REGIONAL ANESTHESIA AND ACUTE PAIN
ORIGINAL ARTICLE
Perineural Versus Intravenous Dexamethasone as an Adjuvant
for Peripheral Nerve Blocks
A Systematic Review and Meta-Analysis
Matthew Alan Chong, MD,* Nicolas Matthew Berbenetz, MD,† Cheng Lin, MD,* and Sudha Singh, MD*
Background and Objectives: Dexamethasone is a useful adjuvant in
regional anesthesia that is used to prolong the duration of analgesia for
peripheral nerve blocks. Recent randomized controlled trials (RCTs)
have demonstrated conflicting results as to whether perineural versus
intravenous (IV) administration is superior in this regard, and the perineural
use of dexamethasone remains off-label. Therefore, we sought to perform a
systematic review and meta-analysis of RCTs.
Methods: In accordance with PRISMA guidelines, we performed a
random-effects meta-analysis of RCTs comparing perineural versus IV
dexamethasone with duration of analgesia as the primary outcome.
Results: Eleven RCTs met the inclusion criteria with a total of 1076
subjects. Perineural dexamethasone prolonged the duration of analgesia
by 3.77 hours (95% confidence interval [CI], 1.87–5.68 hours; P < 0.001)
compared to IV dexamethasone, with high statistical heterogeneity. For
secondary outcomes, perineural dexamethasone prolonged the duration of
both motor (3.47 hours [95% CI, 1.49–5.45]; P < 0.001) and sensory
(2.28 hours [95% CI, 0.38–4.17]; P = 0.019) block compared to IVadminis-
tration. Furthermore, perineural dexamethasone patients consumed slightly
less oral opioids at 24 hours than IV dexamethasone patients (7.1 mg of oral
morphine equivalents [95% CI, 0.74–13.5 mg]; P = 0.029), and there were
no statistically significant differences in the other secondary outcomes.
Notably, no increase in adverse events was detected.
Conclusions: Perineural dexamethasone prolongs the duration of analge-
sia across the RCTs included in our meta-analysis. The magnitude of effect
of 3.77 hours raises the question as to whether perineural dexamethasone
should be administered routinely over its IV counterpart—or reserved for
selected patients where such prolongation would be clinically important.
(Reg Anesth Pain Med 2017;42: 319–326)
D examethasone has seen much interest in the field of regional
anesthesia as an adjuvant for peripheral nerve blocks.1
Numerous meta-analyses have established the superiority of
intravenous (IV) dexamethasone compared with placebo for
prolonging peripheral nerve blocks, reflected in longer analgesic
duration without any significant adverse events.1–3 Although the
precise mechanism is unknown, dexamethasone is thought to
function by altering the inflammatory response and may have a
direct effect on nociceptive fibers.4
From the *Department of Anesthesia and Perioperative Medicine, and
†Department of Medicine, Western University, London, Ontario, Canada.
Accepted for publication December 6, 2016.
Address correspondence to: Matthew Alan Chong, MD, Department of
Anesthesia and Perioperative Medicine University Hospital-London,
Health Sciences Centre, 339 Windermere Rd, C3-108 London, Ontario,
Canada, N6A 5A5 (e‐mail: matthew.a.chong@gmail.com).
The authors declare no conflict of interest.
Supplemental digital content is available for this article. Direct URL citations
appear in the printed text and are provided in the HTML and PDF versions
of this article on the journal's Web site (www.rapm.org).
Copyright © 2017 by American Society of Regional Anesthesia and Pain
Medicine
ISSN: 1098-7339
DOI: 10.1097/AAP.0000000000000571
Regional Anesthesia and Pain Medicine • Volume 42, Number 3, May-June 2017
Copyright © 2017 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this article is prohibited.
Despite the role of IV dexamethasone being well established,
the benefit of placing dexamethasone in a more targeted
(perineural) fashion is unclear, and recent randomized controlled
trials (RCTs) have revealed conflicting results as to whether such
perineural dexamethasone is superior to its IV counterpart for
prolonging analgesic duration.5,6 This question is important: on
one hand, such targeted administration of dexamethasone may
in theory improve its ability as an adjuvant; on the other hand,
animal studies show that certain perineural adjuvants are toxic
and dexamethasone's usage for perineural administration is cur-
rently off-label.7,8 Given this clinical equipoise and conflicting
results from RCTs,5,6 we designed and conducted a systematic
review and meta-analysis of RCTs to delineate the benefits, if
any, of perineural administration of dexamethasone compared
to its IV counterpart. In particular, we were interested if perineural
administration (compared to IV) prolonged the duration of
analgesia for single-shot nerve blocks of the upper or lower
limb and if the usage of perineural dexamethasone led to any
acute or permanent postblock sequelae, such as prolonged pares-
thesias, numbness, or weakness.
METHODS
This systematic review and meta-analysis was conducted in
accordance with the PRISMA statement.9 Our institutional
research ethics board does not require approval for systematic
reviews or meta-analyses, as no data are being collected from
patients. The study selection criteria, outcomes, and the analysis
plan were defined a priori.
Literature Search
We searched Ovid Medline, Embase, and the Cochrane
Library up to November 12, 2016 without language restriction
for RCTs that met the following inclusion criteria.
Population
Studies had to recruit adults receiving any upper or lower
limb peripheral nerve block in anticipation of providing surgical
anesthesia or postoperative analgesia. Trials were excluded if local
anesthetic was administered through an in-dwelling catheter be-
fore full resolution of the initial sensory block or if concomitant
neuraxial technique with long-acting opioids was used.
Intervention and Control
To be included, studies had to administer perineural dexa-
methasone and compare it to IV dexamethasone, with or without
use of an additional true placebo group. Studies comparing
other perineural versus IV additives concomitantly (eg, clonidine)
were excluded.
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Chong et al Regional Anesthesia and Pain Medicine • Volume 42, Number 3, May-June 2017
Outcomes
The primary outcome for this meta-analysis was duration of
postoperative analgesia and the definition used by each study was
used (eg, time to usage of first rescue analgesia vs time to percep-
tion of pain at the surgical site). To account for the heterogeneity
in reporting between clinical trials, we substituted duration of
sensory blockade where the former was not reported. Secondary
outcomes were duration of motor block, duration of sensory
block, block parameters (eg, surgical anesthesia success rate),
pain scores, patient satisfaction, side effects, opioid consumption,
and both acute and long-term block-related complications.
The full search strategy is available in the appendix (Sup-
plemental Digital Content 1, http://links.lww.com/AAP/A196).
The reference lists of included articles and previous meta-
analyses were manually searched for additional studies. We
also searched clinicaltrials.gov for additional studies but did
not seek unpublished data.
Article Selection and Data Extraction
All titles, abstracts, and full texts (if required to assess the ar-
ticle for inclusion) were reviewed in duplicate (by M.C. and N.B.)
and any disagreement resolved by consensus with S.S. Data from
included studies was extracted onto a standardized form indepen-
dently by MC and NB, using the same consensus process for
disagreements. To facilitate meta-analysis, medians, interquar-
tile range, and range values were approximated into means and
their corresponding standard deviation using methods suggested
by the Cochrane Library.10 Where necessary (eg, data values not
reported in text and only within graphs), numerical data were
extracted from graphs by digital measurement. We attempted
to contact principal investigators of included studies for addi-
tional information, where necessary.
Risk of Bias Evaluation
The Cochrane risk of bias tool was used to appraise each
study's risk of bias by M.C. and N.B. and all discrepancies
resolved by consensus.11 We considered studies to be at low risk
of bias if they scored 3 or higher on these criteria: (1) appropriately
generated the randomization sequence, (2) appropriate allocation
concealment, (3) blinded study personnel and participants,
(4) blinded outcome assessors, and (5) reported data completely.
Statistical Analysis
Statistical analysis was carried out in Stata (Version 13.1;
StataCorp, College Station, Texas). Standard summary measures
were generated with the weighted mean difference or standardized
mean difference for continuous data and odds ratios (ORs) for
ordinal data, with their corresponding 95% confidence intervals
(CIs) and an α = 0.05. All analyses were carried out using a
random-effects model. For multiple comparisons over time
(eg, VAS pain score data), a Bonferroni correction was used.
The I2 statistic was used to quantify heterogeneity. We interpreted
an I2 value of 0% to 25% as low heterogeneity, 25% to 50% as
moderate heterogeneity, and greater than 50% as high heterogene-
ity. The continuity correction was used for zero event studies.12 A
funnel plot was constructed for the primary outcome and Egger
regression performed to investigate for statistical evidence of
publication bias.
All subgroup analyses were planned a priori and, where ap-
propriately powered, these included block technique (ultrasound-
guided vs nerve stimulator vs landmark), type of local anesthetic
(short-acting versus long-acting), use of other adjuvants (eg, epi-
nephrine), dose of dexamethasone (4–5 mg vs 8–10 mg), study
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Copyright © 2017 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this article is prohibited.
quality (high risk of bias vs low risk of bias), use of preservative-
free dexamethasone formulation, and block location (upper limb vs
lower limb).
RESULTS
Literature Search and Study Selection
Our search strategy initially revealed 6079 articles with 11
RCTs that recruited 1076 patients, ultimately meeting the
inclusion criteria (Fig. 1, PRISMA flow diagram). 5,6,8,13–20
Notably, we excluded certain studies during our full-text review:
2 studies that compared IV/perineural clonidine and/or buprenorphine
alongside dexamethasone,21,22 one study where a continuous in-
fusion was started prior to complete resolution of the sensory
block,23 one study where all patients received IV dexamethasone,
8 mg,4 and finally one study where all patients received long-acting
intrathecal narcotics.24
Study Characteristics
Overall, the studies identified by our search are a clinically
homogenous group of RCTs, with the following highlighted dif-
ferences (Table 1, baseline characteristics of included studies).
All studies used ultrasound-guidance for placement of the pe-
ripheral nerve block with the exception of Desmet et al who used
a nerve stimulator approach.8 Furthermore, the block placement
technique was undescribed by Wouters et al.20 Only 3 studies
used epinephrine in their study solution.5,15,19 All studies used
intermediate (ropivacaine) or long-acting (bupivacaine) local an-
esthetic, although 2 studies also used short-acting (lidocaine).5,15
Three studies used relatively lower doses of dexamethasone
(4–5 mg) compared with the rest, which used 8 to 10 mg.13–15
All studies but one used equal perineural versus IV dosing.20 Nine
of the 11 RCTs were at low risk of bias (Fig. 2).5,6,8,11,13–15,17–19
Three studies provided enough information to ascertain if the
dexamethasone administered was preservative-free, and this was
left undescribed by the rest.5,6,16 One study published an erratum
to their results and this corrected data were used in our meta-
analysis.6 All studies could be pooled for meta-analysis, except
for the abstract by Wouters et al, where no measures of variance
were reported, thereby making meta-analysis of that study impossible.
Primary Outcome: Duration of Analgesia
Patients receiving perineural dexamethasone experienced
3.77 hours (95% CI, 1.87–5.68 hours; P < 0.001) longer duration
of analgesia compared to patients receiving IV dexamethasone.
This result was consistent across both upper limb (2.83 hours
[95% CI, 1.24–4.42 hours]; P < 0.001) and lower limb (7.99 hours
[95% CI, 0.90–15.1 hours]; P = 0.027) blocks (Fig. 3). The mag-
nitude of effect increased in subgroup analysis of high-quality
studies (4.34 hours [95% CI, 2.70–5.99 hours]; P < 0.001). In fur-
ther subgroup analysis, the magnitude of prolongation was consistent
for studies using ropivacaine versus bupivacaine (ropivacaine stud-
ies: 4.25 hours [95% CI, 0.87–7.64 hours]; P = 0.014; bupivacaine
studies: 3.88 hours [95% CI, 2.59–5.18 hours]; P < 0.001). Finally,
the increased duration of analgesia was also similar between studies
using 4 to 5 mg of dexamethasone versus 8 to 10 mg of dexameth-
asone (4–5 mg studies: 3.90 hours [95% CI, 2.33–5.48 hours];
P < 0.001; 8–10 mg studies: 3.94 hours [95% CI, 0.87–7.02 hours];
P = 0.012). Given the number of RCTs, subgroup analysis by
type of block could only be performed for the interscalene
block RCTs and, in this subgroup, there was no difference be-
tween perineural versus IV dexamethasone (2.34 hours [95%
CI, −0.36 to 5.04 hours]; P = 0.089). The abstract by Wouters et al
© 2017 American Society of Regional Anesthesia and Pain Medicine
Regional Anesthesia and Pain Medicine • Volume 42, Number 3, May-June 2017
FIGURE 1. PRISMA flow sheet describing the study selection process. Three databases (MEDLINE, EMBASE, and Cochrane) were searched
for relevant articles and screened against our inclusion criteria.
could not be pooled in the meta-analysis, as no estimates of vari-
ance were reported, and their results favored the perineural dexa-
methasone group over the IV group.20
Secondary Outcomes
Motor Block and Sensory Block Duration
Motor block duration was prolonged for patients receiving
perineural dexamethasone (3.47 hours [95% CI, 1.49–5.45];
P < 0.001), albeit data were only reported in 4 studies.5,6,15,19
Sensory block duration was also only reported by 5 studies, with
the rest solely reporting the duration of analgesia.5,8,15–17 For
these studies, perineural dexamethasone prolonged sensory block
by 2.28 hours (95% CI, 0.38–4.17; P = 0.019) compared with IV
dexamethasone. In sensitivity analysis where we substituted data
for postoperative analgesia (where data for sensory block were
missing), the direction of effect was unchanged with 3.58 hours
(95% CI, 1.75–5.41; P < 0.001) longer duration with perineural
dexamethasone compared to IV dexamethasone.
Block Success Rate and Other Parameters
Three studies reported block performance time and no signif-
icant difference detected between groups (0.14 minutes [95% CI,
−0.30 to 0.58 minutes]; P = 0.54).5,15,19 In addition, only 2 studies
reported block onset time, precluding meta-analysis, although no
difference was found individually within those studies.5,15 Block
success rate, as defined by each investigator, was not different
© 2017 American Society of Regional Anesthesia and Pain Medicine
Copyright © 2017 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this article is prohibited.
Perineural Versus IV Dexamethasone
between studies (OR for block failure, 0.78; 95% CI, 0.39–1.55;
P = 0.47). Similarly, the surgical anesthesia success rate, where
applicable (eg, not for interscalene blocks) was also not apprecia-
bly different between groups (OR for failure, 0.57; 95% CI, 0.10–
3.20; P = 0.52).
VAS Pain Scores
A forest plot of pain scores by time point is shown in Figure 4.
There was a slight difference in pain scores at 24 hours, where the
perineural dexamethasone group experienced less pain than the
IV dexamethasone group (VAS, 1.09; 95% CI, 0.09–2.08); P =
0.032). However, this was not statistically significant after perform-
ing a Bonferroni correction for the 4 comparisons depicted in the
forest plot (α = 0.0125 for this analysis).
Patients' Satisfaction
There was too much heterogeneity in reporting of patient
satisfaction to perform meta-analysis, but individual studies
did not report a difference between the perineural and IV
dexamethasone groups.
Opioid Consumption
Five studies reported opioid consumption, and in these stud-
ies, there was 7.1 mg (95% CI, 0.74–13.5 mg; P = 0.029) less
opioid consumption (in oral morphine equivalents) at 24 hours
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Chong et al

TABLE 1. Baseline Characteristics of Included Studies

Demographic Details Block Details Intervention Details

Intervention
(Perineural Active Control Volume and
Total Dexamethasone (IV Dexamethasone Placebo Concentration Use of Follow-up for
Trial Year (n) Type of Block Technique Dose) Dose) Group of Local Anesthetic Epinephrine Complications
Abdallah et al6 2015 75 Supraclavicular U/S 8 mg 8 mg Plain local 30 mL of 0.5% bupivacaine No 2 weeks
Aliste et al5 2016 150 Axillary U/S 8 mg 8 mg None 30 mL of 1% lidocaine, Yes 1 week
0.25% bupivacaine
Chun et al13 2016 100 Interscalene U/S 5 mg 5 mg None 12 mL of 0.5% ropivacaine No Unclear
Desmet et al8 2013 150 Interscalene Nerve 10 mg 10 mg Plain local 30 mL of 0.5% ropivacaine No 3–4 months
stimulation
Kawanishi et al14 2014 39 Interscalene U/S 4 mg 4 mg Plain local 20 mL of ropivacaine 0.75% No 4 weeks
Leurcharusmee et al15 2016 150 Infraclavicular U/S 5 mg 5 mg None 35 mL of 1% lidocaine, Yes 1 week
0.25% bupivacaine
Rosenfeld et al16 2016 120 Interscalene U/S 8 mg 8 mg Plain local 28 mL of ropivacaine No 1 week
0.5% up to 30 mL*
Dawson et al17 2016 90 Ankle U/S 8 mg 8 mg Plain local 20 mL of 0.75% ropivacaine No Not performed
Morales-Munoz et al 2016 81 Femoral U/S 8 mg 8 mg Plain local 20 mL of ropivacaine No Not performed
18
0.5% up to 22 mL*
Rahangdale et al19 2014 80 Sciatic U/S 8 mg 8 mg Plain local 0.45 mL/kg of 0.5% Yes 8 weeks†
bupivacaine
Wouters et al20 2013 41 Sciatic Unclear 5 mg 10 mg None 30 mL of ropivacaine 0.75% No Unclear
*After addition of study medication volume.
†Self-reported neurologic complications were followed.
Dex indicates dexamethasone.

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© 2017 American Society of Regional Anesthesia and Pain Medicine
Regional Anesthesia and Pain Medicine • Volume 42, Number 3, May-June 2017
Regional Anesthesia and Pain Medicine • Volume 42, Number 3, May-June 2017
FIGURE 2. Risk of bias assessment. For each assessed domain of the
Cochrane Risk of Bias Tool, green indicates that the study had low
risk of bias, yellow indicates there was unclear risk of bias, and red
indicates a high risk of bias.
in the perineural dexamethasone group compared to the IV
dexamethasone group.6,16–19
Side Effects
No significant difference in postoperative nausea and
vomiting (OR, 0.55; [95% CI, 0.21–1.47]; P = 0.23) was detected
between the perineural dexamethasone and IV dexamethasone
groups. Pruritus was only reported by one study with no differ-
ence between groups.16
Block Complications
The rate of paresthesias at the time of block performance was
not appreciably different for perineural versus IV dexamethasone
(OR, 2.16 [95% CI, 0.71–6.61]; P = 0.18). Follow-up for block
complications ranged from patients' self-report to formal follow-
up 2 to 4 months after discharge (Table 1). During these reported
periods, there was no higher rate of neurologic complications
attributable to the block (OR, 0.82 [95% CI, 0.27–2.51];
P = 0.73), and all reported complications either were self-limited
or (after medical workup) attributed to another etiology.
© 2017 American Society of Regional Anesthesia and Pain Medicine
Copyright © 2017 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this article is prohibited.
Perineural Versus IV Dexamethasone
Publication Bias
The funnel plot for the primary outcome was symmetrical on
visual inspection and Egger regression was insignificant (P = 0.545),
demonstrating no statistical evidence of publication bias.
Ongoing Trials
Clinicaltrials.gov was searched as part of our literature
review to ensure completeness of the search (Table 2). As detailed
in Table 2, there are a few ongoing trials that are mostly focused
on comparing perineural versus IV dexamethasone in interscalene
blocks (NCT02426736, NCT02190760, NCT02322242, and
NCT02506660). The latter study (NCT02506660) was completed
in November 2016, and, according to our search, it has yet
to be published. Lastly, there are 2 trials (NCT02666443 and
NCT02904538) that are investigating the role of IV versus perineural
dexamethasone in supraclavicular and ankle block, respectively.
DISCUSSION
This novel systematic review and meta-analysis of RCTs
compared 11 trials of upper and lower limb peripheral nerve blocks
that used perineural versus IV dexamethasone. Our analysis dem-
onstrates that perineural dexamethasone prolongs the duration of
analgesia by 3.77 hours (95% CI, 1.87–5.68 hours) compared to
IV dexamethasone. Furthermore, this prolongation persisted in sub-
group analysis by location of block (upper vs lower extremity), for
both ropivacaine and bupivacaine, and was accentuated in low risk
of bias studies. With regard to secondary outcomes, there was a
nonsignificant trend toward lower pain scores at 24 hours in the
perineural dexamethasone group. In addition, perineural dexameth-
asone patients consumed less opioids (7.1 mg of oral morphine
equivalents [95% CI, 0.74–13.5 mg]; P = 0.029) than their IV dexa-
methasone counterparts at 24 hours; however, this small magnitude
of effect is also likely to be trivial, and opioid consumption was only
reported by 5 of 11 studies.6,16–19 On the whole, there were no per-
manent block-related complications that could be attributed to the
use of dexamethasone. However, given the rarity of such complica-
tions in contemporary practice, our meta-analysis is underpowered
to investigate such a difference.25
In an era of multimodal analgesia and outpatient surgery, our
findings raise the question: should perineural dexamethasone be
favored over IV dexamethasone for use as an adjuvant for periph-
eral nerve blocks? Some authors would argue that extended
analgesia might be a patient-important outcome, especially in
the outpatient setting, where the placement of continuous catheters
is less feasible and a reasonable goal is pain relief for 24 hours.17,26
On the other hand, others feel strongly about the off-label use of
dexamethasone for perineural administration and insufficient
long-term safety data to support this practice.27 In an in vitro study
on rat sensory neurons, dexamethasone added to ropivacaine did
not enhance the toxicity of the local anesthetic, although the
concentration of dexamethasone used was half to a third that
was used by studies included in our meta-analysis.7 Obviously,
animal studies are not a substitute for long-term safety data in
humans, which currently does not exist.
Study Limitations
Although we used strict study selection criteria to derive a
clinically homogeneous study population, there was still high
statistical heterogeneity in our pooled analysis that persisted
in subgroup analysis by our a priori suspected sources of hetero-
geneity. Therefore, our results should be interpreted with caution.
Although we had hoped to perform a meaningful subgroup anal-
ysis by type of block, this was challenging as four of our included
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Chong et al Regional Anesthesia and Pain Medicine • Volume 42, Number 3, May-June 2017
FIGURE 3. Forest plot of duration of analgesia in hours. Data are presented subgrouped by upper limb block versus lower limb block.
studies used interscalene blocks and 2 assessed sciatic blocks,
whereas the rest of the blocks (supraclavicular, infraclavicular,
axillary, ankle, and femoral) were only investigated in one
RCT. Interestingly, our pooled analysis of interscalene block
data for the primary outcome was not statistically significant
(P = 0.089). We await with great interest the completion and
publication of a few ongoing trials that are registered at
clinicaltrials.gov (NCT02190760, NCT02322242, NCT02426736,
and NCT02506660) that are further investigating perineural versus
IV dexamethasone for interscalene blockade.
With regard to type of local anesthetic, all of the included
RCTs used either ropivacaine or bupivacaine, so our data may
not be extrapolated to shorter-acting local anesthetics. Similarly,
the local anesthetic volume used by some of our RCTs, particu-
larly certain interscalene block studies that injected up to 30 mL
of local anesthetic,8,14,16 was higher than the “low volume” ap-
proaches that are more widely used at other centers.28,29 There-
fore, the magnitude of effect for perineural dexamethasone
versus IV dexamethasone may differ if more conventional local
anesthetic volumes are used. Unfortunately, our meta-analysis
was not powered to perform meaningful subgroup analysis inves-
tigating local anesthetic volume.
With regard to long-term complications, as expected, we did
not find any significant difference in our meta-analysis of RCTs.
A well-conducted and powered study exploring the rate of compli-
cations in regional anesthesia in more than a million patients
demonstrated that the rate of neuropathy after peripheral nerve
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Copyright © 2017 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this article is prohibited.
blockade was 3% or less, with only one case that did not re-
solve.25 Therefore, although our results suggest with some
confidence that perineural dexamethasone is superior to IV
dexamethasone for prolonging analgesia in the nerve block
types within our meta-analysis, we are unable to make definitive
statements about the long-term safety of perineural dexamethasone.
CONCLUSIONS
The usage of perineural dexamethasone is a strong area of
interest and controversy within the regional anesthesia litera-
ture.26,27 Our systematic review and meta-analysis demonstrates
that it is superior to IV dexamethasone for prolonging the dura-
tion of postoperative analgesia, with a modest magnitude of effect
of 3.77 hours (95% CI, 1.87–5.68 hours), high statistical hetero-
geneity, and an overall small number of studies. Although there
is no evidence that perineural dexamethasone is harmful in the
clinical doses used, there are also no long-term studies that dem-
onstrate its safety.7 Therefore, it is our opinion that practitioners
who administer perineural dexamethasone only use it in select
patients (eg, chronic pain or opioid-dependent patients), where
extending the duration of analgesia by a few hours may be of
most benefit and the use of an in-dwelling catheter is not feasible.
Otherwise, we feel that the IV route should be used; as Hippocrates
once said, primum non nocere—first, do no harm.
© 2017 American Society of Regional Anesthesia and Pain Medicine
Regional Anesthesia and Pain Medicine • Volume 42, Number 3, May-June 2017 Perineural Versus IV Dexamethasone

FIGURE 4. Forest plot of VAS pain scores over time. Data are presented by time point with a Bonferroni correction used for multiple
comparisons.

TABLE 2. Ongoing Trials Listed on clinicaltrials.gov

Intervention
(Perineural Comparator (IV
ClinicalTrials.gov Dexamethasone Dexamethasone Estimated Date
Identifier Type of Block Dose) Dose) Placebo Arm Study Status* of Completion*
NCT01495624 Interscalene 8 mg 8 mg None Terminated—lack of N/A
patient recruitment
NCT02154048 Supraclavicular 8 mg 8 mg Plain local Terminated—lack of N/A
patient recruitment
NCT02190760 Interscalene 0.1 mg/kg 0.1 mg/kg Plain local Not yet recruiting September 2016
NCT02322242 Interscalene 4 mg 4 mg None Currently recruiting March 2017
NCT02426736 Interscalene 4 or 8 mg 4 or 8 mg None “Ongoing, but not January 2017
recruiting participants”
NCT02506660 Interscalene 1 mg 1 mg None Unpublished November 2016
NCT02666443 Supraclavicular 1 mg 1 mg Plain local Currently recruiting February 2021
NCT02904538 Ankle 4 mg 10 mg None Not yet recruiting January 2017
*Per clinicaltrials.gov record.

© 2017 American Society of Regional Anesthesia and Pain Medicine 325

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Chong et al Regional Anesthesia and Pain Medicine • Volume 42, Number 3, May-June 2017
ACKNOWLEDGMENTS
The authors thank Brie McConnell for her assistance in
retrieving full text copies of certain study articles. Dr Chong
is grateful to the Medical Evidence, Decision Integrity, Clinical
Impact (MEDICI) Centre at Western University for providing access
to the statistical analysis software.
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