Dexamethasone with bupivacaine increases duration of analgesia in ultrasound-guided interscalene brachial plexus blockade.

BACKGROUND AND OBJECTIVE: Dexamethasone has been shown to prolong the duration of postoperative analgesia when given as an adjunct for peripheral nerve blocks. However, it has not been evaluated when given in conjunction with bupivacaine and clonidine to provide blockade of the brachial plexus at the interscalene level. The purpose of this investigation was to determine whether the addition of dexamethasone to interscalene brachial plexus block would prolong the duration of sensory analgesia in a group of patients undergoing outpatient shoulder arthroscopy. METHODS: This prospective, randomized, double-blind investigation was performed on 88 individuals undergoing shoulder arthroscopy. Patients received interscalene brachial plexus block using 20 ml of bupivacaine 5 mg ml(-1) with 1: 200,000 epinephrine and clonidine 75 microg. Patients were randomly assigned to receive either dexamethasone 8 mg or 0.9% NaCl as an adjuvant to the mixture. After discharge, patients recorded pain scores and analgesic consumption in a diary and estimated the time at which they perceived that the sensory block from the interscalene brachial plexus block resolved. This was based on pain, recovery of sensation and strength in the arm. Variables measured included demographics, timed pain intensity measurements, postoperative analgesic consumption, duration of analgesia and patient satisfaction. RESULTS: Dexamethasone prolonged median sensory (1457 vs. 833 min, P < 0.0001) and motor (1374 vs. 827 min, P < 0.0001) blockade compared with the control. At 24 h, the dexamethasone group had lower median verbal analogue scale scores compared with control (3.0 vs. 6.0). At 48 h, the two groups had similar median pain scores (4.0 vs. 5.0, dexamethasone vs. control, respectively). The opioid requirement in oxycodone equivalency was lower in the dexamethasone group than in the control group for the first 24 h, and similar thereafter. Median patient satisfaction scores were not significantly different between the two groups at 48 h (9.5 vs. 8.0, dexamethasone vs. control, respectively). CONCLUSION: The addition of dexamethasone to a bupivacaine-epinephrine-clonidine interscalene block prolongs sensory block and reduces opioid use.

Best practice recommendations for anesthetic perioperative care and pain management in weight loss surgery.

OBJECTIVE: To develop evidence-based recommendations that optimize the safety and efficacy of perioperative anesthetic care and pain management in weight loss surgery (WLS) patients. RESEARCH METHODS AND PROCEDURES: This Task Group examined the scientific literature on anesthetic perioperative care and pain management published in MEDLINE from January 1994 to March 2004. We also reviewed additional data from other sources (e.g., book chapters). The search yielded 195 abstracts, of which 35 references were reviewed in detail. Task Group consensus was used to provide recommendations when evidence in the literature was insufficient. RESULTS: We developed anesthesia practice and patient safety advisory recommendations for preoperative evaluation, intraoperative management, and postoperative care and pain management of WLS patients. We also provided suggestions related to medical error reduction and systems improvements, credentialing, and future research. DISCUSSION: Obesity-related comorbidities including obstructive sleep apnea place WLS patients at increased risk for complications perioperatively. Regarding perioperative safety and outcomes, conclusive evidence beyond the accepted standard of care in the reviewed literature is limited. Few reports specifically address the perioperative needs of severely obese patients. In this advisory, we synthesize current knowledge and make best practice recommendations for perioperative care and pain management in WLS patients. These recommendations require periodic review as further medical knowledge and evidence evolve.