Department of Anaesthesiology, Oslo University Hospital, Oslo, Norway.
Department of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway.
Anaesthesia. 2020 Nov;75(11):1448-1460. doi: 10.1111/anae.15111. Epub 2020 May 30.
Rebound pain after brachial plexus block resolution and development of long-lasting pain are problems associated with volar plate fixation for distal radius fractures. The aim of this double-blind study was to evaluate the effect of a single prophylactic intravenous dose of dexamethasone in this setting. The primary endpoint was highest pain score during the first 24 hours after surgery. We included 51 adults of ASA physical status 1-2 due to undergo planned acute fixation of the radius. All received premedication with oral paracetamol and etoricoxib, and a pre-operative brachial plexus block with ropivacaine. Patients were randomly allocated into two groups: a dexamethasone group receiving 16 mg dexamethasone intravenously at start of surgery and a control group receiving 4 ml saline. After surgery, all patients received fixed doses of paracetamol, etoricoxib and oxycodone, with further oxycodone added as needed in the first 48 hours. Pain, analgesic consumption and daily function were registered at predefined times up to 1 year after surgery. Median (IQR [range]) worst pain score in the first 24 hours, as assessed by verbal numeric rating scale (0-10), was 4 (2-6 [0-7]) in the dexamethasone group compared with 8 (5-8 [2-10]) in the placebo group (p < 0.001). Average pain score, 2 (1-4 [0-5]) vs. 5 (3-6 [0-8]), p = 0.001 and rescue oxycodone consumption, 5 (0-10 [0-35]) mg vs. 10 (5-15 [0-50]) mg, p = 0.037), respectively, were both significantly lower in the dexamethasone group compared with control from 8 to 24 hours. Brachial plexus block duration was 69% longer in the dexamethasone group, 21.5 (19.1-23.4 [12.9-24.1]) hours vs. 12.7 (11.9-15.3 [7.4-26.6]) hours, p < 0.001. Two patients (9%) in the dexamethasone group compared with 12 (50%) in the placebo group experienced worst pain scores of 8-10 during the first 36 hours (p = 0.002). At 3 and 7 days postoperatively, there were no significant differences between groups for pain scores or opioid consumption. At 6 months, 27 patients (57%) reported pain at the site of surgery, with significantly higher average pain score (p = 0.024) in the placebo group. At 1 year, two patients in the dexamethasone group reported pain compared with 10 in the placebo group (p = 0.015), and worst pain score was significantly higher in the placebo group (p = 0.018). We conclude that intravenous dexamethasone improves early postoperative analgesia and may also improve clinical outcomes after 6 and 12 months.
经桡骨远端骨折掌侧钢板固定后臂丛神经阻滞消退时出现的反弹痛和长期疼痛是相关问题。本双盲研究旨在评估在这种情况下单次预防性静脉给予地塞米松的效果。主要终点是术后 24 小时内的最高疼痛评分。我们纳入了 51 名美国麻醉医师协会（ASA）身体状况 1-2 级的成年人，他们计划接受桡骨的急性固定。所有患者均接受术前口服对乙酰氨基酚和依托考昔，并接受罗哌卡因臂丛神经阻滞。患者被随机分为两组：地塞米松组在手术开始时静脉注射 16 毫克地塞米松，对照组静脉注射 4 毫升生理盐水。手术后，所有患者均接受固定剂量的对乙酰氨基酚、依托考昔和羟考酮治疗，并在前 48 小时内根据需要添加羟考酮。术后至 1 年，在规定时间内登记疼痛、镇痛药物消耗和日常功能。术后 24 小时内通过口头数字评分量表（0-10）评估的最严重疼痛评分中位数（IQR[范围]），地塞米松组为 4（2-6[0-7]），安慰剂组为 8（5-8[2-10]）（p <0.001）。地塞米松组平均疼痛评分分别为 2（1-4[0-5]）和 5（3-6[0-8]），p=0.001，地塞米松组解救羟考酮消耗量分别为 5（0-10[0-35]）mg 和 10（5-15[0-50]）mg，p=0.037），均明显低于对照组 8 至 24 小时。地塞米松组臂丛神经阻滞时间延长 69%，为 21.5（19.1-23.4[12.9-24.1]）小时，而对照组为 12.7（11.9-15.3[7.4-26.6]）小时，p<0.001。地塞米松组有 2 名患者（9%）在头 36 小时内出现 8-10 分的最严重疼痛评分，而安慰剂组有 12 名患者（50%）（p=0.002）。术后 3 天和 7 天，两组之间的疼痛评分或阿片类药物消耗均无显著差异。6 个月时，27 名患者（57%）报告手术部位疼痛，安慰剂组的平均疼痛评分显著较高（p=0.024）。1 年后，地塞米松组有 2 名患者报告疼痛，安慰剂组有 10 名患者报告疼痛（p=0.015），安慰剂组的最严重疼痛评分显著较高（p=0.018）。我们的结论是，静脉内给予地塞米松可改善术后早期镇痛效果，并可能在术后 6 个月和 12 个月时改善临床结局。
