Effect of Dexamethasone in Peripheral Nerve Blocks on Recovery of Nerve Function

Ultrasound-Guided Superior Cluneal Nerve Block: A Narrative Review

Low back pain (LBP) is common and has a complex etiology. Superior cluneal nerve (SCN) entrapment has come to the attention of pain physicians as a cause of LBP. SCN block is the mainstay of treatment for LBP due to SCN entrapment. The aim of this narrative review is to summarize the approaches and techniques for ultrasound-guided SCN block. Meanwhile, the evidence for the clinical use of SCN block is reviewed, based on relevant and recent literature. The authors expect this article to provide a reference point for the diagnosis and treatment of LBP.

Intravenous injection of dexamethasone is non-inferior to perineural administration for popliteal sciatic nerve and saphenous nerve blocks: A randomized, controlled, triple-blind study

Background

The aim of this study was to assess whether intravenous dexamethasone was noninferior to perineural dexamethasone as an adjuvant to ropivacaine for a combination of saphenous and sciatic nerve blocks in patients undergoing foot and ankle surgery.

Methods

This was a prospective, blinded, randomized noninferiority study. Seventy-five patients, aged 18-75 years, with an American Society of Anesthesiologists (ASA) physical status I-III who underwent foot and ankle surgery were involved. Patients scheduled for ultrasound-guided popliteal sciatic nerve block and saphenous nerve block were randomized to receive 0.375% ropivacaine with 7.5 mg of dexamethasone perineurally (Dex-PN), 10 mg of dexamethasone intravenously (Dex-IV) or neither (Placebo). The primary outcome was the duration of analgesia. The major secondary outcomes were the composite pain intensity and opioid consumption score at 0-48 h intervals after anesthesia.

Results

The mean analgesic duration was 26.2 h in the Dex-IV group and 27.9 h in the Dex-PN group (duration difference, -1.7; 95% CI, -3.8 to 0.43; P = 0.117), and both durations were significantly longer than that in the placebo group (17.6 h, P < 0.001). Conditions for establishing non-inferiority were met.

Conclusions

Our findings indicate that a single 10-mg intravenous dose of dexamethasone was noninferior to the combined dose of ropivacaine plus deaxmethasone in terms of duration of analgesia for foot and ankle surgery.

Rebound pain after interscalene brachial plexus block for shoulder surgery: a randomized clinical trial of the effect of different multimodal analgesia regimens

BACKGROUND

Rebound pain is characterized by sudden, significant acute postoperative pain occurring after the resolution of inter-scalene block (ISB); it affects the quality of recovery postoperatively. Dexamethasone increases ISB resolution time and decreases opioid consumption and the incidence of rebound pain.

OBJECTIVE

Evaluate whether multimodal analgesia including intravenous dexamethasone administration with preoperative ISB reduces the incidence of rebound pain.

DESIGN

Prospective, randomized, controlled trial.

SETTING

Tertiary university hospital.

SAMPLE SIZE

60 patients.

PATIENTS AND METHODS

Patients who underwent shoulder surgery under general anesthesia were assigned randomly to two different multimodal analgesia protocols. Thirty patients received 5 mg IV dexamethasone with non-steroid, paracetamol, and ISB with 15 mL 0.5% bupivacaine, while the control patients received the same regimen and ISB with 15 mL 0.5% bupivacaine without dexamethasone. Postoperative opioids were given to any patient on demand.

MAIN OUTCOMES MEASURES

Effect of IV dexamethasone on pain score and incidence of rebound pain after ISB resolution and postoperative opioid consumption at 0-48 hours, numerical pain rating scale (NPRS) scores, sleep scale scores, and quality of recovery-15 scores (QoR-15).

RESULTS

The incidence of rebound pain was lower in the dexamethasone group than in the control group (73.3% and 30%, respectively, P=.001). NPRS scores after ISB resolution were lower in the dexamethasone group (5 ([4-7]), 8 ([5.75-8]), P<.001, respectively). Those who received IV dexamethasone had less sleep disturbances (P<.001) and higher QoR-15 on day 1 (P<.001) and day 7 (P=.020) postoperatively.

CONCLUSIONS

IV dexamethasone added to the ISB block resulted in a lower incidence of rebound pain. In addition, better results were obtained in postoperative sleep quality and QoR-15.

LIMITATIONS

Single-center study.

Adding Dexamethasone to Adductor Canal Block Combined with iPACK Block Improve Postoperative Analgesia of Total Knee Arthroplasty

OBJECTIVE

Both adductor canal block (ACB) and infiltration between the popliteal artery and capsule of knee (iPACK) block are mainly sensory blocks, preserved muscle strength and ability to ambulate. This study was designed to evaluate whether adding dexamethasone to ropivacaine could improve postoperative analgesia after total knee arthroplasty (TKA).

METHODS

This prospective double-blind randomized controlled trial included 60 patients who underwent unilateral TKA under general anesthesia. All patients who received ACB and iPACK block were randomly divided into a dexamethasone group (Group D, ropivacaine combined with dexamethasone) and a control group (Group C, ropivacaine only). The primary outcome was the time to first administration of rescue analgesic drugs. Secondary outcomes included the total amount of rescue analgesic drugs and the pain scores at different time points within 72 hours postoperatively; the time to first getting out of bed, quality of recovery scale (QOR-15 score), and the levels of plasma inflammatory markers (IL-6 and CRP) on postoperative day 1.

RESULTS

Compared with Group C, the time to first administration of rescue analgesic drugs of Group D was significantly extended by approximately 10.5 hours. Patients in Group D had significantly lower pain scores at postoperative different time points and consumed significantly smaller total morphine within 72 hours postoperatively. In addition, patients in group D reported significantly higher QoR-15 scores on postoperative days 1 and 3, earlier first time of getting out of bed, and significantly lower levels of CRP and IL-6 on postoperative day 1.

CONCLUSIONS

Compared with using ropivacaine alone, ultrasonic guided ACB combined with iPACK using ropivacaine and dexamethasone could prolong the duration of postoperative analgesia and strength analgesic intensity and promote the early rehabilitation exercise of patients undergoing TKA.

Potential Adverse Effects of Dexamethasone Therapy on COVID-19 Patients: Review and Recommendations

In the context of the coronavirus disease 2019 (COVID-19) pandemic, the global healthcare community has raced to find effective therapeutic agents against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). To date, dexamethasone is the first and an important therapeutic to significantly reduce the risk of death in COVID-19 patients with severe disease. Due to powerful anti-inflammatory and immunosuppressive effects, dexamethasone could attenuate SARS-CoV-2-induced uncontrolled cytokine storm, severe acute respiratory distress syndrome and lung injury. Nevertheless, dexamethasone treatment is a double-edged sword, as numerous studies have revealed that it has significant adverse impacts later in life. In this article, we reviewed the literature regarding the adverse effects of dexamethasone administration on different organ systems as well as related disease pathogenesis in an attempt to clarify the potential harms that may arise in COVID-19 patients receiving dexamethasone treatment. Overall, taking the threat of COVID­19 pandemic into account, we think it is necessary to apply dexamethasone as a pharmaceutical therapy in critical patients. However, its adverse side effects cannot be ignored. Our review will help medical professionals in the prognosis and follow-up of patients treated with dexamethasone. In addition, given that a considerable amount of uncertainty, confusion and even controversy still exist, further studies and more clinical trials are urgently needed to improve our understanding of the parameters and the effects of dexamethasone on patients with SARS-CoV-2 infection.

Adjuvant Drugs for Peripheral Nerve Blocks: The Role of Alpha-2 Agonists, Dexamethasone, Midazolam, and Non-steroidal Anti-inflammatory Drugs

Adjuvant drugs for peripheral nerve blocks are a promising solution to acute postoperative pain and the transition to chronic pain treatment. Peripheral nerve blocks (PNB) are used in the brachial plexus, lumbar plexus, femoral nerve, sciatic nerve, and many other anatomic locations for site-specific pain relief. However, the duration of action of a PNB is limited without an adjuvant drug. The use of non-opioid adjuvant drugs for single-shot peripheral nerve blocks (sPNB), such as alpha-2 agonists, dexamethasone, midazolam, and non-steroidal anti-inflammatory drugs, can extend the duration of local anesthetics and reduce the dose-dependent adverse effects of local anesthetics. Tramadol is a weak opioid that acts as a central analgesic. It can block voltage-dependent sodium and potassium channels, cause serotonin release, and inhibit norepinephrine reuptake and can also be used as an adjuvant in PNBs. However, tramadol's effectiveness and safety as an adjuvant to local anesthetic for PNB are inconsistent. The effects of the adjuvants on neurotoxicity must be further evaluated with further studies to delineate the safety in their use in PNB. Further research needs to be done. However, the use of adjuvants in PNB can be a way to help control postoperative pain.