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The investigators will conduct a prospective, randomized, double-blinded study using an axillary brachial plexus block in patients undergoing elective surgery of the distal forearm and hand to characterize and describe the pharmacokinetics of bupivacaine associated with perineural dexamethasone.
The pharmacokinetic analysis will be performed by measuring bupivacaine plasma levels at different time intervals after the blockade (15, 30, 45, 60, and 90 minutes), allowing comparison between 2 different groups: Bupivacaine (B) and Bupivacaine-dexamethasone (BD).
Thus, the hypothesis is that plasma levels of bupivacaine during the first 90 minutes after a blockade are lower in the presence of perineural dexamethasone, suggesting a decrease, at least initially, in systemic absorption from the injection site.
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| Label | Type | Description | Intervention Names |
|---|---|---|---|
| Perineural Bupivacaine | Active Comparator | Bupivacaine without Dexamethasone in axillary brachial plexus blockade |
|
| Perineural Bupivacaine plus Dexamethasone | Experimental | Bupivacaine with Dexamethasone in axillary brachial plexus blockade |
|
| Name | Type | Description | Arm Group Labels | Other Names |
|---|---|---|---|---|
| Bupivacaine Hydrochloride | Drug | Patients will receive a total volume of 30 ml of bupivacaine 0.5% in an axillary block with a double puncture. |
|
| Measure | Description | Time Frame |
|---|---|---|
| Maximum plasma concentration (Cmax) of bupivacaine | Maximum plasmatic level of bupivacaine | 0 to 90 minutes after the ending time of local anesthetic injection |
| Measure | Description | Time Frame |
|---|---|---|
| Plasmatic concentration of bupivacaine at 15 minutes | Plasmatic level of bupivacaine 15 minutes after local anesthetic injection (ng/ml) | 15 minutes after the ending time of local anesthetic injection |
| Plasmatic concentration of bupivacaine at 30 minutes |
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Inclusion Criteria:
Exclusion Criteria:
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| Facility | Status | City | State | ZIP | Country | Contacts |
|---|---|---|---|---|---|---|
| Hospital ClÃnico Universidad de Chile | Santiago | Metropolitan | Chile |
| PubMed Identifier | Type | Citation | Retractions |
|---|---|---|---|
| 33456903 | Background | Desai N, Albrecht E, El-Boghdadly K. Perineural adjuncts for peripheral nerve block. BJA Educ. 2019 Sep;19(9):276-282. doi: 10.1016/j.bjae.2019.05.001. Epub 2019 Jul 6. No abstract available. | |
| 27015546 | Background | Leurcharusmee P, Aliste J, Van Zundert TC, Engsusophon P, Arnuntasupakul V, Tiyaprasertkul W, Tangjitbampenbun A, Ah-Kye S, Finlayson RJ, Tran DQ. A Multicenter Randomized Comparison Between Intravenous and Perineural Dexamethasone for Ultrasound-Guided Infraclavicular Block. Reg Anesth Pain Med. 2016 May-Jun;41(3):328-33. doi: 10.1097/AAP.0000000000000386. |
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A research assistant (licensed anesthesiologist) will prepare the local anesthetic solutions and will add the study drug following the randomization order. The operator, patient and investigator assessing the block will be blinded to group allocation.
| Bupivacaine Hydrochloride with Dexamethasone | Drug | Patients will receive a total volume of 30 ml of bupivacaine 0.5% with Dexamethasone 4 mg in an axillary block with a double puncture. |
|
Plasmatic level of bupivacaine 30 minutes after local anesthetic injection (ng/ml) |
| 30 minutes after the ending time of local anesthetic injection |
| Plasmatic concentration of bupivacaine at 45 minutes | Plasmatic level of bupivacaine 45 minutes after local anesthetic injection (ng/ml) | 45 minutes after the ending time of local anesthetic injection |
| Plasmatic concentration of bupivacaine at 60 minutes | Plasmatic level of bupivacaine 60 minutes after local anesthetic injection (ng/ml) | 60 minutes after the ending time of local anesthetic injection |
| Plasmatic concentration of bupivacaine at 90 minutes | Plasmatic level of bupivacaine 90 minutes after local anesthetic injection (ng/ml) | 90 minutes after the ending time of local anesthetic injection |
| Time to obtain the maximum plasma concentration of bupivacaine (Tmax) | Time in minutes in which the maximum plasmatic level of bupivacaine is reached | 0 to 90 minutes after the ending time of local anesthetic injection |
| Area under the curve of plasma concentration versus time at 90 minutes (AUC90) | Area under the curve at 90 minutes | 0 to 90 minutes after the ending time of local anesthetic injection |
| Sensory and motor block score | The sensorimotor block will be assessed every 5 minutes until 30 minutes after the end of local anesthetic injection using a 16-point composite score evaluating sensory and motor block of musculocutaneous, medium, radial, and ulnar nerves. Sensation will be assessed with ice in each nerve territory with a 0 to 2 point scale. 0= no block, patients can feel cold; 1= analgesic block, the patient can feel touch but not cold; 2= anesthetic block, the patient cannot feel cold or touch. The motor function will be assessed for each nerve with a 0 to 2 points scale where 0= no motor block; 1= paresis; 2= paralysis. Successful blocks at 30 minutes correlate with a final score ( sum of all individual sensory and motor scores) of at least 14 points out of 16. | 30 minutes after the ending time of local anesthetic injection |
| Block onset time | Time required to reach a minimal sensorimotor composite score of 14 points out of a maximum of 16 points. The sensorimotor score is described in outcome 9. | 30 minutes after the ending time of local anesthetic injection |
| Incidence of successful block | Percentage of blocks with a minimal sensorimotor composite score of 14 points out of a maximum of 16 points at 30 minutes after the injection | 30 minutes after the ending time of local anesthetic injection |
| Motor block duration | The elapsed period in minutes between the ending time of the local anesthetic injection and the time of return of hand and fingers movement. | 48 hours after the ending time of local anesthetic injection |
| Sensory block duration | The elapsed period in minutes between the ending time of the local anesthetic injection and the time of the return of hand and fingers sensation | 48 hours after the ending time of local anesthetic injection |
| Analgesic block duration | The elapsed period in minutes between the ending time of the local anesthetic injection and the time of the first sensation of pain in the surgical area | 48 hours after the ending time of local anesthetic injection |
| Intensity of pain during block procedure | Evaluated with the Numeric Rating Scale for Pain. This scale is graduated from 0 to 10 points. A 0-point score represents the absence of pain, and a 10-points score represents the worst imaginable pain. Patients will be asked to rate their pain verbally with this scale. The blinded assessor will register the score reported. | During the execution of the nerve blockade |
| Block performance time | Sum of: 1- the acquisition time of the ultrasonographic image. and 2- the time to perform the block itself (from the skin anesthesia to the end of local anesthetic injection) | From the skin anesthesia to the end of local anesthetic injection |
| Incidence of nerve block side effects | Determined by the presence of paresthesia, local anesthetic systemic toxicity, vascular puncture after the block. | From the skin anesthesia to the end of local anesthetic injection |
| Persistent neurologic deficit | Presence of persistent sensory or motor postoperative deficit. | 7 days after surgery |
| 27663451 | Background | Aliste J, Leurcharusmee P, Engsusophon P, Gordon A, Michelagnoli G, Sriparkdee C, Tiyaprasertkul W, Tran DQ, Van Zundert TC, Finlayson RJ, Tran DQH. A randomized comparison between intravenous and perineural dexamethasone for ultrasound-guided axillary block. Can J Anaesth. 2017 Jan;64(1):29-36. doi: 10.1007/s12630-016-0741-8. Epub 2016 Sep 23. |
| 29406171 | Background | Heesen M, Klimek M, Imberger G, Hoeks SE, Rossaint R, Straube S. Co-administration of dexamethasone with peripheral nerve block: intravenous vs perineural application: systematic review, meta-analysis, meta-regression and trial-sequential analysis. Br J Anaesth. 2018 Feb;120(2):212-227. doi: 10.1016/j.bja.2017.11.062. Epub 2017 Nov 22. |
| 25123271 | Background | Albrecht E, Kern C, Kirkham KR. A systematic review and meta-analysis of perineural dexamethasone for peripheral nerve blocks. Anaesthesia. 2015 Jan;70(1):71-83. doi: 10.1111/anae.12823. Epub 2014 Aug 14. |
| 11884905 | Background | Shishido H, Kikuchi S, Heckman H, Myers RR. Dexamethasone decreases blood flow in normal nerves and dorsal root ganglia. Spine (Phila Pa 1976). 2002 Mar 15;27(6):581-6. doi: 10.1097/00007632-200203150-00005. |
| 23146999 | Background | Gonzalez AP, Bernucci F, Pham K, Correa JA, Finlayson RJ, Tran DQ. Minimum effective volume of lidocaine for double-injection ultrasound-guided axillary block. Reg Anesth Pain Med. 2013 Jan-Feb;38(1):16-20. doi: 10.1097/AAP.0b013e3182707176. |
| 28922230 | Background | Kirkham KR, Jacot-Guillarmod A, Albrecht E. Optimal Dose of Perineural Dexamethasone to Prolong Analgesia After Brachial Plexus Blockade: A Systematic Review and Meta-analysis. Anesth Analg. 2018 Jan;126(1):270-279. doi: 10.1213/ANE.0000000000002488. |
| 30399533 | Background | Souza MCO, Marques MP, Duarte G, Lanchote VL. Analysis of bupivacaine enantiomers in plasma as total and unbound concentrations using LC-MS/MS: Application in a pharmacokinetic study of a parturient with placental transfer. J Pharm Biomed Anal. 2019 Feb 5;164:268-275. doi: 10.1016/j.jpba.2018.10.040. Epub 2018 Oct 23. |
| 21270721 | Background | Tran DQ, Dugani S, Dyachenko A, Correa JA, Finlayson RJ. Minimum effective volume of lidocaine for ultrasound-guided infraclavicular block. Reg Anesth Pain Med. 2011 Mar-Apr;36(2):190-4. doi: 10.1097/AAP.0b013e31820d4266. |
| 30640652 | Background | Bravo D, Aliste J, Layera S, Fernandez D, Leurcharusmee P, Samerchua A, Tangjitbampenbun A, Watanitanon A, Arnuntasupakul V, Tunprasit C, Gordon A, Finlayson RJ, Tran DQ. A multicenter, randomized comparison between 2, 5, and 8 mg of perineural dexamethasone for ultrasound-guided infraclavicular block. Reg Anesth Pain Med. 2019 Jan;44(1):46-51. doi: 10.1136/rapm-2018-000032. |
| 29042063 | Background | Ferraro LHC, Takeda A, Barreto CN, Faria B, Assuncao NA. [Pharmacokinetic and clinical effects of two bupivacaine concentrations on axillary brachial plexus block]. Braz J Anesthesiol. 2018 Mar-Apr;68(2):115-121. doi: 10.1016/j.bjan.2017.09.001. Epub 2017 Oct 16. |
| 41547610 | Derived | Bravo D, Aguilera G, Giordano A, Layera S, Erpel H, Mora D, Ramirez C, Jara A, Aliste J. Bupivacaine pharmacokinetics in the absence or presence of perineural dexamethasone in axillary block: an exploratory trial. Br J Anaesth. 2026 Mar;136(3):1090-1092. doi: 10.1016/j.bja.2025.12.009. Epub 2026 Jan 16. |
| ID | Term |
|---|---|
| D000377 | Agnosia |
| D059787 | Acute Pain |
| D001134 | Arm Injuries |
| ID | Term |
|---|---|
| D010468 | Perceptual Disorders |
| D019954 | Neurobehavioral Manifestations |
| D009461 | Neurologic Manifestations |
| D009422 | Nervous System Diseases |
| D012816 | Signs and Symptoms |
| D013568 | Pathological Conditions, Signs and Symptoms |
| D010146 | Pain |
| D014947 | Wounds and Injuries |
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| ID | Term |
|---|---|
| D002045 | Bupivacaine |
| D003907 | Dexamethasone |
| ID | Term |
|---|---|
| D000813 | Anilides |
| D000577 | Amides |
| D009930 | Organic Chemicals |
| D000814 | Aniline Compounds |
| D000588 | Amines |
| D011246 | Pregnadienetriols |
| D011245 | Pregnadienes |
| D011278 | Pregnanes |
| D013256 | Steroids |
| D000072473 | Fused-Ring Compounds |
| D011083 | Polycyclic Compounds |
| D013259 | Steroids, Fluorinated |
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