Is this the end of LESI?

[BuzzPhreed]

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Just saw this on Medscape. Slightly misleading headline.

Spinal Corticosteroids Run Risk of Severe Neuro Effects

In today's announcement, directed at anesthesiologists and pain management physicians, the agency said it has not established the effectiveness and safety of epidural administration of corticosteroids such as hydrocortisone and methylprednisolone. As a consequence, "the FDA has not approved corticosteroids for such use."

http://www.medscape.com/viewarticle/824043

Anyone still thinking about doing a chronic pain fellowship?

 

[deleted126335]

Anybody reconsidering decagon in peripheral nerve blocks?

 

[Stank811]

"Epidural injections of corticosteroids to relieve pain — a widespread, off-label use — run the rare risk for blindness, stroke, paralysis, and death, the US Food and Drug Administration (FDA) announced today."

I am assuming this risk profile is secondary to placement of the steroid not within the epidural space and has been a known risk profile for sometime.

 

[BuzzPhreed]

I am assuming this risk profile is secondary to placement of the steroid not within the epidural space and has been a known risk profile for sometime.

That's a good question and the Medscape article didn't make that clear.

Here's the press safety announcement from the FDA which also doesn't make that clear. http://www.fda.gov/Drugs/DrugSafety/ucm394280.htm

But what is clear is that you're going to start seeing those ambulance chaser adds on TV about this. Probably today. "Have you or a loved one been injured by epidural steroid injections? Call 1-800-SUE-MYASS!"

 

[BuzzPhreed]

Anybody reconsidering decagon in peripheral nerve blocks?

No.

 

[aneftp]

My pain friends say the FDA advisory doesn't mean much.

The FDA advisory is the same as the saying "It is like saying antidepressant increase risk of suicide "

 

[pgg]

Anybody reconsidering decagon in peripheral nerve blocks?

"Epidural injections of corticosteroids to relieve pain — a widespread, off-label use — run the rare risk for blindness, stroke, paralysis, and death, the US Food and Drug Administration (FDA) announced today."

I am assuming this risk profile is secondary to placement of the steroid not within the epidural space and has been a known risk profile for sometime.

My understanding is that the blindness/stroke/paralysis risk is related to particulate steroids.

I'll still use dexamethasone for PNBs.

 

[BLADEMDA]

I have reduced my dosages of Decadron In my PNBs. My anecdotal experience still shows a prolonged block with a reduced, safer dosage of dexamethasone. I recommend you read this month's (05/14) A & A.

 

[urge]

Doesn't dex prolong the block as well when given iv? I don't see a good reason to inject it with the local.

 

[Noyac]

I have reduced my dosages of Decadron In my PNBs. My anecdotal experience still shows a prolonged block with a reduced, safer dosage of dexamethasone. I recommend you read this month's (05/14) A & A.

How low have you gone?

 

[Intubate]

Doesn't dex prolong the block as well when given iv? I don't see a good reason to inject it with the local.

This seems to be what the data says. However, I've given IV dex to almost every patient that I've ever put to sleep. I never had a block last 24 hours until I put it in with the block. Now it happens all the time.

 

[pgg]

Doesn't dex prolong the block as well when given iv? I don't see a good reason to inject it with the local.

There was a study that made the claim that IV dex was as good as mixed-with-local. We talked about it in a thread a while ago and IIRC nobody really bought into that.

IV dex does have some analgesic enhancing effects, but I don't believe it prolongs blocks. I'd been routinely using it IV for its antiemetic effects in cases with blocks, and the block duration was normal. Adding it to the local definitely prolongs the duration.


Blade, how much dex are you using now? Some speaker at the last ASA rec'd 1 mg for diabetics and 2 mg for everyone else IIRC. I've still been using 4 mg for non-diabetics.

 

[BLADEMDA]

There was a study that made the claim that IV dex was as good as mixed-with-local. We talked about it in a thread a while ago and IIRC nobody really bought into that.

IV dex does have some analgesic enhancing effects, but I don't believe it prolongs blocks. I'd been routinely using it IV for its antiemetic effects in cases with blocks, and the block duration was normal. Adding it to the local definitely prolongs the duration.


Blade, how much dex are you using now? Some speaker at the last ASA rec'd 1 mg for diabetics and 2 mg for everyone else IIRC. I've still been using 4 mg for non-diabetics.

I utilize 1-2 mg of decadron per Plexus block. I no longer mix anything greater than 2 mg of decadron per Plexus block. For TAP/BD TAP I am still utilizing up to 4 mg of decadron per side for a total of 8 mg per patient. Sometimes I use 2 mg per side particularly in diabetics.

For those concerned about the duration of the block being significantly shorter when you use 2 mg instead of 4 mg my anecdotal experience shows this isn't the case as block duration is maintained.

 

[psychbender]

I utilize 1-2 mg of decadron per Plexus block. I no longer mix anything greater than 2 mg of decadron per Plexus block. For TAP/BD TAP I am still utilizing up to 4 mg of decadron per side for a total of 8 mg per patient. Sometimes I use 2 mg per side particularly in diabetics.

For those concerned about the duration of the block being significantly shorter when you use 2 mg instead of 4 mg my anecdotal experience shows this isn't the case as block duration is maintained.

I'll second what Blade says here. One of my colleagues here uses 4mg decadron, I stick with just 2mg, and our durations seem to be the same when I follow up with the pts who stay the night.