Dexamethasone Added to Lidocaine Prolongs Axillary Brachial Plexus Blockade

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Dexamethasone Added to Lidocaine Prolongs
AxillaryBrachial Plexus Blockade

• (Anesthesia and Analgesia 20061022637)
• R2???

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Introduction

• Increasing the duration of local anesthetic
  action is often desirable because it prolongs
  surgical anesthesia and analgesia.
• Different additives have been used to prolong
  regional blockade. Ex Vasoconstrictors,
  Clonidine, systemic corticosteroids.

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Introduction

• Dexamethasone have been found to prolong the
  block duration in animal and human studies
• This placebo-controlled clinical trial evaluates
  the effect of dexamethasone added to lidocaine on
  the onset and duration of axillary brachial
  plexus block

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Methods

• 60 patients, ASA class I-II, aged 2050 yr
  scheduled for elective short to moderate (90 min)
  hand and forearm surgery under axillary brachial
  plexus block.
• peptic ulcer disease, DM, hepatic or renal
  failure, pregnant women, premedications
  (including opioids, benzodiazepines, and
  clonidine) were excluded from the study.

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Methods

• Patients were allocated into 2 groups computer
• control group (34 mL lidocaine 1.5 with 2 mL
  of normal saline)
• dexamethasone group (34 mL lidocaine 1.5 with
  2 mL of dexamethasone (8 mg)).
• All local anesthetic solutions and adjuvant drugs
  were prepared by an anesthesiologist not involved
  in the study.

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Methods

• In OR, standard monitoring was performed
• Premedication 1ug/kg IV fentanyl.
• Axillary block was performed with a nerve
  stimulator (Polymedic ), which used for precise
  localization of each nerve. (multiple
  stimulations technique).
• Increments of anesthetic mixture (8 mL/nerve in
  total) were injected the 4 nerves (median,
  radial, ulnar, and musculocutaneous) in each
  patient
• Remaining 4 mL was injected the
  intercosto-brachial nerve

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Methods

• Sensory and motor blockade of 4 nerves were
  recorded after 5, 15, and 30 min and every 10 min
  after the end of the surgery
• Sensory blockade was assessed by pinprick and
  compared with contralateral hand. 100 (normal
  sensations) to 0 (no sensation).
• Motor blockade was evaluated by thumb abduction
  (radial nerve), thumb adduction (ulnar nerve),
  flexion of the elbow in supination and pronation
  of the forearm (musculocutaneous), and thumb
  opposition (median nerve)

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Methods

• The onset time (sensory and motor blockade)
  defined as the time between the end of last
  injection and the total abolition of the pinprick
  response and complete paralysis in all of the
  nerve distributions.
• The duration of sensory block was considered as
  the time interval between the administration of
  the local anesthetic and the first postoperative
  pain
• The duration of motor block was defined as the
  time interval between the local anesthetic
  administration and complete recovery of motor
  functions

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Results
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Results

• Onset time of sensory and motor blockade no
  significant difference dexamethasone group and
  control group.
• sensory dexamethasone group 145min
• control group 114 min
• motor dexamethasone group 267 min
• control group 228 min

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Results

• Duration of sensory and motor blockade
  significant longer in the dexamethasone group.
• sensorydexamethasone group 24276min
• control group 9833 min
• motor dexamethasone group 31081min
• control group 13031min

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Results
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Discussion

• Duration of axillary brachial plexus block with
  lidocaine (9833min and 13031min for sensory and
  motor blockade) is moderately shorter than other
  works
• Adnan T, Elif AA, Ayshe K, et al. Clonidine as an
  adjuvant for lidocaine in axillary brachial
  plexus block in patients with chronic renal
  failure. Acta Anesthesiol Scand 20054956368.
• Duration of sensory block 16443 min
• Duration of motor block 15549 min

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Discussion

• The 21 incidence of failure may be frequent
• Adnan T, Elif AA, Ayshe K, et al. Clonidine as an
  adjuvant for lidocaine in axillary brachial
  plexus block in patients with chronic renal
  failure. Acta Anesthesiol Scand 20054956368.
• Dunlop DJ, Graham CM, Watt JM. The practical use
  of axillary brachial plexus block for hand
  surgery. J Hand Surg 199520 6778.
• Iohom J, Machmachi A, Diarra D. The effects of
  clonidine added to mepivacaine for paronychia
  surgery under axillary brachial plexus block.
  Anesth Analg 2005100117983

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Discussion

• In one study, a prolonged percutaneous blockade
  of sciatic nerve in rat using bupivacaine-dexameth
  asone microspheres was demonstrated
• Castillo J, Curley J, Hotz J, et al.
  Glucocorticoids prolong rat sciatic nerve
  blockade in vivo from bupivacaine microspheres.
  Anesthesiology 199685115766.
• Dexamethasone could act directly on the nerve via
  glucocorticoid receptors, altering the
  functioning of ion channel, thereby reducing the
  bupivacaine concentration required to produce
  conduction failure

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Discussion

• In another study, incorporation of dexamethasone
  into bupivacaine microspheres significantly
  prolonged intercostal nerve block in sheep
• Droger C, Benziger D, Gao F, Berde CB. Prolonged
  intercostals nerve blockade in sheep using
  controlled-release of bupivacaine and
  dexamethasone from polymer microspheres.
  Anesthesiology 19988996974.
• Dexamethasone can suppress inflammatory process.
• In the presence of inflammation, the axonal
  conduction and impulse-generating properties may
  be altered and higher intraneural bupivacaine
  concentrations may be required to produce
  blockade.

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Discussion

• It has been reported that the intercostal
  injection of dexamethasone containing bupivacaine
  microcapsules produces a prolonged duration of
  anesthesia and analgesia in healthy volunteers.
• Kopacz DJ, Lacouture PG, Wu D, et al. The dose
  response and effects of dexamethasone on
  bupivacaine microcapsules for intercostals
  blockade (T9 to T11) in healthy volunteers.
  Anesth Analg 20039657682.

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Discussion

• Some authors believe that analgesic properties of
  corticosteroids are the result of their systemic
  effect.
• Unfortunately, a control group receiving
  parenteral administration of the same dose of
  dexamethasone was not considered when this study
  was designed.
• Local effect gt systemic effect

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Discussion

• The safety of dexamethasone use in a nerve sheath
  may raise some concerns.
• Previous studies have demonstrated that
  short-term (24 hours) use of dexamethasone was
  safe
• Administration of this dose (8mg dexamthasone)
  seems to be safe in adults
• Nerve injury is a rare complication of
  dexamethasone injection, and it usually occurs in
  the context of needle trauma

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Discussion

• Steroid-local anesthetic solution may not be
  indicated for all patients.
• Diabetic patients may experience hyperglycemia
• Patients with a continuing infectious process may
  be detrimentally affected by the antiinflammatory
  effects of steroids

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Discussion

• In our center, lidocaine is routinely used for
  regional block procedures, which is why we chose
  lidocaine for this study.
• Considering cardiovascular toxicity, lidocaine is
  safer than bupivacaine.

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Conclusion

• In conclusion, the addition of dexamethasone to
  lidocaine 1.5 solution in axillary brachial
  plexus block prolongs the duration of sensory and
  motor blockade

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Thanks for your attention