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Review
.2017 Nov 9;11(11):CD011770.
doi: 10.1002/14651858.CD011770.pub2.

Dexamethasone as an adjuvant to peripheral nerve block

Affiliations
Review

Dexamethasone as an adjuvant to peripheral nerve block

Carolyne Pehora et al. Cochrane Database Syst Rev..

Abstract

Background: Peripheral nerve block (infiltration of local anaesthetic around a nerve) is used for anaesthesia or analgesia. A limitation to its use for postoperative analgesia is that the analgesic effect lasts only a few hours, after which moderate to severe pain at the surgical site may result in the need for alternative analgesic therapy. Several adjuvants have been used to prolong the analgesic duration of peripheral nerve block, including perineural or intravenous dexamethasone.

Objectives: To evaluate the comparative efficacy and safety of perineural dexamethasone versus placebo, intravenous dexamethasone versus placebo, and perineural dexamethasone versus intravenous dexamethasone when added to peripheral nerve block for postoperative pain control in people undergoing surgery.

Search methods: We searched the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, DARE, Web of Science and Scopus from inception to 25 April 2017. We also searched trial registry databases, Google Scholar and meeting abstracts from the American Society of Anesthesiologists, the Canadian Anesthesiologists' Society, the American Society of Regional Anesthesia, and the European Society of Regional Anaesthesia.

Selection criteria: We included all randomized controlled trials (RCTs) comparing perineural dexamethasone with placebo, intravenous dexamethasone with placebo, or perineural dexamethasone with intravenous dexamethasone in participants receiving peripheral nerve block for upper or lower limb surgery.

Data collection and analysis: We used standard methodological procedures expected by Cochrane.

Main results: We included 35 trials of 2702 participants aged 15 to 78 years; 33 studies enrolled participants undergoing upper limb surgery and two undergoing lower limb surgery. Risk of bias was low in 13 studies and high/unclear in 22. Perineural dexamethasone versus placeboDuration of sensory block was significantly longer in the perineural dexamethasone group compared with placebo (mean difference (MD) 6.70 hours, 95% confidence interval (CI) 5.54 to 7.85; participants1625; studies 27). Postoperative pain intensity at 12 and 24 hours was significantly lower in the perineural dexamethasone group compared with control (MD -2.08, 95% CI -2.63 to -1.53; participants 257; studies 5) and (MD -1.63, 95% CI -2.34 to -0.93; participants 469; studies 9), respectively. There was no significant difference at 48 hours (MD -0.61, 95% CI -1.24 to 0.03; participants 296; studies 4). The quality of evidence is very low for postoperative pain intensity at 12 hours and low for the remaining outcomes. Cumulative 24-hour postoperative opioid consumption was significantly lower in the perineural dexamethasone group compared with placebo (MD 19.25 mg, 95% CI 5.99 to 32.51; participants 380; studies 6). Intravenous dexamethasone versus placeboDuration of sensory block was significantly longer in the intravenous dexamethasone group compared with placebo (MD 6.21, 95% CI 3.53 to 8.88; participants 499; studies 8). Postoperative pain intensity at 12 and 24 hours was significantly lower in the intravenous dexamethasone group compared with placebo (MD -1.24, 95% CI -2.44 to -0.04; participants 162; studies 3) and (MD -1.26, 95% CI -2.23 to -0.29; participants 257; studies 5), respectively. There was no significant difference at 48 hours (MD -0.21, 95% CI -0.83 to 0.41; participants 172; studies 3). The quality of evidence is moderate for duration of sensory block and postoperative pain intensity at 24 hours, and low for the remaining outcomes. Cumulative 24-hour postoperative opioid consumption was significantly lower in the intravenous dexamethasone group compared with placebo (MD -6.58 mg, 95% CI -10.56 to -2.60; participants 287; studies 5). Perinerual versus intravenous dexamethasoneDuration of sensory block was significantly longer in the perineural dexamethasone group compared with intravenous by three hours (MD 3.14 hours, 95% CI 1.68 to 4.59; participants 720; studies 9). We found that postoperative pain intensity at 12 hours and 24 hours was significantly lower in the perineural dexamethasone group compared with intravenous, however, the MD did not surpass our pre-determined minimally important difference of 1.2 on the Visual Analgue Scale/Numerical Rating Scale, therefore the results are not clinically significant (MD -1.01, 95% CI -1.51 to -0.50; participants 217; studies 3) and (MD -0.77, 95% CI -1.47 to -0.08; participants 309; studies 5), respectively. There was no significant difference in severity of postoperative pain at 48 hours (MD 0.13, 95% CI -0.35 to 0.61; participants 227; studies 3). The quality of evidence is moderate for duration of sensory block and postoperative pain intensity at 24 hours, and low for the remaining outcomes. There was no difference in cumulative postoperative 24-hour opioid consumption (MD -3.87 mg, 95% CI -9.93 to 2.19; participants 242; studies 4). Incidence of severe adverse eventsFive serious adverse events were reported. One block-related event (pneumothorax) occurred in one participant in a trial comparing perineural dexamethasone and placebo; however group allocation was not reported. Four non-block-related events occurred in two trials comparing perineural dexamethasone, intravenous dexamethasone and placebo. Two participants in the placebo group required hospitalization within one week of surgery; one for a fall and one for a bowel infection. One participant in the placebo group developed Complex Regional Pain Syndrome Type I and one in the intravenous dexamethasone group developed pneumonia. The quality of evidence is very low due to the sparse number of events.

Authors' conclusions: Low- to moderate-quality evidence suggests that when used as an adjuvant to peripheral nerve block in upper limb surgery, both perineural and intravenous dexamethasone may prolong duration of sensory block and are effective in reducing postoperative pain intensity and opioid consumption. There is not enough evidence to determine the effectiveness of dexamethasone as an adjuvant to peripheral nerve block in lower limb surgeries and there is no evidence in children. The results of our review may not apply to participants at risk of dexamethasone-related adverse events for whom clinical trials would probably be unsafe.There is not enough evidence to determine the effectiveness of dexamethasone as an adjuvant to peripheral nerve block in lower limb surgeries and there is no evidence in children. The results of our review may not be apply to participants who at risk of dexamethasone-related adverse events for whom clinical trials would probably be unsafe. The nine ongoing trials registered at ClinicalTrials.gov may change the results of this review.

PubMed Disclaimer

Conflict of interest statement

Carolyne Pehora: none known.

Annabel Pearson: none known.

Alka Kaushal: none known.

Mark Crawford: none known.

Bradley Johnston: none known.

Figures

1
1
Flow diagram of included studies.
2
2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
3
3
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
4
4
Forest plot of comparison: 1 Duration of sensory block: perineural dexamethasone versus placebo, outcome: 1.1 Duration of sensory block [hours].
5
5
Forest plot of comparison: 4 Postoperative pain intensity at 12 hours: perineural dexamethasone versus placebo, outcome: 4.1 Postoperative pain intensity at12 hours.
6
6
Forest plot of comparison: 5 Postoperative pain intensity at 24 hours: perineural dexamethasone versus placebo, outcome: 5.1 Postoperative pain intensity at 24 hours.
7
7
Forest plot of comparison: 9 Duration of sensory block: intravenous dexamethasone versus placebo , outcome: 9.1 Duration of sensory block.
8
8
Forest plot of comparison: 12 Postoperative pain intensity at 12 hours: intravenous dexamethasone versus placebo, outcome: 12.1 Postoperative pain intensity at 12 hours.
9
9
Forest plot of comparison: 13 Postoperative pain intensity at 24 hours: intravenous dexamethasone versus placebo, outcome: 13.1 Postoperative pain intensity at 24 hours.
1.1
1.1. Analysis
Comparison 1 Duration of sensory block: perineural dexamethasone versus placebo, Outcome 1 Duration of sensory block.
1.2
1.2. Analysis
Comparison 1 Duration of sensory block: perineural dexamethasone versus placebo, Outcome 2 Duration of sensory block: long‐ versus medium‐acting local anaesthetic subgroups.
1.3
1.3. Analysis
Comparison 1 Duration of sensory block: perineural dexamethasone versus placebo, Outcome 3 Duration of sensory block: additive versus no additive subgroups.
1.4
1.4. Analysis
Comparison 1 Duration of sensory block: perineural dexamethasone versus placebo, Outcome 4 Duration of sensory block: high‐ versus low‐dose dexamethasone subgroups.
1.5
1.5. Analysis
Comparison 1 Duration of sensory block: perineural dexamethasone versus placebo, Outcome 5 Duration of sensory block: high/unclear versus low risk of bias subgroups.
2.1
2.1. Analysis
Comparison 2 Duration of motor block: perineural dexamethasone versus placebo, Outcome 1 Duration of motor block.
2.2
2.2. Analysis
Comparison 2 Duration of motor block: perineural dexamethasone versus placebo, Outcome 2 Duration of motor block: long‐ versus medium‐acting local anaesthetic subgroups.
2.3
2.3. Analysis
Comparison 2 Duration of motor block: perineural dexamethasone versus placebo, Outcome 3 Duration of motor block: additives verus no additives subgroups.
2.4
2.4. Analysis
Comparison 2 Duration of motor block: perineural dexamethasone versus placebo, Outcome 4 Duration of motor block: high‐ versus low‐dose dexamethasone subgroups.
2.5
2.5. Analysis
Comparison 2 Duration of motor block: perineural dexamethasone versus placebo, Outcome 5 Duration of motor block: high/unclear versus low risk of bias subgroups.
3.1
3.1. Analysis
Comparison 3 Incidence of mild to moderate adverse events: perineural dexamethasone versus placebo, Outcome 1 Overall incidence of block‐related adverse events.
3.2
3.2. Analysis
Comparison 3 Incidence of mild to moderate adverse events: perineural dexamethasone versus placebo, Outcome 2 Numbness/tingling 14 days after surgery.
3.3
3.3. Analysis
Comparison 3 Incidence of mild to moderate adverse events: perineural dexamethasone versus placebo, Outcome 3 Residual motor block/weakness 24 hours after surgery.
3.4
3.4. Analysis
Comparison 3 Incidence of mild to moderate adverse events: perineural dexamethasone versus placebo, Outcome 4 Horner Syndrome.
3.5
3.5. Analysis
Comparison 3 Incidence of mild to moderate adverse events: perineural dexamethasone versus placebo, Outcome 5 Hoarseness.
3.6
3.6. Analysis
Comparison 3 Incidence of mild to moderate adverse events: perineural dexamethasone versus placebo, Outcome 6 Diaphragmatic paresis.
3.7
3.7. Analysis
Comparison 3 Incidence of mild to moderate adverse events: perineural dexamethasone versus placebo, Outcome 7 Dyspnoea.
3.8
3.8. Analysis
Comparison 3 Incidence of mild to moderate adverse events: perineural dexamethasone versus placebo, Outcome 8 Vascular injury.
3.9
3.9. Analysis
Comparison 3 Incidence of mild to moderate adverse events: perineural dexamethasone versus placebo, Outcome 9 Cranial nerve 12 palsy.
3.10
3.10. Analysis
Comparison 3 Incidence of mild to moderate adverse events: perineural dexamethasone versus placebo, Outcome 10 Bruising.
3.11
3.11. Analysis
Comparison 3 Incidence of mild to moderate adverse events: perineural dexamethasone versus placebo, Outcome 11 Overall non‐block‐related adverse events.
3.12
3.12. Analysis
Comparison 3 Incidence of mild to moderate adverse events: perineural dexamethasone versus placebo, Outcome 12 Postoperative nausea and vomiting.
3.13
3.13. Analysis
Comparison 3 Incidence of mild to moderate adverse events: perineural dexamethasone versus placebo, Outcome 13 Deep sedation.
3.14
3.14. Analysis
Comparison 3 Incidence of mild to moderate adverse events: perineural dexamethasone versus placebo, Outcome 14 Dermatological symptoms (pruritus/rash).
3.15
3.15. Analysis
Comparison 3 Incidence of mild to moderate adverse events: perineural dexamethasone versus placebo, Outcome 15 Syncope/fainting.
3.16
3.16. Analysis
Comparison 3 Incidence of mild to moderate adverse events: perineural dexamethasone versus placebo, Outcome 16 Bradycardia.
3.17
3.17. Analysis
Comparison 3 Incidence of mild to moderate adverse events: perineural dexamethasone versus placebo, Outcome 17 Hypotension.
3.18
3.18. Analysis
Comparison 3 Incidence of mild to moderate adverse events: perineural dexamethasone versus placebo, Outcome 18 Headache/10‐pound fluid gain/diarrhoea/frequent urination/muscle soreness.
4.1
4.1. Analysis
Comparison 4 Postoperative pain intensity at 12 hours: perineural dexamethasone versus placebo, Outcome 1 Postoperative pain intensity at12 hours.
4.2
4.2. Analysis
Comparison 4 Postoperative pain intensity at 12 hours: perineural dexamethasone versus placebo, Outcome 2 Postoperative pain intensity at 12 hours: medium‐ versus long‐acting local anaesthetic subgroups.
4.3
4.3. Analysis
Comparison 4 Postoperative pain intensity at 12 hours: perineural dexamethasone versus placebo, Outcome 3 Postoperative pain intensity at 12 hours: additive versus no additive subgroups.
4.4
4.4. Analysis
Comparison 4 Postoperative pain intensity at 12 hours: perineural dexamethasone versus placebo, Outcome 4 Postoperative pain intensity at 12 hours: high‐ versus low‐dose dexamethasone subgroups.
4.5
4.5. Analysis
Comparison 4 Postoperative pain intensity at 12 hours: perineural dexamethasone versus placebo, Outcome 5 Postoperative pain intensity at 12 hours: high/unclear versus low risk of bias subgroups.
5.1
5.1. Analysis
Comparison 5 Postoperative pain intensity at 24 hours: perineural dexamethasone versus placebo, Outcome 1 Postoperative pain intensity at 24 hours.
5.2
5.2. Analysis
Comparison 5 Postoperative pain intensity at 24 hours: perineural dexamethasone versus placebo, Outcome 2 Postoperative pain intensity at 24 hours: long‐ versus medium‐acting local anaesthetic subgroups.
5.3
5.3. Analysis
Comparison 5 Postoperative pain intensity at 24 hours: perineural dexamethasone versus placebo, Outcome 3 Postoperative pain intensity at 24 hours: additive versus no additive subgroups.
5.4
5.4. Analysis
Comparison 5 Postoperative pain intensity at 24 hours: perineural dexamethasone versus placebo, Outcome 4 Postoperative pain intensity at 24 hours: high‐ versus low‐dose dexamethasone subgroups.
5.5
5.5. Analysis
Comparison 5 Postoperative pain intensity at 24 hours: perineural dexamethasone versus placebo, Outcome 5 Postoperative pain intensity at 24 hours: high/unclear versus low risk of bias subgroups.
6.1
6.1. Analysis
Comparison 6 Postoperative pain intensity at 48 hours: perineural dexamethasone versus placebo, Outcome 1 Postoperative pain intensity at 48 hours.
6.2
6.2. Analysis
Comparison 6 Postoperative pain intensity at 48 hours: perineural dexamethasone versus placebo, Outcome 2 Postoperative pain intensity at 48 hours: additives versus no additives subgroups.
6.3
6.3. Analysis
Comparison 6 Postoperative pain intensity at 48 hours: perineural dexamethasone versus placebo, Outcome 3 Postoperative pain intensity at 48 hours: high/unclear versus low risk of bias subgroups.
7.1
7.1. Analysis
Comparison 7 Postoperative opioid consumption at 24 hours: perineural dexamethasone versus placebo, Outcome 1 Postoperative opioid consumption at 24 hours.
7.2
7.2. Analysis
Comparison 7 Postoperative opioid consumption at 24 hours: perineural dexamethasone versus placebo, Outcome 2 Opioid consumption at 24 hours medium‐ versus long‐acting local anaesthetic subgroups.
7.3
7.3. Analysis
Comparison 7 Postoperative opioid consumption at 24 hours: perineural dexamethasone versus placebo, Outcome 3 Opioid consumption at 24 hours: additive versus no additive subgroups.
7.4
7.4. Analysis
Comparison 7 Postoperative opioid consumption at 24 hours: perineural dexamethasone versus placebo, Outcome 4 Opioid consumption at 24 hours: high/unclear versus low risk of bias subgroups.
8.1
8.1. Analysis
Comparison 8 Participant satisfaction with pain control; perineural dexamethasone versus placebo, Outcome 1 Participant satisfaction with pain control: perineural dexamethasone versus placebo.
9.1
9.1. Analysis
Comparison 9 Duration of sensory block: intravenous dexamethasone versus placebo, Outcome 1 Duration of sensory block.
9.2
9.2. Analysis
Comparison 9 Duration of sensory block: intravenous dexamethasone versus placebo, Outcome 2 Duration sensory block: additive versus no additive subgroups.
9.3
9.3. Analysis
Comparison 9 Duration of sensory block: intravenous dexamethasone versus placebo, Outcome 3 Duration of sensory block: high‐ versus low‐dose dexamethasone subgroups.
9.4
9.4. Analysis
Comparison 9 Duration of sensory block: intravenous dexamethasone versus placebo, Outcome 4 Duration of sensory block: high/unclear versus low risk of bias subgroups.
10.1
10.1. Analysis
Comparison 10 Duration of motor block: intravenous dexamethasone versus placebo, Outcome 1 Duration of motor block.
10.2
10.2. Analysis
Comparison 10 Duration of motor block: intravenous dexamethasone versus placebo, Outcome 2 Duration of motor block: additive versus no additive subgroups.
10.3
10.3. Analysis
Comparison 10 Duration of motor block: intravenous dexamethasone versus placebo, Outcome 3 Duration of motor block high‐ versus low‐dose dexamethasone subgroups.
10.4
10.4. Analysis
Comparison 10 Duration of motor block: intravenous dexamethasone versus placebo, Outcome 4 Duration of motor block: high/unclear versus low risk of bias subgroups.
11.1
11.1. Analysis
Comparison 11 Incidence of mild to moderate adverse events: intravenous dexamethasone versus placebo, Outcome 1 Overall incidence of block‐related adverse events.
11.2
11.2. Analysis
Comparison 11 Incidence of mild to moderate adverse events: intravenous dexamethasone versus placebo, Outcome 2 Numbness/tingling 14 days after surgery.
11.3
11.3. Analysis
Comparison 11 Incidence of mild to moderate adverse events: intravenous dexamethasone versus placebo, Outcome 3 Residual motor block/muscle weakness 24 hours after surgery.
11.4
11.4. Analysis
Comparison 11 Incidence of mild to moderate adverse events: intravenous dexamethasone versus placebo, Outcome 4 Horner syndrome.
11.5
11.5. Analysis
Comparison 11 Incidence of mild to moderate adverse events: intravenous dexamethasone versus placebo, Outcome 5 Hoarsenss.
11.6
11.6. Analysis
Comparison 11 Incidence of mild to moderate adverse events: intravenous dexamethasone versus placebo, Outcome 6 Dyspnoea.
11.7
11.7. Analysis
Comparison 11 Incidence of mild to moderate adverse events: intravenous dexamethasone versus placebo, Outcome 7 Cranial nerve 12 palsy.
11.8
11.8. Analysis
Comparison 11 Incidence of mild to moderate adverse events: intravenous dexamethasone versus placebo, Outcome 8 Overall non‐block‐related adverse events.
11.9
11.9. Analysis
Comparison 11 Incidence of mild to moderate adverse events: intravenous dexamethasone versus placebo, Outcome 9 Postoperative nausea and vomiting.
11.10
11.10. Analysis
Comparison 11 Incidence of mild to moderate adverse events: intravenous dexamethasone versus placebo, Outcome 10 Dermatological symptoms.
11.11
11.11. Analysis
Comparison 11 Incidence of mild to moderate adverse events: intravenous dexamethasone versus placebo, Outcome 11 Dizziness/wrist, hand or finger pain, constipation.
12.1
12.1. Analysis
Comparison 12 Postoperative pain intensity at 12 hours: intravenous dexamethasone versus placebo, Outcome 1 Postoperative pain intensity at 12 hours.
12.2
12.2. Analysis
Comparison 12 Postoperative pain intensity at 12 hours: intravenous dexamethasone versus placebo, Outcome 2 Postoperative pain intensity at 12 hours: high‐ versus low‐dose dexamethasone subgroups.
12.3
12.3. Analysis
Comparison 12 Postoperative pain intensity at 12 hours: intravenous dexamethasone versus placebo, Outcome 3 Postoperative pain intensity at 12 hours: high/unclear versus low risk of bias subgroups.
13.1
13.1. Analysis
Comparison 13 Postoperative pain intensity at 24 hours: intravenous dexamethasone versus placebo, Outcome 1 Postoperative pain intensity at 24 hours.
13.2
13.2. Analysis
Comparison 13 Postoperative pain intensity at 24 hours: intravenous dexamethasone versus placebo, Outcome 2 Postoperative pain intensity at 24 hours: additive versus no additive subgroups.
13.3
13.3. Analysis
Comparison 13 Postoperative pain intensity at 24 hours: intravenous dexamethasone versus placebo, Outcome 3 Postoperative pain intensity at 24 hours: high‐ versus low‐dose dexamethasone subgroups.
13.4
13.4. Analysis
Comparison 13 Postoperative pain intensity at 24 hours: intravenous dexamethasone versus placebo, Outcome 4 Postoperative pain intensity at 24 hours: high/unclear versus low risk of bias subgroups.
14.1
14.1. Analysis
Comparison 14 Postoperative pain intensity at 48 hours: intravenous dexamethasone versus placebo, Outcome 1 Postoperative pain intensity at 48 hours.
14.2
14.2. Analysis
Comparison 14 Postoperative pain intensity at 48 hours: intravenous dexamethasone versus placebo, Outcome 2 Postoperative pain intensity at 48 hours: additive versus no additive subgroups.
15.1
15.1. Analysis
Comparison 15 Postoperative opioid consumption at 24 hours: intravenous dexamethasone versus placebo, Outcome 1 24‐hour opioid consumption.
15.2
15.2. Analysis
Comparison 15 Postoperative opioid consumption at 24 hours: intravenous dexamethasone versus placebo, Outcome 2 24‐hour opioid consumption: additive verus no additive subgroups.
16.1
16.1. Analysis
Comparison 16 Postoperative opioid consumption at 48 hours: intravenous dexamethasone versus placebo, Outcome 1 Postoperative opioid consumption at 48 hours opioid consumption.
17.1
17.1. Analysis
Comparison 17 Participant satisfaction with pain control: intravenous dexamethasone versus placebo, Outcome 1 Participant satisfaction with pain control.
18.1
18.1. Analysis
Comparison 18 Duration of sensory block: perineural versus intravenous dexamethasone, Outcome 1 Duration of sensory block.
18.2
18.2. Analysis
Comparison 18 Duration of sensory block: perineural versus intravenous dexamethasone, Outcome 2 Duration of sensory block additive versus no additive subgroups.
18.3
18.3. Analysis
Comparison 18 Duration of sensory block: perineural versus intravenous dexamethasone, Outcome 3 Duration sensory block high‐dose versus low‐dose dexamethasone subgroups.
18.4
18.4. Analysis
Comparison 18 Duration of sensory block: perineural versus intravenous dexamethasone, Outcome 4 Duration sensory block high/unclear versus low risk of bias subgroups.
19.1
19.1. Analysis
Comparison 19 Duration of motor block: perineural versus intravenous dexamethasone, Outcome 1 Duration of motor block.
19.2
19.2. Analysis
Comparison 19 Duration of motor block: perineural versus intravenous dexamethasone, Outcome 2 Duration of motor block: additive versus no additive subgroups.
19.3
19.3. Analysis
Comparison 19 Duration of motor block: perineural versus intravenous dexamethasone, Outcome 3 Duration of motor block: high‐ versus low‐dose dexamethasone subgroups.
19.4
19.4. Analysis
Comparison 19 Duration of motor block: perineural versus intravenous dexamethasone, Outcome 4 Duration of motor block: high/unclear versus low risk of bias subgroups.
20.1
20.1. Analysis
Comparison 20 Incidence of mild to moderate adverse events: perineural versus intravenous dexamethasone, Outcome 1 Overall incidence of block‐related adverse events.
20.2
20.2. Analysis
Comparison 20 Incidence of mild to moderate adverse events: perineural versus intravenous dexamethasone, Outcome 2 Numbness/tingling 14 days after surgery.
20.3
20.3. Analysis
Comparison 20 Incidence of mild to moderate adverse events: perineural versus intravenous dexamethasone, Outcome 3 Residual motor block/weakness at 24 hours.
20.4
20.4. Analysis
Comparison 20 Incidence of mild to moderate adverse events: perineural versus intravenous dexamethasone, Outcome 4 Horner syndrome.
20.5
20.5. Analysis
Comparison 20 Incidence of mild to moderate adverse events: perineural versus intravenous dexamethasone, Outcome 5 Hoarsness.
20.6
20.6. Analysis
Comparison 20 Incidence of mild to moderate adverse events: perineural versus intravenous dexamethasone, Outcome 6 Cranial nerve 12 motor palsy.
20.7
20.7. Analysis
Comparison 20 Incidence of mild to moderate adverse events: perineural versus intravenous dexamethasone, Outcome 7 Overall incidence of non block‐related adverse events.
20.8
20.8. Analysis
Comparison 20 Incidence of mild to moderate adverse events: perineural versus intravenous dexamethasone, Outcome 8 Postoperative nausea and vomiting.
20.9
20.9. Analysis
Comparison 20 Incidence of mild to moderate adverse events: perineural versus intravenous dexamethasone, Outcome 9 Dermatologicial symptoms (pruritus/rash).
20.10
20.10. Analysis
Comparison 20 Incidence of mild to moderate adverse events: perineural versus intravenous dexamethasone, Outcome 10 Syncope/fainting.
20.11
20.11. Analysis
Comparison 20 Incidence of mild to moderate adverse events: perineural versus intravenous dexamethasone, Outcome 11 Dizziness.
20.12
20.12. Analysis
Comparison 20 Incidence of mild to moderate adverse events: perineural versus intravenous dexamethasone, Outcome 12 Wrist, hand or finger pain.
20.13
20.13. Analysis
Comparison 20 Incidence of mild to moderate adverse events: perineural versus intravenous dexamethasone, Outcome 13 Headache, 10‐pound fluid gain/diarrhoea/frequent urination/ muscle soreness.
21.1
21.1. Analysis
Comparison 21 Postoperative pain intensity at 12 hours: perineural versus intravenous dexamethasone, Outcome 1 Postoperative pain intensity at 12 hours.
21.2
21.2. Analysis
Comparison 21 Postoperative pain intensity at 12 hours: perineural versus intravenous dexamethasone, Outcome 2 Postoperative pain intensity at 12 hours: low‐ versus high‐dose dexamethasone subgroups.
21.3
21.3. Analysis
Comparison 21 Postoperative pain intensity at 12 hours: perineural versus intravenous dexamethasone, Outcome 3 Postoperative pain intensity at 12 hours: high/unclear versus low risk of bias subgroups.
22.1
22.1. Analysis
Comparison 22 Postoperative pain intensity at 24 hours: perineural versus intravenous dexamethasone, Outcome 1 Postoperative pain intensity at 24 hours.
22.2
22.2. Analysis
Comparison 22 Postoperative pain intensity at 24 hours: perineural versus intravenous dexamethasone, Outcome 2 Postoperative pain intensity at 24 hours: additive versus no additive subgroups.
22.3
22.3. Analysis
Comparison 22 Postoperative pain intensity at 24 hours: perineural versus intravenous dexamethasone, Outcome 3 Postoperative pain intensity at 24 hours: low‐ versus high‐dose dexamethasonesubgroups.
22.4
22.4. Analysis
Comparison 22 Postoperative pain intensity at 24 hours: perineural versus intravenous dexamethasone, Outcome 4 Intensity of postoperative pain at 24 hours: high/unclear risk of bias versus low risk of bias subgroups.
23.1
23.1. Analysis
Comparison 23 Postoperative pain intensity at 48 hours: perineural versus intravenous dexamethasone, Outcome 1 Postoperative pain intensity at 48 hours.
23.2
23.2. Analysis
Comparison 23 Postoperative pain intensity at 48 hours: perineural versus intravenous dexamethasone, Outcome 2 Postoperative pain intensity at 48 hours: additive versus no additive subgroups.
23.3
23.3. Analysis
Comparison 23 Postoperative pain intensity at 48 hours: perineural versus intravenous dexamethasone, Outcome 3 Postoperative pain intensity at 48 hours: low‐ versus high‐dose dexamethasone subgroups.
23.4
23.4. Analysis
Comparison 23 Postoperative pain intensity at 48 hours: perineural versus intravenous dexamethasone, Outcome 4 Postoperative pain intensity at 48 hours: high/unclear versus low risk of bias subgroups.
24.1
24.1. Analysis
Comparison 24 Postoperative opioid consumption at 24 hours: perineural versus intravenous dexamethasone opioid consumption: perineural versus intravenous dexamethasone subgroups, Outcome 1 Opioid consumption at 24 hours: perineural versus intravenous dexamethasone.
24.2
24.2. Analysis
Comparison 24 Postoperative opioid consumption at 24 hours: perineural versus intravenous dexamethasone opioid consumption: perineural versus intravenous dexamethasone subgroups, Outcome 2 24‐hour opioid consumption: additive versus no additive subgroups.
25.1
25.1. Analysis
Comparison 25 Participant satisfaction with pain control: perineural versus intravenous dexamethasone, Outcome 1 Participant satisfaction with pain control.
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References

References to studies included in this review

Abdallah 2015 {published and unpublished data}
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Biradar 2013 {published data only}
    1. Biradar PA, Kaimar P, Gopalakrishna K. Effect of dexamethasone added to lidocaine in supraclavicular brachial plexus block: a prospective randomized, double blind study. Indian Journal of Anaesthesia 2013;57(2):180‐4. [PUBMED: 23825819] - PMC - PubMed
Chalifoux 2017 {published data only}
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Chun 2016 {published data only}
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Cummings 2011 {published and unpublished data}
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Dar 2013 {published data only}
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Dawson 2016 {published data only}
    1. Dawson RL, McLeod DH, Koerber JP, Plummer JL, Dracopoulos GC. A randomized controlled trial of perineural vs intravenous dexamethasone for foot surgery. Anaesthesia 2016;71(3):285‐90. [PUBMED: 26682721] - PubMed
Desmet 2013 {published data only}
    1. Desmet C, Braems H, Reynvoet M, Plasschaert S, Cauwelaert J, Pottel H, et al. I.V. and perineural dexamethasone are equivalent in increasing the analgesic duration of a single‐shot interscalene block with ropivacaine for shoulder surgery: a prospective, randomized, placebo‐controlled study. British Journal of Anaesthesia 2013;111(3):445‐52. [PUBMED: 23587875] - PubMed
Desmet 2015 {published data only}
    1. Desmet M, Vanneste B, Reynovoet M, Cauwelaert J, Verhelst L, Pottell H, et al. A randomized controlled trial of intravenous dexamethasone combined with interscalene brachial plexus block for shoulder surgery. Anaesthesia 2015;70(10):1180‐5. [PUBMED: 26082203] - PubMed
Ganvit 2014 {published data only}
    1. Ganvit KS, Akshay HM, Singhal I, Upadhyay MR. The efficacy of dexamethasone added as an adjuvant to ropivacaine (0.5%) for brachial plexus block. International Journal of Research in Medicine 2014;3(1):71‐4. [ISSN: 2320‐2734]
Golwala 2009 {published data only}
    1. Golwala MP, Swadia VN, Dhimar AA, Sridhar NV. Pain relief by dexamethasone as an adjuvant to local anaesthetics in supraclavicular brachial plexus blocks. Journal of Anaesthesiology and Clinical Pharmacology 2009;25(3):285‐8.
Jadon 2015 {published data only}
    1. Jadon A, Dixit S, Kedia SK, Chakraborty S, Agrawal A, Sinha N. Interscalene brachial plexus block for shoulder surgery: Prospective randomized controlled study of effects of 0.5% ropivacaine and 0.5% ropivacaine with dexamethasone. Indian Journal of Anaesthesia 2015;59(3):171‐6. [DOI: ] - PMC - PubMed
Kawanishi 2014 {published and unpublished data}
    1. Kawanishi R, Yamamoto K, Tobetto Y, Nomura K, Kato M, Go R, et al. Perineural but not systemic low‐dose dexamethasone prolongs the duration of interscalene block with ropivacaine: a prospective randomized trial. Local and Regional Anesthesia 2014;7:5‐9. [PUBMED: 24817819] - PMC - PubMed
Kim 2012 {published data only}
    1. Kim YJ, Lee GY, Kim DY, Kim CH, Baik HJ, Heo S. Dexamethasone added to levobupivacaine improves postoperative analgesia in ultrasound guided interscalene brachial plexus blockade for arthroscopic shoulder surgery. Korean Journal of Anesthesiology 2012;62(2):130‐4. [PUBMED: 22379567] - PMC - PubMed
Kumar 2014 {published data only}
    1. Kumar S, Palaria U, Sinha AK, Punera DC, Pandey V. Comparative evaluation of ropivacaine and ropivacaine with dexamethasone in supraclavicular brachial plexus block for postoperative analgesia. Anesthesia: Essays and Researches 2014;8(2):202‐8. [PUBMED: 25886227] - PMC - PubMed
Lee 2016 {published data only}
    1. Lee MJ, Koo DJ, Chou YS, Lee KC, Kim HY. Dexamethasone or dexmedetomidine as local anesthetic agents for ultrasound‐guided axillary brachial plexus blocks with nerve stimulation. Korean Jounal of Pain 2016;29:29‐33. [PUBMED: 26839668 ] - PMC - PubMed
Leurcharusmee 2016 {published data only}
    1. Leurcharusmee P, Aliste J, Zundert CRV, Engsusophon P, Arnuntasupakul V, Tiyaprasertkul W, et al. A multicenter randomized comparison between intravenous and perineural dexamethasone for ultrasound‐guided infraclavicular block. Regional Anesthesia and Pain Medicine 2016;41:328‐33. [PUBMED: 27015546] - PubMed
Movafegh 2006 {published data only}
    1. Movafegh A, Razazian M, Hajimaohamadi F, Meysamie A. Dexamethasone added to lidocaine prolongs axillary brachial plexus blockade. Anesthesia and Analgesia 2006;102(1):263‐7. [PUBMED: 16368840] - PubMed
Nallam 2014 {published data only}
    1. Nallam SR. Interscalene brachial plexus block: Comparison of efficacy of varying doses of dexamethasone combined with levobupivacaine: A double‐blind randomized trial. Journal of Evolution of Medical and Dental Sciences 2014;3(25):6900‐8.
Parrington 2010 {published data only}
    1. Parrington SJ, O'Donnell D, Chan VW, Brown‐Shreves D, Subramanyam R, Qu M, et al. Dexamethasone added to mepivacaine prolongs the duration of analgesia after supraclavicular brachial plexus block. Regional Anesthesia and Pain Medicine 2010;35(5):422‐6. [PUBMED: 20814282 ] - PubMed
Rahangdale 2014 {published and unpublished data}
    1. Rahangdale R, Kendall MC, McCarthy RJ, Tureanu L, Doty R, Weingart A, et al. The effects of perineural versus intravenous dexamethasone on sciatic nerve blockade outcomes: a randomized, double‐blind, placebo controlled study. Anesthesia and Analgesia 2014;118(5):1113‐9. [PUBMED: 24686045] - PubMed
Rosenfeld 2016 {published and unpublished data}
    1. Rosenfeld DM, Ivancic MG, Hattrup SJ, Renfree KJ, Watkins AR, Hentz JG, et al. Perineural versus intravenous dexamethasone as adjuncts to local anaesthetic brachial plexus block for shoulder surgery. Anaesthesia 2016;71(4):380‐8. [PUBMED: 26899862] - PubMed
Sakae 2017 {published data only}
    1. Sakae TM, Marchioro P, Schuelter‐Trevisol F, Trevison DJ. Dexamethasone as a ropivacaine adjuvant for ultrasound‐guided interscalene brachial plexus block: A randomized, double‐blinded clinical trial. Journal of Clinical Anesthesia 2017;38:113‐6. - PubMed
Saritas 2014 {published data only}
    1. Saritas A, Sabuncu C. Comparison of clinical effects of prilocaine, dexamethasone added to prilocaine and levobupivacaine on brachial plexus block. Journal of the Pakistani Medical Association 2014;64(4):433‐6. [PUBMED: 24864639] - PubMed
Shah 2015 {published and unpublished data}
    1. Shah DM, Arora M, Trikha A, Prasad G, Sunder R, Kotwal P, et al. Comparison of dexamethasone and clonidine as an adjuvant to 1.5% lignocaine with adrenaline in infraclavicular brachial plexus block for upper limb surgeries. Journal of Anaesthesiology Clinical Pharmacology 2015;13(3):354‐9. [PUBMED: 26330715 ] - PMC - PubMed
Shaikh 2013 {published data only}
    1. Shaikh MR, Majumdar S, Das A, Saha TK, Bandyopadhyay SN, Mikherjee D, et al. Role of dexamethasone in supraclavicular brachial plexus block. IOSR Journal of Dental and Medical Sciences 2013;12(1):1‐7.
Talukdar 2013 {published data only}
    1. Talukdar M, Begum H, Shoman MM, Khatun UHS. Anaesthetic and analgesic effects of adding dexamethasone to bupivacaine in supraclavicular brachial plexus block ‐ a comparative study. Journal of Bangladesh College of Physicans and Surgeons 2013;31(1):11‐7.
Tandoc 2011 {published data only}
    1. Tandoc MN, Fan L, Kolesnikov S, Kruglov A, Nader ND. Adjuvant dexamethasone with bupivacaine prolongs the duration of interscalene block: a prospective randomized trial. Journal of Anesthesia 2011;25(5):704‐9. [PUBMED: 21681533] - PubMed
Viera 2010 {published and unpublished data}
    1. Viera PA, Pulai I, Tsao GC, Manikantan P, Keller B, Connelly NR. Dexamethasone with bupivacaine increases duration of analgesia in ultrasound‐guided interscalene brachial plexus block. European Journal of Anaesthesiology 2010;27(3):285‐8. [PUBMED: 20009936] - PubMed
Vishnu 2014 {published data only}
    1. Vishnu VA, Vishnu MB, Sai NL. Effect of dexamethasone with bupivacaine on duration of supra clavicular block compared to bupivacaine with normal saline: A prospective, randomized and double blind study. Journal of Evolution of Medical and Dental Sciences 2014;3(28):7861‐9. [DOI: 10.14260/jemds/2014/2984] - DOI
Woo 2015 {published data only}
    1. Woo JH, Kim YJ, KIm DY, Cho S. Dose‐dependency of dexamethasone on th analgesic effect of interscalene block for arthroscopic should surgery using ropivacaine 0.5%. European Journal of Anaesthesiology 2015;32(9):650‐5. [PUBMED: 25603389] - PubMed
Yadov 2008 {published data only}
    1. Yadov RK, Sah BP, Kumar P, Singh SN. Effectiveness of addition of neostigmine or dexamethasone to local anaesthetic in providing perioperative analgesia for brachial plexus block: a prospective, randomized, double blinded, controlled study. Kathmandu University Medical Journal 2008;6(23):302‐9. [PUBMED: 20071811] - PubMed

References to studies excluded from this review

Fredrickson 2013 {published data only}
    1. Fredrickson Franzca MJ, Danesh‐Clough TK, White R. Adjuvant dexamethasone for bupivacaine sciatic and ankle blocks. Results from 2 randomized‐controlled trials. Regional Anesthesia and Pain Medicine 2013;38(4):300‐7. [PUBMED: 23698496] - PubMed
Lui 2015 {published data only}
    1. Lui J, Richman KA, Grodfsky SR, Bhatt S, Huffman GR, Kelly JD, et al. Is there a dose relationship of dexamethasone as adjuvant for supraclavicular brachial plexus block? A prospective randomized double‐blinded clinical study. Journal of Clinical Anesthesia 2015;27(3):237‐42. [PUBMED: 25637938] - PubMed
Percec 2014 {published data only}
    1. Persec J, Persec Z, Kopljar M, Zupcic M, Sakic L, Zrinjscak IK, et al. Low‐dose dexamethasone with levobupivacaine improves analgesia after supraclavicular brachial plexus blockade. International Orthopedics 2014;38(1):101‐5. [PUBMED: 24173676] - PMC - PubMed
Shethra 2007 {published data only}
    1. Shesthra BR, Maharjan SK, Shrestha S, Gautam B, Thapa C, Thapa PB, et al. Comparative study between tramadol and dexamethasone as an admixture to bupivacaine in supraclavicular brachial plexus block. Journal of the Napali Medical Association 2007;46(168):158‐64. [PUBMED: 18340366] - PubMed

References to ongoing studies

NCT01277159 {published data only}
    1. NCT01277159. Duration of analgesia after popliteal fossa nerve blockade: effects of dexamethasone and buprenophine.clinicaltrials.gov/show/NCT01277159 (first received 13 January 2011).
NCT01495624 {published data only}
    1. NCT01495624. The effect of systemic or perineural dexamethasone in the duration of interscalene nerve blocks with ropivacaine.clinicaltrials.gov/show/NCT1495624 (first received 12 December 2011).
NCT01586806 {published data only}
    1. NCT01586806. Comparing subsartorial saphenous nerve blocks with and without dexamethasone from anterior cruciate ligament reconstruction.clinicaltrials.gov/show/NCT01586806 (first received 25 April 2012).
NCT01971645 {published data only}
    1. NCT01971645. Decadon as adjuvant in femoral nerve blocks in knee arthroscopy.clinicaltrials.gov/show/NCT01971645 (first received 22 October 2013).
NCT02178449 {published data only}
    1. NCT02178449. Prolongation of pain free time by the use of dexamethasone in peripheral nerve blocks.clinicaltrials.gov/show/NCT02178449 (first received 26 May 2014).
NCT02322242 {published data only}
    1. NCT02322242. The effects of dexamethasone on low dose interscalene brachial plexus block (ISB‐Dex).clinicaltrials.gov/show/NCT02322242 (first received 16 December 2014).
NCT02436694 {published data only}
    1. NCT02436694. Nerve blocks with dexamethasone and local anaesthetic to improve postoperative analgesia.clinicaltrials.gov/show/NCT02436694 (first received 1 April 2015).
NCT02462148 {published data only}
    1. NCT02462148. Perineural steroids for peripheral nerve block.clinicaltrials.gov/show/NCT02462148 (first received 1 June 2015).
NCT02506660 {published data only}
    1. NCT02506660. Interscalene block with low‐dose IV vs. perineural dexamethasone for shoulder arthroscopy (Dex ISB).clinicaltrials.gov/show/NCT02506660 (first received 2 July 2015).

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References to other published versions of this review

Pehora 2015
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