Perineural and intravenous dexamethasone and dexmedetomidine: network meta‐analysis of adjunctive effects on supraclavicular brachial plexus block

Abstract

Both perineural and intravenous dexamethasone and dexmedetomidine are used as local anaesthetic adjuncts to enhance peripheral nerve block characteristics. However, the effects of dexamethasone and dexmedetomidine based on their administration routes have not been directly compared, and the relative extent to which each adjunct prolongs sensory blockade remains unclear. This network meta-analysis sought to compare and rank the effects of perineural and intravenous dexamethasone and dexmedetomidine as supraclavicular block adjuncts. We sought randomised trials investigating the effects of adding perineural and intravenous dexamethasone or dexmedetomidine to long-acting local anaesthetics on supraclavicular block characteristics, including time to block onset and durations of sensory, motor and analgesic blockade. Data were compared and ranked according to relative effectiveness for each outcome. Our primary outcome was sensory block duration, with a 2-h difference considered clinically important. We performed a frequentist analysis, using the GRADE framework to appraise evidence. One-hundred trials (5728 patients) were included. Expressed as mean (95%CI), the control group (local anaesthetic alone) had a duration of sensory block of 401 (366-435) min, motor block duration of 369 (330-408) min and analgesic duration of 435 (386-483) min. Compared with control, sensory block was prolonged most by intravenous dexamethasone [mean difference (95%CI) 477 (160-795) min], followed by perineural dexamethasone [411 (343-480) min] and perineural dexmedetomidine [284 (235-333) min]. Motor block was prolonged most by perineural dexamethasone [mean difference (95%CI) 294 (236-352) min], followed by intravenous dexamethasone [289 (129-448)min] and perineural dexmedetomidine [258 (212-304)min]. Analgesic duration was prolonged most by perineural dexamethasone [mean difference (95%CI) 518 (448-589) min], followed by intravenous dexamethasone [478 (277-679) min] and perineural dexmedetomidine [318 (266-371) min]. Intravenous dexmedetomidine did not prolong sensory, motor or analgesic block durations. No major network inconsistencies were found. The quality of evidence for intravenous dexamethasone, perineural dexamethasone and perineural dexmedetomidine for prolongation of supraclavicular sensory block duration was 'low', 'very low' and 'low', respectively. Regardless of route, dexamethasone as an adjunct prolonged the durations of sensory and analgesic blockade to a greater extent than dexmedetomidine. Differences in block characteristics between perineural and intravenous dexamethasone were not clinically important. Intravenous dexmedetomidine did not affect block characteristics.

Efficacy of Dexamethasone versus Dexmedetomidine Combined with Local Anaesthetics in Brachial Plexus Block: A Meta-Analysis and Systematic Review

“…Additionally, the analgesic time and motor block time were extended by an average of 351 min and 277 min, respectively. The latest research shows that compared with placebo, the perineural or systemic use of dexamethasone equally extends the block time [ 8 ].…”

“…Numerous reports have confirmed that dexamethasone and dexmedetomidine prolong the action time following the introduction of local anaesthesia to peripheral nerve block [4][5][6][7]. Combining dexamethasone or dexmedetomidine as a local anaesthetic adjuvant improves block characteristics, whether around the nerve or in the vein [8]. Multiple metaanalyses have convincingly demonstrated its effectiveness in prolonging the duration of brachial plexus block pain relief [9][10][11][12].…”

The Effect of Intravenous Dexamethasone and Dexmedetomidine on Analgesia Duration of Supraclavicular Brachial Plexus Block: A Randomized, Four-Arm, Triple-Blinded, Placebo-Controlled Trial

“…In contrast, previous studies reported that intravenous administration of dexamethasone prolonged motor blockade [24,25], whereas intravenous dexmedetomidine did not [13,19,25]. Recently published network meta-analysis reports prolongation of sensory and motor blocks, especially with dexamethasone [25]. Such difference may be attributed to the distinct analgesic protocol, difference in the block technique and the accompanying baseline quality of the blockade.…”

“…Second, there were no significant differences in motor blockade among the four groups. In contrast, previous studies reported that intravenous administration of dexamethasone prolonged motor blockade [24,25], whereas intravenous dexmedetomidine did not [13,19,25]. Recently published network meta-analysis reports prolongation of sensory and motor blocks, especially with dexamethasone [25].…”

Adjuvants in Peripheral Nerve Blocks

“…Perineural administration has shown to be more effective and associated with lesser hemodynamic side effects as compared to the intravenous route of administration. Researchers have also compared dexamethasone and dexmedetomidine as adjuvant and found that perineural dexamethasone causes the longest block prolongation with the least amount of side effects [30,31].…”