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To review the current knowledge of dexmedetomidine as an additive drug to local anesthetics in peripheral and neuraxial regional anesthesia.Recent studies show a perineural mode of action of dexmedetomidine. Pharmacodynamic characteristics of peripheral and neuraxial regional anesthetic techniques are optimized by the addition of dexmedetomidine to long-acting local anesthetics. Bradycardia and sedation are the main systemic side-effects of dexmedetomidine for regional anesthesia purposes. A dose of approximately 100 μg dexmedetomidine for peripheral techniques may represent the optimal balance between optimization of block characteristics and side-effects. Doses between 3 and 10 μg are described to be sufficient for spinal administration.Dexmedetomidine has a potency to ameliorate pharmacodynamic characteristics of peripheral and neuraxial regional anesthetic techniques and is therefore currently the most promising additive drug in regional anesthesia. Future scientific efforts should focus on dose finding studies for particular regional anesthetic techniques. Approval of dexmedetomidine for regional anesthetic indications should be the final target.