INTRODUCTION: The article discusses the use of dexamethasone as an adjuvant to local anesthetic solution for ultrasound (US)-guided femoral nerve block in patients after total knee joint replacement. A literature review on the clinical use of other adjuvants is also presented. DESIGN: This was a clinical prospective randomized study. AIM: The aim of this article is to investigate the effect of dexamethasone adjuvant on the local anesthetic solution when performing a US-guided femoral block in patients after total knee joint replacement. METHODS: The study included 53 patients, randomized into two groups: Group 1: single shot femoral nerve block (FNB) + constant infusion through a perineural catheter 15 mL bolus (ropivacaine 0.5%/levobupivacaine 0.375%) with a subsequent infusion of 5-9 mL per hour, including 20 patients; Group 2: single shot FNB 20 mL bolus (ropivacaine 0.5%/levobupivacaine 0.375%) ± dexamethasone 4 mg, including 33 patients. In Group 2, 2 subgroups were formed: patients with single shot FNB with chirocain-10 patients; patients with single shot FNB with ropivacaine-23 patients. Of these, 15 patients were fasted with single shot FNB with ropivacaine + dexamethasone 4 mg, and 8 patients with pure ropivacaine. Evaluation of effective control of pain relief symptoms was done on 2 nd , 4 th , 6 th , 12 th , 18 th , 24 th , and 36 th hours postoperatively according to the Visual Analogue Scale (VAS). RESULTS: No statistically significant difference in VAS scores was observed between the two groups in the 2 nd , 6 th , 12 th , 18 th and 36 th hours. Such was found only in the 24 th hour. We did not detect statistically significant benefits of this adjuvant. We do not have clinically registered adverse drug reactions (ADRs). We have not established a correlation between these occurrences and the use of dexamethasone. CONCLUSION: Although our results correspond to those of authors who refute the benefits of dexamethasone as an adjuvant to the peripheral nerve block (PNB), we believe, based on clinical observation data, that it actually attenuated reversible hyperalgesia (patients did not report abruptly, acute, sudden onset of pain), therefore prolongation of the analgesic effect was observed until the 18 th , 20 th postoperative hour.
Anesthetic management of patients with severe sepsis is a great challenge. Systemic inflammation and acute organ dysfunction in response to infection is a major problem, especially respiratory failure and hemodynamic instability. Avoidance of lung injury during mechanical ventilation is possible with peripheral nerve blocks.
Clinical case 1:We present a 73-year-old male hemodialysis patient with sepsis. He had infectious complication of aneurysm formation of A-V fistula. The patient was hypoxic -SpO 2 86-88%, with presence of tachypnea, RR-150/75, HR-125/min, Temp -38 0 C, coagulation abnormalities -INR 1, 58 (clopidogrel intake), elevated CRP and WBC.The patient was indicated for emergency procedures of incision, drainage and ligation of A-V fistula. We performed supraclavicular brachial plexus block + sedation.
Clinical case 2:We present a 61-year-old woman with sepsis, with past medical history of diabetes, COPD, and endometrial cancer. She was with clinical presentation of necrotizing fasciitis of the upper extremity.We performed ultrasound-guided supraclavicular brachial plexus block -"in plane" technique, 30 mL/25 mL ropivacaine 0.5% in moderate sedated patients.During the operation the patients were conscious, hemodynamically and respiratory stable, with oxygen supply by a mask, and with excellent intraoperative and postoperative pain control.We think that ultrasound-guided peripheral nerve blocks are safe and effective alternatives for septic patients with/without coagulation abnormalities.
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