Perineural Low-Dose Dexamethasone Prolongs Interscalene Block Analgesia With Bupivacaine Compared With Systemic Dexamethasone

Kahn, Richard L.; Cheng, Jennifer; Gadulov, Yuliya; Fields, Kara G.; YaDeau, Jacques T.; Gulotta, Lawrence V.

doi:10.1097/aap.0000000000000817

Cited by 32 publications

(44 citation statements)

References 24 publications

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“…24 Individual studies have had varied results (ISB and other blocks). Whereas some studies have concluded that perineural dexamethasone provides superior analgesia, 25,26 others have determined statistically significant but clinically insignificant differences, 27 and yet others have found no statistically significant differences between groups thereby concluding equivalence. 16,18,28 There are potential explanations for the contrasting results between these studies and our results identifying minimal differences.…”

Section: Discussionmentioning

confidence: 99%

Comparison of the effects of perineural or intravenous dexamethasone on low volume interscalene brachial plexus block: a randomised equivalence trial

McHardy

Singer

Awad

et al. 2020

British Journal of Anaesthesia

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Background: Efforts to prolong interscalene block (ISB) analgesia include the use of local anaesthetic adjuvants such as dexamethasone. Previous work showing prolonged block duration suggests that both perineural and intravenous (i.v.) routes can both prolong analgesia. The superiority of either route is controversial given the design of previous studies. As perineural dexamethasone is an off-label use, anaesthesiologists should be fully informed of the clinical differences, if any, on block duration. This study was designed to test whether perineural vs i.v. dexamethasone administration are equivalent. Methods: We randomised 182 eligible patients scheduled for arthroscopic shoulder surgery to receive low-dose ISB (0.5% ropivacaine 5 ml) with perineural or i.v. dexamethasone 4 mg. Subjects, anaesthesiologists, and research personnel were blinded. All subjects also received a standardised general anaesthetic and multimodal analgesia. The primary outcome was duration of analgesia analysed as an equivalence outcome (2 h equivalency margin) using the two one-sided test (TOST) method. Results: For the primary outcome, duration of analgesia, and perineural and i.v. administration of dexamethasone were not equivalent. The upper and lower bounds of the 90% confidence interval were 1 h (P¼0.12) and e2.5 h (P¼0.01), respectively. The observed difference in mean block duration was not clinically relevant (0.75 h longer for i.v. dexamethasone). There were no other clinically significant differences between groups. Conclusion:In the context of low-volume ISB with ropivacaine, perineural and i.v. dexamethasone were not equivalent in terms of their effects on block duration. However, there were no clinically significant differences in outcomes, and there is no advantage of perineural over intravenous dexamethasone. www.clinicaltrials.gov registration: NCT02322242.

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Section: Discussionmentioning

confidence: 99%

Comparison of the effects of perineural or intravenous dexamethasone on low volume interscalene brachial plexus block: a randomised equivalence trial

McHardy

Singer

Awad

et al. 2020

British Journal of Anaesthesia

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“…Limited comparative efficacy among routes of administration has emerged. This appears most true for dexamethasone, which confers similar benefits to pain control and opioid use when administered via either modality [259,[327][328][329][330]333]. Although administering dexamethasone as a component of peripheral nerve blockade may avoid systemic side effects, perineural dexamethasone may have a local effect on nerve tissues that may be undesirable in some patient populations.…”

Section: Systemic Multimodal Adjunctsmentioning

confidence: 99%

Perioperative Pain Management and Opioid Stewardship: A Practical Guide

et al. 2021

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Surgical procedures are key drivers of pain development and opioid utilization globally. Various organizations have generated guidance on postoperative pain management, enhanced recovery strategies, multimodal analgesic and anesthetic techniques, and postoperative opioid prescribing. Still, comprehensive integration of these recommendations into standard practice at the institutional level remains elusive, and persistent postoperative pain and opioid use pose significant societal burdens. The multitude of guidance publications, many different healthcare providers involved in executing them, evolution of surgical technique, and complexities of perioperative care transitions all represent challenges to process improvement. This review seeks to summarize and integrate key recommendations into a “roadmap” for institutional adoption of perioperative analgesic and opioid optimization strategies. We present a brief review of applicable statistics and definitions as impetus for prioritizing both analgesia and opioid exposure in surgical quality improvement. We then review recommended modalities at each phase of perioperative care. We showcase the value of interprofessional collaboration in implementing and sustaining perioperative performance measures related to pain management and analgesic exposure, including those from the patient perspective. Surgery centers across the globe should adopt an integrated, collaborative approach to the twin goals of optimal pain management and opioid stewardship across the care continuum.

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“…78 potentially relevant articles are identi ed initially. Finally, ve RCTs that meet our inclusion criteria are included in the meta-analysis [10,12,13,19,20].…”

Section: Resultsmentioning

confidence: 99%

“…The doses of perineural or intravenous dexamethasone supplemented to interscalene block range from 1 mg to 5 mg. Among the ve studies included here, three studies report block duration [10,12,13], three studies report pain scores at 12 h [10,19,20], four studies report pain scores at 24 h [10,12,19,20], three studies report opioid consumption [10,12,13], and three studies report nausea/vomiting [10,19,20]. Jadad scores of the ve included studies vary from 3 to 5, and all ve studies are considered to have high quality according to quality assessment.…”

Section: Resultsmentioning

confidence: 99%

“…Recently, several studies have explored the analgesic e cacy of perineural with intravenous dexamethasone for the pain management of shoulder arthroscopy, but the results are con icting [10,12,13]. With accumulating evidence, we therefore perform this meta-analysis of RCTs to compare perineural with intravenous dexamethasone in patients with shoulder arthroscopy.…”

Section: Introductionmentioning

confidence: 99%

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Analgesic Comparison of Perineural With Intravenous Dexamethasone on Interscalene Block for Shoulder Arthroscopy: a Meta-analysis of Randomized Controlled Trials

Huang¹,

Zhang²,

Kang³

et al. 2021

Preprint

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Introduction: The analgesic comparison of perineural with intravenous dexamethasone on interscalene block for pain management of shoulder arthroscopy remains controversial. We conduct a systematic review and meta-analysis to explore the influence of perineural with intravenous dexamethasone on interscalene block on the postoperative pain intensity of shoulder arthroscopy.Methods: We have searched PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases through April 2021 for randomized controlled trials (RCTs) assessing the effect of perineural with intravenous dexamethasone on interscalene block for pain control of shoulder arthroscopy. This meta-analysis is performed using the random-effect model.Results: Five RCTs are included in the meta-analysis. Overall, compared with intravenous dexamethasone for shoulder arthroscopy, perineural dexamethasone leads to similar block duration (SMD=0.12; 95% CI=-0.12 to 0.35; P=0.33), pain scores at 12 h (SMD=-0.67; 95% CI=-1.48 to 0.15; P=0.11), pain scores at 24 h (SMD=-0.33; 95% CI=-0.79 to 0.14; P=0.17), opioid consumption (SMD=0.01; 95% CI=-0.18 to 0.19; P=0.95) and nausea/vomiting (OR=0.74; 95% CI=0.38 to 1.44; P=0.38).Conclusions: Perineural and intravenous dexamethasone demonstrated comparable pain control after shoulder arthroscopy when supplemented to interscalene block.

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Perineural Low-Dose Dexamethasone Prolongs Interscalene Block Analgesia With Bupivacaine Compared With Systemic Dexamethasone

Abstract: This study was registered at Clinicaltrials.gov, identifier NCT02506660.

Cited by 32 publications

References 24 publications

Comparison of the effects of perineural or intravenous dexamethasone on low volume interscalene brachial plexus block: a randomised equivalence trial

Comparison of the effects of perineural or intravenous dexamethasone on low volume interscalene brachial plexus block: a randomised equivalence trial

Perioperative Pain Management and Opioid Stewardship: A Practical Guide

Analgesic Comparison of Perineural With Intravenous Dexamethasone on Interscalene Block for Shoulder Arthroscopy: a Meta-analysis of Randomized Controlled Trials

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