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Should we mix local anesthetics and additives? Matthias Desmet MD az│groeninge ESRA Winterweek 2017 Why would we use additives? • Benefit of sISB up to 6 hours with motion and up to 8 hours in rest. • No benefits after 8 hours. • More pain between 16 and 24 hours. • Similar pain after 24 hours. Abdallah et al. Anesth and Analg 2015 Bingham et al. RAPM 2012 Additives? Additives? • Dexamethasone • Dexmedetomidine Dexamethasone Long acting, potent glucocorticoid. Henzi, Anesth Analg 2000 Waldron, BJA 2013 Dexmedetomidine? Abdallah et al. BJA 2013 Mechanism of action? Ideal route of administration? Yimaz et al. RAPM 2012 Buvanendran et al. RAPM 2016 Desmet et al. BJA 2013 Rahangdale et al. Anesth and Analg 2014 Fredrickson et al. RAPM 2013 Dawson et al. Anaesth 2015 Rosenfeld et al Anaesth 2016 Abdallah et al. RAPM 2015 Alternatives for perineural DXM? • 5 studies (n= 509) showed no difference. • 2 studies (n = 188) in favour of perineural DXM. • Where is the meta-analysis when you need it… If there is any difference, the clinical impact is probably small… Jaeger P et al. BJA 2016 “Importantly, the physician is free to use any drug for off-label indications as long as the use is based on sound clinical judgment and reasonable scientific rationale.” Neal J et al. RAPM 2009 Safety of IV DXM? • Isolated sensory neurons of rats. (n = 16) • Exposure to different combo’s of LA and additives. • Measure cell death. Williams BA et al RAPM 2011 High dose DXM In vivo evaluation of Bupi/MDZ/Clonidine/Buprenorphine/DXM. Results: 1) No neurobehavioural changes. 2) No changes in the sciatic nerve, DRG or dorsal and ventral nerve roots. Williams et al Pain Medicine 2015 • “No histopathological changes” • Changes were caused by: 1. Local manipulation/trauma/injection. 2. Tissue handling and manipulation. 3. Isolated/suspected spontaneous changes with no relationship to the study drug. Williams B et al, Pain Medicine 2015 What about intraneural DXM? Superiority of perineural DXM? Ma et al. Neuroscience 2010 Superiority of perineural DXM? An et al. PLOS ONE 2015 Mechanism of action: dexmedetomidine • Limited evidence for local vasoconstrictor effect. • No evidence for α receptor mediated effect. • Evidence for inhibition of the Ih- current. Nishikawa et al. Anesthesiol 1990 Kopacz et al. Anesthesiol 2001 Kroin et al. Anesthesiol 2004 Brummett C et al. Anesthesiol 2011 Brummett et al. Anesthesiol 2011 240 min 150 min Brummett et al. RAPM 2010 Andersen et al. Anesthesiology 2017 Abdallah et al. Anesthesiol 2015 Safety of dexmedetomidine? • Longstanding experience with clonidine. • No clinical reports on dexmedetomidine for peripheral nerve blocks. • Little evidence for a neurotoxic potential. Zhang et al. PLOS one 2013 Very high doses of DEX (28-40µg/kg) did not cause perineural inflammation. Less perineural inflammation in the DEX-BUPI group than in BUPI group. Take home message Perineural administration of DXM should not be preferred based on current literature. Perineural administration of DEX seems reasonable based on current literature.
