Question re: Decadron in PNBs

[Ignatius J]

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Do you need a preservative free Decadron? We have the Decadron with methyparaben preservative and I am wondering if that is okay for a PNB?

 

[2ndyear]

No, get preservative free.

 

[pgg]

I use PF dexamethasone.

It probably doesn't matter in the real world (we're talking miniscule amounts of preservative diluted in 10s of mL of local), but god help you if the surgeon bangs a nerve, the patient ends up with a deficit, and then some lawyer asks you to explain to the jury why you injected benzene into the patient's nerve.

 

[GaseousClay]

I use PF dexamethasone.

It probably doesn't matter in the real world (we're talking miniscule amounts of preservative diluted in 10s of mL of local), but god help you if the surgeon bangs a nerve, the patient ends up with a deficit, and then some lawyer asks you to explain to the jury why you injected benzene into the patient's nerve.

I don't think a jury will understand why you injected any type of dexamethasone into a peripheral nerve. Lawyers will have a field day with this since its not standard of care nor will any regional "experts" agree that it is standard of care (i know im beating a dead horse here...)

 

[pgg]

I don't think a jury will understand why you injected any type of dexamethasone into a peripheral nerve. Lawyers will have a field day with this since its not standard of care nor will any regional "experts" agree that it is standard of care (i know im beating a dead horse here...)

There's a world of difference between saying that a regional technique is "not standard of care" and saying that a regional technique is "below the standard or care."

Consider your average garden variety total knee arthroplasty: a femoral nerve block with plain bupivacaine is absolutely NOT the standard of care for pain management. Of course it isn't. That of course doesn't imply that an anesthesiologist who has done one of the many (millions?) of femoral blocks for TKAs in the last few decades is working below the standard of care.


What you seem to be arguing is that the use of dexamethasone in PNBs is "off label" which is an entirely different subject. There is a growing body of literature showing safely increased block durations with a dexamethasone additive. A reasonable person can easily argue (convincingly!) that a single shot PNB with dexamethasone that achieves the same analgesic effect as a nerve catheter, for a comparable period of time, at far lower cost, and possibly less risk (smaller needle), is appropriate. I've listened to a parade of regional experts at the ASA and elsewhere talk about its use as an additive, and the biggest criticism I've seen of it is that we probably only need a mg or two, not the 4 or 8 that people were commonly using a year or two ago.

 

[GaseousClay]

There's a world of difference between saying that a regional technique is "not standard of care" and saying that a regional technique is "below the standard or care."

Consider your average garden variety total knee arthroplasty: a femoral nerve block with plain bupivacaine is absolutely NOT the standard of care for pain management. Of course it isn't. That of course doesn't imply that an anesthesiologist who has done one of the many (millions?) of femoral blocks for TKAs in the last few decades is working below the standard of care.


What you seem to be arguing is that the use of dexamethasone in PNBs is "off label" which is an entirely different subject. There is a growing body of literature showing safely increased block durations with a dexamethasone additive. A reasonable person can easily argue (convincingly!) that a single shot PNB with dexamethasone that achieves the same analgesic effect as a nerve catheter, for a comparable period of time, at far lower cost, and possibly less risk (smaller needle), is appropriate. I've listened to a parade of regional experts at the ASA and elsewhere talk about its use as an additive, and the biggest criticism I've seen of it is that we probably only need a mg or two, not the 4 or 8 that people were commonly using a year or two ago.

what I am arguing is that a jury is not made of medical people, likely far from it. It won't take much to convince them that there is no consensus that this off label use is justified when a person has a peripheral nerve injury. The safety data is definitely there but its by no means a vast number of studies or patients. Those parades of experts may agree of its use but there will be parades of experts not agreeing with its use.

 

[Intubate]

what I am arguing is that a jury is not made of medical people, likely far from it. It won't take much to convince them that there is no consensus that this off label use is justified when a person has a peripheral nerve injury. The safety data is definitely there but its by no means a vast number of studies or patients. Those parades of experts may agree of its use but there will be parades of experts not agreeing with its use.

I've brought this up before in this context, but here goes again... Steroid has been placed on peripheral nerves, in doses and concentrations more than tenfold that used in PNBs, literally millions of times in transforaminal epidurals/ nerve root blocks. I dont know of a single nerve injury that has been attributed to a neurotoxic effect of the steroid.