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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 5  |  Issue : 2  |  Page : 98-102

Superficial cervical plexus block in thyroid surgery and the effect of adding dexamethasone: a randomized, double-blinded study


Department of Anesthesia, Mansoura University, Mansoura, Egypt

Date of Submission02-Apr-2017
Date of Acceptance06-Dec-2017
Date of Web Publication28-Jun-2018

Correspondence Address:
Alaa El-Deeb
Department of Anesthesia, Mansoura University, Mansoura, 35514
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/roaic.roaic_45_17

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  Abstract 

Background Thyroid surgeries are widely performed nowadays as an ambulatory procedure; so, the use of regional block for postoperative analgesia has gained popularity. Bilateral superficial cervical plexus blocks (BSCPB) alone or in combination with deep cervical plexus block are good examples. The duration of analgesia following these nerve blocks last for only a few hours.
Patients and methods We randomly allocated 90 patients who are American Society of Anesthesiologists I or II scheduled for thyroid surgeries into three groups according to the contents of cervical block in addition to general anesthesia. Group C, which is the control group, received BSCPB with ropivacaine 0.2%. Group DB received BSCPB with ropivacaine 0.2% plus 8 mg dexamethazone. BSCPB with ropivacaine 0.2% plus 8 mg dexamethazone intravenously was given in group DI. Time to the first administration of supplemental analgesic postoperatively is our primary concern. Secondary outcomes include discharge time, rescue analgesic, rescue antiemetic, postoperative nausea or vomiting, pain score, and side effects of either block or drugs.
Results Patients in group DB and DI need less postoperative rescue analgesic requirement than in the control group. Pain scores was statistically significantly less in group DB and in the DI group than in control groups at 6 and 8 h postoperatively. The occurrence of nausea and/or vomiting is statistically significantly less frequent in groups DB and DI when compared with the control group postoperatively.
Conclusion The addition of dexamethasone to BSCPB resulted in decrease in time that elapsed until the first administration of supplemental analgesic, improved pain control, and reduced analgesic requirements postoperatively. This finding does not differ if dexamethazone is given either with block or intravenously.

Keywords: dexamethazone, superficial cervical plexus block, thyroid surgeries


How to cite this article:
Elbahrawy K, El-Deeb A. Superficial cervical plexus block in thyroid surgery and the effect of adding dexamethasone: a randomized, double-blinded study. Res Opin Anesth Intensive Care 2018;5:98-102

How to cite this URL:
Elbahrawy K, El-Deeb A. Superficial cervical plexus block in thyroid surgery and the effect of adding dexamethasone: a randomized, double-blinded study. Res Opin Anesth Intensive Care [serial online] 2018 [cited 2018 Jul 19];5:98-102. Available from: http://www.roaic.eg.net/text.asp?2018/5/2/98/235486


  Introduction Top


Nowadays, thyroid surgeries are performed on an ambulatory basis; so, regional techniques have been considered as the mainstay for postoperative analgesia. Good examples of such techniques are bilateral superficial cervical plexus block (BSCPB) and BSCPB with block of deep cervical plexus [1]. Many authors are concerned with the duration of analgesia after nerve blocks because of the short duration reported in most of cases [2].

BSCPB for thyroid surgeries has been shown to reduce general anesthetics, shorten the hospital stay as well as there was a significant decrease in the severity of pain in the first day postoperatively [3],[4],[5].

Postoperative nausea and/or vomiting (PONV) are common problems that occurred after general anesthesia with reported higher incidence after thyroid surgery [6],[7]. The possible reasons for PONV after thyroid surgery are edema and inflammation of the surrounding tissues transmitted to the vomiting center by means of three nerves: vagus, recurrent laryngeal, and glossopharyngeal nerves [8]. PONV resulted in patient discomfort as well as serious postoperative complications, such as the aspiration of the gastric contents, electrolyte imbalances, rupture of the esophagus, bleeding, and hospital stay [9].

For the purpose of increasing the duration of peripheral single-shot nerve blocks, dexamethasone might be an excellent choice [10]. It has been added to thoracic paravertebral block, interscalene block, supraclavicular brachial plexus block, and infraclavicular block [11],[12],[13],[14]. Other authors deny its effect on the success of the block, postoperative pain scores, recue analgesics, or nausea and vomiting [15].

To the best of our knowledge, dexamethasone has not been investigated in BSCPB. Comparing the effect of dexamethasone in the superficial cervical plexus block in thyroid surgeries by two routes on postoperative request of analgesia is the target of this study. The other goals are its effect on nausea, pain scores, vomiting, and hospital stay.


  Patients and methods Top


After obtaining informed consent and IRB/Ethics committee approval, 90 patients undergoing thyroid surgeries were randomized using a computer-generated code into three groups. Those patient groups are American Society of Anesthesiologists (physical status) I or II. Control group who received ropivacaine 0.2% in BSCPB plus 2 ml normal saline intravenously (group C). Ropivacaine 0.2% and 8 mg dexamethasone in the BSCPB plus 2 ml normal saline intravenous were given in the second group (group DB). The third group received ropivacaine 0.2% in BSCPB with 2 ml dexamethasone (8 mg) intravenously (group DI). Either block or intravenous solutions looked identical, and were prepared by a pharmacist unaware of the randomization code. All personnel involved in the block were blinded to the components of either block or intravenous injection. Reasons for exclusion from this study include obstructive lung disease, diabetes, history of allergy to the used drugs, or neuromuscular disease.

Induction of general anesthesia was achieved with intravenous propofol (2–2.5 mg/kg), and fentanyl (1 μg/kg). Cisatracurium.0.15 mg/kg was used to facilitate intubation. Then, anesthesia was maintained with 2–2.5% sevoflurane and 50% oxygen in 50% air. Additional fentanyl was given to achieve hemodynamic stability. The target of mechanical ventilation was an end-tidal concentration of carbon dioxide of 30–40 mmHg throughout the surgery. Monitoring during surgery includes ECG, heart rate, pulse oximetry, blood pressure (noninvasive), and end-tidal carbon dioxide concentration.

Then, BSCPB is done guided by a SonoSite portable ultrasound unit (SonoSite, Bothell, Washington, USA). A 22 G needle was used in this block through the in-plane approach. The patient was positioned with his neck rotated to the opposite side. The probe was placed on the cricoid and sliding laterally toward the sternocleidomastoid to have the best possible view of the cervical plexus. The point of needle insertion is the middle of the posterior border of the sternocleidomastoid muscle, between two points: mastoid process and C-6 transverse process. The endpoint of needle placement is to keep the needle between the superficial and the deep cervical fascia. After that, 10 ml of anesthetic solution was injected into the plane. Metoclopramide 10 mg intravenous was given to all patients. At the end of the surgery, reversal of the residual paralysis was achieved with atropine and neostigmine (0.02 and 0.04 mg/kg, respectively).

Postoperative pain was assessed using a visual analog scale (in which 0 cm=no pain and 10 cm=the worst pain imaginable) every 15 min in the postanesthesia care unit, then at 2, 4, 6, 12, 24 h postoperatively. Nausea and vomiting were evaluated every 2 h for 6 h then every 6 h up to 24 h by an observer who is blinded to group assignment. Nausea was assessed using a numerical scale (0=no nausea; 10=worst imaginable nausea). An antiemetic ‘rescue’ drug (4 mg ondansetron intravenously) was administered in case of severe nausea (scale 4 or more) or vomiting within the study period. Patients were discharged from the postanesthesia care unit according to the Aldrete discharge criteria [16]. Rescue analgesic is tramadol 0.5 mg/kg and is given if visual analog scale is more than 4. Time to the first administration of supplemental analgesic postoperatively is our primary concern. Secondary outcomes include discharge time, rescue analgesic, rescue antiemetic, PONV, pain score, side effects of either block or drugs.

The primary target of this study is the time elapsed until the first administration of supplemental analgesic postoperatively.

Statistical analysis

Data will be first tested for normality by Kolmogorov–Smirnov test. Normally distributed continuous data will be analyzed using unpaired t-test. Non-normally distributed data will be analyzed using the Wilcoxon test. Normally distributed data will be analyzed using the one-way analysis of variance test. Categorical data will be analyzed by χ2 as appropriate. The results were presented as mean (SD), median (range), or number (%) of patients as appropriate. The results were expressed as mean diameter±SD. P value less than 0.05 was considered statistically significant with 95% confidence. SPSS for Windows, version 18 (SPSS Inc., Chicago, Illinois, USA) was utilized for statistical analyses.

Sample size

Based on a pilot study, it was found that a number of 28 patients were sufficient to achieve a study power of 0.8 with an α error of 0.05 to detect 15% difference. We increased the sample to 30 cases to compensate for possible dropouts. Calculations were done using G, version 3.0.10, power software Windows (Christian-Albrechts-Universität, Kiel, Germany).


  Results Top


Ninety-four patients, submitted for thyroid surgeries, were checked for eligibility; out of them 90 patients were included in this study after randomization. Four patients were excluded because of obstructive pulmonary disease, diabetes, neuropathy, and patient’s refusal ([Figure 1]).
Figure 1 Study flowchart. BSCPB, bilateral superficial cervical plexus block.

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Patients showed no statistically significant difference with respect to patients’ age, sex, weight, duration of surgery, and type of surgery ([Table 1]).
Table 1 Patient characteristics, duration, and type of surgery

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The postoperative rescue analgesic requirement was statistically significant less in groups DB and in the DI than in the control group. Also, patients in the control group requested analgesic earlier than those in the treatment groups ([Table 2]).
Table 2 Intraoperative and postoperative data

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Also, the mean pain scores were statistically significantly less in groups DB and in DI than in control groups at 6 and 8 h postoperatively. Rather at 6 and 8 h postoperatively, three groups did not differ in the pain score ([Figure 2]).
Figure 2 Postoperative visual analog scale.

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The occurrence of nausea and/or vomiting is statistically significantly less frequent in groups DB and DI when compared with the control group postoperatively ([Table 2]).


  Discussion Top


Among the worldwide endocrine surgical procedures, thyroidectomy is considered the most common. Numerous challenges can be encountered either in the preoperative, intraoperative, or in the postoperative period [17].

BSCPB is the more advantageous or effective choice after thyroidectomy. It decreases postoperative pain, analgesic requirements, and postoperative vomiting [18].

The main finding of this study is that the first postoperative request of analgesia in patients submitted for thyroid surgeries under general anesthesia plus BSCPB with dexamethasone, either intravenous or added to the block, was later than those in the control group. Also, there was less pain score in dexamethasone groups (DB and DI groups) at 6 and 8 h postoperatively and less rescue analgesic compared with the control ropivacaine group.

In agreement with this finding, a randomized, controlled study was done by Andrieu et al. [18]. They concluded that analgesic requirements after thyroid surgery were reduced by BSCPB with ropivacaine or ropivacaine plus clonidine.

A similar result has been documented by Karthikeyan et al. [1], which concluded that BSCPB using 0.25% bupivacaine is effective in reducing analgesic requirements and pain either intraoperatively or postoperatively in thyroidectomy. Moreover, Shih et al. [3] has shown a reduction of pain after thyroid operations in the case of BSCPB in addition to general anesthesia.

A meta-analysis by Huynh et al. [19] reported that dexamethasone prolongs the duration of local anesthetic in the peripheral nerve blocks and decreases postoperative pain.

In contrast to our findings, Herbland et al. [20] denied any improvement of postoperative analgesia after total thyroidectomy with BSCPB using 0.75% ropivacaine. Also, Eti et al. [21] concluded there was no reduction in postoperative analgesic requirements after thyroidectomy with either BSCPB or wound infiltration. No change was observed in either pain scores or total patient-controlled analgesia doses among groups. Reasons for such conflict might be unknown as many studies and meta-analysis prove such effects [1],[18],[22],[23],[24],[25].

This study showed that the treatment groups (DB and DI) did not differ statistically in pain scores, analgesic consumption, or nausea and vomiting postoperatively. This means that whatever the route of dexamethasone administration, the results are nearly the same.

Our study has shown that the incidence of PONV was decreased after dexamethasone either intravenously or was added to the block.

In agreement with our results, Abdallah et al. [13] have shown that in the case of a supraclavicular block using long-acting local anesthetic, intravenous or perineural dexamethasone increase the duration of analgesia in a similar manner. Also, Dawson et al. [15] concluded that whatever be the route of dexamethasone, its effects will not vary.

A similar result was documented by Rosenfeld et al. [12]. However, they advised the intravenous route to eradicate the possibility of neural toxicity of dexamethasone.

Furthermore, Shih et al. [3] have shown that a BSCPB in addition to general anesthesia resulted in a decrease in the occurrence of nausea and/or vomiting in the postoperative period in parathyroid and thyroid operations.

One of limitations of this study is that no placebo group such as BSCPB is proven to be effective in pain relief. In accordance of this belief, Barua et al. [26] studied the effect of BSCPBs compared with no block and found that it could decrease postoperative pain after thyroidectomy.


  Conclusion Top


The addition of dexamethasone to BSCPB resulted in a decrease in time that elapsed until the first administration of supplemental analgesic, improved pain control, reduced analgesic requirements postoperatively, and decrease of PONV. This finding does not differ if dexamethazone is given either with block or intravenously.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Karthikeyan VS, Sistla SC, Badhe AS, Mahalakshmy T, Rajkumar N, Ali SM, Gopalakrishnan S. Randomized controlled trial on the efficacy of bilateral superficial cervical plexus block in thyroidectomy. Pain Pract 2013; 13:539–546.  Back to cited text no. 1
    
2.
Santosh BS, Mehandale SG. Does dexmedetomidine improve analgesia of superficial cervical plexus block for thyroid surgery? Indian J Anaesth 2016; 60:34–38.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Shih ML, Duh QY, Hsieh CB, Liu YC, Lu CH, Wong CS et al. Bilateral superficial cervical plexus block combined with general anesthesia administered in thyroid operations. World J Surg 2010; 34:2338–2343.  Back to cited text no. 3
    
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Steffen T, Warschkow R, Brändle M, Tarantino I, Clerici T. Randomized controlled trial of bilateral superficial cervical plexus block versus placebo in thyroid surgery. Br J Surg 2010; 97:1000–1006.  Back to cited text no. 4
    
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Fujii Y, Saitoh Y, Tanaka H, Toyooka H. Prophylactic antiemetic therapy with granisetron in women undergoing thyroidectomy. Br J Anaesth 1998; 81:526–528.  Back to cited text no. 7
    
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Sonner JM, Hynson JM, Clark O, Katz JA. Nausea and vomiting following thyroid and parathyroid surgery. J Clin Anesth 1997; 9:398–402.  Back to cited text no. 8
    
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Wiesmann T, Volk T, Steinfeldt T. Glucocorticoids as an adjunct in peripheral regional anesthesia: move to the ‘Holy Grail of perineuralanalgesia’?! Anaesthesist 2016; 65:295–298.  Back to cited text no. 10
    
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Tomar GS, Ganguly S, Cherian G. Effect of perineural dexamethasone with bupivacaine in single space paravertebral block for postoperative analgesia in elective nephrectomy cases: a double-blind placebo-controlled trial. Am J Ther 2016; 24:e713–e717.  Back to cited text no. 11
    
12.
Rosenfeld DM, Ivancic MG, Hattrup SJ, Renfree KJ, Watkins AR, Hentz JG et al. Perineural versus intravenous dexamethasone as adjuncts to local anaesthetic brachial plexus block for shoulder surgery. Anaesthesia 2016; 71:380–388.  Back to cited text no. 12
    
13.
Abdallah FW, Johnson J, Chan V, Murgatroyd H, Ghafari M, Ami N et al. Intravenous dexamethasone and perineural dexamethasone similarly prolong the duration of analgesia after supraclavicular brachial plexus block: a randomized, triple-arm, double-blind, placebo-controlled trial. Reg Anesth Pain Med 2015; 40:125–132.  Back to cited text no. 13
    
14.
Leurcharusmee P, Aliste J, van Zundert TC, Engsusophon P, Arnuntasupakul V, Tiyaprasertkul W et al. A multicenter randomized comparison between intravenous and perineural dexamethasone for ultrasound-guided infraclavicular block. Reg Anesth Pain Med 2016; 41:328–333.  Back to cited text no. 14
    
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Dawson RL, McLeod DH, Koerber JP, Plummer JL, Dracopoulos GC. A randomised controlled trial of perineural vs intravenous dexamethasone for foot surgery. Anaesthesia 2016; 71:285–290.  Back to cited text no. 15
    
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18.
Andrieu G, Amrouni H, Robin E, Carnaille B, Wattier JM, Pattou F et al. Analgesic efficacy of bilateral superficial cervical plexus block administered before thyroid surgery under general anaesthesia. Br J Anaesth 2007; 99:561–566.  Back to cited text no. 18
    
19.
Huynh TM, Marret E, Bonnet F. Combination of dexamethasone and local anaesthetic solution in peripheral nerve blocks: a meta-analysis of randomized controlled trials. Eur J Anaesthesiol 2015; 32:751–758.  Back to cited text no. 19
    
20.
Herbland A, Cantini O, Reynier P, Valat P, Jougon J, Arimone Y, Janvier G. The bilateral superficial cervical plexus block with 0.75% ropivacaine administered before or after surgery does not prevent postoperative pain after total thyroidectomy. Reg Anesth Pain Med 2006; 31:34–39.  Back to cited text no. 20
    
21.
Eti Z, Irmak P, Gulluoglu BM, Manukyan MN, Gogus FY. Does bilateral superficial cervical plexus block decrease analgesic requirement after thyroid surgery? Anesth Analg 2006; 102:1174–1176.  Back to cited text no. 21
    
22.
Cai HD, Lin CZ, Yu CX, Lin XZ. Bilateral superficial cervical plexus block reduces postoperative nausea and vomiting and early postoperative pain after thyroidectomy. J Int Med Res 2012; 40:1390–1398.  Back to cited text no. 22
    
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Sardar K, Rahman SH, Khandoker MR, Amin ZA, Pathan FH, Rahman M. The analgesic requirement after thyroid surgery under general anaesthesia with bilateral superficial cervical plexus block. Mymensingh Med J 2013; 22:49–52.  Back to cited text no. 23
    
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25.
Warschkow R, Tarantino I, Jensen K, Beutner U, Clerici T, Schmied BM, Steffen T. Bilateral superficial cervical plexus block in combination with general anesthesia has a low efficacy in thyroid surgery: a meta-analysis of randomized controlled trials. Thyroid 2012; 22:44–52.  Back to cited text no. 25
    
26.
Barua SM, Mishra A, Kishore K, Mishra SK, Chand G, Agarwal G et al. Effect of preoperative nerve block on postthyroidectomy headache and cervical pain: a randomized prospective study. J Thyroid Res 2016; 2:465–487.  Back to cited text no. 26
    


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