Interscalene block without decadron

[BobBarker]

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Darn. Memory is failing me at a young age. I thought it was in the tetracaine/lidocaine study.

 

[Oggg]

My ortho surgeon absolutely wants a preop block because he says the bleeding is waaaaaaaaaaaay less ( because no pain = more stable hemodynamics). Sell that to your surgeon. Heck, challenge him to see how much better the bleeding is after a block. (Arthroscopic)

 

[Oggg]

http://www.iosrjournals.org/iosr-jdms/papers/Vol4-issue3/G0433039.pdf

I looked at this study. They showed buprenorphine and clonidine prologmbgung the block conpared to bupiv alone, but... The mean duration of analgesia for bupiv 0.25% 40cc supraclav block was like 180min = 3h. That's pathetic. I still want to try buprenorphine but these results are weird.

 

[BLADEMDA]

Darn. Memory is failing me at a young age. I thought it was in the tetracaine/lidocaine study.

I found the study. It was the Candido December 2010 study in Anesthesiology. The authors state the Vomiting was increased because prophylaxis against N/V was not utilized.

In this study Buprenorphine increased postop analgesia by 6 hours on average.


"Vomiting was a more frequent adverse event in patients
receiving buprenorphine (groups 2 and 3) (table 4). Other
side effects or complications such as urinary retention (total
three patients), pruritus (total six patients), or fatigue (total
nine patients) were less frequent than vomiting"

 

[BLADEMDA]

Anesthesiology:
December 2010 - Volume 113 - Issue 6 - pp 1419-1426
doi: 10.1097/ALN.0b013e3181f90ce8
Pain Medicine
Buprenorphine Enhances and Prolongs the Postoperative Analgesic Effect of Bupivacaine in Patients Receiving Infragluteal Sciatic Nerve Block
Candido, Kenneth D. M.D.*; Hennes, Jason M.D.†; Gonzalez, Sergio M.D.‡; Mikat-Stevens, Marianne M.D.§; Pinzur, Michael M.D.∥; Vasic, Vladimir Ph.D.#; Knezevic, Nebojsa Nick M.D., Ph.D.**


Collapse BoxAbstract
Background: Results from previous studies have shown favorable effects from the addition of buprenorphine to local anesthetics used for interscalene or axillary perivascular brachial plexus blocks. The main objective of the current study was to determine whether addition of buprenorphine could enhance bupivacaine analgesia after infragluteal sciatic nerve block.
Methods: One hundred and three consenting adult patients for elective foot and ankle outpatient surgeries were prospectively assigned randomly, in double-blind fashion, to one of three groups. Group 1 received 0.5% bupivacaine with epinephrine 1:200,000 for infragluteal sciatic block plus 1 ml normal saline intramuscularly. Group 2 received bupivacaine sciatic block along with intramuscular buprenorphine (0.3 mg). Group 3 received bupivacaine plus buprenorphine for infragluteal sciatic block and 1 ml normal saline intramuscularly.
Results: Although patients receiving buprenorphine either for sciatic block or intramuscularly had less pain in the postanesthesia care unit compared with patients receiving only bupivacaine, the individual pair-wise comparison of the analysis of variance model showed no statistical difference. However, only buprenorphine added to bupivacaine for sciatic block prolonged postoperative analgesia. Patients receiving a combination of buprenorphine and bupivacaine for sciatic block had lower numeric rating pain scores and received less opioid medication at home than patients in the other two groups.
Conclusions: The results show that buprenorphine may enhance and prolong the analgesic effect of bupivacaine when used for sciatic nerve blocks in patients undergoing foot and ankle surgery under general anesthesia but does not do so to the extent shown in previous studies using brachial plexus models with mepivacaine and tetracaine

 

[BLADEMDA]

+1 to dexamethasone IV doing nothing for a block.
+1 to dexamethasone absolutely making a block last longer and more dense

The new article in RAPM by Fredriksen seems to say that dexamethasone works but it doesn't make a difference at 48h, and because of that, he says its not useful. I think we can all say BS to that.

When I tried clonidine I got inconsitent results that were no better than my partners who used 20cc 2%lido and 20cc 0.5%bupiv NS. Maybe it was cuz I wasn't as good with the ultrasound then.

Haven't tried buprenorphine.

I thought fentanyl was pretty much found to be useless for PNB.

http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2044.1997.174-az0311.x/pdf

In this study out of France Sufenta beat Buprenorphine. Almost all of us have access to Sufenta so maybe all we need to do is add 20 ug to our blocks?

 

[BLADEMDA]

To date, data on the efficacy of the combination of opioids and local anesthetics in peripheral nerve block are not conclusive yet. In this study, the onset time, duration as well as quality of lumbar plexus and sciatic nerve blockade were evaluated using sufentanil and ropivacaine combination compared with plain ropivacaine. Forty patients scheduled for lower extremity surgery under combined lumbar plexus and sciatic nerve block were randomly allocated into two groups. Fifty millilitres of 0.375% ropivacaine with 0.5μg/ml sufentanil (trial group) and 0.375% plain ropivacaine (control group) were administered when the location of lumbar plexus and sciatic nerve were confirmed by a nerve stimulator. Onset and duration of sensory and motor block were investigated. Opioid-related side effects were recorded. Quality of anesthesia in terms of success rate of block and patients' satisfaction were reviewed after surgery. The addition of sufentanil to ropivacaine did not facilitate the onset of the block, nor the duration of analgesia. For lumbar plexus block, the mean onset time of sensory block was 13.9±7.4min (trial group) versus 12.4±5.9min (control group), respectively, 11.3±6.5min versus10.5±4.2min, respectively, for motor block. For sciatic nerve block, the onset time of sensory block was 14.6±8.6min versus 14.2±7.0min, respectively, 15.4±7.3min versus 13.6±9.5min, respectively, for motor block. The mean duration of sensory block is 14.3±4.5h (trial group) versus 15.2±4.6h (control group), respectively; the mean duration of motor block 17.3±6.1h versus 16.7±5.3h, respectively. Opioid-related side effects were similar between groups, as well as the success rate of the block and patients' satisfaction. We concluded that, during combined lumbar plexus and sciatic nerve block, adding sufentanil 0.5μg/ml to 0.375% ropivacaine solution did not provide clinically relevant advantages in terms of onset time, duration and quality of anesthesia for patients undergoing elective lower extremity surgery.

http://www.acutepainjournal.com/article/S1366-0071(07)00003-4/abstract

 

[BLADEMDA]

http://www.iosrjournals.org/iosr-jdms/papers/Vol4-issue3/G0433039.pdf

I looked at this study. They showed buprenorphine and clonidine prologmbgung the block conpared to bupiv alone, but... The mean duration of analgesia for bupiv 0.25% 40cc supraclav block was like 180min = 3h. That's pathetic. I still want to try buprenorphine but these results are weird.

Look what I found for you:


Title Is there a Dosage Effect of Dexamethasone as an Adjuvant for Brachial Plexus Nerve Block? - A Prospective Randomized Double-blinded Clinical Study
Speaker: Jiabin J. Liu
Author: Jiabin Liu, M.D., Kenneth A. Richman, M.D., Nabil Elkassabany, M.D.
Affiliation: Anesthesiology and Critical Care, The University of Pennsylvania, Philadelphia, PA, USA
Session: Moderated E-Poster Session 5
Date: Saturday - May 04, 2013 08:15-09:45
Location: ePoster Area
Subtopic: Regional Anesthesia
Topic: Scientific Abstracts
Introduction: Brachial plexus block is a great option for postoperative pain management after shoulder arthroscopy. Dexamethasone, as an adjuvant, to local anesthetics further expanded our capability to provide longer duration of analgesia with a single shot nerve block. Recent evidence showed that that 8mg of preservative-free dexamethasone has been able to prolong the analgesia duration of brachial plexus nerve block by 50 to 100 percent. There is only one study with reduced dosage of dexamethasone of 4mg by Dr. Nader´s group. The authors observed decreased analgesia duration from 25.2 to 21.6 hours, while not statistic significant.
The safety of adding dexamethasone and the implication to the incidence of neuronal damage are still in question. Available studies failed to draw any definitive conclusion about the safety of adding dexamethasone because of the limited number of the studies and the small sample size in each. It is appealing that lower dose of dexamethasone may be clinically effective with decreased risks. We hypothesize that dexamethasone as an adjuvant to local anesthetic has dose response effects in regards to the duration of sensory and motor nerve blocks.
Methods: The study was reviewed and approved by the institutional review board of the University of Pennsylvania. We proposed to recruit 100 outpatient patients undergoing shoulder arthroscopic surgery between the age of 18 to 70 with ASA I-III physical status. All patients will receive general anesthesia and an ultrasound guided supraclavicular brachial plexus nerve block with 30ml of 0.25% bupivacaine. All patients will be randomly assigned into one of four groups: control group, 1mg dexamethasone, 2mg dexamethasone, or 4mg dexamethasone in addition to 0.25% bupivacaine. All patients will be interviewed over the phone on post-operative day 1, day 2, and day 7. The recovery of sensory, motor, time to first opioid requirement, and opioid consumptions will be recorded. All data will be analyzed via ANOVA.
Results: Currently, we have recruited over 40 patients into the study. Preliminary data analysis showed that duration of analgesia was significantly prolonged in all groups received dexamethasone. The average analgesia duration of plain 0.25% bupivacaine was 15.7 hours, while average analgesia durations were 22.4, 23.4, and 22.2 hours for dexamethasone 1mg, 2mg, or 4mg group respectively. The average durations of motor block showed similar trend.
Discussion: Our preliminary data analysis showed no dose response effect of dexamethasone as an adjuvant to local anesthetic for brachial plexus nerve block. The addition of dexamethasone to bupivacaine significantly prolonged the duration of sensory and motor nerve block. In addition, our preliminary finding indicated shorter motor block duration than sensory block. We are currently actively recruiting additional patients into this study.

 

[BLADEMDA]

Here is what I am seeing after several hundred ISB under u/s with 0.5% Bup with decadron PF.

1. There is no prolongation of the block as you go from 20mls to 30 mls to 40 mls (using 0.5% Bup). A well placed ISB with 20 mls of 0.5% Bup seems to be the magic number.

2. The effective amount of Decadron seems to be 1-2 mg added to the local. That is, you start getting a significant effect with as little as 1 mg. I use 1-2 mg in Diabetics with excellent results. I have gotten 30 hours from a single shot ISB utilizing 20 mls of 0.5% Bup with 2 mg of Decadron in a diabetic.

3. 4 mg of PF decadron is usually plenty of decadron. This will reliably get you over 24 hours of post op pain relief with 0.5% Bup 20 mls.

4. 8 mg of PF decadron seems to give an extra 2 hours of postop pain relief over the 4 mg dose. Not a lot of bang for the buck by doubling the dosage. Hence, I utilize 8 mg only on ASA 1 or 2 young, healthy patients. (usually ASA 1 or an ASA 1 who smokes=ASA 2)

 

[BLADEMDA]

J Anesth. 2011 Oct;25(5):704-9. doi: 10.1007/s00540-011-1180-x. Epub 2011 Jun 17.

Adjuvant dexamethasone with bupivacaine prolongs the duration of interscalene block: a prospective randomized trial.

Tandoc MN, Fan L, Kolesnikov S, Kruglov A, Nader ND.


Source

Department of Anesthesiology, SUNY-Buffalo, Buffalo, USA.


Abstract


PURPOSE:

To identify the effects of adding two different doses of dexamethasone on the duration and quality of interscalene block in patients undergoing shoulder surgery in ambulatory surgery settings.

METHODS:

The study design was reviewed and approved by the University at Buffalo Institutional Review Board for Human Subjects. After obtaining informed consent, a total of 90 patients undergoing shoulder surgery using interscalene block with 0.5% bupivacaine (40 mL) were assigned randomly to one of three groups: control patients, "Group C," who received no additive; low dose, "Group L," who received additional dexamethasone 4 mg; and high dose, "Group H," who received dexamethasone 8 mg in addition to 0.5% bupivacaine. Postoperative analgesia was assessed using the numeric rating scores of pain and the postoperative consumption of acetaminophen 325 mg + hydrocodone 7.5 mg tablets. Analysis was by intention to treat. Statistical significance was tested using a two-way analysis of variance and a nonparametric analysis of variance for consumption of analgesics.

RESULTS:

Four patients were excluded from the study due to either a failed block or inadequate follow-up. The duration of analgesia was significantly prolonged in both Group L (21.6 ± 2.4 h) and Group H (25.2 ± 1.9 h) compared with Group C (13.3 ± 1.0 h) (p < 0.05). Similarly, the duration of motor block was longer in both Group L (36.7 ± 4.1 h), and Group H (39.2 ± 3.9 h) compared to Group C (24.6 ± 3.3 h) (p < 0.05). Postoperative analgesic consumption for the first 48 h was significantly lower in Group L (6.5 [4-8] tabs) and in Group H (5.5 [4-7] tabs) vs. 9.5 [8-12] tabs in Group C (p < 0.01). There were no adverse events related to dexamethasone during the 4-week follow-up period.

CONCLUSION:

The addition of dexamethasone to bupivacaine significantly prolonged the duration of the motor block and improved the quality of analgesia following interscalene block. There was no difference in the duration of analgesia and motor block between low-dose and high-dose dexamethasone

 

[BLADEMDA]

For those of using Decadron with the 0.5% Bupivacaine adding Clonidine doesn't seem to provide any benefit in terms of analgesia. The duration of postop pain relief appears similar whether you add clonidine or not provided Decadron is used with the Bupivacaine.

http://www.ncbi.nlm.nih.gov/pubmed/20009936

 

[dhb]

My ortho surgeon absolutely wants a preop block because he says the bleeding is waaaaaaaaaaaay less ( because no pain = more stable hemodynamics). Sell that to your surgeon. Heck, challenge him to see how much better the bleeding is after a block. (Arthroscopic)

That's what my surgeons says too

 

[Oggg]

J Anesth. 2011 Oct;25(5):704-9. doi: 10.1007/s00540-011-1180-x. Epub 2011 Jun 17.

Adjuvant dexamethasone with bupivacaine prolongs the duration of interscalene block: a prospective randomized trial.

Tandoc MN, Fan L, Kolesnikov S, Kruglov A, Nader ND.


Source

Department of Anesthesiology, SUNY-Buffalo, Buffalo, USA.


Abstract


PURPOSE:

To identify the effects of adding two different doses of dexamethasone on the duration and quality of interscalene block in patients undergoing shoulder surgery in ambulatory surgery settings.

METHODS:

The study design was reviewed and approved by the University at Buffalo Institutional Review Board for Human Subjects. After obtaining informed consent, a total of 90 patients undergoing shoulder surgery using interscalene block with 0.5% bupivacaine (40 mL) were assigned randomly to one of three groups: control patients, "Group C," who received no additive; low dose, "Group L," who received additional dexamethasone 4 mg; and high dose, "Group H," who received dexamethasone 8 mg in addition to 0.5% bupivacaine. Postoperative analgesia was assessed using the numeric rating scores of pain and the postoperative consumption of acetaminophen 325 mg + hydrocodone 7.5 mg tablets. Analysis was by intention to treat. Statistical significance was tested using a two-way analysis of variance and a nonparametric analysis of variance for consumption of analgesics.

RESULTS:

Four patients were excluded from the study due to either a failed block or inadequate follow-up. The duration of analgesia was significantly prolonged in both Group L (21.6 ± 2.4 h) and Group H (25.2 ± 1.9 h) compared with Group C (13.3 ± 1.0 h) (p < 0.05). Similarly, the duration of motor block was longer in both Group L (36.7 ± 4.1 h), and Group H (39.2 ± 3.9 h) compared to Group C (24.6 ± 3.3 h) (p < 0.05). Postoperative analgesic consumption for the first 48 h was significantly lower in Group L (6.5 [4-8] tabs) and in Group H (5.5 [4-7] tabs) vs. 9.5 [8-12] tabs in Group C (p < 0.01). There were no adverse events related to dexamethasone during the 4-week follow-up period.

CONCLUSION:

The addition of dexamethasone to bupivacaine significantly prolonged the duration of the motor block and improved the quality of analgesia following interscalene block. There was no difference in the duration of analgesia and motor block between low-dose and high-dose dexamethasone

I have to think that the author mixed up motor block and analgesia and meant ~20h of motor block and ~35h of analgesia.

 

[excalibur]

Well, the pharmacy ordered buprenex for me. It should be here tomorrow.

Next shoulder I get, I will do it with Bupi 0.5% + decadron + buprenorphine 150 mcg and see how it goes.

 

[BLADEMDA]

Well, the pharmacy ordered buprenex for me. It should be here tomorrow.

Next shoulder I get, I will do it with Bupi 0.5% + decadron + buprenorphine 150 mcg and see how it goes.

my hunch is 35 hours or so of solid analgesia

 

[Planktonmd]

If you use Dxamethasone there is no need for Buprenorphine.

 

[BLADEMDA]

If you use Dxamethasone there is no need for Buprenorphine.

Unless you want longer analgesia postoperatively.

Examples:

Shoulder Replacement
Total Knee replacement
Total Hip Replacement (posterior approach)
Open Laparotomy


I'd like a little Buprenorphine in my block if I was the patient in these examples especially the open laparotomy.

 

[Oggg]

I want to add buprenorphine to ropiv 0.2% 20ml for TKA. If it doesn't worsen the motor block, this would be great as the ropiv doesn't last long enough and the bupiv often gives excessive motor block.

 

[excalibur]

I want to add buprenorphine to ropiv 0.2% 20ml for TKA. If it doesn't worsen the motor block, this would be great as the ropiv doesn't last long enough and the bupiv often gives excessive motor block.

I like that idea a lot, Oggg. Let me know how it goes.

 

[Ferrismonk]

I haven't tried many of the adjuvants mentioned here yet, so I've found this topic very interesting. My question is have you considered using an On-Q pump catheter with 2% Ropivicaine? We've had great success and our patients and surgeons love them. Titratable analgesia for approximately 3 days is nothing to scoff at. Cost is similar to Exparel.

 

[BLADEMDA]

I haven't tried many of the adjuvants mentioned here yet, so I've found this topic very interesting. My question is have you considered using an On-Q pump catheter with 2% Ropivicaine? We've had great success and our patients and surgeons love them. Titratable analgesia for approximately 3 days is nothing to scoff at. Cost is similar to Exparel.

I think you mean 0.2% Ropivacaine. Yes, I have tried the On-Q pumps and they work well.

But, I have been on the other side as a patient as was quite satisfied with a single shot block (long acting) as well. The sweet spot is around 40-48 hours of post pain relief.

The jury is still out on Exparel vs ON-Q pumps but I will be in the Exparel camp.

 

[BLADEMDA]

Single shot femoral nerve block offers superior postoperative mobilisation at an equal analgesia level after total knee arthroplasty compared to continuous nerve block using a catheter: 8AP6&#8208;1
Heeremans, E. H.; Pape, N.; Koorevaar, R. C.T.; Cobben, J. M.G.


http://journals.lww.com/ejanaesthes..._femoral_nerve_block_offers_superior.423.aspx

 

[BLADEMDA]

This is the same reason Anesthesiologists place continuous catheters- because they can.

 

[BLADEMDA]

A single shot block which can offer 35 hours plus of postop pain relief may be all the patient needs 95% of the time to get through the perioperative period. Most studies looking at On-Q pumps show NO long term benefits over a single shot block. The industry is built around profit so this means expensive pumps and catheters vs a $10.00 single shot block.

Yes, pain scores may be lower in certain procedures at 48 hours with a ON-Q pump vs. a single shot block but is that small benefit worth the cost and increased risk? No. There is simply no good, hard evidence to support anything other than a long acting single shot block.

Hence, even though I am a big proponent of Exparel the fact remains that a cocktail of Bupivacaine 0.5%, Decadron and Buprenorphine likely offers excellent results at a fraction of the cost.

I place continuous catheters from time to time and will continue to do so but for the vast majority of my patients the SuperCocktail remains my primary choice. Once Exparel gets FDA approval I will examine its role in outpatients vs the Supercocktail.

FYI, I highly recommend the Supercocktail to family members and friends. While it won't replace the On-Q pump in every situation it can certainly reduce the need for continuous catheters for the vast majority of patients.

 

[sevoflurane]

I will humbly disagree.

Motor block is a BIG negative for a single shot femoral block vs. continuous catheters. Nothing like having motors present and analgesia with a continuous block.

Our patients are up and walking POD #0 and out of the hospital in 2-3 days. This saves a tremendous amount of $$$ to the hospital.

Remember, a lot of insurance companies rarely pay for TKA hospital costs past 3 days.

At this point I've abandoned fem. nerve blocks for tka's and am using ACB + Exparel infiltration for TKA's.

 

[BLADEMDA]

I will humbly disagree.

Motor block is a BIG negative for a single shot femoral block vs. continuous catheters. Nothing like having motors present and analgesia with a continuous block.

Our patients are up and walking POD #0 and out of the hospital in 2-3 days. This saves a tremendous amount of $$$ to the hospital.

Remember, a lot of insurance companies rarely pay for TKA hospital costs past 3 days.

At this point I've abandoned fem. nerve blocks for tka's and am using ACB + Exparel infiltration for TKA's.

This is a slightly different discussion regarding TKA. I use 20 mls 0.5% Rop with decadron 4 mg for the Femoral combined with 10 mls of 0.5% Rop with 1 of decadron for the tibial.

They are walking on POD 1 and out on POD 3. Pain scores are good.

My other combo is a ACB with 20 mls of 0.5% Bup with 4 mg of decadron combined with a selective tibial block ( 8mls of 0.25% Bup). These patients are walking on POD zero and are out on POD 3. (plus surgeon infiltration into the knee).

 

[BLADEMDA]

I will humbly disagree.

Motor block is a BIG negative for a single shot femoral block vs. continuous catheters. Nothing like having motors present and analgesia with a continuous block.

Our patients are up and walking POD #0 and out of the hospital in 2-3 days. This saves a tremendous amount of $$$ to the hospital.

Remember, a lot of insurance companies rarely pay for TKA hospital costs past 3 days.

At this point I've abandoned fem. nerve blocks for tka's and am using ACB + Exparel infiltration for TKA's.

If the surgeon does not infiltrate the knee then the failure rate of the ACB is significant. The ACB without surgeon infiltration is inadequate for postop pain relief a significant % of the time.

 

[sevoflurane]

if the surgeon does not infiltrate the knee then the failure rate of the acb is significant. The acb without surgeon infiltration is inadequate for postop pain relief a significant % of the time.

+1

 

[excalibur]

If the surgeon does not infiltrate the knee then the failure rate of the ACB is significant. The ACB without surgeon infiltration is inadequate for postop pain relief a significant % of the time.

Good to know. Likely why I am not having as much success with ACB on TKA