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pearl
1
Adjuvant perineural dexamethasone (4-10 mg) prolongs brachial plexus sensory and motor blockade by between 65% and 100% longer.
Choi S, Rodseth R, McCartney CJ. Effects of dexamethasone as a local anaesthetic adjuvant for brachial plexus block: a systematic review and meta-analysis of randomized trials. Br J Anaesth. 2014 Mar 1; 112 (3): 427-39.
  Daniel Jolley
pearl
1
Peri-operative nicotine very slightly reduces opioid consumption in non-smokers but not pain scores — and increases the incidence of post-op nausea.
Mishriky BM Habib AS. Nicotine for Postoperative Analgesia: A Systematic Review and Meta-Analysis. Anesth. Analg. 2014 Aug 1; 119 (2): 268-75.
  Daniel Jolley
pearl
1
Neither speed of onset or duration of Labat sciatic block is influenced by volume or LA concentration when the total dose of mepivacaine is constant.
Cappelleri G, Ambrosoli AL, Turconi S et al. Effect of Local Anesthetic Dilution on the Onset Time and Duration of Double-Injection Sciatic Nerve Block: A Prospective, Randomized, Blinded Evaluation. Anesth. Analg. 2014 Aug 1;119(2):489-93.
  Daniel Jolley
pearl
1
Intra-operative use of remifentanil may have a dose-response effect on inducing hyperalgesia and consequentially increasing post-operative pain.
Fletcher D Martinez V. Opioid-induced hyperalgesia in patients after surgery: a systematic review and a meta-analysis. Br J Anaesth. 2014 Jun 1; 112 (6): 991-1004.
  Daniel Jolley
pearl
1
Intrathecal clonidine slightly improves the analgesic effects of intrathecal morphine, though increases hypotension (harm ratio 1.8).
Engelman E Marsala C. Efficacy of adding clonidine to intrathecal morphine in acute postoperative pain: meta-analysis. Br J Anaesth. 2013 Jan 1;110(1):21-7.
  Daniel Jolley
pearl
0
Intraoperative dexamethasone is not associated with wound infection or delayed healing, but does increase post-operative blood glucose levels.
Waldron NH, Jones CA, Gan TJ et al. Impact of perioperative dexamethasone on postoperative analgesia and side-effects: systematic review and meta-analysis. Br J Anaesth. 2013 Feb 1; 110 (2): 191-200.
  Daniel Jolley
pearl
1
Intraoperative dexamethasone produces a small, though clinically insignificant post-operative analgesic benefit.
Waldron NH, Jones CA, Gan TJ et al. Impact of perioperative dexamethasone on postoperative analgesia and side-effects: systematic review and meta-analysis. Br J Anaesth. 2013 Feb 1; 110 (2): 191-200.
  Daniel Jolley
summary
0
The incidence of systemic local anesthetic toxicity showed different risk profiles at different injection sites. In order of decreasing incidence of systemic toxicity events:
1. Paravertebral – OR 3.62 [95% CI, 1.33–7.86]
2. Upper limb — OR 1.75 [95% CI, 0.93–2.99]
3. Lower limb — OR 0.24 [95% CI, 0.05–0.71]
4. Trunk — 0.00 [95% CI, 0–0.94]
Of the 25,336 peripheral nerve blocks in the study, there were only 22 episodes of local anesthetic toxicity. 12 events occurred in the 20,401 PNBs performed with ultrasound guidance and 10 events in the 4,745 blocks performed without ultrasound.
Barrington MJ Kluger R. Ultrasound guidance reduces the risk of local anesthetic systemic toxicity following peripheral nerve blockade. Reg Anesth Pain Med. 2013 Jul 1; 38 (4): 289-99.
  Daniel Jolley
pearl
1
The use of ultrasound for peripheral nerve blockade reduces the incidence of systemic local anesthetic toxicity by at least 65%, possibly 80%.
Barrington MJ Kluger R. Ultrasound guidance reduces the risk of local anesthetic systemic toxicity following peripheral nerve blockade. Reg Anesth Pain Med. 2013 Jul 1; 38 (4): 289-99.
  Daniel Jolley
comment
1
Important to note that the 9 studies included for meta-analysis (524 patients in total) were quite heterogenous: 7 performed under spinal anaesthesia and 2 under general; TAP performed using anatomical landmarks in 3 and ultrasound in 6; spinals used various doses of fentanyl and/or morphine; and the TAP blocks used ropivacaine (4), bupivacaine (4) or levobupivacaine (1). Post-operative analgesic regimes also varied.
Thus these findings should be cautiously applied to your local setting.
Mishriky BM, George RB, Habib AS. Transversus abdominis plane block for analgesia after Cesarean delivery: a systematic review and meta-analysis. Can J Anaesth. 2012 Aug 1; 59 (8): 766-78.
  Daniel Jolley