European Journal of Cardiovascular Medicine

Among anesthesia techniques, brachial plexus block is a very well-known procedure used for upper limb surgeries. In fact, brachial plexus block for upper limb procedures is akin to spinal anesthesia for lower limb surgeries. Halstel and Hall first described the technique of brachial plexus block in 1885 for upper limb surgeries upper extremity. It provides a superior quality of analgesia and avoids the common side effects associated with general anesthesia1 and equally useful in patients with significant comorbidities. It can significantly reduce pain and nausea, allowing for faster discharge from hospital when compared to general anesthesia 1, 2.

In various approaches of brachial plexus, supraclavicular brachial plexus block is preferred for ambulatory upper limb surgeries except shoulder due to its rapid onset, reliable anesthesia and as a safe technique. Among the local anesthetics like lignocaine, bupivacaine, ropivacaine has been popular drugs due to motor blockade, long acting as well as less cardiotoxicity, neurotoxicity. However, it was not very effective for postoperative analgesia. Ropivacaine is a long-acting new amide type of pure enantiomer introduced in 1988. Ropivacaine provides pain relief with less motor blockade &less cardiotoxic. Thus, acts as a suitable drug for supraclavicular block. Dexamethasone can prolong the effect of regional anaesthesia and don't have sedative-opioid related side effects 3.

Kumar Avinash et al., in 2020, conducted a prospective observational comparative study on 70 patients and concluded that dexamethasone as adjuvant is a good choice to prolong the duration of postoperative analgesia without any serious adverse effects. However, prolonged motor block is a matter of concern and the search for adjuvant that selectively prolongs the analgesia without impairing motor function continues. He evaluated the effect of dexamethasone or colonizing with ropivacaine with consideration to onset and duration of sensory, motor blockade, hemodynamic variables 4.

Kulshreshtha S et al., in the year 2018, 5 studied in 80 patients and divided randomly into 2 groups using a computer-generated programme. Ultrasound guided SCBP block was given to eighty patients, randomly assigned into two groups. Group R (forty patients) received 2 mL normal saline with 30 mL Ropivacaine (0.5%) and Group D (forty patients) received 2 mL of dexamethasone (8 mg) with 30 mL of Ropivacaine (0.5%), respectively He found that the requirement for rescue analgesics was more in group R when compared to group D. The onset and duration of sensory and motor block was faster in group D than group R. Addition of dexamethasone to ropivacaine in supraclavicular brachial plexus blockade prolonged time for first rescue analgesia and reduce requirement of rescue analgesics with faster onset and prolonged duration of sensory and motor block 5.

Shrestha BR et al., with the help of computer-generated coded envelope, a prospective study was done among 50 patients. He studied that addition of dexamethasone as an adjuvant to local anesthetics in brachial plexus block provides in significantly early onset and markedly prolonged duration of analgesia without hemodynamic disturbances. Post operative analgesia was assessed using visual analog scale (VAS) score. Found that it shortens onset of sensory and motor block and prolongs the duration of block between both the groups6.

Hence study was designed to study the efficacy of dexamethasone. Thus, many adjuvants are used with local anesthesia in prolonging the duration of block and postoperative analgesia in a single injection block. A little literature of the Ropivacaine 0.75% alone or with dexamethasone is available. Hence, we have designed this study to compare the hemodynamic, sensory and motor effects, postoperative analgesia and patient satisfaction of plain Ropivacaine 0.75% with or without Dexamethasone.

Aim and Objectives

This study aimed to assess onset and duration of sensory block as well as onset and duration of motor block.This also assessed the relative duration of postoperative analgesia, hemodynamic changes, side effects or complications and patient satisfaction.

This prospective observational comparative study was conducted in Department of Anaesthesia in association with Orthopedics, Akash Institute of Medical Sciences and Research Centre (AIMSRC), Devanahalli, Bangaluru rural-562110, Karnataka, India. This study was approved by Institutional Ethical clearance committee.

Inclusion criteria

Age group 18-60 years, ASA grade 1 & 2 status, posted for elective upper limb surgeries, Patients who will give informed consent.

Exclusion criteria

Patients age of less than18 years and more than 80 years, complicated hernias such as bowel obstruction, bowel strangulation, bowel perforation, local and systemic infections, recurrent hernia, immuno-compromised.

After following inclusion and exclusion criteria, a total of 60 patients were included in this study. Patients with ASA grade 1, 2, either gender with age of 18-60 years posted for upper limb surgeries were included in this study. Written informed consent was taken from patients by explaining the procedure with possible complications. Patients were kept under nil per oral overnight. Preanesthetic checkup was done for all patients which includes a detailed history, general physical and systemic examination. Routine blood investigations were done for all the study subjects.

In both groups, patient’s IV access was secured with 18G cannula on opposite hand and IV fluids was started. All patients were premedicated with IV midazolam as sedative dose/kg body weight 20 minutes before giving the block.

Baseline parameters were recorded by attaching all basic monitoring devices like SpO2, ECG, NIBP.SCBP block was performed using a portable ultrasound machine (Sonosite JMC WA, USA) with a liner transducer(8-13MHz) with all aseptic precautions in supine position. The patients were adequately monitored perioperatively. Duration of surgery was noted.

Group R: Patient were received plain ropivacaine 0.75% (28ml of local anesthetic + 2ml of 0.9% NS) alone.

Group RD: Patient were received plain ropivacaine 0.75% with dexamethasone 8mg (28ml of local anesthetic + 2ml of dexamethasone 8mg)

All assessment in the study protocol were noted up to 24 hours and patient’s satisfaction were noted at the end of study. In postoperative period when patient complains of pain at operative site injection diclofenac 75 mg i.m. was given as rescue analgesia.

Parameters to be monitored - Hemodynamic variables- HR, SBP, DBP, onset of sensory block, onset of motor block, duration of sensory block, duration of motor block, number of rescue analgesics in 24 hours, duration of analgesia. Complications such as nausea, vomiting, dysrhythmia, pruritus, neurotoxicity and Horner’s syndrome, phrenic nerve palsy.

Patients’ appraisal: 1. Unsatisfactory, 2. Satisfactory, 3. Good, 4. Excellent. Pain by VAS score: (0-10), 0-Indicates no pain and 10- indicates worst pain imagined.

Onset of sensory blockade is considered as time interval between end of local anesthetic administration and loss of sensation to pin prick. Sensory blockade assessed by pinprick method at duration of 5,10,15,20,25,30 minutes.

Grade1: normal sensation

Grade2: decreased sensation

Grade3: complete loss of sensation

Onset of motor blockade is considered as time interval between time of injection of local anesthetic to inability to move their limbs. It was assessed by flexion at elbow for musculocutaneous nerve, extension at elbow, and wrist for radial nerve, opposition of thumb and index finger for median nerve and opposition of thumb and small finger for ulnar nerve. It is measured by Modified 3-point Bromage score.

Grade 1: Normal power

Grade2: Decrease in motor response with able to move fingers only

Grade3: Complete motor block with inability to move fingers

To evaluate the duration of sensory and motor block, patients were asked to inform the time when incisional discomfort VAS>4 score as a sensation of pain and also the when full power returned to the shoulder.

Duration of analgesia was defined as time interval between the onset of complete sensory block to postoperative VAS score more than 3 or the time for request for first rescue analgesic. It was monitored every 15 minutes up to 24hrs.That was the endpoint of study.

Timing of recording:

1-Haemodynamic variables: every 5 minutes for first 30`1 minutes then every 15 minutes till termination of the study.

2-Onset of sensory and motor blockade: every 5 minutes for first 30 minutes

3-Duration of sensory and motor blockade: every 15 minutes for 24 hours

4-Duration of analgesia: every 15 minutes for 24 hours

Statistical analysis

Demographic data were analysed using descriptive statistics to summarize the characteristics of the study subjects in group R and group RD. Fischer’s exact test and Chi -square test analysis was conducted to compare the characteristics between the study groups. Analysis of clinical parameters like HR, SBP, DBP, RR, SPO2 was done using independent t test among study participants in both the groups. VAS score was analysed using independent t test. All the values were expressed as mean ± SD.P value (P<0.05) was considered statistically significant.

The mean age of the patients in Group R was 37.86 ± 13.86 years as compared to 37.93 ± 12.21 years in Group RD. In Group R there were 25 males (83.3%) and 5 females (16.7%). In Group RD there were 24 males (80%) and 6 females (20%). The mean weight of the patients in Group R was 68.23±10.44 kgs and in Group RD was 68.33±12.43 kgs. The mean duration of surgery in Group R was 147 ± 59 minutes and 149.16 ± 45.66 minutes in Group RD. There was no statistically significant difference between the two groups with regard to age, weight and duration of surgery table 1.

Table 1: Comparison of demographic details and duration of surgery between Group R and Group RD

In group R, Heart rate was 83.83 ± 13.45, systolic blood pressure was 145.90 ± 26.23 mmHg, and diastolic blood pressure was 83.37 ± 12.63 mmHg whereas in Group RD, heart rate was 83.67 ± 10.69, systolic blood pressure was 139.23 ± 22.01 mmHg and diastolic blood pressure was 77.60 ± 11.31 mmHg. The difference was statistically no significant table 2.

Table 2: Comparison of heart rate (HR), systolic blood pressure (SBP) and diastolic blood pressure (DBP) between Group R and Group RD

In this, study, heart rate was compared between Group R and Group RD, which was not statistically significant as shown in table 3.

Table 3: Comparison of variation in heart rate between Group R and Group RD post operatively

In this, study, systolic blood pressure was compared between Group R and Group RD, which was not statistically significant as shown in table 4.

Table 4: Comparison of variation in systolic blood pressure between Group R and Group RD post operatively

In this, study, diastolic blood pressure was compared between Group R and Group RD, which was not statistically significant as shown in table 5.

Table 5: Comparison of variation in diastolic blood pressure between Group R and Group RD post operatively

Onset of Sensory block:

The mean time for onset of sensory block was 4.13 ± 2.31 minutes in Group R and 3.97 ± 2.90 minutes in Group RD, which was statistically insignificant.  

Onset of Motor block:

The mean time for onset of motor block was 12.01 ± 5.37 minutes and 11.03 ± 3.30 minutes in group R and group RD respectively which was statistically not significant.

Duration of Sensory block:

The mean duration of sensory block in group R was 696.83 ± 127.26 minutes and 1044 ± 120.46 minutes in group RD. There was statistically significant difference between the two groups with regards to the duration of sensory blockade (p<0.05).

Duration of Motor block:

The mean duration of motor block in group R and in group RD were 763 ± 132.37 minutes and 1107.8 ± 147.76 minutes respectively, which was statistically significant (p<0.05).

Duration of Analgesia:

The mean duration of analgesia was 817 ± 131.69 minutes in group R and 1185.93 ± 165.59 minutes in group RD which was statistically significant (p<0.05) as shown in table 6.

Table 6: Comparison of mean variation in duration for motor and sensory between Group R and Group RD

Number of Rescue analgesia:

In group R, 21 (70%) patients required three and 9 (30%) of patients were given two rescue analgesic doses in the post operative 24 hours. In group RD, 16 (53.3%) of patient were given two rescue analgesics and 14 (46.7%) patients were given only one rescue analgesics in the post operative 24 hours. The difference in both the groups was statistically significant (p<.0.05) as shown in table 7.

Table 7: Number of rescue doses administered among study and control population

Analgesia was started from 10^th minute. In Group R 4 (13.3%) and in Group RD 1 (3.3%) patient starts developing sensory block. At 15^th minute 5 (16.7%) patients in Group R and 9 (30%) in Group RD had no pain. At both 10th and 15^th minutes though there was no statistically significant difference in onset of sensory blockade, clinically different significant numbers 4 and 1 at 10^th minutes, 5 and 9 at 15^th minutes in Group R and Group RD respectively. Showed sensory onset time difference. From 20^th to 6 hours, there was no statistically clinically significant difference between the groups in No pain segment. At 12^th hours, significant difference was observed between the groups (1 in Group R and 8 in Group RD had no pain). At 24^th hours, in moderate pain segment, there was clinically significant difference. 7 (23%) patients in group R and only 2 (80%) patients in group RD had moderate pain. At 24th hours,5 (16.6%) patients in group R still complained of severe pain, whereas none in Group RD complained the pain which is statistically significant (p<0.05) as shown in table 8.

Table 8: Comparison of mean pain scores between the study and control groups.

Significant difference in mean pain experienced at 12 hours and 24 hours post operatively.

In group RD the satisfaction grading of anaesthesia and analgesia was excellent in 19 (70.4 %) of patients and good in 8 (29.6%) of patients, but in group R it was excellent in 9 (30%) and good in 21 (70%) of patients. which was statistically significant (p=0.00). None of the patients in either group had any post operative complications.

Peripheral nerve blocks provide excellent anaesthesia, it markedly decreases the postoperative analgesic requirement. Surgery on hand and the forearm benefits greatly by supraclavicular block of the brachial plexus. The convenience, dependability, and safety of the supraclavicular approach make it a common method for blocking the brachial plexus; but, once the block starts, the patient may have moderate to severe postoperative discomfort.

Long-acting local anaesthetics like Bupivacaine and Ropivacaine are used to lengthen the duration of the block, however using high doses of these drugs might have negative effects on the patient's nervous and cardiovascular systems. The rationale of using Ropivacaine is that it is a relatively new amide type long acting, pure enantiomer-S-type used for surgery and postoperative pain relief. As a result, for a long time, researchers have been searching for different adjuvants to extend and potentiate the effects of local anaesthetics. An ideal adjuvant should provide a longer duration of analgesia and better hemodynamic stability.

Many drugs have been used as adjuvants to local anaesthetic agents to prolong the duration of peripheral nerve blocks. Dexamethasone is known for its anti-inflammatory, immunosuppressive, and antiemetic properties, these corticosteroids exert their effects by inhibition of phospholipase A 2 as well as changes in cell function induced by glucocorticoid receptor activation. Although these drugs are associated with sign if can’t toxicity when administered in large doses for long periods 7,8.

The mechanism involved for the extended analgesic effect of dexamethasone is attributed to their action locally on nociceptive C-fibres (via glucocorticoid receptors) to increase the activity of inhibitory potassium channels, thus decreasing their activity 9, 10.

This study conducted to compare the efficacy of plain Ropivacaine 0.75%with and without Dexamethasone for supraclavicular brachial plexus block in respect of onset of sensory and motor block, duration of sensory and motor block, duration of analgesia, VAS, time for first rescue analgesic and total number of rescue analgesic.

This study also compared the hemodynamic changes, duration of surgery, side effects and patient satisfaction. There was no difference between the groups with regard to age sex, weight, ASA physical status and duration of surgery. There was no statistically significant difference regarding heart rate, systolic blood pressure and diastolic blood pressure between two groups

The mean onset of sensory block was faster in group RD compared to group R ,even though it was statistically not significant (p>0.05),but clinically significant .The mean onset of motor block in group RD was faster than group R, however it was statistically not significant (p>0.05)but clinically significant .The duration of surgery and motor block in group RD was significantly longer than group R(p=0.000).The duration of analgesia was also significantly longer in group RD compared to group R. It was statistically significant.

The mean time for first rescue analgesic in group R was earlier then group RD which was statistically significant (p=0.000). In group RD the number of rescue analgesics administered was significantly lower than group R(p=0.000). This was statistically significant.

The patient relief in group RD was significantly better than group R. In group RD the VAS score was significantly lower than group R at 10th and 24th hrs (p<0.05). Patient acceptance was high in Dexamethasone group than plain Ropivacaine. There was no reported complications among the groups.

Heart rate

In our study, the mean baseline heart rate in group R and group RD were (83.83±13.45 and 83.67±10.69 beats /min) respectively. The mean heart rate was comparable between the groups during next 24 hrs.

Systolic Blood Pressure

In our study the mean baseline systolic blood pressure in group R and group RD were (145.90±26.23 and 139.23±22.01 mm of hg) respectively. The mean systolic blood pressure was comparable between both the groups during next 24 hrs.

Diastolic blood pressure

In our study the mean baseline diastolic blood pressure in group R and group RD were (83.37±12.63 and 77.60 ±11.31 mm of hg) respectively. The mean diastolic blood pressure was comparable between both the groups during next 24 hrs.

Duration of surgery

In our study the mean baseline of duration of surgery in group R and group RD were (147±59 and 149.16±45.66 minutes) respectively. The mean duration of surgery was comparable between the groups.

Onset of sensory and motor blockade

In our study the mean time to onset of sensory and motor block in minutes in group R and group RD were (4.13±2.31 and 3.97 ± 2.90) and (12.01±5.37 and 11.03 ±3.30) respectively. The onset of sensory and motor block was clinically earlier in group RD compared to group R, which may be attributed to synergistic action of dexamethasone with local anaesthetic.  In a study done by Kulshrestha.S.et al (6), the mean time to onset of sensory and motor block in plain Ropivacaine 0.5% + 30 ml normal saline and Ropivacaine 0.5% + Dexamethasone 8mg (30ml) were (7.000 ± 1.73 and 4.40 ± 1.32) and (10.03 ± 1.73 and 06.33 ± 0.96) minutes respectively. Concluded onset of sensory and motor block was faster in Dexamethasone groups than plain Ropivacaine group 5.

In another study done by Parveen et al (10), the mean time to onset of sensory and motor block in minutes was similar between group R and group RD, (12.5 ± 2.6 and 11.9 ± 2.8) and (17.3 ± 27 and 16.2 ± 1.89) respectively which is statistically not significant (p>0.05) but clinically significant earlier onset of sensory and motor blockade in Dexamethasone group (group R). Our study findings also in accordance with findings of Parveen S et al., 11

Duration of sensory and motor block

In our study the mean duration of sensory and motor blockade were prolonged in group RD compared to group R (1044±120.46 and 1107.8±147.76 minutes, 763.83±132.37 and 696.83±127.26 minutes) respectively. This may be due to addition of dexamethasone exerts its local action at nerve fibres by altering the function of potassium channels in the excited cells, bind to intracellular receptors and modulate nucleus transcription from Shrestha BR et al. In a study done by Krishna et al (7) the duration of sensory block and motor block in plain Ropivacaine 0.5% + normal saline (30) ml and 0.5% Ropivacaine + Dexamethasone 8mg (30) ml were (508.83 ± 32.04 and 455.5 ± 27.42 minutes ,1011.66 ± 25.40 and 862.0 ± 27.93 minutes) respectively, concluded adding Dexamethasone significantly prolong the sensory and motor blockade which is comparable to our study 13. In another study by Ganvit KS et al., the mean duration of sensory and motor block was were prolonged in Dexamethasone group compared to plain Ropivacaine group which is similar to our study 14. In another study by Kumar S et al., they also found statistically significant prolongation of sensory and motor blockade after addition of Dexamethasone to Ropivacaine in supraclavicular brachial plexus block, which is comparable to our study result 15.

Duration of analgesia

In our study the duration of analgesia was prolonged in group RD (1185.93 ±165.59 minutes) compared to group R (817.83 ±131.69 minutes) which is statistically significant (P=0.00) This depict that the mean time for the initial request for rescue analgesia were earlier in group R than group RD. A study done by Shende SY et al., the duration of analgesia in minutes were prolonged in Dexamethasone groups compared to plain local anaesthetic group (815±13.87 and 398.8±42.88) respectively. They used Inj. Bupivacaine 0.5%, but in our study Inj. Ropivacaine 0.75 % were used 16.

Time for first rescue analgesia

The mean time for first rescue analgesics in group R was earlier than group RD which was statistically significant (p=0.00).

Number of rescue analgesic doses

In our study, in group R 21 (70%) and 9 (30%) patients asked for three and two doses of rescue analgesic, however in group RD 16 (53.3 %) and 14 (46.7%) Patient were administered two and one rescue analgesics during study period which is statistically significant (p=0.00). In a study by Kulshreshtha S et al., found that addition of dexamethasone to Ropivacaine in supraclavicular brachial plexus block reduces the requirement of total number of rescue analgesics; they used Inj. tramadol as rescue analgesic 5. In another study by Krishna SS et al., with similar to our study, they concluded that the total number of rescue analgesic (Inj. diclofenac IM) required in 24 hrs in group R was more as compared to group RD (Dexamethasone) 13.

Variations in VAS score

In our study, Analgesia was started from 10^th minute. In Group R 4 (13.3%) and in Group RD 1 (3.3%) patient starts developing sensory block. At 15^th minute 5 (16.7%) patients in Group R and 9 (30%) in Group RD had no pain. At both 10^th and 15^th minutes though, there was no statistically significant difference in onset of sensory blockade, clinically different significant numbers 4 and 1 at 10^th minutes, 5 and 9 at 15^th minutes in Group R and Group RD respectively. Showed sensory onset time difference. From 20^th to 6 hours, there was no statistically clinically significant difference between the groups in No pain segment. At 12^th hours, significant difference was observed between the groups (1 in Group R and 8 in Group RD had no pain). At 24^th hours, in moderate pain segment, there was clinically significant difference. 7 (23%) patients in group R and only 2 (80%) patients in group RD had moderate pain. At 24^th hours,5 (16.6%) patients in group R still complained of severe pain, whereas none in Group RD complained the pain which is statistically significant (p<0.05). In a study done by Shende et al., They compared the VAS score in two groups. Group 1 (Inj. lignocaine 2% plain) and Group 2 (Inj. lignocaine 2% plain and Inj. Dexamethasone), and concluded that in group 2 had VAS score of 8 by 8 hours 16.

Side effects

In our study we found that in ultrasound guided supraclavicular brachial plexus block and control group there was not any complications. A study done by Kulshresta S et al., in their study they concluded there were no side effects in either groups0. In another study by Kumud SG et al., they also concluded there was no any side effects which is similar to our study 14.

Patient satisfaction

Patient satisfaction was assessed by 4-point scale (table 10). The patient satisfaction with analgesics was significantly better with group RD than group R (p=0.00).

Limitations of study

Sample size used in our study is smaller to access the complications. Since, it is a monocentric study, the result may vary with multicentric study. Study was done only in ASA 1 and ASA 2 grade. Blinding of the study would have given the better results.

This study may conclude that duration of sensory, motor blockade and duration of analgesia was prolonged in Group RD. Significant difference between the two groups with regard to time for first rescue analgesia administered and total number of rescue analgesics consumed during 24 hours. In Group RD, time for first rescue analgesic administered were delayed and the total number of rescue analgesic doses administered were lesser compared to Group R. VAS score was lesser in Group RD at 12^th and 24 hours compared to Group R which shows better pain relief in Group RD. There was no incidence of complications in both the groups. The patient’s satisfaction was significantly better with Group RD than Group R. The findings of this study suggests that dexamethasone added to Ropivacaine in supraclavicular brachial plexus block for upper limb surgery clinically shortens the onset time and prolongs the duration of sensory and motor block. Dexamethasone prolongs the duration of analgesia, time for first rescue analgesic and substantially reduces the requirement of rescue analgesia without any side effects. Further studies with large sample size are recommended.

Conflict of interest: Nil

Funding: Nil

Acknowledgements: We would like to thank the authorities of Akash Institute of Medical Sciences and Research Centre (AIMSRC), Devanahalli, Bengaluru, Karnataka, India.

1. Tziavrangos E, Schug SA. Regional anaesthesia and perioperative outcome. Curr Opin Anaesthesiol. 2006;19(5):521-5.
2. McCartney CJ, Brull R, Chan VW, Katz J, Abbas S, Graham B, et al. Early but no long-term benefit of regional compared with general anesthesia for ambulatory hand surgery. Anesthesiology. 2004;101:461-7.
3. Cummings KC, Napierkowski DE, Parra Sanchez I, Kurz A, Dalton JE, Brems JJ, et al. Effect of dexamethasone on the duration of interscalene nerve blocks with ropivacaine or bupivacaine. Br J Anaesth. 2011;107(3):446-53.
4. Yadav S, Yadav K, Bogra J, Kohli M, Gupta R. A Comparison Between Dexamethasone and Clonidine as Adjuvants to Levobupivacaine in the Supraclavicular Approach to the Brachial Plexus Block: A Double-Blind Study. Cureus. 2023;15(10):e46776.
5. Kulshreshtha S, Gupta R. Clinical comparison between 0.5%Ropivacaine and 0.5%Ropivacaine with dexamethasone combination in Supraclavicular brachial plexus Approach. Int J Res Med. 2014; 3(1);71-74.
6. Shrestha BR, Maharjan SK, Tabedar S. Supraclavicular brachial plexus block with and without dexamethasone - a comparative study. Kathmandu Univ Med J (KUMJ). 2003;1(3):158-60.
7. Sauerland S, Nagelschmidt M, Mallmann P, Neugebauer EA. Risks and benefits of preoperative high dose methylprednisolone in surgical patients: a systematic review. Drug Saf. 2000;23:449-61.
8. Schulze S, Andersen J, Overgaard H, Nørgard P, Nielsen HJ, Aasen A, Gottrup F, Kehlet H. Effect of prednisolone on the systemic response and wound healing after colonic surgery. Arch Surg. 1997;132(2):129-35.
9. Attardi B, Takimoto K, Gealy R, Severns C, Levitan ES. Glucocorticoid induced up- regulation of a pituitary K+ channel mRNA in vitro and in vivo. Recept Channels. 1993;1(4):287-93.
10. Kopacz DJ, Lacouture PG, Wu D, Nandy P, Swanton R, Landau C. The dose response and effects of dexamethasone on bupivacaine microcapsules for intercostal blockade (T9 to T11) in healthy volunteers. Anesth Analg. 2003;96:576-82.
11. Parveen S, Athaluri VV, Lakshmi BS. Effect of Intravenous Dexamethasone in Prolonging the Duration of Supraclavicular Brachial Plexus Block with 0.5% Ropivacaine: A Prospective, Randomized, Placebo Controlled Study. Int J Sci Stud. 2015;2(10):56-60.
12. Shrestha BR, Maharjan SK, Tabedar S. Supraclavicular brachial plexus block with and without dexamethasone - a comparative study. Kathmandu Univ Med J (KUMJ). 2003;1(3):158-60.
13. Krishna SS, Chandra GP, Chaitanya KC. Comparative study of ropivacaine alone versus ropivacaine with dexamethasone in supraclavicular brachial plexus block. International Surgery Journal. 2017;4(12);3879-3883.
14. Ganvit KS, H.M Akshay, Singhal Isha, Upadhyay M.R. The efficacy of dexamethasone added as an adjuvant to ropivacaine for brachial plexus block. Paripex Indian Journal of Research. 2014:3(1):71-74.
15. 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. Anesth Essays Res. 2014;8:202-8.
16. Shende SY, Khairmode UB, Gorgile RN, Marathe RM. Supraclavicular brachial plexus block with and without dexamethasone as an adjuvant to local anesthetics- An observational study. Indian J Clin Anaesth. 2020;7(4):645-651.