Background Brachial plexus nerve blocks (BPBs) have analgesic and opioid sparing benefits for upper extremity surgery. Single-injection techniques are limited by the pharmacological duration and therapeutic index of local anaesthetics (LAs). Continuous catheter techniques, while effective can present management challenges. Off-label use of perineural dexamethasone as an LA adjuvant has been utilized to prolong single-injection techniques. The objectives of this systematic review and meta-analysis are to assess the contemporary literature and quantify the effects of dexamethasone on BPB. Methods The authors searched for randomized, placebo-controlled trials that compared BPB performed with LA alone with that performed with LA and perineural dexamethasone. Meta-analysis was performed using a random effects model with subgroup analysis stratified by LA (long vs intermediate). The primary outcome was duration of sensory block or analgesia; the secondary outcomes were motor block duration, opioid consumption, and BPB complications. Results Nine trials (801 patients) were included with 393 patients receiving dexamethasone (4–10 mg). Dexamethasone prolonged the analgesic duration for long-acting LA from 730 to 1306 min [mean difference 576 min, 95% confidence interval (CI) 522–631] and for intermediate from 168 to 343 min (mean 175, 95% CI 73–277). Motor block was prolonged from 664 to 1102 min (mean 438, 95% CI 89–787). The most recent trial demonstrated equivalent prolongation with perineural or systemic administration of dexamethasone compared with placebo. Conclusions Perineural administration of dexamethasone with LA prolongs BPB effects with no observed adverse events. The effects of systemic administration of dexamethasone on BPB must be investigated.

Effects of dexamethasone as a local anaesthetic adjuvant for brachial plexus block: a systematic review and meta-analysis of randomized trials

Background and objectiveDexamethasone has been shown to prolong the duration of postoperative analgesia when given as an adjunct for peripheral nerve blocks. However, it has not been evaluated when given in conjunction with bupivacaine and clonidine to provide blockade of the brachial plexus at the

Dexamethasone with bupivacaine increases duration of analgesia in ultrasound-guided interscalene brachial plexus blockade.

We systematically reviewed the safety and efficacy of perineural dexamethasone as an adjunct for peripheral nerve blockade in 29 controlled trials of 1695 participants. We grouped trials by the duration of local anaesthetic action (short- or medium- vs long-term). Dexamethasone increased the mean (95% CI) duration of analgesia by 233 (172-295) min when injected with short- or medium-term action local anaesthetics and by 488 (419-557) min when injected with long-term action local anaesthetics, p < 0.00001 for both. However, these results should be interpreted with caution due to the extreme heterogeneity of results, with I2 exceeding 90% for both analyses. Meta-regression did not show an interaction between dose of perineural dexamethasone (4-10 mg) and duration of analgesia (r2 = 0.02, p = 0.54). There were no differences between 4 and 8 mg dexamethasone on subgroup analysis.

https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/pdf/10.1111/anae.12823

A systematic review and meta-analysis of perineural dexamethasone for peripheral nerve blocks.

Background
Peripheral nerve block (infiltration of local anaesthetic around a nerve) is used for anaesthesia or analgesia. A limitation to its use for postoperative analgesia is that the analgesic effect lasts only a few hours, after which moderate to severe pain at the surgical site may result in the need for alternative analgesic therapy. Several adjuvants have been used to prolong the analgesic duration of peripheral nerve block, including perineural or intravenous dexamethasone.

Objectives
To evaluate the comparative efficacy and safety of perineural dexamethasone versus placebo, intravenous dexamethasone versus placebo, and perineural dexamethasone versus intravenous dexamethasone when added to peripheral nerve block for postoperative pain control in people undergoing surgery.

Search methods
We searched the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, DARE, Web of Science and Scopus from inception to 25 April 2017. We also searched trial registry databases, Google Scholar and meeting abstracts from the American Society of Anesthesiologists, the Canadian Anesthesiologists' Society, the American Society of Regional Anesthesia, and the European Society of Regional Anaesthesia.

Selection criteria
We included all randomized controlled trials (RCTs) comparing perineural dexamethasone with placebo, intravenous dexamethasone with placebo, or perineural dexamethasone with intravenous dexamethasone in participants receiving peripheral nerve block for upper or lower limb surgery.

Data collection and analysis
We used standard methodological procedures expected by Cochrane.

Main results
We included 35 trials of 2702 participants aged 15 to 78 years; 33 studies enrolled participants undergoing upper limb surgery and two undergoing lower limb surgery. Risk of bias was low in 13 studies and high/unclear in 22.

Perineural dexamethasone versus placebo

Duration of sensory block was significantly longer in the perineural dexamethasone group compared with placebo (mean difference (MD) 6.70 hours, 95% confidence interval (CI) 5.54 to 7.85; participants1625; studies 27). Postoperative pain intensity at 12 and 24 hours was significantly lower in the perineural dexamethasone group compared with control (MD -2.08, 95% CI -2.63 to -1.53; participants 257; studies 5) and (MD -1.63, 95% CI -2.34 to -0.93; participants 469; studies 9), respectively. There was no significant difference at 48 hours (MD -0.61, 95% CI -1.24 to 0.03; participants 296; studies 4). The quality of evidence is very low for postoperative pain intensity at 12 hours and low for the remaining outcomes. Cumulative 24-hour postoperative opioid consumption was significantly lower in the perineural dexamethasone group compared with placebo (MD 19.25 mg, 95% CI 5.99 to 32.51; participants 380; studies 6).

Intravenous dexamethasone versus placebo

Duration of sensory block was significantly longer in the intravenous dexamethasone group compared with placebo (MD 6.21, 95% CI 3.53 to 8.88; participants 499; studies 8). Postoperative pain intensity at 12 and 24 hours was significantly lower in the intravenous dexamethasone group compared with placebo (MD -1.24, 95% CI -2.44 to -0.04; participants 162; studies 3) and (MD -1.26, 95% CI -2.23 to -0.29; participants 257; studies 5), respectively. There was no significant difference at 48 hours (MD -0.21, 95% CI -0.83 to 0.41; participants 172; studies 3). The quality of evidence is moderate for duration of sensory block and postoperative pain intensity at 24 hours, and low for the remaining outcomes. Cumulative 24-hour postoperative opioid consumption was significantly lower in the intravenous dexamethasone group compared with placebo (MD -6.58 mg, 95% CI -10.56 to -2.60; participants 287; studies 5).

Perinerual versus intravenous dexamethasone

Duration of sensory block was significantly longer in the perineural dexamethasone group compared with intravenous by three hours (MD 3.14 hours, 95% CI 1.68 to 4.59; participants 720; studies 9). We found that postoperative pain intensity at 12 hours and 24 hours was significantly lower in the perineural dexamethasone group compared with intravenous, however, the MD did not surpass our pre-determined minimally important difference of 1.2 on the Visual Analgue Scale/Numerical Rating Scale, therefore the results are not clinically significant (MD -1.01, 95% CI -1.51 to -0.50; participants 217; studies 3) and (MD -0.77, 95% CI -1.47 to -0.08; participants 309; studies 5), respectively. There was no significant difference in severity of postoperative pain at 48 hours (MD 0.13, 95% CI -0.35 to 0.61; participants 227; studies 3). The quality of evidence is moderate for duration of sensory block and postoperative pain intensity at 24 hours, and low for the remaining outcomes. There was no difference in cumulative postoperative 24-hour opioid consumption (MD -3.87 mg, 95% CI -9.93 to 2.19; participants 242; studies 4).

Incidence of severe adverse events

Five serious adverse events were reported. One block-related event (pneumothorax) occurred in one participant in a trial comparing perineural dexamethasone and placebo; however group allocation was not reported. Four non-block-related events occurred in two trials comparing perineural dexamethasone, intravenous dexamethasone and placebo. Two participants in the placebo group required hospitalization within one week of surgery; one for a fall and one for a bowel infection. One participant in the placebo group developed Complex Regional Pain Syndrome Type I and one in the intravenous dexamethasone group developed pneumonia. The quality of evidence is very low due to the sparse number of events.

Authors' conclusions
Low- to moderate-quality evidence suggests that when used as an adjuvant to peripheral nerve block in upper limb surgery, both perineural and intravenous dexamethasone may prolong duration of sensory block and are effective in reducing postoperative pain intensity and opioid consumption. There is not enough evidence to determine the effectiveness of dexamethasone as an adjuvant to peripheral nerve block in lower limb surgeries and there is no evidence in children. The results of our review may not apply to participants at risk of dexamethasone-related adverse events for whom clinical trials would probably be unsafe.

There is not enough evidence to determine the effectiveness of dexamethasone as an adjuvant to peripheral nerve block in lower limb surgeries and there is no evidence in children. The results of our review may not be apply to participants who at risk of dexamethasone-related adverse events for whom clinical trials would probably be unsafe. The nine ongoing trials registered at ClinicalTrials.gov may change the results of this review.

/pdf/dexamethasone-as-an-adjuvant-to-peripheral-nerve-block-1c27t3vjra.pdf

Dexamethasone as an adjuvant to peripheral nerve block

https://ccme.osu.edu/RSSeriesBrochure/30142-Miller%20Article%20(Intravenous).pdf

Intravenous dexamethasone and perineural dexamethasone similarly prolong the duration of analgesia after supraclavicular brachial plexus block: a randomized, triple-arm, double-blind, placebo-controlled trial

This is a prospective, randomized, double blind study to evaluate the postoperative analgesia following supraclavicular brachial plexus block with Tramadol or Dexamethasone as an admixture to bupivacaine in upper extremity surgery. Total 60 patients of ASA I and II undergoing upper extremity surgery under brachial plexus block with Bupivacaine were randomly divided in to two groups; one group received Tramadol (2 mg/kg) and the other group received Dexamethasone (8 mg) as an admixture to Bupivacaine. The duration of postoperative analgesia was recorded in both groups using pain VAS score which was determined by maximum VAS score of 8-10 and when patient demands for additional analgesics. The mean duration of postoperative analgesia in the Dexamethasone group was 1028.00 minutes while in the tramadol group it was 453.17 minutes We concluded that Dexamethasone with local anaesthetic prolongs postoperative analgesia significantly than Tramadol (P<0.05) when used as admixture to local anaesthetic in brachial plexus block in upper extremity surgery.

/pdf/comparative-study-between-tramadol-and-dexamethasone-as-an-147f6arkza.pdf

Comparative study between tramadol and dexamethasone as an admixture to bupivacaine in supraclavicular brachial plexus block.

Background: Pelvic organ prolapse (POP) is a most common gynecological health problem contributing to maternal morbidity and mortality among women of reproductive age in developing countries. In Nepal prevalence of uterus prolapse among reproductive age women is around 17-27%. Still large numbers of rural Nepalese women are deprived of access to early diagnosis and quality treatment services related uterus prolapse. The present study was conducted with the aims to assess knowledge on risk factors on uterine prolapse among the reproductive age group of women who have at least one child below five years of age and residing at Bajrabarahi municipality of Lalitpur district. Methods: This is a cross sectional descriptive study. Total 185 individuals were randomly selected from the list of safe motherhood register book of Bajrabarahi municipality for the interview. Semi-structured questionnaire was used as tools to collect data from study participants. Data collected was entered in Epi-data and data analysis was done using SPSS 16.0 version. Bivariate analysis was done using Chi-Square test to find the association between the selected variables of the study. Results: The study results shows that out of total 46.5% of respondents have adequate knowledge and 53.5% of respondents have inadequate knowledge regarding risk factors of uterus prolapse. The study results explicitly reflects the knowledge on risk factors of uterus prolapse is significantly associated with the age of respondent (p=0.021), age at marriage of respondents (p=0.011), education status of respondents (p=0.001) and age at first child birth of respondent (p=0.001). Conclusions: Though majority of respondents have heard about uterus prolapse, very few participants have in-depth or adequate knowledge about risk factors of uterus prolapse. Still extensive efforts of government and non-government organizations are essential to improve maternal health status of rural Nepalese women.

Knowledge on risk factors of uterine prolapse among reproductive age group women of Bajrabarahi Municipality of Lalitpur, Nepal

BACKGROUND The aim of the study is to investigate the effect of oral gabapentin or clonidine versus placebo premedication on haemodynamic and endocrine responses in patients of American Society of Anesthesiology (ASA) physical status I and II undergoing laparoscopic cholecystectomy. METHODS This was a randomized prospective double-blinded comparative study of 75 ASA I and II patients with three groups: clonidine, gabapentin and placebo group having 25 patients in each. They were randomly allocated to receive 600 mg oral gabapentin or clonidine 150 mcg one hour prior to induction of anesthesia and a placebo group. Hemodynamic parameters were recorded before pneumoperitonium (PP) and every 5 minutes till 35 minutes of post PP. Blood samples for serum glucose and cortisol were collected before PP and 10 mins after PP. The investigators were blinded to what the patients received. RESULTS With similar demographic profiles and baseline haemodynamics in three groups (p>0.05) significant rise in haemodynamic parameters were observed in placebo group at different time points before and following PP where as those parameters remained stable in gabapentin and clonidine group (p<0.05). The serum cortisol level was high in placebo group before PP than in two other groups, p<0.05. The same marker measured at 10th minute after PP was significantly higher in placebo group than that in clonidine or gabapentin group, p<0.05. CONCLUSIONS Oral clonidine or gabapentin premedication offers intraoperative haemodynamic stability in laparoscopic cholecystectomy. When serum cortisol is taken as a stress marker, gabapentin group exhibited significant attenuation of stress of PP, p<0.05.

Study of haemodynamic and endocrine stress responses following carbon dioxide pneumoperitonium.

ABSTRACT Introduction: The knowledge of the variations of the abnormal anatomy of pancreaticobiliary union is of great importance for understanding various pathologies of the biliary tract, gall bladder, and pancreas as well as to avoid surgical complications and morbidity which may arise from pancreaticobiliary maljunction. Moreover, it helps in the early diagnosis and preventive treatment of pancreaticobiliary disease. The objective of this study was to find out the prevalence of abnormal anatomic variations of the pancreaticobiliary union in magnetic resonance cholangiopancreatography examinations. Methods: This descriptive cross-sectional study was done in patients referred for Magnetic resonance cholangiopancreatography examinations for various clinical indications from 1 February 2021 to 30 May 2021. Ethical approval was obtained from the Institutional Review Committee [Reference number: 306 (6-11)E 2 077/078]. The variations in the pancreaticobiliary union, length of the common channel, and angle between the common bile duct and major pancreatic duct were obtained from the 1.5T magnetic resonance scanner in 90 patients. The three-dimensional magnetic resonance cholangiopancreaticography images were visually analyzed and classified into four categories. Convenience sampling method was used. Point estimate and 90% Confidence Interval were calculated. Results: Out of 90 patients, 73 (81.11%) (74.34-87.88, 90% Confidence Interval) patients had abnormal pancreaticobiliary union with pancreaticobiliary type as the most common occurrence seen in 33 (36.67%) patients. Conclusions: The prevalence of abnormal anatomic variation of pancreaticobiliary union was found to be higher than other studies done in similar settings.

/pdf/abnormal-anatomic-variation-of-pancreaticobiliary-union-in-3pzyf9c8.pdf

Abnormal Anatomic Variation of Pancreaticobiliary Union in Magnetic Resonance Cholangiopancreatography Department of Radiology and Imaging in a Tertiary Care Centre: A Descriptive Cross-sectional Study

Introduction: Dimensions of the foramen magnum are clinically important because of the vital structures passing through it and for sex determination of the skull. The objective of this study was to measure various dimensions of the foramen magnum in Computed Tomography (CT) and correlate them with sex.
Methods: Descriptive cross-sectional study was done on 120 CT head images in the Department of Radiology and Imaging, from July to October 2019. The shape of the foramen magnum (FM), anteroposterior diameter (APD), transverse diameter (TD), FM area and FM index were calculated. Statistical analysis was done with SPSS 25 and Excel 2016. Discriminant function analysis and binary logistic regression analysis were used for gender verification.
RESULTS: The mean values of the APD, TD, area and FM index in males and females were 33.56 ± 4.30 mm, 29.76 ± 4.10 mm, 792.94 ± 191.60 mm2, 85.01 ± 8.67 and 30.01 ± 2.04 mm, 25.33 ± 4.6 mm, 599.63± 128.13 mm2, 83.17 ± 7.78  respectively.  All dimensions were significantly greater in males (r = 0.906, P<0.001). The most common shape of the foramen magnum was oval (40.8%). The accuracy of sex identification was 68.3% using dimensions of the foramen magnum.
Conclusion: There was sexual dimorphism in the diameter and area of the foramen magnum which can be used for sex determination.

Santosh Maharjan

Papers

Comparative study between tramadol and dexamethasone as an admixture to bupivacaine in supraclavicular brachial plexus block.

Knowledge on risk factors of uterine prolapse among reproductive age group women of Bajrabarahi Municipality of Lalitpur, Nepal

Study of haemodynamic and endocrine stress responses following carbon dioxide pneumoperitonium.

Abnormal Anatomic Variation of Pancreaticobiliary Union in Magnetic Resonance Cholangiopancreatography Department of Radiology and Imaging in a Tertiary Care Centre: A Descriptive Cross-sectional Study

Measurement of Foramen Magnum Dimensions in Computed Tomography of Head