Comparison of Dexamethasone and Buprenorphine as Adjuvant in Ultrasound-guided Brachial Plexus Blocks: A Randomized Controlled Trial

What Is the Risk of Postoperative Neurologic Symptoms After Regional Anesthesia in Upper Extremity Surgery? A Systematic Review and Meta-analysis of Randomized Trials

BACKGROUND

The risk of neurologic symptoms after regional anesthesia in orthopaedic surgery is estimated to approach 3%, with long-term deficits affecting 2 to 4 per 10,000 patients. However, current estimates are derived from large retrospective or observational studies that are subject to important systemic biases. Therefore, to harness the highest quality data and overcome the challenge of small numbers of participants in individual randomized trials, we undertook this systematic review and meta-analysis of contemporary randomized trials.

QUESTIONS/PURPOSES

In this systematic review and meta-analysis of randomized trials we asked: (1) What is the aggregate pessimistic and optimistic risk of postoperative neurologic symptoms after regional anesthesia in upper extremity surgery? (2) What block locations have the highest and lowest risk of postoperative neurologic symptoms? (3) What is the timing of occurrence of postoperative neurologic symptoms (in days) after surgery?

METHODS

We searched Ovid MEDLINE, Embase, Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews, Web of Science, Scopus, and PubMed for randomized controlled trials (RCTs) published between 2008 and 2019 that prospectively evaluated postoperative neurologic symptoms after peripheral nerve blocks in operative procedures. Based on the Grading of Recommendations, Assessment, Development, and Evaluation guidance for using the Risk of Bias in Non-Randomized Studies of Interventions tool, most trials registered a global rating of a low-to-intermediate risk of bias. A total of 12,532 participants in 143 trials were analyzed. Data were pooled and interpreted using two approaches to calculate the aggregate risk of postoperative neurologic symptoms: first according to the occurrence of each neurologic symptom, such that all reported symptoms were considered mutually exclusive (pessimistic estimate), and second according to the occurrence of any neurologic symptom for each participant, such that all reported symptoms were considered mutually inclusive (optimistic estimate).

RESULTS

At any time postoperatively, the aggregate pessimistic and optimistic risks of postoperative neurologic symptoms were 7% (915 of 12,532 [95% CI 7% to 8%]) and 6% (775 of 12,532 [95% CI 6% to 7%]), respectively. Interscalene block was associated with the highest risk (13% [661 of 5101] [95% CI 12% to 14%]) and axillary block the lowest (3% [88 of 3026] [95% CI 2% to 4%]). Of all symptom occurrences, 73% (724 of 998) were reported between 0 and 7 days, 24% (243 of 998) between 7 and 90 days, and 3% (30 of 998) between 90 and 180 days. Among the 31 occurrences reported at 90 days or beyond, all involved sensory deficits and four involved motor deficits, three of which ultimately resolved.

CONCLUSION

When assessed prospectively in randomized trials, the aggregate risk of postoperative neurologic symptoms associated with peripheral nerve block in upper extremity surgery was approximately 7%, which is greater than previous estimates described in large retrospective and observational trials. Most occurrences were reported within the first week and were associated with an interscalene block. Few occurrences were reported after 90 days, and they primarily involved sensory deficits. Although these findings cannot inform causation, they can help inform risk discussions and clinical decisions, as well as bolster our understanding of the evolution of postoperative neurologic symptoms after regional anesthesia in upper extremity surgery. Future prospective trials examining the risks of neurologic symptoms should aim to standardize descriptions of symptoms, timing of evaluation, classification of severity, and diagnostic methods.

LEVEL OF EVIDENCE

Level I, therapeutic study.

Effectiveness of dexamethasone or adrenaline with lignocaine 2% for prolonging inferior alveolar nerve block: a randomized controlled trial

Objectives

Inferior alveolar nerve block (IANB) is commonly used for mandibular dentoalveolar surgery. The objective of this study was to evaluate and compare the effectiveness of coadministration of dexamethasone (4 mg/mL) or adrenaline (0.01 mg/mL) as an adjuvant with lignocaine 2% in IANB during third molar surgery (TMS).

Patients and Methods This double-blind, randomized controlled trial was conducted between March and August 2020. The investigators screened patients needing elective TMS under local anesthesia. Based on strict inclusion and exclusion criteria, patients were enrolled in this study. These patients were assigned randomly into two study groups dexamethasone group (DXN) or adrenaline group (ADN). Outcome variables were postoperative edema, trismus, visual analogue scale (VAS), perioperative analgesia, onset time, and duration of IANB.

Results

Eighty-three patients were enrolled in this study, of whom 23 (27.7%) were eliminated or excluded during follow-up. This study thus included data from 60 samples. Mean age was 32.28±11.74 years, including 28 females (46.7%) in the ADN (16 patients, 57.1%) and DXN (12 patients, 42.9%) groups. The duration of action for DXN (mean±standard deviation [SD], 40207±03401 hours; standard error [SE], 00600 hours; log-rank P=0.001) and for ADN (mean±SD, 15834±02452 hours; SE, 00442 hours; log-rank P=0.001) were found. Similarly, time at which 1st analgesic consume and total number of nonsteroidal antiinflammatory drugs need to rescue postoperative analgesia was found statistically significant between study groups (t (58)=–11.95; confidence interval, –22541 to –14353; P=0.001). Early-hours VAS was also significantly different between the study groups.

Conclusion

A single injection of dexamethasone prolongs the duration of action of lignocaine 2% IANB. Additionally, it can be used in cases where adrenaline is contraindicated.

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.

A Comparative Study of Dexamethasone versus Midazolam as Adjuvant to 0.5% Bupivacaine in Ultrasound-Guided Supraclavicular Brachial Plexus Block for Upper-Limb Surgeries

Background:

Ultrasound has been effective in using low volume of local anesthetics for supraclavicular block. Steroids have been shown to increase the duration of local anesthetics.

Aims and Objectives:

In this study, we compare the efficacy of dexamethasone versus midazolam when added to bupivacaine in supraclavicular brachial plexus block for upper-limb surgeries with regard to the time of onset and duration of sensory and motor blockades, duration of analgesia, sedation, and hemodynamic parameters.

Setting and Design:

This is a prospective, randomized, double-blind study conducted on 60 patients belonging to the American Society of Anesthesiologists physical status classes 1 and 2, undergoing upper-limb surgeries under ultrasound-guided supraclavicular brachial plexus block.

Materials and Methods:

Sixty patients were divided into two groups of 30 each. Group dexamethasone (Group D) received bupivacaine 0.5% 18 mL + dexamethasone 4 mg + 1 mL normal saline. Group midazolam (Group M) received bupivacaine 0.5% 18 mL + 2 mg midazolam. We compared the onset and duration of sensory and motor blocks, hemodynamic variables, pain and sedation scores, and duration of analgesia.

Statistical Analysis:

The statistical software, namely SPSS 18.0 and R environment ver. 3.2.2, were used for the analysis of the data. P < 0.05 was considered statistically significant.

Results:

The onset of sensory and motor blocks was significantly faster in Group D compared to Group M. The duration of sensory and motor blockades and duration of analgesia showed a significant increase in Group D in comparison with Group M.

Conclusion:

Dexamethasone as an adjuvant hastens the onset and prolongs the duration of both sensory and motor blocks and reduces postoperative analgesic requirement when compared to midazolam.