Perineural Dexamethasone

[Noyac]

An interesting review article that appeared in Medscape this week:
Medscape: Medscape Access

In conclusion, there is moderate evidence that perineural dexamethasone combined with bupivacaine but not with ropivacaine slightly prolongs the duration of analgesia when compared with systemic dexamethasone, without an impact on the other secondary pain-related outcomes. The administration of dexamethasone in this setting should be balanced properly with recognition of the off-label indication of perineural administration and with consideration for the possibility of crystallization when combined with ropivacaineInteresting review article in Medscape this week.


Will this change your practice?

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[facted]

An interesting review article that appeared in Medscape this week:
Medscape: Medscape Access

In conclusion, there is moderate evidence that perineural dexamethasone combined with bupivacaine but not with ropivacaine slightly prolongs the duration of analgesia when compared with systemic dexamethasone, without an impact on the other secondary pain-related outcomes. The administration of dexamethasone in this setting should be balanced properly with recognition of the off-label indication of perineural administration and with consideration for the possibility of crystallization when combined with ropivacaineInteresting review article in Medscape this week.


Will this change your practice?

Don't use ropi and have been using dex with bupi for a few years, so no. What's new in this article?

 

[sigrhoillusion]

Don't use ropi and have been using dex with bupi for a few years, so no. What's new in this article?

Not sure if there's anything "New" per se, but might cause people who have used ropi to switch over to bupi...

 

[OB1🤙]

Haven't used ropi since residency, so no change here.

 

[dhb]

I haven't read it but it makes no sense why would it increase duration with bupi and not ropi?
Anyhow i've been using it for 10 years in all my blocks and i don't see why i'd change.

 

[pjl]

I haven't read it but it makes no sense why would it increase duration with bupi and not ropi?
Anyhow i've been using it for 10 years in all my blocks and i don't see why i'd change.

Worst part is reading this, getting ready to call you on the 10 years, then realizing we have been doing this for 10 years

 

[Planktonmd]

Every conceivable adjuvant to local anesthetics in blocks anyone could think of has been already tried and there will be proponents and opponents to it's use.
I say do what you feel works for you.

 

[Mman]

Every conceivable adjuvant to local anesthetics in blocks anyone could think of has been already tried and there will be proponents and opponents to it's use.
I say do what you feel works for you.

while I would agree, I wouldn't do what you feels works, I would collect actual data in your practice and make an informed decision about it.

 

[dhb]

while I would agree, I wouldn't do what you feels works, I would collect actual data in your practice and make an informed decision about it.

You could do what you feel doesn't work

 

[sevoflurane]

I can't open the attached medscape paper but I bet it is the Meta-analysis that was published recently.

Here is my take on the paper:

1) I've never believed in IV decadron increasing block duration. Never have. Those earlier studies are not good ones. People have been giving IV decadron for eons... it's not like all of a sudden people were getting longer duration of analgesia.
2) I have always used bupivicaine because it last longer. This paper supports the fact that adding decadron to bupivicaine will get you maximal duration. I've been doing this for a long time.
3) The steroid doses they are using in some of these studies is quite high. 10 mg of decadron? I cap it at 4 mg.
4) Ropivicaine in vitro forms crystals when mixed with decadron. Just another reason I don't use it. That's amunition for the lawyers.
5) Ropivicaine is expensive
6) Interesting looking at different institutions and their volume/LA concentration- wide range in what people are doing.

Won't change my practice one bit.

 

[deleted162650]

Wait - perinueral??? I've been giving it perineal.

 

[nimbus]

3) The steroid doses they are using in some of these studies is quite high. 10 mg of decadron? I cap it at 4 mg.

And decadron 10mg IV will reduce pain scores whether the patient gets a block or not.

 

[dhb]

I can't open the attached medscape paper but I bet it is the Meta-analysis that was published recently.

Here is my take on the paper:

1) I've never believed in IV decadron increasing block duration. Never have. Those earlier studies are not good ones. People have been giving IV decadron for eons... it's not like all of a sudden people were getting longer duration of analgesia.
2) I have always used bupivicaine because it last longer. This paper supports the fact that adding decadron to bupivicaine will get you maximal duration. I've been doing this for a long time.
3) The steroid doses they are using in some of these studies is quite high. 10 mg of decadron? I cap it at 4 mg.
4) Ropivicaine in vitro forms crystals when mixed with decadron. Just another reason I don't use it. That's amunition for the lawyers.
5) Ropivicaine is expensive
6) Interesting looking at different institutions and their volume/LA concentration- wide range in what people are doing.

Won't change my practice one bit.

I'm not sure it's the ropivacaine per se that forms cristals with dexa: i've seen some brands of ropivacaine thay precipitated with dexa and others not.

 

[Mman]

Wait - perinueral??? I've been giving it perineal.

do they still get the itching down there?

 

[acidbase1]

Does anyone use perineural precedex? Have to noticed a superior results compared to decadron? How much are you using, I’ve been doing about 100mcg per 30cc of 0.5% marcaine.(my attendings used this) But I’ve seen studies using 2mcg per cc.

 

[sevoflurane]

I'm not sure it's the ropivacaine per se that forms cristals with dexa: i've seen some brands of ropivacaine thay precipitated with dexa and others not.

Ropivicaine can be incompatible with alkaline solutions with resultant crystal formation. Dexamethasone is alkaline.

 

[psychbender]

Does anyone use perineural precedex? Have to noticed a superior results compared to decadron? How much are you using, I’ve been doing about 100mcg per 30cc of 0.5% marcaine.(my attendings used this) But I’ve seen studies using 2mcg per cc.

I used 75mcg in 30 of 0.5% Rop for my own shoulder. It worked nicely, good gradual fade in block density over 10 hours, after a dense 24hr block. I definitely feel some systemic absorption, though. During the case, I could hear my heart rate in the low 50s, and I got a little cross-eyed and sleepy despite no sedation for the block or case. If I need another extremity procedure in the future, I'll definitely try it again.

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[abolt18]

At my program, we regularly do 100mcg of clonidine in 30cc of 0.5% Ropi. I don't have enough exposure or experience to comment on other methods and additives to LA. I don't really know why we use Ropi vs bupivacaine.

 

[Noyac]

At my program, we regularly do 100mcg of clonidine in 30cc of 0.5% Ropi. I don't have enough exposure or experience to comment on other methods and additives to LA. I don't really know why we use Ropi vs bupivacaine.

Probably because cost doesn’t matter in your facility.

But the chance of you using clonidine when you get out is extremely low as far as I can tell.

 

[facted]

I don't really know why we use Ropi vs bupivacaine.

Technically, ropi has a better safety profile when it comes to preventing LAST. In clinical reality, with ultrasound, that difference doesn't exist and the cost difference (and the fact it likely lasts longer lmakes bupi a much better choice IMO.

 

[OB1🤙]

Technically, ropi has a better safety profile when it comes to preventing LAST. In clinical reality, with ultrasound, that difference doesn't exist and the cost difference (and the fact it likely lasts longer lmakes bupi a much better choice IMO.

This.

 

[abolt18]

Probably because cost doesn’t matter in your facility.

But the chance of you using clonidine when you get out is extremely low as far as I can tell.

Yeah I wondered. It's surprising to me though because I feel like our pharmacists are always arguing efficacy of XYZ vs ABC so they can go to the cheaper drug. As I've been reading more it seems like across the board bupivacaine is usually cheaper and clonidine is definitely far from cheap.

Technically, ropi has a better safety profile when it comes to preventing LAST. In clinical reality, with ultrasound, that difference doesn't exist and the cost difference (and the fact it likely lasts longer lmakes bupi a much better choice IMO.

Yeah I had also considered this. The whole 'r enantiomer' of bupivacaine being higher risk, but it seems the point is almost moot with ultrasound, so long as you aspirate and it's negative.

 

[Noyac]

The whole 'r enantiomer' of bupivacaine being higher risk, but it seems the point is almost moot with ultrasound, so long as you aspirate and it's negative.

I wouldn’t be so sure of that. No matter how technology continues to improve, there are always plenty of people out there that are ready willing and able to test the limits. It never ceases to amaze me how people seem to think that because something is new and fancy, it can’t be abused or that the laws of physics don’t relate any longer.

 

[BLADEMDA]

I have on occasion used low dose Precedex (small vial) about 50ug per 20 mls of local combined with 2 mg of dexamethsaone. It's a nice block.


http://www.iosrjournals.org/iosr-jdms/papers/Vol15-Issue 8/Version-4/Y150804124133.pdf

http://www.ijcem.com/files/ijcem0050006.pdf

Perineural Dexmedetomidine Is More Effective Than Clonidine When Added to Local Anesthetic for Supraclavicular Brachial Plexus Block: A Systematic ... - PubMed - NCBI

Buprenorphine, Clonidine, Dexamethasone, and Ropivacaine for Interscalene Nerve Blockade: A Prospective, Randomized, Blinded, Ropivacaine Dose-Resp... - PubMed - NCBI

 

[BLADEMDA]

• Format: Abstract

Send to



Br J Anaesth. 2017 Feb;118(2):167-181. doi: 10.1093/bja/aew411.
Evidence basis for using perineural dexmedetomidine to enhance the quality of brachial plexus nerve blocks: a systematic review and meta-analysis of randomized controlled trials.
Vorobeichik L1,2, Brull R1,3, Abdallah FW4,2,5.
Author information
1
Department of Anaesthesia, University of Toronto, Toronto, Canada.
2
Department of Anaesthesia, St. Michael's Hospital, University of Toronto, Toronto, Canada.
3
Department of Anaesthesia, Women's College Hospital, Toronto, Canada.
4
Department of Anaesthesia, University of Toronto, Toronto, Canada [email protected].
5
The Li Ka Shing Knowledge Institute, University of Toronto, Toronto, Canada.
Abstract
BACKGROUND:
Dexmedetomidine has been proposed as a perineural local anaesthetic (LA) adjunct to prolong peripheral nerve block duration; however, results from our previous meta-analysis in the setting of brachial plexus block (BPB) did not support its use. Many additional randomized trials have since been published. We thus conducted an updated meta-analysis.

METHODS:
Randomized trials investigating the addition of dexmedetomidine to LA compared with LA alone (Control) in BPB for upper extremity surgery were sought. Sensory and motor block duration, onset times, duration of analgesia, analgesic consumption, pain severity, patient satisfaction, and dexmedetomidine-related side-effects were analysed using random-effects modeling. We used ratio-of-means (lower confidence interval [point estimate]) for continuous outcomes.

RESULTS:
We identified 32 trials (2007 patients), and found that dexmedetomidine prolonged sensory block (at least 57%, P < 0.0001), motor block (at least 58%, P < 0.0001), and analgesia (at least 63%, P < 0.0001) duration. Dexmedetomidine expedited onset for both sensory (at least 40%, P < 0.0001) and motor (at least 39%, P < 0.0001) blocks. Dexmedetomidine also reduced postoperative oral morphine consumption by 10.2mg [-15.3, -5.2] (P < 0.0001), improved pain control, and enhanced satisfaction. In contrast, dexmedetomidine increased odds of bradycardia (3.3 [0.8, 13.5](P = 0.0002)), and hypotension (5.4 [2.7, 11.0] (P < 0.0001)). A 50-60µg dexmedetomidine dose maximized sensory block duration while minimizing haemodynamic side-effects. No patients experienced any neurologic sequelae. Evidence quality for sensory block was high according to the GRADE system.

CONCLUSIONS:
New evidence now indicates that perineural dexmedetomidine improves BPB onset, quality, and analgesia. However, these benefits should be weighed against increased risks of motor block prolongation and transient bradycardia and hypotension.

 

[BLADEMDA]

J Clin Anesth. 2017 May;38:133-136. doi: 10.1016/j.jclinane.2017.02.004. Epub 2017 Feb 16.
Dexamethasone as a ropivacaine adjuvant for ultrasound-guided interscalene brachial plexus block: A randomized, double-blinded clinical trial.
Sakae TM1, Marchioro P2, Schuelter-Trevisol F3, Trevisol DJ4.
Author information

Abstract
STUDY OBJECTIVE:
The purpose of this study was to evaluate the effect of intravenous or perineuraldexamethasone added to ropivacaine on the duration of ultrasound-guided interscalene brachial plexus blocks(BPB).

DESIGN:
Randomized clinical trial.

SETTING, PATIENTS AND INTERVENTIONS:
Sixty ASA physical status I-II patients with elective shoulder arthroscopic surgeries under interscalene brachial plexus blocks were randomly allocated to receive 20ml of 0.75% ropivacaine with 1ml of isotonic saline (C group, n=20), 20ml of 0.75% ropivacaine with 1ml (4mg) of perineural dexamethasone (Dpn group, n=20), or 20ml of 0.75% ropivacaine with 1ml of isotonic saline and intravenous 4mg dexamethasone (IV) (Div group, n=20). A nerve stimulation technique with ultrasound was used in all patients.

MEASUREMENTS:
The onset time and duration of sensory blocks were assessed. Secondary outcomes were pain scores (VAS) and postoperative vomiting and nausea (PONV).

MAIN RESULTS:
The duration of the motor and sensory block was extended in group Dpn compared with group Div and group C (P<0.05). In addition, within 24h, group Dpn presented lower levels of VAS and lower incidence of PONV as compared with the other groups. Moreover, there was a significant reduction on onset time between group Dpn and the other groups.

CONCLUSIONS:
Perineural 4mg dexamethasone was more effective than intravenous in extending the duration of ropivacaine in ultrasound-guided interscalene BPB. Moreover, Dpn has significant effects on onset time, PONV, and VAS.

 

[BLADEMDA]

In a separate commentary [1] , we reported on potential clinical research priorities with respect to multimodal perineural anesthesia and analgesia (MMPNA). This was based on our group's review of institutional quality assurance/improvement (QA/QI) data routinely using this technique for over 1,300 patients from late 2011 to the present at the Veterans Affairs Pittsburgh Healthcare System. This previous commentary addressed the four-drug combination of bupivacaine, clonidine, buprenorphine, and dexamethasone (BPV-CBD) used for postoperative perineural analgesia (e.g., combined with intraoperative spinal anesthesia), or for the dual role of intraoperative perineural anesthesia and postoperative analgesia. The average block duration (block insertion time until peak rebound pain score on a 0 to 10 scale) in this previous commentary was 33 to 37 hours, depending on the context. We believe that this clinical observation warrants high-priority research for the specialty, especially in the context of the effects of buprenorphine dose response and the parameters of block duration and rebound pain.


Clinical Benchmarks Regarding Multimodal Peripheral Nerve Blocks for Postoperative Analgesia: Observations Regarding Combined Perineural Midazolam-Clonidine-Buprenorphine-Dexamethasone | Pain Medicine | Oxford Academic

 

[BLADEMDA]

The questions raised are important to note when using perineural adjuvants. When applying medications perineurally, further questioning of unintended consequences, including negative effects ranging from unwanted hyperalgesia to neurotoxicity, must be sought. On the basis of the laboratory data2,3 and clinical observation,4,6 our current recommendation regarding perineural DXMS is to limit dosing to ≤2 mg DXMS per plexus, especially when using ropivacaine or bupivacaine. Ultimately, perineural adjuvant doses would and should be studied to specifically decrease both the total local anesthetic doses and the doses of each adjuvant.

Nicholas Schott, MD

Brian A. Williams, MD, MBA

Department of Anesthesiology

University of Pittsburgh

Pittsburgh, Pennsylvania

[email protected]

In Response : Anesthesia & Analgesia

 

[Noyac]

So Blade, are you using Dexamthasone with ropiv?

 

[The Physician Philosopher]

I can't open the attached medscape paper but I bet it is the Meta-analysis that was published recently.

Here is my take on the paper:

1) I've never believed in IV decadron increasing block duration. Never have. Those earlier studies are not good ones. People have been giving IV decadron for eons... it's not like all of a sudden people were getting longer duration of analgesia.
2) I have always used bupivicaine because it last longer. This paper supports the fact that adding decadron to bupivicaine will get you maximal duration. I've been doing this for a long time.
3) The steroid doses they are using in some of these studies is quite high. 10 mg of decadron? I cap it at 4 mg.
4) Ropivicaine in vitro forms crystals when mixed with decadron. Just another reason I don't use it. That's amunition for the lawyers.
5) Ropivicaine is expensive
6) Interesting looking at different institutions and their volume/LA concentration- wide range in what people are doing.

Won't change my practice one bit.

A little Birdy has told me that there will be a paper coming out in the BJA in the next few months that will help debunk the systemic Dex argument for prolonging blocks.

I, too, cap perineural doses at 4mg. 10 mg of Dex is equivalent to more than 60 of Prednisone. It's a massive dose that we don't even wink at because it comes in a 1 cc vial.

I've done studies on comparing 4mg to 1mg and found it superior. It's in the works to get published, too.

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[caligas]

This will all be moot in a few months when we are all using Exparel.

Buy stock now!

 

[BLADEMDA]

A little Birdy has told me that there will be a paper coming out in the BJA in the next few months that will help debunk the systemic Dex argument for prolonging blocks.

I, too, cap perineural doses at 4mg. 10 mg of Dex is equivalent to more than 60 of Prednisone. It's a massive dose that we don't even wink at because it comes in a 1 cc vial.

I've done studies on comparing 4mg to 1mg and found it superior. It's in the works to get published, too.

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I use 2mg routinely (perineural) and it prolongs the block to 22 hours. If i use 4 mg that may add an additional 2-3 hours of analgesia for a total of 24-25 hours. For MAX duration of analgesia the combination of dexamethasone, Precedex and Buprenorphine combined with Bupivacaine is typically over 30 hours. The duration of analgesia is very close to Exparel at a fraction of the cost.

 

[BLADEMDA]

So Blade, are you using Dexamthasone with ropiv?

yes. No issues. Low dose Dex only.

 

[The Physician Philosopher]

I use 2mg routinely (perineural) and it prolongs the block to 22 hours. If i use 4 mg that may add an additional 2-3 hours of analgesia for a total of 24-25 hours. For MAX duration of analgesia the combination of dexamethasone, Precedex and Buprenorphine combined with Bupivacaine is typically over 30 hours. The duration of analgesia is very close to Exparel at a fraction of the cost.

I use 0.25% bupi, clonidine, 2 mg dexamethasone, 150 mcg buprenorphine, and 1:400k epi for my cocktail. Agree works as good as exparel and exparels data is terrible and misleading. If you know how to read a paper it's obvious.

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[The Physician Philosopher]

I use 2mg routinely (perineural) and it prolongs the block to 22 hours. If i use 4 mg that may add an additional 2-3 hours of analgesia for a total of 24-25 hours. For MAX duration of analgesia the combination of dexamethasone, Precedex and Buprenorphine combined with Bupivacaine is typically over 30 hours. The duration of analgesia is very close to Exparel at a fraction of the cost.

Also, this depends on what block. Dex clearly prolongs an adductor canal block on an individual sensory nerve (saphenous that lasts 36 to 42 hours) substantially longer than a brachial plexus block (24 hours or so).

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[Noyac]

yes. No issues. Low dose Dex only.

So how would you know if it precipitated?

I use 0.25% bupi, clonidine, 2 mg dexamethasone, 150 mcg buprenorphine, and 1:400k epi for my cocktail. Agree works as good as exparel and exparels data is terrible and misleading. If you know how to read a paper it's obvious.

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Holy crap!!!
By the time you have mixed up all that nonsense I have blocked my pt and we are in the room with surgery underway.

 

[dhb]

I had the impression that clonidine did not prolong sensory block especially if using dexamethasone, can anybody confirm?

 

[The Physician Philosopher]

So how would you know if it precipitated?

Holy crap!!!
By the time you have mixed up all that nonsense I have blocked my pt and we are in the room with surgery underway.

You haven't seen me block anyone ;-) doesn't take long.

Also I have residents/fellows. So... I am not mixing it.

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[The Physician Philosopher]

I had the impression that clonidine did not prolong sensory block especially if using dexamethasone, can anybody confirm?

Brian Williams (referenced above by Blade) would disagree. I'll try and look for the study, but he combined a bunch of Adjuvants and then did them all separately, too, and felt clonidine had a substantial impact.

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[BLADEMDA]

I had the impression that clonidine did not prolong sensory block especially if using dexamethasone, can anybody confirm?

Dexamethasone and Clonidine, but not Epinephrine, Prolong Duration of Ropivacaine Brachial Plexus Blocks, Cross-Sectional Analysis in Outpatient Surgery Setting
Dexamethasone and Clonidine, but not Epinephrine, Prolong Duration of Ropivacaine Brachial Plexus Blocks, Cross-Sectional Analysis in Outpatient Surgery Setting | Pain Medicine | Oxford Academic

Abstract
Objective
The primary aim of this study is to determine the effect of adding dexamethasone, clonidine or both with and without epinephrine to ropivacaine and bupivacaine brachial plexus blocks.

Design
Observational study of prospectively collected data

Setting
Single academic outpatient surgery center

Methods
We evaluated 5,515 patient entries who received brachial plexus block (BPB). Multiple, rescue, unsuccessful, and distal nerve blocks of the upper extremity were excluded. The duration was calculated from the time the block was performed until the resolution of the block by patient report. Block durations were compared using Analysis of Variance.

Results
After exclusions, 3,706 nerve blocks were analyzed. The median concentration of ropivacaine used was 0.5%. Both clonidine and dexamethasone significantly increased block duration by 1.1 and 3.0 hours, respectively. Combining clonidine and dexamethasone with ropivacaine increased block duration by 6.2 hours (p<0.001) when compared to ropivacaine alone. Dexamethasone and Clonidine increased block duration by 5.2 hours (p<0.001) when compared to clonidine alone and by 3.2 hours (p<0.001) compared to dexamethasone alone. The addition of epinephrine to any of the adjuvants made no statistically significant difference to the duration of action except when it was added to dexamethasone.

Summary
For brachial plexus blocks, epinephrine did not affect the duration of analgesia when added to ropivacaine. Epinephrine did not enhance the observed increase of block duration induced by clonidine or the combination of clonidine and dexamethasone. The most block duration enhancement was observed when combination of clonidine and dexamethasone were added to ropivacaine.

 

[BLADEMDA]

I had the impression that clonidine did not prolong sensory block especially if using dexamethasone, can anybody confirm?

In summary, if pain reduction is the main priority, then combining perineural additives (buprenorphine, clonidine, dexamethasone) with either ropivacaine 0.375% (High Dose) or 0.2% (Medium Dose) is supported by this study. Pain with movement was reduced at 24 hours in the Medium Dose group, compared to Control. The High Dose group had reduced pain on the morning after surgery, as well as prolonged time until first need for opioid analgesics. Alternatively, if the priority is minimizing motor blockade, then perineural additives can be combined with Low Dose ropivacaine (0.1%). The Low Dose group had greater handgrip strength in the PACU, compared to Control, but also had more pain in the PACU.

Buprenorphine, Clonidine, Dexamethasone, and Ropivacaine for Interscalene Nerve Blockade: A Prospective, Randomized, Blinded, Ropivacaine Dose-Response Study | Pain Medicine | Oxford Academic

 

[dhb]

Both clonidine and dexamethasone significantly increased block duration by 1.1 and 3.0 hours, respectively.

Thanks for the study but that's BS: dexa increasing block duration by 3h? I'd like to see a study once done by someone who knows what he's doing!

 

[The Physician Philosopher]

Thanks for the study but that's BS: dexa increasing block duration by 3h? I'd like to see a study once done by someone who knows what he's doing!

In my experience (have done multiple RCTs in the works of getting published) perineural Dex at 4 mg prolongs an adductor about 7 to 8 hours.

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