Dose-response relationship of perineural dexamethasone for interscalene brachial plexus block: a randomised, controlled, triple-blind trial.

Perineural dexamethasone has a ceiling dose of 4 mg for prolongation of analgesia duration after injection of long-acting local anaesthetic for peripheral nerve block, but evidence for doses < 4 mg is lacking. This randomised controlled triple-blind trial tested the hypothesis that increasing doses of perineural dexamethasone between 1 mg and 4 mg would prolong the duration of analgesia in a dose-dependent manner. Eighty ASA physical status 1-2 patients scheduled for shoulder arthroscopy under general anaesthesia with ultrasound-guided interscalene brachial plexus block were randomly allocated to receive saline (control), dexamethasone 1 mg, 2 mg, 3 mg and 4 mg, together with 20 ml ropivacaine 0.5%. Postoperative analgesia consisted of paracetamol, diclofenac and oxycodone on request, using a pre-defined protocol. The primary outcome was the duration of analgesia, defined as the time between the block procedure and the first analgesic request. Secondary outcomes included rest and dynamic pain scores, and analgesic consumption at 2 h, 24 h and 48 h postoperatively. An analysis of the dose-response relationship was performed using multiple comparison procedure-modelling. The median (IQR [range]) duration of analgesia was significantly prolonged in a dose-dependent manner: control 685 (590-860 [453-1272]) min; 1 mg 835 (740-1110 [450-1375]) min; 2 mg 904 (710-1130 [525-1365]) min; 3 mg 965 (875-1025 [730-1390]) min; 4 mg 1023 (838-1239 [518-1500]) min (p = 0.03). There were no significant differences between the secondary outcomes. Perineural administration of dexamethasone with doses between 1 mg and 4 mg, combined with ropivacaine for interscalene brachial plexus block, prolongs duration of analgesia in a dose-dependent manner.

A randomised controlled trial of intravenous dexamethasone combined with interscalene brachial plexus blockade for shoulder surgery.

We recruited patients scheduled for shoulder rotator cuff repair or subacromial decompression under general anaesthesia and interscalene brachial plexus blockade (30 ml ropivacaine 0.5%). We allocated 240 participants into four groups of 60 that were given pre-operative saline 0.9% or dexamethasone 1.25 mg, 2.5 mg or 10 mg, intravenously. We recorded outcomes for 48 h. The median (IQR [range]) time to first postoperative analgesic request after saline was 12.2 (11.0-14.1 [1.8-48]) h, which was extended by intravenous dexamethasone 2.5 mg and 10 mg to 17.4 (14.9-21.5 [7.2-48]) h, p < 0.0001, and 20.1 (17.2-24.3 [1.3-48]) h, p < 0.0001, respectively, but not by dexamethasone 1.25 mg, 14.0 (12.1-17.7 [2.1-48]) h, p = 0.05. Postoperative analgesia was given sooner after rotator cuff repair than subacromial decompression, hazard ratio (95% CI) 2.2 (1.6-3.0), p < 0.0001, but later in older participants, hazard ratio (95% CI) 0.98 (0.97-0.99) per year, p < 0.0001.

I.V. and perineural dexamethasone are equivalent in increasing the analgesic duration of a single-shot interscalene block with ropivacaine for shoulder surgery: a prospective, randomized, placebo-controlled study.

BACKGROUND: Interscalene brachial plexus block (ISB) provides excellent, but time-limited analgesia. Dexamethasone added to local anaesthetics prolongs the duration of a single-shot ISB. However, systemic glucocorticoids also improve postoperative analgesia. The hypothesis was tested that perineural and i.v. dexamethasone would have an equivalent effect on prolonging analgesic duration of an ISB. METHODS: We performed a prospective, double blind, randomized, placebo-controlled study. Patients presenting for arthroscopic shoulder surgery with an ISB were randomized into three groups: ropivacaine 0.5% (R); ropivacaine 0.5% and dexamethasone 10 mg (RD); and ropivacaine 0.5% with i.v. dexamethasone 10 mg (RDiv). The primary outcome was the duration of analgesia, defined as the time between performance of the block and the first analgesic request. Standard hypothesis tests (t-test, Mann-Whitney U-test) were used to compare treatment groups. The primary outcome was analysed by Kaplan-Meier survival analysis with a log-rank test and Cox's proportional hazards regression. RESULTS: One hundred and fifty patients were included after obtaining ethical committee approval and patient informed consent. The median time of a sensory block was equivalent for perineural and i.v. dexamethasone: 1405 min (IQR 1015-1710) and 1275 min (IQR 1095-2035) for RD and RDiv, respectively. There was a significant difference between the ropivacaine group: 757 min (IQR 635-910) and the dexamethasone groups (P<0.0001). CONCLUSIONS: I.V. dexamethasone is equivalent to perineural dexamethasone in prolonging the analgesic duration of a single-shot ISB with ropivacaine. As dexamethasone is not licensed for perineural use, clinicians should consider i.v. administration of dexamethasone to achieve an increased duration of ISB.

Epidural dextran 40 patch for postdural puncture headache.

We report a case where two consecutive blood patches failed to relieve postdural puncture headache and hearing loss following inadvertent dural puncture. Initial conservative therapy with analgesics, fluids and later two blood patches had no effect and the patient's symptoms only resolved after an epidural dextran 40 patch performed 8 weeks after the dural tap. Two months later, the patient is still asymptomatic.

Surgical analgesia for knee arthroscopy with epidural lignocaine and sufentanil--effect of varying sufentanil doses.

In a double blind trial the additional analgesic effect of the combination of epidural lignocaine 2% + epinephrine 1/200,000 with varying epidural Sufentanil doses was studied per- and postoperatively in patients undergoing arthroscopy of the knee. Fifty patients were randomly divided into five groups. They received epidural lignocaine 2% + epinephrine 1/200,000 in addition with respectively 0, 20, 30, 40 or 50 micrograms Sufentanil. There was no additional surgical analgesia when Sufentanil was added. On the other hand, at 40 and 50 micrograms of Sufentanil significantly more patients demonstrated respiratory depression and pronounced sedation during surgery as compared to lignocaine alone. Patients in these groups had better postoperative analgesia. In addition nausea, vomiting and pruritus were seen in some patients at all doses of Sufentanil.