European Journal of Cardiovascular Medicine

Regional anesthesia, particularly peripheral nerve blocks, plays a crucial role in multimodal analgesia in the peri-operative period. It provides superior analgesia, reduces opioid consumption and minimizes systemic side effects1,2. Among various regional anesthetic techniques, the supraclavicular brachial plexus block (SCBPB) is widely employed for upper limb surgeries, offering a dense and reliable block of the entire upper extremity distal to the shoulder.1,2,3,4

Levobupivacaine is the S-enantiomer of bupivacaine, meaning it has a lower affinity for cardiac sodium channels, reducing the risk of cardiotoxicity and CNS toxicity compared to the R-enantiomer present in racemic bupivacaine.5

This chirality-based advantage makes levobupivacaine safer for High risk patients, including those with cardiac disease.6

Various Adjuvants used with local anesthetic agent in Supraclavicular block. are: Dexamethasone, Clonidine ,Midazolam, Tramadol, Magnesium sulphate, Dexmedetomidine, Ketamine, Buprenorphine.7,8

Dexamethasone, a potent synthetic glucocorticoid, has been widely used to prolong the duration of local anesthetics in peripheral nerve blocks.9

Proposed Mechanisms of Action: 

1. Anti-inflammatory Effects

 Reduces perineural inflammation and edema, prolonging local  anaesthetic effect. 10

2. Vasoconstrictive Effects :

Limits systemic absorption of levobupivacaine, increasing its residence time.10

3. Sodium and Potassium Channel Modulation11
4. Inhibits neuronal depolarization, enhancing conduction blockade.11,12

Very few studies have been done to study and compare efficacy and safety of Dexamethasone as an adjuvant to 0.5% Levobupivacaine for supraclavicular brachial plexus block in same setting. Keeping all this in mind our current prospective observational study was done to compare the efficacy and safety of Levobupivacaine with Dexamethasone in Supraclavicular brachial plexus block.

Objectives:

1. To compare the onset of sensory and motor blockade.
2. To compare the time for complete sensory and motor blockade.
3. To compare the duration of sensory and motor blockade.
4. To compare the duration of analgesia provided.

The present study “Comparison of Levobupivacaine 0.5% with Dexamethasone and 0.5%Levobupivacaine in Supraclavicular Brachial Plexus Block was carried out prospectively in Department of Anesthesiology in a tertiary care hospital after getting approval from ethical committee of institution during period November 2022-September 2025. The total population of 70 patients of age 18 to 60 years scheduled for elective upper limb surgeries e.g. Fracture radius, fracture ulna, fracture both bone forearm, distal 1/3rd humerus etc. were included in the study. Source of data: Primary data from the patients posted for elective upper limb surgeries under Supraclavicular brachial plexus block was collected. It included patients coming for pre-anesthetic check-up after confirmation of diagnosis from surgical specialists posted for upper limb surgeries. The study was carried out in 70 adult patients admitted in the department of Orthopedics, with age in the range of 18-60 years, ASA Grade I & II posted for elective upper limb surgeries under Supraclavicular brachial plexus block. All the patients participating in the study were explained clearly about the purpose and nature of the study in the language they could understand. They were included in the study only after obtaining a written informed consent. Inclusion criteria: - 1. Age between 18 years - 60 years of either sex. 2. Body weight between 50 kg - 80 kg. 3. ASA physical status I and II. 4. Patients to be posted for upper limb surgeries involving elbow, forearm, hand. 5. Patients willing to undergo surgeries under regional anesthesia. Exclusion criteria: 1. Patients unwilling for the procedure under regional anesthesia. 2. ASA Grade III & IV. 3. Patients with neurological deficit in the upper limb. 4. Patients with diabetic neuropathy, psychiatric illness and neurological disease. 5. Patients with history of allergy to local anesthetic drugs. 6. Contraindications to peripheral nerve block e.g. bleeding diathesis, local infection and patients on anticoagulants. 7. History of cardiovascular diseases like arrhythmias, ischemic heart disease and valvular heart disease, Liver, Respiratory, Kidney and Endocrine diseases. Data collection: Primary data collection was done from the patients undergoing the supraclavicular block for upper limb surgeries in our tertiary teaching hospital in Central India. • Sample size calculation • A study conducted by M V Kameshwar Rao et al7 concluded that the mean time to onset of sensory blockade in the group who received Dexamethasone with Levobupivacaine was 4.30 ± 1.32 minutes and the group, which received Levobupivacaine alone was 7.20 ± 1.73 minutes. Using these means, 95% confidence interval and 80 % power the minimum sample size in each group was 35 patients in each group. So, total of 70 study subjects to be included in the study. • • The following formula was used to calculate the sample size It was thus decided to take a sample size of 70 patients, 35 in each group. HYPOTHESIS: There is no difference in efficacy and clinical profile of Supraclavicular block with Injection Levobupivacaine with Dexamethasone and Inj. Levobupivacaine alone. METHODOLOGY: An anesthesiologist, a day before the surgery performed detailed pre-anesthetic evaluation of the patients. 70 patients satisfying the inclusion and exclusion criteria were included in the study. 70 patients of ASA I and II of either sex, who were scheduled to undergo upper limb (i.e. elbow, forearm and hand) orthopedic surgery under ultrasound guided supraclavicular brachial plexus block were included in the study. The sample size of total 70 patients satisfying inclusion criteria were alternatively allocated into one of the two groups of 35 patients each. Group L (N = 35): patients received 20 mL of Levobupivacaine 0.5% +2ml normal saline. (Total volume 22 ml). Group LD (N = 35): patients received 20mL of Levobupivacaine 0.5% with Dexamethasone 8mg (2cc) (Total volume 22 ml). All patients were kept nil by mouth for 8 hrs. In operation theatre, multipara monitoring device with ECG, pulse rate, non-invasive blood pressure, SpO2 were attached to the patient and baseline parameters were noted. Patients received Inj. Pantoprazole 40 mg and Inj. Ondansetron 4 mg IV slowly as a premedication after establishing intravenous access with 20G cannula. Positioning of the patient: Patients were placed in supine position with head turned away from the side where block was performed. A pillow was placed below the shoulder to make landmarks prominent. The arm to be anaesthetized was adducted and hand was extended along the side. TECHNIQUE OF USG GUIDED SUPRACLAVICULAR BLOCK: FIGURE 1: Landmark for needle insertion in supraclavicular block FIGURE 2: IMAGE SHOWING POSITION OF ULTRASOUND PROBE With the patient in the proper position, the skin was disinfected and a sonosite SII- HFL 38xi/13-6 mhz PCPNDT No. MH transducer was positioned in the transverse plane immediately proximal to the clavicle, slightly posterior to at its midpoint. The transducer was tilted caudally, to image the chest contents, to obtain a cross-sectional view of the subclavian artery. The brachial plexus was seen as a collection of hypoechoic oval structures (honey comb appearance) posterior and superficial to the artery. Color Doppler was routinely used prior to needle insertion to rule out the passage of large vessels in the anticipated trajectory of the needle. Using a 25- to 27-gauge needle, 1–2 mL of local anesthetic was injected into the skin 1 cm lateral to the transducer to decrease discomfort during needle insertion. To avoid inadvertent puncture of and injection into the brachial plexus, the needle was not initially inserted deeper than 1 cm. The distribution of local anesthetic via small-volume injections was observed as the needle advances through tissue layers (hydro-localization), small-volume injections were used to avoid inadvertent needle insertion into the brachial plexus. Locate the subclavian artery and identify the bunch of grapes. The plexus contains more connective tissue moving from interscalene to supraclavicular views, thus resulting in more hyperechoic echotexture. Supraclavicular fossa is scanned in the parasagittal plane to visualize the structures 1. Uninterrupted acoustic shadow of the first rib. 2. Subclavian artery in the Centre of the screen with the plexus superolateral to the artery. 3. Comet tail artefact of the pleura Visualised. Needle is advanced carefully by using hydrodissection technique and subfascial intracluster administration of drug is made After careful aspiration, 1–2 mL of local anesthetic was injected to confirm proper needle placement. When the injection displaced the brachial plexus away from the needle, an additional advancement of the needle 1–2 mm closer to the plexus was required to accomplish adequate local anesthetic spread. Corner pocket or ulnar pocket is carefully separated under visualization to avoid lower trunk sparing. Needle image is maintained above the level of first rib and pleura. When the injection of local anesthetic did not appear to result in a spread around the brachial plexus, needle repositioning was necessary. Typically, 23mL of local anesthetic with adjuvant was required for adequate block. The total volume of the Anaesthetic solution was injected at an incremental dose of 5 ml, each which was given over 10-15 minutes, preceded by negative aspiration of blood in each group. Time of injection was considered as Time 0. Intra-operative Monitoring All patients were monitored for: Heart rate, Blood pressure (systolic, diastolic and mean), Respiratory rate, SpO2, Sensory block: onset and duration by Hollmen Scale, Motor block: onset, duration and density of motor block using Bromage scale for upper extremity, Visual analogue scale score for pain assessment. Cardiorespiratory parameters (pulse rate, respiratory rate, non-invasive blood pressure, SpO2) were monitored continuously. Recordings were made at an interval of every 5 minutes until 60 mins, every 10 mins until 2 hours and every 15 minutes till the end of surgery. Postoperatively, patients were shifted to recovery room for further monitoring. Post-operative Monitoring After the completion of the surgery patient were shifted to post operative recovery ward without prescribing any analgesics in any form. Patient were monitored till the complete recession of sensory as well as motor block occurred and till the time patient did not demand any analgesic or VAS Score ≥ 4. For pain relief, patient was given systemic analgesic Inj. Diclofenac Sodium 1.5mg/kg (75mg) IV slowly or as per individual requirement. Definitions: TIME OF ONSET OF SENSORY BLOCK The sensory block was evaluated by a Hollmen scale Score. The onset time of the sensory block (OTSB) was taken as the time interval in minutes from time-0 till the sensory block started appearing i.e Hollmen score > 1. THE TIME FOR COMPLETE SENSORY BLOCK (TCSB) It was taken from time-0 till the complete sensory block was achieved i.e Hollmen Score=4. The findings were recorded at an interval of 2 min till a complete sensory block was achieved i.e Hollmen Score=4 TOTAL DURATION OF SENSORY BLOCK (TDSB) It was taken as the duration of time in minutes from the time-0 till the Hollmen Score = 1 Hollmen Score 1 Normal sensation of pinprick 2 Weaker sensation of pin prick felt as compared with other upper limb 3 Pin prick recognized as touch with blunt object 4 No perception of pin prick EVALUATION OF MOTOR BLOCK The motor block was evaluated by using the Modified Bromage Scale (MBS) for the upper extremity and the finding was recorded from time-0 till the complete loss of the motor power was achieved i.e MBS Score=3. MODIFIED BROMAGE SCALE GRADE CRITERIA DEGREE OF BLOCK 0 Able to raise extended arm to 90° for a full 2 sec Nil (0%) 1 Able to flex the elbow and move the fingers but unable to raise the extended arm Partial (33%) 2 Unable to flex the elbow but able to move the fingers Almost complete (66%) 3 Unable to move the arm, elbow, fingers Complete (100%) TIME OF ONSET OF MOTOR BLOCK: It was the time interval in minutes from Time =0 to the time when modified Bromage scale MBS =1 achieved). THE TIME FOR COMPLETE MOTOR BLOCK (TCMB) It was the time interval from Time = 0 to the time we achieved Modified Bromage scale (MBS) = 3 The onset of the motor blockade will be assessed every 2 min till the onset of motor block. The patient had weakness of any of the three joints -Shoulder, elbow, or wrist, upon trying to perform active movements. TOTAL DURATION OF MOTOR BLOCK (TDMB) It was the time interval from Time= 0 to the time we achieved Modified Bromage scale (MBS) = 0. Quality of sensory block: The quality of the sensory block was assessed every 5 min after the onset established. It was assessed using pin prick and application of ice-cold water. At the end of 30 minutes, the quality of the sensory block was assessed by the number of dermatomes having a full block. The sensory block in each dermatome was graded as follows: Quality of sensory block 0 No block Normal sensation. 1 Partial block Reduced sensation when compared to the opposite limb 2 Complete block Complete absence of sensation Quality of motor block: The quality of the motor block was assessed every 5 min after the onset established. It was assessed by asking the patient to perform active movements of each of the three joints − Shoulder, elbow, and wrist. Quality of motor block 0 No block no loss of force 1 Partial reduced force compared with the contralateral arm 2 Complete block incapacity to overcome gravity ADEQUACY OF BLOCK: Adequacy of block will be evaluated by Allis clamp test before handing over the patient to surgeon. The test will be done by asking the patient whether they felt any discomfort when pressure applied with the Allis clamp at the area of the surgical field. The reading will be recorded as follows: i. Complete block (Total comfort to patient) ii. Inadequate block (Discomfort: Requiring supplementation These patients were supplemented with intravenous fentanyl (1mcg/kg) and midazolam (0.02 mg/kg). Surgery was allowed to proceed when there was complete block or patient did not complain of pain at the surgical site by Allis clamp test after supplementation, in case of inadequate effect. Block will be considered as a failure if complete sensory and motor block not achieved even after 45 minutes. Failed blocks will be converted to GA and these patients will be excluded from the study. COMPLICATIONS: • Inadequacy of block, • Any reaction at injection site like hematoma, • Any respiratory distress, pneumothorax, • Fall in respiratory rate to <10 per min, • Fall in Spo2 to < 90%, • Dryness of mouth, nausea, vomiting, local hematoma. • Any symptoms or signs of local anesthetic toxicity, Any significant ECG changes and Horner’s syndrome DURATION OF COMPLETE ANALGESIA:S Duration of post-operative analgesia was taken till the time patient asked for rescue analgesia i.e. VAS ≥4. Visual Analogue Scale (VAS) will assess pain. Time of first dose of post–operative systemic analgesic was on the basis of VAS score ≥ 4 and was noted for use as duration of analgesia. 0 = no pain 10= maximum pain Visual analogue scale: Visual analogue scale consists of a 10 cm line, marked at 1 cm each. The patient made a mark on the line that represents the intensity of pain he or she experienced. Mark “0” represents no pain and mark “10” represents worst possible pain. The numbers marked by the patient was taken as units of pain intensity. STATISTICAL ANALYSIS: Data were collected, tabulated, coded then analysed using SPSS computer software version 19 and Microsoft word and excel have been used to generate graphs and tables etc. Continuous variables (age, height, weight, intraoperative vital parameters and duration of surgery, Block execution time, Time for sensory block onset, Time for complete sensory block, Time for motor block onset and Time for complete motor block) were presented as Mean ± S.D. Categorical variables (Gender, ASA status, Quality of block) were expressed in frequency and percentage. Age, intraoperative vital parameters, Block execution time, Time for sensory block onset, Time for complete sensory block, Time for motor block onset and Time for a complete motor block between 2 groups were compared by using unpaired t-test. The number of pricks in 2 groups was compared by using the non-parametric Mann Whitney U test. Success, failure and supplementation, complications were compared by applying Fisher exact T-test. Categorical variables between 2 groups were compared by performing Pearson’s chi-square test. P<0.05 was considered significant. Statistical software STATA version 16 and SPSS software version 19 were used for analysis with Microsoft excel 2022.

70 ASA I & II of either sex aged 18-60 years, of weight (50-80 kg) posted for upper limb surgeries under supraclavicular brachial plexus block were selected for the study. The study was undertaken to compare the efficacy of Dexamethasone 8mg as an adjuvant to Levobupivacaine (0.5%) for brachial plexus block.

TABLE 1: DISTRIBUTION OF STUDY SUBJECTS BASED ON THE AGE GROUP.

Test applied -Unpiared T test

In our study minimum age of the patient was 18 years and maximum age was 56 years. Mean values for age were comparable in both the groups. The mean age was 41.51 ± 12.557and 52.3± 17.892in years in Group LD and Group L respectively.

Thus, the difference in age distribution was not statistically significant (P = 0.072)(NS).   Both the groups were comparable with respect to age of the patients. 

FIGURE 3. AGE-WISE DISTRIBUTION OF PATIENTS

TABLE 2: DISTRIBUTION OF STUDY SUBJECTS BASED ON THE SEX

Test Applied -Unpaired T test

Patients of both the sex were included in the study. In group LD, 68.6%   of the patients were males while 31.4 patients were females. In group L,  62.9% of the patients were males while 37.1 were females. Both groups were comparable (P=0.615) (NS).Majority of patients are male in both groups.

FIGURE 4: GENDER-WISE DISTRIBUTION OF PATIENTS

TABLE 3: DISTRIBUTION OF STUDY SUBJECTS BASED ON THE WEIGHT

Test applied -Unpaired T test.

The mean weight was 67.14 ± 11.225 and 67.03 ± 12.408 in Group LD and Group L respectively. Thus, the difference in weight distribution on using unpaired t-test was not statistically significant (p = 0.968) (NS). Both groups were comparable with respect to     the weight of patients.

FIGURE 5 -Weight wise distribution of groups

TABLE 4: DISTRIBUTION OF STUDY SUBJECTS BASED ON ASA GRADE

Test applied:  chi-square test.

Among the group LD, 80% were with ASA grade l and 20% were with ASA grade ll. Among the group L, 65.7% were with grade l and 34.3% were   with grade ll.

The maximum number of patients in both groups were of ASA grade I.On applying the chi-square test for analysis, there was no statistical difference between the ASA grades of both the groups (p = 0.179) (NS).

FIGURE 6: DISTRIBUTION BASED ON ASA GRADE

TABLE 5: DISTRIBUTION OF PATIENTS BASED ON TYPES OF SURGERIES

Test applied:CHI square test.

In Group L, 8 (22.9%) patients were posted for radius plating, 12 (34.3%) patients were posted for ulna plating, 6 (17.1%) patients were posted for both bone forearm fracture plating, 4 (11.4%) patients were posted for supracondylar humerus K-wire insertion, 2 (5.7%) patients were posted for olecranon fracture fixation, 2 (5.7%) patients for distal humerus fracture fixation, and 1 (2.9%) patient for proximal humerus fracture fixation.

In Group LD, 10 (28.6%) patients were posted for radius plating, 12 (34.3%) patients were posted for ulna plating, 5 (14.3%) patients were posted for both bone forearm fracture plating, 5 (14.3%) patients were posted for supracondylar humerus K-wire insertion, 1 (2.9%) patient was posted for olecranon fracture fixation, 1 (2.9%) patient for distal humerus fracture fixation, and 1 (2.9%) patient for proximal humerus fracture fixation.

Thus, the difference in the distribution of surgical procedures between the two groups was not statistically significant (p > 0.05).

TABLE 6: NUMBER OF ATTEMPTS

TEST APPLIED :UNPAIRED T TEST

P VALUE=0.112(NS)

In group LD in 33 cases block achieved in first attempt and in 2 cases block achieved in second attempt  while in group L in 33 cases block achieved in first attempt and in 2 cases block achieved in second attempt. There is no statistical difference in both groups and are comparable.

FIGURE 7 :NUMBER OF ATTEMPT

TABLE 7: DISTRIBUTION OF STUDY SUBJECTS BASED ON DURATION OF SURGERY

Test applied: student’s unpaired t test.

The mean time taken for duration of surgery was 254 ±29.53 and 241.9 ± 30.14 minutes in Group LD and Group L respectively.

The statistical analysis by student’s unpaired t test showed this difference was statistically significant (p<0.001) (S).

FIGURE 8: DURATION OF SURGERY (MINUTES)

TABLE 8: DISTRIBUTION OF STUDY SUBJECTS BASED ON THE TIME TAKEN FOR ONSET OF SENSORY BLOCK. (OTSB)

Test applied: student’s unpaired t test.

The mean time taken for onset of sensory block was 3.64 ± 0.858 and 6.26 ± 1.038 minutes in Group LD and Group L respectively.

The statistical analysis by student’s unpaired t test showed this difference was statistically significant (p<0.001) (HS).

FIGURE 9: ONSET OF SENSORY BLOCK

TABLE NO 9: TIME FOR COMPLETE SENSORY BLOCK. (TCSB)

Test applied: student’s unpaired t test.

The mean time taken for the complete sensory block was 7.12 ± 1.165 and 11.58 ± 1.309 minutes in Group LD and Group L respectively. The statistical analysis by student’s unpaired t-test showed that this difference was statistically significant. (p<0.001)(HS). The mean time for the complete sensory block was statistically significant   in both the groups.

FIGURE 10: TIME FOR COMPLETE SENSORY BLOCK.

TABLE 10: TOTAL DURATION OF SENSORY BLOCK (TDSB)

Test applied: student’s unpaired t test.

Patients of both groups were observed for 24hrs. The time was noted when the patient asked for rescue analgesics. The mean duration of sensory block in group LD was 1027.71 ± 78.930 mins and in group L was 800 ± 49.110mins. The statistical analysis by student’s unpaired “t” test showed that the time of duration of sensory block in group LD was significantly longer than group L (p < 0.001)(HS).

FIGURE 11: TOTAL DURATION OF SENSORY BLOCK IN

TABLE 11: TIME FOR ONSET OF MOTOR BLOCK. (OTMB)

Test applied: student’s unpaired t test.

The mean time taken for onset of motor block was 5.72 ± 1.269 and 8.15 ± 1.32minutes in Group LD and Group L respectively.The statistical analysis by student’s unpaired t-test showed that this difference was statistically significant (p<0.001)(HS). The mean time for onset of motor block was statistically significant in both the groups.

FIGURE 12: ONSET OF MOTOR BLOCK.

TABLE 12: TIME FOR COMPLETE MOTOR BLOCK. (TCMB)

Test applied: student’s unpaired t test.

The mean time taken for the complete motor block was 10.67 ± 2.432 and 14.17 ± 1.532  minutes in Group LD and Group L respectively. The statistical analysis by Student’s unpaired t test showed that this difference was statistically significant (p<0.001) (HS). The mean time for the complete motor block was statistically significant in both groups.

FIGURE 13 TIME FOR COMPLETE MOTOR BLOCK

TABLE 13: TOTAL DURATION OF MOTOR BLOCK. (TDMB)

Test applied: student’s unpaired t test.

In our study, the mean (±SD) total duration of motor block in Group LD was 818.57 ±73.370 minutes and in Group L  was 679.71 ±39.294  minutes. The mean (±SD) total duration of motor block was significantly prolonged in Group LD than Group L (p<0.001) (HS).

FIGURE 14 : TOTAL DURATION OF MOTOR BLOCK

TABLE 14: DURATION OF ANALGESIA IN 2 GROUPS

Test applied: student’s unpaired t test.

The mean duration of analgesia in group LD was 1217.43 ± 90.597 mins and in group L was 955.14 ± 41.683 mins. The statistical analysis by student’s unpaired “t” test showed that the time of duration of analgesia in group LD was significantly longer than group L (p < 0.001)(HS).

FIGURE 15 :DURATION OF ANALGESIA

The study was conducted at a tertiary care center after institutional ethic committee approval. A total of 70 adult patients admitted in the department of Orthopedics, with age in the range of 18-60 years, of weight 50-80 kg, ASA Grade I & II posted for elective upper limb surgeries under Supraclavicular brachial plexus block were included in the study, after taking written informed consent, observations and results were measured.

These patients were divided into 2 groups, Group L and Group LD, of 35 patients each.

Group LD (N=35): 20ml of 0.5% Levobupivacaine with injection Dexamethasone (8mg) (2ml) in supraclavicular brachial plexus block. (Total volume 22 ml).

Group L (N=35): 20ml of 0.5% Levobupivacaine+2ml normal saline in supraclavicular brachial plexus block. (Total volume 22ml).

Demographic characteristics:

In our study, the mean ± SD age in Group LD (Dexamethasone) was 41.51± 12.557 years and in Group L  was 52.43 ± 17.891 years (p=0.072) (NS)which was statistically non significant. The mean (±SD) weight of patients in Group LD was 67.14 ± 11.225 kg and in Group L was 67.03 ± 12.408 kg (p=0.968) (NS)which was statistically non significant. The two groups were comparable with respect to age and weight.

In our study, out of 35 patients, in Group LD (Dexamethasone), 24(68.6%) patients were males and 11(31.4%) patients were females. In Group L(control),22(62.9%) patients were males and 13(37.1%) patients were females. Male: female ratio in both groups was comparable (p=0.615) (NS).

Out of 35 patients, in Group LD (Dexamethasone), 28 patients (80%) were belonging to ASA class I and 7 patients (20%) were belonging to ASA class II and in Group L (control), 23 patients (65.7%) were belonging to ASA class I and 12 patients (34.3%) were belonging to ASA class II. There was no statistically significant difference between two groups with respect to ASA grading of patients (p=0.179) (NS).

In our study, the mean (±SD) duration of surgery in Group LD (Dexamethasone) was 254(± 29.53.) minutes and in Group L(control) was 241.89 (± 30.14) minutes respectively. The two groups were comparable with respect to the duration of surgery (p=0.094) (NS).

Kameswar RaoMV, PalaiPK(2019).13

Conducted a randomized prospective study  in a tertiary care hospital after approval of the institutional Ethics Committee. Patients with ASA Grade I / II status and with age limit of 16 to 65 years of both sexes posted for upper limb surgery were included in present study.

They are divided into 2 groups  :

Group S (thirty patients) received 2 mL normal saline with 25 mL Levobupivacaine (0.5%)

Group D (thirty patients) received 2 mL of Dexamethasone (8 mg) with 25 mL of Levobupivacaine (0.5%).

The mean(±SD)  age in Group S and Group D were 38.17 ± 11.72 years and 39.77 ± 11.61 years respectively and both were comparable(p>0.05). The mean (±SD) weight in two groups Group S and Group D were 64.23 ± 7.92 kg and 63.77 ± 6.74 kg and both were comparable(p>0.05). The sex ratio (Male/Female) in two groups Group S and Group D were 21/9 and 20/10  and both were comparable. The ASA class in two groups Group S and Group D were 27/3 and 26/4 and both were comparable (P>0.05). The mean (±SD) duration of surgery in Group LD was 122.4 (± 8.4) minutes and in Group L was 124.8 (± 9.2 )  minutes which was comparable (P>0.05).

The demographics characteristics such as age ,weight,male to female ratio,ASA grading ,duration of surgery from our study were similar to the study conducted by KameswarRaoMV,PalaiPK(2019)13.

Sensory block characteristics:

Onset of sensory block (OTSB):

The Onset time of sensory block was considered as the time interval in minutes from the end of administration of local anesthetic solution (time-0) till sensory block started appearing i.e Hollmen score = 2.

In our study, the mean±(SD) time taken for onset of sensory block was 3.64 ± 0.858 and 6.26 ± 1.03 minutes in Group LD and Group L respectively. The statistical analysis by student’s unpaired t test showed that the difference was statistically significant(p<0.001)(HS).The onset time for sensory block was earlier in Levobupivacaine + Dexamethasone   group (Group LD) than Control group (Group L).

Baloda R,Kumar P,Gandhi GS.(2016)14 conducted prospective randomized, controlled, double blinded study to observe the effect of Dexamethasone on onset and duration of anaesthesia, when used as an adjuvant to Levobupivacaine in supraclavicular brachial plexus block.They found that, the mean (±SD) onset of sensory block in Dexamethasone   group was 8.1667±0.985 minutes and in control group  was 10.20 ±1.349 minutes. Onset time of sensory block was earlier in  Dexamethasone  group than  Control  group      ,       was statistically significant (p< 0.001)(HS).

 Pani N, RoutrayS,et al(2017)19 conducted a randomized , study to evaluate Dexamethasone as an adjuvant to Levobupivacaine for supraclavicular brachial plexus (SCBP) block. They found that, the mean (±SD) time for onset of sensory block in Dexamethasone group was 4.3(±1.32 ) minutes and in control group  was 7.20(±1.73) minutes. Onset time of sensory block was earlier in Dexamethasone group than Control group      ,         Which was statistically significant (p< 0.001)(HS).

In a study conducted by  Kameswar Rao MV,  Palai PK(2019)13, they found that, the mean (±SD) onset of sensory block in Dexamethasone group was 4.3 (±1.32 ) minutes and in control group  was 7.20(±1.73) minutes. Onset time of sensory block was earlier in Dexamethasone group than Control group       which was statistically significant (p< 0.001)(HS).

KumarR, DandaTK, Tandon A(2020)18 conducted a randomized prospective study assess supraclavicular brachial plexus block with or without dexamethasone as an adjuvant to 0.5% Levobupivacaine. They found that, the mean onset of sensory block in Dexamethasone   group was 8.1 minutes and in control group was 10.4 minutes. Onset time of sensory block was earlier in Dexamethasone group than  Control  group  ,       which was  statistically significant (p< 0.05)(S).

Dr. Cherian S, Dr.KumarS, Dr. Jaleel J (2021)17 conducted study to assess supraclavicular brachial plexus block with or without Dexamethasone as an adjuvant to 0.5%Levobupivacaine.They found that, the mean onset of sensory block in Dexamethasone group was 8.1 minutes and in control group  was 10.4minutes.Onset time of sensory block was earlier in Dexamethasone group than Control group   ,  Which was statistically significant (p<0.05)(S).

Das C,Mathur R, Kukreja S (2022)16.

Conducted  a randomized prospective study evaluating   the analgesic  and  anesthetic  effects  of   Dexamethasone  (8mg) as an adjuvant to 0.5%Levobupivacaine  determines the time for first rescue analgesia and number of rescue analgesics needed  in  24  hours  duration  in  brachial  plexus  blockade  in  posted  for  upper  limb surgeries.

They found that, the mean (±SD) onset of sensory block in  Dexamethasone  group was 5.80 ±1.21 minutes and in control group  was 7.60 ±1.63 minutes. Onset time of sensory block was earlier in Dexamethasone group than Control  group      ,       which was  statistically significant (p< 0.05)(S).

The findings regarding Mean(±SD) onset time of sensory block from our study were similar to findings of study conducted by  Baloda R et al (2016)14, PaniN et al (2017)19, M V Kameswar Rao, Pramod Kumar Palai(2019)13, KumarR, DandaTK, Tandon A(2020)18, Dr. Cherian S, Dr.KumarS, Dr. Jaleel J (2021)17, Das C ,Mathur R,  Kukreja S (2022)16.

Time for complete sensory block (TCSB):

The time for complete sensory block was taken as the duration of time in minutes from time-0 (Time of injection of local anesthetic) till complete sensory block was achieved i.e Hollmen Score=4.

In our study, the mean(±SD)  time taken for the complete sensory block was 7.12 ± 1.165 mins  and 11.58 ± 1.309 minutes in Group LD and Group L respectively. The statistical analysis by student’s unpaired t-test showed that this difference was statistically significant (p<0.001). The mean time for the complete sensory block was earlier in Dexamethasone group than Control group (P<0.001)(HS).

TOTAL DURATION OF SENSORY BLOCK (TDSB) :

Total duration of sensory block (TDSB) was taken as the duration of time in minutes from the time-0 (Time of injection of local anesthetic) till the time when patient came back to Hollmen score 1.In our study, the mean (±SD)  total duration of sensory block in Group LD(Dexamethasone) was 1027.71(±78.930) minutes and in Group L(control) was 800(±49.110) minutes. The mean (±SD) total duration of sensory block was significantly prolonged in Group LD (Dexamethasone) than Group L(Control) (p<0.001) (HS).

In a study conducted by Baloda R ,KumarP,GandhiGS (2016)14 conducted They found that, the mean (±SD) total duration of sensory block in Control group was657(±8.38) minutes and in Dexamethasone group was 923 (±12.905) minutes. The mean(±SD) total duration of sensory block was significantly prolonged in Dexamethasone group than Control group (p <0.001)(HS).

In a study conducted by Pani N, RoutrayS, Debasis(2017)15, they found that, the mean(±SD) total duration of sensory block in Dexamethasone   group was 420.73(±80.87) minutes and in control group was 178.60(±30.6) minutes. The mean (±SD) total duration of sensory block was significantly prolonged in Dexamethasone group than Control group (p < 0.001)(HS).

In a study conducted by Hanumansetty K, Hemalatha S,Gurudatt C. L(2017)19they found that mean(±SD) total duration of sensory block in Dexamethasone group was 10.17±1.1 hours (610.2 mins) and in control group it was 6.5±0.6hours (390mins) .The mean (±SD) total duration of sensory block was prolonged in Dexamethasone group than control group(p<0.001)(HS).

In a study conducted by Kameswar Rao MV, Palai  P(2019)13They found that mean(±SD)  total duration of sensory block in Dexamethasone group was 420.73±80.87 mins  and in control group 178±30.26 minutes . The mean(±SD)  total duration of sensory block was significantly prolonged in dexamethasone group than control group(p<0.001)(HS).

In a study conducted by KumarR, Danda TK,Tandon A (2020)18they found that mean total duration of sensory block in Dexamethasone group was 914.8minutes and in control group 620.4 . The mean total duration of sensory block was significantly prolonged in Dexamethasone group than control group(p<0.01) (HS).

The finding in our study regarding prologed mean(±SD)   total duration of sensory block in Dexamethasone group were similar to Baloda R ,KumarP,GandhiGS (2016)14, Pani N, RoutrayS(2017)15, Hanumansetty K, Hemalatha S., Gurudatt C. L.(2017)19, Kameswar RaoMV, Palai P (2019)13, KumarR, Danda TK,Tandon A (2020)18.

ONSET TIME OF MOTOR BLOCK (OTMB):

The Onset Time of Motor Block (OTMB) was taken as the time interval in minutes from time-0 (Time of local anasthetic injection) till motor block started appearing i.e. Bromage scale score ≥1.

In our study, the mean (±SD) time taken for onset of motor block was 5.72 ± 1.269 mins and 8.15± 1.3 minutes in Group LDand Group L respectively. The statistical analysis by student’s unpaired t-test showed that this difference was statistically significant (p<0.001)(HS). Onset time of motor block was significantly earlier in Group LD (Dexamethasone) than Group L (Control) (p<0.001) (HS).

 Baloda R,Kumar P,Gandhi GS (2016)14 found that the mean (±SD) onset of motor block in Dexamethasone group was 13.767(±2.045) minutes and in control group was 15.033(±0.889) minutes. The mean(±SD) onset time of motor block was earlier in Dexamethasone group than Control group which was statistically significant (p <0.003)(HS).

 PaniN, RoutrayS,(2017)15 found that mean (±SD) onset of motor block in Dexamethasone group was 6.03(±0.96) minutes and in control group was 9.033(±1.73) minutes. The mean (SD) onset time of motor block was earlier in Dexamethasone group than Control group which was statistically significant (p <0.001)(HS).

Kameswar Rao MV, Palai P(2019)13 found that mean (±SD) onset of motor block in Dexamethasone group was 6.03(±0.96) minutes and in control group was 9.03(±1.73) minutes. The mean (±SD) onset time of motor block was earlier in Dexamethasone group than Control group which was statistically significant (p <0.05)(S).

 KumarR, Danda TK,Tandon A (2020)18 found that mean onset of motor block in Dexamethasone group was 13.2 minutes and in control group was 15.6. The mean onset time of motor block was earlier in Dexamethasone group than Control group which was statistically significant (p=0.02)(S).

Dr. Cherian S, Dr.KumarS, Dr. Jaleel J (2021)17 found that mean onset of motor block in Dexamethasone group was 13.2 minutes and in control group was 15.4 mins. The mean onset time of motor block was earlier in Dexamethasone group than Control group which was statistically significant (p =0.05)(S).

The findings regarding mean(±SD) onset time of motor block from our study were similar to findings of study conducted by Baloda R,Kumar P,Gandhi GS (2016)14, PaniN, RoutrayS,(2017)15, Kameswar Rao MV, Palai P(2019)13, KumarR, Danda TK,Tandon A (2020)18, Dr. Cherian S, Dr.KumarS, Dr. Jaleel J (2021)17.

TIME FOR COMPLETE MOTOR BLOCK (TCMB):

Time for Complete Motor Block (TCMB) was taken as the duration of time in minutes from time-0 (Time of local anesthetic injection) till complete motor block was achieved i.e. BS score=3. In our study, the mean time (±SD) taken for the complete motor block was 10.67 ± 2.432 minutes and 14.17 ± 1.532 minutes in Group LD and Group L respectively. The statistical analysis by Student’s unpaired t test showed that this difference was statistically significant (p<0.001)(HS). The mean (±SD) time for the complete motor block was earlier in Dexamethasone group than Control group.

TOTAL DURATION OF MOTOR BLOCK (TDMB):

Total Duration of Motor Block (TDMB) was taken as the duration of time in minutes from time-0 (Time of local anesthetic injection) till the time when BS score= 0 with complete recovery of motor functions in the postoperative period. In our study, the mean (±SD) total duration of motor block in Group LD (Dexamethasone) was 818.57(±73.370) minutes and in Group L (control) was 679.71(±39.294) minutes. The mean (±SD) total duration of motor block was significantly prolonged in Group LD (Dexamethasone) than Group L(Control) (p<0.001) (HS).

Baloda R,Kumar P,Gandhi GS (2016)14found that the mean (±SD) total duration of motor block in Dexamethasone group was 798.83 (±15.010) minutes and in control group was 540 (±7.428) minutes. The mean (±SD) total duration of motor block was significantly prolonged in Dexamethasone group than Control group (p <0.01)( HS).

Hanumansetty K, Hemalatha S, Gurudatt C. L.(2017)15 found that the mean (±SD) total duration of motor block in Dexamethasone group was 501 (±0.81) minutes and in control group was 445.2 (±0.78) minutes. The mean(±SD) total duration of motor block was significantly prolonged in Dexamethasone group than Control group (p <0.01)(HS).

Kameswar Rao MV, Palai(2019)13 found that the mean (±SD) total duration of motor block in Dexamethasone group was 306.83(±70.24) minutes and in control group was 150.70 (±32.32) minutes. The mean (±SD)total duration of motor block was significantly prolonged in Dexamethasone group than Control group (p <0.01)(HS).

 KumarR, Danda TK,Tandon A (2020)18 found that, the mean total duration of motor block in Dexamethasone group was 712.6 minutes and in control group was 542.6minutes. The mean total duration of motor block was significantly prolonged in Dexamethasone group than Control group (P <0.04)(S).

Dr. Cherian S, Dr.KumarS, Dr. Jaleel J (2021)17 found that, the mean  total duration of motor block in Dexamethasone group was 764.2 minutes and in control group was 658.2minutes. The mean total duration of motor block was significantly prolonged in Dexamethasone group than Control group (p <0.01)(HS).

The findings  in our study were  similar to studies conducted by Baloda R,Kumar P,Gandhi GS (2016)14, Hanumansetty K, Hemalatha S., Gurudatt C. L.(2017)15, Kameswar Rao MV, Palai(2019)13, KumarR, Danda TK,Tandon A (2020)18, Dr. Cherian S, Dr.KumarS, Dr. Jaleel J (2021)17.

DURATION OF ANALGESIA:

Duration of post-operative analgesia was taken from T (0) till the time patient had VAS ≥4. Time of first dose of post–operative systemic analgesic   was on the basis of VAS score ≥ 4 and was noted for use as duration of analgesia. In our study, the mean (±SD) duration of analgesia in Group LD (Dexamethasone) was 1217(±90.59) minutes and in Group L was 955.14(±41.68) minutes. The mean (±SD) duration of analgesia was significantly prolonged in Group LD (Dexamethasone) than Group L (Control) (p<0.001) (HS).

Hanumansetty K, Hemalatha S., Gurudatt C.L.(2017)15 found that, the mean (±SD) duration of analgesia in Dexamethasone group was 1272(±3.23) minutes and in control group was 614.4 (±1.57) minutes. The mean duration of analgesia was significantly prolonged in Dexamethasone group than Control group (p <0.01)(S).

 Kameswar Rao MV,  Palai P(2019)13found that, the mean (±SD) duration of analgesia in Dexamethasone group was 705(±121.46) minutes and in control group was 396.13 (±109.42) minutes. The mean duration of analgesia was significantly prolonged in Dexamethasone group than Control group (p <0.001)(HS).

Dr. Cherian S, Dr.KumarS, Dr. Jaleel J (2021)17 found that, the mean (±SD) duration of analgesia in Dexamethasone group was 705.80(±121.46) minutes and in control group was 396.13 (±109.42) minutes. The mean duration of analgesia was significantly prolonged in Dexamethasone group than Control group (p <0.001)(HS).

The findings regarding prolonged duration of analgesia in Levobupivacaine +Dexamethasone group than Levobupivacaine group in our study were similar to Hanumansetty K, Hemalatha S., Gurudatt C.L.(2017)15,Kameswar Rao MV, Palai P(2019)13 , Dr. Cherian S, Dr.KumarS, Dr. Jaleel J (2021)17.

From the present study based on results and methodology employed ,we conclude that Dexamethasone can be used as an adjuvant to Levobupivacaine for supraclavicular brachial plexus block, as it provides earlier onset of sensory and motor block, earlier time for complete sensory and motor block , prolongs the duration of sensory motor block and postoperative analgesia.

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