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 Table of Contents  
ORIGINAL ARTICLE
Year : 2013  |  Volume : 27  |  Issue : 3  |  Page : 165-169

Effect of addition of dexamethasone to ropivacaine in supraclavicular brachial plexus block


1 Department of Anaesthesiology and Critical Care, S.K.I.M.S, Medical College and Hospital, Srinagar, J&K, India
2 Department of Medicine, S.K.I.M.S, Srinagar, J&K, India

Date of Web Publication7-Jan-2014

Correspondence Address:
Feroz Ahmad Dar
Dar Mohala, Habak Naseembagh, Hazratbal Srinagar - 190 006, Jammu and Kashmir
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-5333.124602

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  Abstract 

Background and Objectives: We evaluated the effect of adding dexamethasone to ropivacaine for supraclavicular brachial blockade. The primary endpoints were the onset and total duration of sensory and motor block, quality of analgesia, and duration of analgesia. Materials and Methods: Eighty patients of age group 20-50 years, scheduled for various elective orthopedic surgeries on forearm and around the elbow under supraclavicular brachial block were divided into two equal groups in a randomized, double-blinded fashion. In group R (n = 40), 30 ml (150 mg) of 0.5% ropivacaine + 2 ml saline; and in group RD (n = 40), 30 ml (150 mg) of 0.5% ropivacaine + 2 ml dexamethasone (8 mg) were given. Motor and sensory block onset times, block durations, quality of intraoperative analgesia, and duration of analgesia were recorded. Results: Demographic data and surgical characteristics were similar in both groups. The sensory and motor block onset time was earlier in group RD as compared to group R (P < 0.05). Sensory and motor blockade durations were longer in group RD than in group R (P < 0.001). Duration of analgesia was longer in group RD than in group R (P < 0.001). The 24 h Visual Analogue Scale (VAS) was more in group R as compared to group RD. The quality of anesthesia was excellent in both the groups. Mean arterial blood pressure levels in groups at 5, 10, 15, 30, 45, 60, 90, 120, and 150 min were statistically insignificant between the two groups (P > 0.05). The mean pulse rate at different time intervals was statistically insignificant between the groups (P > 0.05). Conclusions: Dexamethasone added to ropivacaine for supraclavicular brachial plexus block prolongs the duration of the block and the duration of postoperative analgesia.

Keywords: Dexamethasone, ropivacaine, supraclavicular brachial plexus block


How to cite this article:
Dar FA, Najar MR, Jan N. Effect of addition of dexamethasone to ropivacaine in supraclavicular brachial plexus block. Indian J Pain 2013;27:165-9

How to cite this URL:
Dar FA, Najar MR, Jan N. Effect of addition of dexamethasone to ropivacaine in supraclavicular brachial plexus block. Indian J Pain [serial online] 2013 [cited 2019 Sep 18];27:165-9. Available from: http://www.indianjpain.org/text.asp?2013/27/3/165/124602


  Introduction Top


Ropivacaine is structurally closely related to bupivacaine. Compared to racemic bupivacaine, ropivacaine has lower central nervous system toxicity and cardiotoxicity, [1],[2],[3] and it is better tolerated than bupivacaine. [4],[5] Based on its profile, ropivacaine may be preferable to bupivacaine. Controversy exists regarding the potency of ropivacaine: In some areas it is clearly less potent, whereas in other areas this is less obvious. However, ropivacaine alone provide analgesia for not more than 4-6 h in peripheral nerve blocks. Increasing the duration of local anesthetic action is often desirable because it prolongs surgical anesthesia and analgesia. Different additives have been used to prolong regional blockade. Additives like opioids, clonidine, verapamil, etc., were added to local anesthetics, but the results are either inconclusive or associated with side effects. [6],[7],[8] Steroids have powerful anti-inflammatory as well as analgesic property. Perineural injection of steroids is reported to influence postoperative analgesia. Dexamethasone microspheres have been found to prolong the block duration in animal and human studies and adding methyl prednisolone to local anesthetic increases the duration of axillary brachial block. [9],[10],[11],[12] With this background, this study was carried out to evaluate the efficacy of dexamethasone as an adjuvant to ropivacaine in supraclavicular brachial block. Dexamethasone with ropivacaine use in axillary blocks has not been described. In this study, we investigated the effect of adding dexamethasone to ropivacaine for supraclavicular brachial plexus blocks. Our primary endpoints were the onset time, duration of motor and sensory blocks, and quality of intraoperative analgesia.

[TAG:2]Materials and Methods [/TAG:2]

After ethical committee approval and informed consent, eighty patients of American Society of Anesthesiologists (ASA) grades I-II of either sex, aged 20-50 years scheduled for elective orthopedic surgeries of upper limb under supraclavicular brachial plexus block were included in this study. Patients were not pre-medicated before the block. After insertion of a 20-gauge intravenous cannula in the non-operated arm, a 5 ml/kg/h infusion of 0.9% NaCl solution was started. After standard anesthesia monitoring, baseline measurements of heart rate (HR), noninvasive arterial blood pressure, peripheral oxygen saturation (SpO 2 ), and respiratory rate were recorded before the block was performed. After appropriate patient positioning and strict aseptic and antiseptic precautions midclavicular point, external jugular vein, and subclavian artery pulsation were identified. About 2 cm above the midclavicular point just lateral to subclavian artery pulsation, a 24 gauge 1.5 inch needle was introduced and directed caudal and medially until paresthesia was encountered, when local anesthetics with or without dexamethasone was injected in this area. Patients were randomly allocated using a sealed envelope technique to receive either 30 ml of 0.5% ropivacaine with 2 ml of isotonic sodium chloride solution (group R, n = 40), or 30 ml of 0.5% ropivacaine with 2 ml (8 mg) of dexamethasone (group RD, n = 40) in a double-blind fashion. The drug solutions were prepared by an anesthesiologist not involved in the study. Sensory block was assessed by pinprick test using a 3-point scale: 0 = normal sensation, 1 = loss of sensation of pinprick (analgesia), and 2 = loss of sensation of touch anesthesia). Motor block was evaluated by Modified Bromage Scale (4 = full power in relevant muscle group, 3 = reduced power but ability to move muscle group against resistance, 2 = ability to move relevant muscle group against gravity but inability to move against resistance, 1 = flicker of movement in relevant muscle group, 0 = no movement in relevant group). Sensory and motor blocks were evaluated every 3 min up to 30 min after injection, and then every 30 min after surgery, until they had resolved. Sensory onset time was defined as the time interval between the end of total local anesthetic administration and complete sensory block (score 2). Duration of sensory block was defined as the time interval between the end of local anesthetic administration and the complete resolution of sensory block (normal sensation or score 0). Motor block was defined as no movement in relevant group (Modified Bromage score 0). Duration of motor block was defined as the time interval between the end of local anesthetic administration and the recovery of full power in relevant muscle group (Modified Bromage score 4). The quality of intraoperative analgesia was judged by the investigator at the end of surgery as excellent (no discomfort or pain), good (mild pain or discomfort, no need for additional analgesics), fair (pain that required additional analgesics), or poor (moderate or severe pain that needed more than fentanyl 100 μg or general anesthesia). HR, systolic arterial blood pressure (SAP), and diastolic arterial blood pressure (DAP) were recorded at 0, 5, 10, 15, 30, 45, 60, 90, 120, and 150 min. Adverse events comprised hypotension (a 20% decrease in relation to the baseline value), bradycardia (HR < 50 beats per min), hypoxemia (SpO 2 < 90%), or nausea and vomiting. Pain was assessed using the Visual Analogue Scale (VAS;0-10) every 60 min during first 24 h. Nursing staff administered intramuscular (IM) diclofenac 75 mg when the VAS > 4. The time between the end of local anesthetic administration and the first analgesic request was recorded as the duration of the analgesia. Data were entered and analyzed with the Graph Pad.com (version 5, 2010). Statistical tests used for comparison is unpaired t-test and Fisher's exact test. Results are presented as mean (standard deviation (SD)) and number (%) of cases as appropriate. The level of significance was set at P < 0.05, and 95% confidence intervals were calculated for the main outcome measures.


  Results Top


The demographic data and surgical characteristics were similar in each group [Table 1]. Sensory and motor block onset time was earlier in group RD as compared with group R [Table 2] (P < 0.05). Sensory and motor blockade durations were longer in group RD than in group R [Figure 1] (P < 0.001). Duration of analgesia was significantly longer in group RD than in group R [Table 3] (P < 0.001). The intraoperative quality of analgesia was excellent and similar in both groups [Table 3]. However, two patients in group R and one patient in group RD complain mild pain and discomfort, but no additional analgesic required. It was statistically insignificant between the two groups (P-value > 0.05). None of the patients in both the groups had poor quality of analgesia [Table 3]. From the 6th h, patients who received dexamethasone showed a significantly lower VAS than the patients received ropivacaine only [Figure 2]. Mean arterial pressure and mean pulse rate in group R and group RD at 0, 5, 10, 15, 30, 45, 60, 90, 120, and 150 min were statistically insignificant (P > 0.05). No side effects including nausea, vomiting, hypotension, and hypoxemia were reported in either group.
Table 1: Patients' characteristics, procedure time, and surgical duration

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Table 2: Comparison of quality of block in two groups

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Table 3: Quality of analgesia in two groups

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Figure 1: Quality of blocks of two groups

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Figure 2: Visual analogue scale (VAS) of two groups

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  Discussion Top


In this study, we demonstrated that in patients undergoing supraclavicular brachial plexus block, dexamethasone added to ropivacaine, shortens sensory and motor block onset time, and extends block durations.

Brachial plexus block is an easy and relatively safe procedure for upper limb surgeries. Ropivacaine provided better operating conditions, but the duration of analgesia is rarely maintained for more than 4-6 h. Addition of steroid to local anesthetics effectively and significantly prolongs the duration of analgesia as well as producing earlier onset of action. [13] Steroids are very potent anti-inflammatory and immunosuppressive agents. Perineural injection of steroid is reported to influence postoperative analgesia. Epidural steroids were used for treatment of back pain and sciatica. [14] Various steroids has been used for this purpose, but dexamethasone, a derivative synthetic glucocorticoid is preferred because of its highly potent anti-inflammatory property, about 25-30 times as potent as hydrocortisone and without any mineralocorticoid activity. Thus was found to be safer and devoid of potential side effects. Preoperative administration of dexamethasone by oral and intravenous routes has been shown to reduce overall pain scores and analgesic requirements in the postoperative period without any adverse effects in various oral and general surgical procedures. [15] Dexamethasone is also known to reduce postoperative nausea and vomiting. The possible mechanism of analgesic and antiemetic actions are due to anti-inflammatory property of dexamethasone. [16],[17]

In reported study, significantly early onset of sensory and motor block was noticed in group DR compared to group R (P < 0.05). The early onset of action might be due to synergistic action of dexamethasone with local anesthetics on blockage of nerve fibers. The duration of pain relief (postoperative analgesia) was markedly prolonged in group RD (14.5 ± 0.3 h), while it was only 8.3 ± 0.4 h in group R (P < 0.001). A variety of animal studies have reported the analgesic effect of corticosteroids by adding to local anesthetics for peripheral nerve blockade. Droger and colleagues have shown that dexamethasone incorporation into bupivacaine caused prolongation of the intercostals nerve blockade in sheep. [10] Castillo and coworkers reported that addition of dexamethasone to bupivacaine resulted in prolongation of sciatic nerve blockade in rats. [9] These studies have attributed the prolongation of the block duration to the anti-inflammatory effect of steroids. In one study on human volunteers, addition of dexamethasone to bupivacaine microcapsules provided prolongation of the intercostals nerve blockade. [11] Use of oral dexamethasone succeeded in reducing pain and swelling following tooth extraction. [18] Addition of dexamethasone to lidocaine [19] 1.5% solution for axillary brachial plexus block resulted in longer sensory and motor blockade duration (sensory blockade duration was 242 ± 76 vs 98 ± 33 min for control and motor blockade duration was 310 ± 81 vs 130 ± 31 min for control). In another study, 40 mg methylprednisolone was added to a mixture of local anesthetic formed of 20 ml bupivacaine + 20 ml mepivacaine + 0.2 ml epinephrine for axillary brachial plexus block. [12] It resulted in longer analgesia (23 vs 16 h for control) and longer motor blockade duration (19 vs 13 h for control). Shrestha and coworkers [20] added 8 mg of dexamethasone to a mixture of lidocaine and bupivacaine for supraclavicular brachial plexus block. Dexamethasone provided a faster onset of action and longer duration of analgesia without any adverse effects. Parrington and colleagues [21] added 8 mg of dexamethasone to 30 ml mepivacaine 1.5% during supraclavicular brachial plexus blockade. The dexamethasone group showed a longer duration of analgesia: 332 (225-448) vs 228 (207-263) min in the control group; whereas, the onset times of sensory and motor blockade were similar in both groups. In another study, [22] Cummings III and coworkers reported longer analgesia when using ropivacaine or bupivacaine for interscalene blocks, with the effect being more potent with ropivacaine. However, the block duration was more prolonged with bupivacaine than with ropivacaine.


  Conclusion Top


Addition of dexamethasone to ropivacaine in supraclavicular brachial plexus block significantly prolongs the duration of analgesia and motor block in patients undergoing upper limb surgeries and is a remarkably safe and cost effective method of providing postoperative analgesia.

 
  References Top

1.Reiz S, Häggmark S, Johansson G, Nath S. Cardiotoxicity of ropivacaine - a new amide local anaesthetic agent. Acta Anaesthesiol Scand 1989;33:93-8.  Back to cited text no. 1
    
2.Pitkänen M, Feldman HS, Arthur GR, Covino BG. Chronotropic and inotropic effects of ropivacaine, bupivacaine and lidocaine in the spontaneously beating and electrically paced isolated, perfused rabbit heart. Reg Anesth 1992;17:183-92.  Back to cited text no. 2
    
3.Sztark F, Malgat M, Dabadie P, Mazat JP. Comparison of the effects of bupivacaine and ropivacaine on heart cell mitochondrial bioenergetics. Anesthesiology 1998:88;1340-9.  Back to cited text no. 3
    
4.Scott DB, Lee A, Fagan D, Bowler GM, Bloomfield P, Lundh R. Acute toxicity of ropivacaine compared with that of bupivacaine. Anesth Analg 1989;69:563-9.  Back to cited text no. 4
[PUBMED]    
5.Knudsen K, Beckman Suurkula M, Blomberg S, Sjovall J, Edvardsson N. Central nervous and cardiovascular effects of i.v. infusions of ropivacaine, bupivacaine and placebo in volunteers. Br J Anaesth 1997;78:507-14.  Back to cited text no. 5
    
6.Wakhlo R, Gupta V, Raina A, Gupta SD, Lahori VU. Supraclavicular plexus block: Effect of adding tramadol or butorphanol as an adjuncts to local anaesthetic on motor and sensory block and duration of post-operative analgesia. J Anaesth Clin Pharmacol 2009;25:17-20.  Back to cited text no. 6
    
7.Iohom G, Machmachi A, Diarra DP, Khatouf M, Boileau S, Dap F, et al. The effects of clonidine added to mepivacaine for paronychia surgery under axillary brachial plexus block. Anesth Analg 2005;100:1179-83.  Back to cited text no. 7
[PUBMED]    
8.Lalla RL, Anant S, Nanda HS. Verapamil as an adjunct to local anaesthetic for brachial plexus blocks. MJAFI 2010;66:22-4.  Back to cited text no. 8
    
9.Castillo J, Curley J, Hotz J, Uezono M, Tigner J, Chasin M, et al. Glucocorticoids prolong rat sciatic nerve blockade in vivo from bupivacaine microspheres. Anesthesiology 1996;85:1157-66.  Back to cited text no. 9
[PUBMED]    
10.Droger C, Benziger D, Gao F, Berde CB. Prolonged intercostals nerve blockade in sheep using controlled-release of bupivacaine and dexamethasone from polymer microspheres. Anesthesiology 1998;89:969-79.  Back to cited text no. 10
    
11.Kopacz DJ, Lacouture PG, Wu D, Nandy P, Swanton R, Landau C, et al. The dose response and effects of dexamethasone on bupivacaine microcapsules for intercostals blockade (T9 to T11) in healthy volunteers. Anesth Analg 2003;96:576-82.  Back to cited text no. 11
    
12.Stan T, Goodman EJ, Bravo-Fernandez C, Holbrook CR. Adding methylprednisolone to local anesthetic increases the duration of axillary block. Reg Anesth Pain Med 2004;29:380-1.  Back to cited text no. 12
[PUBMED]    
13.Golwala MP, Swadia VN, Dhimar AA, Sridhar NV. Pain relief by dexamethasone as an adjuvant to local anaesthetics in supraclavicular brachial plexus block. J Anaesth Clin Pharmacol 2009;25:285-8.  Back to cited text no. 13
    
14.Benzon HT. Epidural steroids. In: Raj PP, editor. Pain Medicine, a Comprehensive Review. Maryland Heights: Mosby Publications; 1999. p. 259-63.  Back to cited text no. 14
    
15.Elhakim M, Ali NM, Rashed I, Riad MK, Refat M. Dexamethasone reduces postoperative vomiting and pain after paediatric tonsillectomy. Can J Anaesth 2003;50:392-7.  Back to cited text no. 15
[PUBMED]    
16.Bisgaard T, Klarskov B, Kehlet H, Rosenberg J. Pre-operative dexamethasone improves surgical outcome after laproscopic cholecystectomy. A randomized double blind placebo controlled trial. Ann Surg 2003;238;651-60.  Back to cited text no. 16
    
17.Liu K, Hsu CC, Chia YY. Effect of dexamethasone on postoperative emesis and pain. Br J Anaesth 1998;80:85-6.  Back to cited text no. 17
[PUBMED]    
18.Baxendale BR, Vater M, Lavery KM. Dexamethasone reduces pain and swelling following extraction of third molar teeth. Anaesthesia 1993;48:961-4.  Back to cited text no. 18
[PUBMED]    
19.Movafegh A, Razazian M, Hajimaohamadi F, Meysamie A. Dexamethasone added to lidocaine prolongs axillary brachial plexus blockade. Anesth Analg 2006;102:263-7.  Back to cited text no. 19
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20.Shrestha BR, Maharjan SK, Tabedar S. Supraclavicular brachial plexus block with and without dexamethasone - A comparative study. Kathmandu Univ Med J (KUMJ) 2003;3:158-60.  Back to cited text no. 20
    
21.Parrington SJ, O'Donnell D, Chan VW, Brown-Shreves D, Subramanyam R, Qu M, et al. Dexamethasone added to mepivacaine prolongs the duration of analgesia after upraclavicular brachial plexus blockade. Reg Anesth Pain Med 2010;35:422-6.  Back to cited text no. 21
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22.Cummings KC 3rd, Napierkowski DE, Parra-Sanchez I, Kurz A, Dalton JE, Brems JJ, et al. Effect of dexamethasone on the duration of interscalene nerve blocks with ropivacaine or bupivacaine. Br J Anaesth 2011;107:446-53.  Back to cited text no. 22
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    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]


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