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13 Zhang P, Deng X, Zhang R, Zhu T. Comparison of transversus abdominis plane block and epidural analgesia for pain relief after surgery. Already, Desai et al. have conducted an analysis that is stronger than any of the previous meta-analyses examining the TAP block and epidural analgesia but they go still further by including several sensitivity tests for their analysis. Epidural analgesia remains superior to the TAP block in the immediate postoperative period for patient-reported pain scores, but only statistically superior, and with a difference that does not seem clinically-relevant. Comparison of efficacy and safety of lateral-to-medial continuous transversus abdominis plane block with thoracic epidural analgesia in patients undergoing abdominal surgery: a randomised, open label feasibility study. [Extracted from the article]

The shoulder block may impair ventilatory function and diaphragmatic movement less than the interscalene brachial plexus block. We randomly allocated 30 adults who underwent shoulder arthroscopy under general anaesthesia to ultrasound-guided shoulder block or interscalene block with 20 ml bupivacaine 0.5%. The primary outcome, rate of ultrasound-measured hemidiaphragmatic excursion < 25% of baseline 30 min after blockade, was reduced from 12/15 with brachial plexus block to 2/15 with shoulder block, a difference (95%CI) of 67% (40-93%), p < 0.001. The mean (SD) numeric rating scale pain scores at rest after shoulder block were higher than after interscalene block at two postoperative hours, 1.4 (1.2) vs. 0.3 (0.7), p = 0.02, but lower at 24 postoperative hours, 1.3 (1.3) vs. 3.4 (2.3), p = 0.008. Mean (SD) pain scores on movement in the shoulder and interscalene blocks were similar, with respective values of 1.9 (1.9) vs. 0.7 (1.2), p = 0.13 at two postoperative hours and 3.7 (2.3) vs. 5.3 (2.5), p = 0.41, at 24 postoperative hours. [ABSTRACT FROM AUTHOR]

Long-acting neuraxial opioids provide excellent analgesia after surgery, but are associated with higher rates of postoperative nausea and vomiting. Dexamethasone effectively prevents postoperative nausea and vomiting after general anaesthesia, but its value in patients receiving long-acting neuraxial opioids is undetermined. Therefore, the objective of this meta-analysis was to assess the prophylactic anti-emetic efficacy of intravenous (i.v.) dexamethasone in this population. The study methodology followed the PRISMA statement guidelines. The primary outcome was the need for rescue anti-emetics during the first 24 postoperative hours, analysed according to the dose of dexamethasone (low-dose 2.5-5.0 mg; intermediate dose 6.0-10.0 mg), timing of administration (beginning or end of surgery) and route of long-acting opioid administration (intrathecal or epidural). Additionally, the rates of complications (restlessness, infection, hyperglycaemia) were sought. Thirteen trials were identified, representing a total of 1111 patients. When compared with placebo, intravenous dexamethasone reduced the need for rescue anti-emetics (risk ratio (95%CI) 0.44 (0.35-0.56); I2 = 43%; p < 0.00001; quality of GRADE evidence: moderate), without differences between dexamethasone doses (p for sub-group difference = 0.67), timing of administration (p for sub-group difference = 0.32) or route of long-acting opioid (p for sub-group difference = 0.10). No patients developed infection or restlessness among trials that sought these complications. No trial measured blood glucose levels. In conclusion, there is enough evidence to state that intravenous dexamethasone provides effective anti-emetic prophylaxis during the first 24 postoperative hours in patients who receive long-acting neuraxial opioids. [ABSTRACT FROM AUTHOR]

Perineural dexamethasone has gained popularity in regional anaesthesia to prolong the duration of analgesia, but its advantage over systemic administration is disputed. The objective of this meta-analysis was to compare the analgesic efficacy of both routes of administration during peripheral nerve block. The methodology followed the PRISMA statement guidelines. The primary outcome was the duration of analgesia analysed according to the type of local anaesthetic administered (bupivacaine or ropivacaine). Secondary outcomes included cumulative opioid consumption in morphine i.v. equivalents, pain scores, and complication rates (neurological complications, infection, or hyperglycaemia). Eleven controlled trials, including 914 patients, were identified. The duration of analgesia was significantly increased with perineural dexamethasone vs systemic dexamethasone by a mean difference of 3 h [95% confidence interval (CI): 1.4, 4.5 h; P=0.0001]. Subgroup analysis revealed that the duration of analgesia was increased by 21% with bupivacaine (mean difference: 4.0 h; 95% CI: 2.8, 5.2 h; P<0.00001) and 12% with ropivacaine (mean difference: 2.0 h; 95% CI: -0.5, 4.5 h; P=0.11). The quality of evidence for our primary outcome was moderate according to the GRADE system. There were no significant differences in other secondary outcomes. No neurological complications or infections were reported. Glucose concentrations were not increased when dexamethasone was injected systemically, but this outcome was reported by only two trials. There is, therefore, moderate evidence that perineural dexamethasone combined with bupivacaine, but not ropivacaine, slightly prolongs the duration of analgesia, without an impact on other pain-related outcomes, when compared with systemic dexamethasone. Injection of perineural dexamethasone should be cautiously balanced in light of the off-label indication for this route of administration. [ABSTRACT FROM AUTHOR]