Decadron IV prolongs Nerve Blocks

[BLADEMDA]

Reg Anesth Pain Med 2015 March/April;40(2):125-132.
Intravenous Dexamethasone and Perineural Dexamethasone Similarly Prolong the Duration of Analgesia After Supraclavicular Brachial Plexus Block: A Randomized, Triple-Arm, Double-Blind, Placebo-Controlled Trial.
Abdallah FW1, Johnson J, Chan V, Murgatroyd H, Ghafari M, Ami N, Jin R, Brull R.
Author information

Abstract
BACKGROUND AND OBJECTIVES:
Perineural dexamethasone prolongs the duration of single-injection peripheral nerve block when added to the local anesthetic solution. Postulated systemic mechanisms of action along with theoretical safety concerns have prompted the investigation of intravenous dexamethasone as an alternative, with decidedly mixed results. We aimed to confirm that addition of intravenous dexamethasone will prolong the duration of analgesia after single-injection supraclavicular block compared with conventional long-acting local anesthetic alone or in combination with perineural dexamethasone for ambulatory upper extremity surgery.

METHODS:
Seventy-five patients were randomized to receive supraclavicular block using 30-mL bupivacaine 0.5% alone (Control), with concomitant intravenous dexamethasone 8 mg (DexIV), or with perineural dexamethasone 8 mg (DexP). Duration of analgesia was designated as the primary outcome. To test our hypothesis, the superiority of DexIV was first compared with Control and then with DexP. Motor block duration, pain scores, opioid consumption, opioid-related side effects, patient satisfaction, and block-related complications were also analyzed.

RESULTS:
Twenty-five patients per group were analyzed. The duration of analgesia (mean [95% confidence interval]) was prolonged in the DexIV group (25 hours [17.6-23.6]) compared with Control (13.2 hours [11.5-15.0]; P < 0.001) but similar to the DexP group (25 hours [19.5-27.4]; P = 1). The DexIV group experienced longer motor block (30.1 hours) compared with DexP (25.5 hours) and Control (19.7 hours) groups. Both DexIV and DexP had reduced pain scores, reduced postoperative opioid consumption, and improved satisfaction compared with Control.

CONCLUSIONS:
In a single-injection supraclavicular block with long-acting local anesthetic, the effectiveness of intravenous dexamethasone in prolonging the duration of analgesia seems similar to perineural dexamethasone.

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[BLADEMDA]

This study adds to the growing body of evidence that Decadron 8 mg given IV before the nerve block prolongs analgesia as well as the motor block. Based on this study and several others I am more inclined to make sure only low dose decadron is mixed with the local solution (no more than 2 mg per 20 mls and 1 ml per 20 for diabetics). For non diabetic patients the remainder of the decadron should be given IV ( 6mg) prior to the block.

For diabetic patients only 1 mg of decadron should be added to the local anesthetic and then an additional 3 mg can be given IV. This combination of perineural plus IV should result in a prolonged nerve block.

For those who don't utilize perineural decadron perhaps you should consider giving the decadron IV prior the administration of the block.

 

[BLADEMDA]

Br J Anaesth. 2013 Sep;111(3):445-52. doi: 10.1093/bja/aet109. Epub 2013 Apr 15.
I.V. and perineural dexamethasone are equivalent in increasing the analgesic duration of a single-shot interscalene block with ropivacaine for shoulder surgery: a prospective, randomized, placebo-controlled study.
Desmet M1, Braems H, Reynvoet M, Plasschaert S, Van Cauwelaert J, Pottel H, Carlier S, Missant C, Van de Velde M.
Author information

Abstract
BACKGROUND:
Interscalene brachial plexus block (ISB) provides excellent, but time-limited analgesia. Dexamethasone added to local anaesthetics prolongs the duration of a single-shot ISB. However, systemic glucocorticoids also improve postoperative analgesia. The hypothesis was tested that perineural and i.v. dexamethasone would have an equivalent effect on prolonging analgesic duration of an ISB.

METHODS:
We performed a prospective, double blind, randomized, placebo-controlled study. Patients presenting for arthroscopic shoulder surgery with an ISB were randomized into three groups: ropivacaine 0.5% (R); ropivacaine 0.5% and dexamethasone 10 mg (RD); and ropivacaine 0.5% with i.v. dexamethasone 10 mg (RDiv). The primary outcome was the duration of analgesia, defined as the time between performance of the block and the first analgesic request. Standard hypothesis tests (t-test, Mann-Whitney U-test) were used to compare treatment groups. The primary outcome was analysed by Kaplan-Meier survival analysis with a log-rank test and Cox's proportional hazards regression.

RESULTS:
One hundred and fifty patients were included after obtaining ethical committee approval and patient informed consent. The median time of a sensory block was equivalent for perineural and i.v. dexamethasone: 1405 min (IQR 1015-1710) and 1275 min (IQR 1095-2035) for RD and RDiv, respectively. There was a significant difference between the ropivacaine group: 757 min (IQR 635-910) and the dexamethasone groups (P<0.0001).

CONCLUSIONS:
I.V. dexamethasone is equivalent to perineural dexamethasone in prolonging the analgesic duration of a single-shot ISB with ropivacaine. As dexamethasone is not licensed for perineural use, clinicians should consider i.v. administration of dexamethasone to achieve an increased duration of ISB.

 

[Mman]

I guess the question is if the mechanism of action of the dexamethasone is systemic absorption. If so, is there any benefit to adding it to the local? Conversely, does adding it to the local have the same ability to decrease PONV as an IV dose?

 

[BLADEMDA]

Pain Res Treat. 2014;2014:179029. doi: 10.1155/2014/179029. Epub 2014 Nov 18.
Perineural dexamethasone to improve postoperative analgesia with peripheral nerve blocks: a meta-analysis of randomized controlled trials.
De Oliveira GS Jr1, Castro Alves LJ1, Nader A1, Kendall MC1, Rahangdale R1, McCarthy RJ1.
Author information

Abstract
Background. The overall effect of perineural dexamethasone on postoperative analgesia outcomes has yet to be quantified. The main objective of this quantitative review was to evaluate the effect of perineural dexamethasone as a nerve block adjunct on postoperative analgesia outcomes. Methods. A systematic search was performed to identify randomized controlled trials that evaluated the effects of perineural dexamethasone as a block adjunct on postoperative pain outcomes in patients receiving regional anesthesia. Meta-analysis was performed using a random-effect model. Results. Nine randomized trials with 760 subjects were included. The weighted mean difference (99% CI) of the combined effects favored perineural dexamethasone over control for analgesia duration, 473 (264 to 682) minutes, and motor block duration, 500 (154 to 846) minutes. Postoperative opioid consumption was also reduced in the perineural dexamethasone group compared to control, -8.5 (-12.3 to -4.6) mg of IV morphine equivalents. No significant neurological symptoms could have been attributed to the use of perineural dexamethasone. Conclusions. Perineural dexamethasone improves postoperative pain outcomes when given as an adjunct to brachial plexus blocks. There were no reports of persistent nerve injury attributed to perineural administration of the drug.

 

[BLADEMDA]

Pain Physician. 2015 Jan-Feb;18(1):1-14.
Perineural dexamethasone added to local anesthesia for brachial plexus block improves pain but delays block onset and motor blockade recovery.
Knezevic NN, Anantamongkol U, Candido KD1.
Author information

Abstract
BACKGROUND:
Multiple studies have shown that perineural dexamethasone improves postoperative analgesia. However, some studies have shown minimal benefit, and have raised concerns regarding adverse physio-chemical effects of perineural dexamethasone. Furthermore, there is a paucity of studies wherein control (IV) dexamethasone was considered.

OBJECTIVE:
The purpose of this meta-analysis was to evaluate the effectiveness of different concentrations of perineural dexamethasone injection on postoperative analgesia, as well as complications from its use for brachial plexus blocks.

METHODS:
A systematic literature search was conducted using the Cochrane Central Registry of Controlled Trials, PubMed, and Scopus. Trials comparing control and local dexamethasone-treated groups, and those which reported duration of analgesia and/or pain scores/opioid consumptions were selected. Meta-analysis was performed using the Review Manager (RevMan) software 5.1.

RESULTS:
Fourteen studies consisting of a total of 1,022 patients were included. Perineural dexamethasone significantly prolonged the duration of postoperative analgesia in patients receiving both low-dose (4 - 5 mg) [SMD 2.41 (95% CI: 1.47, 3.35 P = 0<0.00001) I² = 82%], and higher-doses (8 - 10 mg) [SMD 4.46 (95% CI 3.54, 5.38 P < 0.00001) I² = 94%]. However, the duration of motor block was also prolonged [SMD 2.52 (95% CI: 1.06, 3.98 P = 0.0007) I² = 97%] and dexamethasone delayed latency of onset of sensory [SMD -0.49 (95% CI: -0.89, -0.09 P = 0.02) I² = 76%] and motor [SMD -0.56 (95% CI: -1.13, 0.00 P = 0.05) I² = 87%] blocks. Postoperative pain scores were improved at both 24 hours [SMD -1.46 (95% CI: -2.43, -0.50 P = 0.003) I² = 95%] and 48 hours [SMD -1.20 (95% CI: -2.26, -0.13 P = 0.03) I² = 95%] in dexamethasone-treated groups, whereas opioid consumption was reduced only at 48 hours [SMD -2.97 (95% CI: -4.17, -1.76 P < 0.00001) I² = 88%]. Complications were comparable between control and dexamethasone-adjuvant groups, except for the excessively prolonged nerve block that was observed predominantly in the dexamethasone-adjuvant group.

LIMITATIONS:
The limitations include different definitions used for the measurements of certain parameters such as the duration of analgesia and duration of motor block, number of studies assessing certain parameters having high heterogeneity, and varying types of local anesthetics used in various studies.

CONCLUSIONS:
Perineural dexamethasone addition to local anesthetic solutions significantly improved postoperative pain in brachial plexus block without increasing complications. However, perineural adjuvant dexamethasone delayed the onset of sensory and motor block, and prolonged the duration of motor block. Smaller doses of dexamethasone (4 - 5 mg) were as effective as higher doses (8 - 10 mg).

 

[BLADEMDA]

I guess the question is if the mechanism of action of the dexamethasone is systemic absorption. If so, is there any benefit to adding it to the local? Conversely, does adding it to the local have the same ability to decrease PONV as an IV dose?

The safety profile of Perineural Decadron can be enhanced by reducing the dosage to no more than 2 mg per 20 mls (1 mg per 20 for diabetics). The remainder of the decadron should/could be given IV prior to initiation of the block.

My anecdotal experience shows significant enhancement of analgesia with the use of perineural decadron. While I understand the concern about adding it to the local this small dosage of decadron has been show to be safe clinically and in the lab.

 

[Mman]

The safety profile of Perineural Decadron can be enhanced by reducing the dosage to no more than 2 mg per 20 mls (1 mg per 20 for diabetics). The remainder of the decadron should/could be given IV prior to initiation of the block.

My anecdotal experience shows significant enhancement of analgesia with the use of perineural decadron. While I understand the concern about adding it to the local this small dosage of decadron has been show to be safe clinically and in the lab.

Is it safer than just giving it all IV? PNBs have a very good risk profile. You'd need a very large N to determine the relative safety of various additives. I'm simply wondering if you get the same effect giving it IV if there is any benefit to adding it to the local?

 

[BLADEMDA]

Pain Med. 2015 Jan;16(1):186-98. doi: 10.1111/pme.12592. Epub 2014 Oct 23.
Multimodal perineural analgesia with combined bupivacaine-clonidine-buprenorphine-dexamethasone: safe in vivo and chemically compatible in solution.
Williams BA1, Butt MT, Zeller JR, Coffee S, Pippi MA.
Author information

Abstract
OBJECTIVES:
The use of adjuvants in regional anesthesia has increased. However, there are knowledge gaps pertaining to 1) in vivo local tissue effects of these adjuvants; and 2) chemical compatibility and solubility of these drugs in solution with each other and with local anesthetics. This study addresses these gaps in knowledge.

DESIGN:
In vivo rat safety/toxicopathology study and analytical chemistry study.

SETTING:
Collaborating Good Laboratory Practice laboratories under the direction of the university-based principal investigator.

METHODS:
Single-injection formulations of clonidine, buprenorphine, and dexamethasone were combined with either bupivacaine or midazolam, and were administered to groups of rats. Post-injection behavior was monitored to assess changes related to the block. A continuous infusion of bupivacaine, clonidine, and dexamethasone was administered to another group of rats, and behavioral effects were recorded. After 15 days, rats were sacrificed and their nerves/dorsal root ganglia were examined by the pathologist. Samples of combined drug solutions were processed at an analytical chemistry laboratory for compatibility, solubility, and stability.

RESULTS:
Each of the single-injection formulations produced reversible sensory and/or motor block. None of the study drugs caused damage to any of the nerve segments or related tissue. The text describes the concentrations at which compatibility and solubility of the combined drug solutions were achieved.

CONCLUSIONS:
Four-drug single-injection formulations are described that 1) had compatible and stable concentrations in solution; and 2) produced reversible nerve block without causing long-term motor or sensory deficits or damage to sciatic nerves/dorsal root ganglia.

 

[BLADEMDA]

Is it safer than just giving it all IV? PNBs have a very good risk profile. You'd need a very large N to determine the relative safety of various additives. I'm simply wondering if you get the same effect giving it IV if there is any benefit to adding it to the local?

I've been giving Decadron IV ( 4mg) prior to my nerve blocks for over 10 years and while I may get some enhanced analgesia it is NOTHING like the improvement in analgesia I see with perineural administration of Dexamethasone. That said, the literature is quite clear that large doses of perineural decadron may be harmful to nerves (lab data) while small doses are safe; this adds to the growing body of evidence that IV administration is the safer route to go for many of us in practice. I will continue to use low dose perineural decadron in select patients.

As for whether IV only Decadron will equal or exceed to the combination of low dose perineural decadron plus IV decadron I can not say at this time.

 

[OB1🤙]

I was very skeptical of this at first. Seems like there's enough signal in the noise there to say *something* is going on with the IV decadron.

So my question is this- do you have to give it before/during the block, or can you give it after induction of GA and get the same result? I want to see a head-to-head RCT on this.

 

[Planktonmd]

This debate is just another proof that we really don't know much about the most basic things we do everyday!
There are so many examples similar to this in the practice of medicine which confirms that what we know or what we think we know is nothing but a small fraction of what we still don't know.
For that reason I tend to adopt only what makes sense to me and most of the time it turns out to be the best option.
In my opinion perineural steroids make sense so I will keep on using them.

 

[OB1🤙]

Agree, Plank.

Note of warning to folks wanting to start to give preop decadron- don't rapid bolus it.

http://forums.studentdoctor.net/thr...ast-over-24-hours.973311/page-2#post-14011457

 

[deleted162650]

Anybody else find it strange that in that first study Blade posted the motor block far exceeded the analgesia in all groups? That's the opposite of what I typically see in my practice. Kinda makes me question the validity of the whole study. Thoughts?

 

[Ezekiel2517]

I've always used plain old 0.25% bupivicaine for my blocks and get great block duration
Technique and perfecting U/S visualization will get you a great block and are much more important than adding this and that