Dr. Heather A. Towers, DNAP Does dexamethasone affect the duration of a supraclavicular brachial plexus blocks (SBPB) when added to low volumes of ropivacaine?

Heather A. Towers CRNA, DNAP RN – 22 YEARS CRNA – 17 YEARS MS – LaRoche College 2000 MERCY HOSPITAL (TRAUMA CENTER IN PGH, PA FROM 2000- PRESENT) BPW ASSOCIATES 2010 – PRESENT DNAP 2017

Heather A. Towers Does dexamethasone affect the duration of a supraclavicular brachial plexus blocks (SBPB) when added to low volumes of ropivacaine?

Background and Significance In 1996 there were 2,200 Ambulatory Surgery Centers nationwide, by 2013 this number increased to 5,364 (Savych, 2014) In 2007 – 72% of all surgical procedures done in the United States are outpatient (Koch & Calder, 2011) Upper extremity orthopedic surgeries are frequently performed on an outpatient basis at an ambulatory surgery center Precepting SRNA

Background and Significance Pain can effect a patient’s recovery, quality of life, their mood and limit their daily activities According to the Centers for Disease Control and Prevention, there were more deaths from drug overdose in 2014 than ever recorded in the past. Everyday seventy-eight Americans die from an overdose. Opioid involvement occurs in six out of ten of these deaths (Prevention, 2016).

Background and Significance Brachial plexus nerve block (BPNB) – alternative to opioids Postoperative pain management for orthopedic surgery Decreases overall opioid use thus decreasing adverse reactions Promotes fast-tracking of patients Improves patients overall satisfaction (Chen, Shen, Tsai, Kao, & Yu, 2015)

Purpose Statement The purpose of this study is to compare the analgesic duration between ultrasound guided supraclavicular blocks that use low volumes (20ml) of ropivacaine with addition of dexamethasone and those that use 30ml of ropivacaine without dexamethasone.

Literature Review American Pain Society – published pain management guidelines that included the modality of ultrasound guided peripheral nerve blocks for postoperative pain (Chou, et al., 2016). Ultrasound technique chosen over nerve stimulation for the administration of the block because it can be done with a lower volume of local anesthetic which decreases the incidence of neurological symptoms (Chun, Kim, & Woo, 2016). Reducing the volume of local anesthetic has been shown to decrease Horner’s syndrome, phrenic nerve palsy, and systemic toxicity, which are some potential side effects of SBPB (Alarasan, et al., 2016). Ultrasound level II

Ultrasound photo of Supraclavicular brachial plexus

Literature Review Ropivacaine – S(-) enantiomer of bupivacaine similar in structure and duration of action but less cardiac toxicity (Kumar, et al., 2014). Cummings III, et al. (2011) – compared ropivacaine and bupivacaine. Although bupivacaine lasts longer alone, when dexamethasone is added to each local anesthetic, the ropivacaine mixture last longer Forty times stronger than hydrocortisone but no mineralocorticoid activity (control of water); has anti-inflammatory properties

Literature Review Dexamethasone – a highly potent glucocorticoid that has been proven to be a safe adjunct to prolong the analgesic duration of BPNB Dexamethasone – forty times more potent than hydrocortisone but has no mineralocorticoid properties despite both being excreted by the Adrenal Cortex

Literature Review Rasmussen, et al., (2013) – study supported the addition of dexamethasone to high volumes of ropivacaine (30-40ml) to prolong duration of analgesia A meta-analysis systemic review compared two doses of dexamethasone 4mg and 8 mg and both were effective in prolonging analgesic duration when added to 30 ml of 0.5% ropivacaine (Albrecht, Kern, & Kirkham, 2015) Another article compared 14 studies – all demonstrated that the addition of dexamethasone prolonged the interscalene block; however, only two studies used the local anesthetic 0.5% Ropivacaine (Knezevik, Anantamongkol, & Candido, 2015). Level III

Literature Review Seven randomized control studies were reviewed All the studies except one showed the comparison of adding dexamethasone to the local anesthetic in a PNB to a control group that used the local anesthetic alone. All six studies demonstrated that dexamethasone was effective in prolongation of the block; however, these studies used the local anesthetic bupivacaine (Alarasan et al., 2016; Kumar et al.,2014; Liu et al., 2015).

Literature Review The final RTC study used the addition of dexmedetomidine in the experimental group This article was included to extract the control group data for comparison to this study The control group contained a similar population and sample size to this study. It also performed the PNB by using ultra-sound guidance and used ropivacaine as the local anesthetic of choice (Kathuria, Gupta, & Dhawan, 2015).

FRAMEWORK Comfort Theory: Katharine Kolcaba – a middle range theory Three Types of comfort - Relief - Ease - Transcendence Four Types of Context in which comfort occurs - Physical - Psychospiritual - Environmental - Sociocultural Performing a review of evidence –based practice processes helped guide this study’s purpose ------------ the frame work I choose was ………midrange…..(blends practice with research- uses nursing, medicine, derived her conceptual analysis of comfort from psychology, psychiatry, ergonomics and English disciplines ) (Wilson & Kolcaba, 2004).

(Wilson & Kolcaba, 2004) CONTEXT RELIEF EASE TRANSCENDENCE PHYSICAL Pain Nausea Comfortable bed, Homeostasis Patient thinking “How can I tolerate pain when I wake up?” PSYCHOSPIRITUAL Anxiety Uncertainty about prognosis Need for spiritual support ENVIORNMENTAL Noisy PACU; bright lights, cold Lack of privacy Need for calm, familiar environment elements SOCIOCULTURAL Absence of traditions and culturally sensitive care Family not present: language barriers Need for support from family or significant other; need for information, consultation Transcendence – inspires a person to be motivated to help themselves (Wilson & Kolcaba, 2004)

Methodology Quasi-experimental study – the experimental subjects were not randomly assigned Retrospective chart review – October 2015 to February 2017 - height, weight, sex, age recorded - anesthesia provider - amount of ropivacaine - amount of dexamethasone (if used) - duration of pain relief from completion of block until the time the subjects verbalized he/she had pain and block wore off

Methodology Inclusion criteria: - subjects 18 years of age and older with an utrasound guided supraclavicular block - block administered with only 20 ml of 0.5% ropivacaine and 6 mg of dexamethasone - subjects who could adequately convey an accurate time when their block wore off and pain was felt Exclusion criteria: - younger than 18 years of age - different dosage of ropivacaine and dexamethasone then stated in the inclusion criteria - incomplete blocks - patients with previous nerve damage

Methodology Null Hypothesis: There is no significance in the duration of pain relief of an ultrasound-guided SBPB when dexamethasone is added to low volumes of the local anesthetic ropivacaine. Statistical Analysis Design – independent sample t-test; G-power analysis determined appropriate sample size to be n=26

Results 57 charts were reviewed 24 subjects met the inclusion criteria 22 subjects data was analyzed

Control Group Experimental Group Sample Size 20 (F =3, M =17) 22 (F =7, M =15) Mean Age 32.7 years 55.45 years Mean Weight 72.65 KG 88.26 KG Mean Height 65.82 IN 68.39 IN The descriptive data of age, weight, height and sex were collected for potential future studies.

The experimental group was under analgesia for twice as long The experimental group was under analgesia for twice as long. Results expressed as the mean, standard deviation of control – 251.19 and experimental – 411.203, p<0.0001

Discussion The use of ultrasound to insert SBPB effective in achieving analgesic with lower volumes (20ml) It has been demonstrated with this study that the adjunct dexamethasone (6mg) when added to the local anesthetic 0.5% ropivacaine (20 ml) does prolong the analgesic duration. The experimental group’s mean of analgesia duration was 722.85 minutes longer than the control group’s mean analgesic duration The experimental group used 20 ml of 0.5% ropivacaine with 6mg dexamethasone and the control group used 30 ml of 0.5 % ropivacaine plain

Recommendations and Limitations - decrease in the number of orthopedic surgeries conducted at the facility secondary to departure of the orthopedic group - sample size less than G Power analysis recommended - different experience level of anesthesia provider - patients inability to adequately convey time block wore off and pain was felt

Recommendations and Limitations - control group and experimental group obtained at same facility and obtain random samples - limit number of anesthesia providers - provide patients with education tool to assess duration of block - increase the sample size

Implications for Career Development Alternative method for postoperative pain management Decrease in opioid consumption and potentially lead to a decrease in opioid addition Medicare reimbursement – hospital value –based purchasing based on performance of care. Patient satisfaction and pain management are two domains of clinical care being measured (Medicare.gov, 2016).

References Alarasan, A. K., Agrawal, J., Choudhary, B., Melhotra, A., Uike, S., & Mukherji, A. (2016). Effect of dexamethasone in low volume supraclavicular brachial plexus block: A double-blinded randomized clinical study. Journal of Anaesthesiology Clinical Pharmacology, 32 (2), 234-239. Albrecht, E., Kern, C., & Kirkham, K. R. (2015). A systemic review and meta-analysis of perineural dexamethasone for peripheral nerve blocks. Anaesthesia, 71-83. Alemdar, D. K., & Aktas, Y. Y. (2014). Comparison of Nurses' and Patients' Assessments of Postoperative Pain. International Journal of Caring Sciences, 882-888. Chen, H.-P., Shen, S.-J., Tsai, H. I., Kao, S. C., & Yu, H. P. (2015). Effects of Interscalene Nerve Block for Postoperative Pain Management in Patients after Shoulder Surgery. New York: Hindawi Publishing Corporation.

References Chou, R., Gordon, D. B., de Leon-Casasola, O. A., Rosenberg, J., Bickler, S., Brennan, T., . . . Wu, C. L. (2016). Guidelines on the management of postoperative pain. The Journal of Pain, 17 (2), 131-157. Chun, E. H., Kim, Y. J., & Woo, J. H. (2016). Which is your choice of prolonging the analgesic duration of single-shot interscalene brachial blocks for arthroscopic shoulder surgery? Intravenous dexamaethasone 5mg vs. perineural dexamethasone 5 mg randomixed, controlled clinical trial. Medicine, 1-6. Kathuria, S., Gupta, S., & Dhawan, I. (2015). Dexmedetomidine as an adjuvant to ropivacaine in supraclavicular brachial plexus block. Saudi Journal of Anesthesia, 148-154. Knezevik, N. N., Anantamongkol, U., & Candido, K. D. (2015). Perineural dexamethasone added to local anesthesia for brachial plexus block improves pain but delays block onset and motor blockade recovery. Pain Physician, 18, 1-14.

References Koch, M., & Calder, D. B. (2011). 4 decisions that can affect your anesthesia subsidy. Healthcare Finance Mangement, 104-108 Krinsky, R., & Johnson, J. (2014). A Practical application of Katharine Kolcaba's comfort theory to cardiac patients. Applied Nursing Research, 147-150. Kumar, S., Palaria, U., Sinha, A. K., Punera, D. C., & Pandey, V. (2014). Comparative evaluation of ropivacaine and ropivacaine with dexamethasone in supralavicular brachial plexus block for postoperative pain. Anesthesia Essays and Researches, 8 (2), 202-208. Medicare.gov. (2016, Decemeber 19). Retrieved from Hospital value-based purchasing: https://www.medicare.gov/hospitalcompare/Data/hospital-vbp.html

References Newhouse, R., Dearholt, S., Pugh, L. C., & White, K. (2005, July). John Hopkins nursing evidence-bases practice rating scale. Retrieved from JHNEBP EVIDENCE RATING SCALE; Retrieved July 2016: http://www.mc.vanderbilt.edu/documents/CAPNAH/files/Mentoring/Section%206/JHNEDP%20Evidence%20Scale.pdf Prevention, C. f. (2016, June 21). CDC 24/7: Saving lives, protecting people. Retrieved from Injury prevention & control: Opioid overdose: Http://www.cdc.gov/drugoverdose/epidemic Savych, B. (2014). Comparing payments to ambulatory surgery centers and hospital outpatient departments. Cambridge, Massachusetts: Workers Compensation Research Institute. Wilson , L., & Kolcaba, K. (2004). Practical application of comfort theory in the perianesthesia setting. Journal of Perianesthesia Nursing, 164-173.

DNAP Graduates class of 2017 La Roche College DNAP Graduates class of 2017

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