Original Article | J Adv Med Biomed Res. 2019; 27(124): 16-22
Journal of Advances in Medical and Biomedical Research | ISSN:2676-6264
The Analgesic Efficacy of Low Dose Dexamethasone Added to Bupivacaine
in Ilioinguinal and Iliohypogastric Nerves Block in Patients Undergoing
Inguinal Hernia Surgery Under Spinal Anesthesia
Hamid Kayalha1,2
1.
2.
3.
, Somayeh Ahmadi Gooraji2
, Hossein Parsa3
, Marzieh Beigom Khezri*1,2
Rajaee Clinical Research Development Unit, Qazvin University of Medical Sciences, Qazvin, Iran
Metabolic Disease Research Center, Qazvin University of Medical Sciences, Qazvin, Iran
Dept. of Biostatistics, Guilan University of Medical Sciences, Guilan, Iran
Article Info
ABSTRACT
10.30699/jambs.27.124.16
Received: 2018/12/19;
Accepted: 2020/01/13;
Published Online: 08 Feb 2020;
Use your device to scan and read the
article online
Corresponding Information:
Dr. Marzieh Beigom Khezri, Rajaee Clinical
Research Development Unit, Qazvin
University of Medical Sciences, Qazvin,
Iran.
E-mail:
mkhezri@qums.ac.ir
Background & Objective: Dexamethasone has been emerged as an adjuvant to
local anesthetics to provide optimal analgesia. We have evaluated the postoperative
analgesic efficacy of adding a low dose dexamethasone to bupivacaine in
ilioinguinal (II) and iliohypogastric (IH) blocks in patients undergoing inguinal
herniorraphy under spinal anesthesia.
Materials & Methods: 50 patients in the range of 20-80 years of age who had
underwent elective surgery for the purpose of inguinal hernia repair under spinal
anesthesia were recruited in a prospective, double-blinded, and randomized manner.
At the end of the surgery, the patients received an II and IH block through the direct
injection of drugs around nerves. Meanwhile, the control group received bupivacaine
0.5% (2 cc) plus normal saline 1 cc (group C), and the dexamethasone group received
bupivacaine 0.5% (2 cc) plus 4 mg (1 cc) dexamethasone (group D). The pain
intensity was measured using the visual analogue scale (VAS) scale at 1, 2, 4, 12, and
24 hours after surgery.
Results: The mean time of analgesic duration in group C (3.6±3.8 hr) was greater
than group D (1.6±1.14 hr). This difference was statistically significant (P=0.043).
The pain intensity 2 hours after surgery in group D was higher than in group C
(median with IQR: 3±4 vs. 2±2; P=0.007). The difference in the total analgesic
consumption in group D (51.1±32.4 mg) versus group C (26.4±33.8 mg) was
significant (P=0.018).
Conclusion: The addition of 4 mg dexamethasone to bupivacaine in an II and IH
block at the end of surgery in patients undergoing inguinal herniorraphy under
spinal anesthesia failed to prolong the time to the first analgesic request. It provides
only a minor analgesic effect 12 hours following the surgery.
Keywords: Dexamethasone, Inguinal herrniorraphy, Ilioinguinal nerve,
Iliohypogastric nerve, Pain
Copyright © 2019, This is an original open-access article distributed under the terms of the Creative Commons Attribution-noncommercial 4.0 International License which
permits copy and redistribution of the material just in noncommercial usages with proper citation.
Introduction
The management of postoperative pain causes better
surgical outcomes and fewer cognitive changes
following surgery. It reduces the risk of chronic pain
and improves the quality of life. Using common
analgesic agents such as opioids after inguinal hernia
repair surgery causes delayed intestinal function and
increases side effects such as nausea and vomiting (13), resulting in increased hospital costs (4).
and hemodynamic disturbance, and reduced lung
capacity. Ilioinguinal (II) and iliohypogastric (IH)
nerve blocks could provide satisfactory analgesia after
inguinal hernia. Many drugs have been added to local
anesthetics to offer ideal analgesia with lesser side
effects such as opioids, epinephrine, ketamine,
midazolam, clonidine, dexamethasone, and magnesium
(5).
Postoperative pain management after abdominal
surgical procedure (inguinal herniorrhaphy) is usually
based on conventional agents consisting of maximal
doses of paracetamol non-steroidal anti-inflammatory
drugs, and oral or intravenous opioid. However, this is
associated with such side effects as nausea, drowsiness
II and IH nerve blocks are not used as the sole
anesthesia approaches for surgery because they are
unable to provide visceral insensitivity (6). The II/IH
nerve block has been suggested to decrease the opioid
analgesic requirements and adverse effects after
inguinal herniotomy (7).
Volume 27, September & October 2019
Journal of Advances in Medical and Biomedical Research
Hamid Kayalha et al. 17
Perineural dexamethasone has been shown to have
analgesic effects. It is suggested that the analgesic
effect of dexamethasone is related to decreased
inflammation and the blocking of the nociceptive C
nervous fibers via inhibiting the ectopic nerve
discharges. This enhances the time of the nerve block
(8). Furthermore, dexamethasone constricts the blood
vessels and reduces the absorption of local anesthesia
drugs (9). Many studies have reported that there are no
problems associated with the use of perineural
dexamethasone in a peripheral nerve block (9-15).
protocols and provided a written informed consent. The
exclusion criteria were addiction, palliative care, a
surgery time of more than 1.5 h, the inadequate analgesic
efficacy of the spinal anesthesia during surgery, and the
patients considered for hernia repair with a surgical
mesh. Out of 50 patients primarily included in the study,
6 patients were excluded from the study groups for study
protocol reasons. The guidelines provided by the
Consolidated
Standards
of
Reporting
Trials
(CONSORT) for recording randomized controlled
clinical trials (19) were charted (Figure 1).
In a meta-analysis by De Oliveira which included
the overall results of three studies (13,14,16)
examining the effect of perineural dexamethasone on
late pain (24 h), no favorable effect for
dexamethasone was reported compared to the control
group. They also stated that only one study assessed
the effect of perineural dexamethasone on early pain
(<4 h) in patients receiving an interscalene brachial
plexus block with levobupivacaine; the results of the
study proposed that there is a minor effect of
perineural dexamethasone compared to the control
group (11,16). However, the authors declared that the
heterogeneity of the studies was high and it could not
describe the type of regional block or the local
anesthetic used. Although several studies have shown
that perineural dexamethasone prolongs the analgesic
duration (11,13,14,16) of biracial plexus, the literature
on the efficacy of perineural dexamethasone in other
peripheral nerve blocks, such as those in the
distribution of the lumbar or II and IH blocks, is
limited (17,18). Further research is needed in this area.
All patients received an intravenous preload of
lactated Ringer’s solution at 5-7 ml/kg before the
subarachnoid block. Afterward, via an aseptic
technique, a 25-gauge Quincke needle was introduced
intrathecally via a midline method at the L4-5
interspace by the same anesthetist, who was
uninformed of the patient assignment when the patient
was in the sitting position. After the dural puncture, the
anesthetic solution (3 ml bupivacaine 0.5%) was
injected.
We hypothesized that adding a low dose of
dexamethasone to bupivacaine in II and IH nerve
blocks might offer a better pain killer after inguinal
herniorraphy surgery under spinal anesthesia
compared to the common anesthetic agents with lower
side effects. In order to test our hypothesis, we
scheduled a randomized double-blind placebocontrolled (RDBPC) study to assess the postoperative
analgesic effects of a perineural low dose of
dexamethasone added to bupivacaine in II and IH
nerve blocks at the end of inguinal hernia repair
surgery.
Materials and Methods
Using a computer-generated randomization
schedule, 50 patients aligned with the ASA physical
grade I or II, who had underwent inguinal hernia
repair surgery by spinal anesthesia were randomized
to have II and IH blocks with the direct injection of
medicine around the nerves tissues conducted by the
surgeon. At the end of the surgery, all patients had an
established II and IH block with the direct injection of
medicine around the nerve tissues. Patients in the
control group received bupivacaine 0.5% (2 cc) plus
normal saline 1 cc (group C) and the patients in the
intervention group received bupivacaine 0.5% (2 cc)
plus dexamethasone 1 cc (4 mg) (group D). Blinding
was attained through the use of the same volume of
the study drugs (3 mL). The syringes used were
categorized as either A and B according to their
contents. The identically coded syringes, prepared by
an external individual, were arbitrarily given to the
surgeon who was uninformed of the identity of the
syringes. The primary outcomes of this study were to
assess the time taken to first pain feeling and the total
analgesic required in the first 24 hours postoperative.
The patients were preoperatively taught to use the
verbal analog scale (VAS) from 0 to 10 (0: no pain,
and 10: maximum imaginable pain) for the pain
assessment. If the VAS exceeded 4 and the patient
requested a supplement analgesic, then diclofenac Na
sup. 100 mg was administered every 8 hours to
terminate the postoperative pain as needed. If the time
course after the use of diclofenac Na was lesser than 8
hours and the patient requested another supplement
analgesic, then pethidine 50 mg IV was injected. The
study data was analyzed by a statistician who was not
elaborated on the purpose of the study.
The study was approved by the ethics committee of
the Qazvin University of Medical Sciences, Qazvin, Iran.
This was a randomized double blind clinical trial
performed on 50 patients aged between 20-80 years with
ASA class I & II (American society of
anesthesiologists) who underwent one-sided inguinal
hernia repair surgery at the Rajaee and Velayat hospitals,
both of which are affiliated to the Qazvin University of
Medical Sciences, Qazvin, Iran. The time period of the
study was from January 2016 to January 2017 (IRCT
registration number: IRCT2017012425676N6). All
patients were completely informed about the study
To estimate the sample size, the data from a prior
similar study was assessed (20). Our primary outcome
was the duration of analgesia. The data (mean ± SD)
from the previous study (20) which referred to the
Volume 27, September & October 2019
Journal of Advances in Medical and Biomedical Research
18 The analgesic efficacy of low dose dexamethasone
Table 1. Demographic information of patients (n=44)
Variable
Category
D (n=23)
C (n=21)
Male
21(91.3)
20(95.2)
Female
2(8.7)
1(4.8)
52.6(15.6)
52.1(13.2)
Sex, n (%)
Age, Mean (SD)
P-value
0.535a
0.907b
D=bupivacaine &dexamethasone group as case group, C=bupivacaine & normal saline as control group.
a Analysis done based on Chi-square test. b Analysis done based on independent two samples T-test.
Table 2. Comparison the main outcomes between two groups (n=44)
Variable
D (n=23)
Mean ±SD
C (n=21)
Mean ± SD
P-value a
Pethidine consumption
51.1±32.4
26.4 ±21.8
0.018*
Diclofenac Na consumption
91.3±44.8
114.3±57.3
0.303
Pain onset time
1.6±1.14
3.6±3.2
0.043*
a Independent
samples T-test. * Is significant at level of 0.05. D=dexamethasone group, C=control group.
Figure 1. Consort flow diagram
duration of analgesia was entered into the Open Epi
program software. The sample size analysis conducted
suggests that a total of 38 patients are mandatory to
Volume 27, September & October 2019
distinguish if there is a significant difference in the
mean duration of analgesia between the groups using
Journal of Advances in Medical and Biomedical Research
Hamid Kayalha et al. 19
Figure 2. Data are representd based on Median and Interquartile rang(IQR).
the Mann-Whitney U test, with a power of 0.9 and α
equal to 0.05. We employed a total of 50 patients to
allow for dropouts and protocol limitations. The data
was analyzed using SPSS 15 (SPSS Inc., Chicago, IL,
USA). Continuous variables were checked for normal
distribution using the Kolmogorov-Smirnov test. The
parametric data were shown in the form of mean and
standard deviation (SD) and analyzed using the
independent sample t-test. The non-parametric data
was revealed as utilizing the median and interquartile
ranges, and this was analyzed using the MannWhitney U test and Chi-square test. A P-value less
than 0.05 was considered to be statistically
significant.
Results
A total of 50 patients were first registered in this
study, out of whom 6 patients were excluded due to
the following reasons: drug addiction (1 patient), a
surgery time of more than 1.5 hours (1 patient),
patients undergoing hernia repair with surgical mesh
(2 patients), and the inadequate analgesic efficacy of
spinal anesthesia during surgery (2 patients). Finally,
44 patients were involved and randomly allocated to
their treatment groups (Figure 1).
As shown in Table 1, there were no significant
differences between the two groups concerning the
demographic characteristics.
Table 2 shows that the mean time of analgesic
duration in group C (3.6±3.8 h) was greater than that
in group D (1.6±1.14 h). This difference was
statistically significant (P=0.043). Meanwhile, the
difference in total analgesic consumption in group D
(51.1±32.4 mg) vs. group C (26.4±33.8 mg) was
significant (P=0.018).
Figure 2 presents the comparison of trends in pain
intensity in each time and by groups. As observed,
although the pain intensity at 12 (P=0.083) and 24
Volume 27, September & October 2019
(P=0.161) hours following surgical operation was
lower in group D, compared to group C, the difference
was not statistically significant.
Discussion
Based on the results of the present study, we
concluded that the addition of 4 mg dexamethasone to
bupivacaine in the II and IH blocks at the end of
surgery in patients undergoing inguinal herniorraphy
under spinal anesthesia could not prolong the time to
the first analgesic request. It only provided minor
analgesic effects 12 hours after surgery. Contrary to
our results, most of the previous studies reported a
significant analgesic effect for dexamethasone plus
bupivacaine
or
ropivacaine
(9,17,21-27).
Nevertheless, partially consistent with present results
and in a meta-analysis by De Oliveira et al. (11), it
was described that the results of three studies
(13,14,16) showed that the effect of perineural
dexamethasone on late pain (24 h) did not have a
favorable effect compared to the control group.
The discrepancy in the results of the current study
with those of the previous studies may be due to
different routes, dosages, and also the time of
dexamethasone administration used. For example, in a
study by Vieira et al. (14), it was described that the
addition of 8 mg dexamethasone to a bupivacaineepinephrine-clonidine interscalene block prolonged
the sensory block and reduced opioid use. They
declared that minor doses of dexamethasone (4-5 mg)
were not as effective as major doses (8-10 mg) at
decreasing analgesic consumption 24 and 48 hours
after surgery (14). In another study performed by
Parrington et al. (13), for 46 adult patients undergoing
elective surgery under the supraclavicular brachial
plexus, a longer median time for analgesia after
surgery was reported in the group that received
Journal of Advances in Medical and Biomedical Research
20 The analgesic efficacy of low dose dexamethasone
mepivacaine 1.5% (30 mL) plus dexamethasone 8 mg
compared to the group that received mepivacaine
1.5% (30 mL) plus normal saline 2 ml. However, the
onset of the sensory and motor block did not lessen in
comparison with normal saline (13). In our previous
study we concluded that adding 8 mg dexamethasone
to 40 mL lidocaine meaningfully elongated the
duration of analgesia compared with the
fentanyl/lidocaine mixture or lidocaine alone using
the axillary block in patients suffering post-forearm
fracture surgery (5). In a study by Cummings et al.
(9), it was also revealed that adding 8 mg
dexamethasone elongated the analgesia from the
interscalene blocks using ropivacaine or bupivacaine,
compared to ropivacaine. Castillo et al. (28) reported
that in rats, dexamethasone alone or when combined
with aqueous bupivacaine has no effect on the
analgesic effects of a sciatic nerve block. However,
when combined with bupivacaine microspheres, the
effects were meaningful. This result is partly
consistent with the finding of the present study;
however, it should be noted that microsphere
technology provides a sustained and prolonged release
of the drug in contrast to the aqueous solutions used in
our study.
Ammar et al. (17) reported that adding 8 mg
dexamethasone to bupivacaine in the transversus
abdominis plane block (TAPB), before the start of the
surgery and after the induction of general anesthesia,
prolonged the duration of the analgesia. In a study by
Fouad et al. (23), it was revealed that the preemptive
addition of 8 mg dexamethasone to bupivacaine in
patients receiving a TAPB for inguinal hernia repair
under general anesthesia resulted in a longer time for
the first opioid requirement.
We performed the II and IH block at the end of the
surgery, but in the above-mentioned studies,
dexamethasone was given before starting the surgery.
It is known that the biological half-life of
dexamethasone in plasma is about 190 minutes (29).
Nevertheless, the exact onset of the perineural
dexamethasone action is not well established; but the
onset of the biological action of dexamethasone is
reported to be between 1-2 hours following
administration (30,31). Therefore, it seems that the
drug should ideally be administered prior to surgery in
order to achieve the maximum benefit. The authors of
the present study assumed that the time of blocking
and injection of drugs may be important in relation to
the
analgesic
efficacy
of
dexamethasone.
Dexamethasone has long-acting effects and it could
work as an optimal agent when used as preemptive
analgesia (32).
The important finding of the present study that
should be noted is the occurrence of the early onset of
pain in patients who received a low dose of
dexamethasone added to bupivacaine in the II and IH
blocks at the end of surgery. This result was somehow
comparable with the finding of the literature review
Volume 27, September & October 2019
by Knezevic et al. (33). They described that perineural
adjuvant dexamethasone prolonged the onset of the
sensory and motor block. In the present study, in
patients who received dexamethasone, the onset of
pain appeared earlier than expected. In other words,
the onset of bupivacaine effect in the II block was
delayed.
The
vasoconstriction
effect
of
dexamethasone may be a possible explanation for
delaying the onset of the bupivacaine block. That is to
say, dexamethasone constricts vessels and reduces the
absorption of the local anesthesia drugs (9). Another
possibility worth mentioning as an explanation for the
delayed onset of the bupivacaine block is that the
effect of dexamethasone in this study was more
pronounced because we added 1 mL dexamethasone
to 2 ml bupivacaine 0.5%. In most of the
aforementioned studies, 1-2 ml dexamethasone was
added to 20 ml bupivacaine 0.5%.
We chose the administration of 4 mg
dexamethasone because some previous studies
revealed that minor doses of dexamethasone (4-5 mg)
were as effective as major doses (8-10 mg) (16, 30).
In a study by Khafagy et al. (22), it was also reported
that the addition of 4 mg dexamethasone to epidural
bupivacaine had almost the same analgesic effect as
bupivacaine-fentanyl with
opioid-sparing
and
antiemetic properties.
Our study had some limitations. We did not assess
the dose–response of dexamethasone. Also,
measuring pain intensity is challenging, especially for
patients with severe and chronic pain. The VAS is
limited by ceiling effects, in that often the patients
were unable to quantify their worsening pain.
Moreover, this assessment is clearly subjective and
the medical staff were unable to monitor the patients'
pain over extensive periods of time (34,35).
Additional research is necessary to assess either
different dosages of the short-acting steroids at the
end of surgery on postoperative pain or the use of one
of the alkalization agents such as bicarbonate Na in
addition to steroids to accelerate the analgesic effect
of the drugs with an evaluation of the patients’ pain
via a digital VAS scale to offer a suitable way for the
medical staff to monitor the patients' pain over
substantial periods of time. We suggest the use of
preemptive perineural high dose dexamethasone in
addition to II and IH blocks for postoperative pain
relief.
Conclusion
The addition of 4 mg dexamethasone to bupivacaine
in II and IH blocks at the end of surgery in patients
undergoing inguinal herniorraphy under spinal
anesthesia could not prolong the time to the first
analgesic request. It could provide only a minor
analgesic effect 12 hours following surgery.
Journal of Advances in Medical and Biomedical Research
Hamid Kayalha et al. 21
Acknowledgement
Authors of this paper are thankful for the valuable
cooperation of the staff of Clinical Research
Development units of Velayat and Rajaee hospitals.
Conflict of Interest
Authors declared no conflict of interests.
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How to Cite This Article:
Kayalha H, Ahmadi Gooraji S, Parsa H, Khezri M B. The Analgesic Efficacy of Low Dose Dexamethasone
Added to Bupivacaine in Ilioinguinal and Iliohypogastric Nerves Block in Patients Undergoing Inguinal Hernia
Surgery under Spinal Anesthesia. J Adv Med Biomed Res. 2019; 27 (124): 16-22
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