Adjuvants in Peripheral Nerve Blocks

Vol 2 | Issue 1 | January-June 2021 | Page 63-66 | Rudra Deshpande, Harshal Wagh, Satish Kulkarni

Authors: Rudra Deshpande [1], Harshal Wagh [2], Satish Kulkarni [1]

[1] Department of Anaesthesia, Lilavati Hospital & Research Centre, Mumbai, Maharashtra, India.
[2] Department of Anaesthesia, Kokilaben Dhirubhai Ambani Hospital, Mumbai, Maharashtra, India.

Address of Correspondence
Dr. Satish Kulkarni,
Consultant, Department of Anaesthesia, Lilavati Hospital & Research Centre, Mumbai, Maharashtra, India.


An increase in the use of peripheral nerve blocks (PNBs) has been noted in recent years. Not only do these blocks provide adequate anaesthesia intraoperatively, but they are also now the cornerstone of perioperative pain management. Superior pain control, a significant decrease in opioid requirements as well as opioid-related side effects, improved patient satisfaction, earlier discharge from hospital and increasing use with the advancement of ultrasound technology have contributed to the increasing use of peripheral nerve blocks [1-4].
Regional anaesthesia techniques including PNBs have also become the need of the hour in recent times of the Covid19 pandemic. As per recent practice recommendations (American Society of Regional Anaesthesia May 2020), Regional anaesthesia is preferred to avoid aerosol-generating procedures associated with General anaesthesia [5].

For postoperative pain management, PNBs are used as a single injection or as a continuous catheter infusion. Single-injection nerve blocks are more commonly done as they are technically easier and quicker. They provide superior analgesia in the immediate postoperative period for various procedures in which the pain intensity is high initially and reduces over significantly over time. Oral analgesics may be effective by then as the effect of PNBs is wearing off gradually over 12 to 24 hours. Rebound pain can however be a significant problem [6]. Continuous catheter techniques are not only technically challenging but require greater monitoring and are prone to secondary block failures due to catheter blockage and displacement [7]. They are labour and resource intensive. Hence the need for adjuvants that will help prolong the duration of PNBs and avoid the placement of continuous catheters has been part of the quest of regional anaesthesiologists. Multiple classes of drugs have been tested as adjuvants in the past. Some have stood the test of time and helped improve the practice of regional anaesthesia while others proved more detrimental. Discussed below are some of the adjuvants that have been successfully used (Table 1).


1. Hughes MS, Matava MJ, Wright RW, Brophy RH, Smith MV. Interscalene brachial plexus block for arthroscopic shoulder surgery: a systematic review. J Bone Joint Surg Am. 2013;95(14):1318-24.
2. Liu Q, Chelly JE, Williams JP, Gold MS. Impact of peripheral nerve block with low dose local anesthetics on analgesia and functional outcomes following total knee arthroplasty: a retrospective study. Pain Med. 2015;16(5):998-1006.
3. Lenart MJ, Wong K, Gupta RK, Mercaldo ND, Schildcrout JS, Michaels D, et al. The impact of peripheral nerve techniques on hospital stay following major orthopedic surgery. Pain Med. 2012;13(6):828-34.
4. Chan EY, Fransen M, Parker DA, Assam PN, Chua N. Femoral nerve blocks for acute postoperative pain after knee replacement surgery. Cochrane Database Syst Rev. 2014;2014(5):Cd009941.
5. Uppal V, Sondekoppam RV, Lobo CA, Kolli S, Kalagara HK. Practice recommendations on neuraxial anesthesia and peripheral nerve blocks during the COVID-19 pandemic. ASRA/ESRA COVID-19 Guidance for Regional Anesthesia March. 2020;31.
6. Nobre LV, Cunha GP, Sousa P, Takeda A, Cunha Ferraro LH. [Peripheral nerve block and rebound pain: literature review]. Rev Bras Anestesiol. 2019;69(6):587-93.
7. Ahsan ZS, Carvalho B, Yao J. Incidence of failure of continuous peripheral nerve catheters for postoperative analgesia in upper extremity surgery. J Hand Surg Am. 2014;39(2):324-9.
8. Karaman S, Kocabas S, Uyar M, Hayzaran S, Firat V. The effects of sufentanil or morphine added to hyperbaric bupivacaine in spinal anaesthesia for Caesarean section. Eur J Anaesthesiol. 2006;23(4):285-91.
9. Axelsson K, Johanzon E, Essving P, Weckström J, Ekbäck G. Postoperative extradural analgesia with morphine and ropivacaine. A double-blind comparison between placebo and ropivacaine 10 mg/h or 16 mg/h. Acta Anaesthesiologica Scandinavica. 2005;49(8):1191-9.
10. Flory N, Van-Gessel E, Donald F, Hoffmeyer P, Gamulin Z. Does the addition of morphine to brachial plexus block improve analgesia after shoulder surgery? British Journal of Anaesthesia. 1995;75(1):23-6.
11. Alemanno F, Ghisi D, Fanelli A, Faliva A, Pergolotti B, Bizzarri F, et al. Tramadol and 0.5% levobupivacaine for single-shot interscalene block: effects on postoperative analgesia in patients undergoing shoulder arthroplasty. Minerva Anestesiol. 2012;78(3):291-6.
12. Kesimci E, Izdes S, Gozdemir M, Kanbak O. Tramadol does not prolong the effect of ropivacaine 7.5 mg/ml for axillary brachial plexus block. Acta Anaesthesiologica Scandinavica. 2007;51(6):736-41.
13. Fanelli G, Casati A, Magistris L, Berti M, Albertin A, Scarioni M, et al. Fentanyl does not improve the nerve block characteristics of axillary brachial plexus anaesthesia performed with ropivacaine. Acta Anaesthesiol Scand. 2001;45(5):590-4.
14. Jain N, Khare A, Khandelwal S, Mathur P, Singh M, Mathur V. Buprenorphine as an adjuvant to 0.5% ropivacaine for ultrasound-guided supraclavicular brachial plexus block: A randomized, double-blind, prospective study. Indian Journal of Pain. 2017;31(2):112-8.
15. Tulsyan V, Singh J, Thakur L, Verma V, Minhas A. A comparative study of buprenorphine in two different doses as an adjuvant to levobupivacaine in US-guided lumbar plexus block for postoperative analgesia. Ain-Shams Journal of Anesthesiology. 2021;13(1):7.
16. Virk MS, Arttamangkul S, Birdsong WT, Williams JT. Buprenorphine is a weak partial agonist that inhibits opioid receptor desensitization. J Neurosci. 2009;29(22):7341-8.
17. Schoenmakers KPW, Fenten MGE, Louwerens JW, Scheffer GJ, Stienstra R. The effects of adding epinephrine to ropivacaine for popliteal nerve block on the duration of postoperative analgesia: a randomized controlled trial. BMC Anesthesiology. 2015;15(1):100.
18. Dogru K, Duygulu F, Yildiz K, Kotanoglu MS, Madenoglu H, Boyaci A. Hemodynamic and blockade effects of high/low epinephrine doses during axillary brachial plexus blockade with lidocaine 1.5%: A randomized, double-blinded study. Reg Anesth Pain Med. 2003;28(5):401-5.
19. Schoenmakers KP, Vree TB, Jack NT, van den Bemt B, van Limbeek J, Stienstra R. Pharmacokinetics of 450 mg ropivacaine with and without epinephrine for combined femoral and sciatic nerve block in lower extremity surgery. A pilot study. Br J Clin Pharmacol. 2013;75(5):1321-7.
20. Weber A, Fournier R, Van Gessel E, Riand N, Gamulin Z. Epinephrine does not prolong the analgesia of 20 mL ropivacaine 0.5% or 0.2% in a femoral three-in-one block. Anesth Analg. 2001;93(5):1327-31.
21. Tschopp C, Tramèr MR, Schneider A, Zaarour M, Elia N. Benefit and Harm of Adding Epinephrine to a Local Anesthetic for Neuraxial and Locoregional Anesthesia: A Meta-analysis of Randomized Controlled Trials With Trial Sequential Analyses. Anesth Analg. 2018;127(1):228-39.
22. Pöpping DM, Elia N, Marret E, Wenk M, Tramèr MR. Clonidine as an adjuvant to local anesthetics for peripheral nerve and plexus blocks: a meta-analysis of randomized trials. Anesthesiology. 2009;111(2):406-15.
23. Chakraborty S, Chakrabarti J, Mandal MC, Hazra A, Das S. Effect of clonidine as adjuvant in bupivacaine-induced supraclavicular brachial plexus block: A randomized controlled trial. Indian J Pharmacol. 2010;42(2):74-7.
24. McCartney CJL, Duggan E, Apatu E. Should We Add Clonidine to Local Anesthetic for Peripheral Nerve Blockade? A Qualitative Systematic Review of the Literature. Regional Anesthesia & Pain Medicine. 2007;32(4):330-8.
25. El-Boghdadly K, Brull R, Sehmbi H, Abdallah FW. Perineural Dexmedetomidine Is More Effective Than Clonidine When Added to Local Anesthetic for Supraclavicular Brachial Plexus Block: A Systematic Review and Meta-analysis. Anesth Analg. 2017;124(6):2008-20.
26. Sachdev S, Sharma V, Malawat A, Jethava D, Moin K. Comparison of levobupivacaine alone and levobupivacaine with dexmedetomidine in supraclavicular brachial plexus block: A prospective randomized clinical trial. Indian Journal of Clinical Anaesthesia. 2020;7(1):16-22.
27. Lundblad M, Trifa M, Kaabachi O, Ben Khalifa S, Fekih Hassen A, Engelhardt T, et al. Alpha-2 adrenoceptor agonists as adjuncts to peripheral nerve blocks in children: a meta-analysis. Pediatric Anesthesia. 2016;26(3):232-8.
28. Ray A, Kulkarni S, Kaur K, Paul D, Singh S, Khan S. Comparative study of two different doses of dexmedetomidine as an adjuvant to bupivacaine in the peripheral nerve block. Journal of Marine Medical Society. 2020;22(2):161-5.
29. Xue X, Fan J, Ma X, Liu Y, Han X, Leng Y, et al. Effects of local dexmedetomidine administration on the neurotoxicity of ropivacaine for sciatic nerve block in rats. Mol Med Rep. 2020;22(5):4360-6.
30. Sehmbi H, Brull R, Ceballos KR, Shah UJ, Martin J, Tobias A, et al. Perineural and intravenous dexamethasone and dexmedetomidine: network meta-analysis of adjunctive effects on supraclavicular brachial plexus block. Anaesthesia. 2020. doi: 10.1111/anae.15288. Online ahead of print
31. Albrecht E, Vorobeichik L, Jacot-Guillarmod A, Fournier N, Abdallah FW. Dexamethasone Is Superior to Dexmedetomidine as a Perineural Adjunct for Supraclavicular Brachial Plexus Block: Systematic Review and Indirect Meta-analysis. Anesth Analg. 2019;128(3):543-54.
32. Choi S, Rodseth R, McCartney CJ. Effects of dexamethasone as a local anaesthetic adjuvant for brachial plexus block: a systematic review and meta-analysis of randomized trials. Br J Anaesth. 2014;112(3):427-39.
33. Pehora C, Pearson AM, Kaushal A, Crawford MW, Johnston B. Dexamethasone as an adjuvant to peripheral nerve block. Cochrane Database Syst Rev. 2017;11(11):Cd011770.
34. Marhofer P, Columb M, Hopkins PM, Greher M, Marhofer D, Bienzle M, et al. Dexamethasone as an adjuvant for peripheral nerve blockade: a randomised, triple-blinded crossover study in volunteers. Br J Anaesth. 2019;122(4):525-31.
35. Golwala M, Swadia V, Dhimar AA, Sridhar N. Pain relief by dexamethasone as an adjuvant to local anaesthetics in supraclavicular brachial plexus block. J Anaesth Clin Pharmacol. 2009;25(3):285-8.
36. Liu J, Richman KA, Grodofsky SR, Bhatt S, Huffman GR, Kelly IV JD, et al. Is there a dose response of dexamethasone as adjuvant for supraclavicular brachial plexus nerve block? A prospective randomized double-blinded clinical study. Journal of clinical anesthesia. 2015;27(3):237-42.
37. Williams BA, Hough KA, Tsui BY, Ibinson JW, Gold MS, Gebhart G. Neurotoxicity of adjuvants used in perineural anesthesia and analgesia in comparison with ropivacaine. Regional Anesthesia & Pain Medicine. 2011;36(3):225-30–30.
38. Attardi B, Takimoto K, Gealy R, Severns C, Levitan E. Glucocorticoid induced up-regulation of a pituitary K+ channel mRNA in vitro and in vivo. Receptors & channels. 1993;1(4):287-93.
39. Chong MA, Berbenetz NM, Lin C, Singh S. Perineural versus intravenous dexamethasone as an adjuvant for peripheral nerve blocks: a systematic review and meta-analysis. Regional Anesthesia & Pain Medicine. 2017;42(3):319-26.
40. Zhao W-L, Ou X-F, Liu J, Zhang W-S. Perineural versus intravenous dexamethasone as an adjuvant in regional anesthesia: a systematic review and meta-analysis. Journal of Pain Research. 2017;10:1529-43.
41. Desmet M, Braems H, Reynvoet M, Plasschaert S, Van Cauwelaert J, Pottel H, et al. IV and perineural dexamethasone are equivalent in increasing the analgesic duration of a single-shot interscalene block with ropivacaine for shoulder surgery: a prospective, randomized, placebo-controlled study. British journal of anaesthesia. 2013;111(3):445-52.
42. Zorrilla-Vaca A, Li J. Dexamethasone Injected Perineurally is More Effective than Administered Intravenously for Peripheral Nerve Blocks. The Clinical journal of pain. 2018;34(3):276-84.
43. Tien M, Gan T, Dhakal I, White W, Olufolabi A, Fink R, et al. The effect of anti‐emetic doses of dexamethasone on postoperative blood glucose levels in non‐diabetic and diabetic patients: a prospective randomised controlled study. Anaesthesia. 2016;71(9):1037-43.
44. Kassem H, Urits I, Viswanath O, Kaye AD, Eskander JP. Use of Dexmedetomidine With Dexamethasone for Extended Pain Relief in Adductor Canal/Popliteal Nerve Block During Achilles Tendon Repair. Cureus. 2020;12(12):e11917-e.
45. Zusman RP, Urits I, Kaye AD, Viswanath O, Eskander J. Synergistic Effect of Perineural Dexamethasone and Dexmedetomidine (Dex-Dex) in Extending the Analgesic Duration of Pectoral Type I and II Blocks. Cureus. 2020;12(9):e10703-e.
46. Lee IO, Kim WK, Kong MH, Lee MK, Kim NS, Choi YS, et al. No enhancement of sensory and motor blockade by ketamine added to ropivacaine interscalene brachial plexus blockade. Acta Anaesthesiol Scand. 2002;46(7):821-6.
47. Nishiyama T, Matsukawa T, Hanaoka K. Continuous epidural administration of midazolam and bupivacaine for postoperative analgesia. Acta Anaesthesiol Scand. 1999;43(5):568-72.
48. Malinovsky JM, Cozian A, Lepage JY, Mussini JM, Pinaud M, Souron R. Ketamine and midazolam neurotoxicity in the rabbit. Anesthesiology. 1991;75(1):91-7.
49. Demirel E, Ugur HC, Dolgun H, Kahilogullari G, Sargon ME, Egemen N, et al. The neurotoxic effects of intrathecal midazolam and neostigmine in rabbits. Anaesth Intensive Care. 2006;34(2):218-23.
50. Mukherjee K, Das A, Basunia SR, Dutta S, Mandal P, Mukherjee A. Evaluation of Magnesium as an adjuvant in Ropivacaine-induced supraclavicular brachial plexus block: A prospective, double-blinded randomized controlled study. J Res Pharm Pract. 2014;3(4):123-9.
51. Jebali C, Kahloul M, Hassine NI, Jaouadi MA, Ferhi F, Naija W, et al. Magnesium Sulfate as Adjuvant in Prehospital Femoral Nerve Block for a Patient with Diaphysial Femoral Fracture: A Randomized Controlled Trial. Pain Research and Management. 2018;2018:2926404.
52. Hung Y-C, Chen C-Y, Lirk P, Wang C-F, Cheng J-K, Chen C-C, et al. Magnesium Sulfate Diminishes the Effects of Amide Local Anesthetics in Rat Sciatic-Nerve Block. Reg Anesth Pain Med. 2007;32(4):288-295.
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How to Cite this Article: Deshpande R, Wagh H, Kulkarni S | Adjuvants in Peripheral Nerve Blocks | International Journal of Regional Anaesthesia | January-June 2021; 2(1): 63-66.


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