Dexamethasone Addition to Popliteal Nerve Blocks: Effects on Duration of Analgesia and Incidence of Postoperative Nerve Complication

The effect of perineural dexamethasone on nerve injury and recovery of nerve function after surgery: A randomized controlled trial

Background

While numerous studies have examined the influence of perineural dexamethasone on nerve block duration, its potential impact on postoperative nerve injury has not been adequately addressed.

Objective

This study aims to elucidate the effect of perineural dexamethasone on nerve injury and nerve function recovery after surgery.

Design

A prospective randomized double-blinded trial.

Setting

The First Affiliated Hospital of Chengdu Medical College, Chengdu, China. The study was conducted between 14 June and 30 December 2022.

Participants

Patients aged 18 - 80 years, ASA I - II, scheduled for elective orthopedic or burn and plastic surgery.

Interventions

Patients were randomized to receive either perineural dexamethasone (D group) or no dexamethasone (ND group).

Main outcome measures

Primary outcomes were the incidence and recovery of nerve injury. Secondary outcomes included postoperative pain scores, analgesic consumption, and adverse events.

Results

Initial postoperative nerve injury rates were similar between groups (D: 30.4 %, ND: 33.3 %, P > 0.05). At 12 weeks post-discharge, significantly more patients in the ND group recovered from nerve deficits (78.8 % vs 60.3 %; OR = 2.45, 95 % CI = 1.05 - 5.72, P < 0.05). No significant differences were observed in postoperative hyperglycemia or surgical site infection rates.

Conclusion

Perineural dexamethasone may impede nerve function recovery, suggesting caution in its use, particularly for patients with pre-existing nerve damage or diabetes. Further research is needed to elucidate the long-term effects of dexamethasone on nerve tissue recovery.

Trial registration

chictr.org.cn, ChiCTR2200059424.

Intravenous injection of dexamethasone is non-inferior to perineural administration for popliteal sciatic nerve and saphenous nerve blocks: A randomized, controlled, triple-blind study

Background

The aim of this study was to assess whether intravenous dexamethasone was noninferior to perineural dexamethasone as an adjuvant to ropivacaine for a combination of saphenous and sciatic nerve blocks in patients undergoing foot and ankle surgery.

Methods

This was a prospective, blinded, randomized noninferiority study. Seventy-five patients, aged 18-75 years, with an American Society of Anesthesiologists (ASA) physical status I-III who underwent foot and ankle surgery were involved. Patients scheduled for ultrasound-guided popliteal sciatic nerve block and saphenous nerve block were randomized to receive 0.375% ropivacaine with 7.5 mg of dexamethasone perineurally (Dex-PN), 10 mg of dexamethasone intravenously (Dex-IV) or neither (Placebo). The primary outcome was the duration of analgesia. The major secondary outcomes were the composite pain intensity and opioid consumption score at 0-48 h intervals after anesthesia.

Results

The mean analgesic duration was 26.2 h in the Dex-IV group and 27.9 h in the Dex-PN group (duration difference, -1.7; 95% CI, -3.8 to 0.43; P = 0.117), and both durations were significantly longer than that in the placebo group (17.6 h, P < 0.001). Conditions for establishing non-inferiority were met.

Conclusions

Our findings indicate that a single 10-mg intravenous dose of dexamethasone was noninferior to the combined dose of ropivacaine plus deaxmethasone in terms of duration of analgesia for foot and ankle surgery.

Evolving techniques for reducing phantom limb pain

At least two million people in the United States of America live with lost limbs, and the number is expected to double by 2050, although the incidence of amputations is significantly greater in other parts of the world. Within days to weeks of the amputation, up to 90% of these individuals develop neuropathic pain, presenting as phantom limb pain (PLP). The pain level increases significantly within one year and remains chronic and severe for about 10%. Amputation-induced changes are considered to underlie the causation of PLP. Techniques applied to the central nervous system (CNS) and peripheral nervous system (PNS) are designed to reverse amputation-induced changes, thereby reducing/eliminating PLP. The primary treatment for PLP is the administration of pharmacological agents, some of which are considered but provide no more than short-term pain relief. Alternative techniques are also discussed, which provide only short-term pain relief. Changes induced by various cells and the factors they release are required to change neurons and their environment to reduce/eliminate PLP. It is concluded that novel techniques that utilize autologous platelet-rich plasma (PRP) may provide long-term PLP reduction/elimination.

Adding Dexamethasone to Adductor Canal Block Combined with iPACK Block Improve Postoperative Analgesia of Total Knee Arthroplasty

OBJECTIVE

Both adductor canal block (ACB) and infiltration between the popliteal artery and capsule of knee (iPACK) block are mainly sensory blocks, preserved muscle strength and ability to ambulate. This study was designed to evaluate whether adding dexamethasone to ropivacaine could improve postoperative analgesia after total knee arthroplasty (TKA).

METHODS

This prospective double-blind randomized controlled trial included 60 patients who underwent unilateral TKA under general anesthesia. All patients who received ACB and iPACK block were randomly divided into a dexamethasone group (Group D, ropivacaine combined with dexamethasone) and a control group (Group C, ropivacaine only). The primary outcome was the time to first administration of rescue analgesic drugs. Secondary outcomes included the total amount of rescue analgesic drugs and the pain scores at different time points within 72 hours postoperatively; the time to first getting out of bed, quality of recovery scale (QOR-15 score), and the levels of plasma inflammatory markers (IL-6 and CRP) on postoperative day 1.

RESULTS

Compared with Group C, the time to first administration of rescue analgesic drugs of Group D was significantly extended by approximately 10.5 hours. Patients in Group D had significantly lower pain scores at postoperative different time points and consumed significantly smaller total morphine within 72 hours postoperatively. In addition, patients in group D reported significantly higher QoR-15 scores on postoperative days 1 and 3, earlier first time of getting out of bed, and significantly lower levels of CRP and IL-6 on postoperative day 1.

CONCLUSIONS

Compared with using ropivacaine alone, ultrasonic guided ACB combined with iPACK using ropivacaine and dexamethasone could prolong the duration of postoperative analgesia and strength analgesic intensity and promote the early rehabilitation exercise of patients undergoing TKA.

Effect of Dexamethasone in Peripheral Nerve Blocks on Recovery of Nerve Function

BACKGROUND

Peripheral nerve blocks (PNBs) have revolutionized distal extremity surgery reducing pain and improving hospital efficiency. Perineural dexamethasone has been administered with PNBs to prolong their effects, although the safety of dexamethasone has not been established in the literature. This study aimed to determine if the addition of dexamethasone affected the postoperative neurological sensory status for foot and ankle surgeries and the recovery of nerve injuries. We hypothesized that the rate of persistent nerve injury would be higher in the dexamethasone group.

METHODS

This is a retrospective observational cohort study of prospectively collected data of all patients from a single foot and ankle surgeon's practice. Perineural dexamethasone was routinely used as an adjunct by the regional anesthesia group until a clinical trend of increased paresthesia was found on short-term follow-up, which led to the discontinuation of its use. In this study, the cohort that received dexamethasone with ropivacaine was compared with the cohort that received ropivacaine alone. The primary outcome was a separate sensory nerve status sheet that was completed for every distal nerve territory for every patient at their follow-up visits at 2 weeks, 6 weeks, 3 months, and 6 months. Univariate analysis and a logistic regression model were used to determine the association between dexamethasone and delayed nerve recovery. A total of 250 patients were included in the study, with 117 patients in the dexamethasone group and 133 in the ropivacaine-only group.

RESULTS

The rates of nerve injuries were not different between the groups (72 [62%] in the dexamethasone group vs 79 [59%] in the ropivacaine-only group). However, nerve injury symptoms were more likely to persist and not fully recover in the dexamethasone group (n = 47, 65%) compared with the ropivacaine-only group (n = 32, 41%) (OR, 2.12; P = .006).

CONCLUSION

Perineural dexamethasone added to PNBs may be associated with delayed nerve recovery after foot and ankle surgery. It may be prudent to avoid its use until its full safety profile is established in larger prospective trials.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.