Dexmedetomidine versus clonidine as an adjuvant to local anaesthetic in brachial plexus blocks: a metaanalysis of randomised controlled trials

Bajpai, Vijeta; Patel, Tejas K.; Dwivedi, Priyanka; Bajpai, Amrita; Gupta, Astha; Gangwar, Pradeepika; Singh, Yashpal; Agarwal, Richa; Kishore, Surekha

doi:10.1016/j.bjane.2022.07.005

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Brazilian Journal of Anesthesiology

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Sumário

SYSTEMATIC REVIEW • para Braz. J. Anesthesiol. 73 (5) • 2023 • https://doi.org/10.1016/j.bjane.2022.07.005 copy

Dexmedetomidine versus clonidine as an adjuvant to local anaesthetic in brachial plexus blocks: a metaanalysis of randomised controlled trials

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objective:

This meta-analysis aimed to compare the efficacy and safety of dexmedetomidine and Clonidine as an adjuvant to local anesthetics in BPBs.

Methods:

Two investigators independently searched databases to identify all RCTs comparing the efficacy and/or safety of dexmedetomidine and Clonidine as an adjuvant to local anesthetics in BPBs. All outcomes were pooled using the inverse variance method with a random-effect model. An I² test was used to assess heterogeneity. The source of heterogeneity was explored through meta-regression. The quality of the evidence was assessed using the GRADE approach.

Results:

Out of 123 full texts assessed, 24 studies (1448 patients) were included in the analysis. As compared to Clonidine, dexmedetomidine groups showed significantly longer sensory block duration (MD = 173.31; 95% CI 138.02–208.59; I² = 99%; GRADE approach evidence: high); motor block duration (MD = 158.35; 95% CI 131.55–185.16; I² = 98%; GRADE approach evidence: high), duration of analgesia (MD = 203.92; 95% CI 169.25–238.58; I² = 99%; GRADE approach evidence-high), and provided higher grade quality of block (RR = 1.97; 95% CI 1.60–2.41 ; I² = 0%; GRADE approach evidence: moderate). The block positioning technique (regression coefficient: 51.45, p = 0.005) was observed as a significant predictor of the heterogeneity in the case of sensory block duration. No significant difference was observed for the risk of hypotension (RR = 2.59; 95% CI 0.63–10.66; I² = %).

Conclusion:

Moderate to high-quality evidence suggests dexmedetomidine is a more efficacious adjuvant to local anesthetic in BPBs than Clonidine.

KEYWORDS
Dexmedetomidine; Clonidine; Brachial plexus block; Meta-analysis

Author	N° of patients/ study design	Types of surgery	Type of local anesthetic with concentration and volume	Type of blocks/ technique localization	Scale for sensory block	Scale for motor block	Scale for analgesia	Scale for sedation	Analgesic regimen			Efficacy outcomes
Author	N° of patients/ study design	Types of surgery	Type of local anesthetic with concentration and volume	Type of blocks/ technique localization	Scale for sensory block	Scale for motor block	Scale for analgesia	Scale for sedation	Preoperative	Intra operative	Post operative	Efficacy outcomes
Bafna²⁰20 Bafna U, Sharma G, Sapru S, Khandelwal M, Kothari V, Mathur R. Comparison of Clonidine and dexmedetomidine as an adjuvant to 0.5% ropivacaine in supraclavicular brachial plexus block: a prospective, randomized, double-blind and controlled study. J Recent Adv Pain. 2015;1:73–7.	80/ RCT-Double blind	Upper limb surgery	0.50% Ropivacaine 30 mL	SCBP/ Paresthesia	3-point pin prick scale	Modified Bromage Scale	VAS	Four-point Scale	ND	ND	Tramadol 100 mg iv	SBO, MBO, SBD, MBD, DA, SS
Channabasappa²¹21 Channabasappa SM, Shruthi DK, Shobha MM. A comparative study between dexmedetomidine and Clonidine as an adjuvant to ropivacaine in supraclavicular brachial plexus block: a prospective study. J Evolution Med Dent Sci. 2016;5:433–7.	60/ RCT-Double blind	Upper limb orthopedic surgery	0.25% Ropivacaine 35 mL	SCBP/ Nerve Stimulator	3-point pin prick scale	Modified Bromage Scale	NRS	Ramsay Sedation Score	ND	IV midazolam 0.02 mg.kg^–1+ fentanyl 1 μ. kg^–1	Diclofenec 1.5 mg.kg^–1 im	SBO, MBO, SBD, MBD, DA, QB
Harshvardhana²²22 Harshavardhana HS. Efficacy of dexmedetomidine compared to Clonidine added to ropivacaine in supraclavicular nerve blocks: a prospective, randomized, double blind study. Int J Med Health Sci. 2014;3:127–32.	50/ RCT-Double blind	Upper limb orthopedic surgery	0.50% Ropivacaine 29 mL	SCBP/ Paresthesia	Spirit Swab method	Modified Bromage Scale	Not Mentioned	Ramsay Sedation Score	ND	ND	ND	SBO, MBO, SBD, MBD, DA
Jinjil²³23 Jinjil K, Bhatnagar V, Swapna P, Tandon U. Comparative evaluation of alpha two agonists dexmedetomidine with Clonidine as adjuvants to 0.25% ropivacaine for ultrasound guided supraclavicular block: a randomised double-blind prospective study. Int J Healthc Biomed Res. 2015;3:20–31.	60/ RCT-Double blind	Upper limb arm and forearm surgery	0.25% Ropivacaine 20 mL	SCBP/ USG	Hollmen Score	Modified Bromage Scale	VAS	5-point sedation scale.	Alprazolam 0.25 mg p.o.	ND	Diclofenec 75 mg im	SBO, MBO, SBD, MBD, DA
Kakad²⁴24 Kakad RR, Chaudhari DR, Lawhale SS, Ghodki SG, Bite BM. Comparative study between dexmedetomidine and Clonidine as an adjunct to bupivacaine in brachial plexus block in orthopaedic surgeries. J Cont Med A Dent. 2015;3:39–43.	68/ RCT-Double blind	Upper limb orthopedic surgery	0.38% Bupivacaine 40 mL	SCBP/ Nerve Stimulator	3-point pin prick scale	Modified Bromage Scale	ND	University of Michigan Sedation Scale (UMSS)	ND	ND	ND	SBO, MBO, SBD, MBD, AC
Kalyanam²⁵25 Kalyanam P, Julakanti M, Babu BS, Kiran M, Raghuram CG. A prospective randomized study to compare dexmedetomidine with Clonidine as an adjuvant to bupivacaine in supraclavicular brachial plexus block. J Evol Med Dent Sci. 2015;4:15289–97.	60/ RCT-Double blind	Forearm and Hand surgery	0.25% Bupivacaine 35 mL	SCBP/ Nerve Stimulator	3-point pin prick scale	loss of motor function of any nerve	ND	Modified Ramsay sedation score. (12)	ND	ND	Paracetamol 1 gm iv	SBO, MBO, SBD, MBD, DA, SS
Kanvee²⁶26 Kanvee V, Patel K, Doshi M, Vania M, Gandha K. Comparative study of Clonidine and dexmedetomidine as an adjuvant with inj. ropivacaine in supraclavicular brachial plexus block for upper limb surgery. J Res Med Den Sci. 2015;3:127–30.	50/ RCT-Double blind	Upper limb surgery	0.50% Ropivacaine 30 mL	SCBP/ Nerve Stimulator	3-point pin prick scale	Modified Bromage Scale	VAS	ND	Midazolam 0.02 mg.kg^–1	ND	Diclofenec 75 mg im	SBO, MBO, SBD, MBD, DA
Karthik²⁷27 Karthik GS, Sudheer R, Sahajananda H, Rangalakshmi S, Kumar R. Dexmedetomidine and Clonidine as adjuvants to levobupivacaine in supraclavicular brachial plexus block: a comparative randomised prospective controlled study. J Evol Med Dent Sci. 2015;4:3207–21.	50/ RCT-Double blind	Upper limb orthopedic surgery	0.50% Levobupivacaine 30 mL	SCBP/ Paresthesia	3-point pin prick scale	Modified Bromage Scale	VAS	ND	ND	ND	ND	SBO, MBO, SBD, MBD, DA, SS
Kataria²⁸28 Kataria AP, Jarewal V, Singh G, Attri JP. Comparison of dexmedetomidine and Clonidine as an adjuvant to levobupivacaine in supraclavicular brachial plexus block. Int J Med Res Rev. 2017;5:399–404.	60/ RCT-Double blind	Upper limb orthopedic surgery	0.50% Levobupivacaine 30 mL	SCBP/ Nerve Stimulator	3-point pin prick scale	3-point pin prick scale	VAS	ND	Alprazolam 0.25 mg	IV Ketamine-0.5 mg.Kg^–1	ND	MBD, DA
Kirubhar²⁹29 Kirubahar R, Bose S, Kanna V, Murugadoss K. Comparison of Clonidine and dexmedetomidine as an adjuvant to bupivacaine in supraclavicular brachial plexus block for upper limb orthopedic procedures. Int J Res Med Sci. 2016;4:1172–6.	60/ RCT- Open label	Upper limb orthopedic Surgery	0.38% Bupivacaine 35 mL	SCBP/ Paresthesia	Hollmen Score	Modified Bromage Scale	ND	ND	ND	ND	ND	SBO, MBO, SBD, MBD, DA
Munshi³⁰30 Munshi FA, Bano F, Khan AA, Saleem B, Rather MA. Comparison of dexmedetomidine and Clonidine as an adjuvant to bupivacaine in supraclavicular brachial plexus block: a randomised double-blind prospective study. J Evol Med Dent Sci. 2015;4:7263–78.	60/ RCT-Double blind	Upper limb orthopedic surgery	0.25% Bupivacaine 30 mL	SCBP/ Paraesthesia	3-point pin prick scale	Modified Bromage Scale	NRS	Ramsay Sedation Score	ND	ND	Diclofenec 75 mg im	SBO, MBO, SBD, MBD, DA, QB
Narolia³¹31 Narolia AK, Bhati K, Saini K, Pareek A, Kumari K. To Compare the effect of dexmedetomidine and Clonidine as adjuvant to ropivacaine in supraclavicular brachial plexus block for upper limb surgery. IAIM. 2017;4:82–90.	60/ RCT-Double blind	Upper limb orthopedic surgery	0.75% Ropivacaine 30 mL	SCBP/ Nerve Stimulator	3-point pin prick scale	Modified Bromage Scale	VAS	Ramsay Sedation Score	Alprazolam 0.5 mg and ranitidine 150 mg p.o. at night	ND	Paracetamol iv	SBO, MBO, SBD, MBD, DA, SS, CSB
Nazir³²32 Nazir O, Bhat AH, Sharma T, Khatuja A, Misra R. Comparison of Clonidine and dexmedetomidine as adjuvants for ropivacaine in supraclavicular brachial plexus block. Sri Lankan J Anaesthesiol. 2019;27:53–8.	50/ RCT-Not specified blinding	Upper limb surgery	0.50% Ropivacaine 30 mL	SCBP/ Nerve Stimulator	3-point pin prick scale	Modified Bromage Scale	VAS	ND	ND	ND	ND	SBO, MBO, SBD, MBD, DA, AC
Palai³³33 Palai PK, Soren DK, Panda P, Das SK. A comparative study of Clonidine and dexmedetomidine as an adjuvant in supraclavicular brachial plexus block. J Evol Med Dent Sci. 2018;7:1806–10.	60/ RCT-Double blind	Forearm surgery	0.5% + 2% Bupivacaine + Lignocaine with Adrenaline 2 mg.kg^–1 + 5 mg. kg^–1	SCBP/ ND	Hollmen Score	Modified Bromage Scale	VAS	Ramsay Sedation Score	Alprazolam 0.5 mg and ranitidine 150 mg p.o. at night	ND	ND	SBO, MBO, SBD, MBD, DA, CSB, CMB
Rao³⁴34 Rao KG, Kapoor P, Chaurasiya MK, Shukla A. A Randomised double blind prospective study to compare Clonidine and dexmedetomidine as an adjuvant in supra-clavicular brachial plexus block. Indian J Fundamental Appl Life Sci. 2014;4:226–9.	60/ RCT-Double blind	Upper limb surgery	0.25% Bupivacaine 38 mL	SCBP/ Paresthesia	Cold Alcohol Swabs	Modified Bromage Scale	VAS	ND	ND	ND	Diclofenec 1–5 mg.kg^–1 im	SBO, MBO, SBD, MBD, DA
Reddy³⁵35 Reddy MS, Bhaskar KU, Paturu M, Srinivasan KV. A comparative study of the efficacy of dexmedetomidine and Clonidine as an adjuvant to bupivacaine in supraclavicular brachial plexus block. Indian J Anesth Analg. 2020;7:562–9.	60/ RCT-Double blind	Upper limb surgery	0.33% Bupivacaine 30 ml	SCBP/ Nerve Stimulator	3-point pin prick scale	Modified Bromage Scale	NRS	Modified Ramsay Sedation Score RSS	ND	IV midazolam 0.02 mg.kg^–1+ fentanyl 1 μ. kg^–1	Diclofenec 1.5 mg.kg^–1 im	SBO, MBO, SBD, MBD, DA, QB
Sebastian³⁶36 Sebastian D, Ravi M, Dinesh K, Somasekharam P. Comparison of dexmedetomidine and Clonidine as adjuvant to ropivacaine in supraclavicular brachial plexus nerve blocks. J Dent Med Sci. 2015;14:91–7.	60/ RCT-Double blind	Upper limb urgery	0.50% Ropivacaine 29 mL	SCBP/ Nerve Stimulator	3-point pin prick scale	Modified Bromage Scale	VAS	ND	ND	ND	Tramadol 100 mg iv	SBO, MBO, SBD, MBD, DA
Sharma³⁷37 Sharma A, Sharma A, Sharma A, Sood A, Sharma G, Thakur A. Comparison of Clonidine with dexmedetomidine as an adjuvant to local anesthetic agent in supraclavicular brachial plexus block. Indian J Anesth Analg. 2019;6:1889–93.	60/ RCT-Double blind	Upper limb orthopedic surgery	0.25% Bupivacaine 35 mL	SCBP/ Paresthesia	3-point pin prick scale	Modified Bromage Scale	VAS	ND	Alprazolam 0.5 mg	IV midazolam 0.02 mg.kg^–1+ fentanyl 1 μ. kg^–1	ND	SBO, MBO, SBD, MBD, DA, AC
Singh³⁸38 Singh R, Singam A. Comparative evaluation of dexmedetomedine versus Clonidine as an adjuvant in supraclavicular brachial plexus block. J Krishna Inst Med Sci Univ. 2019;8:2231–4261.	60/ RCT-Open label	^a a Emergency hemodynamically stable patients were also included. Upper limb surgery excluding shoulder surgery	0.50% Ropivacaine 30 mL	SCBP/ Nerve Stimulator	3-point pin prick scale	Modified Bromage Scale	VAS	ND	No premedication given	ND	Diclofenec 1.5 mg.kg^–1 im	SBO, MBO, SBD, MBD, DA, CSB, CMB
Sinha³⁹39 sur S Sinha S, Pal S, Chaterjee S, Pahari S. Comparative evaluation of efficacy and duration of analgesia of Clonidine and dexmedetomidine as adjuvant to bupivacaine in supraclavicular brachial plexus nerve block in upper limb orthopaedic surgery. Int Res J Nat Appl Sci. 2017;4:231–44.	80/ RCT-Double blind	Upper limb orthopedic surgery	0.25% Bupivacaine 38 mL	SCBP/ Nerve Stimulator	3-point pin prick scale	Modified Lovett Rating Scale.	VAS	Modified Ramsay Sedation Score RSS	Alprazolam 0.25 mg and	ND	Diclofenec 3 mg.kg^–1 im	SBO, MBO, DA
									omeprazole 20 mg p.o. at bedtime
Spurthi⁴⁰40 Spurthi George B, Lagoo J. Comparison of low dose dexmedetomidine and Clonidine as additives to bupivacaine in ultrasound directed supraclavicular blocks. Indian J Clin Anaesth. 2019;6:134–9.	60/ RCT-Double blind	Upper limb surgery	0.38% Bupivacain 25 mL	SCBP/ USG	3-point pin prick scale	Modified Bromage	Not Mentioned	Ramsay Sedation Score	ND	ND	ND	SBO, MBO, SBD, MBD, DA, SS
Swami⁴¹41 Swami SS, Keniya VM, Ladi SD, Rao R. Comparison of dexmedetomidine and Clonidine (a2 agonist drugs) as an adjuvant to local anaesthesia in supraclavicular brachial plexus block: A randomised double-blind prospective study. Indian J Anaesth. 2012;56:243–9.	60/ RCT-Double blind	Upper limb orthopedic surgery	0.25% Bupivacaine 35 mL	SCBP/ Nerve Stimulator	3-point pin prick scale	Modified Bromage Scale	NRS	Ramsay Sedation Score	ND	IV midazolam 0.02 mg.kg^–1+ fentanyl 1μ. kg^–1	Diclofenec 1.5 mg.kg^–1 im	SBO, MBO, SBD, MBD, DA, QB
Tandon⁴²42 Tandon N, Gupta M, Agrawal J, et al. A comparative clinical study to evaluate the efficacy of levobupivacaine with Clonidine and levobupivacaine with dexmedetomidine in supraclavicular brachial plexus block. J Evol Med Dent Sci. 2016;5:925–9.	60/ RCT-Double blind	Upper limb surgery	0.50% Levobupivacaine 30 mL	SCBP/ Nerve Stimulator	3-point pin prick scale	Modified Lovett Rating Scale.	VAS	Chernik Sedation Score	ND	ND	ND	SBO, MBO, SBD, MBD
Tripathi⁴³43 Tripathi A, Sharma K, Somvanshi M, Samal RL. A comparative study of Clonidine and dexmedetomidine as an adjunct to bupivacaine in supraclavicular brachial plexus block. J Anaesthesiol Clin Pharmacol. 2016;32:344–8.	60/ RCT-Double blind	Upper limb orthopedic surgery	0.25% Bupivacaine 39 mL	SCBP/ Nerve Stimulator	3-point pin prick scale	Modified Bromage Scale	VAS	ND	Midazolam 2 mg iv	ND	Diclofenec 75 mg im	SBO, MBO, SBD, MBD, DA, QB

Certainty assessment		Effect	Certainty							N°of patients
N° of studies	Study design	Risk of bias	Inconsistency	Indirectness	Imprecision	Other considerations	Dexmedetomidine	Clonidine	Absolute (95% CI)
Sensory block duration 21	Randomized trials	Not serious	Serious^a a Heterogeneity (I2 = 99%).	Not serious	Not serious	Strong association	624	624	MD 173.31 Minutes higher (138.02 higher to 208.59 higher)	⨁⨁⨁⨁ High
Motor block duration 23	Randomized trials	Not serious	Serious^b b Heterogeneity (I2 = 98%).	Not serious	Not serious	Strong association	684	684	MD 158.35 Minutes higher (131.55 higher to 185.16 higher)	⨁⨁⨁⨁ High
Duration of analgesia 22	Randomized trials	Not serious	Serious^c c Heterogeneity (I2 = 99%).	Not serious	Not serious	Strong association	690	690	MD 203.92 Minutes higher (169.25 higher to 238.58 higher)	⨁⨁⨁⨁ High

Sociedade Brasileira de Anestesiologia (SBA) Rua Professor Alfredo Gomes, 36, Botafogo , cep: 22251-080 - Rio de Janeiro - RJ / Brasil , tel: +55 (21) 97977-0024 - Rio de Janeiro - RJ - Brazil
E-mail: editor.bjan@sbahq.org

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[1] * Corresponding author. E-mail: dr.tkp2006@yahoo.co.in (T.K. Patel).