Decadron in Peripheral never blocks

[ASA6]

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So I went to a new hospital the other day, and the surgeon asks for a "long acting block." They add decadron to their blocks with good results. Not wanting to buck trend i asked for PF decadron to add to my block. Well, pharmacy doesnt carry it. They use the regular decadron from the card. all it says on the vial is dexamethasone sodium phosphate. Is this ok to use? Anyone else using regular vs PF decadron? is there any data on this for peripheral nerve blocks?

 

[BobBarker]

Your block will last even longer with benzyl alcohol on its side. Generally the purple scrip dex is pf, red isn't. At least where I work.

 

[Planktonmd]

So I went to a new hospital the other day, and the surgeon asks for a "long acting block." They add decadron to their blocks with good results. Not wanting to buck trend i asked for PF decadron to add to my block. Well, pharmacy doesnt carry it. They use the regular decadron from the card. all it says on the vial is dexamethasone sodium phosphate. Is this ok to use? Anyone else using regular vs PF decadron? is there any data on this for peripheral nerve blocks?

Let me tell you a little secret: For a couple of years we did not have PF Decadron and I added the one with preservative to almost all my blocks with zero problems!

 

[BLADEMDA]

The amount of preservative added to the mixture is minuscule. Recent recommendations are to use 1-2 mg of decadron per plexus block. This means no more than 1/2 ml of the 4 mg/ml vial. Again, minuscule amounts of preservative.

I recommend and try to use the PF decadron in my blocks. I've had excellent results with 1 mg, 2 mg and 4 mg aliquots added to the local. I see no need to every use more than 4 mg and have switched to 1-2 mg per plexus based on best available data.

 

[excalibur]

Too funny. One ortho doc wants a long acting block. You go to another hospital and the ortho doc complains the block is lasting too long

 

[Intubate]

I dont have a comment about the preservative vs preservative free, but I do use PF as a matter of course. Regarding dosing, the idea that we should be concerned about the effects of a single small dose of decadron on these nerves borders on absurdity. Literally millions of much larger doses of decadron have been placed on cervical, thoracic, and lumbar nerve roots.

 

[okayplayer]

I dont have a comment about the preservative vs preservative free, but I do use PF as a matter of course. Regarding dosing, the idea that we should be concerned about the effects of a single small dose of decadron on these nerves borders on absurdity. Literally millions of much larger doses of decadron have been placed on cervical, thoracic, and lumbar nerve roots.

Unless the concern is that the steroid is specifically neurotoxic in the setting of unrecognized trauma to the nerve (second hit) during a PNB. I read a paper by Joseph Neal out of VM that drew a similar conclusion in regards to epi added to LA for PNB but there is more of a plausible mechanism for injury there in my opinion.

My concern (and I think a lot of folks') is the lack of good long term data on the safety of the practice, which shifts the risk/ benefit ratio away from using it in a lot of cases.

 

[Noyac]

Is the steroid any more toxic to the nerve than the local?

 

[Intubate]

Unless the concern is that the steroid is specifically neurotoxic in the setting of unrecognized trauma to the nerve (second hit) during a PNB. I read a paper by Joseph Neal out of VM that drew a similar conclusion in regards to epi added to LA for PNB but there is more of a plausible mechanism for injury there in my opinion.

My concern (and I think a lot of folks') is the lack of good long term data on the safety of the practice, which shifts the risk/ benefit ratio away from using it in a lot of cases.

This is what I'm saying-- how big of an "n" do you need? We have millions given over decades. As far as a second hit, I would think a little steroid might (might) actually be beneficial in the setting of neural injury.

 

[Noyac]

This is what I'm saying-- how big of an "n" do you need? We have millions given over decades. As far as a second hit, I would think a little steroid might (might) actually be beneficial in the setting of neural injury.

You may be right about the benefit after second hit. We just don't know. All speculation to this point.

 

[okayplayer]

This is what I'm saying-- how big of an "n" do you need? We have millions given over decades. As far as a second hit, I would think a little steroid might (might) actually be beneficial in the setting of neural injury.

Correct me if I'm wrong, but I would think the risk of mechanical injury to the nerve related to needle trauma would be much higher with a PNB (even us-guided) than an epidural steroid injection.

 

[Intubate]

Correct me if I'm wrong, but I would think the risk of mechanical injury to the nerve related to needle trauma would be much higher with a PNB (even us-guided) than an epidural steroid injection.

Not sure what you're getting at. Do you mean that there should be more damage when you intraneurally inject 20-30 ccs (PNB) vs 2-3 ccs (epi). I would say yes. However if its the decadron specifically we're worried about (for the purposes of this conversation anyway), shouldn't 4 mg diluted in 20-30 ccs be safer than 10-15 mg diluted in 2-3ccs?

 

[BLADEMDA]

Clearly you chaps haven't read the Editorial in this month's Anesthesia and Analgesia. There is no reason to use more than 2 mg of decadron as you get significant prolongation of analgesia at that dosage. Doubling the dosage to 4 mg doesn't increase duration by much if at all.

Secondly, the decadron in the block is expressed as ug/ml utilized per the bench research data. This means we should be staying below the 133 ug/ml threshold for increased safety. Ropivacaine plus decadron at 133 ug/ml is more neurotoxic over 24 hours than Ropivacaine alone. There is significant bench data that staying below 133 ug/ml maintains the highest reserve level of safety for the patient.

 

[BLADEMDA]

Perineural Dexamethasone and Multimodal Perineural Analgesia: How Much Is Too Much?

Williams, Brian A. MD, MBA*; Schott, Nicholas J. MD†; Mangione, Michael P. MD‡; Ibinson, James W. MD, PhD*




As a clinical research community, the era of high-dose single perineural adjuvants (especially related to dexamethasone at doses >2 mg per nerve or plexus) needs to be relegated to legacy status. Our specialty must avoid the temptation to incorporate high-dose perineural dexamethasone into routine practice based on cursory skimming of the current article by Rahangdale et al.14 and the recent meta-analysis by Choi et al.20 To continue to incorporate high-dose perineural dexamethasone in our nerve blocks would be a significant setback in both patient care and in clinical research. When basic cytotoxicity research shows more neuronal death in a dose-response curve with higher concentrations of dexamethasone combined with clinically relevant concentrations of local anesthetics,9 then our patients and our health care colleagues of all disciplines need to trust that we incorporate such basic science findings in our drug selection for off-label use.

 

[Intubate]

Perineural Dexamethasone and Multimodal Perineural Analgesia: How Much Is Too Much?

Williams, Brian A. MD, MBA*; Schott, Nicholas J. MD†; Mangione, Michael P. MD‡; Ibinson, James W. MD, PhD*




As a clinical research community, the era of high-dose single perineural adjuvants (especially related to dexamethasone at doses >2 mg per nerve or plexus) needs to be relegated to legacy status. Our specialty must avoid the temptation to incorporate high-dose perineural dexamethasone into routine practice based on cursory skimming of the current article by Rahangdale et al.14 and the recent meta-analysis by Choi et al.20 To continue to incorporate high-dose perineural dexamethasone in our nerve blocks would be a significant setback in both patient care and in clinical research. When basic cytotoxicity research shows more neuronal death in a dose-response curve with higher concentrations of dexamethasone combined with clinically relevant concentrations of local anesthetics,9 then our patients and our health care colleagues of all disciplines need to trust that we incorporate such basic science findings in our drug selection for off-label use.

I understand that there is some basic science out there indicating potential neurotoxicity, some bizarre studies showing equivalence of iv decadron, and some controversy. Once again though, there have been huge numbers of patients who have received perineural steroids at doses orders of magnitude greater than those in PNBs over the last several decades and there has been, to my knowledge, no suggestion of direct neurotoxic injury related to the steroid. Giving a drug to millions of people and finding no harmful effect should be more important that lab data, right?

But, if 2 is as good as 4, 2 it shall be.

 

[BLADEMDA]

I understand that there is some basic science out there indicating potential neurotoxicity, some bizarre studies showing equivalence of iv decadron, and some controversy. Once again though, there have been huge numbers of patients who have received perineural steroids at doses orders of magnitude greater than those in PNBs over the last several decades and there has been, to my knowledge, no suggestion of direct neurotoxic injury related to the steroid. Giving a drug to millions of people and finding no harmful effect should be more important that lab data, right?

But, if 2 is as good as 4, 2 it shall be.

Yes I agree with you. I wouldn't get upset about my partner using 4 mg of decadron with his local. The clinical data is clear that dosage is safe for single shot blocks.
But, you don't get much more bang for the buck using 4 mg instead of 2 mg so I have backed down to that amount. Recently, I did a nice Popliteal block under U/S with 0.5% Bup and decadron 2 mg (no intraneural injection, block was perfect). The patient reported 30 hours of analgesia from the block ( no history of DM).

 

[ASA6]

Yes I agree with you. I wouldn't get upset about my partner using 4 mg of decadron with his local. The clinical data is clear that dosage is safe for single shot blocks.
But, you don't get much more bang for the buck using 4 mg instead of 2 mg so I have backed down to that amount. Recently, I did a nice Popliteal block under U/S with 0.5% Bup and decadron 2 mg (no intraneural injection, block was perfect). The patient reported 30 hours of analgesia from the block ( no history of DM).

thanks for the discussion everyone. So I have added decadron 4mg to two nerve blocks now. I got about 26 hrs out of the first one and about 22 hrs out of the second. It looks like i should be switching to 2mg.