{
  "abstract": "Dexamethasone (DXM) is frequently administered as an adjuvant of postoperative analgesia with widely varying dosing regimens. Based on the assumption that the optimal dosage of a drug should correspond to the amount needed to produce the desired effect with minimal adverse effects, when talking about the dosage of dexamethasone we should also refer to the route of administration, which for dexamethasone historically has been perineural and intravenous. 1 Recently a meta-analysis published by Albrecht et colleagues2 comparing the intravenous versus perineural route of administration found low quality evidence that perineural administration of DXM increases duration of analgesia by an average of 2 hours compared with intravenous injection for interscalene brachial plexus block. This increase in the duration of analgesic block, from a clinical point of view was considered to be of little significance, even in the face of an administration, that of perineural, which remains off label, and which in any case should be considered only in cases where preservative free formulations are available, because of the otherwise known neurotoxic effects.3 These data also appear to be confirmed by a metanalysis by Sehmbi et colleagues4 which showed that intravenous dexamethasone given at the time of regional anesthesia increases the duration of sensory block by 76 minutes, compared to local anesthetic alone, also recording a better performance respect to perineural route. In this regard, the authors of the paper pointed out that in addition to the route of administration of dexamethasone, reference must also be made to the type of locoregional blockade performed; peripheral blocks of the upper limb in fact, with greater vascularization than the lower limb, can certainly result in different systemic absorption, even with regard to perineural administration, creating a bias in the results of the studies. In addition, intravenous dexamethasone administration might present better efficacy in reducing the incidence of rebound pain.5 A meta-analysis published in 2011 by De Oliveira et al.6 that considered the administration of DXM at low doses (less than 0.1 mg/kg), intermediate doses (0.11–0.2 mg/kg) and high doses (major or equal to 0.21 mg/kg) claimed that analgesic effects appeared at intermediate doses of DXM, and adverse effects typically related to the administration of DXM such as hyperglycemia, increased surgical wound healing times, surgical site infections remained negligible at these dosages. Recently, a study by Corcoran and colleagues7 analyzing 8,880 adult patients undergoing non-urgent, non-cardiac surgery that received 8 mg of intravenous dexamethasone in comparison to placebo did not find a significant increase in surgical site infections within 30 days after surgery. A study by Porter and colleagues8 investigated the impact of DXM on glycemic control and outcomes in patients with type 2 diabetes mellitus undergoing elective primary total joint arthroplasty showed an increased risk of elevated mean glucose on postoperative day (POD) 0–2 and hyperglycemia on POD 0, but this was not associated with an increase in total insulin dose administered or the occurrence of surgical site infections, hospital readmission, or mortality within 30 days after surgery. A metanalysis by Laconi and collegues9 about high doses of glucocorticoids (DXM major or equal to 0.2 mg/kg or major or equal to 15 mg intravenously) administered preoperatively 1 hours before surgery found an opioid-sparing effect at 24 hours after surgery of approximately 10 mg Oral Morphine Equivalents (OME), however, there are still inconsistent data on the adverse effects that high doses of DXM may cause. Another study by Van Der Weegen and colleagues,10 a matched cohort study, found no difference in the proportion of patients needing rescue analgesics during hospitalization between the group of patients who received 20 mg of DXM preoperatively and the group of patients who received 8 mg. Robust scientific evidence on the optimal dosage of DXM as adjunct to postoperative analgesia, especially with regard to the administration of high doses, has yet to be established. Administration of DXM should also take into account the type of peripheral nerve block that will need to be performed (sites with high or low vascularization). The most consistent data in the literature currently available concern intermediate doses (< 10 mg of DXM), which demonstrate an adequate safety profile, possibly even in high-risk populations such as diabetics. There are still no consistent data on high doses of DXM, particularly with regard to the possible assessment of adverse effectsReferences Pehora C, Pearson AM, Kaushal A, et al. Dexamethasone as an adjuvant to peripheral nerve block. Cochrane Database of Systematic Reviews 2017;2017. doi: 10.1002/14651858.CD011770.pub2.Albrecht E, Renard Y, Desai N. Intravenous versus perineural dexamethasone to prolong analgesia after interscalene brachial plexus block: a systematic review with meta-analysis and trial sequential analysis. British Journal of Anaesthesia 2024;133:135–45. doi: 10.1016/j.bja.2024.03.042.Knight JB, Schott NJ, Kentor ML, et al. Neurotoxicity of common peripheral nerve block adjuvants. Current Opinion in Anaesthesiology 2015;28:598–604. doi: 10.1097/ACO.0000000000000222.Sehmbi H, Brull R, Ceballos KR, et al. Perineural and intravenous dexamethasone and dexmedetomidine: network meta-analysis of adjunctive effects on supraclavicular brachial plexus block. Anaesthesia 2021;76:974–90. doi: 10.1111/anae.15288Makkar JK, Singh NP, Khurana BJK, et al. Efficacy of different routes of dexamethasone administration for preventing rebound pain following peripheral nerve blocks in adult surgical patients: a systematic review and network meta-analysis. Anaesthesia 2025;80:704–12. doi: 10.1111/anae.165666De Oliveira GS, Almeida MD, Benzon HT, et al. Perioperative single dose systemic dexamethasone for postoperative pain: a meta-analysis of randomized controlled trials. Anesthesiology 2011;115:575–88. doi: 10.1097/ALN.0b013e31822a24c2Corcoran TB, Myles PS, Forbes AB, et al. Dexamethasone and surgical-site infection. N Engl J Med. 2021;384:1731–41. doi: 10.1056/NEJMoa2028982Porter SB, Wilson JR, Sherman CE, et al. Dexamethasone, glycemic control, and outcomes in patients with type 2 diabetes mellitus undergoing elective, primary total joint arthroplasty. Arthroplasty Today 2024;27:101391. doi: 10.1016/j.artd.2024.101391Laconi G, Coppens S, Roofthooft E, et al. High dose glucocorticoids for treatment of postoperative pain: a systematic review of the literature and meta-analysis. Journal of Clinical Anesthesia 2024;93:111352. doi: 10.1016/j.jclinane.2023.111352.Van Der Weegen W, Das D, Vrints K, et al. A 20 mg dose of dexamethasone does not reduce the proportion of joint replacement patients needing rescue analgesia: a matched cohort study. Ann Joint. 2023;8:4–4. doi: 10.21037/aoj-22-34.",
  "authors": [
    {
      "affiliations": [
        "Department of Anesthesia, Intensive Care, and Pain Management, University Hospital of Ferrara Italy, Ferrara, Italy"
      ],
      "name": "Giulia Laconi"
    }
  ],
  "title": "FT42 Optimal dose of dexamethasone to prolong a block",
  "uid": "3dac618b-13c3-5e55-919b-b6c3ed376fd9"
}