aer_40_22_R2_OA

Original Article
1 1
2 2
3
4 Comparing Different Doses of Dexmedetomidine Combined 3
4
5
6
with Ropivacaine for Ultrasound‑Guided Supraclavicular 5
6
7
8
Brachial Plexus Block in Upper Limb Surgeries ‑ A Prospective 7
8
9 Randomized Controlled Trial 9
10 10
11
AQ1 P. Akshara1, Dilip Kumar Govindan1, Jagan Govindasamy1, Mohamed Arif1, Raghuraman M. Sethuraman2 11
12 1
Department of Anaesthesiology, Shri Sathya Sai Medical College Hospital, Shri Balaji Vidyapeeth (Deemed to be University), Kancheepuram, Tamil Nadu, India, 12
13 2
Department of Anesthesiology, Sree Balaji Medical College and Hospital, BIHER, Chennai, Tamil Nadu, India 13
14 14
15 15
16 Abstract 16
17 17
Background: Dexmedetomidine is used as an adjuvant to local anesthetic agents to provide prolonged analgesia in peripheral nerve blocks.
18 This study aimed at determining the optimal dose of dexmedetomidine, which when combined with ropivacaine will produce a superior 18
19 quality block in terms of extended pain‑free period and reduced perioperative analgesic/opioid use, which in turn improves patient satisfaction. 19
20 Objective: The objective of the study is to assess the duration of analgesia with two different doses (25 μg and 50 μg) of dexmedetomidine 20
21 with ropivacaine in supraclavicular brachial plexus block. Subjects and Methods: This prospective randomized controlled study included 21
50 patients undergoing upper limb surgeries under supraclavicular brachial plexus block randomly divided into two groups. Group D25 received
22 22
29 mL of 0.5% ropivacaine +25 μg dexmedetomidine diluted in 1 mL of normal saline (total 30 mL); Group D50 received 29 mL of 0.5%
23 ropivacaine +50 μg dexmedetomidine diluted in 1 mL of normal saline (total 30 mL). Onset and duration of sensorimotor block, duration 23
24 of analgesia, and time interval for the rescue analgesia and hemodynamic stability were observed. Results: The mean onset of motor and 24
25 sensory block was significantly higher in the D25 group (P = 0.001). The Visual Analog Scale pain scores and rescue analgesia consumption 25
26 were significantly lower in the D50 group (P = 0.013, 0.001). The duration of analgesia was significantly higher in the D50 group (P = 0.001). 26
27 Conclusion: Dexmedetomidine 50 μg is an effective adjuvant dose to ropivacaine with insignificant hemodynamic changes with better duration 27
of analgesia and lesser pain scores.
28 28
29 Keywords: Dexmedetomidine, pain score, perioperative analgesia, ropivacaine, supraclavicular brachial plexus block 29
30 30
31 31
32 additional analgesic properties that reduce the anesthetic 32
33 Introduction 33
requirement and also perioperative sympatholytic and
34 With the advent of ultrasound, regional anesthesia 34
cardiovascular stabilizing effects.[3‑5]
35 techniques have taken acceleration in its application and 35
36 are being used as a choice of anesthesia by anesthetists 36
37 with success rates up to 95%.[1] Regional anesthesia has the Address for correspondence: Dr. Mohamed Arif,
37
Department of Anaesthesiology, Shri Sathya Sai Medical College Hospital,
advantage that it can provide a good perioperative analgesia,
38 Shri Balaji Vidyapeeth (Deemed to be University), Ammapet, Kancheepuram, 38
safety, and better patient satisfaction. Supraclavicular block, Tamil Nadu, India.
39 39
also known as “spinal of the arm,” blocks the nerves at the E‑mail: sam7arif@gmail.com
40 base of the neck and gives a uniform distribution of the
40
41 drug throughout the brachial plexus with high anesthetic 41
Submitted: 26‑Feb‑2022 Revised: 12‑May‑2022
42 efficacy.[2] Accepted: 17‑May‑2022 Published: ***
42
43 43
44 Dexmedetomidine, being an alpha‑2 adrenoceptor agonist, 44
This is an open access journal, and articles are distributed under the terms of the Creative
has a sedative action by acting on the locus coeruleus. It has
45 Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows others to 45
remix, tweak, and build upon the work non‑commercially, as long as appropriate credit
46 Access this article online is given and the new creations are licensed under the identical terms. 46
47 Quick Response Code: For reprints contact: WKHLRPMedknow_reprints@wolterskluwer.com 47
48 Website: 48
www.aeronline.org
49 How to cite this article: Akshara P, Govindan DK, Arif M, Govindasamy J, 49
Sethuraman RM. Comparing different doses of dexmedetomidine combined
50 with ropivacaine for ultrasound‑guided supraclavicular brachial plexus block
50
DOI:
51 10.4103/aer.aer_40_22 in upper limb surgeries ‑ A prospective randomized controlled trial. Anesth 51
52 Essays Res 2022;XX:XX-XX. 52

© 2022 Anesthesia: Essays and Researches | Published by Wolters Kluwer - Medknow 1

 Akshara, et al.: Optimal adjuvant dose of dexmedetomidine in supraclavicular brachial plexus block

1 Although there is adequate literature to prove that The loss of sensation to pinprick and the complete paralysis of 1
2 dexmedetomidine extends the duration of analgesia provided mentioned actions from the time of injection were considered 2
3 by local anesthetics for nerve blocks,[6‑8] the optimal dose range commencement of sensory and motor blockade, respectively. 3
4 has always been debatable. As lesser doses do not provide Similarly, the time taken for reappearance of pinprick 4
5 effective analgesia and the higher doses are reported to cause response from the onset of sensory blockade and achieving 5
6 bradycardia and hypotension,[9] it is warranted to identify the complete movement of wrist and fingers from the onset of 6
optimal dose of dexmedetomidine which will provide the motor blockade was considered the duration of sensory and
7 7
desired effect and also not compromise on the hemodynamic motor blockade, respectively. The time duration after which
8 status. Previous studies compared dexmedetomidine in the
8
the patients required their first dose of rescue analgesic from
9 doses of 50 μg, 100 μg, and 150 μg.[10,11] Therefore, this 9
the time of sensory blockade was considered the duration of
10 study was done to evaluate perioperative analgesic effects analgesia provided by the drugs. 10
11 and hemodynamic changes with the lower doses of 25 μg 11
12 and 50 μg. Patients in whom a sensory and motor block of Grade 2 was 12
13 achieved were included in the study, while those with Grade 0 13
14 or 1 sensory or motor block were excluded from the study and 14
Subjects and Methods converted to general anesthesia.
15 15
This was a randomized, double‑blinded study conducted
16 Feedback regarding patient satisfaction was obtained at the 16
for a period of 18 months in our institute after obtaining
17 end of the procedure and was graded as follows:[15] 17
clearance from the Institutional Ethics Committee  (IEC
18 • “Excellent (4): No complaint from the patient 18
No. 2019/561, dated November 29, 2019). The trial was
19 • Good (3): Minor complaint with no need for supplemental 19
registered prospectively with Clinical Trial Registry of
20 India (CTRI/2020/02/030963). Written and informed consent analgesics 20
21 was obtained from all the patients for participating in the • Moderate  (2): Complaint that required supplemental 21
22 study, as well as for using their data for research and academic analgesics 22
purposes. All the procedures were performed as per the • Unsuccessful (1): Patient required general anesthesia.”
23 23
24 guidelines laid down in the Declaration of Helsinki (1964). Postoperative pain was assessed using Visual Analog 24
25 Included patients were randomly divided into two groups Scale  (VAS), [16,17] and thereafter, pain was assessed 25
26 by computer‑generated list of random numbers. Both regularly for every 1 h till the patient regains his motor 26
27 Group 1 and Group 2 consisted of 25 patients. Following power. 27
28 the preanesthetic assessment, patients were admitted to the Rescue analgesia was provided with injection tramadol 50 mg 28
29 hospital the day before the surgery. After obtaining informed if the VAS ≥4/10. Level of sedation was measured using the 29
30 consent, the patients were shifted to the operation theater with Ramsay sedation score.[18,19] The occurrence of side effects 30
31 a preoperative fasting status of 8 h. such as bradycardia and hypotension was noted. 31
32 In the operation theater, an intravenous  (i.v.) access was It was decided to manage bradycardia  (heart rate  [HR] 32
33 secured and American Society of Anesthesiologists monitoring ≤50 beats/min) with 0.6  mg i.v. bolus of atropine and 33
34 devices were attached which includes electrocardiograph, pulse hypotension  (fall in BP by 20% from the baseline or an 34
35 oximetry (SpO2), and noninvasive blood pressure (BP), and the absolute mean aterial pressure [MAP] ≤60 mmHg) with i.v. 35
36 baseline parameters were recorded. Supplemental oxygen was ringer lactate or normal saline or increments of mephentermine 36
37 provided through nasal cannula at 4 L.min−1 and the patients 3 mg i.v., depending on the requirements. Total amount of 37
38 were sedated with i.v. midazolam 1 mg and fentanyl 1 μg.kg−1 rescue analgesic given and hemodynamic parameters were 38
39 before the block. monitored regularly. 39
40 Under all aseptic precautions, supraclavicular brachial plexus Statistical analysis was done using the SPSS(Statistical 40
41 block was performed by an anesthesiologist under ultrasound Package for the Social Sciences) Statistics for Windows, 41
42 guidance with 30 mL of study drug. The anesthesiologist Version 25.0. (Armonk, NY: IBM Corp.). The Chi‑square test 42
43 performing the procedure and the observer were both blinded and Fisher’s exact test were used to calculate the significance. 43
44 to the drug administered to both groups. Motor and sensory P < 0.05 was considered statistically significant. 44
45 components were evaluated every 3 min after giving the block 45
46 until complete motor and sensory block of the upper limb has
been achieved. Sensory block was assessed by the pinprick Results 46
47 47
test using a blunt 26G needle in the dermatomes supplied by A total of 50 patients satisfied the inclusion criteria and were
48 the ulnar, radial, median, and musculocutaneous nerves. This enrolled in the study, among which 25 patients were in the 48
49 was charted using a three‑point scale. Motor block for the D25 group and 25 patients were allocated to D50 group. 49
50 mentioned nerves were evaluated by thumb adduction, thumb The demographic characteristics of patients in both groups 50
51 abduction, thumb opposition, and flexion at elbow, respectively, including age, body mass index (BMI), and type and duration 51
52 and this was also charted on a three‑point scale.[12‑14] of surgery were comparable. 52

2 Anesthesia: Essays and Researches  ¦  Volume XX  ¦  Issue XX  ¦  Month 2022
 Akshara, et al.: Optimal adjuvant dose of dexmedetomidine in supraclavicular brachial plexus block

1 The onset of sensory block was earlier in the D50 group when The hemodynamic parameters such as HR and BP were 1
2 compared to the D25 group  (11.47  ±  2.21  vs. 14.6  ±  2.42, similar in both groups intraoperatively. Although there was 2
3 P  = 0.001). Similarly, the onset of motor block was also a significant increase in the postoperative MAP in the D50 3
4 earlier in the D50 group when compared to the D25 group group, it was still well within normal limits. 4
5 (18.92 ± 1.94 vs. 23.01 ± 3.00, P = 0.001) [Table 1]. 5
6 Though the pain score at 4 h was more with 25 μg Discussion 6
7 dexmedetomidine, the results were not statistically significant. Among the 50 patients included in our study, both groups 7
8 Pain score at 8 h (2.40 vs. 1.64, P = 0.001), 12 h (2.60 vs. 1.84, had 25 patients who were randomly allocated to both groups. 8
9 P = 0.001), 20 h (3.00 vs. 2.36, P = 0.015). and 24 h (3.36 vs. Adjuvant dose of 25 μg and 50 μg of dexmedetomidine was 9
10 2.56, P = 0.013) was significantly higher in the D25 group compared. Our study shows that there is a dose‑dependent 10
11 [Figure 1]. improvement in perioperative pain relief in the group that 11
12 received 50 μg dexmedetomidine when given as an adjuvant 12
The mean duration of analgesia (652.32 ± 83.25 min in D25 vs. to ropivacaine during supraclavicular nerve block in patients
13 13
960.00  ±  78.67  min in D50, P =  0.001) was significantly undergoing upper limb surgeries. The age, BMI, duration, and
14 more in the D50 group [Figure 2], whereas the requirement
14
type of surgery were comparable in both groups.
15 for rescue analgesia at 16 h (1.71 ± 0.49 vs. 1.00 ± 0 doses, 15
16 The addition of dexmedetomidine to local anesthetics for 16
P = 0.008), 20 h (2.1 ± 0.32 vs. 1.00 ± 0 doses, P = 0.001), and
17 peripheral nerve blocks has been time‑tested to provide 17
24 h (2.56 ± 0.62 vs. 2.00 ± 0 doses, P = 0.001) was more in
18 better perioperative analgesia in terms of earlier onset of 18
the group that received 25 μg of dexmedetomidine [Table 2].
19 sensory and motor blockade, prolongation of duration of 19
20 this sensory and motor blockade, and duration of analgesia 20
Table 1: Distribution of onset of sensory and motor block postoperatively without hemodynamic changes or significant
21 21
with drug group among the study population adverse effects.[10,20,21]
22 22
23 Drug group n Mean±SD P value by t‑test When the adjuvant action of fentanyl and dexmedetomidine with 23
24 Onset of sensory D25 25 14.60±2.42 0.001 local anesthetics was compared, addition of dexmedetomidine 24
block (min) D50 25 11.47±2.21 was found to provide better and prolonged sensory and motor
25 25
Onset of motor D25 25 23.01±3.00 0.001 blockade when compared to fentanyl as an adjuvant.[22]
26 block (min) D50 25 18.92±1.94
26
27 SD=Standard deviation Studies comparing adjuvant dexmedetomidine doses of 27
28 50 μg and 100 μg with 0.5% levobupivacaine suggested that 28
29 though the onset of sensory and motor blockade was earlier, 29
30 Table 2: Distribution of rescue analgesia with drug group the duration of analgesia was more  (1033.6  ±  141.6  vs. 30
among the study population 776.4 ± 138.6 min; P = 0.001) and need for rescue analgesia
31 31
32 Rescue analgesia Drug n Mean±SD P value was lesser in the group that received 100 μg, and the incidence 32
33 (number of doses) group by t‑test of hypotension and bradycardia was significantly higher 33
34 16 h D25 7 1.71±0.49 0.008 in that group.[6] Therefore, we do not prefer adding higher 34
D50 13 1.00±0.00 doses of dexmedetomidine and decided to compare doses of
35 35
20 h D25 10 2.10±0.32 0.001 25 μg and 50 μg.
36 D50 12 1.00±0.00
36
37 24 h D25 18 2.56±0.62 0.001
Very few studies have compared different doses of adjuvant 37
38 D50 5 2.00±0.00 dexmedetomidine. [10,11] While comparing 1 μg.kg −1 and 38
39 SD=Standard deviation 2 μg.kg −1 doses of dexmedetomidine as adjuvant to 39
40 40
41 4.00
Μg
1200
Μg 41
42 3.50 960
42
1000
43 3.00 43
800
44 2.50 652.32 44
45 2.00 600 45
46 1.50
400 46
1.00
47 200 47
0.50
48 0.00 0
48
49 4 hours 8 hours 12 hours 16 hours 20 hours Duration of Analgesia (min) 49
50 D25 D50 D25 D50 50
51 Figure 1: Distribution of Visual Analog Scale pain score 4th hourly Figure 2: Distribution of duration of analgesia with drug group among 51
52 postsurgery with drug group among the study population the study population 52

Anesthesia: Essays and Researches  ¦  Volume XX  ¦  Issue XX  ¦  Month 2022 3
 Akshara, et al.: Optimal adjuvant dose of dexmedetomidine in supraclavicular brachial plexus block

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5 whereas in our study, there was no significant difference in 5. Chiu  TH, Chen  MJ, Yang  YR, Yang  JJ, Tang  FI. Action of
5
the HR and MAP intraoperatively in both groups. Though dexmedetomidine on rat locus coeruleus neurones: Intracellular
6 recording in vitro. Eur J Pharmacol 1995;285:261‑8. 6
postoperatively the MAP seemed to be significantly higher 6. Kaur H, Singh G, Rani S, Gupta KK, Kumar M, Rajpal AS, et al. Effect of
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in the group that received 50 μg of dexmedetomidine, it was dexmedetomidine as an adjuvant to levobupivacaine in supraclavicular
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9 J Anaesthesiol Clin Pharmacol 2015;31:333‑8. 9
10 Studies comparing 1 μg.kg−1 with 2 μg.kg−1 of dexmedetomidine 7. Kathuria S, Gupta S, Dhawan I. Dexmedetomidine as an adjuvant to 10
have shown similar time to onset of sensory (9.36 ± 1.114 min ropivacaine in supraclavicular brachial plexus block. Saudi J Anaesth
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with 1 μg.kg−1  vs. 8.32  ±  0.945  min with 2 μg.kg−1) and
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13 13
with 2 μg.kg−1) blockade.[14] The duration of sensory and motor block: A randomized controlled trial. Anesth Analg 2015;121:1655‑60.
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with levobupivacaine: A double‑blind randomised trial. Indian J Anaesth
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2017;61:256‑61.
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18 requiring treatment with atropine. Therefore, the authors of dexmedetomidine with ropivacaine in supraclavicular brachial 18
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19
20 as adjuvant to 0.5% ropivacaine.[14] Since our study was 11. Singh J, Shakya S, Ghimire A, Saha S, Singh PB. A comparative study 20
21 done on adult patients, effects obtained with 50 μg dose of between two different doses of dexmedetomidine combined with 21
dexmedetomidine were similar to the effects obtained with ropivacaine in ultrasound guided supraclavicular brachial plexus block.
22 J Coll Med Sci-Nepal 2018;14:127–131.
22
23 1 μg.kg−1 dose of dexmedetomidine in these studies.[14] 12. Fassoulaki A, Sarantopoulos C, Zotou M, Karabinis G. Assessment of 23
24 Thus, of the two different doses  (25 μg and 50 μg) of the level of sensory block after subarachnoid anesthesia using a pressure 24
palpator. Anesth Analg 1999;88:398‑401.
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25
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27 supraclavicular brachial plexus block with insignificant and disc herniation. Clin Orthop Relat Res 2021;479:651‑63. 27
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of patient satisfaction in postoperative pain management following hand
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Conflicts of interest
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There are no conflicts of interest. Clin Pharmacol 2014;30:36‑40.
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49 49
50 Author Queries??? 50
51 AQ1: The author P. Akshara has not agreed to the copyright terms and conditions which was sent on the author’s 51
52 email address 52

4 Anesthesia: Essays and Researches  ¦  Volume XX  ¦  Issue XX  ¦  Month 2022