Rev Esp Anestesiol Reanim.

2016;63(3):135---140

Revista Española de Anestesiología

y Reanimación
www.elsevier.es/redar

ORIGINAL ARTICLE

Supraclavicular brachial plexus block using ropivacaine

alone or combined with dexmedetomidine for upper
limb surgery: A prospective, randomized,
double-blinded, comparative study夽
B. Das a,∗ , M. Lakshmegowda b , M. Sharma b , S. Mitra a , R. Chauhan a

a
Departamento de Anestesiología y Cuidados Críticos, Government Medical College, Haldwani, Uttarakhand, India
b
J N Medical College, AMU Aligarh, Uttar Pradesh, India

Received 26 December 2014; accepted 13 April 2015

Available online 9 October 2015

KEYWORDS Abstract
Dexmedetomidine; Background: Dexmedetomidine is a new ␣2 receptor agonist with analgesic and sedative prop-
Ropivacaine; erties. We used dexmedetomidine along with ropivacaine for supraclavicular brachial plexus
Supraclavicular block.
brachial plexus block Methods: Eighty ASA grade I--II patients, 18---60 years old, scheduled for elective upper limb
orthopaedic surgery under supraclavicular brachial plexus block, were included in this prospec-
tive study. The patients were randomly assigned to group R (ropivacaine alone) and group RD
(ropivacaine and dexmedetomidine) (40 patients in each group). Group R received ropivacaine
0.50% (30 cc) + placebo and group RD received ropivacaine 0.50% (30 cc) + dexmedetomidine
1 ␮g/kg. Primary outcome measure was duration of analgesia. Secondary measures were onset
and duration of sensory blockade, pain scores, onset and duration of motor blockade, and
evidence of any adverse drug reactions.
Results: There was no significant difference haemodynamic parameter during intra-operative
period. Group RD showed a statistically significant shorter time to onset of sensory blockade
(10.75 ± 2.71 vs. 16.75 ± 2.96 min, p = 0.003), longer sensory block duration (379.40 ± 55.09
vs. 211.60 ± 47.88 min, p = 0.002), shorter onset time to motor blockade (14.35 ± 2.58 vs.
20.25 ± 4.13 min, p = 0.003), longer motor block duration (312.0 ± 49.91 vs. 184.7 ± 36.76 min,
p = 0.002), longer duration of postoperative analgesia (413.73 ± 89.92 vs. 197.35 ±
28.67 min, p = 0.002). Three patients in the group RD developed somnolence (p = 0.04).

夽 Please cite this article as: Das B, Lakshmegowda M, Sharma M, Mitra S, Chauhan R. Bloqueo supraclavicular del plexo braquial con ropiva-

caína sola o en combinación con dexmedetomidina en cirugías de extremidades superiores: ensayo comparativo, prospectivo, monitorización
y con doble enmascaramiento. Rev Esp Anestesiol Reanim. 2016;63:135---140.
∗ Corresponding author.

E-mail address: [email protected] (B. Das).

2341-1929/© 2014 Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor. Published by Elsevier España, S.L.U. All rights
reserved.
136 B. Das et al.

Conclusion: Dexmedetomidine along with ropivacaine decreases the onset of motor and sensory
block and increases the duration of sensory and motor block in supraclavicular brachial plexus
block.
© 2014 Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor. Published
by Elsevier España, S.L.U. All rights reserved.

PALABRAS CLAVE Bloqueo supraclavicular del plexo braquial con ropivacaína sola o en combinación
Dexmedetomidina; con dexmedetomidina en cirugías de extremidades superiores: ensayo comparativo,
Ropivacaína; prospectivo, monitorización y con doble enmascaramiento
Bloqueo
supraclavicular Resumen
del plexo braquial Antecedentes: La dexmedetomidina es un nuevo agonista de los receptores ␣2 con propiedades
analgésicas y sedantes. Utilizamos dexmedetomidina junto con ropivacaína para realizar un
bloqueo supraclavicular del plexo braquial.
Métodos: En esta investigación se incluyeron 80 pacientes ASA I-II, de 18---60 años, progra-
mados para cirugía ortopédica de extremidad superior con bloqueo supraclavicular del plexo
braquial. A los pacientes (40 en cada grupo) se les asignó aleatoriamente el grupo R (solo ropi-
vacaína) y el grupo RD (ropivacaína y dexmedetomidina). El grupo R recibió ropivacaína 0,50%
(30 cc) + placebo y el grupo RD ropivacaína 0,50% (30 cc) y dexmedetomidina 1 ␮g/kg. El criterio
de valoración primario fue la duración de la analgesia, mientras que los secundarios fueron el
inicio y la duración del bloqueo sensitivo, las puntuaciones de dolor, el inicio y la duración del
bloqueo motor y la reacción adversa a los fármacos.
Resultados: No hubo diferencias significativas en los parámetros hemodinámicos durante el
período intraoperatorio. El grupo RD presentó un tiempo significativamente más corto desde
el punto de vista estadístico para el inicio del bloqueo sensitivo (10,75 ± 2,71 frente a
16,75 ± 2,96 min; p = 0,003), una duración más prolongada del bloqueo sensitivo (379,40 ± 55,09
frente a 211,60 ± 47,88 min; p = 0,002), un menor tiempo para el inicio del bloqueo motor
(14,35 ± 2,58 frente a 20,25 ± 4,13 min; p = 0,003), una duración más prolongada del bloqueo
motor (312 ± 49,91 frente a 184,7 ± 36,76 min; p = 0,002), y una duración más prolongada de la
analgesia postoperatoria (413,73 ± 89,92 frente 197,35 ± 28,67 min; p = 0,002). Tres pacientes
del grupo RD presentaron somnolencia (p = 0,04).
Conclusión: La dexmedetomidina combinada con la ropivacaína reduce el inicio del bloqueo
sensitivo y motor, y aumenta la duración del bloqueo sensitivo y motor en el bloqueo supracla-
vicular del plexo braquial.
© 2014 Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor. Publicado
por Elsevier España, S.L.U. Todos los derechos reservados.

Introduction and human studies have shown that adding dexmedetomi-

dine to local anaesthetics in various regional anaesthesia
Supraclavicular brachial plexus block (SCB) is as regional techniques, such as subarachnoid, epidural, and caudal
anaesthesia technique widely used in various types of upper injections, is both safe and effective. Other studies, how-
limb surgery. It is cost-effective and associated with good ever, have reported reduced or negative analgesic effects
outcomes, patient safety and postoperative analgesia. The with dexmedetomidine.8---12 Nevertheless, much has still to
supraclavicular approach to the brachial plexus gives the be learned about the analgesic efficacy and clinical util-
most effective block for upper extremity surgery.1 The ity of adding dexmedetomidine to local anaesthetics during
blockade is performed in the middle of the brachial plexus, peripheral nerve and nerve plexus block in humans.13,14
where it is most compact,2 thus ensuring even distribution This study was designed to investigate the efficacy of
of the anaesthetic, and rapid onset of complete anesthesia.3 dexmedetomidine as an adjuvant to ropivacaine solutions
Ropivacaine is an aminoamide local anaesthetic, formulated during SCB for upper extremity surgery, on the hypothesis
as an S-enantiomer. It is less cardiotoxic, less arrythmogenic that dexmedetomidine may improve overall efficacy of this
and less toxic to CNS than bupivacaine, and also has intrinsic anaesthesia technique.
vasoconstrictor properties.4
Several adjuvants, both opioids and non-opioids, have Materials and methods
been studied for brachial plexus block. Dexmedetomidine,
a selective ␣2 adrenergic agonist, has been used as an This is a prospective, randomized, double-blinded study
adjuvant during regional and local anesthesia.5---7 Animal in 80 ASA Grade I and II patients was conducted from
Supraclavicular brachial plexus block using ropivacaine alone or combined with dexmedetomidine for upper limb surgery 137

2011 to 2012. The study was approved by the Institu- Sensory block was evaluated as:
tional Ethics Committee, and written informed consent was Grade 0 Sharp sensation to pin prick
obtained from all study subjects. Patients of both sexes, Grade 1 Analgesia, dull sensation
aged between 18 and 60 years, undergoing different types Grade 2 Anaesthesia, loss of sensation
of upper limb orthopaedic surgery under supraclavicular
brachial plexus block were included and randomized to two Motor block was evaluated by the ability to flex the elbow
groups of 40 subjects each using a computer programme. and hand against gravity, as follows15 :
The following groups were formed: Grade 1 Ability to flex and extend the forearm
Grade 2 Ability to flex and extend only the wrist
and fingers
• Group R: ropivacaine 0.50% (30 cc) + placebo. Grade 3 Ability to flex and extend only the fingers
• Group RD: ropivacaine 0.50% (30 cc) + dexmedetomidine Grade 4 Inability to move the forearm, wrist,
1 ␮g/kg. and fingers

Randomization was performed by an independent statis- Onset of motor block was defined as the time from injec-
tician, and both patients and investigators were blinded to tion of local anaesthetic solution to grade 3 loss of motor
randomization until completion of statistical analysis. Exclu- function.
sion criteria were: patient refusal, patients with chronic Blockade was defined as incomplete when analgesia was
pain (pain lasting more than 12 weeks), patients using ineffective in one of the segments supplied by the median,
chronic analgesic medication (opiods, NSAIDS, anticonvul- radial, ulnar and musculocutaneous nerve, even 30 min after
sants, antidepressants), patients with clotting disorders, a anaesthesia administration. These patients received supple-
history of brachial plexus injury, allergy to the study drugs, mentary i.v. fentanyl (2 ␮g/kg) and midazolam. Blockade
patients taking other ␣ adrenergic blockers, patients with failure occurred when more than one nerve was unaffected.
hepatic or renal insufficiency, systemic infection or infection In this case, intraoperative general anaesthesia was admin-
at the injection site, and shoulder surgery. Prior to surgery, istered. Haemodynamic variables such as heart rate, blood
patients were instructed in the use of the verbal rating scale pressure and oxygen saturation were monitored intraop-
(VRS) for pain assessment (VRS: 0 = no pain, 10 = worst pain eratively every 30 min after blockade and every 60 min
possible). post-operatively.
On arrival in the operating room, baseline heart rate, Patients rated duration of analgesia subjectively on a
blood pressure and oxygen saturation were recorded. An VRS of 0---10. VRS scores were noted at 1, 2, 4 and 6 h
intravenous line was placed in the unaffected limb and post-operatively. Duration of analgesia (time from com-
infusion of Ringer’s lactate was started. Patients were pre- pletion of local anaesthetic administration to first need
medicated with 0.03 mg/kg i.v. midazolam 10---15 min before for i.m. ketorolac as rescue analgesia) was noted. All
the start of the nerve block technique. Subcutaneous injec- patients were monitored intra- and post-operatively for
tion of 2 mL of 2% lidocaine was administered at the needle side effects, such as nausea, vomiting, dryness of mouth
insertion site. or somnolence, and complications such as pneumothorax,
All the patients received supraclavicular brachial plexus haematoma, local anaesthetic toxicity and post-block neu-
block administered by an experienced anaesthesiolo- ropathy. The duration of sensory block was defined as the
gist (ML). Two different anaesthesiologists (MS and SM), time from completion of local anaesthetic administration
blinded to study groups, assessed the patient intra- and to complete regression of block in all nerves. The duration
post-operatively. Neural localization was achieved using of motor block was defined as the time from completion of
a nerve locator (Stimuplex® Dig RC, B. Braun Melsun- local anaesthetic administration to full recovery of motor
gen AG, Melsungen, Germany) connected to a 22 G, function of the hand and forearm.
50 mm stimulating needle (Stimuplex® , Braun, Germany). Primary outcome measure was duration of analgesia.
The location end point was a distal motor response at Secondary measures were onset and duration of sensory
less than 0.5 mA in the median nerve region. Following blockade, pain scores, onset and duration of motor block-
negative aspiration, 30 mL of local anaesthetic solution ade, and evidence of any adverse drug reactions.
combined with either placebo or dexmedetomidine, as Sample size was estimated using first rescue analgesic
described above, was infused. A 5-min compression was requirement between two groups as the primary outcome.
performed to facilitate even distribution of the anaes- Mean duration in each group was 120 min. The probability
thetic. Dexmedetomidine was taken from an unlabeled of detecting a difference of 10% (12 min), at the p < 0.05
bottle. level, is 80% (1 − beta = 0.80). On the basis of a previous
Sensory blockade was evaluated every 3 min, and motor study assuming an inter-group standard deviation of 18 min,
block every 5 min over the first 30 min following comple- we needed to study at least 38 patients per group to be able
tion of drug administration. Sensory block was confirmed by to reject the null hypothesis that the means of the study
pinprick sensation using a 23 G needle in all dermatomes of population are equal, with a power of 0.80. Raw data were
the brachial plexus (C5-T1) including median nerve, radial entered into a Microsoft Excel spreadsheet and analysed
nerve, ulnar nerve and musculocutaneous nerve. Onset of using standard statistical software SPSS® version 19.0 (SPSS
sensory block was defined as a dull sensation to pin prick Inc., Chicago, IL, USA). Categorical variables were analysed
along any of these nerves (Grade 1). Complete sensory using the Fisher’s exact test. Normally distributed continu-
block was defined as complete loss of sensation to pin ous variables were analysed using the t test, and significance
prick. was set at p < 0.05.
138 B. Das et al.

98 VRS
5
96
4.5
94 4
92 3.5
3
Heart rate/min

90
2.5 R
88 R
2 RD
86
RD 1.5
84
1
82
0.5
80 0
78 1 HR 2 HR 4 HR 6 HR
pre-op 5 min 30 min 1 hour 30 min 2 hour 8 hour
post op post op post op
Figure 3 Verbal rating scale (VRS) scores in both groups. Data
Figure 1 Heart rate in both groups. Data shown as mean shown as mean (SD).
(SD).
Discussion

Dexmedetomidine is a selective ␣2-adrenergic receptor (AR)

Results agonist with evidence of a high ratio of ␣2---␣1 activity
(1620:1) compared to clonidine (220:1).16 The mechanism by
Demographic variables, duration of surgery, and intravenous which ␣-AR agonists produce analgesia and sedation is not
sedation for block placement (p > 0.05) were comparable in fully understood, but is likely to be multi-factorial. Although
both groups, and are shown in Table 1. dexmedetomidine has analgesic properties and many other
Baseline haemodynamic parameters were comparable in advantages, it does not cause respiratory depression,17,18
both groups. No significant differences were observed making it a potentially useful and safe adjuvant in many clin-
in intraoperative pulse rate or mean arterial pressure ical procedures. Both the hypnotic and supraspinal analgesic
between groups (Table 2, Figs. 1 and 2). effects of dexmedetomidine are mediated by noradrenergic
In the RD (dexmedetomidine) group vs. R group (con- neurons (via hyperpolarization). The mechanism of action
trols), time to onset of sensory blockade was shorter is as follows: (1) it inhibits norepinephrine release and its
(10.75 ± 2.71 vs. 16.75 ± 2.96 min, p = 0.003), sensory block associated activity in the descending noradrenergic path-
duration was longer (379.40 ± 55.09 vs. 211.60 ± 47.88 min, way (secondary to activation of central ␣2s); and (2) it
p = 0.002), time to onset of motor blockade was shorter suppresses neuronal firing in the locus coeruleus.19,20 Sup-
(14.35 ± 2.58 vs. 20.25 ± 4.13 min, p = 0.003), motor block pression of these inhibitory controls leads to the release
duration was longer (312.0 ± 49.91 vs. 184.7 ± 36.76 min, of mediators and neurotransmitters that reduce histamine
p = 0.002), duration of postoperative analgesia was longer secretion and produce hypnosis (similar to normal sleep),
(413.73 ± 89.92 vs. 197.35 ± 28.67 min, p = 0.002) (Table 2) with no evidence of respiratory depression.21 In addition,
and pain scores were lower. All these differences were sta- suppression of activity of the descending noradrenergic
tistically significant. (Fig. 3). Five patients in group R and pathway (which modulates nociceptive neurotransmission)
three patients in group RD required supplementary i.v. fen- prevents propagation of pain signals, resulting in analgesia
tanyl (Table 2). Six patients in the dexmedetomidine group or decreased awareness of noxious stimuli.
presented somnolence vs. none in the control group (Group In our study, onset of sensory block was signifi-
R) (p = 0.04) (Table 2). cantly shorter in the RD group compared to the R
group (10.75 vs. 16.75 min). Similar results were reported
by Ammar and Mahmoud,22 who found that onset of
sensory block was significantly faster in bupivacaine
98 combined with dexmedetomidine, compared to bupiva-
96 caine alone (13.2 ± 2.1 vs. 19.4 ± 2.8 min) in ultrasound
94 guided infraclavicular brachial plexus block. According to
92 Swami et al.,23 time to sensory onset after supraclavi-
90 cular brachial plexus block was 1.77 ± 1.28 min in the
bupivacaine-dexmedetomidine group vs. 2.33 ± 1.21 min in
MAP

88 R
86
the bupivacaine-clonidine group. We found no studies com-
RD
84
bining dexmedetomidine with ropivacaine in brachial plexus
block.
82
In our study, sensory block duration was also significantly
80
longer in the RD group compared to the R group. Esmaoglu
78
et al.,24 reported similar results in axillary brachial block
pre-op 5 min 30 min 1 hour 30 min 2 hour 8 hour
post op post op post op combining dexmedetomidine with levobupivacaine. In their
study, the duration of sensory block in the levobupivacaine-
Figure 2 Mean arterial pressure in both groups. Data shown dexmedetomidine group was 887 ± 66.23 min, compared to
as mean (SD). 673 ± 73.77 min in the levobupivacaine group. Ammar and
Supraclavicular brachial plexus block using ropivacaine alone or combined with dexmedetomidine for upper limb surgery 139

Table 1 Demographic data and surgical parameters.

Parameters R Group (n = 40) RD Group (n = 40) p-Value
Age (years) 35.2 (9.6) 34.52 (12.8) 0.43
Sex (M/F) 20/20 23/17 0.65
Weight (kg) 61.33 (7.6) 60.85 (7) 0.45
Duration of surgery (min) 92 (12) 93 (9.9) 0.49
I.v. Midazolam (mg) 1.9 (0.22) 1.8 (0.21) 0.49
Data expressed as mean (SD).

Table 2 Ropivacaine (R Group) + Placebo and Ropivacaine + dexmedetomidine (RD Group). Data expressed as mean (SD) and
numbers (%).

Parameters RD Group (n = 40) R Group (n = 40) p-Value 95% confidence interval

*
Onset of sensory block (min) 10.75 (2.71) 16.75 (2.96) 0.003 0.58---0.71
Duration of sensory block (min) 379.40 (55.09) 211.60 (47.88) 0.002* 1.65---1.96
Onset of motor block (min) 14.35 (2.58) 20.25 (4.13) 0.003* 0.65---0.77
Duration of motor block (min) 312.0 (49.91) 184.7 (36.76) 0.002* 1.56---1.83
Durantion of analgesia (min) 413.73 (89.92) 197.35 (28.67) 0.002* 1.93---2.27
No. of patients requiring i.v. fentanyl 3 (7.5) 5 (12.5) 0.71
No. of patients requiring i.v. ketorolac 35 (87.5) 26 (65) 0.03* ---
Postoperative somnolence 6 (15) 0 (0) 0.03*
Data expressed as mean (SD) and numbers (%).
* Statistically significant.

Mahmoud22 and Swami et al.23 reported similar results in analgesia compared to ropivacaine alone, with little
their studies. alteration in haemodynamic parameters. This shows that
In this study, we found that onset of motor blockade was dexmedetomidine can be safely used as an adjuvant to
shorter and duration longer in the RD group. These find- ropivacaine for supraclavicular brachial plexus block.
ings echo those of Ammar and Mahmoud,22 Swami et al.23
and Esmaoglu et al.24 in terms of motor blockade. Kaygusuz
et al.25 found prolonged duration of motor blockade in the Conflict of interest
levobupivacaine-dexmedetomidine group vs. the levobupi-
vacaine group, but found no significant difference in onset The authors declare they have no conflict of interest.
of motor blockade.
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