Efficacy of perineural vs systemic dexamethasone to prolong analgesia after peripheral nerve block: a systematic review and meta-analysis

Abstract

Perineural dexamethasone has gained popularity in regional anaesthesia to prolong the duration of analgesia, but its advantage over systemic administration is disputed. The objective of this meta-analysis was to compare the analgesic efficacy of both routes of administration during peripheral nerve block. The methodology followed the PRISMA statement guidelines. The primary outcome was the duration of analgesia analysed according to the type of local anaesthetic administered (bupivacaine or ropivacaine). Secondary outcomes included cumulative opioid consumption in morphine i.v. equivalents, pain scores, and complication rates (neurological complications, infection, or hyperglycaemia). Eleven controlled trials, including 914 patients, were identified. The duration of analgesia was significantly increased with perineural dexamethasone vs systemic dexamethasone by a mean difference of 3 h [95% confidence interval (CI): 1.4, 4.5 h; P=0.0001]. Subgroup analysis revealed that the duration of analgesia was increased by 21% with bupivacaine (mean difference: 4.0 h; 95% CI: 2.8, 5.2 h; P<0.00001) and 12% with ropivacaine (mean difference: 2.0 h; 95% CI: -0.5, 4.5 h; P=0.11). The quality of evidence for our primary outcome was moderate according to the GRADE system. There were no significant differences in other secondary outcomes. No neurological complications or infections were reported. Glucose concentrations were not increased when dexamethasone was injected systemically, but this outcome was reported by only two trials. There is, therefore, moderate evidence that perineural dexamethasone combined with bupivacaine, but not ropivacaine, slightly prolongs the duration of analgesia, without an impact on other pain-related outcomes, when compared with systemic dexamethasone. Injection of perineural dexamethasone should be cautiously balanced in light of the off-label indication for this route of administration.

A randomised controlled trial of the pectoral nerves‐2 (PECS‐2) block for radical mastectomy

“…The reduction in the morphine consumption during the 24-48-h interval in favour of the PECS-2 group should be interpreted with caution as it is a secondary outcome and as the duration of the local anaesthetics is not expected to last more than 24 h, even if combined with i.v. dexamethasone [12]. A possible mechanism might be secondary hyperalgesia [17,18], but this needs further research to confirm this hypothesis.…”

Caudal and intravenous dexamethasone as an adjuvant to pediatric caudal block: A systematic review and meta‐analysis

“…Additionally, one recently published systematic review evaluated the effectiveness of perineural dexamethasone via systemic administration to prolong analgesia after a peripheral nerve block. The review included 11 studies with 914 participants and the review showed that bupivacaine combined with perineural dexamethasone could provide a longer duration of analgesia compared with systemic dexamethasone (4 hours, P < .0001) …”

“…Additionally, another systematic review evaluated the safety of perineural and systemic dexamethasone. Side effects including subsequent infection, hyperglycemia, and neurotoxic effects in these 2 groups were comparable, which were similar to the result of our analysis. So we conclude that a single dose of dexamethasone (<5 mg/kg) is likely safe in terms of postoperative surgical complications regarding wound healing, dehiscence, or infection.…”

“…A single intravenous dose of dexamethasone 0.5 mg/kg combined with caudal block can prolong the duration of postoperative analgesia 18,19,24 and a single intravenous dose of dexamethasone 0.5 mg/kg has an equivalent analgesic effect to a single caudal dose of dexamethasone 0.1 mg/kg when patients received caudal block after induction of anesthesia.Additionally, one recently published systematic review evaluated the effectiveness of perineural dexamethasone via systemic administration to prolong analgesia after a peripheral nerve block. The review included 11 studies with 914 participants and the review showed that bupivacaine combined with perineural dexamethasone could provide a longer duration of analgesia compared with systemic dexamethasone (4 hours, P < .0001) 25. 3.2 | Analgesics administrationThis analysis included 4 trials[18][19][20]24 with a total of 267 participants, of whom 133 were assigned to THE experimental group and the other 134 to THE control group.…”

Blinded by certainties

“…Baeriswyl claims in his recent meta-analysis ‘moderate evidence that perineural dexamethasone combined with bupivacaine, but not ropivacaine , slightly prolongs the duration of analgesia’ 7. Chong meta-analysis suggests that ‘perineural dexamethasone prolonged the duration of analgesia….compared with intravenous dexamethasone, with high statistical heterogeneity ’ 8.…”