ESRA UPDATES Journal Club invites leading experts in (regional) anaesthesia to select one (or more) article(s) which for him/her were/are important, interesting or changed his/her clinical practice. This choice can be a general big randomized study but can also be very personal. For this edition our choice went to Dr Giuseppe Pascarella.
Dr. Giuseppe Pascarella is a distinguished expert in the field of anaesthesiology, recognized for his clinical expertise, innovative techniques, and contributions to advancing perioperative care. With a focus on optimizing patient outcomes through evidence-based practices, Dr. Pascarella is dedicated to the development and application of cutting-edge methods in regional anaesthesia and pain management. His commitment to education and mentorship has also established him as a respected leader in training the next generation of anaesthesiologists.
Dr. Giuseppe Pascarella
Unit of Anaesthesia, Intensive Care and Pain Management Campus Bio-Medico University Hospital Foundation Via Alvaro del Portillo 200, Rome, Italy
I would like to share with you my recent interest in new insights about the use of adjuvant drugs for regional anesthesia. These drugs may not only extend block duration and postoperative analgesia but also reduce the effective local anesthetic (LA) dosage administered in single-shot blocks, with consequent less adverse effects. 1 Low-dose blocks do not only mean less systemic reabsorption but also a lower incidence of specific technique-related adverse effects: this is the case of brachial plexus block, where even standard dosages of local anesthetic give a high incidence (around 100%) of phrenic nerve block with consequent hemi-diaphragmatic paresis.
In this regard, I would like to report a recent randomized controlled trial by Kim Y and colleagues, investigating the use of low-volume local anesthetic ultrasound-guided superior trunk block combined with intravenous dexamethasone on 84 patients undergoing arthroscopic shoulder surgery. 2 They compared the interventional group (7 mL of perineural ropivacaine 0.5% + 0.15 mg/kg i.v. dexamethasone) vs. control group (15 mL of perineural ropivacaine 0.5% + i.v. saline solution). They found that the low-volume group was not inferior to the control group in term of analgesia duration, considered as the time between block completion and the onset of moderate postoperative pain (Numeric Rating Scale ³ 4). However, the treatment group showed a significant reduction of diaphragmatic paresis (45.2% and 85.4%), defined as a decrease in diaphragm excursion between 25% and 75%. Based on these results, although phrenic nerve block is asymptomatic in most of cases, it is reasonable to consider low-volume superior trunk block combined with i.v. dexamethasone an important option to manage analgesia in specific frail populations, i.e. morbidity obese or patients with severe respiratory conditions, undergoing shoulder surgery.
Novel adjuvants may also be combined to act synergically and maximize postoperative analgesia in fascial plane blocks. This is highlighted by Zeng et al. in their recent publications about the use of combined perineural dexamethasone and dexmedetomidine as adjuvants of transversus abdominis plane block for postoperative analgesia in gastric cancer patients.3
This large randomized controlled trial included 312 patients divided in 3 groups, depending on whether where TAP block was performed with dexamethasone, dexmedetomidine or a combination of both. Results showed that The combination of dexamethasone and dexmedetomidine as adjuvants for TAP block reduced the incidence of moderate-to-severe pain and pain score both on movement and at rest at 24 h, as well as morphine consumption. I think this study may also open an interesting debate regarding the use of off-label drugs like dexmedetomidine. Although its use is not officially approved by the major drug regulatory agencies, its efficacy and safety as a perineural adjuvant has already been assessed by different systematic review/metanalysis. 4; 5 However, at present most of the trials have been approved and conducted outside American and/or European institutions. Thus, it is reasonable to hope in a future worldwide extension of this research field in order to definitively explore the whole potentiality of dexmedetomidine.
Furthermore, the effect of adjuvants in prolonging analgesia has been established not only in peripheral blocks but also when applied to Local Infiltration Analgesia (LIA), as underlined by this recent network metanalysis by Schubert et al.6
According to their analysis, dexamethasone added to LA was shown to be the most effective adjuvant to prolong analgesia and recommended with a “moderate” level of evidence together with alfa-2-agonists (clonidine and dexmedetomidine). This conclusion may support the use of adjuvants as a good solution to reduce LA total dosage which is typically elevated in the context of LIA. In this case, LIA could be more easily associated with regional blocks to enhance postoperative analgesia without increasing the risk of systemic toxicity.
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