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Created May 21, 2015, last updated about 4 years ago.
Notes
The potential for dexamethasone and other glucocorticoids to prolong peripheral nerve blocks was first noted almost 20 years ago.
While the effect has been observed with several different blocks (upper & lower extremity, and even TAP blocks), the clinical significance varies and several questions still remain:
Is the effect exclusive to perineural dexamethasone? Several studies have observed similar effects for both IV and perineural dexamethasone (though less profound than other papers).
Is the effect safe? This is perhaps the most concerning, as there are suggestions that the effect may represent an enhancement of the well-known neurotoxicity of local anaesthetic agents.
Daniel Jolley
Knowledge, pearl, summary or comment to share?Collected Articles
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Review Meta Analysis
A systematic review and meta-analysis of perineural dexamethasone for peripheral nerve blocks.
Perineural dexamethasone may significantly increase the duration of analgesia after regional blockade, though without dose-response effect.
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Review Meta Analysis
Combination of dexamethasone and local anaesthetic solution in peripheral nerve blocks: A meta-analysis of randomised controlled trials.
Dexamethasone doubled the duration of postoperative analgesia after brachial plexus block, as well as speeding onset and reducing PONV.
pearl -
A cautionary summary of the benefits and potential risks of perineural dexamethasone.
"...there have been no reports of neurotoxicity or complications of any kind attributed to perineural dexamethasone in the nearly 700 patients who have received it in published studies of peripheral nerve blocks ... We must acknowledge that complications in regional anesthesia are rare, and 700 patients are woefully inadequate to declare dexamethasone safe for routine perineural use." (Noss 2014)
Noss concludes that:
- Perineural dexamethasone is probably safe, though conclusive safety evidence is still lacking.
- Systemic effects from IV dex is unlikely to explain the profound block prolongation.
- Prolongation is not enough on its own.
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Reg Anesth Pain Med · Mar 2015
Randomized Controlled Trial Comparative StudyIntravenous Dexamethasone and Perineural Dexamethasone Similarly Prolong the Duration of Analgesia After Supraclavicular Brachial Plexus Block: A Randomized, Triple-Arm, Double-Blind, Placebo-Controlled Trial.
Dexamethasone 8 mg has equal effect in prolonging single-shot supraclavicular block whether given perineurial or intravenously.
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Journal of anesthesia · Oct 2011
Randomized Controlled Trial Multicenter StudyAdjuvant dexamethasone with bupivacaine prolongs the duration of interscalene block: a prospective randomized trial.
Dexamethasone added to bupivacaine significantly prolongs the duration of interscalene analgesia and motor blockade.
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Randomized Controlled Trial
Dose-dependency of dexamethasone on the analgesic effect of interscalene block for arthroscopic shoulder surgery using ropivacaine 0.5%: A randomised controlled trial.
Dexamethasone shows a dose-dependent effect on speeding onset and increasing the duration of analgesia after interscalene block for shoulder surgery.
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Reg Anesth Pain Med · Jul 2015
Randomized Controlled TrialAddition of Dexamethasone and Buprenorphine to Bupivacaine Sciatic Nerve Block: A Randomized Controlled Trial.
Sciatic nerve block provides analgesia after foot and ankle surgery, but block duration may be insufficient. We hypothesized that perineural dexamethasone and buprenorphine would reduce pain scores at 24 hours. ⋯ Pain scores were very low at 24 hours after surgery in the context of multimodal analgesia and were not improved by additives. However, perineural buprenorphine and dexamethasone prolonged block duration, reduced the worst pain experienced, and reduced opioid use. Intravenous buprenorphine caused troubling nausea and vomiting. Future research is needed to confirm and extend these observations.
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Mixing of various adjuvants has been tried with local anesthetics in an attempt to prolong anesthesia from peripheral nerve blocks but have met with inconclusive success. More recent studies indicate that 8 mg dexamethasone added to perineural local anesthetic injections augment the duration of peripheral nerve block analgesia. ⋯ Addition of dexamethasone (8 mg) to ropivacaine in supraclavicular brachial plexus approach significantly and safely prolongs motor blockade and postoperative analgesia (sensory) that lasted much longer than that produced by local anesthetic alone.
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Review Meta Analysis
Perineural dexamethasone added to local anesthesia for brachial plexus block improves pain but delays block onset and motor blockade recovery.
Multiple studies have shown that perineural dexamethasone improves postoperative analgesia. However, some studies have shown minimal benefit, and have raised concerns regarding adverse physio-chemical effects of perineural dexamethasone. Furthermore, there is a paucity of studies wherein control (IV) dexamethasone was considered. ⋯ Perineural dexamethasone addition to local anesthetic solutions significantly improved postoperative pain in brachial plexus block without increasing complications. However, perineural adjuvant dexamethasone delayed the onset of sensory and motor block, and prolonged the duration of motor block. Smaller doses of dexamethasone (4 - 5 mg) were as effective as higher doses (8 - 10 mg).
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Randomized Controlled Trial
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.
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. ⋯ 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.
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Anesthesia and analgesia · May 2014
Randomized Controlled TrialThe Effects of Perineural Versus Intravenous Dexamethasone on Sciatic Nerve Blockade Outcomes: A Randomized, Double-Blind, Placebo-Controlled Study.
Neither IV or perineural dexamethasone as part of a sciatic nerve block improved the quality of surgical recovery, but did prolong block duration.
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Randomized Controlled Trial Comparative Study
A randomised controlled trial of perineural vs intravenous dexamethasone for foot surgery.
We used 20 ml ropivacaine 0.75% for ankle blocks before foot surgery in 90 participants who we allocated in equal numbers to: perineural dexamethasone 8 mg and intravenous saline 0.9%; perineural saline 0.9% and intravenous dexamethasone 8 mg; or perineural and intravenous saline 0.9%. Dexamethasone increased the median (IQR [range]) time for the return of some sensation or movement, from 14.6 (10.8-18.8 [5.5-38.0]) h with saline to 24.1 (19.3-29.3 [5.0-44.0]) h when given perineurally, p = 0.00098, and to 20.9 (18.3-27.8 [8.8-31.3]) h when given intravenously, p = 0.0067. ⋯ Dexamethasone did not affect the rates of block success, postoperative pain scores, analgesic use, or nausea and vomiting. The route of dexamethasone administration did not alter its effects.
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Cochrane Db Syst Rev · Nov 2017
Review Meta AnalysisDexamethasone as an adjuvant to peripheral nerve block.
Peripheral nerve block (infiltration of local anaesthetic around a nerve) is used for anaesthesia or analgesia. A limitation to its use for postoperative analgesia is that the analgesic effect lasts only a few hours, after which moderate to severe pain at the surgical site may result in the need for alternative analgesic therapy. Several adjuvants have been used to prolong the analgesic duration of peripheral nerve block, including perineural or intravenous dexamethasone. ⋯ Low- to moderate-quality evidence suggests that when used as an adjuvant to peripheral nerve block in upper limb surgery, both perineural and intravenous dexamethasone may prolong duration of sensory block and are effective in reducing postoperative pain intensity and opioid consumption. There is not enough evidence to determine the effectiveness of dexamethasone as an adjuvant to peripheral nerve block in lower limb surgeries and there is no evidence in children. The results of our review may not apply to participants at risk of dexamethasone-related adverse events for whom clinical trials would probably be unsafe.There is not enough evidence to determine the effectiveness of dexamethasone as an adjuvant to peripheral nerve block in lower limb surgeries and there is no evidence in children. The results of our review may not be apply to participants who at risk of dexamethasone-related adverse events for whom clinical trials would probably be unsafe. The nine ongoing trials registered at ClinicalTrials.gov may change the results of this review.
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Reg Anesth Pain Med · Oct 2018
Randomized Controlled Trial Comparative StudyPerineural Versus Systemic Dexamethasone in Front-Foot Surgery Under Ankle Block: A Randomized Double-Blind Study.
Among the different adjuvants, dexamethasone is one of the most accepted to prolong the effect of local anesthetics. This study aims to determine the superiority of perineural over systemic dexamethasone administration after a single-shot ankle block in metatarsal osteotomy. ⋯ This study was registered at ClinicalTrials.gov, identifier NCT02904538.