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Li J, Dong Y, Guo J, Wang L, Tian J, Wang L, Che G. Thoracoscopic Intercostal Nerve Block with Cocktail Analgesics for Pain Control After Video-Assisted Thoracoscopic Surgery: A Prospective Cohort Study. J Pain Res 2024; 17:1183-1196. [PMID: 38524689 PMCID: PMC10959176 DOI: 10.2147/jpr.s446951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 02/22/2024] [Indexed: 03/26/2024] Open
Abstract
OBJECTIVE To evaluate whether using a cocktail of intercostal nerve blocks (TINB) during thoracoscopic surgery results in better clinical outcomes than patient-controlled analgesia (PCIA). METHODS Patients in two medical groups undergoing video-assisted thoracoscopic surgery (VATS) for pulmonary nodules in West China Hospital of Sichuan University were collected consecutively between March 2022 and December 2022. The groups were divided into two subgroups based on their analgesic program, which were TINB group and PCIA group. The primary outcome was the visual analogue scale (VAS) of the two groups at different stage after surgery and after discharge. Any analgesic related adverse events (ARAEs) were also recorded. RESULTS A total of 230 patients who underwent VATS were enrolled, in which 113 patients (49.1%) received a cocktail TINB after surgery, and 117 patients (50.9%) received a PCIA. After PSM, 62 patients in each group were selected. The difference of resting VAS (RVAS) and active VAS (AVAS) at different stage during hospitalization was only related to the change of period (p < 0.05, p < 0.05), and the two groups showed no significant differences in RVAS or AVAS during hospitalization (p = 0.271, p = 0.915). However, the rates of dizziness (4.84% vs 25.81%, p = 0.002), nausea and vomiting (0 vs 22.58%, p < 0.05), fatigue (14.52% vs 34.87%, p = 0.012), and insomnia (0 vs 58.06%, p < 0.05) in TINB group were lower than that in PCIA group. Besides, AVAS and RVAS at 7, 14, and 30 days after discharge in TINB group were both significantly lower than that in PCIA group (p < 0.05, p < 0.05). CONCLUSION Cocktail TINB provided better analgesia after discharge and reduced the incidence of ARAEs in patients undergoing VATS.
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Affiliation(s)
- Jue Li
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, People’s Republic of China
- Lung Cancer Center, West China Hospital, Sichuan University, Chengdu, Sichuan, People’s Republic of China
- West China Clinical Medical College, Sichuan University, Chengdu, Sichuan, People’s Republic of China
| | - Yingxian Dong
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, People’s Republic of China
- Lung Cancer Center, West China Hospital, Sichuan University, Chengdu, Sichuan, People’s Republic of China
- West China Clinical Medical College, Sichuan University, Chengdu, Sichuan, People’s Republic of China
| | - Jiawei Guo
- The Third Affiliated Hospital of Xinxiang Medical University, Xinxiang, Henan, People’s Republic of China
| | - Lei Wang
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, People’s Republic of China
| | - Jie Tian
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, People’s Republic of China
- Lung Cancer Center, West China Hospital, Sichuan University, Chengdu, Sichuan, People’s Republic of China
- West China Clinical Medical College, Sichuan University, Chengdu, Sichuan, People’s Republic of China
| | - Li Wang
- The Third Affiliated Hospital of Xinxiang Medical University, Xinxiang, Henan, People’s Republic of China
| | - Guowei Che
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, People’s Republic of China
- Lung Cancer Center, West China Hospital, Sichuan University, Chengdu, Sichuan, People’s Republic of China
- West China Clinical Medical College, Sichuan University, Chengdu, Sichuan, People’s Republic of China
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Schubert AK, Seneviratne V, Stolz J, Wiesmann T, Wulf H, Eberhart L, Dinges HC. The effect of adjuvants added to local anaesthetics for single-injection upper extremity peripheral regional anaesthesia: A systematic review with network meta-analysis of randomised trials. Eur J Anaesthesiol 2023; 40:672-690. [PMID: 37337656 DOI: 10.1097/eja.0000000000001860] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
BACKGROUND Peripheral regional anaesthesia is frequently used for upper extremity surgery. To prolong the duration of analgesia, adjuvants can be added to single-injection local anaesthetics. Despite attempts to compare several adjuvants in pairwise meta-analyses, a comprehensive comparison is still missing. OBJECTIVE The objective of this network meta-analysis was to determine the effectiveness of adjuvants in upper extremity peripheral nerve blocks. DESIGN A systematic review of randomised controlled trials with network meta-analyses. DATA SOURCES A literature search in Embase, CENTRAL, MEDLINE and Web of Science was performed up to March 2023. ELIGIBILITY CRITERIA Randomised trials comparing different adjuvants injected perineurally in peripheral upper extremity nerve blocks were eligible. Frequentist network meta-analysis was conducted using a random effects model with physiological saline as the comparator. The primary endpoint was the ratio of means (ROM) of the duration of analgesia. RESULTS The review included 242 randomised controlled trials with a total of 17 391 patients. Twenty-eight adjuvants were compared in the largest networks. Most network estimations consisted of a high proportion of direct evidence. Fourteen adjuvants increased the duration of analgesia significantly by the following factors, ROM [95% confidence interval (CI)]: dexamethasone 1.95 (1.79 to 2.13), buprenorphine 1.83 (1.51 to 2.24), butorphanol 1.84 (1.41 to 2.39), potassium chloride 1.89 (1.15 to 3.11), dexmedetomidine 1.70 (1.59 to 1.81), sufentanil 1.70 (1.27 to 2.29), ketorolac 1.68 (1.24 to 2.27), midazolam 1.55 (1.24 to 1.94), tramadol 1.52 (1.32 to 1.75), nalbuphine 1.50 (1.30 to 1.72), morphine 1.43 (1.09 to 1.88), magnesium sulfate 1.42 (1.20 to 1.67), clonidine 1.36 (1.24 to 1.50) and fentanyl 1.23 (1.08 to 1.40). Inconsistency in network meta-analysis was substantial. Overall side effect rates were low with all adjuvants. CONCLUSION The best interventions to prolong the duration of analgesia were dexamethasone, followed by dexmedetomidine, opioids, electrolytes, ketorolac and midazolam. There are general concerns about the quality of underlying studies and the risk of publication bias. TRIAL REGISTRATION PROSPERO 2018 CRD42018115722.
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Affiliation(s)
- Ann-Kristin Schubert
- From the Department of Anaesthesiology and Intensive Care Medicine, University Hospital Marburg, Philipps University of Marburg, Marburg (A-KS, VS, JS, TW, HW, LE, H-CD), and the Department of Anaesthesiology and Intensive Care Medicine, Diakoneo Diak Klinikum Schwäbisch-Hall, Schwäbisch-Hall, Germany (TW)
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Chen Z, Liu Z, Feng C, Jin Y, Zhao X. Dexmedetomidine as an Adjuvant in Peripheral Nerve Block. Drug Des Devel Ther 2023; 17:1463-1484. [PMID: 37220544 PMCID: PMC10200118 DOI: 10.2147/dddt.s405294] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 05/05/2023] [Indexed: 05/25/2023] Open
Abstract
Peripheral nerve block technology is important to balanced anesthesia technology. It can effectively reduce opioid usage. It is the key to enhance clinical rehabilitation as an important part of the multimodal analgesia scheme. The emergence of ultrasound technology has accelerated peripheral nerve block technology development. It can directly observe the nerve shape, surrounding tissue, and diffusion path of drugs. It can also reduce the dosage of local anesthetics by improving positioning accuracy while enhancing the block's efficacy. Dexmedetomidine is a highly selective drug α2-adrenergic receptor agonist. Dexmedetomidine has the characteristics of sedation, analgesia, anti-anxiety, inhibition of sympathetic activity, mild respiratory inhibition, and stable hemodynamics. Numerous studies have revealed that dexmedetomidine in peripheral nerve blocks can shorten the onset time of anesthesia and prolong the time of sensory and motor nerve blocks. Although dexmedetomidine was approved by the European Drug Administration for sedation and analgesia in 2017, it has not yet been approved by the US Food and Drug Administration (FDA). It is used as a non-label drug as an adjuvant. Therefore, the risk-benefit ratio must be evaluated when using these drugs as adjuvants. This review explains the pharmacology and mechanism of dexmedetomidine, the effect of dexmedetomidine on various peripheral nerve block as an adjuvant, and compare it with other types of adjuvants. We summarized and reviewed the application progress of dexmedetomidine as an adjuvant in nerve block and look forward to its future research direction.
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Affiliation(s)
- Zheping Chen
- Department of Anesthesiology, The Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250012, People’s Republic of China
| | - Zhenzhen Liu
- Department of Anesthesiology, The Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250012, People’s Republic of China
| | - Chang Feng
- Department of Anesthesiology, The Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250012, People’s Republic of China
| | - Yanwu Jin
- Department of Anesthesiology, The Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250012, People’s Republic of China
| | - Xin Zhao
- Department of Anesthesiology, The Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250012, People’s Republic of China
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Andersen JH, Karlsen A, Geisler A, Jaeger P, Grevstad U, Dahl JB, Mathiesen O. Alpha 2 -receptor agonists as adjuvants for brachial plexus nerve blocks-A systematic review with meta-analyses. Acta Anaesthesiol Scand 2022; 66:186-206. [PMID: 34811722 DOI: 10.1111/aas.14002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 10/27/2021] [Accepted: 11/03/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND We review the efficacy and safety of dexmedetomidine and clonidine as perineural or systemic adjuvants for brachial plexus blocks (BPB). METHODS We included randomised controlled trials on upper limb surgery with BPBs in adults, comparing dexmedetomidine with clonidine or either drug with placebo. The primary outcome was duration of analgesia. Secondary outcomes included adverse and serious adverse events. The review was conducted using Cochrane standards, trial sequential analyses (TSA) and Grading of Recommendations Assessment, Development and Evaluation (GRADE). RESULTS We included 101 trials with 6248 patients. Overall, duration of analgesia was prolonged with both clonidine (176 min [TSA adj. 95% CI: 118, 205, p < .00001; 33 trials]) and dexmedetomidine (292 min [TSA adj. 95% CI: 245 329, p < .00001; 53 trials]), but was longer for dexmedetomidine than clonidine (205 min [TSA adj. 95% CI: 157, 254, p < .00001; 19 trials]). Compared with placebo, dexmedetomidine was associated with bradycardia (RR 4.2 [95% CI 2.2, 8.3]), and both clonidine (RR 4.5 [95% CI 1.1, 18.3]) and dexmedetomidine (RR 3.9 [95% CI 2.0, 7.5]) were associated with hypotension. Serious adverse events were mostly related to block technique. GRADE-rated quality of evidence was low or very low. CONCLUSION Alpha2-receptor agonists used as adjuvants for BPBs lead to a prolonged duration of analgesia, with dexmedetomidine as the most efficient. Alpha2-receptor agonists were associated with increased risk of cardiovascular adverse events. The quality of evidence was low to very low.
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Affiliation(s)
- Jakob H Andersen
- Department of Anaesthesiology, Centre for Anaesthesiological Research, Zealand University Hospital, Køge, Denmark
| | - Anders Karlsen
- Department of Anaesthesiology, Centre for Anaesthesiological Research, Zealand University Hospital, Køge, Denmark
| | - Anja Geisler
- Department of Anaesthesiology, Centre for Anaesthesiological Research, Zealand University Hospital, Køge, Denmark
| | - Pia Jaeger
- Department of Anaesthesiology, Centre of Head and Orthopedics, Rigshospitalet, Copenhagen, Denmark
| | - Ulrik Grevstad
- Department of Anaesthesiology, Gentofte Hospital, Hellerup, Denmark
| | - Jørgen B Dahl
- Department of Anaesthesiology, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
| | - Ole Mathiesen
- Department of Anaesthesiology, Centre for Anaesthesiological Research, Zealand University Hospital, Køge, Denmark
- Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
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Veena G, Pangotra A, Kumar S, Prakash J, Rao NS, Priye S. Comparison of Perineural and Intravenous Dexamethasone as an Adjuvant to Levobupivacaine in Ultrasound-Guided Infraclavicular Brachial Plexus Block: A prospective Randomized Trial. Anesth Essays Res 2021; 15:45-50. [PMID: 34667347 PMCID: PMC8462415 DOI: 10.4103/aer.aer_69_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 06/18/2021] [Accepted: 06/18/2021] [Indexed: 12/04/2022] Open
Abstract
Background: The effect of perineural versus intravenous (i.v.) dexamethasone (4 mg) when added to levobupivacaine as an adjuvant has not been well studied. Aims: This study was conducted to compare the analgesic efficacy of perineural and i.v. dexamethasone as an adjuvant to levobupivacaine in infraclavicular brachial plexus (ICBP) block. Settings and Design: This was a prospective, randomized, double-blind study. Materials and Methods: This study was conducted on 68 patients with the ultrasound-guided ICBP block, randomly allocated into two groups (34 each). Four patients had failed block (2 in each group) that was excluded from the study. Group A received 25 mL of levobupivacaine 0.5% and 1 mL of normal saline for the block and i.v. dexamethasone 4 mg. Group B received 25 mL of levobupivacaine 0.5% with 4 mg of perineural dexamethasone for the block. Postoperative vitals and different block characteristics were assessed. Statistical Analysis Used: Student's independent sample t-test and Chi-square test were used for statistical analysis. Results: The duration of motor block and analgesia in Group A was 1245.94 ± 153.22 min and 1310.16 ± 151.68 min, respectively. However, in Group B, the duration of motor block and analgesia was 1768.13 ± 309.86 min and 1743.59 ± 231.39 min, respectively, which was more when compared to Group A (P < 0.001). The Visual Analog Scale score of ≥3 in Group A was 37% and in Group B was 9% (P = 0.008). Four cases had delayed regression of motor block in the perineural group. Conclusions: Perineural dexamethasone significantly prolonged the duration of motor block promoted by levobupivacaine in infraclavicular brachial plexus block, reduced pain intensity and rescue analgesia needs in the postoperative period when compared with the intravenous dexamethasone.
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Affiliation(s)
- G Veena
- Department of Anaesthesia, Vydehi Institute of Medical Sciences and Research Centre, Bengaluru, Karnataka, India
| | - Anshu Pangotra
- Department of Superspeciality Anaesthesia, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India
| | - Shailesh Kumar
- Department of Anaesthesia, MVJ Medical College and Research Hospital, Bengaluru, Karnataka, India
| | - Jay Prakash
- Department of Critical Care Medicine, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India
| | - Natesh S Rao
- Department of Anaesthesia, Vydehi Institute of Medical Sciences and Research Centre, Bengaluru, Karnataka, India
| | - Shio Priye
- Department of Superspeciality Anaesthesia, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India
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Wang Q, Li H, Wei S, Zhang G, Ni C, Sun L, Zheng H. Dexmedetomidine Added to Ropivacaine for Ultrasound-guided Erector Spinae Plane Block Prolongs Analgesia Duration and Reduces Perioperative Opioid Consumption After Thoracotomy: A Randomized, Controlled Clinical Study. Clin J Pain 2021; 38:8-14. [PMID: 34636753 PMCID: PMC8635250 DOI: 10.1097/ajp.0000000000000992] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 08/10/2021] [Accepted: 09/17/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Single-injection erector spinae plane block (ESPB) provides good control of pain relief after open thoracotomy surgeries. However, the duration of pain relief does not last long. For this purpose, we hypothesized that adding α2-adrenoceptor agonist, dexmedetomidine, for interfascial nerve blockade may increase the duration of analgesia. There are only few studies using dexmedetomidine for interfasical nerve blocks in humans. In this study, our aim is to investigate whether addition of dexmedetomidine to ropivacaine for ESPB could effectively prolong the duration of postoperative analgesia and reduce opioid consumption after open thoracotomy. MATERIALS AND METHODS Sixty patients with esophageal cancer were randomized to receive ESPB using 28 mL of 0.5% ropivacaine, with 2 mL of normal saline (group R) or 0.5 µg/kg dexmedetomidine in 2 mL (group RD) administered interfascially. ESPB was performed at the fifth thoracic level under ultrasound guidance. The primary outcome was the duration of analgesia. The secondary outcomes were total postoperative sufentanil consumption, Numeric Rating Scale pain scores, Ramsay Sedation Scale scores and adverse effects. RESULTS The duration of analgesia in group RD (505.1±113.9) was longer than that in group R (323.2±75.4) (P<0.001). The total postoperative sufentanil consumption was lower in group RD (23.3±10.0) than in group R (33.8±13.8) (P=0.001). There was no significant difference in the incidence of adverse effects between the 2 groups. CONCLUSION After open thoracotomy, addition of dexmedetomidine to ropivacaine for ESPB effectively prolonged the duration of postoperative analgesia and reduced opioid consumption without increasing additional incidence of adverse effects.
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Affiliation(s)
- Qiang Wang
- Department of Anesthesiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing
| | - Huixian Li
- Department of Anesthesiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing
| | - Shijing Wei
- Department of Anesthesiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing
| | - Guohua Zhang
- Department of Anesthesiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing
| | - Cheng Ni
- Department of Anesthesiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing
| | - Li Sun
- Department of Anesthesiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital & Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shenzhen, China
| | - Hui Zheng
- Department of Anesthesiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing
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Cai H, Fan X, Feng P, Wang X, Xie Y. Optimal dose of perineural dexmedetomidine to prolong analgesia after brachial plexus blockade: a systematic review and Meta-analysis of 57 randomized clinical trials. BMC Anesthesiol 2021; 21:233. [PMID: 34583650 PMCID: PMC8477554 DOI: 10.1186/s12871-021-01452-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Accepted: 09/09/2021] [Indexed: 01/08/2023] Open
Abstract
Background and Objectives Peripheral injection of dexmedetomidine (DEX) has been widely used in regional anesthesia to prolong the duration of analgesia. However, the optimal perineural dose of DEX is still uncertain. It is important to elucidate this characteristic because DEX may cause dose-dependent complications. The aim of this meta-analysis was to determine the optimal dose of perineural DEX for prolonged analgesia after brachial plexus block (BPB) in adult patients undergoing upper limb surgery. Method A search strategy was created to identify suitable randomized clinical trials (RCTs) in Embase, PubMed and The Cochrane Library from inception date to Jan, 2021. All adult patients undergoing upper limb surgery under BPB were eligible. The RCTs comparing DEX as an adjuvant to local anesthetic (LA) with LA alone for BPB were included. The primary outcome was duration of analgesia for perineural DEX. Secondary outcomes included visual analog scale (VAS) in 12 and 24 h, consumption of analgesics in 24 h, and adverse events. Results Fifty-seven RCTs, including 3332 patients, were identified. The subgroup analyses and regression analyses revealed that perineural DEX dose of 30-50 μg is an appropriate dosage. With short−/intermediate-acting LAs, the mean difference (95% confidence interval [CI]) of analgesia duration with less than and more than 60 μg doses was 220.31 (153.13–287.48) minutes and 68.01 (36.37–99.66) minutes, respectively. With long-acting LAs, the mean differences (95% CI) with less than and more than 60 μg doses were 332.45 (288.43–376.48) minutes and 284.85 (220.31–349.39) minutes. Conclusion 30-50 μg DEX as adjuvant can provides a longer analgesic time compared to LA alone and it did not increase the risk of bradycardia and hypotension. Supplementary Information The online version contains supplementary material available at 10.1186/s12871-021-01452-0.
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Affiliation(s)
- Hai Cai
- Department of Anesthesiology, The First Affiliated Hospital of Guangxi Medical University, No. 6 Shuangyong Road, Nanning, 530021, Guangxi Zhuang Autonomous Region, China
| | - Xing Fan
- Department of Anesthesiology, The First Affiliated Hospital of Guangxi Medical University, No. 6 Shuangyong Road, Nanning, 530021, Guangxi Zhuang Autonomous Region, China
| | - Pengjiu Feng
- Department of Anesthesiology, Liuzhou Hospital of Traditional Chinese Medicine, Liuzhou, Guangxi Zhuang Autonomous Region, China
| | - Xiaogang Wang
- Department of Anesthesiology, Liuzhou Hospital of Traditional Chinese Medicine, Liuzhou, Guangxi Zhuang Autonomous Region, China
| | - Yubo Xie
- Department of Anesthesiology, The First Affiliated Hospital of Guangxi Medical University, No. 6 Shuangyong Road, Nanning, 530021, Guangxi Zhuang Autonomous Region, China.
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Feng Y, Chang P, Chen XB, Yang XL, Zhang YJ, Zhang WS. Intravenous versus perineural dexmedetomidine in prolongation of analgesia with regional anesthesia: a meta-analysis and systematic review. PAIN MEDICINE 2021. [DOI: 10.31636/pmjua.v6i2.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Background and Objective. It is unclear whether perineural administration offers advantages when compared to intravenous dexmedetomidine in local anesthesia. To compare the efficacy of perineural versus intravenous dexmedetomidine as local anesthetic adjuvant, we conducted the meta analysis and systematic review.
Materials and Methods. Two researchers searched MEDLINE, OVID, PubMed, Embase, Cochrane Central, Web of Science and Wanfang data for randomized controlled trials comparing the effect of intravenous versus perineural dexmedetomidine as local anesthetic adjuvant without any language restrictions.
Results. We identified 14 randomized controlled trials (801 patients). The results revealed that the duration of analgesia (SMD: -1.76, 95 % CI, [-2.7, -0.83] P = 0.000, I2 = 96 %), the duration of sensory block (SMD:- 3.99, 95 % CI, [-5.88, -2.0], P = 0.000, I2 = 97.6 %), the duration of motor block (SMD: -1.6, 95 % CI, [-2.78, -0.41] P = 0.008, I 2 = 95.5 %) were significantly longer in the perineural group, when compared to systematic dexmedetomidine. The onset time of sensory block (SMD: 1.55, 95 % CI, [0.16, 2.94] P = 0.028, I2 = 96.7 %) and the onset time of motor block (SMD: 0.84, 95 % CI, [0.17, 1.5] P = 0.013, I2 = 88.3 %) were shorter in perineural group compared to intrave nous dexmedetomidine. Meanwhile, analgesic consumption in 24 hours (SMD: 0.37, 95 % CI, [0.05, 0.69] P = 0.023, I 2 = 55.6 %) and the incidence of patients of Ramsay Sedation Scale > 3 (RR: 3.8, 95 % CI, [1.45, 9.97] P = 0.000, I 2 = 26.9 %), hypotension (RR: 1.74, 95 % CI, [1.15, 2.65] P= 0.009, I2 = 32.7 %) and bradycardia (RR: 3.71, 95 % CI, [1.27, 10.86] P = 0.017, I2 = 0 %) were lower in perineural dexmedetomidine compared to the intravenous group.
Conclusions. Our meta-analysis generates the evidence that perineural dexmedetomidine is a superior adminstration for prolonging the duration of analgesia. Perineural dexmedetomidine also shows the advantages in duration of sensory block and the onset time of sensory and motor block, when compared to the intravenous administration. Simultaneously, dexmedetomidine as a local anesthetic adjuvant for perineural injection may be much safer than intravenous application because of the lower incidence of patients of Ramsay Sedation Scale > 3 and lower incidence of hypotension and bradycardia.
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Edinoff AN, Fitz-Gerald JS, Holland KAA, Reed JG, Murnane SE, Minter SG, Kaye AJ, Cornett EM, Imani F, Khademi SH, Kaye AM, Urman RD, Kaye AD. Adjuvant Drugs for Peripheral Nerve Blocks: The Role of NMDA Antagonists, Neostigmine, Epinephrine, and Sodium Bicarbonate. Anesth Pain Med 2021; 11:e117146. [PMID: 34540646 PMCID: PMC8438710 DOI: 10.5812/aapm.117146] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 06/21/2021] [Accepted: 06/22/2021] [Indexed: 01/02/2023] Open
Abstract
The potential for misuse, overdose, and chronic use has led researchers to look for other methods to decrease opioid consumption in patients with acute and chronic pain states. The use of peripheral nerve blocks for surgery has gained increasing popularity as it minimizes peripheral pain signals from the nociceptors of local tissue sustaining trauma and inflammation from surgery. The individualization of peripheral nerve blocks using adjuvant drugs has the potential to improve patient outcomes and reduce chronic pain. The major limitations of peripheral nerve blocks are their limited duration of action and dose-dependent adverse effects. Adjuvant drugs for peripheral nerve blocks show increasing potential as a solution for postoperative and chronic pain with their synergistic effects to increase the duration of action and decrease the required dosage of local anesthetic. N-methyl-d-aspartate (NMDA) receptor antagonists are a viable option for patients with opioid resistance and neuropathic pain due to their affinity to the neurotransmitter glutamate, which is released when patients experience a noxious stimulus. Neostigmine is a cholinesterase inhibitor that exerts its effect by competitively binding at the active site of acetylcholinesterase, which prevents the hydrolysis of acetylcholine and subsequently retaining acetylcholine at the nerve terminal. Epinephrine, also known as adrenaline, can potentially be used as an adjuvant to accelerate and prolong analgesic effects in digital nerve blocks. The theorized role of sodium bicarbonate in local anesthetic preparations is to increase the pH of the anesthetic. The resulting alkaline solution enables the anesthetic to more readily exist in its un-ionized form, which more efficiently crosses lipid membranes of peripheral nerves. However, more research is needed to show the efficacy of these adjuvants for nerve block prolongation as studies have been either mixed or have small sample sizes.
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Affiliation(s)
- Amber N. Edinoff
- Louisiana State University Health Science Center Shreveport, Department of Psychiatry and Behavioral Medicine, Shreveport, LA, USA
| | - Joseph S. Fitz-Gerald
- Louisiana State University Health Science Center Shreveport, Department of Psychiatry and Behavioral Medicine, Shreveport, LA, USA
| | - Krisha Andrea A. Holland
- School of Allied Health, Louisiana State University Shreveport, Department of Physical Therapy, Shreveport, LA, USA
| | - Johnnie G. Reed
- School of Allied Health, Louisiana State University Shreveport, Department of Physical Therapy, Shreveport, LA, USA
| | - Sarah E. Murnane
- School of Allied Health, Louisiana State University Shreveport, Department of Physical Therapy, Shreveport, LA, USA
| | - Sarah G. Minter
- School of Allied Health, Louisiana State University Shreveport, Department of Physical Therapy, Shreveport, LA, USA
| | - Aaron J. Kaye
- Medical University of South Carolina, Department of Anesthesiology and Perioperative Medicine, Charleston, SC, USA
| | - Elyse M. Cornett
- Louisiana State University Shreveport, Department of Anesthesiology, Shreveport, LA, USA
| | - Farnad Imani
- Pain Research Center, Department of Anesthesiology and Pain Medicine, Iran University of Medical Sciences, Tehran, Iran
| | | | - Adam M. Kaye
- Thomas J. Long School of Pharmacy and Health Sciences, University of the Pacific, Department of Pharmacy Practice, Stockton, CA, USA
| | - Richard D. Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Alan D. Kaye
- Louisiana State University Shreveport, Department of Anesthesiology, Shreveport, LA, USA
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Vasconcelos MM, Pontes JPJ, Rodrigues ADM, Neto DRDB, Alves RR, Silva FCDP, Souza DFD. [Perineural dexamethasone in ultrasound-guided interscalene brachial plexus block with levobupivacaine for shoulder arthroscopic surgery in the outpatient setting: randomized controlled trial]. Rev Bras Anestesiol 2020; 70:588-594. [PMID: 33189370 DOI: 10.1016/j.bjan.2020.07.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 06/09/2020] [Accepted: 07/11/2020] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND AND OBJECTIVES In shoulder arthroscopy, on an outpatient basis, the patient needs a good control of the postoperative pain that can be achieved through regional blocks. Perineural dexamethasone may prolong the effect of these blocks. The aim of this study was to evaluate the effect of perineural dexamethasone on the prolongation of the sensory block in the postoperative period for arthroscopic shoulder surgery in outpatient setting. METHODS After approval by the Research Ethics Committee and informed consent, patients undergoing arthroscopic shoulder surgery under general anesthesia and ultrasound-guided interscalene brachial plexus block were randomized into Group D - blockade performed with 30 mL of 0.5% levobupivacaine with vasoconstrictor and 6 mg (1.5 mL) of dexamethasone and Group C - 30 mL of 0.5% levobupivacaine with vasoconstrictor and 1.5 mL of 0.9% saline. The duration of the sensory block was evaluated in 4 postoperative moments (0, 4, 12 and 24 hours) as well as the need for rescue analgesia, nausea and vomiting incidence, and Visual Analog Pain Scale (VAS). RESULTS Seventy-four patients were recruited and 71 completed the study (Group C, n=37; Group D, n=34). Our findings showed a prolongation of the mean time of the sensitive blockade in Group D (1440±0 min vs. 1267±164 min, p<0.001). It was observed that Group C had a higher mean pain score according to VAS (2.08±1.72 vs. 0.02±0.17, p <0.001) and a greater number of patients (68.4% vs. 0%, p <0.001) required rescue analgesia in the first 24 hours. The incidence of postoperative nausea and vomiting was not statistically significant. CONCLUSION Perineural dexamethasone significantly prolonged the sensory blockade promoted by levobupivacaine in interscalene brachial plexus block, reduced pain intensity and rescue analgesia needs in the postoperative period.
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Affiliation(s)
| | - João Paulo Jordão Pontes
- Hospital Santa Genoveva, Uberlândia, MG, Brasil; Sociedade Brasileira de Anestesiologia (TSA-SBA), Rio de Janeiro, RJ, Brasil; European Diploma in Anaesthesiology and Intensive Care (EDAIC), European Society of Anaesthesiology, Brussels, Belgium.
| | | | - Demócrito Ribeiro de Brito Neto
- Hospital Santa Genoveva, Uberlândia, MG, Brasil; Sociedade Brasileira de Anestesiologia (TSA-SBA), Rio de Janeiro, RJ, Brasil
| | - Rodrigo Rodrigues Alves
- Hospital Santa Genoveva, Uberlândia, MG, Brasil; Sociedade Brasileira de Anestesiologia (TSA-SBA), Rio de Janeiro, RJ, Brasil
| | - Fernando Cássio do Prado Silva
- Hospital Santa Genoveva, Uberlândia, MG, Brasil; Sociedade Brasileira de Anestesiologia (TSA-SBA), Rio de Janeiro, RJ, Brasil; Hospital Santa Genoveva, CET, Uberlândia, MG, Brasil
| | - Denis Fabiano de Souza
- Instituto do Coração do Triângulo (ICT), Uberlândia, MG, Brasil; Universidade Federal de Uberlândia (UFU), Ciências da Saúde, MG, Brasil
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Vasconcelos MM, Pontes JPJ, Rodrigues ADM, Neto DRDB, Alves RR, Silva FCDP, Souza DFD. Perineural dexamethasone in ultrasound-guided interscalene brachial plexus block with levobupivacaine for shoulder arthroscopic surgery in the outpatient setting: randomized controlled trial. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ENGLISH EDITION) 2020. [PMID: 33189370 PMCID: PMC9373568 DOI: 10.1016/j.bjane.2020.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background and objectives In shoulder arthroscopy, on an outpatient basis, the patient needs a good control of the postoperative pain that can be achieved through regional blocks. Perineural dexamethasone may prolong the effect of these blocks. The aim of this study was to evaluate the effect of perineural dexamethasone on the prolongation of the sensory block in the postoperative period for arthroscopic shoulder surgery in outpatient setting. Methods After approval by the Research Ethics Committee and informed consent, patients undergoing arthroscopic shoulder surgery under general anesthesia and ultrasound-guided interscalene brachial plexus block were randomized into Group D – blockade performed with 30 mL of 0.5% levobupivacaine with vasoconstrictor and 6 mg (1.5 mL) of dexamethasone and Group C – 30 mL of 0.5% levobupivacaine with vasoconstrictor and 1.5 mL of 0.9% saline. The duration of the sensory block was evaluated in 4 postoperative moments (0, 4, 12 and 24 hours) as well as the need for rescue analgesia, nausea and vomiting incidence, and Visual Analog Pain Scale (VAS). Results Seventy-four patients were recruited and 71 completed the study (Group C, n = 37; Group D, n = 34). Our findings showed a prolongation of the mean time of the sensitive blockade in Group D (1440 ± 0 min vs. 1267 ± 164 min, p < 0.001). It was observed that Group C had a higher mean pain score according to VAS (2.08 ± 1.72 vs. 0.02 ± 0.17, p < 0.001) and a greater number of patients (68.4% vs. 0%, p < 0.001) required rescue analgesia in the first 24 hours. The incidence of postoperative nausea and vomiting was not statistically significant. Conclusion Perineural dexamethasone significantly prolonged the sensory blockade promoted by levobupivacaine in interscalene brachial plexus block, reduced pain intensity and rescue analgesia needs in the postoperative period.
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Affiliation(s)
| | - João Paulo Jordão Pontes
- Hospital Santa Genoveva, Uberlândia, MG, Brasil; Sociedade Brasileira de Anestesiologia (TSA-SBA), Rio de Janeiro, RJ, Brasil; European Diploma in Anaesthesiology and Intensive Care (EDAIC), European Society of Anaesthesiology, Brussels, Belgium.
| | | | - Demócrito Ribeiro de Brito Neto
- Hospital Santa Genoveva, Uberlândia, MG, Brasil; Sociedade Brasileira de Anestesiologia (TSA-SBA), Rio de Janeiro, RJ, Brasil
| | - Rodrigo Rodrigues Alves
- Hospital Santa Genoveva, Uberlândia, MG, Brasil; Sociedade Brasileira de Anestesiologia (TSA-SBA), Rio de Janeiro, RJ, Brasil
| | - Fernando Cássio do Prado Silva
- Hospital Santa Genoveva, Uberlândia, MG, Brasil; Sociedade Brasileira de Anestesiologia (TSA-SBA), Rio de Janeiro, RJ, Brasil; Hospital Santa Genoveva, CET, Uberlândia, MG, Brasil
| | - Denis Fabiano de Souza
- Instituto do Coração do Triângulo (ICT), Uberlândia, MG, Brasil; Universidade Federal de Uberlândia (UFU), Ciências da Saúde, MG, Brasil
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12
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Han M, Kang F, Yang C, Liu Z, Wang T, Zhai M, Li J. Comparison of Adrenaline and Dexmedetomidine in Improving the Cutaneous Analgesia of Mexiletine in Response to Skin Pinpricks in Rats. Pharmacology 2020; 105:662-668. [PMID: 32460288 DOI: 10.1159/000506487] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 02/05/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Adrenaline (Adr) and dexmedetomidine (Dex) are commonly used adjuvants of local anesthetics; however, the difference in the improvement of analgesia of local anesthetics between the 2 adjuvants remains unclear. OBJECTIVE The objective of this experimental research was to evaluate the cutaneous analgesic effect of mexiletine (Mex) by coadministration with Dex or Adr. METHODS The effect of a nociceptive block was assessed based on the inhibition of the cutaneous trunci muscle reflex in response to skin pinpricks in rats. The analgesic activity of Mex alone and Mex coadministered with Dex or Adr was evaluated after subcutaneous injections. Subcutaneous injections of drugs or combinations include Mex 0.6, 1.8, and 6.0 μmol; Adr 13.66 nmol; Dex 1.05600 nmol; saline; and Mex 1.8 and 6.0 μmol, respectively, combined with Dex 0.01056, 0.10560, and 1.05600 nmol or Adr 0.55, 2.73, and 13.66 nmol, with each injection dose of 0.6 mL. RESULTS Subcutaneous injections of Mex elicited dose-related cutaneous analgesia. Compared with Mex (1.8 μmol), adding Dex or Adr to Mex (1.8 μmol) solutions for skin nociceptive block potentiated and prolonged the action. Mex (6.0 μmol) combined with Dex or Adr extended the duration of cutaneous analgesia when compared with Mex (6.0 μmol) alone. A high dose of Adr is more effective with Mex 1.8 μmol than that of Dex, whereas medium and low doses were less effective. Mex 6.0 μmol combined with any dose of Adr is superior to that of Dex. CONCLUSIONS Both Dex and Adr improve the sensory block and enhance the nociceptive block duration of Mex. But in most cases, Adr is superior to Dex. It may be that different mechanisms of action of the 2 adjuvants lead to the differences.
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Affiliation(s)
- Mingming Han
- Department of Anesthesiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Fang Kang
- Department of Anesthesiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Chengwei Yang
- Department of Anesthesiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Ziyou Liu
- Department of Anesthesiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Ting Wang
- Department of Anesthesiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Mingyu Zhai
- Department of Anesthesiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Juan Li
- Department of Anesthesiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China,
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Mariano ER, El-Boghdadly K, Ilfeld BM. Using postoperative pain trajectories to define the role of regional analgesia in personalised pain medicine. Anaesthesia 2020; 76:165-169. [PMID: 32368794 DOI: 10.1111/anae.15067] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/24/2020] [Indexed: 12/31/2022]
Affiliation(s)
- E R Mariano
- Department of Anesthesiology, Peri-operative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA.,Anesthesiology and Peri-operative Care Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - K El-Boghdadly
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, UK.,King's College London, UK
| | - B M Ilfeld
- In Residence, Department of Anesthesiology, School of Medicine, University of California, San Diego, San Diego, CA, USA.,Outcomes Research Consortium, Cleveland, OH, USA
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Mostafa MF, Aal FAA, Ali IH, Ibrahim AK, Herdan R. Dexmedetomidine during suprazygomatic maxillary nerve block for pediatric cleft palate repair, randomized double-blind controlled study. Korean J Pain 2020; 33:81-89. [PMID: 31888322 PMCID: PMC6944365 DOI: 10.3344/kjp.2020.33.1.81] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 12/03/2019] [Accepted: 12/03/2019] [Indexed: 12/23/2022] Open
Abstract
Background For children with cleft palates, surgeries at a young age are necessary to reduce feeding or phonation difficulties and reduce complications, especially respiratory tract infections and frequent sinusitis. We hypothesized that dexmedetomidine might prolong the postoperative analgesic duration when added to bupivacaine during nerve blocks. Methods Eighty patients of 1-5 years old were arbitrarily assigned to two equal groups (forty patients each) to receive bilateral suprazygomatic maxillary nerve blocks. Group A received bilateral 0.2 mL/kg bupivacaine (0.125%; maximum volume 4 mL/side). Group B received bilateral 0.2 mL/kg bupivacaine (0.125%) + 0.5 µg/kg dexmedetomidine (maximum volume 4 mL/side). Results The modified children's hospital of Eastern Ontario pain scale score was significantly lower in group B children after 8 hours of follow-up postoperatively (P < 0.001). Mean values of heart rate and blood pressure were significantly different between the groups, with lower mean values in group B (P < 0.001). Median time to the first analgesic demand in group A children was 10 hours (range 8-12 hr), and no patients needed analgesia in group B. The sedation score assessment was higher in children given dexmedetomidine (P = 0.03) during the first postoperative 30 minutes. Better parent satisfaction scores (5-point Likert scale) were recorded in group B and without serious adverse effects. Conclusions Addition of dexmedetomidine 0.5 µg/kg to bupivacaine 0.125% has accentuated the analgesic efficacy of bilateral suprazygomatic maxillary nerve block in children undergoing primary cleft palate repair with less postoperative supplemental analgesia or untoward effects.
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Affiliation(s)
- Mohamed F Mostafa
- Department of Anesthesia and Intensive Care, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Fatma A Abdel Aal
- Department of Anesthesia and Intensive Care, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Ibrahim Hassan Ali
- Department of Anesthesia and Intensive Care, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Ahmed K Ibrahim
- Department of Public Health, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Ragaa Herdan
- Department of Anesthesia and Intensive Care, Faculty of Medicine, Assiut University, Assiut, Egypt
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Prabhakar A, Lambert T, Kaye RJ, Gaignard SM, Ragusa J, Wheat S, Moll V, Cornett EM, Urman RD, Kaye AD. Adjuvants in clinical regional anesthesia practice: A comprehensive review. Best Pract Res Clin Anaesthesiol 2019; 33:415-423. [PMID: 31791560 DOI: 10.1016/j.bpa.2019.06.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 06/24/2019] [Indexed: 12/30/2022]
Abstract
Adjuvants are medications that work synergistically with local anesthetics to help enhance the duration and quality of analgesia in regional techniques. Regional anesthesia has become more prevalent as evidence continues to show efficacy, enhancement of patient care, increased patient satisfaction, and improved patient safety. Practitioners in the perioperative setting need to not only be familiar with regional techniques but also the medications used for them. Some examples of adjuvant medications for regional techniques include dexamethasone, alpha 2 agonists such as clonidine and dexmedetomidine, midazolam, buprenorphine, NMDA antagonists, including ketamine and magnesium, neostigmine, sodium bicarbonate, epinephrine, and non-steroidal anti-inflammatory drugs. The aim of the present investigation, therefore, is to provide a comprehensive review of the most commonly used non-opioid adjuvants in clinical practice today. Regional adjuvants can improve patient safety, increase patient satisfaction, and enhance clinical efficacy. Future studies and best practice techniques can facilitate standardization of regional anesthesia adjuvant dosing when providing nerve blocks in clinical practice.
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Affiliation(s)
- Amit Prabhakar
- Department of Anesthesiology, Division of Critical Care, Emory University School of Medicine, 550 Peachtree Street, Atlanta, GA, 30308, USA.
| | - Todd Lambert
- LSU Health Sciences Center New Orleans, 1901 Perdido Street, New Orleans, LA, 70112, USA.
| | - Rachel J Kaye
- Medical University of South Carolina, Charleston, SC, 29425, USA.
| | - Scott M Gaignard
- LSU Health Sciences Center New Orleans, 1901 Perdido Street, New Orleans, LA, 70112, USA.
| | - Joseph Ragusa
- LSU Health Sciences Center New Orleans, 1901 Perdido Street, New Orleans, LA, 70112, USA.
| | - Shannon Wheat
- Department of Anesthesiology, Division of Critical Care, Emory University School of Medicine, 550 Peachtree Street, Atlanta, GA, 30308, USA.
| | - Vanessa Moll
- Department of Anesthesiology, Division of Critical Care, Emory University School of Medicine, 550 Peachtree Street, Atlanta, GA, 30308, USA.
| | - Elyse M Cornett
- Department of Anesthesiology, LSU Health Shreveport, 1501 Kings Hwy, Shreveport, LA, 71103, USA.
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02115, USA.
| | - Alan David Kaye
- Department of Anesthesia, LSUHSC, 1542 Tulane Avenue, Suite 659, New Orleans, LA, 70112, USA.
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Hasanein R, Elshal S. Extending labor epidural analgesia using lidocaine plus either dexmedetomidine or epinephrine for emergency cesarean section. EGYPTIAN JOURNAL OF ANAESTHESIA 2019. [DOI: 10.1016/j.egja.2016.05.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Affiliation(s)
- Riham Hasanein
- Anesthesia Department, Faculty of Medicine, Cairo University, Egypt
- Saad Specialist Hospital, Alkhobar, Saudi Arabia
| | - Sahar Elshal
- Anesthesia Department, Faculty of Medicine, Cairo University, Egypt
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Local Anesthetic Additives for Regional Anesthesia: a Review of Current Literature and Clinical Application. CURRENT ANESTHESIOLOGY REPORTS 2019. [DOI: 10.1007/s40140-019-00334-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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18
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Albrecht E, Vorobeichik L, Jacot-Guillarmod A, Fournier N, Abdallah FW. Dexamethasone Is Superior to Dexmedetomidine as a Perineural Adjunct for Supraclavicular Brachial Plexus Block. Anesth Analg 2019; 128:543-554. [PMID: 30303864 DOI: 10.1213/ane.0000000000003860] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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19
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Sedation with dexmedetomidine prolongs the analgesic duration of brachial plexus block: a randomised controlled trial. Anaesth Crit Care Pain Med 2018; 38:231-236. [PMID: 30339891 DOI: 10.1016/j.accpm.2018.08.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Revised: 07/31/2018] [Accepted: 08/21/2018] [Indexed: 11/22/2022]
Abstract
PURPOSE Dexmedetomidine, an alpha 2 receptor agonist, prolongs nerve block duration when administered in conjunction with peripheral nerve blocks. We hypothesised that sedation with dexmedetomidine could also significantly prolong the analgesic duration of brachial plexus block (BPB) during orthopaedic surgery on the upper extremities. MATERIALS AND METHODS One hundred and two patients received upper extremity surgery under BPB. The patients were randomly sedated with dexmedetomidine (D group) or midazolam (M group) following BPB using 25 mL of local anaesthetics (1:1 mixture of 1% lidocaine and 0.75% ropivacaine). Adequate sedation was evaluated with the modified Ramsay Sedation Scale. Primary outcome was measured as the time the patient first requested analgesic via a patient-controlled analgesia device. Total opioid consumption during the first 24 post-operative hours was also measured as secondary outcomes. RESULTS Time to first request for analgesia (mean ± standard deviation) was significantly longer in the D group (616.9 ± 158.2 min) than in the M group (443.7 ± 127.2 min) (P < 0.001, Mean difference [95% CI] 173.2 [114.8-231.5] min). Total opioid consumption were significantly lower in the D group (fentanyl equivalent, 280.0 μg [171.3;374.0] vs. 363.9 μg [208.3;570.1], P = 0.01). Although patients in the D group showed deeper sedation over time (P < 0.001), PACU stay time was only slightly extended in D group (5.2 [1.2-9.2] min). Perioperative complications did not differ in the two groups. CONCLUSION Sedation with dexmedetomidine not only prolongs analgesic duration of BPB, but also reduces total opioid consumption during the first 24 post-operative hours.
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21
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Tschopp C, Tramèr MR, Schneider A, Zaarour M, Elia N. Benefit and Harm of Adding Epinephrine to a Local Anesthetic for Neuraxial and Locoregional Anesthesia. Anesth Analg 2018; 127:228-239. [DOI: 10.1213/ane.0000000000003417] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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22
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Singh V, Thepra M, Kirti S, Kumar P, Priya K. Dexmedetomidine as an Additive to Local Anesthesia: A Step to Development in Dentistry. J Oral Maxillofac Surg 2018; 76:2091.e1-2091.e7. [PMID: 29964002 DOI: 10.1016/j.joms.2018.05.037] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Revised: 05/30/2018] [Accepted: 05/30/2018] [Indexed: 12/12/2022]
Abstract
PURPOSE The study aimed to compare the effect of dexmedetomidine added to lidocaine against epinephrine added to lidocaine on local anesthetic potency and to look for future prospects of dexmedetomidine as an additive to local anesthesia in dentistry. MATERIALS AND METHODS The study included 25 healthy volunteers in whom extraction of all first premolars was scheduled as part of their orthodontic treatment plan. In this split-mouth, double-blind, crossover, randomized controlled trial, patients were randomized into 2 groups: Group 1 received injection lidocaine plus dexmedetomidine, and group 2 was administered lidocaine plus epinephrine. Patients were assessed for the onset of action of anesthesia, duration of analgesia, pain perception, and vital signs. RESULTS The mean values (±standard deviations) for the onset of anesthetic action in groups 1 and 2 were 113 ± 24.9 and 141 ± 34.8 seconds, respectively, for the mandible. For the maxilla, the mean values were 113 ± 24.9 seconds for group 1 and 165 ± 43.8 seconds for group 2. The duration of anesthesia was longer in group 1 (lidocaine plus dexmedetomidine), in which the requirement for the first analgesic on request was seen after a longer time interval, when compared with group 2 (lidocaine plus epinephrine). Pain perception elicited statistically significant results with less perception of pain in group 1 (lidocaine plus dexmedetomidine). The vital parameters remained stable, and the results were not statistically significant. CONCLUSIONS In this study, we observed that the addition of dexmedetomidine to lidocaine for maxillary and mandibular nerve blocks significantly prolonged the block duration and shortened the onset of action, as well as improved postoperative analgesia in terms of the need for fewer analgesics in the postoperative period. Furthermore, the vital parameters remained stable and no complications were encountered. The findings were supportive of the use of dexmedetomidine as an adjunct to local anesthetics in dental procedures.
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Affiliation(s)
- Virendra Singh
- Head, Department of Oral and Maxillofacial Surgery, Post Graduate Institute of Dental Sciences, Rohtak, India.
| | - Manju Thepra
- Resident, Post Graduate Institute of Dental Sciences, Rohtak, India
| | - Shruti Kirti
- Resident, Post Graduate Institute of Dental Sciences, Rohtak, India
| | - Prashant Kumar
- Senior Professor, Department of Anaesthesiology, Post Graduate Institute of Medical Sciences, Rohtak, India
| | - Kannu Priya
- Resident, Post Graduate Institute of Dental Sciences, Rohtak, India
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23
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Jung HS, Seo KH, Kang JH, Jeong JY, Kim YS, Han NR. Optimal dose of perineural dexmedetomidine for interscalene brachial plexus block to control postoperative pain in patients undergoing arthroscopic shoulder surgery: A prospective, double-blind, randomized controlled study. Medicine (Baltimore) 2018; 97:e0440. [PMID: 29668608 PMCID: PMC5916649 DOI: 10.1097/md.0000000000010440] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Adjuvant perineural dexmedetomidine can be used to prolong the analgesic effect of interscalene brachial plexus block (ISB). We investigated the optimal dose of dexmedetomidine in ISB for postoperative analgesia in patients undergoing arthroscopic shoulder surgery. METHODS One hundred patients scheduled for elective shoulder arthroscopic surgery were enrolled in this randomized, double-blind study. Ultrasound-guided ISB was performed before general anesthesia using 22 mL of ropivacaine 0.5% combined with 1, 1.5, or 2 μg/kg of dexmedetomidine (group D1, D2, and D3, respectively) or with normal saline as a control (group R, n = 25 per group). The primary outcome was the duration of analgesia (DOA), numeric pain rating scale (NRS), and consumption of additional analgesics during 36 h after ISB. Secondary outcome included durations of motor and sensory block (DOM and DOS), hemodynamic variables and sedation and dyspnea scores. RESULTS Ninety-seven patients completed the study. The DOS, DOM, and DOA were significantly longer in the dexmedetomidine groups than in group R. The DOA was significantly longer in group D3 than in groups D1 (P = .026) and D2 (P = .039). The DOA was 808.13 ± 179.97, 1032.60 ± 288.14, 1042.04 ± 188.13, and 1223.96 ± 238.06 min in groups R, D1, D2, and D3, respectively. The NRS score was significantly higher in group R than in the dexmedetomidine groups 12 h after ISB (P < .001) and significantly lower in group D3 than in the other groups 18 h after ISB (P = .02). The incidence of hypotension was higher in groups D2 and D3 than in group R during surgery (P = .008 and P = .011, respectively). There were no significant differences in consumption of rescue analgesics, sedation, and dyspnea scores between the study groups. CONCLUSION Perineural dexmedetomidine 2 μg/kg could be the optimal dose in ISB for arthroscopic shoulder surgery in that it provides an adequate DOA. However, this dose was associated with increased risk of hypotension.
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Affiliation(s)
- Hong Soo Jung
- Department of Anesthesiology and Pain Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea
| | - Kwon Hui Seo
- Department of Anesthesiology and Pain Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea
| | - Jae Hyuk Kang
- Department of Anesthesiology and Pain Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea
| | - Jin-Young Jeong
- Department of Orthopedic Surgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Jungbu-daero, Paldal-gu, Suwon-si, Gyeonggi-do, Republic of Korea
| | - Yong-Shin Kim
- Department of Anesthesiology and Pain Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea
| | - Na-Re Han
- Department of Anesthesiology and Pain Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea
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Elyazed MMA, Mogahed MM. Comparison of Magnesium Sulfate and Dexmedetomidine as an Adjuvant to 0.5% Ropivacaine in Infraclavicular Brachial Plexus Block. Anesth Essays Res 2018; 12:109-115. [PMID: 29628564 PMCID: PMC5872844 DOI: 10.4103/aer.aer_70_17] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Background: Magnesium sulfate and dexmedetomidine were used as adjuvants to local anesthesia to improve the quality of regional anesthesia. Aims: The aim of this study is to evaluate and compare the effects of magnesium sulfate and dexmedetomidine when added to ropivacaine on the quality of infraclavicular brachial plexus block (BPB). Settings and Design: This was a prospective randomized double-blinded controlled study. Patients and Methods: A total of 105 adult patients undergoing surgery in hands, wrist, and forearm using infraclavicular BPB were randomly assigned into three groups. Ultrasound-guided infraclavicular BPB was performed using 35 ml ropivacaine 0.5% diluted with 4 ml normal saline 0.9%. Magnesium sulfate 150 mg and dexmedetomidine 100 μg were added in the magnesium sulfate group and dexmedetomidine group, respectively. Duration of analgesia, onset times and durations of sensory block (SB) and motor block (MB), patient's satisfaction, and complications were recorded. Statistical Analysis: Statistical software SPSS 16 was used for statistical analysis. Results: Dexmedetomidine and magnesium sulfate provided longer duration of analgesia and lesser consumption of postoperative rescue analgesia than the control group (P = 0. 000); dexmedetomidine provided the longest duration of analgesia versus control and magnesium sulfate groups (P = 0.000). Dexmedetomidine provided the quickest onset times and the longest durations of both SB and MB than control and magnesium sulfate groups (P = 0.000). Dexmedetomidine group had higher incidences of bradycardia and hypotension. Conclusions: Magnesium sulfate or dexmedetomidine is a useful adjuvant to ropivacaine for infraclavicular BPB in lengthening the duration of analgesia. Dexmedetomidine provided quicker onset and longer duration of both SB and MB and longer duration of analgesia with lesser consumption of postoperative rescue analgesia; however, it showed a higher incidence of intraoperative hypotension and bradycardia than magnesium sulfate.
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Affiliation(s)
- Mohamed M Abu Elyazed
- Department of Anesthesia and Surgical ICU, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Mona M Mogahed
- Department of Anesthesia and Surgical ICU, Faculty of Medicine, Tanta University, Tanta, Egypt
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Koraki E, Stachtari C, Kapsokalyvas I, Stergiouda Z, Katsanevaki A, Trikoupi A. Dexmedetomidine as an adjuvant to 0.5% ropivacaine in ultrasound-guided axillary brachial plexus block. J Clin Pharm Ther 2017; 43:348-352. [DOI: 10.1111/jcpt.12657] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2017] [Accepted: 11/07/2017] [Indexed: 10/18/2022]
Affiliation(s)
- E. Koraki
- Department of Anesthesiology; General Hospital of Thessaloniki “G. Papanikolaou”; Thessaloniki Greece
| | - C. Stachtari
- Department of Anesthesiology; General Hospital of Thessaloniki “G. Papanikolaou”; Thessaloniki Greece
| | - I. Kapsokalyvas
- Department of Anesthesiology; General Hospital of Thessaloniki “G. Papanikolaou”; Thessaloniki Greece
| | - Z. Stergiouda
- Department of Anesthesiology; General Hospital of Thessaloniki “G. Papanikolaou”; Thessaloniki Greece
| | - A. Katsanevaki
- Department of Anesthesiology; General Hospital of Thessaloniki “G. Papanikolaou”; Thessaloniki Greece
| | - A. Trikoupi
- Department of Anesthesiology; General Hospital of Thessaloniki “G. Papanikolaou”; Thessaloniki Greece
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Swain A, Nag DS, Sahu S, Samaddar DP. Adjuvants to local anesthetics: Current understanding and future trends. World J Clin Cases 2017; 5:307-323. [PMID: 28868303 PMCID: PMC5561500 DOI: 10.12998/wjcc.v5.i8.307] [Citation(s) in RCA: 120] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2017] [Revised: 05/03/2017] [Accepted: 05/19/2017] [Indexed: 02/05/2023] Open
Abstract
Although beneficial in acute and chronic pain management, the use of local anaesthetics is limited by its duration of action and the dose dependent adverse effects on the cardiac and central nervous system. Adjuvants or additives are often used with local anaesthetics for its synergistic effect by prolonging the duration of sensory-motor block and limiting the cumulative dose requirement of local anaesthetics. The armamentarium of local anesthetic adjuvants have evolved over time from classical opioids to a wide array of drugs spanning several groups and varying mechanisms of action. A large array of opioids ranging from morphine, fentanyl and sufentanyl to hydromorphone, buprenorphine and tramadol has been used with varying success. However, their use has been limited by their adverse effect like respiratory depression, nausea, vomiting and pruritus, especially with its neuraxial use. Epinephrine potentiates the local anesthetics by its antinociceptive properties mediated by alpha-2 adrenoreceptor activation along with its vasoconstrictive properties limiting the systemic absorption of local anesthetics. Alpha 2 adrenoreceptor antagonists like clonidine and dexmedetomidine are one of the most widely used class of local anesthetic adjuvants. Other drugs like steroids (dexamethasone), anti-inflammatory agents (parecoxib and lornoxicam), midazolam, ketamine, magnesium sulfate and neostigmine have also been used with mixed success. The concern regarding the safety profile of these adjuvants is due to its potential neurotoxicity and neurological complications which necessitate further research in this direction. Current research is directed towards a search for agents and techniques which would prolong local anaesthetic action without its deleterious effects. This includes novel approaches like use of charged molecules to produce local anaesthetic action (tonicaine and n butyl tetracaine), new age delivery mechanisms for prolonged bioavailability (liposomal, microspheres and cyclodextrin systems) and further studies with other drugs (adenosine, neuromuscular blockers, dextrans).
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Koyyalamudi V, Sen S, Patil S, Creel JB, Cornett EM, Fox CJ, Kaye AD. Adjuvant Agents in Regional Anesthesia in the Ambulatory Setting. Curr Pain Headache Rep 2017; 21:6. [PMID: 28210917 DOI: 10.1007/s11916-017-0604-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE OF REVIEW A majority of surgical practice has involved ambulatory centers with the number of outpatient operations in the USA doubling to 26.8 million per year. Local anesthesia delivery provides numerous benefits, including increased satisfaction, earlier discharge, and reduction in unplanned hospital admission. Further, with the epidemic of opioid mediated overdoses, local anesthesia can be a key tool in providing an opportunity to reduce the need for other analgesics postoperatively. RECENT FINDINGS Adjuvants such as epinephrine and clonidine enhance local anesthetic clinical utility. Further, dexmedetomidine prolongs regional blockade duration effects. There has also been a significant interest recently in the use of dexamethasone. Studies have demonstrated a significant prolongation in motor and sensory block with perineural dexamethasone. Findings are conflicting as to whether intravenous dexamethasone has similar beneficial effects. However, considering the possible neurotoxicity effects, which perineural dexamethasone may present, it would be prudent not to consider intravenously administered dexamethasone to prolong regional block duration. Many studies have also demonstrated neurotoxicity from intrathecally administered midazolam. Therefore, midazolam as an adjuvant is not recommended. Magnesium prolongs regional block duration but related to paucity of studies as of yet, cannot be recommended. Tramadol yields inconsistent results and ketamine is associated with psychotomimetic adverse effects. Buprenorphine consistently increases regional block duration and reduce opioid requirements by a significant amount. Future studies are warranted to define best practice strategies for these adjuvant agents. The present review focuses on the many roles of local anesthetics in current ambulatory practice.
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Affiliation(s)
| | - Sudipta Sen
- Department of Anesthesiology, LSUHSC-Shreveport, Shreveport, LA, USA
| | - Shilpadevi Patil
- Department of Anesthesiology, LSUHSC-Shreveport, Shreveport, LA, USA
| | - Justin B Creel
- Department of Anesthesiology, LSUHSC-Shreveport, Shreveport, LA, USA
| | - Elyse M Cornett
- Department of Anesthesiology, LSUHSC-Shreveport, Shreveport, LA, USA
| | - Charles J Fox
- Department of Anesthesiology, LSUHSC-Shreveport, Shreveport, LA, USA.
| | - Alan D Kaye
- Department of Anesthesiology, LSUHSC-NO, New Orleans, LA, USA
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Vorobeichik L, Brull R, Abdallah F. Evidence basis for using perineural dexmedetomidine to enhance the quality of brachial plexus nerve blocks: a systematic review and meta-analysis of randomized controlled trials. Br J Anaesth 2017; 118:167-181. [DOI: 10.1093/bja/aew411] [Citation(s) in RCA: 108] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
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29
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Ouchi K, Sugiyama K. Dexmedetomidine Dose Dependently Enhances the Local Anesthetic Action of Lidocaine in Inferior Alveolar Nerve Block: A Randomized Double-Blind Study. Reg Anesth Pain Med 2017; 41:348-55. [PMID: 27015544 DOI: 10.1097/aap.0000000000000380] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND OBJECTIVES Dexmedetomidine (DEX) dose dependently enhances the local anesthetic action of lidocaine in rats. We hypothesized that the effect might also be dose dependent in humans. We evaluated the effect of various concentrations of DEX with a local anesthetic in humans. METHODS Eighteen healthy volunteers were randomly assigned by a computer to receive 1.8 mL of 1 of 4 drug combinations: (1) 1% lidocaine with 2.5 ppm (parts per million) (4.5 μg) DEX, (2) lidocaine with 5.0 ppm (9.0 μg) DEX, (3) lidocaine with 7.5 ppm (13.5μg) DEX, or (4) lidocaine with 1:80,000 (22.5 μg) adrenaline (AD), to produce inferior alveolar nerve block. Pulp latency and lower lip numbness (for assessing onset and duration of anesthesia) were tested, and sedation level, blood pressure, and heart rate were recorded every 5 minutes for 20 minutes, and every 10 minutes from 20 to 60 minutes. RESULTS Pulp latency of each tooth increased compared with baseline, from 5 to 15 minutes until 60 minutes. There were no significant intergroup differences at any time point. Anesthesia onset was not different between groups. Anesthesia duration was different between groups (that with DEX 7.5 ppm was significantly longer than that with DEX 2.5 ppm and AD; there was no difference between DEX 2.5 ppm and AD). Blood pressure decreased from baseline in the 5.0 and 7.5 ppm DEX groups at 30 to 60 minutes, although there was no hypotension; moreover, heart rate did not change in any group. Sedation score did not indicate deep sedation in any of the groups. CONCLUSIONS Dexmedetomidine dose dependently enhances the local anesthetic action of lidocaine in humans. Dexmedetomidine at 2.5 ppm produces similar enhancement of local anesthesia effect as addition of 1:80,000 AD.
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Affiliation(s)
- Kentaro Ouchi
- From the Department of Dental Anesthesiology, Field of Oral and Maxillofacial Rehabilitation, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
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30
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Ping Y, Ye Q, Wang W, Ye P, You Z. Dexmedetomidine as an adjuvant to local anesthetics in brachial plexus blocks: A meta-analysis of randomized controlled trials. Medicine (Baltimore) 2017; 96:e5846. [PMID: 28121930 PMCID: PMC5287954 DOI: 10.1097/md.0000000000005846] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Revised: 12/14/2016] [Accepted: 12/16/2016] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Brachial plexus block (BPB) for upper extremity surgery provides superior analgesia, but this advantage is limited by the pharmacological duration of local anesthetics. Dexmedetomidine (DEX) as a local anesthetics adjuvant for BPB has been utilized to prolong the duration of the nerve block in some randomized controlled trials (RCTs) but is far from unanimous in the efficacy and safety of the perineural route. Hence, an updated meta-analysis was conducted to assess the efficacy and safety of DEX as local anesthetic adjuvants on BPB. METHODS A search in electronic databases was conducted to collect the RCTs that investigated the impact of adding DEX to local anesthetics for BPB. Sensory block duration, motor block duration, onset time of sensory and motor block, time to first analgesic request, the common adverse effects were analyzed. RESULTS Eighteen trails (1014 patients) were included with 515 patients receiving perineural DEX. The addition of DEX prolonged the duration of sensory block (WMD 257 minutes, 95%CI 191.79-322.24, P < 0.001), motor block (WMD 242 minutes, 95%CI 174.94-309.34, P < 0.001), and analgesia (WMD 26 6 minutes, 95%CI 190.75-342.81, P < 0.001). Perineural DEX also increased the risk of bradycardia (OR=8.25, 95%CI 3.95-17.24, P < 0.001), hypotension (OR = 5.62, 95%CI 1.52-20.79, P < 0.01), and somnolence (OR = 19.67, 95%CI 3.94-98.09, P < 0.001). There was a lack of evidence that perineural DEX increased the risk of other adverse events. CONCLUSIONS DEX is a potential anesthetic adjuvant that can facilitate better anesthesia and analgesia when administered in BPB. However, it also increased the risk of bradycardia, hypotension, and somnolence. Further research should focus on the efficacy and safety of the preneural administration of DEX.
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Affiliation(s)
- Yongmei Ping
- Department of Anaesthesiology, Maternal and Children Hospital of Lishui City, Lishui
| | - Qigang Ye
- Department of Anaesthesiology, Taizhou First People's Hospital and Huangyan Hospital of Wenzhou Medical University, Taizhou, China
| | - Wenwei Wang
- Department of Anaesthesiology, Taizhou First People's Hospital and Huangyan Hospital of Wenzhou Medical University, Taizhou, China
| | - Pingke Ye
- Department of Anaesthesiology, Taizhou First People's Hospital and Huangyan Hospital of Wenzhou Medical University, Taizhou, China
| | - Zhibin You
- Department of Anaesthesiology, Taizhou First People's Hospital and Huangyan Hospital of Wenzhou Medical University, Taizhou, China
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Investigating the Efficacy of Dexmedetomidine as an Adjuvant to Local Anesthesia in Brachial Plexus Block. Reg Anesth Pain Med 2017; 42:184-196. [DOI: 10.1097/aap.0000000000000564] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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32
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Park JY. Factors to bear in mind regarding the use of dexmedetomidine. Korean J Anesthesiol 2017; 70:233-234. [PMID: 28580071 PMCID: PMC5453882 DOI: 10.4097/kjae.2017.70.3.233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Affiliation(s)
- Jong-Yeon Park
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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33
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Lu Y, Sun J, Zhuang X, Lv G, Li Y, Wang H, Wang G. Perineural Dexmedetomidine as an Adjuvant Reduces the Median Effective Concentration of Lidocaine for Obturator Nerve Blocking: A Double-Blinded Randomized Controlled Trial. PLoS One 2016; 11:e0158226. [PMID: 27341450 PMCID: PMC4920423 DOI: 10.1371/journal.pone.0158226] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Accepted: 06/13/2016] [Indexed: 11/18/2022] Open
Abstract
UNLABELLED Research suggests that the addition of dexmedetomidine to local anesthetics can prolong peripheral nerve blocks; however, it is not known whether dexmedetomidine can reduce the quantity of local anesthetic needed. We hypothesized that adding dexmedetomidine as an adjuvant to an obturator nerve block could reduce the median effective concentration of lidocaine. In this double-blinded randomized trial, 60 patients scheduled for elective transurethral resection of bladder tumors on the lateral wall were randomly divided into two groups: the control group (C group, n = 30) and the dexmedetomidine group (D group, n = 30). Two main branches of the obturator nerve (i.e., anterior and posterior) were identified using neural stimulation at the inguinal level, with only lidocaine used for the C group and 1 μg/kg dexmedetomidine combined with lidocaine used for the D group. The median effective concentration was determined by an up-and-down sequential trial. The ratio of two consecutive concentrations was 1.2. The median effective concentration (95% confidence interval) of lidocaine was 0.57% (0.54%-0.62%) in the C group and 0.29% (0.28%-0.38%) in the D group. The median effective concentration of lidocaine was significantly lower in the D group than in the C group (p < 0.05). These results indicate that dexmedetomidine (1 μg/kg) in combination with lidocaine for obturator nerve block decreases the median effective concentration of lidocaine. TRIAL REGISTRATION ClinicalTrials.gov NCT02066727.
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MESH Headings
- Adjuvants, Pharmaceutic
- Adolescent
- Adult
- Aged
- Aged, 80 and over
- Analgesics, Non-Narcotic/administration & dosage
- Analgesics, Non-Narcotic/adverse effects
- Anesthetics, Local/administration & dosage
- Anesthetics, Local/adverse effects
- Anesthetics, Local/therapeutic use
- Dexmedetomidine/administration & dosage
- Dexmedetomidine/adverse effects
- Dose-Response Relationship, Drug
- Female
- Humans
- Lidocaine/administration & dosage
- Lidocaine/adverse effects
- Lidocaine/therapeutic use
- Male
- Middle Aged
- Muscle Strength/drug effects
- Muscle, Skeletal/drug effects
- Muscle, Skeletal/innervation
- Nerve Block/methods
- Obturator Nerve/drug effects
- Young Adult
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Affiliation(s)
- Yuechun Lu
- Department of Anesthesiology, Second Hospital of Tianjin Medical University, Tianjin, China
| | - Jian Sun
- Department of Anesthesiology, Second Hospital of Tianjin Medical University, Tianjin, China
| | - Xinqi Zhuang
- Department of Anesthesiology, Second Hospital of Tianjin Medical University, Tianjin, China
| | - Guoyi Lv
- Department of Anesthesiology, Second Hospital of Tianjin Medical University, Tianjin, China
| | - Yize Li
- Department of Anesthesiology, Tianjin Medical University General Hospital, Tianjin, China
| | - Haiyun Wang
- Department of Anesthesiology, Tianjin Medical University General Hospital, Tianjin, China
| | - Guolin Wang
- Department of Anesthesiology, Tianjin Medical University General Hospital, Tianjin, China
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Lee MJ, Koo DJ, Choi YS, Lee KC, Kim HY. Dexamethasone or Dexmedetomidine as Local Anesthetic Adjuvants for Ultrasound-guided Axillary Brachial Plexus Blocks with Nerve Stimulation. Korean J Pain 2016; 29:29-33. [PMID: 26839668 PMCID: PMC4731548 DOI: 10.3344/kjp.2016.29.1.29] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2015] [Revised: 11/06/2015] [Accepted: 11/27/2015] [Indexed: 11/11/2022] Open
Abstract
Background The purpose of this study was to evaluate the effect of dexamethasone or dexmedetomidine added to ropivacaine on the onset and duration of ultrasound-guided axillary brachial plexus blocks (BPB). Methods Fifty-one ASA physical status I-II patients with elective forearm and hand surgery under axillary brachial plexus blocks were randomly allocated to receive 20 ml of 0.5% ropivacaine with 2 ml of isotonic saline (C group, n = 17), 20 ml of 0.5% ropivacaine with 2 ml (10 mg) of dexamethasone (D group, n = 17) or 20 ml of 0.5% ropivacaine with 2 ml (100 µg) of dexmedetomidine (DM group, n = 17). A nerve stimulation technique with ultrasound was used in all patients. The onset time and duration of sensory blocks were assessed. Results The duration of the sensory block was extended in group D and group DX compared with group C (P < 0.05), but there was no significant difference between group D and group DX. However, there were no significant differences in onset time in all three groups. Conclusions Dexamethasone 10 mg and dexmedetomidine 100 µg were equally effective in extending the duration of ropivacaine in ultrasound-guided axillary BPB with nerve stimulation. However, neither drug has significantly effects the onset time.
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Affiliation(s)
- Myeong Jong Lee
- Department of Anesthesiology and Pain Medicine, Konkuk University Medical School, Chungju, Korea
| | - Dae Jeong Koo
- Department of Anesthesiology and Pain Medicine, Konkuk University Medical School, Chungju, Korea
| | - Yu Sun Choi
- Department of Anesthesiology and Pain Medicine, Konkuk University Medical School, Chungju, Korea
| | - Kyu Chang Lee
- Department of Anesthesiology and Pain Medicine, Konkuk University Medical School, Chungju, Korea
| | - Hye Young Kim
- Department of Anesthesiology and Pain Medicine, Konkuk University Medical School, Chungju, Korea
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Kirksey MA, Haskins SC, Cheng J, Liu SS. Local Anesthetic Peripheral Nerve Block Adjuvants for Prolongation of Analgesia: A Systematic Qualitative Review. PLoS One 2015; 10:e0137312. [PMID: 26355598 PMCID: PMC4565585 DOI: 10.1371/journal.pone.0137312] [Citation(s) in RCA: 163] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Accepted: 08/14/2015] [Indexed: 12/13/2022] Open
Abstract
Background The use of peripheral nerve blocks for anesthesia and postoperative analgesia has increased significantly in recent years. Adjuvants are frequently added to local anesthetics to prolong analgesia following peripheral nerve blockade. Numerous randomized controlled trials and meta-analyses have examined the pros and cons of the use of various individual adjuvants. Objectives To systematically review adjuvant-related randomized controlled trials and meta-analyses and provide clinical recommendations for the use of adjuvants in peripheral nerve blocks. Methods Randomized controlled trials and meta-analyses that were published between 1990 and 2014 were included in the initial bibliographic search, which was conducted using Medline/PubMed, Cochrane Central Register of Controlled Trials, and EMBASE. Only studies that were published in English and listed block analgesic duration as an outcome were included. Trials that had already been published in the identified meta-analyses and included adjuvants not in widespread use and published without an Investigational New Drug application or equivalent status were excluded. Results Sixty one novel clinical trials and meta-analyses were identified and included in this review. The clinical trials reported analgesic duration data for the following adjuvants: buprenorphine (6), morphine (6), fentanyl (10), epinephrine (3), clonidine (7), dexmedetomidine (7), dexamethasone (7), tramadol (8), and magnesium (4). Studies of perineural buprenorphine, clonidine, dexamethasone, dexmedetomidine, and magnesium most consistently demonstrated prolongation of peripheral nerve blocks. Conclusions Buprenorphine, clonidine, dexamethasone, magnesium, and dexmedetomidine are promising agents for use in prolongation of local anesthetic peripheral nerve blocks, and further studies of safety and efficacy are merited. However, caution is recommended with use of any perineural adjuvant, as none have Food and Drug Administration approval, and concerns for side effects and potential toxicity persist.
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Affiliation(s)
- Meghan A Kirksey
- Department of Anesthesiology, Hospital for Special Surgery, New York, New York, United States of America; Department of Anesthesiology, Weill College of Medicine at Cornell University, New York, New York, United States of America
| | - Stephen C Haskins
- Department of Anesthesiology, Hospital for Special Surgery, New York, New York, United States of America; Department of Anesthesiology, Weill College of Medicine at Cornell University, New York, New York, United States of America
| | - Jennifer Cheng
- Department of Anesthesiology, Hospital for Special Surgery, New York, New York, United States of America
| | - Spencer S Liu
- Department of Anesthesiology, Hospital for Special Surgery, New York, New York, United States of America; Department of Anesthesiology, Weill College of Medicine at Cornell University, New York, New York, United States of America
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