|Year : 2016 | Volume
| Issue : 3 | Page : 194-197
Efficacy of low dose intravenous dexamethasone for prolongation of analgesia in supraclavicular block: Randomized controlled trial
Sangeeta Dhanger1, Bhavani Vaidyanathan1, Idhuyya Joseph Rajesh1, Stalin Vinayagam2, Yogesh Bahurupi3, Duraiayyah Vimalraj4
1 Department of Anaesthesiology and Critical Care, Indira Gandhi Medical College and Research Institute, Puducherry, India
2 Department of Anaesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
3 Department of Community Medicine, Indira Gandhi Medical College and Research Institute, Puducherry, India
4 Department of Orthopaedics, Indira Gandhi Medical College and Research Institute, Puducherry, India
|Date of Web Publication||10-Jan-2017|
FR4, Sri Anbalaya Apartments, 17th Cross Street, Krishna Nagar, Puducherry - 605 008
Source of Support: None, Conflict of Interest: None
Clinical trial registration REF/2015/08/009652 , URL - http://ctri.nic.in
Background: Dexamethasone, a long-acting glucocorticoid is used as an additive along with local anesthetics perineurally to prolong the duration of neuraxial blocks. The aim of this prospective, randomized, double-blind study was to evaluate the efficacy of low-dose intravenous (IV) dexamethasone (2 mg) along with bupivacaine for prolongation of supraclavicular block in patients undergoing upper limb surgeries. Materials and Methods: Sixty American Society of Anaesthesiologists 1 and 2 patients, aged between 18 and 60 years were included in this study and randomized into two groups: Group D (dexamethasone group) and Group C (control group). Ultrasound-guided supraclavicular block was performed and patients belonging to Group D received 25 ml of 0.5% bupivacaine and 2 mg (1 ml) dexamethasone intravenously while patients belonging to Group C received 25 ml of 0.5% bupivacaine and 1 ml of normal saline intravenously. Duration of analgesia, motor blockade, and requirement of rescue analgesic were recorded. Results were analyzed using unpaired Student's t-test and Chi-squared test. P <0.05 was considered statistically significant. Results: Duration of analgesia in Group D was 11.88 ± 1.31 h as compared to 6.47 ± 0.93 in Group C (P < 0.05). Rescue analgesic requirement was significantly less in Group D (38.00 ± 20.51) as compared to Group C (173.33 ± 34.07). Patient satisfaction and quality of sleep was better in patients belonging to Group D. Conclusion: We conclude that low dose IV dexamethasone significantly prolongs the duration of analgesia and reduces analgesic requirements without producing any significant side effects.
Keywords: Brachial plexus, bupivacaine, dexamethasone
|How to cite this article:|
Dhanger S, Vaidyanathan B, Rajesh IJ, Vinayagam S, Bahurupi Y, Vimalraj D. Efficacy of low dose intravenous dexamethasone for prolongation of analgesia in supraclavicular block: Randomized controlled trial. Indian J Pain 2016;30:194-7
|How to cite this URL:|
Dhanger S, Vaidyanathan B, Rajesh IJ, Vinayagam S, Bahurupi Y, Vimalraj D. Efficacy of low dose intravenous dexamethasone for prolongation of analgesia in supraclavicular block: Randomized controlled trial. Indian J Pain [serial online] 2016 [cited 2019 Sep 20];30:194-7. Available from: http://www.indianjpain.org/text.asp?2016/30/3/194/198059
| Introduction|| |
Brachial plexus block is a popular and widely employed technique of anesthesia and analgesia for upper limb surgeries.  Various drugs have been used with local anesthetics as additives to achieve faster onset and prolonged block. ,, However, these additives may lead to side-effects such as sedation, psychomimetic effects, respiratory depression, and pruritus depending on the individual drug used. An ideal additive should prolong the duration of analgesia with minimal side effects and should be cost-effective also. Dexamethasone is a long-acting glucocorticoid (t1/2 > 36 h) with potent anti-inflammatory and analgesic effects. Various studies have been done on perineural dexamethasone as additive, ,,] and proved its action to prolong postoperative analgesia.
In recent times, it was found that intravenous (IV) dexamethasone is equally efficacious in prolonging the duration of analgesia as compared to perineural route.  and decrease the requirement of analgesics in orofacial, urological, and orthopedic surgeries. , Various studies have tried different doses of dexamethasone both perineurally and intravenously, but the optimal dose which can prolong analgesia with lesser side effects is still not clearly defined. Hence, the aim of the present study was to evaluate the efficacy of single low dose IV dexamethasone, i.e., 2 mg for prolongation of the duration of analgesia in patients undergoing upper limb surgeries under supraclavicular block with bupivacaine.
| Materials and Methods|| |
After obtaining Institute Ethics Committee approval (IEC/PP/2016/01) and written informed consent, sixty patients weighing 40-70 kg scheduled to undergo upper limb surgeries under supraclavicular block belonging to the American Society of Anaesthesiologists class I and II, aged 18-60 years were included in this study. Patients with diabetes mellitus, hypertension, peripheral neuropathy, hepatic or renal disease, and known allergy to local anesthetic drugs were excluded from the study. All participants were randomized into two groups, Group D (n = 30) and Group C (n = 30) by computer generated a random number sequence.
A standard preanesthetic assessment was done by an attending anesthesiologist, and the procedure was explained to the patients. All patients were premedicated with tablet diazepam 5 mg and tablet Ranitidine 150 mg orally the night before surgery and in the morning. In the operation theater, after securing IV line and attaching standard monitors (electrocardiogram, noninvasive blood pressure, and SpO 2 ), ultrasound-guided Supraclavicular block was performed as per departmental protocol by a trained anesthesiologists who was blinded for group allocation. Patients belonging to Group D received 25 ml of 0.5% bupivacaine and 2 mg (1 ml) dexamethasone intravenously while patients belonging to Group C received 25 ml of 0.5% bupivacaine and 1 ml of normal saline intravenously.
Patients were evaluated at 5 min intervals for 15 min for the development of sensory and motor block. Sensory blockade was tested using pin prick method along the distribution of the four nerves (median nerve, radial nerve, ulnar nerve, and musculocutaneous nerve). Sensory block of each nerve was rated by the patient on a visual analog scale (VAS) from 10 (normal sensation) to 0 (no sensation). Motor blockade assessment was done using the modified Bromage scale for upper extremities on a three-point scale [Table 1]. 
Surgery was started after ensuring adequate block and hemodynamic monitoring was done throughout the intraoperative period. Patients with inadequate block were given general anesthesia and were excluded from the study. Postoperatively, motor blockade and pain was assessed every hour. The pain was evaluated using a VAS.
The duration of analgesia was defined as the time interval between the onset of sensory block to the time when patient had verbal rating scale score of > 4. Injection tramadol 50 mg was administered intravenously as rescue analgesic in the postoperative period when VAS > 4. In case of insufficient analgesia, injection Diclofenac (75 mg) intravenously was administered.
Next day morning, after 24 h of block, all patients were assessed by a blind observer for quality of sleep (1 = no sleep disturbance because of pain, 0 = sleep disturbance because of pain) and patient satisfaction (2-point scale, 1 = satisfied, 0 = unsatisfied).
The sample size was calculated based on a pilot study with ten patients in each group. Patients who received IV dexamethasone (2 mg) had a mean duration of analgesia of 12 ± 3.43 as compared to control group (7.5 ± 3.66) with a mean difference of 4.5 h. It was estimated that a minimum of 24 patients in each group would be required to have a 90% power of detecting a 4.5 h difference at a significance level of 0.05% and 95% confidence interval. We recruited thirty patients in each group to compensate for any dropouts. Data analysis was done using SPSS version 16.0 (SPSS Inc., Chicago, Illinois, USA). Continuous variables were expressed as mean ± standard deviation. Normally, distributed data were compared using t-test as a test of significance for the difference of mean and categorical variables were analyzed using Chi-square test for difference in proportion. The analysis was done with two-tailed test and P < 0.05 was considered as statistically significant.
| Results|| |
The demographic variables such as age, weight, height, body mass index, gender, and duration of surgery were comparable in both groups as shown in [Table 2]. In Group D, duration of analgesia was 6.47 ± 0.93 whereas in Group C it was 11.88 ± 1.31 h. The difference in both groups was found to be statistically significant (P < 0.05). Mean duration of motor block (Bromage score 2) in Group D was 6.12 ± 0.48 h to 4.33 ± 0.47 h in Group C and the difference was found to be statistically significant as P < 0.05.
Rescue analgesic (injection tramadol IV) requirement in Group D and C was 38.00 ± 20.51 and 173.33 ± 34.07 respectively, and the difference was statistically significant (P < 0.05) as depicted in [Table 3].
|Table 3: Comparison of visual analog scale, Bromage scale 2 and requirement of rescue analgesic between Group D and Group C|
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There were no side effects or complications observed in either of the group. Intra- and post-operative hemodynamic parameters such as heart rate mean blood pressure, and oxygen saturation were comparable between the groups.
During the first postoperative night, 26 out of thirty patients had sleep disturbance in Group C, but in Group D none of the patients had sleep disturbance due to pain. Overall patients' satisfaction in Group D was 100% whereas in Group C it was 13% [Figure 1].
|Figure 1: Comparison of incidence of sleep disturbance and patients' satisfaction between Group D and Group C.|
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| Discussion|| |
In this study, we found that IV injection of the low dose (2 mg) dexamethasone significantly prolongs the duration of analgesia and motor blockade in patients undergoing upper limb surgeries under supraclavicular block with 0.5% bupivacaine. Duration of analgesia was 11.88 ± 1.31 h in dexamethasone group whereas 6.47 ± 0.93 h in the normal saline group. There was high patients' satisfaction score and no sleep disturbances in dexamethasone group as compared to control group.
Perineural dexamethasone has been proved as a promising adjuvant with local anesthetic agents which prolongs the duration of analgesia and decreases postopreative analgesia requirements. Dexamethasone is not approved for perineural route by Food and Drug Administration as many in vitro studies have shown that there is a high risk of peripheral neurotoxicity. ,, However, many authors have used it in perineural route, and none of them reported any neurotoxicity.
Desmet et al.  showed that both IV and perineural administration of 10 mg dexamethasone to supraclavicular brachial plexus block equivalently prolonged the duration of analgesia. Two other randomized placebo-controlled studies , also proved injection dexamethasone, 8-10 mg is equally effective in both, IV and perineural route to increase the duration of analgesia. There is controversy regarding route and dose of dexamethasone but systemic toxicity from a single dose of dexamethasone is unlikely as it is widely administered intravenously by anesthesiologists for prophylaxis against postoperative nausea and vomiting. 
Parveen et al.  and Abdallah et al.  had showed 10 mg and 8 mg IV dose with long-acting local anesthetic agents prolongs the duration of analgesia up to 15 h 25 h respectively but none of them reported steroid induced hyperglycemia whereas Desmet et al.  had also used 10 mg IV dexamethasone and showed the increased duration of analgesia up to 21 h but with a higher incidence of hyperglycemia and infection. Various studies had shown variable results with similar doses of dexamethasone, therefore, it is not yet clear whether dose or concentration play a role in the efficacy of dexamethasone.
Therefore, the concerns about steroid-induced hyperglycemia have been born out in high-dose IV regimens,  we used very low dose (2 mg) of dexamethasone and duration of analgesia was clinically comparable with 10 mg iv dose, though it was not statistically comparable. Meta-analysis done by De Oliveira et al.  had concluded dexamethasone moderate dose 0.11-0.2 mg/kg decreased postoperative pain. Another meta-analysis  of approximately 2500 patients showed that low-dose dexamethasone, when given intraoperatively, does not have opioid sparing effects after surgery but the high-dose dexamethasone (more than 0.2 mg/kg) when given intraoperatively has opioid-sparing effects and decreased postoperative pain.
Duration motor block (Bromage score 2) in our study with 25 ml 0.5% bupivacaine was 6 h whereas Parveen et al. showed prolongation of motor block up to 11 h with 30 ml 0.5% ropivacaine. The quality of analgesia indicated by outcome measures such as no sleep disturbance and more patient satisfaction score were comparable to high doses. 
The mechanism of action of dexamethasone as analgesic is still the matter of debate, but interestingly this effect is independent of the route of administration as both perineural and IV injection. The most acceptable theory is that dexamethasone acts on glucocorticoid receptor and alter the functioning of ion channels or produce local acidosis in nerve cell, thereby reducing the concentration of local anesthetic required to produce conduction failure.  This is supported by the finding that the degree of block prolongation had the same rank order as the relative anti-inflammatory potencies of glucocorticoids and is completely reversed by administration of a specific glucocorticoid receptor antagonist. ,, Dexamethasone also increases the activity of inhibitory potassium channels on nociceptive C-fibers (through glucocorticoid receptors), thus decreasing their activity. 
| Conclusion|| |
IV dexamethasone in a low dose that is 2 mg prolongs significantly the duration of postoperative analgesia after a single-shot supraclavicular block with 0.5% bupivacaine. We would like to remind again the clinicians that perineural use of dexamethasone is off-label and needs approval of the appropriate regulatory authority. Therefore, we propose that IV dexamethasone in a low dose can be used as a safe and effective adjuvant for nerve block without any significant side effects and should be considered for routine use in patients having regional analgesia.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]