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Journal of Anesthesia Perioperative [ JAP. 2015;

109-16] RESEARCH ARTICLES
3 (2):

The addition of 5 mg Dexamethasone effects on Bupivacaine 0.5% of the Mula and the
Old Labor Epidural Anesthesia Sensory Blockade
for Lower Extremity Orthopedic Surgery

Irwan, 1 Erwin Pradian, 2 Tatang Bisri 2

1 Air Force Hospital Dr. Salamun Bandung, 2 Department of Anesthesiology and Intensive Therapy Faculty of
Medicine, University of Padjadjaran / Hospital Dr. Hasan Sadikin

Abstract

Lower extremity orthopedic surgery with epidural regional anesthesia has the disadvantage of a long onset of action. This study
examines the effect of the addition of 5 mg of dexamethasone on bupivacaine
0.5% against the onset and duration of sensory blockade work. The prospective study experimentally using a double blind
randomized clinical trial in 32 patients with American Society of Anesthesiologists ( ASA) I-II undergoing lower extremity orthopedic
surgery with epidural anesthesia at Hospital Dr. Hasan Sadikin in February-May 2014. Sampling was done by consecutive
sampling and random block permutation. Group I, dexamethasone 5 mg added to 15 mL of 0.5% bupivacaine. Group

II, bupivacaine 0.5% plus 15 ml 0.9% NaCl. The results were tested statistically using t-test and Mann-Whitney. The results
showed onset of sensory blockade in group I was not faster, which is 13.56 minutes compared with group II, 14.31 minutes (p =
0.27). Sensory blockade old group I work longer, which is 399.81 minutes compared with group II, namely 227.43 minutes (p =
0.00). In conclusion, the addition of dexamethasone 5 mg in 15 mL of 0.5% bupivacaine does not accelerate the onset of sensory
blockade but extend the working time of sensory blockade of 0.5% bupivacaine administered epidural.

Keywords: Epidural anesthesia, sensory blockade, bupivacaine, dexamethasone, length of employment, at work

Effect of Dexamethasone 5 mg Addition to Bupivacaine 0.5% on Onset and Duration of

Sensory Blockade in Epidural Anesthesia for Lower
Extremity Orthopedic Surgery

Abstract

Lower extremity orthopedic surgery performed with regional epidural anesthesia was still have weakness the which is long onset of
time. This study was conducted to Determine the onset time and duration time of sensory blockade epidural anesthesia between the
use of dexamethasone 5 mg addition to the 0.5% bupivacaine for lower limb surgery orthophedic. The study was a randomized
controlled using blind method on 32 ASA I-II Patients undergoing lower limb orthopedic surgery under epidural anesthesia. Consecutive
sampling and random allocation of block of Permutation groups was applied. In group I, dexamethasone 5 mg was added to 15 mL of
0.5% bupivacaine in group II while 1 mL of NaCl was added to 15 mL of 0.5% bupivacaine. The results were statistically tested using
t-test and Mann-Whitney test. It was shown that the onset time of sensory blockade was not Significantly faster when dexamethasone
was added in bupivacaine 0.5%, versus 14:31 minutes 13:56 minutes (p = 0:27). The duration time of sensory blockade in
dexamethasone in bupivacaine

0.5% group was longer 399.81 minutes, Compared to the 0.5% bupivacaine group, 227.43 minutes (p = 0.00). In Conclusions, the addition
of dexamethasone 5 mg to 15 mL of 0.5% bupivacaine does not produced faster onset time. However, the duration of sensory blockade
time is longer than 15 mL of 0.5% bupivacaine is used

Key words: Bupivacaine, dexamethasone, duration time, epidural anesthesia, onset, sensory blockade

Correspondence: Irwan, dr., Span. M. Kes, the Air Force Hospital Dr. Salamun Bandung, Jalan Ciumbuleuit 203 West Java 40142, Tel. (022)
2032090, Mobile 081344225697, E-mail irwanmed93@gmail.com

109
110 Journal of Anesthesia Perioperative
preliminary
Epidural anesthesia is an anesthetic technique that puts
local anesthetic medication in the epidural space. The
advantage of the technique particularly epidural regional
anesthesia, is relatively cheaper, smaller systemic
effect, produce adequate analgesia, preventing a more
perfect stress response, reducing the amount of
intraoperative bleeding, and can also be used for the
treatment of postoperative pain. One of the
disadvantages of regional anesthesia, particularly in the
use of epidural anesthesia is a pure bupivacaine onset
and longer working time is limited, and we are often
faced with the operation to be done immediately or take
a long surgery. 1.2
This is often done during the addition of the adjuvant
to local anesthesia drugs aimed at accelerating onset / onset inflamed tissue. Suppression of prostaglandin
and prolong analgesia local anesthetic drug used for
epidural anesthesia. Presently there are a variety of
adjuvants used in regional anesthesia including opioid
group, clonidine, neostigmine, hyaluronidase,
bicarbonate, and midazolam. 2-4
The use of opioids and other drugs as adjuvant
agents often cause unwanted side effects which mainly
in respiratory depression, nausea, vomiting, and
pruritus. This has spurred researchers to examine other
drugs that can be used as an adjuvant in epidural
anesthesia. 3
The definition of local anesthesia is the loss of
sensation of an area in the body caused by the
depression of the final excitation or inhibition of nerve
impulse conduction in peripheral nerves. Local
anesthesia will give effect in the form of loss of
sensation without loss of consciousness, it is a basic
difference between local anesthesia compared with
general anesthesia. 3
Bupivacaine is a local anesthetic drug amid an
amino group that has long and widely used for regional
anesthesia. Isobaric 0.5% bupivacaine is a type of local
anesthesia that is widely used to
JAP, Volume 3 Number 2, August 2015
epidural anesthesia and can result in systemic toxicity in
case of intravenous injection or systemic absorption
from the epidural space. Manifestations of toxicity, which
first appeared occur in the central nervous system such
as tonic-clonic seizure. This can occur during the
injection of bupivacaine accident
2.5 mg of incoming arteries. Cardiotoxic effects require a
higher drug concentration in the plasma, which is 4-7
times the dose that can cause tonic-clonic seizure. 4-6
Dexamethasone is a glucocorticoid corticosteroid
group which has anti-inflammatory effects of the most
powerful. The exact mechanism of analgesia
dexamethasone can not be explained. Giving
dexamethasone will suppress the formation of
bradykinin and the release of neuropeptides from nerve
endings. Secondly it can lead to painful stimuli to the
production by dexamethasone can produce analgesia by
inhibiting the synthesis of cyclooxygenase pathway in
peripheral tissues. Dexamethasone can also suppress
the inflammatory mediators such as tumor necrosis
factor α (TNF-α) and interleukin-6 (IL-6). 3-5
Subjects and Methods
This study was conducted prospectively experimentally
using a double blind randomized clinical trial ( double-blind
randomized controlled trial) in 32 patients with
American Society of Anesthesiologists ( ASA) I-II
undergoing lower extremity orthopedic surgery with
epidural anesthesia in the operating room Central
Hospital Dr. Hasan Sadikin in the period from February
to May 2014. Sampling was conducted in patients consecutive
sampling and the allocation of a subject into one group
did a randomized block permutation. Based on statistical
calculation of the formula determining the sample size
for analytical research unpaired numerical katagorik to
examine differences in the average with a 95%
confidence level and also the power of the test ( power
test) 95%, obtained total
The addition of 5 mg Dexamethasone effects on Bupivacaine 0.5% of the Mula and Old Work Sensory Blockade
Epidural Anesthesia for Lower Extremity Orthopedic Surgery
samples of 32 patients. Statistical analysis for the
numerical data calculated based on the value of p
unpaired t-test when the normal distribution of data,
while analysis of the data are not normally distributed
using the Mann-Whitney test. P for categorical data is
calculated based on the chi-square test, with no
alternative use Smirvov Kolmogorov test, the value of a
statistical significant if p <0.05. Inclusion criteria that
patients undergoing lower extremity orthopedic surgery,
patients with ASA physical status I-II, aged 18-60 years,
and patients are willing to do epidural anesthesia.
Exclusion criteria which patients with infection around
the injection site epidural medication, blood clotting
disorders, and severe hypovolemia. Criteria of
expenses, in case of failure of the epidural after waiting
more than 30 minutes and more than 6 hours of
operation.
After the approval of the Ethics Committee for Health
Research, Faculty of Medicine / Hasan Sadikin
Bandung, conducted the selection of research subjects
in accordance with the inclusion criteria and were not
included in the exclusion criteria, then made an
explanation to patients and their families about the
procedures that will be experienced by the patient during
the study and signed approval ( informed consent).
Patients were divided into two groups of 16 patients
each group. A group is given dexamethasone 5 mg of
0.5% bupivacaine -15 mL. Group B was given NaCl
0.9% 1 mL of 0.5% bupivacaine -15 mL. The patients
then taken to the operating room, and installed
monitoring equipment such as automatic
sphygmomanometer,
pulse oximetry, pulse rate, respiratory rate, and
electrocardiographic (ECG). Subsequently, the patient
was infused using 18G needle, given Ringer's lactate 15
ml / kg 20 minutes before injection of the epidural
needle. Epidural injection site on the skin do wear
betadin aseptic action and 70% alcohol. epidural needle Tuohy
18 G inserted in the midline of the intervertebral L3-4
until the epidural space with the patient to sleep
sideways (lateral decubitus) after previously injected
local anesthetic lidocaine 2% and
111
with the needle bevel facing the caudal. Epidural space
is identified with the technique
loss of resistance using air.
Epidural catheter is inserted as deep as 3 cm, and
administration of test dose with 3 mL of 2% lidocaine in
the adrenalin 1: 200,000. Thereafter, the patient
returned in a supine position with the head mounted
pillow and given oxygen 2-3 L / min through a cannula.
After waiting for 5 minutes, injected drug research with
the speed of 2-3 seconds / mL until the number reached
15 mL. Onset of sensory blockade was measured by
test
pinprick using needles were measured every minute.
Long sensory block was assessed every hour after drug
research put and continued although the operation has
been completed, the study ended at the time of the first
patient once complained of pain with value
numeric rating scale ( NRS) 3. If during the operation the
patient had complained of pain to the value of NRS 3 it
will be given the drug bupivacaine 0.5% for 35 mg via an
epidural catheter. The operation began when analgesia
has reached L1.
Blood pressure, heart rate, respiratory rate, and
peripheral oxygen saturation measured each
2.5 minutes in the first 30 minutes after anesthesia
drugs injected into the epidural space, then every five
minutes during surgery, every 15 minutes for patients
treated in the recovery room and also last measured
every hour during the patient was transferred to the
infirmary. Other data that is observed is the incidence of
hypotension, bradycardia, nausea and vomiting.
If hypotension given ephedrine 5 mg intravenously. In the
event of bradycardia with atropine sulfate 0.1 mg given
intravenously and in case of nausea and vomiting was given
ondansetron 4 mg intravenously.
result
Additional studies have been conducted on the drug
dexamethasone 5 mg of bupivacaine 0.5% compared
with 0.5% pure bupivacaine to block work early and
work long block on 32 patients undergoing orthopedic
surgery
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112 Journal of Anesthesia Perioperative

Table 1 Characteristics of Patients Two Research Group

The sample group
variables The p-value
Bupivacaine + Dexamethasone bupivacaine

Age (years)
mean ± SD 34.25 (13.84) 34 31 (12.58)
0.54
Median 40 28.5
Range 38
Junior high school elementary
education level S1 3355 1393
0.45

Height (cm)
mean ± SD 163 (6.79) 163.75 (6.15)
0.75
Median 162.5 164.5
Range 23 19
Weight (kg)
mean ± SD 59.19 (8.06) 58.31 (9.03)
0.77
Median 57.5 57.5
Range 27 30
Long operation (min)
mean ± SD 184 (65.01) 178.81 (79.09) 150
0.84
Median 182.5 253
Range 232

lower extremities. The research subjects were divided
into 2 groups of 16 subjects with a combination of
dexamethasone 5 mg group and 0.5% bupivacaine and
16 subjects with a 0.5% pure bupivacaine group. The
general characteristics of the two treatment groups
based on age, educational level, height, weight, and
length of surgery is not found significant differences (p>
0.05; Table 1).
At block work for bupivacaine and dexamethasone
group gained an average of
13.56 minutes with a standard deviation of 4.72 minutes, the
median was 12.5 minutes, and range
by 19 minutes. For bupivacaine group gained an
average of 14.31 minutes with a standard deviation of
3.00 minutes, the median of 14 minutes, and range by 10
minutes. According to statistical analysis using Mann
Test
Whitney because of the requirement of normality were
not met, obtained onset of both groups was not
statistically significant (p> 0.05; Table 2; Figure 1).
Working long blocks to bupivacaine and
dexamethasone group gained an average of
399.81 minutes with a standard deviation of
137.90 minutes, the median of 355.5 minutes, and range for
534 minutes. For bupivacaine group gained an average
of 227.44 minutes with a standard deviation of 40.02
minutes, median of 213 minutes, and range
for 170 minutes. Based on a statistical test by using the
Mann-Whitney test for normality requirements are not
met, then we got the job longer block the two groups
statistically significant (p <0.05; Table 3; Figure 2).

Table 2 Characteristics At Work Blocks Epidural

The sample group
Work At Block
Bupivacaine + The p-value
(minute) bupivacaine
Dexamethasone

mean ± SD 13.56 (4.72) 14.31 (3.00) 14

Median 12.5 10 0.27
Range 19

JAP, Volume 3 Number 2, August 2015

The addition of 5 mg Dexamethasone effects on Bupivacaine 0.5% of the Mula and Old Work Sensory Blockade
Bupivacaine + Dexamethasone
Figure 1 Graph At Work Block (Minutes)
Discussion
There are several methods used to accelerate the onset
and increase the working time of sensory and motor
blockade local anesthetic drug used in epidural
anesthesia. Either by increasing the dose of local
anesthetic drugs or by the addition of other drugs
(adjuvant) into the local anesthesia drugs. Increasing
doses of local anesthetic drugs are used is limited by
systemic toxicity the possibility that the greater. Been
much research done on the addition of the adjuvant to
local anesthesia drugs in order to improve the quality of
work of local anesthetic blockade to see also the side
effects resulting from the use of adjuvants should be
minimal and not a new impact for the patient.
Onset of sensory block epidural anesthesia
Table 3 Characteristics of Old Labor Epidural Block
Work Old Block
(minute) Bupivacaine + Dexamethasone
mean ± SD
Median
Range
113
Epidural Anesthesia for Lower Extremity Orthopedic Surgery
bupivacaine
against the combination of dexamethasone 5 mg and
bupivacaine 0.5%, ie 13.56 (4.71) minutes compared
with 0.5% pure bupivacaine group is 14.31 (3.00)
minutes this difference was not statistically significant (p
> 0.05). Although statistically not significant, but clinically
there are differences in onset of action in both treatment
groups. Results are not statistically significant due to the
number of samples that may be lacking.
Working long sensory blockade was longer in the
combination group dexamethasone 5 mg and bupivacaine
0.5%, which is 399.81 (137.90) minutes. Working time
0.5% pure bupivacaine group, namely 227.43 (40.01)
minutes were statistically significant (p <0.05).
Dexamethasone accelerate the origination / onset
working through the effects of a powerful
anti-inflammatory. Increasing doses of local anesthetics by
increasing the concentration of the local anesthetic will
accelerate the onset of sensory and motor blockade. This
is due to the amount of local anesthesia drugs that
penetrate the nerve membrane increases. 6-9
The sample group
The p-value
bupivacaine
399.81 (137.90) 227.44 (40.02) 213
355.5 170 0,00
534
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114 Journal of Anesthesia Perioperative
Bupivacaine + Dexamethasone
Figure 2 Graph Work Old Block (Minutes)
Another mechanism is locally inhibit impulse
conduction myelinated nerve fibers C for corticosteroids
work affects the speed of the nerve cell membrane
synthesis lipoprotein. Corticosteroid molecules enter
cells then pass through the plasma membrane by
passive diffusion. Corticosteroids are reacting with a
specific receptor protein in the cytoplasm of cells and
formed a steroid receptor complex. The complex is
experiencing a change of formation, and then move
towards the nucleus and binds to chromatin. This bond
also stimulates transcription of RNA and synthesis of
specific proteins. Induction of protein synthesis will
produce physiological effects of steroids. 8-11
Another thing that makes dexamethasone accelerate
the onset of local anesthesia drugs is the effect of
dexamethasone as a local anesthetic that works by
inhibiting the action potential of nerve fibers C. Other
studies claim that the action of corticosteroid receptors
in the spinal cord will blockade the activity in the dorsal
horn caused by nerve fibers type C. 10-12
Mechanism of action of dexamethasone in extending
the working time of bupivacaine in epidural anesthesia is
through a reduction in the release of bradykinin, tumor
necrosis factor,
interleukin-1, interleukin-2, interleukin-6,
and also a decrease in the production of prostaglandins.
The decrease prostaglandins play a role in inhibiting pain
via suppression system
JAP, Volume 3 Number 2, August 2015
bupivacaine
siklooksigenasi 1 and 2 in the peripheral tissues and the central
nervous system. 9,11,12
Endogenous Steroids are part of the body's defense
against things that damage cells. Center response to
inflammation is increased synthesis of cytokines that
activates the hypothalamic pituitary adrenal pathway
resulting in increased synthesis of glucocorticoids.
Glucocorticoids will suppress the expression of
cytokines acting on the target cells by means of negative
feedback, then worked as an immunosuppressant
glucocorticoid to a variety of reactions in the immune
system. 8-10
At the molecular level, interact with the glucocorticoid
receptor ligand complex. Therapeutic effects,
anti-inflammatory and immunosuppressant of glucocorticoids
are mediated by different pathways. Gene that carries the
code of anti-inflammatory proteins, such as lipokortin,
interleukin-1,
receptor antagonists, as well as secretory leukocyte
protease inhibitor will undergo stimulation by the
glucocorticoid receptor by interacting with glucocorticoid deoxyribonucleic
acid
(DNA). In contrast, the gene that expresses pro-inflammatory
proteins such as cytokines and chemokines will be suppressed
as a result of interaction with the receptor glukortikoid as
monomer subunit transcription of genes for these proteins. 6,7,9,10
Inflammatory response, metabolic, hormonal, and
immunologic result of the surgery will be activated
immediately upon skin incision so as corticosteroids at
the time
The addition of 5 mg Dexamethasone effects on Bupivacaine 0.5% of the Mula and Old Work Sensory Blockade
Epidural Anesthesia for Lower Extremity Orthopedic Surgery
Preoperative important to get the beneficial effects of
corticosteroids during and also at the time after surgery.
Dexamethasone proved highly profitable to lower this
response because of anti-inflammatory and
immunosuppressive. 9.10
The immediate effects of corticosteroids applied
locally to the nerve fibers that given electrical stimulation
to prove that corticosteroids suppress the transmission
of impulses in nerve fibers of type C are not
bermielinisasi. This type of nerve fibers play a role in the
delivery of pain impulses (nosiseptik). The effect lasts
until corticosteroids are eliminated. 8-12
Synergies between dexamethasone and local
anestestik which are caused by anti-inflammatory and
immunosuppressive effects, due also to the effects of
dexamethasone vasoconstriction due to migration of
inflammatory cells
and also the local acidosis in nerve cells that cause local
anesthetic increasingly ionized and trapped inside nerve
cells. Corticosteroids work also affects the speed of
protein synthesis, binding with proteins that determine
the length of local anesthesia drugs work. This is caused
by the higher its binding with proteins it will be the longer
the local anesthetic to stay in the nerve cell membrane
lipoproteins. 7.9 to 11
knot
Based on the test results of research and discussion it
can be concluded that the addition of dexamethasone 5
mg 0.5% bupivacaine extend the working time of
sensory blockade epidural anesthesia but does not
accelerate the onset of action / onset sensory blockade
epidural anesthesia.
Dexamethasone 5 mg may be used as an alternative
adjuvant to extend the working time of epidural
anesthesia.
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JAP, Volume 3 Number 2, August 2015