids consumption within the first 24 h (27.5 [17.0,37.2] vs 30.0 [20.0,42.0] vs 32.0 [25.0,44.0] mg; P = 0.01) and the duration to first rescue analgesia (65.5 ± 26.7 vs 45.9 ± 34.5 vs 49.2 ± 27.2 h; P = 0.04).

CONCLUSIONS

The combination with dexamethasone and dexmedetomidine as adjuvants for TAP block reduced the incidence of moderate-to-severe pain and pain score both on movement and at rest at 24 h with prolonged duration to first rescue analgesia after gastric cancer surgery.

TRIAL REGISTRATION NUMBER

ChiCTR2000037981.

Superficial parasternal intercostal plane blocks in cardiac surgery: a systematic review and meta-analysis

PURPOSE

Traditional multimodal analgesic strategies have several contraindications in cardiac surgery patients, forcing clinicians to use alternative options. Superficial parasternal intercostal plane blocks, anesthetizing the anterior cutaneous branches of the thoracic intercostal nerves, are being explored as a straightforward method to treat pain after sternotomy. We sought to evaluate the literature on the effects of superficial parasternal blocks on pain control after cardiac surgery.

METHODS

We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs). We searched MEDLINE, Embase, CENTRAL, and Web of Science databases for RCTs evaluating superficial parasternal intercostal plane blocks in adult patients undergoing cardiac surgery via midline sternotomy published from inception to 11 March 2022. The prespecified primary outcome was opioid consumption at 12 hr. The risk of bias was assessed with the Cochrane Collaboration Risk of Bias Tool, and the quality of evidence was evaluated using the grading of recommendations, assessments, development, and evaluations. Outcomes were analyzed with a random-effects model. All subgroups were prespecified.

RESULTS

We reviewed 1,275 citations. Eleven RCTs, comprising 756 patients, fulfilled the inclusion criteria. Only one study reported the prespecified primary outcome, precluding the possibility of meta-analysis. This study reported a reduction in opioid consumption (-11.2 mg iv morphine equivalents; 95% confidence interval [CI], -8.2 to -14.1) There was a reduction in opioid consumption at 24 hr (-7.2 mg iv morphine equivalents; 95% CI,  -5.6 to -8.7; five trials; 436 participants; moderate certainty evidence). All five studies measuring complications reported that none were detected, which included a sample of 196 blocks.

CONCLUSION

The literature suggests a potential benefit of using superficial parasternal blocks to improve acute postoperative pain control after cardiac surgery via midline sternotomy. Future studies specifying dosing regimens and adjuncts are required.

STUDY REGISTRATION

PROSPERO (CRD42022306914); first submitted 22 March 2022.

Combined Dexamethasone and Dexmedetomidine as Adjuncts to Popliteal and Saphenous Nerve Blocks in Patients Undergoing Surgery of the Foot or Ankle: A Randomized, Blinded, Placebo-controlled Clinical Trial

BACKGROUND

Both dexamethasone and dexmedetomidine increase the duration of analgesia of peripheral nerve blocks. The authors hypothesized that combined intravenous dexamethasone and intravenous dexmedetomidine would result in a greater duration of analgesia when compared with intravenous dexamethasone alone and placebo.

METHODS

The authors randomly allocated participants undergoing surgery of the foot or ankle under general anesthesia and with a combined popliteal (sciatic) and saphenous nerve block to a combination of 12 mg dexamethasone and 1 µg/kg dexmedetomidine, 12 mg dexamethasone, or placebo (saline). The primary outcome was the duration of analgesia measured as the time from block performance until the first sensation of pain in the surgical area as reported by the participant. The authors predefined a 33% difference in the duration of analgesia as clinically relevant.

RESULTS

A total of 120 participants from two centers were randomized and 119 analyzed for the primary outcome. The median [interquartile range] duration of analgesia was 1,572 min [1,259 to 1,715] with combined dexamethasone and dexmedetomidine, 1,400 min [1,133 to 1,750] with dexamethasone alone, and 870 min [748 to 1,138] with placebo. Compared with placebo, the duration was greater with combined dexamethasone and dexmedetomidine (difference, 564 min; 98.33% CI, 301 to 794; P < 0.001) and with dexamethasone (difference, 489 min; 98.33% CI, 265 to 706; P < 0.001). The prolongations exceeded the authors' predefined clinically relevant difference. The duration was similar when combined dexamethasone and dexmedetomidine was compared with dexamethasone alone (difference, 61 min; 98.33% CI, -222 to 331; P = 0.614).

CONCLUSIONS

Dexamethasone with or without dexmedetomidine increased the duration of analgesia in patients undergoing surgery of the foot or ankle with a popliteal (sciatic) and saphenous nerve block. Combined dexamethasone and dexmedetomidine did not increase the duration of analgesia when compared with dexamethasone.

EDITOR’S PERSPECTIVE

Liposomal Bupivacaine Versus Bupivacaine and Dexamethasone Intercostal Nerve Blocks for Robotic Thoracic Surgery: A Randomized Clinical Trial

Introduction For peripheral nerve blocks, using either the liposomal formulation of bupivacaine or plain bupivacaine with epinephrine and dexamethasone as an adjuvant has been shown to improve postoperative pain scores. In a single-blinded, randomized controlled study of patients undergoing robotic-assisted thoracoscopic surgery, we determined if bupivacaine with epinephrine and dexamethasone was noninferior to liposomal bupivacaine mixed with plain bupivacaine when administered intraoperatively as an intercostal nerve block (INB). Methods A total of 34 patients undergoing robotic-assisted thoracoscopic surgery were randomized to receive one of two injectate mixtures during their intraoperative INB. Group LB was administered 266 mg of 13.3 mg/mL liposomal bupivacaine with 24 mL of 0.5% plain bupivacaine, while Group BD was given 42 mL of 0.5% bupivacaine with epinephrine and 8 mg of dexamethasone. The primary outcomes were mean postoperative numerical pain ratings and mean postoperative opioid analgesic requirements. Secondary outcomes included adjuvant pain medication consumption, hospital length of stay, and total opioid use in oral morphine equivalents. Results Group LB exhibited no significant difference in pain scores (p = 0.437) and opioid analgesic requirement (p = 0.095) within the 72-hour postoperative period when compared to Group BD. The median total postoperative opioid requirement was 90 mg in Group LB, compared to 45 mg in Group BD. There were no significant differences in the use of postoperative adjuvant pain medications (gabapentin, p = 0.833; acetaminophen, p = 0.190; ketorolac, p = 0.699). Hospital length of stay did not differ between the groups. Conclusions INBs with the addition of dexamethasone as an adjuvant to 0.5% bupivacaine with epinephrine provided noninferior postoperative analgesia compared to liposomal bupivacaine mixed with plain 0.5% bupivacaine.

Combination of Pericapsular Nerve Group (PENG) and Sacral Erector Spinae Plane (S-ESP) Blocks for Hip Fracture Pain and Surgery: A Case Series

A hip fracture is a serious injury with life-threatening complications, and its risk rises with increasing age. A hip fracture can be a very painful condition, and prompt surgical treatment is recommended to reduce pain and complications. Pain management is considered integral to the management of a broken hip. The choice between general and regional anesthesia in hip fracture surgery continues to be a topic of debate because risks are potentially associated with both approaches. Nerve blockades have proven to be effective in reducing acute pain after a hip fracture and in the perioperative period. For this reason, many regional techniques have been introduced, such as the lumbar plexus block, fascia iliac block, femoral nerve block, and recently, the pericapsular nerve group (PENG) block. Hip joint innervation is complex, not limited to the lumbar plexus but also depending on the sciatic nerve and branches of the sacral plexus (superior and inferior gluteal nerves and an articular branch from the quadratus femoris nerve). We hypothesized that a combination of two emerging regional anesthesia techniques, such as the PENG block and sacral erector spinae plane (S-ESP) block, could represent a good option to obtain pain control of the whole hip joint without opioid administration intraoperatively and postoperatively. Here, we report the cases of three frail patients with significant comorbidities who underwent hip fracture surgery (two cases of intramedullary nailing and one hemiarthroplasty), in which we preoperatively performed PENG and S-ESP blocks. We registered optimal intraoperative and postoperative pain control up to 48 hours after surgery without complications and without opioid administration, allowing the surgery to be performed with intravenous sedation or laryngeal mask general anesthesia. The surgeries were uneventful, and no complications were reported. This approach warrants further investigation in hip fracture surgery.

Comparison of analgesic effects of percutaneous and transthoracic intercostal nerve block in video-assisted thoracic surgery: a propensity score-matched study

BACKGROUND

This study aimed to compare the analgesic efficacy of transthoracic intercostal nerve block (TINB) and percutaneous intercostal nerve block (PINB) for video-assisted thoracic surgery (VATS) using a retrospective analysis.

METHODS

A total of 336 patients who underwent VATS between January 2021 and June 2022 were reviewed retrospectively. Of the participants, 194 received TINB and were assigned to the T group, while 142 patients received PINB and were assigned to the P group. Both groups received 25 ml of ropivacaine via TINB or PINB at the end of the surgery. The study measured opioid consumption, pain scores, analgesic satisfaction, and safety. Propensity score matching (PSM) analysis was performed to minimize selection bias due to nonrandom assignment.

RESULTS

After propensity score matching, 86 patients from each group were selected for analysis. The P group had significantly lower cumulative opioid consumption than the T group (p < 0.01). The Visual Analogue Scale (VAS) scores were lower for the P group than the T group at 6 and 12 h post-surgery (p < 0.01); however, there was no significant difference in the scores between the two groups at 3, 24, and 48 h (p > 0.05). The analgesic satisfaction in the P group was higher than in the T group (p < 0.05). The incidence of back pain, nausea or vomiting, pruritus, dizziness, and skin numbness between the two groups was statistically insignificant (p > 0.05).

CONCLUSION

The study suggests that PINB provides superior analgesia for patients undergoing thoracic surgery compared to TINB without any extra adverse effects.

Effects of combined dexamethasone and dexmedetomidine as adjuncts to peripheral nerve blocks: a systematic review with meta-analysis and trial sequential analysis

BACKGROUND/IMPORTANCE

The effects of combining dexamethasone and dexmedetomidine on block duration are unclear.

OBJECTIVE

To investigate the effects of combining dexamethasone and dexmedetomidine on block duration.

EVIDENCE REVIEW

Systematic review of randomized controlled trials (RCTs) from Medline, Embase, CENTRAL, CINAHL, the Web of Science, and BIOSIS until June 8, 2023. RCTs with adults undergoing surgery with a peripheral nerve block randomized to combined dexamethasone and dexmedetomidine versus placebo or other adjuncts were eligible. Primary outcome was duration of analgesia. We performed meta-analysis, trial sequential analysis, risk of bias-2, and Grading Recommendations Assessment, Development, and Evaluation assessment.

FINDINGS

We included 9 RCTs with 14 eligible comparisons. The combination of dexamethasone and dexmedetomidine was compared with placebo in three RCTs (173 participants), dexamethasone in seven (569 participants), and dexmedetomidine in four (281 participants). The duration of analgesia was likely increased with the combination versus placebo (mean difference 460 min, 95% CI 249 to 671) and versus dexmedetomidine (mean difference 388 min, 95% CI 211 to 565). The duration was likely similar with the combination versus dexamethasone (mean difference 50 min, 95% CI -140 to 239). The certainty of the evidence was moderate because most trials were at high risk of bias.

CONCLUSIONS

Combined dexamethasone and dexmedetomidine likely increased the duration of analgesia when compared with placebo and dexmedetomidine. The combination likely provided a similar duration of analgesia as dexamethasone. Based on this systematic review, it seems reasonable to use dexamethasone as the sole adjunct if the goal is to increase the duration of analgesia.

Dexmedetomidine vs Dexamethasone as an Adjuvant to Levobupivacaine in Ultrasound-Guided Transversus Abdominis Plane Block for Postoperative Analgesia in Patients Undergoing Total Abdominal Hysterectomies

Background

In the postoperative period, open total abdominal hysterectomy (TAH) surgeries induce considerable pain. Multimodal strategies are being used to alleviate pain.

Objectives

This study aimed to examine the efficacy and safety of dexamethasone and dexmedetomidine as an adjuvant to levobupivacaine in ultrasound-guided transversus abdominis plane (TAP) blocks for postoperative pain in TAH patients.

Methods

A total of 72 patients with ASA grade I and grade II were randomly and equally assigned to two groups. After the completion of surgery with a subarachnoid block (SAB), patients in group 1 received a mixture of 20 mL of 0.25% levobupivacaine and 4 mg of dexamethasone on each side of the TAP block. Patients in group 2 received a mixture of 20 mL of 0.25% levobupivacaine and dexmedetomidine, with a total dose of 1 µg/kg body weight evenly distributed bilaterally in the TAP block. Patients were evaluated for pain using the Visual Analog Scale (VAS), total tramadol consumption as rescue analgesia, time to first rescue analgesia, any adverse effects, and patient satisfaction.

Results

When comparing VAS scores for pain assessment, we observed that the mean VAS score was initially comparable between the two groups for the first hour. However, at 6, 9, and 12 h, VAS scores were significantly lower in group 2. The mean total tramadol consumption was higher in group 1 than in group 2 (213.33 ± 44.08 vs 161.11 ± 37.93 mg, P-value 0.027). The time to the first rescue analgesia after the TAP block in the postoperative period was significantly longer in group 2 (47.5 ± 62.76 vs 77.22 ± 56.14 min, P-value 0.002). No significant side effects were noted, and a greater proportion of patients in group 2 expressed satisfaction with their overall pain treatment.

Conclusions

The addition of dexmedetomidine to levobupivacaine is superior to the addition of dexamethasone, as it prolongs the duration of the block in the dexmedetomidine group. However, the use of dexamethasone as an adjuvant is a good alternative option, particularly due to its lower cost and reduced incidence of adverse effects such as postoperative nausea and vomiting.

Comparing Continuous and Intermittent Infusion Effects on Serratus Anterior Plane Blocks in Video-Assisted Thoracoscopic Surgery: A Randomized Clinical Trial

Objective

The programmed intermittent bolus infusion (PIBI) of local anesthetic produces wider sensory blockade and better analgesia than continuous infusion (CI). We designed this trial to compare the effects of these two different infusion methods combined with Serratus Anterior Plane Blocks (cSAPBs) on postoperative pain relief in patients undergoing video-assisted thoracoscopic surgery.

Methods

We randomly allocated 66 patients under going elective video-assisted thoracoscopic unilateral lung resection surgery to two groups (PIBI group and CI group, n=33 per group). After the surgical operation, the patients received ultrasound-guided ipsilateral SAPB, we randomized them to receive either automated intermittent boluses or continuous infusion of 0.3% ropivacaine. Tramadol consumption during the 48 hours following surgery was the primary outcome. Secondary outcomes included cumulative tramadol consumption during the first 24-h and the second 24-h periods after surgery, pain scores, patient satisfaction, blocked dermatomes, and adverse events.

Results

During 48h, tramadol consumption in the PIBI group was significantly lower than in the CI group (190 mg [125, 305] vs 220 mg [170, 480], p= 0.034). As compared to the CI group, the PIBI group consumed less tramadol during the first 24 hours (145 mg [87.5, 210] vs 190 mg [140, 400], p=0.012). The dermatomes anesthetized to the pinprick and cold test were significantly more abundant in the PIBI group than in the CI group (3 [3,4] vs. 5 [4,5], p<0.001). Both groups had similar VAS scores at rest and when moving (p>0.05). Additionally, the PIBI group showed greater patient satisfaction. Both groups experienced similar adverse events (p>0.05).

Conclusion

Compared with CI, PIBI administration regimen (0.3% ropivacaine 5 mL/h) for cSAPBs resulted in lower tramadol consumption, superior analgesia during the initial 12 h after the operation, and higher patient satisfaction. PIBI combined with cSAPBs was a better choice for postoperative analgesia in patients undergoing video-assisted thoracoscopic surgery.

Dexamethasone and dexmedetomidine as adjuvants to ropivacaine do not prolong analgesia in wound infiltration for lumbar spinal fusion: a prospective randomized controlled study

BACKGROUND AND OBJECTIVES

Local anesthetics (LAs) are widely used to infiltrate into surgical wounds for postoperative analgesia. Different adjuvants like dexamethasone and dexmedetomidine, when added to LA agents, could improve and prolong analgesia. The aim of this trial was to evaluate the analgesic efficacy and opioid-sparing properties of dexamethasone and dexmedetomidine when added to ropivacaine for wound infiltration in transforaminal lumbar interbody fusion (TLIF).

METHODS

We conducted a controlled study among 68 adult patients undergoing TLIF, which was prospective, randomized and double-blind in nature. The participants were divided into four equal groups at random. Group R was given 150 mg of 1% ropivacaine (15 mL) and 15 mL of normal saline. Group R + DXM received 150 mg of 1% ropivacaine (15 mL) and 10 mg of dexamethasone (15 mL). Group R + DEX received 150 mg of 1% ropivacaine (15 mL) and 1 µg/kg of dexmedetomidine (15 mL). Lastly, group R + DXM + DEX was given 150 mg of 1% ropivacaine (15 mL), 10 mg of dexamethasone and 1 µg/kg of dexmedetomidine (15 mL). The primary focus was on the length of pain relief provided. Additionally, secondary evaluations included the amount of hydromorphone taken after surgery, the numerical rating scale and safety assessments within 48 h after the operation.

RESULTS

Based on the p value (P > 0.05), there was no significant variance in the duration of pain relief or the total usage of hydromorphone after surgery across the four groups. Similarly, the numerical rating scale scores at rest and during activity at 6-, 12-, 24- and 48-h post-surgery for all four groups showed no difference (P > 0.05). However, the incidence of delayed anesthesia recovery was slightly higher in group R + DEX and group R + DXM + DEX when compared to group R or group R + DXM. Furthermore, there were no significant differences between the four groups in terms of vomiting, nausea, dizziness or delayed anesthesia recovery.

CONCLUSION

For wound infiltration in TLIF, the addition of dexamethasone and dexmedetomidine to ropivacaine did not result in any clinically significant reduction in pain or opioid consumption and could prompt some side effects.

Adjunctive dexamethasone palmitate use for intercostal nerve block after video-assisted thoracoscopic surgery: A prospective, randomized control trial

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.

Dexmedetomidine as an Adjuvant in Peripheral Nerve Block

Peripheral nerve block technology is important to balanced anesthesia technology. It can effectively reduce opioid usage. It is the key to enhance clinical rehabilitation as an important part of the multimodal analgesia scheme. The emergence of ultrasound technology has accelerated peripheral nerve block technology development. It can directly observe the nerve shape, surrounding tissue, and diffusion path of drugs. It can also reduce the dosage of local anesthetics by improving positioning accuracy while enhancing the block's efficacy. Dexmedetomidine is a highly selective drug α₂-adrenergic receptor agonist. Dexmedetomidine has the characteristics of sedation, analgesia, anti-anxiety, inhibition of sympathetic activity, mild respiratory inhibition, and stable hemodynamics. Numerous studies have revealed that dexmedetomidine in peripheral nerve blocks can shorten the onset time of anesthesia and prolong the time of sensory and motor nerve blocks. Although dexmedetomidine was approved by the European Drug Administration for sedation and analgesia in 2017, it has not yet been approved by the US Food and Drug Administration (FDA). It is used as a non-label drug as an adjuvant. Therefore, the risk-benefit ratio must be evaluated when using these drugs as adjuvants. This review explains the pharmacology and mechanism of dexmedetomidine, the effect of dexmedetomidine on various peripheral nerve block as an adjuvant, and compare it with other types of adjuvants. We summarized and reviewed the application progress of dexmedetomidine as an adjuvant in nerve block and look forward to its future research direction.

Nociception Level Index-Directed Erector Spinae Plane Block in Open Heart Surgery: A Randomized Controlled Clinical Trial

Background and Objectives: The erector spinae plane block (ESPB) is a multimodal opioid-sparing component, providing chest-wall analgesia of variable extent, duration, and intensity. The objective was to examine the ESPB effect on perioperative opioid usage and postoperative rehabilitation when used within a Nociception Level (NOL) index-directed anesthetic protocol. Materials and Methods: This prospective, randomized, controlled, open-label study was performed in adult patients undergoing on-pump cardiac surgery in a single tertiary hospital. Eighty-three adult patients who met eligibility criteria were randomly allocated to group 1 (Control, n = 43) and group 2 (ESPB, n = 40) and received general anesthesia with NOL index-directed fentanyl dosing. Preoperatively, group 2 also received bilateral single-shot ultrasound-guided ESPB (1.5 mg/kg/side 0.5% ropivacaine mixed with dexamethasone 8 mg/20 mL). Postoperatively, both groups received intravenous paracetamol (1 g every 6 h). Morphine (0.03 mg/kg) was administered for numeric rating scale (NRS) scores ≥4. Results: The median (IQR, 25th−75th percentiles) intraoperative fentanyl and 48 h morphine dose in group 2-to-group 1 were 1.2 (1.1−1.5) vs. 4.5 (3.8−5.5) µg·kg−1·h−1 (p < 0.001) and 22.1 (0−40.4) vs. 60.6 (40−95.7) µg/kg (p < 0.001). The median (IQR) time to extubation in group 2-to-group 1 was 90 (60−105) vs. 360 (285−510) min (p < 0.001). Two hours after ICU admission, 87.5% of ESPB patients were extubated compared to 0% of controls (p < 0.001), and 87.5% were weaned off norepinephrine compared to 46.5% of controls (p < 0.001). The median NRS scores at 0, 6, 12, 24, and 48 h after extubation were significantly decreased in group 2. There was no difference in opioid-related adverse events and length of stay. Conclusions: NOL index-directed ESPB reduced intraoperative fentanyl by 73.3% and 48 h morphine by 63.5%. It also hastened the extubation and liberation from vasopressor support and improved postoperative analgesia.

Randomized comparison between perineural dexamethasone and combined perineural dexamethasone-dexmedetomidine for ultrasound-guided infraclavicular block

BACKGROUND

This randomized trial compared perineural dexamethasone with combined perineural dexamethasone-dexmedetomidine for ultrasound-guided infraclavicular block. We hypothesized that the combination of perineural adjuvants would result in a longer motor block.

METHODS

Fifty patients undergoing upper limb surgery with ultrasound-guided infraclavicular block (using 35 mL of lidocaine 1%-bupivacaine 0.25% with epinephrine 5 µg/mL) were randomly allocated to receive perineural dexamethasone (2 mg) or combined perineural dexamethasone (2 mg)-dexmedetomidine (50 µg). After the performance of the block, a blinded observer assessed the success rate (defined as a minimal sensorimotor composite score of 14 out of 16 points at 30 min), the onset time (defined as the time required to reach a minimal composite score of 14 points) as well as the incidence of surgical anesthesia (defined as the ability to complete surgery without local infiltration, supplemental blocks, intravenous opioids or general anesthesia).Postoperatively, the blinded observer contacted patients with successful blocks to inquire about the duration of motor block, sensory block and postoperative analgesia.

RESULTS

No intergroup differences were observed in terms of success rate, onset time and surgical anesthesia. Compared with dexamethasone alone, combined dexamethasone-dexmedetomidine provided longer durations of motor block (21.5 (2.7) vs 17.0 (3.9) hours; p<0.001; 95% CI 2.6 to 6.4), sensory block (21.6 (3.6) vs 17.2 (3.6) hours; p<0.001; 95% CI 2.2 to 6.5), and postoperative analgesia (25.5 (9.4) vs 23.5 (5.6) hours; p=0.038; 95% CI 1.0 to 7.7).

CONCLUSION

Compared with perineural dexamethasone (2 mg) alone, combined perineural dexamethasone (2 mg)-dexmedetomidine (50 µg) results in longer durations of sensorimotor block and analgesia. Further studies are required to determine the optimal dosing combination for dexamethasone-dexmedetomidine.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov identifier: NCT04875039.

Comparison of the effects of perineural or intravenous dexamethasone on thoracic paravertebral block in Ivor‐Lewis esophagectomy: A double‐blind randomized trial

Efforts to prolong thoracic paravertebral block (TPVB) analgesia include local anesthetic adjuvants, such as dexamethasone (Dex). Previous studies showed that both perineural (PN) and intravenous (i.v.) routes could prolong analgesia. As PN Dex is an off‐label use, anesthesiologists should be fully informed of the clinical differences, if any, on block duration. This study was designed to evaluate the two administration routes of Dex for duration of analgesia in TPVB. Ninety‐five patients scheduled for Ivor‐Lewis esophagectomy were randomized to receive TPVB (0.5% ropivacaine 15 ml), PN or i.v. Dex 8 mg. The primary end point was the duration of analgesia. The secondary end points included pain scores, analgesic consumption, adverse effects rate, and incidence of chronic pain at 3 months postoperatively. The PN‐Dex group showed better analgesic effects than the i.v.‐Dex group (p < 0.05). Similarly, the visual analogue scale scores in patients at 2, 4, 8, and 12 h postoperatively were lower in the PN‐Dex group than the i.v.‐Dex group (p < 0.05). The analgesic consumption in both the PN‐Dex and i.v.‐Dex groups was significantly lower than that in the control group (p < 0.05). Regarding the incidence of chronic pain, regardless of route, Dex decreased the incidence of chronic postsurgical pain and neuropathic pain at 3 months after surgery (p < 0.05), but there were no clinical differences between the i.v.‐Dex and PN‐Dex groups. Perineural dexamethasone improved the magnitude and duration of analgesia compared to that of the i.v.‐Dex group in TPVB in Ivor‐Lewis esophagectomy. However, there were no clinically significant differences between the two groups in the incidence of chronic pain.

Preoperative Quadratus Lumborum Block Reduces Opioid Requirements in the Immediate Postoperative Period Following Hip Arthroscopy: A Randomized, Blinded Clinical Trial

PURPOSE

To examine acute postoperative opioid consumption in patients undergoing hip arthroscopy and randomized to either receive a preoperative lateral quadratus lumborum block or sham injection.

METHODS

This trial randomized 46 subjects undergoing hip arthroscopy with a single surgeon to receive a preoperative lateral quadratus lumborum block (40 mL, ropivacaine 0.25%) or sham injection. The primary outcome was postoperative opioid consumption in patients with and without a block. All opioid medications were converted to morphine milligram equivalents for comparisons. Categorical data were compared with χ² tests and Fisher exact tests where appropriate. Continuous data were compared with 2-sided t-test and Wilcoxon rank-sum tests.

RESULTS

Forty-six subjects scheduled for elective hip arthroscopy were successfully consented and randomized. Demographic and clinical characteristics did not differ. Postoperative opioid consumption decreased 28.3% in patients who received a preoperative lateral quadratus lumborum block (P = .04). Total perioperative opioid consumption (intraoperative and postoperative combined) was reduced 20% in the block group; however, this did not achieve statistical significance (P = .05). Three subjects in the sham group (12.5%) required unblinding for a rescue block in the postoperative anesthetic care unit (PACU) for uncontrolled pain despite systemic analgesics. While cold sensation was decreased postoperatively over the abdomen (P < .001) and anterior thigh (P = .03) in the block group, other PACU variables did not differ, including VAS pain scores, motor function, side effects, PACU duration, and patient satisfaction.

CONCLUSIONS

Opioid consumption was reduced in patients who received a preoperative lateral quadratus lumborum block combined with a standardized, multimodal protocol as compared with patients who did not receive a block. Our findings support the growing evidence that quadratus lumborum blocks are an effective component of multimodal analgesia options for patients undergoing elective hip arthroscopy.

LEVEL OF EVIDENCE

Level I, randomized controlled trial.

Ambulatory Pain Management in the Pediatric Patient Population

PURPOSE OF REVIEW

Outpatient surgery in the pediatric population has become increasingly common. However, many patients still experience moderate to severe postoperative pain. A poor understanding of the extent of pain after pediatric ambulatory surgery and the lack of randomized control studies of pain management of the outpatient necessitate this review of scientific evidence and multimodal analgesia.

RECENT FINDINGS

A multimodal approach to pain management should be applied to the ambulatory setting to decrease postoperative pain. These include non-pharmacological techniques, multimodal pharmacologics, and neuraxial and peripheral nerve blocks. Postoperative pain management in pediatric ambulatory surgical patients remains suboptimal at most centers due to limited evidence-based approach to postoperative pain control. Pediatric ambulatory pain management requires a multipronged approach to address this inadequacy.

Perineural Dexamethasone as a Peripheral Nerve Block Adjuvant in the Emergency Department: A Case Series

BACKGROUND

Acute pain is one of the most common complaints encountered in the emergency department (ED). Single-injection peripheral nerve blocks are a safe and effective pain management tool when performed in the ED. Dexamethasone has been explored as an adjuvant to prolong duration of analgesia from peripheral nerve blocks in peri- and postoperative settings; however, data surrounding the use of dexamethasone for ED-performed nerve blocks are lacking.

CASE SERIES

In this case series we discuss our experience with adjunctive perineural dexamethasone in ED-performed regional anesthesia. Why Should an Emergency Physician be Aware of This?: Nerve blocks performed with adjuvant perineural dexamethasone may be a safe additive to provide analgesia beyond the expected half-life of local anesthetic alone. Prospective studies exploring the role of adjuvant perineural dexamethasone in ED-performed nerve blocks are needed. © 2021 Elsevier Inc.

Analgesic efficacy of dexamethasone versus dexmedetomidine as an adjuvant to ropivacaine in ultrasound-guided transversus abdominis plane block for post-operative pain relief in caesarean section: A prospective randomised controlled study

Background and Aims:

Transversus abdominis plane (TAP) block is commonly used to treat post-operative pain after lower abdominal surgeries. The aim of this randomised controlled study was to assess the efficacy of addition of dexmedetomidine or dexamethasone to ropivacaine in TAP block and compare the two for post-operative pain relief in caesarean section.

Methods:

A hundred parturients (18–45 years) undergoing caesarean section under spinal anaesthesia received ultrasound-guided (USG) bilateral TAP block with 50ml of 3mg/kg ropivacaine along with 0.1mg/kg dexamethasone (Group A) or 1μg/kg dexmedetomidine (Group B) in this prospective, randomised, double-blind study. Time to initial self-reporting of post-operative pain, time to first rescue analgesic demand, visual analogue scale (VAS) for pain haemodynamic parameters and adverse effects if any were noted, anda P value < 0.005 was considered as statistically significant.

Results:

Time to initial self-reporting of post-operative pain (411.35 vs. 338.20 min, P < 0.005) and time to first rescue analgesic (474.30 vs. 407.30 min, P < 0.005) were significantly longer in group B as compared to group A. VAS score at the time of initial self-reporting of pain was significantly lower in group B. No significant haemodynamic changes or side-effects were noted.

Conclusion:

Addition of dexmedetomidine to ropivacaine as compared with dexamethasone in bilateral TAP block following caesarean section prolongs the time to initial post-operative pain and time to first rescue analgesic consumption.

Comparing the effects of dexmedetomidine and dexamethasone as perineural adjuvants on peripheral nerve block: A PRISMA-compliant systematic review and meta-analysis

BACKGROUND

Dexmedetomidine (Dexm), a selective alpha-2 adrenoceptor agonist, and dexamethasone (Dexa), a very potent and highly selective glucocorticoid, have both been proven effectively to prolong the duration of local anesthetics (LA) in regional anesthesia. However, data comparing the efficacy of Dexm and Dexa as perineural adjuvants are inconsistent. Therefore, this systematic review and meta-analysis of randomized and quasi-randomized controlled trials (RCTs) was conducted to compare the effects of Dexm and Dexa when used as LA adjuvants on peripheral nerve block (PNB).

METHODS

We systematically searched PubMed, Cochrane Library, EMBASE, Web of Science, and ScienceDirect databases up to October, 2020. The primary outcome was the duration of analgesia. Secondary outcomes included incidence of rescue analgesia, cumulative opioid consumption, time required for onset of sensory and motor blockades, duration of sensory and motor blockades, incidence of postoperative nausea and vomiting (PONV), and side effect-associated outcomes (e.g., bradycardia, sedation, hypotension, rates of infection, and neurological complications). The study was registered on PROSPERO, number CRD42020188796.

RESULTS

After screening of full-text relevant articles, 13 RCTs that met the inclusion criteria were retrieved for this systematic review. It was revealed that perineural Dexm provided equivalent analgesic duration to perineural Dexa. Besides, the intake of Dexm increased the incidence of rescue analgesia in limbs surgery, as well as the cumulative opioid consumption, and decreased the time required for onset of sensory and motor blockades for long-acting LA (all P < .05). Other analysis revealed insignificant difference between the 2 groups in terms of the incidence of PONV (P > .05). Additionally, 2 studies demonstrated that Dexm possesses more sedative properties than Dexa (P < .05).

CONCLUSIONS

This meta-analysis indicated that the analgesic duration of Dexm and Dexa as LA adjuvants in PNB is the same. Meanwhile, the effects of perineural Dexm and Dexa on some secondary outcomes, including the incidence of rescue analgesia, cumulative opioid consumption, and time required for onset of sensory and motor blockades, are associated with the surgical site and type of LA.

Intraoperative Administration of Dexmedetomidine and Dexamethasone in Local Anesthetic Infiltration to Improve Postoperative Pain Control After Posterior Cervical Fusion

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.

Single and Repeated Intrapleural Ropivacaine Administration: A Plasma Concentration and Pharmacodynamics Study

Background

Intrapleural analgesia has been increasingly recommended for postoperative analgesia after thoracic surgery. However, the analgesic effect provided by a single intrapleural administration is time limited. This study reports the efficacy and safety of repeated intrapleural 0.75% ropivacaine administration after thoracoscopic surgery.

Methods

Twenty patients were randomly divided into two groups: a single administration group receiving a single intrapleural injection of 0.75% ropivacaine 15 mL (single administration group, SA group), and a repeated administration group with an intrapleural injection of 0.75% ropivacaine 15 mL every 4h for 4 doses (repeated administration group, RA group). The primary outcomes of this study were the peak plasma concentration of ropivacaine and 24h morphine consumption. The secondary outcomes were pain score, patient satisfaction, extubation time, hospital length of stay, and adverse reactions.

Results

In SA group, the highest plasma concentration after intrapleural administration of 0.75% ropivacaine 15 mL was 1345±364 μg/L. The highest plasma concentration in RA group after the fourth administration was 1864±492 μg/L. The 24h morphine consumption in RA group was significantly less than that in SA group (9.0±5.66 vs 15.9±3.48 mg, P=0.004). The NRS scores at rest and while coughing of patients in RA group were significantly lower than those in SA group at 5, 9, 13, 17 and 24h after operation. The patients in RA group had higher satisfaction than those in SA group. There was no significant difference in postoperative adverse events, drainage tube placement days and hospital length of stay between the two groups.

Conclusion

Repeated intrapleural administration with 0.75% ropivacaine, 15 mL every 4h for 4 doses after video-assisted thoracoscopic lobectomies, can provide a more durable and more effective analgesic effect than single intrapleural administration. Repeated intrapleural administration of ropivacaine is an effective postoperative method of analgesia resulting in higher patient satisfaction. Moreover, it was also able to keep the plasma concentration of ropivacaine within a possible safe range.

Clinical Trial Registration Number

ChiCTR-IOR-17010560.

Nalbuphine Versus Ketorolac as an Adjuvant to Local Wound Infiltration Anesthesia in Open Colorectal Surgery: A Prospective Randomized Controlled Study

INTRODUCTION

Adding adjuvants to local wound infiltration (LWI) provides long analgesic duration with fewer adverse effects. We aimed to compare the clinical effects of nalbuphine and ketorolac as an adjuvant to LWI in patients undergoing open colorectal cancer surgery.

METHOD

A total of 126 ASA I-III patients aged ≥ 18 years who were scheduled for open colorectal cancer surgery were included. Patients were randomly assigned to receive LWI using 10 mL 0.75% ropivacaine, with 20 mL normal saline (group R), 10 mg nalbuphine in 1 mL (group RN), or 25 mg ketorolac in 0.8 mL (group RK). Analgesia duration was the primary outcome. The total 48-h postoperative morphine-equivalent consumption and additional rescue analgesia rates were recorded as key secondary outcomes.

RESULTS

Among 126 patients randomized, 124 completed the trial. The duration until the first press of the analgesia pump was significantly shorter in group R (median: 320.0 min) compared with group RN (median: 829.5 min) and group RK (median: 820.0 min) (P < 0.001). The median difference in morphine consumption was 113.0 mg for group R vs. group RN (P < 0.001), and 115.5 mg for group R vs. group RK (P < 0.001). The proportion of patients using additional morphine within the first day after surgery in group R showed a higher relative risk (RR) compared with group RN (RR, 3.89; P = 0.001) and group RK (RR, 3.17; P = 0.001). There were no apparent differences between the RN and RK groups in any outcomes, whether in adjusted or unadjusted analysis.

CONCLUSIONS

Among patients undergoing open colorectal cancer surgery, both nalbuphine and ketorolac infiltration achieved equally prolonged duration of analgesia and reduced morphine consumption compared with ropivacaine alone after surgery, suggesting that the equivalent analgesic dose of nalbuphine and ketorolac as local anesthetic adjuvants in LWI could have a similar analgesic effect.

TRIAL REGISTRATION

ChiCTR1800019209.

Comparison of postoperative analgesic effects in response to either dexamethasone or dexmedetomidine as local anesthetic adjuvants: a systematic review and meta-analysis of randomized controlled trials

This review compares the effects of peripheral dexamethasone and dexmedetomidine on postoperative analgesia. We included six randomized controlled trials (354 patients) through a systematic literature search. We found that analgesia duration was comparable between dexamethasone and dexmedetomidine (58.59 min, 95% CI (confidence interval), -  66.13, 183.31 min) with extreme heterogeneity. Secondary outcome was also compared and no significant difference was observed in sensory block onset and duration and motor block duration and also for postoperative nausea and vomiting. It is noteworthy that dexamethasone reduced analgesic consumption (fentanyl) by 29.12 mcg compared with dexmedetomidine. We performed subgroup analyses and found no significant difference between the following: (1) lidocaine vs ropivacaine (P = 0.28), (2) nerve block vs nerve block + general anesthesia (P = 0.47), and (3) upper limb surgery vs thoracoscopic pneumonectomy (P = 0.27). We applied trial sequential analysis to assess the risks of type I and II errors and concluded that the meta-analysis was insufficiently powered to answer the clinical question, and further analysis is needed to establish which adjuvant is better. In conclusion, we believe that existing research indicates that dexamethasone and dexmedetomidine have equivalent analgesic effects in peripheral nerve blocks.

Efficacy and safety of dexmedetomidine as an adjuvant to local wound infiltration anaesthesia: A meta-analysis with trial sequential analysis of 23 randomised controlled trials

To further identify the real efficacy and safety of dexmedetomidine as an adjuvant to local wound infiltration anaesthesia, we conducted this meta‐analysis. The systematic search strategy was performed using PubMed, Embase, Cochrane Library, and Chinese databases. As a result, a total of 23 RCTs (1445 patients) were included. Patients receiving dexmedetomidine combined with local anaesthetics had a lower rescue analgesia rate [risk ratio (RR): 0.48; 95% confidence interval (CI): 0.36‐0.65] and lower rescue analgesic consumption [weighted mean difference (WMD): −10.80 mg; 95%CI: −13.28 to −8.31 mg] than patients receiving local anaesthetics alone. The dexmedetomidine‐related adverse reactions included bradycardia (RR: 1.33; 95%CI: 0.32‐5.56) and hypotension (RR: 3.00; 95%CI: 0.49‐18.42). In addition, the time to first analgesic request (WMD: 296.16 minutes; 95%CI: 165.69 minutes ~ 426.63 minutes), incidence of postoperative nausea and vomiting (PONV) and pain scores at 4 hours postoperatively were also significantly lower in patients receiving dexmedetomidine combined with local anaesthetics. This meta‐analysis demonstrated that the use of dexmedetomidine as an adjuvant to wound infiltration is effective for reducing the rescue analgesia rate, rescue analgesic consumption and PONV. In addition, limited evidence shows that dexmedetomidine can prolong postoperative analgesia for approximately 5 hours. Further investigations on dexmedetomidine‐related adverse reactions and the dose–response effect of dexmedetomidine in wound infiltration are warranted.

Fascia Iliaca Block Successfully Prolonged With Dexmedetomidine and Dexamethasone for Pain Control in a Patient Undergoing Total Hip Arthroplasty

Regional anesthesia has found many advocates as enhanced recovery after surgery continues to become a more popular option for procedures such as total hip arthroplasty. Among the many benefits is the better pain control with a reduction or complete elimination of the need for opioids for perioperative pain management. With aims to improve the multi-modal approach to pain management, we present a case demonstrating further improvements in the regional anesthetic technique with the addition of a dexamethasone and dexmedetomidine adjuvant to the local anesthetic injectate. Our case is that of a 65-year-old woman with a history of hypertension, hyperlipidemia, and right hip osteoarthritis undergoing a right total hip arthroplasty who received a preoperative ultrasound-guided fascia iliaca block with the adjuvants dexamethasone and dexmedetomidine added to the injectate. The surgery was uneventful. She did not require any postoperative opioid or non-opioid analgesics, denying any pain for the first three postoperative days.

Synergistic Effect of Perineural Dexamethasone and Dexmedetomidine (Dex-Dex) in Extending the Analgesic Duration of Pectoral Type I and II Blocks

Pectoral type I and II (Pecs I and II) blocks are regional anesthesia methods that have shown to decrease postoperative analgesia after breast surgery. Typically, these blocks consist only of a local anesthetic. We performed preoperative Pecs I and II blocks in a female patient undergoing surgical excision and biopsy of a breast mass. The anesthetic consisted of ropivacaine, dexmedetomidine, and dexamethasone (Dex-Dex). The patient experienced an extended postoperative pain relief period. She did not require any opiates postoperatively. Adding dexmedetomidine and dexamethasone to a local anesthetic for peripheral nerve blocks seems to have a synergistic effect and can extend the duration of pain relief. This combination has the potential to decrease postoperative opiate requirements for analgesia. Further studies need to be conducted to further determine the safety and efficacy of the Dex-Dex block.

Dual adjunct therapy with dexamethasone and dexmedetomidine in transversus abdominis plane blocks reduces postoperative opioid use in colorectal surgery

BACKGROUND

The objective of this study is to determine if the addition of dexmedetomidine to dexamethasone in transversus abdominis plane (TAP) blocks lowers postoperative opioid use following colorectal surgery.

METHODS

Retrospective review of patients undergoing minimally invasive colorectal surgery and perioperative TAP block with either 1) local anesthetic and dexamethasone or 2) local anesthetic, dexamethasone, and dexmedetomidine. Post-operative opioid use was converted to morphine milligram equivalents (MME).

RESULTS

55 patients were identified: 38 (69%) receiving dexamethasone only and 17 (31%) receiving dexamethasone and dexmedetomidine. The dexamethasone and dexmedetomidine group had significantly lower median MME use at 12-h (2 vs. 13 mg), 24-h (4 vs. 28 mg), 36-h (8 vs. 38 mg), and 48-h (17 vs. 53 mg) (all p < 0.05). There was no difference at 72-h.

CONCLUSION

Perioperative TAP blocks with dexamethasone and dexmedetomidine following colorectal surgery results in significantly less postoperative opioid use up to 48 h after surgery.

Synergistic Effect of Perineural Dexamethasone and Dexmedetomidine (Dex-Dex) Prolong Analgesic Effect of a Preoperative Interscalene Block

The brachial plexus is often a target of regional anesthesia for procedures involving the upper extremities. These include the supraclavicular, infraclavicular, interscalene, and axillary blocks. The cases we present involve the use of an ultrasound-guided interscalene block using 20 mL 0.2% ropivacaine with dexamethasone and 25 mcg dexmedetomidine as the injectate. This particular block technique has proven to be a very useful adjunct to the perioperative anesthetic care and enhanced recovery after surgery (ERAS) protocol for these patients. The series of cases we present include patients receiving the dexamethasone and dexmedetomidine (Dex-Dex) combination in their local anesthetic injectate for the ultrasound-guided interscalene block. Two of the patients underwent arthroscopic shoulder procedures and one underwent a shoulder total arthroplasty with biceps tenodesis. None of the patients required any postoperative opioids for analgesia. Though the technique is fairly new, with only a limited number of case studies described its efficacy, the understanding of the benefits of ERAS has helped it gain some traction in the field of regional anesthesia. Conduction of further large clinical trials is the next step in providing a better understanding of the Dex-Dex adjuvant method as it moves towards becoming a commonly used component of ERAS protocols in the perioperative period.