31.9.34 Comparison of Intravenous Dexamethasone Adjunctive to Bupivacaine with Perineural Dexamethasone Adjunctive to Bupivacaine in Ultra Sound Guided Interscelene Brachial Plexus Block

Original Article

 

IV  Dexamethasone with  Perineural Dexamethasone  Adjunctive to Bupivacaine

Comparison of Intravenous Dexamethasone Adjunctive to Bupivacaine with Perineural Dexamethasone Adjunctive to Bupivacaine in Ultra Sound Guided Interscelene Brachial Plexus Block

Asif Nadeem1 and Muhammad Muazzam Butt2

ABSTRACT

Objective: To compare intravenous dexamethasone with perineural dexamethasone as adjunctive in bupivacaine  in ultrasound guided interscelene block.

Study Design: Randomized control trial study.

Place and Duration of Study: This study was conducted at the Operation theatres of Sahara Medical College from 01-08-2019 to 01-06-2020.

Materials and Methods: In randomized control trial 135 patients divided in Group X,Y,Z and received bupivacaine, intravenous Dexamethasone 0.25 mg/kg, perineural dexamethasone 0.15mg/kg as adjunctive in interscelene block.

Results: Mean onset of sensory block in minutes was 9.17+1.34, 9.48+1.42 and 8.3+1.01 consecutively in groups X, Y and Z. Time to onset of sensory block was lowest in group Z and highest in group X with significant level of 0.001. Onset of motor block in minutes 10.4+1.03, 10.28+1.19, 9.31+0.96 consecutively in groups X, Y and Z. Time of onset of  motor block was significantly low in group Z and highest in group X with significance level of 0.001. Mean time of analgesia in minutes was 820.08+64.01, 901.96+48.01, 972+27.8 consecutively in groups X, Y and Z. Time of analgesia was highest in group Z and was lowest in group X with significance level of 0.001.

Conclusion: Higher doses of I/V dexamethasone can prolong analgesia and shorten onset of motor and sensory block when compared with bupivacaine alone but not superior to perineural dexamethasone in conjunction with bupivacaine in interscelene block.

Key Words: Dexmethasone intravenous, Bupivacaine, interscelene block

Citation of article: Nadeem A, Butt MM. Comparison of Intravenous Dexamethasone Adjunctive to Bupivacaine with Perineural Dexamethasone Adjunctive to Bupivacaine in Ultra Sound Guided Interscelene Brachial Plexus Block. Med Forum 2020;31(9):146-150.

 

 

INTRODUCTION

In recent decades practice of general anesthesia for upper extremity surgery had been shifted to peripheral nerve blocks. Regional anesthesia is better in many aspects from general anesthesia like   lesser PONV, shivering, sore throat, cough, DVT, Bleeding and better analgesia, cognitive recovery.1 Interestingly peripheral nerve blocks are not absolute risk free, they
can be complicated like nerve injuries, local anesthesia

 

 

1. Department of Anaesthesia, Sahara Medical College, Kasur.

1. Department of Anaesthesia, PGMI/PINS/LGH, Lahore.

 

 

Correspondence: Dr Asif Nadeem, Assistant Professor of Anaesthesia, Sahara Medical College, Lahore.

Contact No: 0321-4090243

Email: drasifnadeem@yahoo.com

 

 

Received:    July, 2020

Accepted:    August, 2020

Printed:        September, 2020

 

 

 

toxicity, patient discomfort, total spinal, horner syndrome, pneumothorax etc.2

Interscelene block is preferably used for shoulder and upper 2/3 of arm for number of procedures varying from fracture, tendon repair, debridements to dislocations.3 perineural dexamethasone significantly prolongs postoperative analgesia in brachial plexus block.4,5

When Chong MA compared intravenous dexamethasone with perineural dexamethasone in brachial plexuses block he advocated significant prolongation in perineural dexamethasone group 6,7,8. On the other hand Rony M advocated that both intravenous and perineural dexamethasone as adjunctive to bupivacaine equally prolonged the analgesia.9 David H and others admits the fact that perineural dexamethasone has pronged analgesia but at the same time they points the under dose of intravenous dexamethasone and suggested further studies especially with higher doses.10

For further clarification in the Data and still no clear outcome we suggested a higher dose of intravenous dexamethasone (0.25mg/kg) and compared with perineural dexamethasone(0.15mg/Kg)

MATERIALS AND METHODS

This double blind randomized control trial study was conducted at the Operation theatres of Sahara Medical College from 01-08-2019 to 01-06-2020.

Sample size and technique: total number of 135 patients included in the study and randomly divided into three groups, Group X  (45 patients) received only bupivacaine 2mg/kg, Group Y (45 patients) received intravenous Dexamethasone 0.25 mg/kg as adjunctive, Group Z (45 patients) received perineural dexamethasone 0.15mg/kg as adjunctive in interscelene block.

Primary outcome: duration of analgesia, time in minutes from start of the surgery till the demand of rescue analgesia by the patient verified by VAS >5

Secondary outcome:

Onset of sensorial block, time in minutes from performance of block to no feel of pinprick

Onset of motor block, time in minutes from performance of block to no movement of forearm.

Side effects

Blood pressure measured by NIBP monitor and considered raised when >140/90 mmHg or increase of 25 from base line

BSF measured with gluco meter and considered raised >110

Inclusion criteria

·         Age between 20-60 years

·         Both sex

·         ASA 1,2

·         Elective procedures of shoulder and upper 2/3 of arm

Exclusion criteria

·         Patient refusal

·         Bleeding disorder

·         Preexisting neurological deficit of surgical limb

·         Infection of injection site

·         Carotid artery aneurysm

Data collection procedure: After ethical committee permission and informed consent from patients 135 patients included in the study randomly divided into 3 groups by slips in box,Group X  (45 patients) received only bupivacaine 2mg/kg, Group Y (45 patients) received intravenous Dexamethasone 0.25 mg/kg as adjunctive, Group Z (45 patients) received perineural dexamethasone 0.15mg/kg as adjunctive in interscelene block. Ultrasound Interscelene blocks performed by experienced anesthetists who were blind to the group of patients under strict antiseptic measures. Monitoring according to standard 1, standard 2 continued.  Time to onset of sensory block, motor block and total duration of analgesia recoded in performa. BSR monitored once at 30 minutes after the block performed and entered in performa. Three consective reading of increased Blood pressure with interval of 3 minutes considered was raised.

Data analysis procedure: Data collected in Performa was entered into SPSS Version 16. Descriptive statistics calculated for quantitative data like age, onset of sensory and motor block, time of analgesia presented as mean and standard deviation. Frequency of gender distribution was elaborated in all groups. ANNOVA test was done to determine significance between different variables

RESULTS

Total 135 patients randomly and equally divided into three groups X, Y and Z, 45 patients in each group. Gender distribution of females was 18, 12, 15 and of males was 27, 33, 30, in X, Y, Z groups consecutively. Mean age was 40.2+ 10.63, 39.22+8.90 and 40.73+9.93  years in groups X,Y and Z consecutively. Mean onset of sensory block in minutes was 9.17+1.34, 9.48+1.42 and 8.3+1.01 consecutively in groups X, Y and Z. Time to onset of sensory block was lowest in group Z and highest in group X with significant level of 0.001. Onset of motor block in minutes 10.4+1.03, 10.28+1.19, 9.31+0.96 consecutively in groups X, Y and Z. Time of onset of  motor block was significantly low in group Z and highest in group X with significance level of 0.001. Mean time of analgesia in minutes was 820.08+64.01, 901.96+48.01, 972+27.8 consecutively in groups X, Y and Z. Time of analgesia was highest in group Z and was lowest in group X with significance level of 0.001. Increase in blood pressure was noticed significantly higher in group Y when compared with group X, Y with significance level of 0.001. Mean blood sugar fasting was 89.09+6.57, 94.6+7.73, 88.8+5.72 mg/dl was significantly higher in group Y when compared with group X and Z with significance level of 0.001.

Figure No.1: Comparison

 

Figure No.2: Comparison

Figure No.3: Comparison

 

 

 

Table No.1: Descriptives

 

 

N

Mean

Std. Deviation

Std. Error

95% Confidence Interval for Mean

Min.

Max.

Lower Bound

Upper Bound

onset of sensory block in minutes

group x

45

9.1733

1.33866

.19956

8.7712

9.5755

7.00

13.00

group Y

45

9.4844

1.42270

.21208

9.0570

9.9119

7.00

14.00

group Z

45

8.3000

1.00792

.15025

7.9972

8.6028

7.00

10.50

Total

135

8.9859

1.35642

.11674

8.7550

9.2168

7.00

14.00

onset of motor block in minutes

group x

45

10.4000

1.02580

.15292

10.0918

10.7082

9.00

13.00

group Y

45

10.2778

1.18971

.17735

9.9204

10.6352

8.00

13.00

group Z

45

9.3111

.95518

.14239

9.0241

9.5981

7.00

11.00

Total

135

9.9963

1.16141

.09996

9.7986

10.1940

7.00

13.00

time of analgesia in minutes

group x

45

8.2009E2

64.00313

9.54102

800.8602

839.3176

703.00

944.00

group Y

45

9.0196E2

48.01418

7.15753

887.5305

916.3806

810.00

981.00

group Z

45

9.7276E2

27.80546

4.14499

964.4019

981.1092

930.00

1035.00

Total

135

8.9827E2

79.22311

6.81844

884.7810

911.7524

703.00

1035.00

increase in blood pressure

group x

45

2.0222

.14907

.02222

1.9774

2.0670

2.00

3.00

group Y

45

2.0667

.25226

.03761

1.9909

2.1425

2.00

3.00

group Z

45

2.0222

.14907

.02222

1.9774

2.0670

2.00

3.00

Total

135

2.0370

.18956

.01631

2.0048

2.0693

2.00

3.00

blood sugar fasting

group x

45

89.0889

6.57413

.98001

87.1138

91.0640

74.00

103.00

group Y

45

94.6000

7.73540

1.15312

92.2760

96.9240

79.00

122.00

group Z

45

88.8000

5.72713

.85375

87.0794

90.5206

77.00

101.00

Total

135

90.8296

7.19612

.61934

89.6047

92.0546

74.00

122.00

 

 

 

 

 

 

Table No.2: ANOVA

 

 

Sum of Squares

df

Mean Square

F

Sig.

onset of sensory block in minutes

Between Groups

33.936

2

16.968

10.535

.000

Within Groups

212.607

132

1.611

 

 

Total

246.543

134

 

 

 

onset of motor block in minutes

Between Groups

32.026

2

16.013

14.212

.000

Within Groups

148.722

132

1.127

 

 

Total

180.748

134

 

 

 

time of analgesia in minutes

Between Groups

525328.533

2

262664.267

109.826

.000

Within Groups

315695.867

132

2391.635

 

 

Total

841024.400

134

 

 

 

increase in blood pressure

Between Groups

.059

2

.030

.822

.442

Within Groups

4.756

132

.036

 

 

Total

4.815

134

 

 

 

blood sugar fasting

Between Groups

961.437

2

480.719

10.615

.000

Within Groups

5977.644

132

45.285

 

 

Total

6939.081

134

 

 

 

DISCUSSION

In our study we observed that dexamethasone intravenous in conjunction to bupivacaine can increase duration of analgesia and shortens the time of onset of sensory block and motor block when compared with bupivacaine alone but at the same time there are increased chances of raised blood pressure and blood sugar in interscelene block. When we compared perinueral dexamethasone in conjunction to bupivacaine with I/V dexamethasone in conjunction to bupivacaine there was significant prolongation of analgesia and less time to achieve sensory and motor block in interscelene block and significantly less side effects.

Rony M, advocated that both intravenous and perineural dexamethasone as adjunctive to bupivacaine equally prolonged the analgesia. in his study mean of analgesia time in minutes for perineural dexamethasone was 817.2 ± 88.011 in comparison to intravenous dexamethasone 858.00 ± 86.168,( P = 0.104). He also concluded that onset of sensory block and motor block was earlier in perineural dexamethasone group with P = 0.001, P = 0.02 consecutively. He did not observed any significant side effects.9 His sample size was of 50 patients which could be insufficient and inconclusive and required more studies to reveal the fact.

Abdallah FW, took 50 patients and concluded that intravenous dexamethasone is equipotent to perineural dexamethasone when given as conjunctive to long acting local anesthesia (P < 0.001)11

Eric D Bolin Sylvia Wilson also added confusion to literature by article in favour of both intravenous and perineural dexamethasone as conjunctive to local anesthesia for regional blocks.12

Desmet M et al. also concluded that I/V and perineural dexamethasone as conjunctive to ropivacaine equally increases analgesia time when compared to ropivacaine alone.p<0.0001,he used comparatively higher doses of dexamethasone 10 mg I/V as compare to earlier authors and reported that 10mg of dexamethsone was safe dose for single use.

Heesen M, et al in ten randomized controlled double blind trials with confidence level of 95% he analyzed that perineural dexamethasone is superior in analgesia when compared with intravenous dexamethasone for peripheral nerve blocks as conjunctive to local anesthetics.14

Matthew A conducted a meta-analysis to establish the fact whether perineural or I/V dexamethasone as adjunctive to local anesthesia prolong the duration of analgesia, they included 11 clinical trial in the meta analysis and reported that perineural dexamethasone increases the duration of analgesia by 3.37 hours when compared to I/V dexamethasone as adjuvant to local anesthesia.8

David H in a review article compared several meta-analysisto establish superiority of either intravenous dexamethasone or perineural dexamethasone in brachial plexuses block he advocated significant prolongation in perineural dexamethasone group, but at the same time they points the under dose of intravenous dexamethasone and suggested further studies especially with higher doses.10

We observed controversy in literature which made us to think for a new study with different interventions, as in all studies maximum dose of dexamethasone was used 10 mg, we used a higher dose to clear the objection of lower dose of dexamethasone, and we used 0.25mg/kg dexamethasone which was safe in single shot dose.15 In these higher doses no life threatening side effects observed and we observed prolongation of analgesia when compared to bupivacaine alone but there were mild to moderate increase in blood sugar and blood pressure, settled without any medical interventions.

In our study we were limited to use dexamethasone 0.25mg/kg due to maximum one shot safe range of dose was 0.30 mg/kg15, no doubt higher doses of I/V dexamethasone increased the duration of analgesia and further increase of dose may be prolonged duration of analgesia further but chance of side effects could be higher especially in diabetics and hypertensive patients. Although mechanism of dexamethasone as adjuvant to local anesthesia is unclear but we observed that its mechanism has more local effects than the systemic effects.16

CONCLUSION

In conclusion Higher doses of I/V dexamethasone can prolong analgesia and shorten onset of motor and sensory block when compared with bupivacaine alone but not superior to perineural dexamethasone in conjunction with bupivacaine in interscelene block.

Recommendation: We suggest the use of perineural dexamethasone as adjunctive to local anesthesia in peripheral nerve blocks as intravenous dexamethasone as adjuvant has no additional benefits.

Acknowledgement: We are thankful for all the participants who shared their knowledge and skill for our trial.

Author’s Contribution:

Concept & Design of Study:

Asif Nadeem

Drafting:

Muhammad Muazzam Butt

Data Analysis:

Muhammad Muazzam Butt

Revisiting Critically:

Asif Nadeem, Muhammad Muazzam Butt

Final Approval of version:

Asif Nadeem

Conflict of Interest: The study has no conflict of interest to declare by any author.

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