Single Shot Nerve Blocks which last over 24 hours

[excalibur]

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And is there any improvement in antiemetic efficacy if decadron is given before induction as compared to immediately after?

 

[BLADEMDA]

And is there any improvement in antiemetic efficacy if decadron is given before induction as compared to immediately after?

The short answer is no.

 

[BLADEMDA]

Korean J Anesthesiol. 2011 Oct;61(4):315-9. doi: 10.4097/kjae.2011.61.4.315. Epub 2011 Oct 22.

Analgesic effect of preoperative versus intraoperative dexamethasone after laparoscopic cholecystectomy with multimodal analgesia.

Lim SH, Jang EH, Kim MH, Cho K, Lee JH, Lee KM, Cheong SH, Kim YJ, Shin CM.


Source

Department of Anesthesiology and Pain Medicine, Busan Paik Hospital, College of Medicine, Inje University, Busan, Korea.


Abstract


BACKGROUND:

Pain after laparoscopy is multifactorial and different treatments have been proposed to provide pain relief. Multimodal analgesia is now recommended to prevent and treat post-laparoscopy pain. Dexamethasone is effective in reducing postoperative pain. The timing of steroid administration seems to be important. We evaluated the analgesic efficacy of preoperative intravenous dexamethasone 1 hour before versus during laparoscopic cholecystectomy with multimodal analgesia.

METHODS:

One hundred twenty patients aged 20 to 65 years old were allocated randomly into one of three groups (n = 40, in each). The patients in the group N received normal saline 1 hour before induction and after the resection of gall bladder. The patients in the group S1 received dexamethasone 8 mg 1 hour before induction and normal saline after the resection of gall bladder. The patients in the group S2 received normal saline 1 hour before induction and dexamethasone 8 mg after the resection of gall bladder.

RESULTS:

VAS scores of group S1 and S2 were lower than that of group N during 48 hours after laparoscopic cholecystectomy. There were no significant differences of VAS scores between the group S1 and the group S2. The analgesic consumption of group S1 and S2 were significantly lower than that of group N.

CONCLUSIONS:

A single dose of dexamethasone (8 mg) intravenously given 1 hour before induction or during operation was effective in reducing postoperative pain after laparoscopic cholecystectomy with multimodal analgesia. The analgesic efficacy of preoperative intravenous dexamethasone 1 hour before versus during surgery was not significantly different.

 

[BLADEMDA]

Although dexamethasone is effective in preventing PONV associated with a surgical procedures (1–11), the optimal timing of its administration for its efficacy as a prophylactic antiemetic on PONV has not been studied. We demonstrated that dexamethasone, when administered immediately before the induction of anesthesia, provided an effective antiemetic effect throughout the first 24 hours of the postoperative period. On the contrary, when administered at the end of anesthesia, dexamethasone did not provide an effective antiemetic effect during the immediate postoperative period of 0–2 hours. Because more than one half of the patients experienced PONV in this early postoperative period (53%, as shown in the placebo group), it is very important that a prophylactic antiemetic should be effective during this period.

Because dexamethasone may have a delayed onset of action, we questioned how much time is required for dexamethasone to initiate its antiemetic effect. After conducting an extensive literature search, we were unable to find a report that mentioned the onset time of a dexamethasone antiemetic effect. After a comparison study design, we found dexamethasone was not effective during zero to two hours after the administration (as shown in Group 2); however, it proved to be effective in the following period (as shown in Groups 1 and 2). Therefore, we suggest the onset time of dexamethasone's antiemetic effect may be approximately two hours.


http://www.anesthesia-analgesia.org/content/91/1/136.long

 

[pjl]

Just an update on our clinical experience doing dexadron in ISBs for over a year. We are averaging 31 hours with a standard cocktail of 30 mL bup and 8 of decadron. I recently dropped back to 4 for a while (local shortage) and was asked if there was something different by the PA who does followup, durations more in the 28-29 hour range. No negative outcomes, we are between 1500 and 2000 blocks with decadron.
So not very scientific, but there seems to be a clinical effect of adding more than 4 mg.
Will wait for a more academic minded individual to do larger formal studies before finalizing mix.
My partner who uses more robust (close to toxic) doses of bup gets mid 30s.

 

[BLADEMDA]

Just an update on our clinical experience doing dexadron in ISBs for over a year. We are averaging 31 hours with a standard cocktail of 30 mL bup and 8 of decadron. I recently dropped back to 4 for a while (local shortage) and was asked if there was something different by the PA who does followup, durations more in the 28-29 hour range. No negative outcomes, we are between 1500 and 2000 blocks with decadron.
So not very scientific, but there seems to be a clinical effect of adding more than 4 mg.
Will wait for a more academic minded individual to do larger formal studies before finalizing mix.
My partner who uses more robust (close to toxic) doses of bup gets mid 30s.

I agree that going from 4 to 8 mg of decadron adds 2 hours. But considering we are doing cutting edge regional by using Bup with decadron and Gurus at Pittsuburgh recommend only 2 mg per block I'm happy using "only 4mg." If there was some reason to push for those extra 2 hours then by all means use 8 mg.

I'm finding that with just 2 mg of Decadron with Bup non diabetics still get 24 hours of solid postop pain relief. I have found it easier to convince ultra conservative types to add 2 mg vs 4 mg. In addition, I would be willing to use 2 mg of regular decadron in my non diabetic patients if I couldn't get preservative free.

I use 2 mg of PF decadron as my dose in diabetic patients. Again, the gurus at Pitt found that even 1 mg of decadron will prolong the block in diabetics.

 

[BLADEMDA]

Just an update on our clinical experience doing dexadron in ISBs for over a year. We are averaging 31 hours with a standard cocktail of 30 mL bup and 8 of decadron. I recently dropped back to 4 for a while (local shortage) and was asked if there was something different by the PA who does followup, durations more in the 28-29 hour range. No negative outcomes, we are between 1500 and 2000 blocks with decadron.
So not very scientific, but there seems to be a clinical effect of adding more than 4 mg.
Will wait for a more academic minded individual to do larger formal studies before finalizing mix.
My partner who uses more robust (close to toxic) doses of bup gets mid 30s.

Does your partner add more than 10 mg of decadron to his local? Very aggressive to say the least. Would your partner add regular decadron with preservative to his local? If so, how much would he use?

Finally, is your partner reducing his decadron dosage in diabetics? If not, then the duration of the block could easily exceed 40 hours. With 8 mg of decadron plus Bup in diabetics my average duration of postop pain relief was 40 hours. I quickly cut back to 2 mg and that seems to still provide extended postop pain relief in the 28 hour range.

 

[OB1🤙]

How is everyone out there doing on obtaining PF dexamethasone? I've been on a crusade to get the stuff here but pharmacy keeps telling me it's unobtainable due to shortage.

 

[BLADEMDA]

How is everyone out there doing on obtaining PF dexamethasone? I've been on a crusade to get the stuff here but pharmacy keeps telling me it's unobtainable due to shortage.

I've got a big supply. If I couldn't get it then I would add 2 mg of regular decadron to my local in non diabetics.

 

[OB1🤙]

Pharmacy just emailed me back, saying "There's some guy over in Florida who's hoarding the stuff- sorry, still on back order."

Until you release some of your stash back on the market, I'll probably make do with the 2mg non-PF, but I won't like it.

 

[sevoflurane]

Pharmacy just emailed me back, saying "There's some guy over in Florida who's hoarding the stuff- sorry, still on back order."

Until you release some of your stash back on the market, I'll probably make do with the 2mg non-PF, but I won't like it.

Funny ---'-!

 

[pjl]

Nope, he just goes hard on the bup (almost always =0.5% at 1/2 weight in kg). Based on my peeking at his charts he uses 8 mg decadron is nondiabetics, 4 mg in diabetics. My guess is that he would add 4 with preservative, but I havent asked him, as it hasn't been an issue at our institution.

The shortage is why I cut mine down to 4 mg, but we apparently wrangled some from elsewhere in system, so have a full semi out back, full of the stuff. There is a guy in a trenchcoat out there too that you can discuss purchasing with, if you wish.

 

[Planktonmd]

You should plan on diluting any decadron dose greater than 4 mg in a 60 ml syringe and administer over 1-2 minutes. Up to 25% of patients who receive 6mg-8mg of IV decadron PUSH will experience serious Perineal Burning.


http://link.springer.com/content/pdf/10.1007/BF03018722.pdf

Really?
Does it have to be 60cc?
Can I use 55cc?
And since for 4mg no dilution is needed, but for 6-8 mg you need 60 cc, How about 5 mg Dexamethasone?
And why 1-2 minutes? can I do it over 3.5 minutes?
😛

 

[BLADEMDA]

Really?
Does it have to be 60cc?
Can I use 55cc?
And since for 4mg no dilution is needed, but for 6-8 mg you need 60 cc, How about 5 mg Dexamethasone?
And why 1-2 minutes? can I do it over 3.5 minutes?
😛

I give 4 mg of Decadron IV preop routinely. I add 1 ml of decadron to a 20 ml syringe (sometimes even a 12 ml syringe) and dilute with LR or NS. Then give the drug. This seems to be quite adequate for eliminating any major complaints.

As for larger doses I rarely give them preop. But, some suggest diluting the drug with 40-50 mls of LR or NS and IV push slowly over 1 minute.

If you have any experiences or anecdotal comments about preop decadron please feel free to post them

 

[Planktonmd]

I give 4 mg of Decadron IV preop routinely. I add 1 ml of decadron to a 20 ml syringe (sometimes even a 12 ml syringe) and dilute with LR or NS. Then give the drug. This seems to be quite adequate for eliminating any major complaints.

As for larger doses I rarely give them preop. But, some suggest diluting the drug with 40-50 mls of LR or NS and IV push slowly over 1 minute.

If you have any experiences or anecdotal comments about preop decadron please feel free to post them

My anecdotal comment is: Give it slow!
There is no magic dose or mysterious formula for dilution.
There is simply some patients who are susceptible to have this annoying phenomena, and in these patients it appears to be dose dependent.
That's all we know... lets not make up numbers!

Back to the thread's main subject:
Has anyone switched to giving Dexamethasone IV at the time of the block?
Did you see comparable results?

 

[BLADEMDA]

My anecdotal comment is: Give it slow!
There is no magic dose or mysterious formula for dilution.
There is simply some patients who are susceptible to have this annoying phenomena, and in these patients it appears to be dose dependent.
That's all we know... lets not make up numbers!

Back to the thread's main subject:
Has anyone switched to giving Dexamethasone IV at the time of the block?
Did you see comparable results?

Intravenous dexamethasone-induced perineal pruritus
has been described in association with antiemetic
use in chemotherapy,1 in the setting of acute head
injury secondary to blunt trauma in an attempt to
reduce intracranial pressure,2 and as an anti-inflammatory
agent in the perioperative course of oral surgery.3
We are not aware of any similar reports in the anesthetic
literature. The incidence of this reaction has not been
clearly defined but could range between 25 to 100%
depending on the dose and speed of administration.1–5
We observed that females seem more at risk of presenting
this adverse effect, a finding that has been already
described in the literature.3,4 The pharmacological
mechanism explaining this phenomenon remains poorly
understood, but could be related to the phosphate
ester of the corticosteroid since perineal irritation has
been described with hydrocortisone-21-phosphate
sodium and prednisolone phosphate.1 Fortunately, this
adverse effect can be diminished or even abolished by
giving dexamethasone diluted in 50 mL of fluid over
five to ten minutes.1,3,5

 

[Planktonmd]

Intravenous dexamethasone-induced perineal pruritus
has been described in association with antiemetic
use in chemotherapy,1 in the setting of acute head
injury secondary to blunt trauma in an attempt to
reduce intracranial pressure,2 and as an anti-inflammatory
agent in the perioperative course of oral surgery.3
We are not aware of any similar reports in the anesthetic
literature. The incidence of this reaction has not been
clearly defined but could range between 25 to 100%
depending on the dose and speed of administration.1–5
We observed that females seem more at risk of presenting
this adverse effect, a finding that has been already
described in the literature.3,4 The pharmacological
mechanism explaining this phenomenon remains poorly
understood, but could be related to the phosphate
ester of the corticosteroid since perineal irritation has
been described with hydrocortisone-21-phosphate
sodium and prednisolone phosphate.1 Fortunately, this
adverse effect can be diminished or even abolished by
giving dexamethasone diluted in 50 mL of fluid over
five to ten minutes.1,3,5

Why did you put the 50cc in bold and not the 5-10 minutes?

 

[BLADEMDA]

Why did you put the 50cc in bold and not the 5-10 minutes?

You accused me of making up numbers. I did no such thing. Several authors recommend dilution of decadron in large volumes like 50 mls. As for the time frame of administration that is open to debate as is the amount of dilution needed to minimize perineal burning.

My anecdotal experience with 4 mg diluted in a 20 ml syringe and given over 30 seconds is that very few patients, if any, will complain of anything other than minor, mild itching in the genital area.

I do not have enough anecdotal experience with larger doses of decadron (over 4 mg) to comment about the effectiveness of volume vs time during administration.

The majority of my block patients receive 4 mg IV decadron immediately prior to the nerve block or within 10 min following its completion. I have not observed any significant prolongation of the nerve block secondary to low dose decadron. That said, perhaps pain score are lower for a longer period of time after the block wears off in those patients getting the decadron IV along with the block.

 

[Planktonmd]

You accused me of making up numbers. I did no such thing. Several authors recommend dilution of decadron in large volumes like 50 mls. As for the time frame of administration that is open to debate as is the amount of dilution needed to minimize perineal burning.

So, we agree that it's all debatable and we shouldn't throw numbers in a dogmatic fashion?

 

[BLADEMDA]

So, we agree that it's all debatable and we shouldn't throw numbers in a dogmatic fashion?

I posted that my routine administration of decadron IV to awake patients is 4 mg. I have given thousands of patients this dosage in a number of ways including dilution or slow IV push. Either way works fine but I find it easier and quicker to dilute the decadron.

I do not have sufficient anecdotal data to comment about decadron 6 mg or 8 mg IV push on awake patients as I abandoned that practice about 5 years ago because of MULTIPLE PATIENTS complaining of VAGINAL or ANUS AREA being on fire. Midazolam is insufficient to mask this short-lived side-effect in some patients.

Some experts recommend Fentanyl IV for the pain but by the time you draw up the Fentanyl and give it the side-effect is gone.

 

[dhb]

Just give it after induction and skip the mental masturbation.
I don't use it iv as much as i used to almost just for blocks now. There was a period when it was out of stock and i didn't miss it much (couldn't appreciate a clinical difference) so i kind of got used to not giving it.

 

[Mman]

Just an update on our clinical experience doing dexadron in ISBs for over a year. We are averaging 31 hours with a standard cocktail of 30 mL bup and 8 of decadron. I recently dropped back to 4 for a while (local shortage) and was asked if there was something different by the PA who does followup, durations more in the 28-29 hour range. No negative outcomes, we are between 1500 and 2000 blocks with decadron.
So not very scientific, but there seems to be a clinical effect of adding more than 4 mg.
Will wait for a more academic minded individual to do larger formal studies before finalizing mix.
My partner who uses more robust (close to toxic) doses of bup gets mid 30s.

Respectfully I'm calling BS on the PA. There is so much interindividual variability in terms of duration of a single shot block that there is no way anybody could guess who got what without a very large N. It's just not possible. You can do the exact same recipe for 2 different people and get a block duration that varies by 8-10 hours, regardless of technique.

 

[BLADEMDA]

Respectfully I'm calling BS on the PA. There is so much interindividual variability in terms of duration of a single shot block that there is no way anybody could guess who got what without a very large N. It's just not possible. You can do the exact same recipe for 2 different people and get a block duration that varies by 8-10 hours, regardless of technique.

There is variation from person to person but by utilizing decadron along with the local you extend mean duration of the block. This has been proven in studies and by the Regional Group at Univ. of Pittsburgh. The Group at Pitt has even proven it's safe at low doses.

I'm sorry for your patients that your single shot blocks won't last through the night (unlike mine); I hope you are utilizing catheters for your early AM blocks because otherwise many patients won't sleep through the night.

 

[BLADEMDA]

Our group recently showed 50% neuronal cytotoxicity in nondiabetic cultured primary sensory neurons after 24-hour exposure to 0.25% ropivacaine, whereas clinically relevant concentrations of clonidine, buprenorphine, dexamethasone, and midazolam were nontoxic.7 As such, we feel that the investigation into the use of these perineural adjuvants should continue, especially within the framework of the ZDF model. The studies in this issue of Regional Anesthesia and Pain Medicine even suggest that dexamethasone is now a viable perineural adjuvant to study in DM because acute tissue hyperglycemia does not appear to influence neurotoxicity sequelae in primary sensory neurons in vitro and does not appear to influence crude long-term sensorimotor outcomes in vivo.

Buoyed by our report that clonidine, buprenorphine, and dexamethasone are nontoxic in cultured neurons,7 we created a clinical pathway at the Veterans Affairs Pittsburgh Medical Center involving the routine use of these perineural adjuvants with bupivacaine for single-injection regional anesthesia. The plan, which included the off-label perineural use of clonidine, buprenorphine, and dexamethasone, was presented to and approved by the hospital's Medical Executive Board before proceeding. Bupivacaine concentrations and analgesic adjuvant doses, as they differed for diabetic and nondiabetic in our clinical pathway, are presented in Tables 1 and 2. We analyzed quality improvement (QI) data for 101 lower-extremity joint replacement patients thus far (not intended to be interpreted as peer reviewed). Our mean nerve block "durations of meaningful patient analgesia" have been 41 hours (95% confidence interval, 36–46 hours) for diabetic patients and 38 (34–41 hours) for nondiabetic patients. If we include all regional anesthesia patients, there have been QI data entered for a total of 275 patients as of this writing, and there have been no peripheral nerve complications to date with respect to multimodal perineural analgesia

 

[Planktonmd]

I posted that my routine administration of decadron IV to awake patients is 4 mg. I have given thousands of patients this dosage in a number of ways including dilution or slow IV push. Either way works fine but I find it easier and quicker to dilute the decadron.

I do not have sufficient anecdotal data to comment about decadron 6 mg or 8 mg IV push on awake patients as I abandoned that practice about 5 years ago because of MULTIPLE PATIENTS complaining of VAGINAL or ANUS AREA being on fire. Midazolam is insufficient to mask this short-lived side-effect in some patients.

Some experts recommend Fentanyl IV for the pain but by the time you draw up the Fentanyl and give it the side-effect is gone.

It's really difficult to have a discussion with you without developing a headache...

 

[Mman]

There is variation from person to person but by utilizing decadron along with the local you extend mean duration of the block. This has been proven in studies and by the Regional Group at Univ. of Pittsburgh. The Group at Pitt has even proven it's safe at low doses.

I'm sorry for your patients that your single shot blocks won't last through the night (unlike mine); I hope you are utilizing catheters for your early AM blocks because otherwise many patients won't sleep through the night.

my patients that need long lasting analgesia are all quite comfy with a catheter, so don't feel too bad for them.

But that's unrelated to my post. I'm stating that a PA on the floor can't tell the difference between someone who got 8 mg of decadron for a 31 hour block and someone who got 4 mg for a 29 hr block. It doesn't work that way. Nothing in regional anesthesia is that precise. Hell, the duration of a spinal isn't exact. Too much variation to tell a difference unless you keep track of a very large number of patients and retrospectively notice the difference.

 

[Mman]

If we include all regional anesthesia patients, there have been QI data entered for a total of 275 patients as of this writing, and there have been no peripheral nerve complications to date with respect to multimodal perineural analgesia

I would hope they wouldn't with such a small sample size for complications that you might need to go into well over 1000 patients to even begin to see a difference for such a rare complication.

 

[BLADEMDA]

I would hope they wouldn't with such a small sample size for complications that you might need to go into well over 1000 patients to even begin to see a difference for such a rare complication.

They are likely well over 1,000 patients by now. Many of us are well over 1,000 patients at this point. Decadron is safe and effective. Time to get on board.

 

[Mman]

They are likely well over 1,000 patients by now. Many of us are well over 1,000 patients at this point. Decadron is safe and effective. Time to get on board.

early adopters vs late adopters, risks and benefits to both. My surgeons and patients are quite happy with the mix of single shots and catheters we provide for any need that arises. The day I need a long acting block and have a contraindication to a cather, I'll consider it. Until then the benefit is nearly nil.

 

[BLADEMDA]

early adopters vs late adopters, risks and benefits to both. My surgeons and patients are quite happy with the mix of single shots and catheters we provide for any need that arises. The day I need a long acting block and have a contraindication to a cather, I'll consider it. Until then the benefit is nearly nil.

30 hours of pain relief from a single shot block utilizing 0.5% Bup and decadron may not be perfection but the benefits are clearly not nil.