Effect of dexmedetomidine as adjuvant in ropivacaine-induced supraclavicular brachial plexus block: A prospective, double-blinded and randomized controlled study

Safety and efficacy of dexmedetomidine in combination with local anesthetics for orthopedic nerve blocks: a systematic review and meta-analysis

INTRODUCTION

Peripheral nerve block, a common technique for managing postoperative pain and providing intraoperative analgesia, often includes adjuncts like dexmedetomidine (DEX) to enhance the effectiveness of local anesthetics. DEX, known for its α2-adrenoceptor agonist properties, extends sensory blockade and improves postoperative analgesia while offering sedative benefits. The objective of this study is to rigorously assess the effectiveness and safety of perineural DEX injection in orthopedic nerve block procedures, focusing on orthopedic surgeries to minimize heterogeneity and provide clearer insights for clinical practice.

EVIDENCE ACQUISITION

This meta-analysis, registered on PROSPERO, involved a comprehensive literature search across multiple databases, focusing on RCTs comparing DEX with local anesthetics for peripheral nerve blocks in orthopedic surgery patients. The eligibility criteria included adult participants and various nerve block methods in orthopedic surgeries. Studies were rigorously appraised for methodological quality using Cochrane Handbook guidelines. GRADE profiler 3.6 was used for evidence grading.

EVIDENCE SYNTHESIS

Among 1391 documents, 21 studies were included, focusing on DEX with local anesthetics in orthopedic nerve blocks. Findings showed significant improvements in analgesia duration, sensory and motor block duration, and reduced postoperative opioid consumption, with an increased risk of bradycardia. Quality assessments indicated moderate bias risk.

CONCLUSIONS

DEX with local anesthetics significantly enhances nerve block effectiveness, extending analgesia and block durations while reducing opioid need. However, it requires careful monitoring due to increased bradycardia risk. These findings highlight the need for cautious use in clinical practice, considering both potential benefits and adverse effects.

The effect of adjuvants added to local anaesthetics for single-injection upper extremity peripheral regional anaesthesia: A systematic review with network meta-analysis of randomised trials

BACKGROUND

Peripheral regional anaesthesia is frequently used for upper extremity surgery. To prolong the duration of analgesia, adjuvants can be added to single-injection local anaesthetics. Despite attempts to compare several adjuvants in pairwise meta-analyses, a comprehensive comparison is still missing.

OBJECTIVE

The objective of this network meta-analysis was to determine the effectiveness of adjuvants in upper extremity peripheral nerve blocks.

DESIGN

A systematic review of randomised controlled trials with network meta-analyses.

DATA SOURCES

A literature search in Embase, CENTRAL, MEDLINE and Web of Science was performed up to March 2023.

ELIGIBILITY CRITERIA

Randomised trials comparing different adjuvants injected perineurally in peripheral upper extremity nerve blocks were eligible. Frequentist network meta-analysis was conducted using a random effects model with physiological saline as the comparator. The primary endpoint was the ratio of means (ROM) of the duration of analgesia.

RESULTS

The review included 242 randomised controlled trials with a total of 17 391 patients. Twenty-eight adjuvants were compared in the largest networks. Most network estimations consisted of a high proportion of direct evidence. Fourteen adjuvants increased the duration of analgesia significantly by the following factors, ROM [95% confidence interval (CI)]: dexamethasone 1.95 (1.79 to 2.13), buprenorphine 1.83 (1.51 to 2.24), butorphanol 1.84 (1.41 to 2.39), potassium chloride 1.89 (1.15 to 3.11), dexmedetomidine 1.70 (1.59 to 1.81), sufentanil 1.70 (1.27 to 2.29), ketorolac 1.68 (1.24 to 2.27), midazolam 1.55 (1.24 to 1.94), tramadol 1.52 (1.32 to 1.75), nalbuphine 1.50 (1.30 to 1.72), morphine 1.43 (1.09 to 1.88), magnesium sulfate 1.42 (1.20 to 1.67), clonidine 1.36 (1.24 to 1.50) and fentanyl 1.23 (1.08 to 1.40). Inconsistency in network meta-analysis was substantial. Overall side effect rates were low with all adjuvants.

CONCLUSION

The best interventions to prolong the duration of analgesia were dexamethasone, followed by dexmedetomidine, opioids, electrolytes, ketorolac and midazolam. There are general concerns about the quality of underlying studies and the risk of publication bias.

TRIAL REGISTRATION

PROSPERO 2018 CRD42018115722.

Comparative Evaluation of Dexmedetomidine and Dexamethasone as Adjuvants in Supraclavicular Brachial Plexus Block

Introduction Currently, peripheral nerve block has shown immense potential with effective patient satisfaction. In the event of upper limb surgeries, the supraclavicular brachial plexus approach under ultrasound guidance renders quick and dense anesthesia. In addition, the clinical utility of adjuvants with local anesthetics elicits a good quality of nerve block with improved duration and inset. So the aim of the present study was to compare the block characteristics of dexmedetomidine and dexamethasone during supraclavicular brachial plexus block in patients undergoing upper limb surgeries. Materials and methods The present study was conducted on 100 patients aged 20-60 years with the American Society of Anesthesiologists (ASA)-I and ASA-II classification who were scheduled for upper limb surgeries. These patients were divided equally into two groups, namely group D (who received 20mL of 0.5% bupivacaine + 50 mcg (0.5mL) of dexmedetomidine +1.5mL normal saline) and group X (who received 20mL of 0.5% bupivacaine +8mg of dexamethasone), ensuring a total volume of 22mL administered to both groups. The time of onset and duration of the sensory and motor blocks, as well as the quality of intraoperative analgesia, were assessed. Results The addition of dexmedetomidine (50mcg) and dexamethasone (8mg) to 0.5% bupivacaine ensured a faster onset and prolonged duration of the sensory and motor blocks. Additionally, dexmedetomidine resulted in more prolonged postoperative analgesia, a lower mean visual analog scale score in the first 24 hours, and lesser opioid consumption in 24 hours than dexamethasone. Conclusion Dexmedetomidine is superior to dexamethasone as an adjuvant to bupivacaine during supraclavicular brachial plexus block in patients undergoing upper limb surgeries.

The role of dexmedetomidine as an adjuvant for high-thoracic erector spinae plane block for analgesia in shoulder arthroscopy; a randomized controlled study

BACKGROUND

Management of postoperative pain after shoulder arthroscopy is an important issue. Dexmedetomidine, as an adjuvant, improves nerve block efficacy and decreases postoperative consumption of opioids. As a result, we designed this study to determine if adding dexmedetomidine to an erector spinae plane block (ESPB) that is guided by ultrasound (US) is beneficial for treating immediate postoperative pain following shoulder arthroscopy.

METHODS

This randomized controlled double-blind trial recruited 60 cases 18-65 years old of both sexes, American Society of Anesthesiologists (ASA) physical status I-II, scheduled for elective shoulder arthroscopy. Random allocation of 60 cases was done equally into two groups according to the solution injected in US-guided ESPB at T2 before general anesthetic induction. Group (ESPB): 20 ml 0.25% bupivacaine. Group (ESPB + DEX): 19 ml bupivacaine 0.25% + 1 mL dexmedetomidine 0.5 µg/kg. The primary outcome was The total rescue morphine consumption in the first 24 postoperative hours.

RESULTS

The mean intraoperative fentanyl consumption was significantly lower in the group (ESPB + DEX) compared to the group (ESPB) (82.86 ± 13.57 versus 100.74 ± 35.07, respectively, P = 0.015). The median (IQR) time of the 1^st rescue analgesic request was significantly delayed in the group (ESPB + DEX) compared to group (ESPB) [18.5 (18.25-18.75) versus 12 (12-15.75), P = 0.044]. The number of cases that required morphine was significantly lower in the group (ESPB + DEX) than in the group (ESPB) (P = 0.012). The median (IQR) of total postoperative morphine consumption in 1^st 24 h was significantly lower in the group (ESPB + DEX) compared to the group (ESPB) [0 (0-0) versus 0 (0-3), P = 0.021].

CONCLUSION

The dexmedetomidine as an adjuvant to bupivacaine in ESPB produced adequate analgesia by reducing the intraoperative and postoperative opioid requirements in shoulder arthroscopy.

TRIAL REGISTRATION

This study is registered on ClinicalTrials.gov (NCT05165836; principal investigator: Mohammad Fouad Algyar; registration date: 21/12/ 2021).

Alpha2 -receptor agonists as adjuvants for brachial plexus nerve blocks-A systematic review with meta-analyses

BACKGROUND

We review the efficacy and safety of dexmedetomidine and clonidine as perineural or systemic adjuvants for brachial plexus blocks (BPB).

METHODS

We included randomised controlled trials on upper limb surgery with BPBs in adults, comparing dexmedetomidine with clonidine or either drug with placebo. The primary outcome was duration of analgesia. Secondary outcomes included adverse and serious adverse events. The review was conducted using Cochrane standards, trial sequential analyses (TSA) and Grading of Recommendations Assessment, Development and Evaluation (GRADE).

RESULTS

We included 101 trials with 6248 patients. Overall, duration of analgesia was prolonged with both clonidine (176 min [TSA adj. 95% CI: 118, 205, p < .00001; 33 trials]) and dexmedetomidine (292 min [TSA adj. 95% CI: 245 329, p < .00001; 53 trials]), but was longer for dexmedetomidine than clonidine (205 min [TSA adj. 95% CI: 157, 254, p < .00001; 19 trials]). Compared with placebo, dexmedetomidine was associated with bradycardia (RR 4.2 [95% CI 2.2, 8.3]), and both clonidine (RR 4.5 [95% CI 1.1, 18.3]) and dexmedetomidine (RR 3.9 [95% CI 2.0, 7.5]) were associated with hypotension. Serious adverse events were mostly related to block technique. GRADE-rated quality of evidence was low or very low.

CONCLUSION

Alpha2-receptor agonists used as adjuvants for BPBs lead to a prolonged duration of analgesia, with dexmedetomidine as the most efficient. Alpha2-receptor agonists were associated with increased risk of cardiovascular adverse events. The quality of evidence was low to very low.

Effect of dexmedetomidine on characteristics of ultrasound-guided supraclavicular brachial plexus block with levobupivacaine-A prospective double-blind randomized controlled trial

Background and Aims:

Levobupivacaine, a less cardiotoxic s-isomer of bupivacaine, is proved to be similar to bupivacaine, hence, proposed as a safer alternative for nerve blocks. We aimed to evaluate the effect of perineural and intravenous dexmedetomidine on characteristics of ultrasound-guided supraclavicular brachial plexus block (BPB) performed with levobupivacaine. The aim of this study is to evaluate the effect of perineural and intravenous dexmedetomidine on characteristics of ultrasound-guided supraclavicular BPB performed with levobupivacaine.

Material and Methods:

A prospective, randomized double-blind control trial done on 120 patients undergoing elective upper limb surgical procedures under supraclavicular BPB. The enrolled patients were allocated to one of the three groups: Group L - 0.5% levobupivacaine +0.9% normal saline (NS) IV infusion; Group LDI - 0.5% levobupivacaine + dexmedetomidine (1 mcg/kg) in NS IV infusion; and Group LDP - 0.5% levobupivacaine +1 mcg/kg of dexmedetomidine perineural + NS IV infusion. The onset and duration of sensory and motor blockade were recorded in minutes. One-way ANOVA was used to observe any differences between the groups, and post hoc comparisons were conducted after Bonferroni correction for multiple comparisons.

Results:

The onset of sensory and motor blockade in Group LDP was significantly shorter than Group L and Group LDI. The duration of sensory blockade in Group LDP was significantly longer than Group LDI and Group L. The duration of motor blockade in Group LDP was prolonged compared to Group LDI and Group L.

Conclusions:

When dexmedetomidine is added as adjunct to levobupivacaine in supraclavicular BPB, onset of sensory and motor blockade is faster in perineural group, whereas duration of sensory and motor blockade and duration of analgesia are more prolonged when used perineurally than intravenously.

Dexmedetomidine and Magnesium Sulfate as Adjuvant to 0.5% Ropivacaine in Supraclavicular Brachial Plexus Block: A Comparative Evaluation

Background:

Dexmedetomidine and magnesium sulfate (MgSO₄) as an adjuvant to local anesthetics and ultrasound guidance improves the quality of peripheral nerve block.

Aim:

We aim to compare the efficacy of dexmedetomidine and MgSO₄ as an adjuvant to ropivacaine in supraclavicular brachial plexus block.

Methodology:

Sixty patients undergoing upper extremity orthopedic surgery were randomly allocated into three groups of 20 each. Group A received 29 mL of 0.5% ropivacaine plus 1 mL of normal saline, Group B received 29 mL of 0.5% ropivacaine plus 1 mL dexmedetomidine (100 μg), and Group C received 29 mL of 0.5% ropivacaine plus 1 mL MgSO₄ (250 mg). Onset and duration of sensory and motor block, duration of analgesia, quality of anesthesia, total 24 h analgesic consumption, sedation, and complications were recorded.

Statistical Analysis:

Software SPSS-16 was used for statistical analysis.

Results:

The onset of sensory block and motor block was fastest for Group B, followed by Group C and slowest in Group A. The duration of sensory block and motor block was maximum for Group B, followed by Group C and minimum for Group A. The duration of analgesia was maximum for Group B, followed by Group C and minimum for Group A. Analgesic consumption was minimum for Group B. Quality of anesthesia was better in Group B than other groups. The visual analog scale was higher in Group A than other groups. Group B reported higher sedation score.

Conclusion:

Dexmedetomidine provides earlier onset of sensory and motor block as well as prolonged duration of sensory and motor blocks and duration of analgesia is longer and postoperative rescue analgesia is less as compared to patients receiving MgSO₄. The incidence of hypotension and bradycardia and sedation score was higher with dexmedetomidine.

To Compare the Efficacy of Postoperative Analgesia between Clonidine and Dexmedetomidine as Adjuvants with 0.5% Ropivacaine by Ultrasound-Guided Supraclavicular Brachial Plexus Block for Upper Limb Surgeries: A Prospective, Double-Blind, Randomized Study

Context:

The supraclavicular brachial plexus block is a very safe, useful and effective method for upper limb surgeries. Among local anesthetics, ropivacaine has special applications in neuraxial and peripheral nerve blocks due to its low cardiotoxicity and less toxicity to central nervous systems compared to bupivacaine and lignocaine. Dexmedetomidine is a newer and potent alpha-2 receptor agonist which has 10 times higher selectivity for alpha-2 receptors as compared to clonidine, So far, very few studies have been undertaken to compare the efficacy of clonidine and dexmedetomidine to provide and prolong postoperative analgesia, especially with the use of ultrasound for nerve localization.

Aims:

To compare the efficacy of postoperative analgesia between clonidine and dexmedetomidine as adjuvants with 0.5% ropivacaine by ultrasound-guided supraclavicular brachial plexus block for upper limb surgeries.

Settings and Design:

Prospective, randomised, double-blind interventional study.

Subjects and Methods:

Eighty patients of ASA grade I or II undergoing elective upper limb surgery were randomly divided into two groups:- Group RC (n = 40) received 35 ml of 0.5% ropivacine with 1 μg.kg⁻¹ of clonidine. Group RD (n = 40) received 35 ml of 0.5% ropivacaine with 1 μg.kg⁻¹ of dexmedetomidine.

Statistical analysis used:

The statistical software SPSS version 20 has been used for the analysis. By using Pearson's Chi-Square test for Independence of Attributes/Fisher's Exact. Continuous variables were expressed as Mean, Median, and Standard Deviation and compared across the groups using unpaired t-test.

Results:

In our comparative study, dexmedetomidine 1 μg.kg⁻¹ with 35 ml of 0.5% ropivacaine provided significantly longer duration of postoperative analgesia and earlier sensory block as compared to clonidine 1 μg.kg⁻¹ with same dose of ropivacaine in ultrasound-guided supraclavicular brachial plexus block.

Conclusions:

The ropivacaine-dexmedetomidine group in our study provided earlier sensory block and more prolonged postoperative analgesia as compared to ropivacaine-clonidine group. Thus ropivacaine-dexmedetomidine combination may be effectively used in all painful upper limb surgeries specially orthopaedic procedures.

Comparison of morphine, dexmedetomidine and dexamethasone as an adjuvant to ropivacaine in ultrasound-guided supraclavicular brachial plexus block for postoperative analgesia-a randomized controlled trial

Background and Aims:

An ideal adjuvant to local anesthetic in a nerve block should prolong the duration of analgesia, and hasten the onset of sensory and motor blockade without significant adverse effects. The aim of this study was to compare morphine, dexmedetomidine, and dexamethasone as an additive to ropivacaine in ultrasound-guided supraclavicular brachial plexus block (SBPB) for postoperative analgesia.

Material and Methods:

In this randomized, double-blinded study, 150 patients undergoing upper extremity surgery were randomly divided into three groups: group A (morphine 5 mg), group B (dexmedetomidine 50 μg), and group C (dexamethasone 8 mg). The additives were added to 30 ml of 0.5% ropivacaine solution and administered in SBPB. The duration of postoperative analgesia, onset of sensory and motor blockade, sedation, and adverse effects were observed. The pain was assessed by visual analog scale (VAS) and sedation by Ramsay sedation score. The duration of postoperative analgesia was taken as time consumed from block completion to administration of rescue analgesia (VAS >3).

Results:

The demographic profile was similar in both groups. The duration of analgesia was significantly longer in dexamethasone (867.2 ± 217.6 min) than morphine (739. 2 ± 162.5 min) and dexmedetomidine (654.2 ± 179.9 min) (P < 0.001). The onset of sensory and motor blockade was quicker with dexmedetomidine than dexamethasone and morphine. Three cases of block failure were reported with morphine. No major adverse effects were reported.

Conclusion:

Dexamethasone is an ideal adjuvant to ropivacaine in brachial plexus block to prolong postoperative analgesia and devoid of adverse effects. Dexmedetomidine has a quicker onset of sensory and motor blockade.

Perineural and intravenous dexamethasone and dexmedetomidine: network meta-analysis of adjunctive effects on supraclavicular brachial plexus block

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.

The effect and safety of dexmedetomidine added to ropivacaine in brachial plexus block: A meta-analysis of randomized controlled trials

BACKGROUND

Dexmedetomidine has been used as an adjuvanty added to local anesthetics to prolong analgesia following peripheral nerve blockade. The aim of this meta-analysis was to investigate the effect and safety of dexmedetomidine added to ropivacaine in brachial plexus block (BPB).

METHODS

A search strategy was created to identify eligible randomized clinical trial (RCT) in PubMed, Embase, and The Cochrane Library (updated May, 2018). The methodologic quality for each included study was evaluated using the Cochrane Tool for Risk of Bias by 2 independent researchers.

RESULTS

Twelve RCTs were included in the meta-analysis (n = 671). As an adjuvant to ropivacaine, dexmedetomidine significantly reduced the onset time of sensory (mean difference [MD], -3.86 minutes, 95% CI -5.45 to -2.27 minutes; I = 85%) and motor (MD, -5.21 minutes; 95% CI -7.48 to -2.94 minutes; I = 94%). In addition, it increased the blockade duration of sensory (MD, 228.70 minutes; 95% CI 187.87-269.52 minutes; I = 93%) and motor (MD, 191.70 minutes; 95% CI 152.48-230.91 minutes; I = 92%). Moreover, the combination prolonged the duration of analgesia (MD, 303.04 minutes; 95% CI 228.84-377.24 minutes; I = 86%). There was no difference of the incidence of bradycardia (risk difference [RD], 0.01, 95% CI -0.02 to 0.05, I = 45%; P = .45) and hypotension (RD, 0.01, 95% CI -0.01 to 0.03, I = 0%; P = .57) between 2 groups.

CONCLUSION

Dexmedetomidine added to ropivacaine in BPB has a better analgesia effect (shorter onset time and longer duration) compared to ropivacaine alone. At the same time, there was no difference in the incidence of bradycardia and hypotension.

The Effect of Adding Dexmedetomidine as an Adjuvant to Lidocaine in Forearm Fracture Surgeries by Supraclavicular Block Procedure Under Ultrasound-Guided

Background

To improve the brachial plexus block (BPB) performance, different compounds have been used as adjuvants to local analgesics.

Objectives

The aim of the present study was to investigate the effects of adding DEX to lidocaine on effectiveness of nerve block, and postoperative pain in forearm fracture surgery by supraclavicular BPB undergoing ultrasound-guided.

Methods

This was a double-blinded randomized clinical trial conducted on 72 patients with ASA classes I and II, which were candidates for forearm fracture surgery. In group A, patients received 3 mg/kg of lidocaine 2%. In group B, patients received 3 mg/kg of lidocaine 2% and DEX (1 µg/kg). The ultrasound-guided supraclavicular BPB was performed in all patients. The onset of sensory and motor blocks were evaluated with pin prick test and modified Bromage scale, respectively. The sensory and motor block moment was recorded as the onset of the block. The first analgesic request time, total consumed analgesic, adverse effect, and hemodynamic parameters of patients were recorded. A visual analog scale (VAS) was used for recording the severity of pain.

Results

The two groups showed no significant difference in the demographic variables. The onset of sensory and motor block in the DEX groups was shorter. The duration of sensory and motor block, and analgesic request was significantly longer than the control groups. Total analgesic consumption 24 hours after surgery in the DEX groups was significantly lower. Moreover, hemodynamic status of patients in both groups was stable and no significant difference was observed between groups. This study showed that DEX, as an adjuvant to lidocaine, improve the characteristics of supraclavicular BPB and decrease the postoperative pain.

A Randomized Controlled Trial Study on the Effect of Adding Dexmedetomidine to Bupivacaine in Supraclavicular Block Using Ultrasound Guidance

Background

The benefits of regional anesthetic techniques are well established. Use of additives to local anesthetics can prolong these benefits. The aim of this study was to find out the effect of adding dexmedetomidine to bupivacaine for supraclavicular block.

Methods

In this randomized, double-blind study, 70 ASA I & II patients of either sex undergoing elective surgeries on the upper limb were given supraclavicular block under ultrasound guidance. Group C (n=35) received 38 mL 0.25% bupivacaine + 2mL normal saline and group D received 38 mL 0.25% bupivacaine + 1 µg/kg dexmedetomidine (2mL). Patients were observed for, onset of motor and sensory block, duration of motor and sensory block, duration of analgesia, sedation score, hemodynamic changes and any adverse events.

Results

In group D, the onset was faster (P< 0.001), durations of sensory and motor block duration of and analgesia were prolonged as compared to group C (P < 0.0001).There was a significant drop in heart rate (HR) from the baseline in group D (P < 0.05) at 30, 60, 90 and 120 min. However, none of the patients dropped HR below 50/min. Mean Arterial Pressure (MAP) remained unaffected. The patients in group D were more effectively sedated than those in group C (P < 0.05). No adverse event was reported in either group.

Conclusion

Dexmedetomidine as adjuvant to bupivacaine in supraclavicular block resulted in faster action, prolonged motor and sensory block, prolonged analgesia with hemodynamic stability and adequate sedation.

Comparison of Two Doses of Dexmedetomidine for Supraclavicular Brachial Plexus Block: A Randomized Controlled Trial

Background:

Dexmedetomidine is commonly used as an additive in supraclavicular brachial plexus block (SBPB). Due to its adverse effects such as bradycardia and hypotension, finding the appropriate dose of dexmedetomidine is the question.

Aims:

We aimed to compare two commonly used doses of dexmedetomidine (1 μg/kg and 2 μg/kg) added to levobupivacaine in ultrasound-guided SBPB in terms of its effect on duration of analgesia, hemodynamics, and associated adverse effects.

Settings and Design:

This randomized, double-blinded prospective study was conducted over a period of 1.5 years in our tertiary care hospital.

Materials and Methods:

Clearance from the Institutional Ethical Committee and Clinical Trial Registry of India was taken. Ninety patients' physical status American Society of Anesthesiologists Classes I and II undergoing upper limb surgeries under SBPB were included in this study. Patients in Group I received 1 μg/kg dexmedetomidine, whereas patients in Group II received 2 μg/kg dexmedetomidine added to 20 cc levobupivacaine. The primary outcome measure was the duration of analgesia after administering the block. Secondary outcomes included effect on hemodynamics, duration of blockade, and adverse effects.

Statistical Analysis:

Statistical analysis was carried out using Stata Version 10. Unpaired t-test and Chi-square test were used.

Results:

The duration of analgesia and sensory and motor blockade were similar in both the groups. The heart rate (HR) and mean arterial pressure were statistically lower in Group II. The incidence of bradycardia and hypotension was more in Group II.

Conclusions:

Increasing the dose of dexmedetomidine does not prolong the duration of analgesia, but it is associated with lower HR and blood pressure. Incidence of hypotension and bradycardia is also more. Hence, a lower dose of 1 μg/kg dexmedetomidine added to 0.5% levobupivacaine is a good balance between safety and efficacy.

Comparison of Magnesium Sulfate and Dexmedetomidine as an Adjuvant to 0.5% Ropivacaine in Infraclavicular Brachial Plexus Block

Background:

Magnesium sulfate and dexmedetomidine were used as adjuvants to local anesthesia to improve the quality of regional anesthesia.

Aims:

The aim of this study is to evaluate and compare the effects of magnesium sulfate and dexmedetomidine when added to ropivacaine on the quality of infraclavicular brachial plexus block (BPB).

Settings and Design:

This was a prospective randomized double-blinded controlled study.

Patients and Methods:

A total of 105 adult patients undergoing surgery in hands, wrist, and forearm using infraclavicular BPB were randomly assigned into three groups. Ultrasound-guided infraclavicular BPB was performed using 35 ml ropivacaine 0.5% diluted with 4 ml normal saline 0.9%. Magnesium sulfate 150 mg and dexmedetomidine 100 μg were added in the magnesium sulfate group and dexmedetomidine group, respectively. Duration of analgesia, onset times and durations of sensory block (SB) and motor block (MB), patient's satisfaction, and complications were recorded.

Statistical Analysis:

Statistical software SPSS 16 was used for statistical analysis.

Results:

Dexmedetomidine and magnesium sulfate provided longer duration of analgesia and lesser consumption of postoperative rescue analgesia than the control group (P = 0. 000); dexmedetomidine provided the longest duration of analgesia versus control and magnesium sulfate groups (P = 0.000). Dexmedetomidine provided the quickest onset times and the longest durations of both SB and MB than control and magnesium sulfate groups (P = 0.000). Dexmedetomidine group had higher incidences of bradycardia and hypotension.

Conclusions:

Magnesium sulfate or dexmedetomidine is a useful adjuvant to ropivacaine for infraclavicular BPB in lengthening the duration of analgesia. Dexmedetomidine provided quicker onset and longer duration of both SB and MB and longer duration of analgesia with lesser consumption of postoperative rescue analgesia; however, it showed a higher incidence of intraoperative hypotension and bradycardia than magnesium sulfate.

A Study to Compare the Analgesic Efficacy of Dexmedetomidine and Fentanyl as Adjuvants to Levobupivacaine in Ultrasound-Guided Supraclavicular Brachial Plexus Block

Background:

Supraclavicular brachial plexus provides complete and reliable anesthesia for upper limb surgeries. Adjuvants are added to local anesthetists to improve various block characteristics. There are limited studies comparing the efficacy of dexmedetomidine and fentanyl as an adjuvant to levobupivacaine.

Aims:

The aim of the study was to evaluate and compare the effect of dexmedetomidine versus fentanyl as an adjuvant with levobupivacaine in ultrasound-guided supraclavicular brachial plexus block.

Settings and Design:

This study design was a prospective, randomized, double-blind controlled study.

Subjects and Methods:

A total of 120 patients in the age group of 30–55 years with physical status American Society of Anesthesiologists Classes I and II undergoing elective upper limb surgeries under ultrasound-guided supraclavicular brachial plexus block were randomly divided into three groups of forty each after taking informed consent and approval from Hospital Ethics Committee: Group A received 25 ml of 0.5% levobupivacaine with 5 ml normal saline (NS). Group B received 25 ml of 0.5% levobupivacaine with 1 μg/kg dexmedetomidine diluted to the volume of 5 ml NS. Group C received 25 ml of 0.5% levobupivacaine with 1 μg/kg fentanyl diluted to the volume of 5 ml NS. Onset and duration of sensory and motor block and duration of analgesia were noted and any side effects were observed.

Statistical Analysis:

The distribution of variables tested with Shapiro–Wilk test. Group comparison of values was made by Kruskal–Wallis test followed by Mann–Whitney test.

Results:

There was fastest onset time as well as longer duration of sensory and motor block in dexmedetomidine group, intermediate in fentanyl group as compared to levobupivacaine group.

Conclusion:

This study concludes that addition of dexmedetomidine to levobupivacaine for supraclavicular brachial plexus block shortens the onset time and prolongs the duration of sensory and motor blockade as compared to the addition of fentanyl.

Tramadol sparing effect of dexmedetomidine as an adjuvant with lignocaine in preoperative stellate ganglion block for postoperative pain relief following upper limb surgeries

Background

Recent literature has established the role of stellate ganglion block (SGB) for management of acute postoperative pain. The effects of dexmedetomidine as an adjuvant to lignocaine in a preoperative SGB for postoperative pain relief have not been evaluated so far.

Methods

The following randomised, double-blinded, control trail included 54 patients scheduled for upper limb orthopaedic surgery under general anaesthesia. Preoperative ultrasound-guided (USG) SGB was performed in all patients. Group I (n = 18) received 3.5 mL of a solution (3 mL 2% lignocaine + 0.5 μg/kg dexmedetomidine for SGB) and 15 mL of intravenous (IV) normal saline (NS). Group II (n = 18) received 3.5 mL of a solution (3 mL 2% lignocaine + 0.5 mL NS for SGB) and 15 mL of IV NS. Group III (n = 18) received 3.5 mL of a solution (3 mL 2% lignocaine + 0.5 mL of NS for SGB) and 0.5 μg/kg dexmedetomidine in 15 mL of IV NS. Postoperatively tramadol consumption and Visual Analogue Scale (VAS) score were recorded up to 48 hours.

Results

The cumulative tramadol consumption at the end of 48 hours (p = 0.01) was significantly reduced in the group I as compared to group II. In group I, postoperative VAS at rest was significantly reduced up to 12 hours postoperatively as compared to group II (p = 0.05). The cumulative tramadol consumption was not reduced significantly in group III compared to group II (p = 0.51).

Conclusion

Dexmedetomidine as an adjuvant to SGB along with lignocaine produced a significant tramadol sparing effect and superior analgesia as compared to IV dexmedetomidine and control group.¹.

Comparative Study of the Efficacy of Dexmedetomidine and Fentanyl as Adjuvants to Ropivacaine in Ultrasound-Guided Supraclavicular Brachial Plexus Block

Objective

Supraclavicular brachial plexus block is preferable to general anaesthesia in upper limb surgeries. Various adjuvants have been added to improve the quality of the block and prolong postoperative analgesia. The aim of the present study was to compare the onset and duration of sensory and motor blockade with the quality of perioperative analgesia and postoperative complications provided by dexmedetomidine and fentanyl as adjuvants to ropivacaine under ultrasound (USG) guidance in supraclavicular block.

Methods

A total of 80 patients with American Society of Anesthesiologists grade I/II scheduled for elective upper limb surgeries were randomly allocated into two groups. Group A received 30 mL of 0.5% ropivacaine with 1 μg kg^-1 dexmedetomidine, and group B received 30 mL of 0.5% ropivacaine with 1 μg kg^-1 fentanyl for supraclavicular brachial block using USG guidance. The onset and duration of sensory and motor block, time for requirement of rescue analgesia and adverse events during the perioperative period were noted.

Results

The onset of sensory blockade was 13.95±1.34 min in the dexmedetomidine group and 14.18±1.41 min in the fentanyl group. There was a highly significant statistical difference in terms of the duration of the sensory blockade, i.e. 801.75±46.07 min with dexmedetomidine compared to 590.25±40.41 min with fentanyl (p<0.0001). The duration of motor blockade was highly statistically significant with 649.56±42.73 min in group A compared to 456.75±32.93 min in group B.

Conclusion

Dexmedetomidine prolongs the duration of sensory and motor block and postoperative analgesia as compared to fentanyl when used as an adjuvant to ropivacaine in supraclavicular brachial plexus block and is not associated with any major adverse events.

Adductor canal block for post-operative analgesia after simultaneous bilateral total knee replacement: A randomised controlled trial to study the effect of addition of dexmedetomidine to ropivacaine

Background and Aims:

Knee replacement surgery causes tremendous post-operative pain and adductor canal block (ACB) is used for post-operative analgesia. This is a randomised, controlled, three-arm parallel group study using different doses of dexmedetomidine added to ropiavcaine for ACB.

Methods:

A total of 150 patients aged 18–75 years, scheduled for simultaneous bilateral total knee replacement, received ultrasound-guided ACB. They were randomised into three groups -Group A received ACB with plain ropivacaine; Groups B and C received ACB with ropivacaine and addition of dexmedetomidine 0.25 μg/kg and 0.50 μg/kg, respectively, on each side of ACB. The primary outcome was the duration of analgesia. Total opioid consumption, success of early ambulation, and level of patient satisfaction were also assessed.

Results:

The patient characteristics and block success rates were comparable in all groups. Group C patients had longer duration of analgesia (Group C 18.4 h ± 7.4; Group B 14.6 ± 7.1; Group A 10.8 ± 7; P < 0.001); lesser tramadol consumption (Group C 43.8 mg ± 53.2; Group B 76.4 ± 49.6; Group A 93.9 mg ± 58.3; P < 0.001) and lesser pain on movement (P < 0.001). The patients in Group B and C walked more steps than in Group A (P < 0.002). The level of patient satisfaction was highest in Group C (P < 0.001).

Conclusions:

The addition of dexmedetomidine to ropivacaine resulted in longer duration of analgesia after adductor canal block for simultaneous bilateral total knee replacement surgery.

Dexmedetomidine as an adjuvant to local anesthetics in brachial plexus blocks: A meta-analysis of randomized controlled trials

BACKGROUND

Brachial plexus block (BPB) for upper extremity surgery provides superior analgesia, but this advantage is limited by the pharmacological duration of local anesthetics. Dexmedetomidine (DEX) as a local anesthetics adjuvant for BPB has been utilized to prolong the duration of the nerve block in some randomized controlled trials (RCTs) but is far from unanimous in the efficacy and safety of the perineural route. Hence, an updated meta-analysis was conducted to assess the efficacy and safety of DEX as local anesthetic adjuvants on BPB.

METHODS

A search in electronic databases was conducted to collect the RCTs that investigated the impact of adding DEX to local anesthetics for BPB. Sensory block duration, motor block duration, onset time of sensory and motor block, time to first analgesic request, the common adverse effects were analyzed.

RESULTS

Eighteen trails (1014 patients) were included with 515 patients receiving perineural DEX. The addition of DEX prolonged the duration of sensory block (WMD 257 minutes, 95%CI 191.79-322.24, P < 0.001), motor block (WMD 242 minutes, 95%CI 174.94-309.34, P < 0.001), and analgesia (WMD 26 6 minutes, 95%CI 190.75-342.81, P < 0.001). Perineural DEX also increased the risk of bradycardia (OR=8.25, 95%CI 3.95-17.24, P < 0.001), hypotension (OR = 5.62, 95%CI 1.52-20.79, P < 0.01), and somnolence (OR = 19.67, 95%CI 3.94-98.09, P < 0.001). There was a lack of evidence that perineural DEX increased the risk of other adverse events.

CONCLUSIONS

DEX is a potential anesthetic adjuvant that can facilitate better anesthesia and analgesia when administered in BPB. However, it also increased the risk of bradycardia, hypotension, and somnolence. Further research should focus on the efficacy and safety of the preneural administration of DEX.

Effect of addition of dexmedetomidine to ropivacaine 0.2% for femoral nerve block in patients undergoing unilateral total knee replacement: A randomised double-blind study

BACKGROUND AND AIMS

Total knee replacement (TKR) patients experience considerable post-operative pain. We evaluated whether addition of perineural dexmedetomidine to ropivacaine 0.2% in the femoral nerve block would enhance post-operative analgesia in patients undergoing unilateral TKR under spinal anaesthesia.

METHODS

Fifty patients were allocated randomly to two groups of 25 each. Group D received ropivacaine (0.2%) with dexmedetomidine (1.5 μg/kg), and Group C received ropivacaine (0.2%) with normal saline. Pain scores, time to the first request for analgesia and total consumption of ropivacaine in 48 h, along with haemodynamic parameters and sedation scores, were recorded. Quantitative data were compared using t-test, categorical data using Chi-square or Fisher's exact test and time variables using ANOVA.

RESULTS

The mean pain scores were significantly low till 2 h post-operatively in Group D. Time to the first demand for analgesia after initial loading dose was statistically prolonged in Group D, with mean duration of 346.8 ± 240 min, compared to 150 ± 115.2 min in Group C (P = 0.001). Total local anaesthetic consumption was also decreased over 24 and 48 h in Group D (P = 0.001). Haemodynamically, there was no significant variation in heart rate from their baseline mean values in either group (P > 0.05). However, the drop in systolic and mean blood pressure post-surgery was significant till 4 (P = 0.002) and 8 h (P = 0.02), respectively, in Group D. Group D patients were also significantly more sedated till 4 h post-operatively (P < 0.005).

CONCLUSION

Adding dexmedetomidine to ropivacaine 0.2% in the femoral nerve block in patients undergoing unilateral TKR improves the quality and prolongs the duration of post-operative analgesia.

IV and Perineural Dexmedetomidine Similarly Prolong the Duration of Analgesia after Interscalene Brachial Plexus Block

Background

Perineural and IV dexmedetomidine have each been suggested to prolong the duration of analgesia when administered in conjunction with peripheral nerve blocks. In the first randomized, triple-masked, placebo-controlled trial to date, the authors aimed to define and compare the efficacy of perineural and IV dexmedetomidine in prolonging the analgesic duration of single-injection interscalene brachial plexus block (ISB) for outpatient shoulder surgery.

Methods

Ninety-nine patients were randomized to receive ISB using 15 ml ropivacaine, 0.5%, with 0.5 μg/kg dexmedetomidine administered perineurally (DexP group), intravenously (DexIV group), or none (control group). The authors sequentially tested the joint hypothesis that dexmedetomidine prolongs the duration of analgesia and reduces the 24-h cumulative postoperative morphine consumption. Motor blockade, pain severity, hemodynamic variations, opioid-related side effects, postoperative neurologic symptoms, and patient satisfaction were also evaluated.

Results

Ninety-nine patients were analyzed. The duration of analgesia was 10.9 h (10.0 to 11.8 h) and 9.8 h (9.0 to 10.6 h) for the DexP and DexIV groups, respectively, compared with 6.7 h (5.6 to 7.8) for the control group (P &lt; 0.001). Dexmedetomidine also reduced the 24-h cumulative morphine consumption to 63.9 mg (58.8 to 69.0 mg) and 66.2 mg (60.6 to 71.8 mg) for the DexP and DexIV groups, respectively, compared with 81.9 mg (75.0 to 88.9 mg) for the control group (P &lt; 0.001). DexIV was noninferior to DexP for these outcomes. Both dexmedetomidine routes reduced the pain and opioid consumption up to 8 h postoperatively and did not prolong the duration of motor blockade.

Conclusion

Both perineural and IV dexmedetomidine can effectively prolong the ISB analgesic duration and reduce the opioid consumption without prolonging motor blockade.