Egyptian Journal of Anaesthesia (2013) 29, 407–411

Egyptian Society of Anesthesiologists

Egyptian Journal of Anaesthesia

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Research Article

Dexamethasone bupivacaine versus bupivacaine

for peribulbar block in posterior segment eye
surgery
Mohamed Sidky Mahmoud *,1, Azza Atef Abd Al Alim, Amira Fathy Hefni
Faculty of Medicine, Ain Shams University, Department of Anesthesia, Intensive Care Medicine and Pain Management, Cairo, Egypt

Received 7 May 2013; revised 30 June 2013; accepted 13 July 2013

Available online 15 August 2013

KEYWORDS Abstract Aim: The study conducted aims to assess the efficacy, time to first analgesic request, and
Bupivacaine; postoperative inflammatory response after adding dexamethasone to local anesthetic mixture for a
Dexamethasone; peribulbar block in posterior segment eye surgery.
Posterior segment; Patients and methods: A double-blind randomized study was carried out on 50 ASA I and II
Vitreoretinal; patients scheduled for elective posterior segment surgery (vitreoretinal). Patients were allocated ran-
Peribulbar block domly into two groups, 25 patients in each group. Group I received equal volumes of 10 ml of a l:1
mixture of bupivacaine 0.5% and saline, supplemented with 4 mg dexamethasone in 1 ml saline and
group II received the same local anesthetic mixture (total volume 10 ml) without adding dexameth-
asone. The duration and onset of motor block, time to first analgesic request, postoperative inflam-
matory response, and other side effects such as nausea and vomiting were assessed.
Results: Patients receiving peribulbar block were significantly pain free by end of surgery (0 h)
(P < 0.05) and throughout the postoperative period in the dexamethasone group at 2 and 6 h postop-
eratively. The number of patients requiring rescue analgesics was significantly lower with dexameth-
asone bupivacaine block (P < 0.05). The incidence of postoperative nausea and vomiting was
significantly less in the first group (I) in comparison to the other group (II) (P < 0.05) and lastly
the level of C reactive protein postoperatively was found to be significantly less in the dexamethasone
group than the other one (P < 0.0001).
Conclusion: Adding dexamethasone to bupivacaine in peribulbar block appears to be a safe and clin-
ically superior adjuvant with less postoperative pain, inflammatory response in patients undergoing
posterior segment eye surgery.
ª 2013 Production and hosting by Elsevier B.V. on behalf of Egyptian Society of Anesthesiologists.

* Corresponding author. Mobile: +20 1221198998.

E-mail address: [email protected] (M.S. Mahmoud).
1
Faculty of Medicine, Ain Shams University, Department of Anes-
thesia, Intensive Care Medicine and Pain Management, Cairo, Egypt.
Peer review under responsibility of Egyptian Society of Anesthesiol-
ogists.

Production and hosting by Elsevier

1110-1849 ª 2013 Production and hosting by Elsevier B.V. on behalf of Egyptian Society of Anesthesiologists.
http://dx.doi.org/10.1016/j.egja.2013.07.003
408 M.S. Mahmoud et al.

1. Introduction intramuscular placement). Ocular compression was performed

for 5 min. Further intraoperative and postoperative monitor-
The majority of ophthalmic procedures are performed under local ing was performed by investigators who were unaware of the
anesthesia as the patient being often elderly with group differences.
inter-current diseases. Moreover, it is associated with less hemo- Hemodynamic variables (heart rate, systolic blood pres-
dynamic instability, less respiratory depression, better postopera- sure, diastolic blood pressure) 5 min after administration of
tive pain relief, and less nausea and vomiting analgesic defined baseline were monitored continuously. Lid
than general anesthesia [1]. The lack of need to fast and the akinesia was assessed by asking the patient to open his eye lids
possibility for diabetics to remain on their normal regimes, the and squeezing them together maximally. It was recorded as
reduction in stress response, maintained oxygen saturation and grade 1 if there was no resistance of the lids on attempted clo-
cardiovascular stability, adding to this, the production of good sure, as grade 2 if there was mild resistance of the lid margins,
akinesia and anesthesia alleviating occulo-medullary reflexes, all and as grade 3 if there was an appearance of creases at the out-
make local anesthesia more superior and safe technique [2]. er canthus [10].
Surgeries for posterior segment are lengthy procedures and On the other hand, ocular motility was recorded for four
associated with relatively significant postoperative pain [3]. quadrants, gaze in the superior, inferior, medial, and lateral
The addition of adjuvant to local anesthesia (LA) in peribulbar directions, using a three-point scale system, where (0 = no
block could be a method to prolong the duration of the block. movement, 1 = reduced movement, and 2 = normal move-
Many drugs had been added including opioids, clonidine, keta- ment). A score of up to 2 suggested a successful block [11].
mine, and dexamethasone. All could be injected either intrathe- The onset and duration of lid and globe akinesia were assessed.
cally, extradurally, or into the peripheral nerves [4,5]. Yet, all At the end of the procedure, pain assessment was done (0 h,
have side effects either hemodynamic instability, increased intra- at end of surgery) then postoperatively at 2, 6, and 12 h. In
ocular pressure, respiratory depression as well as gastro-intesti- each group, pain assessment using 10 points pain scale
nal side effects. Peribulbar block is a much simpler, rapid, and (VAS) and postoperative complications were assessed and
safe technique, especially in elderly patients [6] whom the use compared.
of general anesthesia and narcotics is usually done with caution. Tool for pain assessment is the 0–10 Pain Scale (VAS), with
Dexamethasone is a high potency, long acting glucocorti- numeric values ascribed to pain level, where 0 represents no
coid with little mineralocorticoid effect [7]. Glucocorticoids pain and 10 is the worst pain imaginable.
have been used to reduce inflammation and for prevention of Patients with VAS (pain score) more than 2 and up to 4
postoperative nausea and vomiting; they are also effective in were treated by procetamol (1 g) intravenously. For a score
reducing postoperative pain and edema [8]. of 4 or more, meperidine 1 mg/kg was administered by intrave-
nous route and the patients transferred to the ward when
comfortable.
2. Patients and methods
Degree of postoperative inflammation was assessed among
the patients and compared between the two groups, using level
Fifty adult patients, American Society of Anesthesiology of C reactive protein which was measured preoperatively and
(ASA) I or II, scheduled for elective vitreous body surgery 24 h postoperatively.
or surgery for retinal detachment with or without scleral buck- Postoperative nausea and vomiting was monitored and was
ling were included in the study. managed by metoclopramide 10 mg intravenously.
Patients were informed by the risks and benefits of peribul-
bar block. Patients were excluded from the study if they had 3. Results
any orbital deformity, high myopes, increased intraocular
pressure, or if they were blind in the contralateral eye. Other
exclusion criteria were known allergy to local anesthetics, con- Fifty patients were enrolled in the study. Two patients from
traindication to steroids, mentally retarded patients, or pa- group I (bupivacaine–dexamethasone group) were agitated
tient’s refusal. The study was conducted at Aldemerdash after local injection and received general anesthesia were ex-
hospital, ophthalmology operating theatre from June 2012 till cluded from the study. The two groups were comparable with
January 2013. respect to patients’ demographic data and duration of surgery
After approval of the hospital medical committee, an in- (Table 1). There was no statistically significant difference be-
formed consent was obtained from the patients. All patients
were premedicated with oral midazolam 1–2 mg 1 h before
applying the local anesthesia. Patients were randomly allo- Table 1 Demographic data and duration of surgery.
cated to either of two groups using closed envelopes method. Group I Group II
After routine monitoring, a medial canthus single peribulbar (dexamethasone (bupivacaine)
block was performed using a total volume of 10 ml of 0.5% + bupivacaine) N = 25
bupivacaine local anesthetic added to it 4 mg dexamethasone N = 23
disodium phosphate (in 1 ml) for the bupivacaine-dexametha- Age (years) 53.6 ± 12.3 56.2 ± 11.9
sone group (group I, N = 25), while the other group received Weight (kg) 72.9 ± 9.5 69.7 ± 8.8
peribulbar block using 10 ml of 0.5% bupivacaine only (group Sex (M/F) 13/10 11/12
II, N = 25). Duration of surgery (min) 105.6 ± 27.3 111.3 ± 24.2
Short beveled fine needles (25-gauge) were used for reduc- Data are expressed as mean + SD, or number percent.
ing pain on needle insertion and to enhance the tactile percep- P > 0.05 (non-significant).
tion of resistance during needle insertion (intraneural or
Dexamethasone bupivacaine versus bupivacaine for peribulbar block in posterior segment eye surgery 409

Table 2 Onset of akinesia (globe and lid).

Group I (dexamethasone + bupivacaine) N = 23 Group II (bupivacaine) N = 25 P value
Lid akinesia (min) 2.76 ± 1.1\ 2.8 ± 1.2 P = 0.905
Globe akinesia (min) 7.6 ± 2.00\\ 8.14 ± 1.56 P = 0.300
P value > 0.05 Non-significant\ Non-significant\\
Data are expressed as mean + SD.

Table 3 Duration of akinesia (globe and lid).

Group I N = 23 Group II N = 25 P value
Lid akinesia (min) 158.26 ± 13.42 148.52 ± 12.61 P = 0.012\
Globe akinesia (min) 188.16 ± 12.35 179.02 ± 11.58 P = 0.011
P value < 0.05 Significant\ Significant
Data are expressed as mean + SD.

Table 4 Pain assessment at 2, 6, and 12 h postoperatively. (Number of patients who were pain free postoperatively).
Time 0H 2H 6H 12 H
Group I (dexamethasone + bupivacaine) N = 23 21/23 19/23 21 /23 23/23
(91.3%) (82.6%) (91.3%) (100)
Group II (Bupivacaine) N = 25 20/25 12/25 15 /25 23/25
(80%) (48%) (60) (92)
P value P = 0.48 P = 0.027\ P = 0.03\ P = 0.507
Non-significant Significant Significant Non-significant
Data are expression as number percent.

tween the two groups as regard the onset of lid and globe aki- was performed using student t-test. Comparison between cate-
nesia (p > 0.05, Table 2). gorical data was performed using the chi-squared test. Data
The duration of lid akinesia was longer (158.26 ± were considered significant if p values were <0.05. Statistical
13.42 min.) in group I than in group II (148.52 ± 12.61 min.) analysis was performed with the aid of the MEDCALC com-
and this was statistically significant (P < 0.05) (Table 3). Also, puter program (version 12 windows).
the duration of globe akinesia was longer (188.16 ±
12.35 min.) in group I than in group II (179.02 ± 11.58 min.) 4. Discussion
and this was statistically significant (P < 0.05) (Table 3).
Number of patients who were pain free was less in group II Our study was a prospective, double blinded, randomized
at 2, 6 h postoperatively, in comparison with group I and this study. The primary outcome was the effect of dexamethasone
was statistically significant (P < 0.05) (Table 4), and they were on the duration and quality of peribulbar block and the sec-
almost non-significantly different at 12 h duration postopera- ondary outcome was the confirmation of the efficacy of adding
tively. The number of patients requiring postoperative analge- dexamethasone for prolongation of postoperative analgesia
sia at 2, 6 h postoperatively were significantly less in group I and the anti-inflammatory effect as well. Dexamethasone was
(bupivacaine–dexamethasone group) (P < 0.05) (Table 5); not used before as an adjuvant to local anesthetic for ophthal-
moreover, the time to first analgesic request was significantly mic block but used alone intravitreally, subconjunctival, and in
longer in group I (P < 0.05) than in group II (Table 5). peribulbar injection [12].
The inflammatory response to the surgery was assessed The results of our study indicate that the addition of dexa-
postoperatively by measuring the levels of C – reactive protein methasone to bupivacaine for peribulbar block in posterior
which was significantly less in group I in comparison with segment surgery had led to prolongation of duration of lid
group II P < 0.05) (Table 6). As regard postoperative nausea and globe akinesia; the time of first rescue analgesia was de-
and vomiting, in group 1 (bupivacaine–dexamethasone group) layed together with prolonged postoperative analgesic dura-
only one patient developed nausea and vomiting while in tion indicated by prolonged duration of akinesia and VAS.
group II 3 patients, and this was statistically non-significant The result of our study is in agreement with the analgesia
(P > 0.05) (Table 7). effects of preoperative administration of dexamethasone and
Results are expressed as means ± standard deviation (SD) other glucocorticoids given by oral, intravenous, intramuscu-
or number percent (%). Comparison between numerical data
410 M.S. Mahmoud et al.

Table 5 Comparison between dexamethasone group and the bupivacaine group in no. of patients requiring analgesia postoperative
(pain score > or equal 4 on VAS) also time for first analgesic request.
0H 2H 6H 12 H
Group I (Dexamethasone + Bupivacaine) (N = 23) 0/23 2/23 1 /23 0/23
(0%) (8.69%) (4.34%) (0%)
Group II (Bupivacaine) (N = 25) 5/25 11/25 8/25 2/25
(20%) (44%) (32) (8%)
P value P = 0.073 P = 0.015\ P = 0.037\ P = 0.5

Group I (N = 23) Group II (N = 25) P value

Time to first analgesia request (h) 3.15 ± 0.41 2.55 ± 1.32 P = 0.042\
Data was expressed as mean ± SD, or number percent (%).
Statistically significant \P value < 0.05 significant.
P value < 0.05 = non-significant.

Table 6 Inflammatory response assessment postoperatively, using C reactive protein levels (lg/dl).
Preoperatively 24 h Postoperatively
Group I (dexamethasone + bupivacaine) N = 23 1.39 ± 1.46 6.37 ± 2.11 lg/mL
Group II (bupivacaine) N = 25 1.62 ± 1.84 15.63 ± 3.14 lg/mL
P value =0.635 Non-significant P < 0.0001 highly significant
Data are expressed as mean + SD.

lar, or as an adjuvant to local anesthetics for peripheral nerve

block [13] or epidural analgesia [14] in patients undergoing Table 7 Postoperative nausea and vomiting.
gynecological operations [15], dental extraction [16], laparo- Group I N = 23 Group II N = 25
scopic cholecystectomy [17], and foot surgeries [18]. Nausea and vomiting 1/23 3/25
The pathophysiological mechanisms for steroid effects may P > 0.05 (=0.671) Non-significant Non-significant
be related to the anti-inflammatory action, edema reduction,
Data are expressed as number percent. (P > 0.05) = non-
or shrinkage of connective tissue. Local steroid application
significant.
was found to suppress transmission in thin unmyelinated C fi-
bers [19].
It has been suggested that steroids may bind directly to the effect after intravenous dexamethasone [23,24]. Others re-
intracellular glucocorticoid receptor, and their effects are pre- ported its analgesic effect after epidural administration [25].
dominantly mediated through altered protein gene transcrip- Only one patient in the bupivacaine dexamethasone group
tion [20]. The current study indicates that dexamethasone experienced nausea and vomiting. The mechanism by which
has no effect on the onset of akinesia in peribulbar block; this glucocorticoids alleviated nausea and vomiting is centrally
is because the action of dexamethasone starts after 1–2 h of its mediated through inhibition of the release of endogenous opi-
administration. oids. Other suggested mechanisms include central or peripheral
Also, our study showed that peribulbar block with dexa- inhibition of the production or secretion of serotonin and
methasone led to significantly prolonged duration of akinesia change in permeability of the blood brain barrier to serum pro-
with prolonged postoperative analgesia and time to first rescue tein [26].
analgesia. In support of the direct effect of dexamethasone, Some surgeons have some fears about steroids as it may
Shrestha et al. [21] found that dexamethasone added to local mask the clinical signs of infection. However, since the biolog-
anesthetic prolongs postoperative analgesia significantly com- ical half-life of dexamethasone is 36–58 h, it is normal for a
pared with tramadol when used as an admixture to a local postoperative wound to be re-dressed at 1 week, where by this
anesthetic in brachial plexus block in upper extremity surgery, time the corticosteroids would have been totally eliminated
and Parrington et al. [22] also found that the addition of dexa- from the body [9].
methasone to mepivacaine prolongs the duration of analgesia Immediately after surgical incision, inflammatory, hor-
but does not reduce the onset of sensory and motor blockade monal, immune and metabolic response are activated, so
after ultrasound guided supraclavicular block compared with administration of steroids may decrease these responses by
mepivacaine alone. their anti-inflammatory and immunosuppressive effects by
Furthermore, the analgesic efficacy of dexamethasone was inhibiting cyclooxygenase enzyme and phospholipase A2
found not to be related to the route of administration, this [27]. This was evident with the reduction of C-reactive protein
was supported by multiple studies that reported an analgesic levels in dexamethasone group than bupivacaine group alone.
Dexamethasone bupivacaine versus bupivacaine for peribulbar block in posterior segment eye surgery 411

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