Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 9  |  Issue : 3  |  Page : 422-425

Dexamethasone added to levobupivacaine prolongs ultrasound-guided interscalene brachial plexus blockade: a prospective, randomized, controlled study


Assistant Professor of Anesthesia and ICU, Faculty of Medicine, Benha University, Elharam, Giza, Egypt

Date of Submission15-Aug-2015
Date of Acceptance06-Nov-2015
Date of Web Publication31-Aug-2016

Correspondence Address:
Ahmed M Abd El-Hamid
Department of Anesthesia and ICU, Faculty of Medicine, Benha University, 20 Ezz Eldin Omar St., Elharam, Giza
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1687-7934.189099

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  Abstract 

Objectives
This study aimed to evaluate the effect of the addition of dexamethasone to levobupivacaine on the duration of analgesia in forearm surgeries under ultrasound-guided interscalene brachial plexus block.
Patients and methods
This prospective randomized controlled, double-blind clinical trial was conducted on 60 patients who underwent elective forearm surgeries under ultrasound-guided interscalene brachial plexus block. Patients in the levobupivacaine group (group L) received 25 ml of 0.5% levobupivacaine plus 2 ml of normal saline 0.9%. Patients in the levobupivacaine dexamethasone group (group LD) received 25 ml of 0.5% levobupivacaine plus 2 ml of dexamethasone (8 mg). The onset of sensory and motor block, duration of the sensory block, time to first analgesic request, the number of failed block, total morphine consumption, side effects, and complications were recorded and compared.
Results
Onset of sensory block and motor block was significantly earlier in group LD compared with group L. Duration of sensory block and time to first analgesic request were significantly longer in group LD compared with group L. Total morphine consumption was significantly lower in group LD in comparison with group L. The number of failed blocks was nonsignificantly lower in group LD. The incidence of side effects and complications was low and comparable in both groups.
Conclusion
Addition of dexamethasone to levobupivacaine significantly shortens the onset of sensory and motor block, prolongs the duration of analgesia, decreases the 24 h morphine consumption, and prolongs the time to first analgesic request with minimal side effects.

Keywords: dexamethasone, interscalene brachial plexus block, levobupivacaine


How to cite this article:
Abd El-Hamid AM, Alrabiey MA. Dexamethasone added to levobupivacaine prolongs ultrasound-guided interscalene brachial plexus blockade: a prospective, randomized, controlled study. Ain-Shams J Anaesthesiol 2016;9:422-5

How to cite this URL:
Abd El-Hamid AM, Alrabiey MA. Dexamethasone added to levobupivacaine prolongs ultrasound-guided interscalene brachial plexus blockade: a prospective, randomized, controlled study. Ain-Shams J Anaesthesiol [serial online] 2016 [cited 2021 Oct 22];9:422-5. Available from: http://www.asja.eg.net/text.asp?2016/9/3/422/189572


  Introduction Top


Interscalene block (ISB) provides excellent but time-limited anesthesia and analgesia for shoulder surgery [1],[2]. Various adjuvants have been used to prolong the block duration of local anesthetics [3]. Corticosteroid adjuvants have been found to prolong the block duration when added to local anesthetics [4],[5]. However, its mechanism of action is not clearly understood. It may have a local effect on the nerve [6], or it may have an anti-inflammatory action [7]; they may alter the function of potassium channels in the excitable cells through glucocorticoid receptors [8]. Dexamethasone prolongs the effect of peripheral nerve block when added to local anesthetics [9]. We aimed to evaluate the effect of mixing dexamethasone with levobupivacaine on the duration of analgesia provided by means of ISB.


  Patients and methods Top


This study was conducted in Benha University Hospitals between September 2014 and April 2015 after local ethical committee approval and written informed consent from patients were obtained. This prospective, randomized, controlled, double-blind clinical trial was conducted on 60 patients of ASA physical status I and II between 18 and 65 years of age who underwent elective forearm surgeries under ultrasound-guided interscalene (ISB) brachial plexus block. They were randomly allocated using computer-generated randomization program into two equal groups:

Group L (the control group), for which 25 ml of 0.5% levobupivacaine plus 2 ml of normal saline 0.9% were used for ISB.

Group LD, for which 25 ml of 0.5% levobupivacaine plus 2 ml of dexamethasone (8 mg) were used for ISB.

Sealed envelopes containing group allocation were opened before the blocks were performed.

Exclusion criteria were as follows: patient refusal, known allergy to the local anesthetic, coagulopathy, local infection, having peripheral neuropathy, being uncooperative, and BMI greater than 35 kg/m2.

On arrival to the operation theater, an intravenous cannula was inserted, and oxygen was administered at the rate of 2–4 l/min through nasal prongs. Oxygen saturation (SpO2), noninvasive blood pressure, heart rate, and ECG were monitored. Patients had received intravenous midazolam (0.05 mg/kg) before the block was administered.

Under complete aseptic condition, patients were positioned in the semilateral position with the neck extended. After skin infiltration with lidocaine 1%, a 5 cm 22-G insulated needle was inserted in-line with the ultrasound probe (2–13 MHz) in the transverse plane using a Philips HD11 XE ultrasound machine (Philips Medical Systems, Bothell, Washington, USA). The nerve roots were identified between the anterior and the middle scalene muscles. The local anesthetic was then injected.

After the end of the procedure, patients were monitored at every 5 min interval until 30 min for the development of sensory and motor block.

The measured parameters included the onset of the sensory block (the time from the end of ISB procedure until complete loss of sensation using the pin prick test), duration of the sensory block [the time from maximum sensory block until a visual analogue scale (VAS) score of ≥4], the motor blockade recorded according to the modified Bromage scale (0 = no paralysis, 1 = wrist flexion, 2 = elbow flexion, 3 = complete block), the duration of the motor blockade (the time from the end of ISB procedure until the time when no motor weakness could be detected), time to first analgesic request (the time from maximum sensory block until the patient's first analgesic request), and number of failed block (block was considered failed when sensory anesthesia was not achieved within 30 min).

Any side effects such as Horner's syndrome, ipsilateral diaphragmatic paralysis, difficulty in swallowing, hoarseness of voice, or any complications such as pneumothorax, vascular or nerve injury, intra-arterial injection, epidural or spinal injection were noted and documented.

Pain evaluation was carried out using VAS (0 = no pain and 10 = unbearable pain). When VAS was 4 or greater or when the patient demanded analgesia, intravenous morphine (0.1–0.2 mg/kg) was given. Total morphine given to each patient during the first 24 h of the postoperative period was recorded.

If any patient complained of discomfort/pain intraoperatively they were managed with supplemental intravenous morphine (0.1–0.2 mg/kg) and propofol (1–2 mg/kg).

Statistical analysis

  1. Data were analyzed using SPSS, version 16 (SPSS Inc., Chicago, Illinois, USA).
  2. Quantitative data were presented as a mean and SD and were analyzed using Student's t-test.
  3. Qualitative data were presented as number and percentages and were analyzed using the χ2 and Z-tests.
  4. A P-value less than 0.05 was considered statistically significant, whereas a P-value less than 0.01 was considered statistically highly significant.
  5. Sample size was calculated according to a pilot study from the first eight patients at a-error 0.05 and 80% power. Assuming 30% increase in the duration of sensory block, 30 patients were required for each group.



  Results Top


A total of 75 patients were screened during the study period. Of them, 11 patients did not match the inclusion criteria, two patients refused to participate, and one patient was excluded as he had BMI greater than 35 kg/m2. A total of 61 patients were included in the study, but one more patient was excluded shortly after that because he was uncooperative. Therefore, 60 patients completed the study protocol [Figure 1].
Figure 1 Consort flow diagram.

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Demographic variables and duration of surgery were comparable in both groups [Table 1].
Table 1 Demographic variables and duration of surgery

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Onset of sensory block and motor block was significantly earlier in group LD compared with group L. Duration of sensory block and time to first analgesic request were significantly prolonged in group LD compared with group L. Total morphine consumption was significantly lower in group LD in comparison with group L. The number of failed block was nonsignificantly lower in group LD [Table 2].
Table 2 Intraoperative and postoperative parameters

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The incidence of side effects and complications was low and comparable in both groups [Table 3].
Table 3 Incidence of side effects and complications

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  Discussion Top


The present study demonstrated that addition of dexamethasone to levobupivacaine prolonged the duration of sensory block in ultrasound-guided interscalene brachial plexus block. This finding is generally consistent with those of Movafegh et al. [9], who concluded that the addition of dexamethasone to lidocaine 1.5% solution prolongs the duration of sensory and motor blockade, and Cummings et al. [10], who documented that dexamethasone prolongs analgesia from ISBs using ropivacaine or bupivacaine. Moreover, Dar et al. [11] studied the effect of the addition of dexamethasone to ropivacaine in supraclavicular brachial plexus block and reached the same finding. As regards the onset of sensory block and motor block, our study demonstrated that addition of dexamethasone to a local anesthetic decreases the onset of both sensory and motor block. These findings are almost similar to those of Dar et al. [11], who noticed early onset of sensory and motor block when dexamethasone was mixed with local anesthetic, and Shrestha et al. [12], who found significantly faster onset and longer duration of analgesia in the dexamethasone group than in the other group.

As regards the total analgesic consumption and time to first analgesic request, our study noticed that total morphine consumption was significantly lower and the time to first analgesic request was significantly longer in the dexamethasone group. In a systematic review by Noss et al. [13], they showed that dexamethasone reduces the analgesic consumption when added to the local anesthetic. Moreover, Vieira et al. [14] concluded that the addition of dexamethasone to bupivacaine during ISB prolongs sensory block and reduces the opioid use.

Many studies [2],[15],[16],[17] reported minor complications during their procedures, such as Horner's syndrome, diaphragmatic paralysis, difficulty in swallowing, hoarseness of voice, and vascular injury, but the incidence of complications in our study was less. This may be due to two reasons: first, the use of ultrasound guidance for nerve localization, and, second, the relatively low dose of local anesthetics used.


  Conclusion Top


Addition of dexamethasone to levobupivacaine during ultrasound-guided interscalene brachial plexus block significantly shortens the onset of sensory and motor block, prolongs the duration of analgesia, decreases the 24 h analgesic consumption, and prolongs the time to first analgesic request with minimal side effects.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Jadon A, Dixit S, Kedia SK, Chakraborty S, Agrawal A, Sinha N. Interscalene brachial plexus block for shoulder arthroscopic surgery: prospective randomised controlled study of effects of 0.5% ropivacaine and 0.5% ropivacaine with dexamethasone. Indian J Anaesth 2015; 59:171-176.  Back to cited text no. 1
    
2.
Desmet M, Braems H, Reynvoet M, Plasschaert S, Van Cauwelaert J, Pottel H, et al. 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. Br J Anaesth 2013; 111:445-452.  Back to cited text no. 2
    
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Jadon A, Dixit S, Kedia SK, Chakraborty S, Agrawal A, Sinha N. Interscalene brachial plexus block for shoulder arthroscopic surgery: prospective randomised controlled study of effects of 0.5% ropivacaine and 0.5% ropivacaine with dexamethasone. Indian J Anaesth 2015; 59:171-176.  Back to cited text no. 3
    
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Stan T, Goodman EJ, Bravo-Fernandez C, Holbrook CR. Adding methylprednisolone to local anesthetic increases the duration of axillary block. Reg Anesth Pain Med 2004; 29:380-381.  Back to cited text no. 4
    
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Dräger C, Benziger D, Gao F, Berde CB. Prolonged intercostal nerve blockade in sheep using controlled-release of bupivacaine and dexamethasone from polymer microspheres. Anesthesiology 1998; 89:969-979.  Back to cited text no. 6
    
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Ahlgren SC, Wang JF, Levine JD. C-fiber mechanical stimulus-response functions are different in inflammatory versus neuropathic hyperalgesia in the rat. Neuroscience 1997; 76:285-290.  Back to cited text no. 7
    
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Attardi B, Takimoto K, Gealy R, Severns C, Levitan ES. Glucocorticoid induced up-regulation of a pituitary K+ channel mRNA in vitro and in vivo. Receptors Channels 1993; 1:287-293.  Back to cited text no. 8
    
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Movafegh A, Razazian M, Hajimaohamadi F, Meysamie A. Dexamethasone added to lidocaine prolongs axillary brachial plexus blockade. Anesth Analg 2006; 102:263-267.  Back to cited text no. 9
    
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Cummings KC3rd, Napierkowski DE, Parra-Sanchez I, Kurz A, Dalton JE, Brems JJ, Sessler DI. Effect of dexamethasone on the duration of interscalene nerve blocks with ropivacaine or bupivacaine. Br J Anaesth 2011; 107:446-453.  Back to cited text no. 10
    
11.
Dar FA, Nagar MR, Jan N. Effect of effect of addition of dexamethasone to ropivacaine in supraclavicular brachial plexus block. Indian J Pain 2013; 7.165:9.  Back to cited text no. 11
    
12.
Shrestha BR, Maharjan SK, Tabedar S. Supraclavicular brachial plexus block with and without dexamethasone - a comparative study. Kathmandu Univ Med J 2003; 1:158-160.  Back to cited text no. 12
    
13.
Noss C, Mac Kenzie L, Kostash M. Dexamethasone a promising adjuvant in brachial plexus anesthesia. A systematic review?. J Anesth Clin Res 2014; 5: 421.  Back to cited text no. 13
    
14.
Vieira PA, Pulai I, Tsao GC, Manikantan P, Keller B, Connelly NR. Dexamethasone with bupivacaine increases duration of analgesia in ultrasound-guided interscalene brachial plexus blockade. Eur J Anaesthesiol 2010; 27:285-288.  Back to cited text no. 14
    
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Islam SM, Hossain MH, Maruf AA. Effect of addition of dexamethasone to local anaesthetics in supraclavicular brachial plexus block. JAFMC Bangladesh 2011; 7:11-14.  Back to cited text no. 15
    
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Urmey WF, Talts KH, Sharrock NE. One hundred percent incidence of hemidiaphragmatic paresis associated with interscalene brachial plexus anesthesia as diagnosed by ultrasonography. Anesth Analg 1991; 72:498-503.  Back to cited text no. 16
    
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Hortense A, Perez MV, Amaral JL, Oshiro AC, Rossetti HB. Interscalene brachial plexus block. Effects on pulmonary function. Rev Bras Anestesiol. 2010; 60:130-137, 74-78  Back to cited text no. 17
    


    Figures

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    Tables

  [Table 1], [Table 2], [Table 3]



 

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