Timing of intravenous dexamethasone

for prolongation of analgesia after

brachial plexus block

A randomized, double-blind, placebo-controlled

trial

PRESENTER:

Ben Goodman

BACKGROUND

Intravenous dexamethasone is frequently used to prolong analgesia

after brachial plexus block following upper extremity surgery. However,

the optimal timing for its administration has not been previously

examined.

METHODS

1. Double-blind, randomized, placebo-controlled trial conducted at a

single tertiary academic health sciences center

2. Patients: 18-80 years old, ASA 1-3, BMI <35 kg/m2, undergoing

unilateral upper extremity surgery with a supraclavicular brachial

plexus block

3. Standardized supraclavicular block: intertruncal technique, 15ml

bupivacaine 0.5% with 1:200,000 epinephrine mixed with 15ml

lidocaine 2%

4. Intervention: Intravenous dexamethasone 8 mg administration

randomized 1:1:1:1 to:

• 1 hour before

• during

• 1 hour after

• 2 hours after the block

5. 6. Placebo (saline) was infused at the other time points to blind

patients, providers, investigators

Primary outcome: time from block to first postoperative pain (pain

diary)

RESULTS

• 414 patients were screened, 220 patients provided consent, 23

excluded. The remaining 197 patients were enrolled, randomized,

received the study intervention.

• However, 39 patients could not be reached for follow-up after hospital

discharge. 158 patients with full data sets were included for outcome

analysis.

The timing of intravenous

dexamethasone does not affect

the duration of analgesia after

brachial plexus block

Time of IV

dexamethasone

1 h before During block 1 h after 2 h after

Figure 1: Time to first pain onset by group

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Figure 2: Distribution of time to first pain onset for the

entire cohort. N=Number; *Represents those patients

who were pain-free for the first 48 hours

• There was no difference in the primary outcome measure, time to

first postoperative pain, between the groups (p=0.90); see Figure 1

• There were no differences in demographic or other outcome

measures between the groups including patient satisfaction, block

onset, pain scores, opioid consumption, nausea, sensory or motor

deficit at 3 months.

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• Given the relatively high percentage of missing values of the primary

outcome (n=39 or 19.8%), linear regression and sensitivity analysis

were used to assess for confounding and differences between the

groups. These showed that the missing primary outcome data are

not a concern and that our results are robust despite the missing

values.

DISCUSSION

• The results from this randomized, double- blind, placebo-controlled

study suggest that the timing of intravenous administration of

dexamethasone between 1 hour before and 2 hours after a brachial

plexus block has no impact on the duration of postoperative

analgesia