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Buprenorphine, Clonidine, Dexamethasone, and Ropivacaine for Interscalene Nerve Blockade: A Prospective, Randomized, Blinded, Ropivacaine Dose-Response Study.

ABSTRACT: OBJECTIVE:This study investigated interscalene block for shoulder arthroplasty with various ropivacaine concentrations in the presence of clonidine, dexamethasone, and buprenorphine. The goal was prolonged analgesia with minimal motor blockade. DESIGN:Prospective, double-blind, randomized controlled trial. SETTING:University-affiliated orthopedic hospital. METHODS:Patients (20/group) received acetaminophen, ketorolac, pregabalin, opioids, and "Control"; interscalene block, 0.375% ropivacaine, intravenous additives (buprenorphine, clonidine, dexamethasone); "High Dose"; 0.375% ropivacaine, perineural additives; "Medium Dose"; 0.2% ropivacaine, perineural additives; and "Low Dose"; 0.1% ropivacaine, perineural additives. RESULTS:Pain with movement at 24 hours was 4.9?±?2.5 (mean?±?standard deviation [SD]) (Control), 4.5?±?3.0 (High Dose), 3.4?±?1.8 (Medium Dose), 4.2?±?2.4 (Low Dose). The difference between Medium Dose and Control was?-1.5 (95% CI:?-2.9,?-0.1) (P?=?0.040). Median time until need for opioids was 16.1 hours (Control) vs 23.7 hours (High Dose); hazard ratio 0.37 [95% CI: 0.17, 0.79]. High Dose had less pain with movement the morning after surgery, vs Control; 2.9?±?2.5 vs 4.9?±?2.7; P?=?0.027. Pain with movement in the Post-Anesthesia Care Unit was higher in Low Dose, vs Control; 0.9?±?1.4 vs 0?±?0, P?=?0.009. Low Dose had superior hand strength in the Post-Anesthesia Care Unit (mean?±?SD of pre-operative strength: 44.0?± 20.3%) compared to Control (27.5?±?24.5%) (P?=?0.031). CONCLUSIONS:For maximum pain reduction, combining perineural additives with ropivacaine 0.375% or 0.2% is suggested. To minimize motor blockade, perineural additives can be combined with ropivacaine, 0.1%.

SUBMITTER: YaDeau JT

PROVIDER: S-EPMC6280991 | biostudies-literature | 2016 May

REPOSITORIES: biostudies-literature

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Project description:BACKGROUND AND AIMS:A popliteal block is effective in managing postoperative pain for foot surgery, but since the duration of analgesia is limited following a single-shot popliteal fossa block technique, methods to prolong effective postoperative analgesia are mandatory. The aim of this study was to assess the effect of adjuvants to ropivacaine on the duration of sensory and motor block. METHODS:In this double-blind randomized placebo-controlled study, we evaluated the analgesic effect of clonidine or dexamethasone (DXM) when added to ropivacaine for hallux valgus surgery. After obtaining institutional ethics research board approval and written informed consent, a total of 72 patients were randomly allocated. Fifty-seven of these patients were statistically analyzed. All patients received an ultrasound-guided single-shot popliteal fossa block with 30 mL of ropivacaine 0.75%, supplemented with saline, clonidine 100 µg, or DXM 5 mg. The primary end point was time to first pain sensation. Secondary end points were time to complete sensory and motor block regression. RESULTS:Compared to saline, duration to first pain sensation was prolonged by 9 hours (mean ± standard deviation: 31±9 hours) (42%) in the DXM group (P=0.024) and by 6 hours (28±10 hours) (27%) in the clonidine group (P=0.024). Compared to saline, DXM prolonged both complete sensory and motor blockade by 12 hours (25±7 hours) (46%) and 13 hours (36±6 hours) (55%), respectively, while clonidine prolonged complete sensory and motor blockade by 7 hours (30±7 hours) (27%) and 2 hours (22±5 hours) (10%), respectively. DXM prolonged sensory block regression time by 6 hours (21±7 hours) (41%) and clonidine by 2 hours (17±6 hours) (13%) compared to the control group (P=0.006). Similarly, DXM prolonged motor block regression by 7 hours (25±7 hours) (46%) and clonidine by 4 hours (21±4 hours) (19%) (P<0.0001). CONCLUSION:Addition of DXM and clonidine to ropivacaine significantly prolonged the duration of postoperative sensory and motor block.

Project description:BackgroundModerate-to-severe postoperative pain following craniotomy has a high incidence in pediatric patients. Such pain may cause agitation, intracranial hypertension, epileptic seizures, and postoperative hematoma, which affect morbidity and mortality. Although scalp nerve block (SNB) achieves satisfactory pain relief except for suboccipital mid-craniotomy in adults and ropivacaine is widely used as a long-acting peripheral nerve block agent in children, there are few studies of SNB with ropivacaine in pediatric patients undergoing craniotomy. In addition, the neurosurgery operation time is relatively long, but the duration of action of SNB is limited. It is generally believed that postoperative SNB is better than preoperative SNB for postoperative analgesia. However, considering the concept of preemptive analgesia, we believe that preoperative SNB may achieve a longer postoperative analgesia effect than we expected.MethodsThis trial is a single-institution, prospective, randomized, controlled, double-blind study. A total of 180 children aged between 1 and 12?years who are undergoing elective craniotomy will be randomly allocated in a 1:1:1 ratio to three groups: group B (preoperative ropivacaine block group), group A (postoperative ropivacaine block group), and group N (nonblocking control group). This randomization will be stratified by age in two strata (1-6?years and 7-12?years). The primary outcome is the total consumption of sufentanil within 24?h after surgery. The secondary outcomes include assessment of pain scores, total consumption of sufentanil and emergency-remedy medicine consumption at observation points, the occurrence of postoperative complications, and the length of hospitalization after surgery.DiscussionThis study is designed to explore the effect and feasibility of SNB with ropivacaine for postoperative analgesia in pediatric patients undergoing craniotomy. Further aims are to compare the effects of preoperative and postoperative SNB on postoperative analgesia in order to identify whether there is a preemptive analgesic effect and determine the better time to implement SNB in pediatric patients during craniotomy.Trial registrationChinese Clinical Trial Registry ChiCTR1800017386. Registered on 27 July 2018.

Project description:Ultrasound guidance has reduced the amount of local anesthetics to achieve a successful block. Previous studies of the relationship between the volume or concentration of local anesthetics and the effects of the block were based on relatively high doses of local anesthetics. We tested the hypothesis that providing low dose of ropivacaine at three combinations of volumes and concentrations for ultrasound-guided interscalene brachial plexus block would produce different effects in the aspect of onset time, pain control and the incidence of side effects.Ninety-nine patients undergoing elective arthroscopic shoulder surgery were randomized to receive an ultrasound guided combined with nerve stimulator mediated interscalene block with ropivacaine 0.75 % (6.7 ml, Group 0.75), 0.5 % (10 ml, Group 0.5) or 0.25 % (20 ml, Group 0.25). The primary end point was the onset time of the sensory blockade, assessed by using a pinprick in the C5-6 dermatome. The secondary end points included the onset time of the motor blockade, block success rate, postoperative pain rating score, rescue analgesics requirement, sleep quality, strength of the hand on the block side,and the incidence of hemi-diaphragmatic paresis which was evaluated by ultrasonography.There was a statistically significant difference of the sensory block median onset times among Group 0.75 (5 min), Group 0.5 (10 min) and Group 0.25 (20 min). One patient in Group 0.5 and 20 patients in Group 0.25 did not achieve a complete motor block within 30 min, which were also significantly different. No significant difference was observed in postoperative analgesia, decrease of handgrip strength and the incidence of hemi-diaphragmatic paresis among the 3 groups.This study demonstrates that ropivacaine 50 mg as 0.25, 0.5 or 0.75 % solution for interscalene brachial plexus block before arthroscopic shoulder surgery produces comparable blockade with few side effects, while 0.75 % seems to be more preferable as it is associated with faster onset time.ChiCTR-TRC-13004058 . Registered 4 December 2013.

Project description:BackgroundRebound pain after a single-shot nerve block challenges the real benefit of this technique. We aimed to investigate whether perineural dexamethasone addition decreased the incidence of rebound pain after a single-shot nerve block.MethodsWe randomly allocated 132 patients scheduled for open reduction internal fixation of an upper extremity closed fracture under single-shot peripheral nerve block and sedation into two groups. Patients in the dexamethasone group received nerve block with 0.375% ropivacaine and 8 mg dexamethasone, while those in the control group received ropivacaine only. Sixty-three patients in the dexamethasone group and 60 patients in the control group were analyzed for the incidence of rebound pain 48 h after block administration, which was the primary outcome. The secondary outcomes included the highest self-reported numeric rating scale (NRS) pain score, and NRS at 8, 12, 24, and 48 h after the block, sufentanil consumption, sleep quality on the night of surgery, patient satisfaction with the pain therapy, blood glucose at 6 h after the block, pain and paresthesia at 30 days after surgery.ResultsThe incidence of rebound pain was significantly lower in the dexamethasone group (7 [11.1%] of 63 patients) than in the control group (28 [48.8%] of 60 patients [RR = 0.238, 95% CI (0.113-0.504), p = 0.001]. Dexamethasone decreased opioid consumption in 24 h after surgery (p < 0.001) and improved the sleep quality score on the night of surgery (p = 0.01) and satisfaction with pain therapy (p = 0.001). Multivariate logistic regression analysis showed that only group allocation was associated with the occurrence of rebound pain [OR = 0.062, 95% CI (0.015-0.256)]. Patients in the dexamethasone group reported later onset pain (19.7 ± 6.6 h vs 14.7 ± 4.8 h since block administration, mean ± SD, p < 0.001) and lower peak NRS scores [5 (3, 6) vs 8 (5, 9), median (IQR), p < 0.001] than those in the control group.ConclusionsThe perineural administration of 8 mg dexamethasone reduces rebound pain after a single-shot nerve block in patients receiving ORIF for an upper limb fracture.Trial registrationThis study was retrospectively registered in the Chinese Clinical Trial Registry ( ChiCTR-IPR-17011365 ) on May 11th, 2017.

Project description:BackgroundInterscalene nerve catheters have been proven to be effective in managing pain after rotator cuff repair (RCR) surgery. Liposomal bupivacaine is a newer approved therapy for use around the interscalene brachial plexus, but its analgesic efficacy has limited supporting data in various patient populations.Purpose/hypothesisThe purpose of this study was to investigate the quality of recovery after arthroscopic RCR in patients who received either single-injection interscalene liposomal bupivacaine or an interscalene peripheral nerve catheter. It was hypothesized that interscalene peripheral nerve catheters would provide more reliable analgesia and improved patient satisfaction 48 hours after surgery.Study designCohort study; Level of evidence, 2.MethodsEnrolled were 93 consecutive patients who underwent arthroscopic rotator cuff surgery at a single ambulatory surgery center between October 2020 and June 2021. Of these patients, 13 were lost to follow-up; thus, 80 patients were included in statistical analysis. One group of patients (n = 48) received a preoperative interscalene nerve block placed with 10 mL 0.5% bupivacaine and 10 mL 1.3% liposomal bupivacaine. The second group (n = 32) received a preoperative interscalene catheter with an initial bolus of 20 mL 0.25% bupivacaine and a 0.2% ropivacaine infusion by an elastomeric pump set at 10 mL/hr for 48 hours. The primary outcome was the difference between preoperative and 48-hour postoperative quality of recovery-15 (QoR-15) scores. Secondary outcomes included visual analog pain scores, opioid use, and patient satisfaction. Complications and adverse effects were also noted. The Kruskal-Wallis test was used to analyze means and standard deviations for continuous endpoints; Fisher exact test was used to analyze counts and proportions for categorical endpoints.ResultsThe liposomal bupivacaine group had a mean reduction of 3.9 in their postoperative QoR-15 scores, and the catheter group had a mean reduction of 25.1 in their postoperative QoR-15 scores, indicating a significantly worse functional recovery period compared with liposomal bupivacaine within the first 48 hours (P < .001). Patients who received liposomal bupivacaine also had significantly lower pain scores on the second postoperative day, improved quality of sleep, and improved satisfaction with analgesia (P < .05 for all).ConclusionThe use of interscalene liposomal bupivacaine demonstrated significantly improved quality of recovery when compared with interscalene nerve catheter after RCR.

Project description:BackgroundInterscalene block is one of the popular methods for decreasing pain and analgesic consumption after shoulder arthroscopic surgeries.ObjectivesThe objective is to compare the analgesic duration of effects of dexmedetomidine and dexamethasone as adjuvants to 0.5% ropivacaine in ultrasound-guided interscalene blocks for arthroscopic shoulder surgery in an ambulatory setting.MethodsIn this randomized controlled trial, 117 adult patients candidate for ambulatory arthroscopic shoulder surgery under general anesthesia were divided into three groups to perform an ultra-sound guided interscalene block before the surgery. The ropivacaine (control) group received ropivacaine 0.5% 20 mL, group Dexamethasone received ropivacaine 0.5% 20 mL plus 4mg dexamethasone, and group dexmedetomidine received ropivacaine 0.5% 20 mL plus 75 mcg of dexmedetomidine. Time to return of sensory function, of motor function, of first pain sensation, amount of opioid medication consumed at 24 hours and 48 hours post-operatively were measured.ResultsThe 24-hour median (25th- 75th percentile) opioid consumption in morphine equivalents was similar between groups 22.5 mg (10 - 30), 15 mg (0 - 30), and 15 mg (0 - 20.6) in the ropivacaine, dexmedetomidine, and dexamethasone groups, respectively (P = 0.130). The median (25th- 75th percentile) 48 hours post-operatively, the median opioid consumption in morphine equivalents was 40 mg (25 - 67.5) in the ropivacaine group, 30 mg (22 - 50.6) in the dexamethasone group, and 52.5 mg (30 - 75) in the dexmedetomidine group (P = 0.278). The median 24-hour pain scores were 6 (5 - 8) in the ropivacaine control group, 7 (5.5 - 8) in the dexamethasone group, and 7 (4 - 9) in the dexmedetomidine group (P = 0.573).ConclusionsThere was no statistical difference in opioid consumption at 24 and 48 hours post-operatively when comparing dexmedetomidine, dexamethasone, and no adjuvant. However, intraoperative opioid use was significantly lower with dexmedetomidine compared to dexamethasone and plain 0.5% ropivacaine. The safe side effect profile of dexmedetomidine makes it a reasonable alternative as an adjuvant for peripheral nerve blockade when dexamethasone use may be contraindicated.

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Buprenorphine, Clonidine, Dexamethasone, and Ropivacaine for Interscalene Nerve Blockade: A Prospective, Randomized, Blinded, Ropivacaine Dose-Response Study.

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