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Dexamethasone Injected Perineurally is More Effective than Administered Intravenously for Peripheral Nerve Blocks: A Meta-analysis of Randomized Controlled Trials.

Zorrilla-Vaca, Andres MD; Li, Jinlei MD, PhD
Clinical Journal of Pain: Post Acceptance: June 6, 2017
doi: 10.1097/AJP.0000000000000519
Review Article: PDF Only

Introduction: Peripheral nerve blocks (PNBs) are widely and increasingly used for better acute perioperative pain control for a variety of procedures. Clinically preservative-free dexamethasone is arguably the most commonly used adjuvant and offers the most optimization effects on PNBs yet with the least side-effects noted. Our aim was to compare the effectiveness of intravenous versus perineural dexamethasone on the effectiveness and safety of PNBs.

Methods: Major databases (PubMed, EMBASE, Cochrane library, ISI Web of Science, Google Scholar) were systematically searched for randomized controlled trials (RCTs) comparing the effectiveness of intravenous versus perineural dexamethasone on peripheral nerve blocks. Study characteristics, intraoperative events, and postoperative outcomes including duration of analgesia, duration of sensory block, duration of motor block, pain score at 24 hours, opioid consumption and postoperative nausea and vomiting (PONV), were extracted from the articles. Meta-analysis was performed using random-effect models.

Results: Thirteen RCTs comprising a total of 937 patients (intravenous: 464 patients; perineural: 473 patients) were included in this meta-analysis. Perineural dexamethasone significantly prolonged the duration of analgesia (SMD 0.48 h, 95%CI 0.18-0.79) and sensory block (SMD 0.74, 95%CI 0.53-0.94). In subgroup of studies that used 4-5 mg we found that perineural dexamethasone was universally more effective to prolong analgesia as compared to intravenous dexamethasone (SMD 0.48 h, 95%CI 0.24-0.72), but there was no significant difference between intravenous versus perineural dexamethasone when using a dose of dexamethasone >=8 mg (SMD 0.33 h, 95%CI -0.11-0.77). Perineural dexamethasone had similarly more benefits in terms of prolongation of motor block duration, decreasing pain score, reducing opioid consumption, and less PONV.

Conclusions: This investigation not only confirmed the better analgesic effects of perineurally-administered dexamethasone as compared to its intravenous injection, but also implicitly supported the hypothesis of local interaction between dexamethasone and the nerve as one of the pain modulation mechanisms of dexamethasone, because systemic absorption alone could not explain the superior quality of PNBs.

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