Department of Anesthesia and Perioperative Medicine, University of Manitoba, Winnipeg, MB, R3E 0Z2, Canada.
Department of Orthopedic Surgery, University of Manitoba, Winnipeg, MB, Canada.
Can J Anaesth. 2018 Jan;65(1):34-45. doi: 10.1007/s12630-017-0989-7. Epub 2017 Nov 10.
Dexamethasone prolongs the duration of interscalene block, but the benefits of higher doses and perineural vs intravenous administration remain unclear.
This factorial design, double-blinded trial randomized 280 adult patients undergoing ambulatory arthroscopic shoulder surgery at a single centre in a 1:1:1:1 ratio. Patients received ultrasound-guided interscalene block with 30 mL 0.5% bupivacaine and 4 mg or 8 mg dexamethasone by either the perineural or intravenous route. The primary outcome (block duration measured as the time of first pain at the surgical site) and secondary outcomes (adverse effects, postoperative neurologic symptoms) were assessed by telephone. In this superiority trial, the predetermined minimum clinically important difference for comparisons between doses and routes was 3.0 hr.
The perineural route significantly prolonged the mean block duration by 2.0 hr (95% confidence interval [CI], 0.4 to 3.5 hr; P = 0.01), but 8 mg of dexamethasone did not significantly prolong the mean block duration compared with 4 mg (1.3 hr; 95% CI, -0.3 to 2.9 hr, P = 0.10), and there was no significant statistical interaction (P = 0.51). The mean (95% CI) block durations, in hours, were 24.0 (22.9 to 25.1), 24.8 (23.2 to 26.3), 25.4 (23.8 to 27.0), and 27.2 (25.2 to 29.3) for intravenous doses of 4 and 8 mg and perineural doses of 4 and 8 mg, respectively. There were no marked differences in side effects between groups. At 14 postoperative days, 57 (20.4%) patients reported neurologic symptoms, including dyspnea and hoarseness. At six months postoperatively, only six (2.1%) patients had residual symptoms, with four (1.4%) patients' symptoms unlikely related to interscalene block.
Compared with the intravenous route, perineural dexamethasone prolongs the mean interscalene block duration by a small amount that may or may not be clinically significant, regardless of dose. However, the difference in mean block durations between 8 mg and 4 mg of dexamethasone is highly unlikely to be clinically important, regardless of the administration route.
www.clinicaltrials.gov (NCT02426736). Registered 14 April 2015.
地塞米松延长了肌间沟阻滞的持续时间，但高剂量和神经周围与静脉给药的益处仍不清楚。
本项析因设计、双盲试验将 280 名在单一中心接受日间关节镜肩关节手术的成年患者以 1:1:1:1 的比例随机分为四组。患者接受超声引导下肌间沟阻滞，使用 30 mL 0.5%布比卡因和 4 mg 或 8 mg 地塞米松，通过神经周围或静脉途径给药。主要结局（以手术部位首次疼痛时的时间测量的阻滞持续时间）和次要结局（不良反应、术后神经症状）通过电话评估。在这项优效性试验中，剂量和途径之间比较的预定最小临床重要差异为 3.0 小时。
神经周围途径显著延长了平均阻滞持续时间 2.0 小时（95%置信区间[CI]：0.4 至 3.5 小时；P = 0.01），但与 4 mg 相比，8 mg 地塞米松并未显著延长平均阻滞持续时间（1.3 小时；95%CI：-0.3 至 2.9 小时，P = 0.10），且无显著统计学交互作用（P = 0.51）。静脉内剂量为 4 和 8 mg 以及神经周围剂量为 4 和 8 mg 的平均（95%CI）阻滞持续时间分别为 24.0（22.9 至 25.1）、24.8（23.2 至 26.3）、25.4（23.8 至 27.0）和 27.2（25.2 至 29.3）。各组之间的副作用差异无明显差异。在术后 14 天，57 名（20.4%）患者报告有神经症状，包括呼吸困难和声音嘶哑。术后 6 个月时，仅有 6 名（2.1%）患者仍有残留症状，其中 4 名（1.4%）患者的症状不太可能与肌间沟阻滞有关。
与静脉途径相比，神经周围地塞米松可延长肌间沟阻滞的平均持续时间，但延长幅度较小，可能有临床意义，也可能没有临床意义，而与剂量无关。然而，8 mg 和 4 mg 地塞米松之间的平均阻滞持续时间差异极不可能具有临床意义，而与给药途径无关。
www.clinicaltrials.gov（NCT02426736）。2015 年 4 月 14 日注册。
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