|Year : 2018 | Volume
| Issue : 1 | Page : 65-69
To compare efficacy of bupivacaine and bupivacaine with dexamethasone for supraclavicular brachial plexus block in patients undergoing upper-limb surgeries: A one -year randomized controlled trial
Shwetank Rai, KS Kedareshvara
Department of Anaesthesiology, Jawaharlal Nehru Medical College, KLE University, Belagavi, Karnataka, India
|Date of Web Publication||17-Jan-2018|
Dr. Shwetank Rai
Department of Anaesthesiology, Jawaharlal Nehru Medical College, KLE University, Belagavi, Karnataka
Source of Support: None, Conflict of Interest: None
OBJECTIVE: Brachial plexus block is a viable alternative to general anaesthesia as it provides adequate muscle relaxation,excellent intraoperative and post operative analgesia. Dexamethasone ,a synthetic glucocorticoid was combined with local anaesthetics to study the effects . This study was conducted to compare the onset and duration of sensory and motor block following administration of either bupivacaine and bupivacaine- Dexamethasone in patients undergoing upper limb surgeries under USG guided supraclavicular block.
MATERIALS AND METHODS: 60 ASA I / II patients between of 18 and 60 years who underwent elective upper limb surgeries randomly allocated into two groups of 30 each by a sealed envelope technique to receive 30 ml of 0.5% Bupivacaine and 2 ml of normal saline in Group BS and 30 ml of 0.5% Bupivacaine with 2ml (8mg) of Dexamethasone in Group BD. The onset duration of sensory and motor blockade were observed between the two groups.
RESULTS: The onset of sensory and motor blockade was faster in Group BD when compared to Group BS (p<0.0001). The duration of sensory and motor blockade was longer in Group BD when compared to Group BS (p<0.0001). There were no significant haemodynamic changes in the study group.
CONCLUSION: Dexamethasone when added to Bupivacaine in supraclavicular block shortens the onset time and prolongs the duration of sensory and motor blockade without any systemic side effects.
Keywords: Brachial plexus block, bupivacaine, dexamethasone, supraclavicular, upper-limb surgeries
|How to cite this article:|
Rai S, Kedareshvara K S. To compare efficacy of bupivacaine and bupivacaine with dexamethasone for supraclavicular brachial plexus block in patients undergoing upper-limb surgeries: A one -year randomized controlled trial. Indian J Health Sci Biomed Res 2018;11:65-9
|How to cite this URL:|
Rai S, Kedareshvara K S. To compare efficacy of bupivacaine and bupivacaine with dexamethasone for supraclavicular brachial plexus block in patients undergoing upper-limb surgeries: A one -year randomized controlled trial. Indian J Health Sci Biomed Res [serial online] 2018 [cited 2019 Jun 20];11:65-9. Available from: http://www.ijournalhs.org/text.asp?2018/11/1/65/223427
| Introduction|| |
Surgeries on the upper limb have traditionally been done under general anesthesia. However, this has its own demerits such as airway instrumentation, exposure to multiple drugs, and chances of aspiration if inadequate nil oral status is there. Brachial plexus block has become a viable alternative to general anesthesia for the surgeries on the upper limb as it provides adequate muscle relaxation and an excellent intra- and postoperative analgesia  without the above-mentioned complications.Blind/landmark-based technique had a high rate of failure and complications, and thus the technique was not very popular. The advent of ultrasonography (USG) guidance for locating the brachial plexus has increased the success rate and has renewed the interest in brachial plexus block.
In this study, we plan to use the supraclavicular brachial plexus block which can provide good anesthesia for surgeries extending from mid arm up to the fingers. This approach is associated with a rapid onset of anesthesia and a high rate of success.
The first supraclavicular block was performed by Kullenkampff in 1911–1912.
Ultrasound-guided supraclavicular brachial plexus block is a safe, reliable anesthetic technique for upper-limb surgeries with less complications. Ultrasound guidance leads to decreased procedure time, faster onset of action, and higher block success rates without neural injuries, thereby improving efficacy.
Bupivacaine is a long-acting local anesthetic, commonly used in brachial plexus blocks. Its effects last from 3 to 6 h. This will provide intra operative anesthesia but may be insufficient to provide post-operative analgesia. Postoperative pain causes the patient to demand rescue analgesia commonly provided by opioids and nonsteroidal anti-inflammatory drugs. Prolonging the effect of bupivacaine can help avoid this need for rescue analgesia and avoid the side effects of intravenous (IV) analgesics.
Various adjuncts have been used to prolong brachial plexus block. These include epinephrine, magnesium sulfate, alpha-2 agonists (i.e., clonidine  and dexmedetomidine ), and midazolam. Corticosteroids have been studied recently as adjuncts to local anesthetics in regional blockade. Steroids induce a degree of vasoconstriction, and therefore the first theory states that they act by reducing local anesthetic absorption.
There have been some studies comparing the effect of dexamethasone in interscalene block and transversus abdominis block. Only a few studies have been done to study the role of dexamethasone in supraclavicular block. These studies show that dexamethasone prolongs the effect of local anesthetic solutions, but the duration of this block is varied.
This study aims at finding the effect of dexamethasone when used in supraclavicular block, thereby addressing this knowledge gap.
| Methodology|| |
The present study was conducted in the Department of Anesthesiology, Jawaharlal Nehru Medical College and KLE's society Dr. Prabhakar Kore Charitable Hospital and Medical Research Center, between January 2016 and December 2016. The inclusion criteria for our study were American Society of Anesthesiologists (ASA) Grade I and II patients between the age group of 18 and 60 years and those undergoing elective upper-limb surgeries (i.e., elbow, forearm, and hand). Patients with ASA Grade III and IV, bleeding disorders, respiratory compromise, known allergies to local anesthetics, and those with infections at the site of block or documented neuromuscular disorders were excluded from the study.
Sample size (n)
From the data available from the previous studies and using the formula based on mean and standard deviation, the sample size was calculated as follows:
Where zα is linked with the level of significance and zβ is linked with the power of the test.
For 5% level of the significance, zα = 1.96 and zβ
= 0.84 for 80% power of the test, (the mean of the first group) = 326, (the mean of the second group) = 159, s1(the standard deviation of the first group) = 58.6, and
s2(the standard deviation of the second group) = 20.1
For these values, the minimum sample size calculated is just 1.
Thus, using the thumb rule for minimum sample size for a randomized controlled trial (RCT), i.e., 30 patients in each group, the total sample size was taken as 60.
After obtaining institutional review board and ethical committee clearance, sixty patients were allocated in a randomized manner on a sealed envelope technique into one of the two groups of thirty each.
- Group BS: Will receive 30 ml of 0.5% bupivacaine + 2 ml of normal saline
- Group BD: Will receive 30 ml of 0.5% bupivacaine + 2 ml (8 mg) of dexamethasone.
Once the patient fulfilled the inclusion criteria, History, Clinical examination and Informed consent was taken from the patient. Every Patient was subjected to routine investigations like complete Haemogram, RBS, Chest Xray and ECG.
The anesthesiologist involved in the data collection as well as the patient was blinded to the content of the study solution.
Preoperatively, the patient's IV line was secured with either 18G or 20G branula and IV ringer lactate solution was started at 5 ml/kg/h. The patient was then shifted to the operation theater and monitors such as ECG, SpO2, and blood pressure (BP) were recorded. The patient was placed in 30° propped up position with face turned to opposite side and ipsilateral upper arm placed by the side of the patient.
Under strict aseptic precautions, the area between the mandible and the ipsilateral nipple was painted and draped. The carotid artery was palpated and a skin wheal was raised by injecting 2 ml of lidocaine 2%.
Under ultrasound guidance, a 23G spinal needle was used to localize the brachial plexus which is present posterolateral to the brachial plexus. A 23G spinal needle used was inserted from the right side of the probe for the right side shoulder and vice versa. Aspiration was done for checking the absence of blood. The spinal needle was inserted into the nerve sheath and drug was injected under ultrasonologic view. The injected volume gently expands the connective tissue surrounding the nerves which is called hydrodissection. This allows the needle a clear path.
Sensory block was assessed by pinprick test using a 3-point scale as follows:
- 0 = sharp pin felt
- 1 = dull sensation felt (analgesia)
- 2 = no sensation felt (anesthesia).
Motor block was assessed by thumb abduction (radial nerve), thumb adduction (ulnar nerve), thumb opposition (median nerve), and flexion at the elbow (musculocutaneous nerve) on a 3-point scale for motor function which are described as follows:
- 0 = normal motor function with full flexion and extension of elbow, wrist, and fingers
- 1 = reduced motor strength but able to move fingers
- 2 = complete motor blocks with an inability to move fingers.
Sensory and motor block was assessed every 3 min until 30 min after injection, and then every 30 min after the surgery, until they had resolved. Onset time was defined as the time interval between the end of total local anesthetic administration and complete sensory block. Complete sensory block was defined by anesthetic block (score 2) on all nerve territories. Duration of sensory block was defined as the time interval between the end of local anesthetic administration and the complete resolution of effect of anesthesia on all nerves. Onset of motor block was defined as the time interval between administration of local anesthetic solution to loss of movements. Complete motor block was defined as the absence of voluntary movements in hand and forearm (score 0). Duration of motor block was defined as the time interval between the end of local anesthetic administration and the recovery of complete motor function of the hand and forearm. Heart rate, systolic arterial BP, and diastolic arterial BP were recorded at 0, 5, 10, 15, 30, 45, 60, 90, and 120 min. Adverse events such as hypotension were defined as decrease in systolic BP by 20% from baseline values.
Pain was assessed using a visual analog scale (VAS) (0–10). Nursing staff administered intramuscular diclofenac 75 mg when VAS >4.
All the data were expressed as mean ± standard deviation. Quantitative data were compared using Student's unpaired t-test, while qualitative data were compared using Student's paired t-test. P < 0.05 was considered statistically significant.
| Results|| |
Sixty patients were randomly allocated into two groups of thirty each:
- Group BS: Received 30 ml of 0.5% bupivacaine + 2 ml of normal saline
- Group BD: Received30 ml of 0.5% bupivacaine + 2 ml (8 mg) dexamethasone.
The data obtained were analyzed and the observations and results are summarized in [Table 1], [Table 2] and [Table 3]
The intraoperative mean pulse rate, systolic BP, and diastolic BP were comparable between the two groups at all points of observation. The difference in the two groups was found to be statistically nonsignificant.
However, there was a decline in the mean pulse rates from 0 to 120 min.
| Discussion|| |
Supraclavicular block is a commonly performed anesthetic technique for patients undergoing surgeries on the upper limb. It blocks the plexus at the level of trunks leading to high rates of success, thus making it a popular choice among anesthesiologists.
The addition of USG has revolutionized the field of regional anesthesia. It has increased the success rates of peripheral nerve blocks and avoid complications such as inadvertent intravascular injection, pneumothorax, and trauma to nerves, which were seen with the classical “Blind”/“Landmark” techniques. It also helps to reduce the total volume of drug required to be injected for anesthetizing the plexus, thereby decreasing the chances of systemic toxicity of local anesthetics.
The addition of dexamethasone to regional anesthesia with local anesthetics has added a newer aspect to medical uses of corticosteroids. Steroids have very strong anti-inflammatory and immunosuppressive effects. Perineural injection was found to be safe, devoid of adverse effects. Dexamethasone is a preferred synthetic glucocorticoid as it is 25–30 times more potent than hydrocortisone and lacks any mineralocorticoid activity.
In our study, the mean time of onset of sensory block was 8.43 + 1.04 min in Group BS and 6.49 + 1.09 min in Group BD. This was found to be clinically highly significant with P < 0.0001. The results of our study are similar to the results of a study conducted by Dar et al. (2013) who added dexamethasone to ropivacaine and observed that the onset time in dexamethasone group for sensory block was 14.65 + 3.31 min which was significantly shorter than the control group (17.5 + 4.2 min).
In a meta-analysis of RCTs by Huynh et al. (2013), the authors studied 12 trials where dexamethasone was added to local anesthetic. They concluded that the time of onset of sensory block was significantly reduced from 10 min (control group) by weighted mean difference (Weighted Mean Difference – 78 s, 95% confidence interval, P < 0.001) with the addition of dexamethasone to local anesthetic. This was in concordance with the results of our study.
In our study, the mean time for the onset of motor block was 17.53 ± 1.70 in Group BS and 14.63 ± 2.79 in Group BD. In a study conducted by El-Baradey and Elshmaa, they observed the onset time for motor block with bupivacaine and dexamethasone to be 11.4 ± 3.6 min. This result is similar to the findings of our study.
In our study, the mean duration of sensory block was 289.50 ± 45.71 min in Group BS and 1160 ± 143.10 min in Group BD. This difference was highly statistically significant with P < 0.0001. The mean duration of motor block was 216.27 ± 37.73 min in Group BS and 870.87 ± 101.14 min in Group BD. This too was found to be highly statistically significant with P < 0.0001.
This result was similar to a study by Choi et al. who conducted a meta-analysis of RCTs and included nine trials including 801 patients. They observed that dexamethasone prolonged the analgesic duration for long-acting local anesthetic from 730 to 1306 min, while motor block was prolonged from 664 to 1102 min without any observed adverse events. The minor differences in the results between our studies can be due to the use of varying concentrations of dexamethasone, i.e., 4–10 mg, whereas we used 8 mg for all patients in Group BD.
Similar results were also seen in a study by Vieira et al. (2008) who in a randomized study evaluated the effect of dexamethasone on analgesia with 0.5% bupivacaine with epinephrine and clonidine. The median sensory block duration was 1457 versus 833 min (P< 0.0001) and motor block duration was 1374 versus 827 min (P< 0.0001) when compared with the control. These results though similar are slightly higher than ours. This difference could be due to the added vasoconstrictive effects of epinephrine and also due to the addition of clonidine.
Albrecht et al. (2015) in their study concluded that addition of dexamethasone to local anaesthetic prolonged the duration of both sensory and motor block. The median duration of analgesia (sensory blockade) was increased by 488 mins, when dexamethasone was combined with long action local anaesthetics. This result is in concordance with our findings where the difference due to adding dexamethasone was 871 mins for sensory block.
The difference can be because their study included RCTs on all peripheral blocks and also that they studied and compiled the results considering the overall local anesthetics, i.e., both short and medium duration on one side and long duration on the other side, whereas we studied only bupivacaine which is a long-acting local anesthetic in only supraclavicular block. Another source of difference in the results can be that the inclusion of multiple studies caused the nerve location methods to vary, i.e., landmarks, nerve stimulator, or ultrasound, whereas in our study, we standardized it using USG for nerve location in both groups of patients.
Biradar et al. in their study concluded that dexamethasone caused prolongation of action of lignocaine for both sensory and motor blocks. This is similar to findings in our study where the action of bupivacaine was prolonged.
The addition of dexamethasone induces vasoconstriction, blocks ectopic neuronal discharges, and prevents the release of inflammatory mediators. The prolonged duration of sensory and motor blockade and analgesia observed in dexamethasone group can be attributed to the fact that dexamethasone increases the activity of inhibitory potassium channels on nociceptive
C-fibers (via glucocorticoid receptors), reducing their activity and prolonging local anesthetic activity. The different mechanisms of action of the two drugs when combined have an additive effect.
The hemodynamic parameters such as heart rate, systolic BP, and diastolic BP were stable in both the groups in our study. This was similar to the results of the study conducted by El-Baradey and Elshmaa.
Thus, ultrasound-guided supraclavicular brachial plexus block using 0.5% bupivacaine and 8 mg dexamethasone can provide adequate intra- and postoperative analgesia when used for patients undergoing upper-limb surgeries.
| Conclusion|| |
Dexamethasone shortens the onset and prolongs the duration of sensory and motor blockade effectively and enhances the quality of blockade when used as an adjuvant to bupivacaine in supraclavicular block, with minimal hemodynamic changes, thus making dexamethasone a potential adjuvant for peripheral blocks.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
El-Baradey GF, Elshmaa NS. The efficacy of adding dexamethasone, midazolam, or epinephrine to 0.5% bupivacaine in supraclavicular brachial plexus block. Saudi J Anaesth 2014;8:S78-83.
Lee JA, Atkinson RS, Rushman GB, Davies NJ. Lee's Synopsis of Anaesthesia. 11th
ed. Oxford: Buttersworth-Heinmann Ltd.,; 1993. p. 642.
Duma A, Urbanek B, Sitzwohl C, Kreiger A, Zimpfer M, Kapral S. Clonidine as an adjuvant to local anaesthetic axillary brachial plexus block : a randomized, controlled study. Br J Anaesth 2005;94:112-16.
A, Kaimar P, Gopalkrishna K. Effect of dexamethasone added to Lignocaine in supraclavicular block: A Prospective Randomised double blind study. Indian J Anaesth 2013;57:180-4.
] [Full text]
Choi S. Rodseth R and McCartney CJL. Effects of Dexamethasone as a local anesthetic adjuvant for Brachial Plexus Block : a systematic Review and meta – analysis of randomized trials. Br J Anaesth 2014-112:427-39.
Das A, Majumdar S, Haldaer S, Chattopadhyay S, Pal S, Kundu K et al
. Effect of Dexmeditomidine as adjuvant in Ropivacaine induced Supraclavicular Brachial plexus block: A prospective, double – blind and randomised controlled study. Saudi J Anaesth; Nov 2014:1-8.
Ammar AS, Mahmoud KM. Effect of adding dexamethasone to bupivacaine on transversus abdominis plane block for abdominal hysterectomy: A prospective randomized controlled trial. Saudi J Anaesth 2012;6:229-33.
] [Full text]
Dar FA, Najar Mohd R, Jan N. Effect of addition of dexamethasone to ropivacaine in supraclavicular brachial plexus block. Indian J Pain 2013;27:165-9. [Full text]
Huynh TM, Marret E, Bonnet F. Combination of dexamethasone and local anaesthetic solution in peripheral nerve blocks: A meta-analysis of randomised controlled trials. Eur J Anaesthesiol 2015;32:751-8.
Vieira PA, Pulai I, Tsao GC, Manikantan P, Keller B, Connelly NR, et al.
Dexamethasone with bupivacaine increases duration of analgesia in ultrasound-guided interscalene brachial plexus blockade. Eur J Anaesthesiol 2010;27:285-8.
Albrecht E, Kern C, Kirkham KR. A systematic review and meta-analysis of perineural dexamethasone for peripheral nerve blocks. Anaesthesia 2015;70:71-83.
[Table 1], [Table 2], [Table 3]