Dexamethasone is the most effective adjuvant for prolonging local anaesthetic infiltration, likely superior to dexmedetomidine, clonidine, NSAIDs, opioids and magnesium.

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• Ann-Kristin Schubert, Thomas Wiesmann, Hinnerk Wulf, Jan Daniel Alexander Obert, Leopold Eberhart, Thomas Volk, and Hanns-Christian Dinges.
• Department of Anaesthesiology and Intensive Care Medicine, University Hospital Marburg, Philipps University of Marburg, Germany. Electronic address: aschub@med.uni-marburg.de.
• J Clin Anesth. 2024 Oct 1; 97: 111531111531.

BackgroundLocal infiltration analgesia is commonly used for postoperative pain control after several surgical procedures including intra- and peri-articular as well as wound infiltration. Even though, various adjuvants injected with the local anesthetic have been studied in pairwise comparison or compared to peripheral nerve blocks, the question which adjuvant or combination of adjuvants is the most effective in prolonging the duration of different types of local infiltration analgesia (LIA) has not been answered conclusively.ObjectiveThe objective of this network meta-analysis was to determine the analgesic effectiveness and safety of adjuvants in local infiltration analgesia.DesignSystematic review of randomized controlled trials with network meta-analyses.Data SourcesA comprehensive literature search in Embase, CENTRAL, MEDLINE and Web of Science was performed up to March 2023.ResultsThe best interventions to prolong the duration of analgesia were dexamethasone (Ratio of Means (ROM) 3.33) followed by the combinations of clonidine + morphine (ROM 3.35) and morphine + magnesium sulfate (ROM 2.92), fentanyl (ROM 2.27), ketorolac (ROM 2.26), buprenorphine (ROM 2.04), morphine (ROM 1.93), magnesium sulfate (ROM 1.91), clonidine (ROM 1.89), dexmedetomidine (ROM 1.74) and tramadol (ROM 1.58). Serious adverse events were not reported with either investigated adjuvant.ConclusionThere is moderate evidence that dexamethasone is the most effective adjuvant to prolong the duration of analgesia in LIA. The evidence for the alpha-2 agonists dexmedetomidine and clonidine is also moderate, but their effectivity to prolong analgesia stays behind dexamethasone. Clonidine and dexmedetomidine had a small detectable effect on pain scores, yet below clinical relevance, but the largest effect on MEQ consumption. The effects of different opioids were homogenous for all endpoints. The prespecified subgroup analysis of LIA of the knee did not show significantly different results than the pooled analysis.Study RegistrationPROSPERO 2020 CRD42020176154 (28.04.2020).Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.

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