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

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

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

4. 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

5. 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).

6. 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)

7. 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.

8. 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

9. Ultrasound photo of Supraclavicular brachial plexus

10. 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

11. 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

12. 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

13. 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).

14. 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).

15. 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).

16. (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)

17. Methodology
Quasi-experimental study – the experimental subjects were not randomly assigned
Retrospective chart review – October 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

18. 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

19. 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

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

21. 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.

22. 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 – and experimental – , p<0.0001

23. 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 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

24. 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

25. 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

26. 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).

27. 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),
Albrecht, E., Kern, C., & Kirkham, K. R. (2015). A systemic review and meta-analysis of perineural dexamethasone for peripheral nerve blocks. Anaesthesia,
Alemdar, D. K., & Aktas, Y. Y. (2014). Comparison of Nurses' and Patients' Assessments of Postoperative Pain. International Journal of Caring Sciences,
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.

28. 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),
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,
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.

29. References
Koch, M., & Calder, D. B. (2011). 4 decisions that can affect your anesthesia subsidy. Healthcare Finance Mangement,
Krinsky, R., & Johnson, J. (2014). A Practical application of Katharine Kolcaba's comfort theory to cardiac patients. Applied Nursing Research,
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),
Medicare.gov. (2016, Decemeber 19). Retrieved from Hospital value-based purchasing:

30. 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:
Prevention, C. f. (2016, June 21). CDC 24/7: Saving lives, protecting people. Retrieved from Injury prevention & control: Opioid overdose:
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,

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

32. FAMILY