STH Breakfast Club: Perineural dexamethasone in peripheral nerve blocks

April 19th, 2017. Jake Drinkwater

A copy of the full presentation is available at the following link (Perineural Dexamethasone), with a summary shown below.


Additives to local anaesthetic (LA) have long been used in an attempt to prolong the duration, reduce the onset time and improve the safety profile of LA’s. Recently there has been much interest in the addition of dexamethasone to LA used for peripheral nerve blockade with the aim of prolonging the duration of the block. As with any new technique there are often undesirable consequences, side effects and often a degree of risk. As ever, the clinical benefit of the technique must be weighed against the risks and against alternative techniques. In this presentation we look at the current evidence for the use of Dexamethasone to prolong to duration of peripheral nerve blockade.

Main question/ issues discussed:

  1. Does dexamethasone increase duration analgesia of nerve blocks?
  2. Is perineural dexamethasone better than systemic administration?
  3. Is perineural dexamethasone safe?

Take home messages:

Perineural dexamethasone significantly prolongs the duration of peripheral nerve blocks, with greater effect when added to longer acting local anaesthetics. However, a statistically similar prolongation of the duration of peripheral nerve blocks can be achieved with systemically administered dexamethasone. Owing to uncertainty regarding the neurotoxic effects of dexamethasone and in the absence of a clear benefit of perineural administration, current evidence points towards the systemic administration to prolong the duration of peripheral nerve blockade.


  1. Abdallah FW, Brull R. Facilitatory effects of perineural dexmedetomidine on neuraxial and peripheral nerve block: a systematic review and meta-analysis. British Journal of Anaesthesia. 2013 May 19;110(6):915–25.
  2. Abdallah FW, Johnson J, Chan V, Murgatroyd H, Ghafari M, Ami N, et al. Intravenous Dexamethasone and Perineural Dexamethasone Similarly Prolong the Duration of Analgesia After Supraclavicular Brachial Plexus Block. Regional Anesthesia and Pain Medicine. 2015;40(2):125–32.
  3. Albrecht E, Kern C, Kirkham KR. Perineural vs intravenous administration of dexamethasone: more data are available. British Journal of Anaesthesia. 2014 Dec 11;114(1):160–0.
  4. Aliste J, Leurcharusmee P, Engsusophon P, Gordon A, Michelagnoli G, Sriparkdee C, et al. Comparaison randomisée entre la dexaméthasone intraveineuse et périneurale pour réaliser un bloc axillaire échoguidé. Canadian Journal of Anesthesia/Journal canadien d’anesthésie. 2016 Sep 23;64(1):29–36.
  5. Bjørn S, Linde F, Nielsen KK, Børglum J, Hauritz RW, Bendtsen TF. Effect of Perineural Dexamethasone on the Duration of Single Injection Saphenous Nerve Block for Analgesia After Major Ankle Surgery. Regional Anesthesia and Pain Medicine. 2017;42(2):210–6.
  6. Chisholm MF, Cheng J, Fields KG, Marx RG, Maalouf DB, Liguori GA, et al. Perineural dexamethasone with subsartorial saphenous nerve blocks in ACL reconstruction. Knee Surg Sports Traumatol Arthrosc. 2016 Apr 13;40(2):125–2.
  7. Choi S, Rodseth R, McCartney CJL. Effects of dexamethasone as a local anaesthetic adjuvant for brachial plexus block: a systematic review and meta-analysis of randomized trials. British Journal of Anaesthesia. 2014 Feb 17;112(3):427–39.
  8. Chun EH, Kim YJ, Woo JH. Which is your choice for prolonging the analgesic duration of single-shot interscalene brachial blocks for arthroscopic shoulder surgery? intravenous dexamethasone 5 mg vs. perineural dexamethasone 5 mg randomized, controlled, clinical trial. Medicine. 2016 Jun;95(23):e3828–8.
  9. Dawson RL, McLeod DH, Koerber JP, Plummer JL, Dracopoulos GC. A randomised controlled trial of perineural vs intravenous dexamethasone for foot surgery. Anaesthesia. 4 ed. 2015 Dec 18;71(3):285–90.
  10. Desmet M, Braems H, Reynvoet M, Plasschaert S, Van Cauwelaert J, Pottel H, et al. I.V. and perineural dexamethasone are equivalent in increasing the analgesic duration of a single-shot interscalene block with ropivacaine for shoulder surgery: a prospective, randomized, placebo-controlled study. British Journal of Anaesthesia. 2013 Aug 14;111(3):445–52.
  11. Fredrickson FANZCA MJ, Danesh-Clough TK, White R. Adjuvant Dexamethasone for Bupivacaine Sciatic and Ankle Blocks. Regional Anesthesia and Pain Medicine. 2013;38(4):300–7.
  12. Jæger P, Grevstad U, Koscielniak-Nielsen ZJ, Sauter AR, Sørensen JK, Dahl JB. Does dexamethasone have a perineural mechanism of action? A paired, blinded, randomized, controlled study in healthy volunteers. British Journal of Anaesthesia. 2016 Oct 31;117(5):635–41.
  13. Tanaka K, Kawanishi R, Tsutsumi YM, Takeda Y, Yamamoto K, Nomura K, et al. Perineural but not systemic low-dose dexamethasone prolongs the duration of interscalene block with ropivacaine: a prospective randomized trial. LRA. 2014 Apr;:5–5.
  14. Leurcharusmee P, Aliste J, Van Zundert TCRV, Engsusophon P, Arnuntasupakul V, Tiyaprasertkul W, et al. A Multicenter Randomized Comparison Between Intravenous and Perineural Dexamethasone for Ultrasound-Guided Infraclavicular Block. Regional Anesthesia and Pain Medicine. 2016;41(3):328–33.
  15. Maher DP, Serna-Gallegos D, Mardirosian R, Thomas OJ, Zhang X, McKenna R, et al. The Combination of IV and Perineural Dexamethasone Prolongs the Analgesic Duration of Intercostal Nerve Blocks Compared with IV Dexamethasone Alone. Pain Med. 2016 Jul 29;:pnw149–2.
  16. Marty P, Bennis M, Legaillard B, Cavaignac E, Ferre F, Lebon J, et al. A New Step Toward Evidence of In Vivo Perineural Dexamethasone Safety. Regional Anesthesia and Pain Medicine. 2017 Apr;:1–2.
  17. Morales-Muñoz C, Sánchez-Ramos JL, Díaz-Lara MD, González-González J, Gallego-Alonso I, Hernández-del-Castillo MS. Eficacia analgésica de una dosis única de dexametasona perineural en el bloqueo ecoguiado del nervio femoral en cirugía de prótesis total de rodilla. Revista Española de Anestesiología y Reanimación. 2017 Jan;64(1):19–26.
  18. De Oliveira GS, Almeida MD, Benzon HT, McCarthy RJ. Perioperative Single Dose Systemic Dexamethasone for Postoperative PainA Meta-analysis of Randomized Controlled Trials. Anesthesiology. The American Society of Anesthesiologists; 2011 Sep 1;115(3):575–88.
  19. Rahangdale R, Kendall MC, McCarthy RJ, Tureanu L, Doty R Jr, Weingart A, et al. The Effects of Perineural Versus Intravenous Dexamethasone on Sciatic Nerve Blockade Outcomes. Anesth Analg. 2014 May;118(5):1113–9.
  20. Rosenfeld DM, Ivancic MG, Hattrup SJ, Renfree KJ, Watkins AR, Hentz JG, et al. Perineural versus intravenous dexamethasone as adjuncts to local anaesthetic brachial plexus block for shoulder surgery. Anaesthesia. 4 ed. 2016 Feb 22;71(4):380–8.
  21. Tandoc MN, Fan L, Kolesnikov S, Kruglov A, Nader ND. Adjuvant dexamethasone with bupivacaine prolongs the duration of interscalene block: a prospective randomized trial. Journal of Anesthesia. 2011 Jun 17;25(5):704–9.
  22. Tomar GS, Ganguly S, Cherian G. Effect of Perineural Dexamethasone With Bupivacaine in Single Space Paravertebral Block for Postoperative Analgesia in Elective Nephrectomy Cases. American Journal of Therapeutics. 2016 Jan;:1–2.
  23. Williams BA, Hough KA, Tsui BYK, Ibinson JW, Gold MS, Gebhart GF. Neurotoxicity of Adjuvants Used in Perineural Anesthesia and Analgesia in Comparison With Ropivacaine. Regional Anesthesia and Pain Medicine. 2011 May;36(3):225–30.
  24. Yilmaz-Rastoder E, Gold MS, Hough KA, Gebhart GF, Williams BA. Effect of Adjuvant Drugs on the Action of Local Anesthetics in Isolated Rat Sciatic Nerves. Regional Anesthesia and Pain Medicine. 2012;37(4):403–9.

STH Consultant CPD Updates: Trauma

This is the summary of the PowerPoint presentations from the STH Consultant CPD teaching programme.

This month’s session provided an update on trauma anaesthesia in line with the Royal College of Anaesthetists Matrix.

The following areas were covered by our trauma lead, Dr Ben Edwards @madders76 (Consultant Anaesthetist, Sheffield Teaching Hospitals NHS Foundation Trust). Please click on the links for a copy of the presentation.

STH Consultant CPD Updates: Regional Anaesthesia

This is the latest video from the Sheffield Teaching Hospitals Consultant CPD teaching programme.

This month’s session provided an update on regional anaesthesia  in line with the Royal College of Anaesthetists Matrix.

The following areas were covered by Dr Tim Moll (Consultant Anaesthetist, Sheffield Teaching Hospitals NHS Foundation Trust) in an outstanding presentation. He is on Twitter as @tim_moll

  • Indications, risks and benefits of regional anaesthesia (2C01)
  • Principles of performing local, regional and neuraxial techniques (2C02)
  • Use of nerve/plexus location techniques (2C03)
  • Recognition and management of side and complications of regional anaesthesia (2C04)

Please note that the video has no sound/commentary and is over 500MB in size. A download speed of at least 2 Mbps is recommnded.

ABRA ASM Nottingham 2013: Key Points

Dr Steve Rowe (@Kangaroosteve) recently attended the Association of Burns & Reconstructive Anaesthetists ASM (November 2013) held in N0ttingham, and has very kindly provided us with his reflections on the talks.

The RCOA Matrix Codes for each talk are shown (in my opinion, the organisers didn’t provide them), along with the details of the speaker.

Association of Burns and Reconstructive Anaesthetists Nottingham 15th November 2013

Long Term Outcomes in Chronic Pain – do perioperative techniques alter outcome? (2E03): Dr Simon Tordoff, Leicester.

  • Chronic pain after surgery is common, but not often consented for
  • Hernia repair @ 1 Year – 19% some pain; 6% moderate or severe pain; 6% Severe pain restricting daily function (Callesen Br J Surg 1999)
  • These outcomes are verified by a very large Swedish study looking at their hernia registry (like our joint registry).
  • Knee replacements – 20% unsatisfied at 1 year due to pain (and pain commonest indication to perform surgery in first place….)
  •  Thoracotomy –   61% pain after 1 year, 3-5% severe pain; Neuropathic pain 21% at 7 years
  •  Amputation – 50-75% Phantom limb pain; 20-50% Stump pain
  • Given the above, the suggestion was that it may be prudent to screen for psychological vulnerability to develop chronic pain.

Significant risk factors are:

  1. Poor post operative pain control
  2. Pre-existing chronic pain
  3. Surgical complication
  4. Multiple surgeries
  5. Obesity and disordered glucose metabolism – sensitizes to post op pain.

Take home message – a conservative estimate of 2-4% severe chronic pain after surgery – probably should be consented for specifically, and a big national audit would be nice.

Opioid rotations and other strategies (2E01): Dr Doug Johnson, Birmingham.

S/E of opioids well known – constipation, N+V, Itch, tolerance

Opioid induced hyperalgesia (OIH) is recognised more, especially in burns patients.

OIH gives increased pain with increased doses of opioids, with a change in the pain charateristics – more diffuse, allodynia, aslong with neuro-excitation phenomena (this is something we are most familiar with – “post-remifentanil” patients in recovery).

Thought to be NMDA/Glutamate mediated.

Recognition is important. First line therapy is to increase the dose of opioid and evaluate for increased efficacy – this would be indicative of tolerance rather than OIH. If pain and other symptoms worsen, OIH likely.


  1. Decrease or eliminate opioid
  2. Switch or rotate opioids
  3. Utilise other agents with NMDA receptor activity – ketamine/gapapentoid
  4. Utilise combination therapies – paracetamol/Nsaids etc etc

Opioid rotation

  • There is incomplete cross tolerance, with different drugs having a range of effects on other receptor systems e.g. Methadone and NMDA receptors
  • The switch is thought to allow the body to get rid of morphine-3-glucuronide, a metabolic product with no significant opioid receptor activity, but implicated in tolerance and other side effects.
  • Switching morphine to fentanyl often fails dues to rapid tolerance developing to fentanyl.
  • Methadone theoretically a good option.
  • Oxycodone also a viable alternative.


Cochrane review in 2010 supports is use in acute post op pain

Ketamine in subanaesthetic dose (that is a dose which is below that required to produce anaesthesia) is effective in reducing morphine requirements in the first 24 hours after surgery. Ketamine also reduces postoperative nausea and vomiting. Adverse effects are mild or absent.”

Benefits shown with:

  1. Pre-incision bolus/Bolus at wound closure/continuous peri-operative infusion/post-op infusion with morphine.
  2. No benefit demonstrated with >30mg TOTAL in 24 hours
  3. Doses discussed for bolus treatment peri-operatively were in the range 75-100mcg/kg, though it seems that p to 0.5mg/kg can be used without a rise in side effects.


  • Indirectly inhibits NMDA receptor overactivity
  • Only convincing evidence is that it decreases “Burns itch” – 300-1200mg tds po


  • BD dosing, Lower doses, NICE approved
  • More expensive
  • >5% body surface area burns – gives a significant reduction in pain/itch and procedural pain
  • No difference in LOS or opioid consumption
  • No difference in pain at 6 months

Other talks were related to foreign forays providing anaesthesia for reconstructive surgery

The first was for reconstructive surgery after noma (cancrum oris) a disease of poverty in sub-Saharan Africa – the main thrust of the talk was that these patients have difficult airways, often with absolute trismus, but with very careful planning airway disasters were avoided. This involved a 2-consultant airway assessment and documentation of airway plan.

The second was a trainee presentation that won the Russell Davis and Stuart Laird Prize  – the trainee discussed providing regional anaesthesia in a resource poor environment.

The final discussion related to revalidation and appraisal. Whilst useful, it generated no significant take home points.

It is likely that the meeting next year will be held in Manchester, and Sheffield in 2015.

BSOA ASM London 2013: Key Points

I recently attended the British Society of Orthopaedic Anaesthetists Annual Scientific Meeting, November 2013.

In order to allow those who were unable to attend the meeting to gain a flavour of the topics covered by the speakers I have created a summary of the key points of each talk (in my opinion).

The RCOA Matrix Codes for each talk are shown (in my opinion, the organisers didn’t provide them), along with the details of the speaker.

An orthogeriatric perspective on the peri-operative care of patients with fractured neck of femur (2A07): Dr Celia Gregson, Bristol

  • Avoid drugs with anticholinergic effects due to risk of delirium in NOF. Remember constipation as a cause of confusion. Use Lactulose!
  • Orthogeriatrics view on NOF. Usual Hb drop 2.5g (4g in IM nail). Do Hemocue in PACU. Transfuse early so can mobilise next day.

Perioperative orthopaedics: The perfect translational research model (1A02): Dr Gareth Ackland, UCL

  • VISION study (JAMA 2012); 40K pats, age>45, non-cardiac SxGA. 12% had T-I inc (>50% asymptomatic w/o ECG changes). Assoc with inc LOS.
  • Research update: postop complications double mortality up to 10 yr postop! This includes “small” complications like wound infections.

What matters in cervical spine injury (2A01): Dr Rob McCahon, Nottingham

  • Direct laryngoscopy induces forces primarily at C0-C2 BUT lots of room here for the cord to flex & extend (only takes up 25% of available room). The space is decreased if your rotate the neck – avoid rotational forces at all costs.
  • Risk factors for c-spine injury: pelvic #, ISS > 15, age < 40. [Clayton Injury 2012]. Max-fax injuries not a factor (despite ATLS teaching).
  • < 50% of the normal population aged over fifty have evidence of canal stenosis/impingement on MRI. Don’t just take care in trauma cases!

Paediatric regional anaesthesia (2D05, 2G03): Prof Peter Marhofer, University of Vienna

  • aPPT frequently abnormal < 45 weeks post conceptual age. Not a CI to central neuraxial blockade.
  • ADARPEF study (2010) Complication rate for RA in children 0.12% (Central:Peripheral 6:1). No serious morbidity.
  • Paed RA: Supraclavicular best for upper limb as axillary nerves as superficial and difficult to visualise with USS

Lower limb arthroplasty, regional anaesthesia and outcome (2G01): Dr Barrie Fischer, Redditch

  • No clear benefit between analgesic technique & functional outcome or LOS. The total package of care is more important.
  • PROSPECT Guidelines: THR: SAB plus IT opiate or GA plus LPB. Little evidence for LIA. TKR: SAB plus IT opiate or GA plus FNB (not SNB)
  • THR/TKR: Meta-analyses show RA less blood loss, pain, PONV, and possibly VTE. In US >75% GA only 11% SAB. SAB decreases postop comps & RIP.
  • TKR: femoral nerve catheters are not associated with better analgesia compared to single-shot FNB and just impair mobilisation.
  • Enhanced Recovery & FNB. Adductor canal blockade may be no better in terms of ability to mobilise (RAPM 2013;38).
  • Local anaesthetic infiltration: not beneficial in THR; may be of value for 6-12 h in TKR (if used as part of multimodal analgesia regimen)
  • Do not ignore pain in favour of non-EBM local anaesthetic infiltration techniques. 36% of TKR pats end up with chronic pain, or which having severe early postoperative pain is a predictor.

Ultrasound for regional anaesthesia: Teaching, learning and competence (1H02): Dr John Barcroft, Royal National Orthopaedic Hospital

  • Training in USS & RA: 1. Go on good course 2. Learn sonoanatomy 3. Practice on phantoms & cadavers 4. Try on patients with an expert.
  • Dreyfus Skill Levels: 1. Novice 2. Competent 3. Proficient 4. Expert 5. Master. We should aim for expertise not competence in USS RA.
  • Newly acquired motor skills (e.g. USS RA skills) will almost degrade to baseline if not used for 18 days! No place for occasional USS RA!
  • Create your own USS phantom: 4 x packets of supermarket jelly with 25% of the recommended water, filled with some olives. Cost < £4!!
  • “Only those who have the patience to do simple things perfectly ever acquire the skills to do difficult things easily”. Practice USS!!

Pathophysiology and management of acute coagulopathy of trauma (ATC) (1A01, 2A05): Mr Ross Davenport, The Royal London

  • Acute trauma coagulopathy (ATC): 24% on arrival to ED. ATC directly related to ISS & base deficit and increases RIP by 400%.
  • ATC thought to be caused by “thrombin switch”. Thrombin production decreased and aPC activated (decreasing factors V & VIII).
  • ATC predominately aPC mediated thrombinolysis, not DIC (other clotting factors often still > 75%). Platelet dysfunction is also a factor.
  • Only 50% of those with ATC will have PT that is abnormal and the test will take > 60 mins. Use ROTEM/TEG for a diagnosis in < 5 mins.
  • ROTEM can miss occult fibrinolysis. Most of your trauma patients with ISS > 16 will be fibrinolytic and will need tranexamic acid.
  • Ratio of PRC:FFP:Plts still unknown. Probably not 1:1:1 but optimal ratios unclear. RCT in progress (PROPPR) – results awaited.

Damage control resuscitation and anaesthesia for major trauma (2A02): Major Claire Park, King’s College Hospital.

  • Trauma Team Dynamics. Good review J R Army Corps 2001; 157: S299-304. Concepts such as tunnel vision, situational awareness, task fixation.
  • Damage control anaesthesia: suggestion for RSI Fentanyl:Ketamine:Rocuronium 3:2:1 (reducing to 1:1:1 if unstable).

STH Consultant CPD Updates: Obstetrics

This is the summary of the PowerPoint presentation from the new consultant CPD teaching programme.

This month’s session provided an update on obstetric anaesthesia (for the non-obstetric anaesthetist) in line with the Royal College of Anaesthetists Matrix.

The following areas were covered by Dr Ian Wrench (Consultant Obstetric Anaesthetist, Sheffield Teaching Hospitals NHS Foundation Trust). Please click the link for a copy of the presentation. Obstetric Anaesthesia for Non-obstetric Anaesthetists

  • Assessment of the critically ill parturient (2B06)
  • Analgesia for labour (2B01)
  • Regional anaesthesia complications in the pregnant patient (2B04)
  • Regional & general anaesthesia for emergency & elective LSCS (2B02, 2B03)

AAGBI Core Topics Nottingham 2013: Key Points

I recently attended the Association of Anaesthetists Core Topics Meeting, September 2013.

In order to allow those who were unable to attend the meeting to gain a flavour of the topics covered by the speakers I have created a summary of the key points of each talk (in my opinion).

The RCOA Matrix Codes for each talk are shown, along with the details of the speaker.

Anaesthesia for emergency laparotomy (2A03, 2C03): Dr Craig Morris, Derby

  • If bowel perforation 50% of bacteria are resistant to cephalosporins. Give Tazocin 4.5g intraoperatively. No need to reduce dose even if patient has ARF.

Managing fluids in hip fracture patients (2A04, 2A05): Dr Iain Moppett, Nottingham

  • Check Hb in PACU and make a transfusion decision. Late blood transfusions on the ward delays rehab by up to 24 h.
  • Transfusion triggers: no evidence for transfusion preop; intraoperatively only if Hb very low. Postoperative transfusions make no difference to LOS or mortality with triggers 80 vs 100g/l
  • 40% of #NOF patients have significant intraoperative hypotension (SBP <60). Need a low threshold for invasive monitoring
  • Intraoperative fluid administration probably best with GDT (LiDCO or TOD): decreased LOS & postoperative complications but no decrease in mortality (for GA patients). The role of GDT with SAB is yet to be answered.
  • 10% Hb<10; 16% ARF. Mild hyponatraemia on presentation very common (usually due to diuretic dose) and can be ignored. 25% pats respond to fluid blouses in theatre.

Maintaining skills for the difficult airway (2A01): Dr Rob McCahon, Nottingham

  • Maintenance of airway skills. Skill fade an issue for anaesthetists. Needle cric/alternate DL (e.g. GlideScope, CMA etc) skills drop off at 1-12 months.
  • Airway skills. Anaesthetists often ignore anticipated airway difficulties with overreliance on direct laryngoscopy with reluctance to do AFOI

Analgesia for lower limb arthroplasty (2E01, 2G01): Dr Nigel Bedforth, Nottingham

  • Enhanced recovery for TKR/THR – whole package of care more important than anaesthetic and analgesic techniques.
  • Analgesia for THR. Local anaesthetic infiltration ineffective, providing oral multimodal analgesia used.
  • Analgesia for TKR. Local infiltration of LA effective for 26-32 h; this effect magnified by addition of compression bandage.
  • Analgesia for TKR. Obdurator & sciatic nerve blocks probably only of value for first 6 h postop. SAB+FNB alone probably best.
  • Analgesia for TKR. Pain worse than THR (up to 48h). FNB more effective than epidural after 4 h with lower SE.
  • THR postoperative pain scores only significant for 6 h postop. Lumbar plexus block better than FNB but neither as good as spinal morphine.
  • Analgesia for TKR/THR. Evolving evidence that regional techniques assoc with less surgical site infections.
  • Analgesia for TKR/THR. Perineural & epidural techniques superior to opiates at all time points (+less blood loss & VTE!)

Safety of spinal anaesthesia Domain (2B04, 2G04): Dr David Bogod, Nottingham

  • How safe is SAB? 65% of anaesthetists are higher up the spinal cord than they think (1-2 levels). Only 30% are correct!
  • Beware of chlorhexidine & SAB (severe arachnoiditis). Use only 0.5%, keep trolley covered, check gloves for contamination