Effect of Perioperative Intravenous Lidocaine Administration on Pain, Opioid Consumption, and Quality of Life after Complex Spine Surgery

[Risk factors for nausea and vomiting after adolescent idiopathic scoliosis surgery]

OBJECTIVE

To explore risk factors for postoperative nausea and vomiting (PONV) that requires intervention with medications during adolescent idiopathic scoliosis (AIS) surgery.

METHODS

We analyzed the data of 986 patients with AIS (including 156 male and 830 female patients) undergoing scoliosis surgery through a posterior approach between December, 2012 and January, 2016 in Nanjing Drum Tower Hospital. The data were collected from the patients including ASA grade, body mass index (BMI), Cobb angle, preoperative respiratory and cardiovascular diseases, operation time, type of anesthesia, quantity of intraoperative liquid infusion, blood loss, urine volume, the lowest MAP and CVP, intraoperative fentanyl consumption, and intraoperative administration of dexmedetomidine, dexamethasone, ondansetran and droperidol. The incidence of PONV in 48 h following the surgery, hemoglobin variation after operation (ΔHb), postoperative analgesia, times of use and types of antiemetic drugs, and postoperative hospital stay were recorded for all the patients. The potential risk factors of PONV within 48 h were analyzed using univariate analysis and multivariate logistic regression.

RESULTS

Of the 986 patients analyzed, 151 (15.3%) experienced PONV within 48 h following surgeries for AIS. Multivariate logistic regression analysis suggested that an high intraoperative fentanyl dose (> 0.65 mg; OR=9.303, 95% CI: 2.373-8.622, P < 0.001), an obvious ΔHb (> 28.5 g/L; OR=1.107, 95% CI: 1.060-1.157, P < 0.001), and postoperative analgesia with fentanyl (OR=11.671, 95% CI: 2.381-11.284, P < 0.001) were risk factors for PONV. Intraoperative administration of dexmedetomidine (OR=0.027, 95% CI: 0.006-0.123, P=0.002) and dexamethasone combined with ondansetron (OR=0.241, 95%CI: 0.066-0.886, P=0.032) were protective factors against PONV.

CONCLUSIONS

A high-dose intraoperative fentanyl consumption, a marked ΔHb, and postoperative analgesia with fentanyl are risk factors for PONV while intraoperative administration of dexmedetomidine and dexamethasone combined with ondansetron are protective factors against PONV following surgeries for AIS.

Lidocaine Reduces Sevoflurane Consumption and Improves Recovery Profile in Children Undergoing Major Spine Surgery

Background

Intravenous lidocaine administered during surgery improves postoperative outcomes; however, few studies have evaluated the relationship between intravenous lidocaine and volatile anesthetics requirements. This study assessed the effects of lidocaine treatment on sevoflurane consumption and postoperative consciousness disorders in children undergoing major spine surgery.

Material/Methods

Patients were randomly divided into 2 treatment groups: lidocaine and placebo (control). The lidocaine group received lidocaine as a bolus of 1.5 mg/kg over 30 min, followed by a continuous infusion at 1 mg/kg/h to 6 h after surgery. The following data were assessed: end-tidal sevoflurane concentration required to maintain a bispectral index BIS between 40 and 60, intraoperative blood pressure, heart rate, demand for fentanyl, and consciousness level assessed after surgery using the Richmond Agitation-Sedation Scale. Any treatment-related adverse events were recorded.

Results

Compared to the control group, lidocaine treatment reduced by 15% the end-tidal sevoflurane concentration required to maintain the intraoperative hemodynamic stability and appropriate level of anesthesia (P=0.0003). There were no intergroup differences in total dose of fentanyl used, average mean arterial pressure, or heart rate measured intraoperatively. The postoperative level of patient consciousness did not differ during the first 6 h between groups. After 9 h, more patients in the control group were still sleepy (P=0.032), and there were fewer perioperative complications in the lidocaine group.

Conclusions

Lidocaine treatment decreases sevoflurane consumption and improves recovery profiles in children undergoing major spine surgery.

Effect of Intravenous Lidocaine Infusion on Postoperative Early Recovery Quality in Upper Airway Surgery

OBJECTIVES/HYPOTHESIS

Systemic infusions of lidocaine have been widely used as perioperative analgesic adjuvants. The aim of this randomized, double-blinded, controlled trial was to investigate the effect of perioperative lidocaine infusion on postoperative early recovery quality in upper airway surgery.

STUDY DESIGN

Prospective, randomized, double-blinded, placebo-controlled trial.

METHODS

A total of 99 patients were randomly assigned to the lidocaine group (group L) or the control group (group C). The patients received 2 mg/kg lidocaine completed within 10 minutes before the induction of anesthesia followed by continuous infusions of 2 mg/kg/hr lidocaine (group L) or the same volume of 0.9% normal saline (group C) intravenously during anesthesia. The Quality of Recovery-40 (QoR-40) survey was administered on the preoperative day (Pre) and postoperative days 1 (POD1) and 2 (POD2). The primary endpoint was QoR-40 score on POD1 and POD2.

RESULTS

Compared with Pre, global QoR-40 scores on POD1 and POD2 were significantly lower (P < .05). Compared with group C, global QoR-40 scores were significantly higher in group L on POD1 and POD2 (P < .05). Among the five dimensions of QoR-40, the scores for physical comfort, emotional state, and pain were superior in group L compared to group C (P < .05). Compared with group C, the consumption of remifentanil and diclofenac as well as the incidence of postoperative nausea and vomiting (PONV) and postoperative 48-hour numeric rating scale (NRS) scores in group L were significantly lower (P < .05).

CONCLUSIONS

Systemic lidocaine infusion can improve QoR-40 scores in patients with upper airway surgery, reduce the dosage of intraoperative opioids, decrease the incidence of PONV and NRS scores 2 days after surgery, thus improving postoperative early recovery quality.

LEVEL OF EVIDENCE

1b Laryngoscope, 131:E63-E69, 2021.

The identification of risk factors for increased postoperative pain following minimally invasive transforaminal lumbar interbody fusion

PURPOSE

To evaluate specific demographic and perioperative variables associated with higher inpatient pain scores following minimally invasive transforaminal lumbar interbody fusion (MIS TLIF).

METHODS

Patients who underwent a single-level, primary MIS TLIF were retrospectively reviewed. Perioperative outcomes were collected, and postoperative inpatient VAS pain scores were measured. Both bivariate and stepwise multivariate Poisson regressions with robust error variance were used to assess risk factors for average inpatient pain score ≥ 5.0. A final backward stepwise regression model was created using age, gender, smoking status, diabetes status, insurance status, BMI, comorbidity burden, pedicle screw laterality, operative time, and estimated blood loss.

RESULTS

A total of 255 patients undergoing primary, single-level MIS TLIF were included. Age less than 50 years, workers' compensation insurance, preoperative VAS pain score ≥ 7, and operative duration ≥ 110 min were associated with greater postoperative pain. However, other variables such as gender, BMI, smoking status, comorbidity burden, diabetes status, and pedicle screw laterality were not associated with increased postoperative pain.

CONCLUSION

The results of this study suggest that younger age, workers' compensation, elevated preoperative pain scores, and longer operative times are independently associated with greater inpatient pain following TLIF. Surgeons can use this information to better assess which patients may require additional pain control following TLIF. Patient expectations of postoperative outcomes in regard to pain and recovery may also be better managed. These slides can be retrieved under Electronic Supplementary Material. (paragraph). Then process the ppt slide as graphical image.

Anesthetic management of complex spine surgery in adult patients: a review based on outcome evidence

PURPOSE OF REVIEW

The aim of this article is to review the evidence regarding the anesthetic management of blood loss, pain control, and position-related complications of adult patients undergoing complex spine procedures.

RECENT FINDINGS

The most recent evidence of the anesthetic management of complex spine surgery was identified with a systematic search and graded. In our review, prophylactic tranexamic acid and optimal prone positioning were shown to be effective blood conservation strategies with minimal risks to the patients. Cell saver was cost-effective in complex surgeries with expected blood loss of greater than 500 ml. As for pain control, most interventions only produced mild analgesic effects, suggesting a multimodal approach is necessary to achieve optimal pain control after spine surgery. Regional techniques and NSAIDs were effective but because of their risks, their usage should be discussed with the surgical team. Further studies are required to assess the effectiveness, cost-effectiveness, and risks associated with combined uses of different analgesic interventions. On the basis of the available evidence, we recommend a combined use of gabapentinoids, ketamine, and opioids to achieve optimal analgesia. Lastly, literature for position-related injuries is heavily relied on case reports and the Anesthesia Closed Claim Study because of their rarity. Therefore, we advocate for a structured team-based approach with checklists to minimize position-related complications.

SUMMARY

As the number and complexity of spine procedures are being performed worldwide is increasing, we suggested to bundle the aforementioned effective interventions as part of an ERAS spine protocol to improve the patient outcome of spine surgery.

Evolving the management of acute perioperative pain towards opioid free protocols: a narrative review

Objective: Identification of pain as the fifth vital sign has resulted in over-prescription and overuse of opioids in the US, with addiction reaching epidemic proportions. In Europe, and more recently in the US, a shift has occurred with the global adoption of multimodal analgesia (MMA), which seeks to minimize perioperative opioid use. Improved functional outcomes and reduced healthcare utilization costs have been demonstrated with MMA, but wide scale use of opioids in pain management protocols continues. As a next step in the pain management evolution, opioid-free analgesia (OFA) MMA strategies have emerged as feasible in many surgical settings.Methods: Articles were limited to clinical studies and meta-analyses focusing on comparisons between opioid-intensive and opioid-free/opioid-sparing strategies published in English.Results: In this review, elimination or substantial reduction in opioid use with OFA strategies for perioperative acute pain are discussed, with an emphasis on improved pain control and patient satisfaction. Improved functional outcomes and patient recovery, as well as reduced healthcare utilization costs, are also discussed, along with challenges facing the implementation of such strategies.Conclusions: Effective MMA strategies have paved the way for OFA approaches to postoperative pain management, with goals to reduce opioid prescriptions, improve patient recovery, and reduce overall healthcare resource utilization and costs. However, institution-wide deployment and adoption of OFA is still in early stages and will require personalization and better management of patient expectations.

Continuous Intravenous Lidocaine as an Effective Pain Adjunct for Opioid-Induced Bowel Dysfunction: A Case Report

This case study describes a patient with suspected opioid-induced bowel dysfunction who had improved pain control when treated with intravenous (IV) lidocaine. An 80-year-old man with failed back surgery syndrome managed with an intrathecal (IT) pump presented with protracted abdominal pain. The acute pain service initiated a lidocaine infusion at 1 mg·min, and the patient reported significant pain relief. The patient experienced refractory abdominal pain with 3 attempts to wean the lidocaine infusion. Eventually, a successful transitional regimen was achieved with methylnaltrexone and transdermal lidocaine patches. Lidocaine infusions may be an effective and underutilized multimodal adjunct for nonsurgical pain conditions.

Anesthesia and postoperative pain control-multimodal anesthesia protocol

Multimodal analgesia (MMA) involves the use of additive or synergistic combinations of analgesics to achieve clinically required analgesia while minimizing significant side effects associated with higher dose of a single equianalgesic medication such as an opioid analgesic. MMA generally involves optimizing non-opioid pharmacologic and non-pharmacologic interventions and reserving opioid use to treat breakthrough pain. Patients receiving medications via MMA protocols are likely to have lower opioid consumption compared to those managed using primarily IV opioid patient-controlled analgesia. MMA pain management strategies have become important components of enhanced recovery after surgery (ERAS) protocols in an effort to optimize care by standardizing analgesic medications in the perioperative setting while minimizing adverse effects and improving quality and patient outcomes. Successful implementation of a MMA requires the input and cooperation of all of the stakeholders including the caregivers as well as the patients. Health system benefits can also be realized from the implementation of an effective MMA, as fewer opioid related side effects can improve patient recovery and lead to faster discharge and improved utilization of resources.

Incidence and Risk Factors for Chronic Postoperative Opioid Use After Major Spine Surgery: A Cross-Sectional Study With Longitudinal Outcome

BACKGROUND

Chronic opioid use is a significant public health concern. Surgery is a risk factor for developing chronic opioid use. Patients undergoing major spine surgery frequently are prescribed opioids preoperatively and may be at risk for chronic opioid use postoperatively. The aim of this study was to investigate the incidence of and perioperative risk factors associated with chronic opioid use after major spine surgery.

METHODS

The records of patients who underwent elective major spine surgery at the University of Virginia between March 2011 and February 2016 were retrospectively reviewed. The primary outcome was chronic opioid use through 12 months postoperatively. Demographic data, medical comorbidities, preoperative pain scores, and medication use including daily morphine-equivalent (ME) dose, intraoperative use of lidocaine and ketamine, estimated blood loss, postoperative pain scores and medication use, and postoperative opioid use were collected. Logistic regression models were used to examine factors associated with chronic opioid use.

RESULTS

Of 1477 patient records reviewed, 412 patients (27.9%) were opioid naive and 1065 patients (72.3%) used opioids before surgery. Opioid data were available for 1325 patients, while 152 patients were lost to 12-month follow-up and were excluded. Of 958 preoperative opioid users, 498 (52.0%) remained chronic users through 12 months. There was a decrease in opioid dosage (mg ME) from preoperative to 12 months postoperatively with a mean difference of -14.7 mg ME (standard deviation, 1.57; 95% confidence interval [CI], -17.8 to -11.7). Among 367 previously opioid-naive patients, 67 (18.3%) became chronic opioid users. Factors associated with chronic opioid use were examined using logistic regression models. Preoperative opioid users were nearly 4 times more likely to be chronic opioid users through 12 months than were opioid-naive patients (odds ratio, 3.95; 95% CI, 2.51-6.33; P < .001). Mean postoperative pain score (0-10) was associated with increased odds of chronic opioid use (odds ratio for a 1 unit increase in pain score 1.25, 95% CI, 1.13-1.38; P < .001). Use of intravenous ketamine or lidocaine was not associated with chronic opioid use through 12 months.

CONCLUSIONS

Greater than 70% of patients presenting for major spine surgery used opioids preoperatively. Preoperative opioid use and higher postoperative pain scores were associated with chronic opioid use through 12 months. Use of ketamine and lidocaine did not decrease the risk for chronic opioid use. Surveillance of patients for these factors may identify those at highest risk for chronic opioid use and target them for intervention and reduction strategies.

Adjuvant analgesics in spinal surgery

Peri- and postoperative pain control can present a challenge to any doctor, particularly in the setting of spinal surgery. The use of adjuvant pain agents and multimodal analgesia is changing the face of modern anaesthesia and offering clinicians more avenues to control perioperative pain. This article discusses the use of adjuvant medications and some of the evidence surrounding their use in spinal surgery.

Analgesic effects of amiodarone in mouse models of pain

Purpose: Although amiodarone is classified as a Vaughan-Williams class Ⅲ antiarrhythmic drug, it has inhibitory effects on voltage-gated sodium and calcium channels and on β-adrenergic receptors. Given these pharmacological profiles, amiodarone may have analgesic properties. Most patients who are prescribed amiodarone possess multiple cardiovascular risk factors. Despite the fact that pain plays a crucial role as a clinical indicator of cardiovascular events, the effects of amiodarone on pain have not been investigated. The aim of the current study was to investigate the analgesic effects of amiodarone by using mouse models of pain in an effort to elucidate underlying mechanisms. Methods: Adult male C57B6 mice received single bolus intraperitoneal injections of amiodarone at doses of 25, 50, 100, and 200 mg/kg, while the mice in the control group received only normal saline. The analgesic effects of amiodarone were evaluated using the acetic acid-induced writhing test, formalin test, and tail withdrawal test. In addition, the potassium channel opener NS1643, voltage-gated sodium channel opener veratrine, calcium channel opener BAYK8644, and selective β-adrenergic agonist isoproterenol were used to uncover the underlying mechanism. Results: During the acetic acid-induced writhing test, formalin test, and tail withdrawal test, amiodarone induced analgesic responses in a dose-dependent manner. The analgesic effects of amiodarone were abolished by veratrine but not by NS1643, BAYK8644, or isoproterenol. Conclusion: Amiodarone induced analgesic responses in a dose-dependent manner, likely by blocking voltage-gated sodium channels. These results indicate that clinical doses of amiodarone can affect nociception and may mask or attenuate pain induced by acute cardiovascular events.

Pain management in neurocritical care; an update

PURPOSE OF REVIEW

Pain management in neurocritical care is a subject often avoided because of concerns over the side-effects of analgesics and the potential to cause additional neurological injury with treatment. The sedation and hypercapnia caused by opioids have been feared to mask the neurological examination and contribute to elevations in intracranial pressure. Nevertheless, increasing attention to patient satisfaction has sparked a resurgence in pain management. As opioids have remained at the core of analgesic therapy, the increasing attention to pain has contributed to a growing epidemic of opioid dependence. In this review, we summarize the most recent literature regarding opioids and their alternatives in the treatment of acute pain in patients receiving neurocritical care.

RECENT FINDINGS

Studies on pain management in neurocritical care continue to explore nonopioid analgesics as part of a multimodal strategy aimed at decreasing overall opioid consumption. Agents including local anesthetics, acetaminophen, ketamine, gabapentinoids, and dexmedetomidine continue to demonstrate efficacy. In addition, the prolonged longitudinal course of many recent trials has also revealed more about the transition from acute to chronic pain following hospitalization.

SUMMARY

In an era of increasing attention to patient satisfaction mitigated by growing concerns over the harms imposed by opioids, alternative analgesic therapies are being investigated with promising results.

Evaluation of intravenous lidocaine in head and neck cancer surgery: study protocol for a randomized controlled trial

BACKGROUND

Pain after major head and neck cancer surgery is underestimated and has both nociceptive and neuropathic characteristics. Extended resection, flap coverage, nerve lesions, inflammation, and high-dose opioid administration can also lead to hyperalgesia and chronic postoperative pain. Opioids are frequently associated with adverse events such as dizziness, drowsiness, nausea and vomiting, or constipation disturbing postoperative recovery and extending the length of hospital stay. Patients eligible for major head and neck cancer surgery cannot benefit from full multimodal pain management with locoregional anesthesia. Intravenous lidocaine, investigated in several studies, has been found to decrease acute pain and morphine consumption. Some data suggest also that it can prevent chronic postsurgical pain. Evidence supporting its use varies between surgical procedures, and there is no published study regarding systemic lidocaine administration in major head and neck cancer surgery. We hypothesized that intravenous lidocaine infused in the perioperative period would lead to opioid sparing and chronic postsurgical pain reduction.

METHODS/DESIGN

A total of 128 patients undergoing major head and neck surgery will be included in this prospective two-center, double-blind, randomized controlled trial. Patients will be randomly assigned to lidocaine or placebo treatment. After induction of general anesthesia, an intravenous lidocaine bolus will be administered (1.5 mg.kg^- 1), followed by a continuous infusion (2 mg.kg^- 1.h^- 1) which will be reduced in the postanesthesia care unit (1 mg.kg^- 1.h^- 1). The primary outcome measure is morphine consumption 48 h after surgery. The secondary outcomes include intraoperative remifentanil consumption, morphine consumption 24 h after surgery, and chronic postsurgical pain that will be assessed 3-6 months after surgery.

DISCUSSION

Recent evidence suggests that intravenous lidocaine can lead to opioid sparing and chronic postsurgical pain reduction for certain types of surgery. This is the first trial to prospectively investigate the efficacy and safety of intravenous lidocaine in major head and neck cancer surgery.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02894710 . Registered on 11 August 2016.

Development and implementation of a comprehensive spine surgery enhanced recovery after surgery protocol: the Cleveland Clinic experience

Enhanced recovery after surgery (ERAS) protocols have been shown to be effective at reducing perioperative morbidity and costs while improving outcomes. To date, spine surgery protocols have been limited in scope, focusing only on specific types of procedures or specific parts of the surgical episode. The authors describe the creation and implementation of one of the first comprehensive ERAS protocols for spine surgery. The protocol is unique in that it has a comprehensive perioperative paradigm encompassing the entire surgical period that is tailored based on the complexity of each individual spine patient.

Effect of magnesium and lignocaine on post-craniotomy pain: A comparative, randomized, double blind, placebo-controlled study

Background:

Lignocaine and Magnesium have an analgesic action and reduce perioperative opioid requirements. We carried out this study to evaluate the effect of magnesium and lignocaine on postoperative pain as assessed using the visual analog scale (VAS) and fentanyl consumption. We also measured S-100 B levels and noted the side effect of drugs if any.

Materials and Methods:

In this prospective preliminary study, 45 patients undergoing supratentorial craniotomy for tumor surgery were randomized to receive either lignocaine (group I-1.5 mg/kg bolus followed by 2 mg/kg/h infusion), saline (Group II) or magnesium (group III: bolus of 50 mg/kg followed by 25 mg/kg/hr) intraoperatively. The amount of fentanyl required, VAS over first 24 hours and any side effects were noted. S100 B levels were also measured to assess brain protective effect of these drugs, if any. Appropriate statistical tests were applied for analysis of data and a P value < 0.05 was considered statistically significant.

Results:

None of the patient experienced any adverse hemodynamic effect intraoperatively secondary to the study drugs. The amount of intraoperative fentanyl consumption was comparable among the three groups. The mean VAS score was significantly less in group I and III [Group I (15.3 ± 6.0), Group II (24.8 ± 6.7), Group III (17.9 ± 7.6); (P < 0.01)]. The fentanyl consumed in first 24 hours was significantly less in those patients who received lignocaine and magnesium [Group I (204.4 ± 136.4), Group II (383 ± 168.2), Group III (194 ± 148.9); (P = 0.01)]. S100 value did not differ in the lignocaine and the saline group during the perioperative period. However, a significant decline was noted in the levels of S100 B in the magnesium group.

Conclusion:

Intraoperative infusion of lignocaine and magnesium results in lower VAS score and decreases the postoperative opioid requirement in patients undergoing craniotomy for excision of supratentorial tumors.

Designing the ideal perioperative pain management plan starts with multimodal analgesia

Multimodal analgesia is defined as the use of more than one pharmacological class of analgesic medication targeting different receptors along the pain pathway with the goal of improving analgesia while reducing individual class-related side effects. Evidence today supports the routine use of multimodal analgesia in the perioperative period to eliminate the over-reliance on opioids for pain control and to reduce opioid-related adverse events. A multimodal analgesic protocol should be surgery-specific, functioning more like a checklist than a recipe, with options to tailor to the individual patient. Elements of this protocol may include opioids, non-opioid systemic analgesics like acetaminophen, non-steroidal anti-inflammatory drugs, gabapentinoids, ketamine, and local anesthetics administered by infiltration, regional block, or the intravenous route. While implementation of multimodal analgesic protocols perioperatively is recommended as an intervention to decrease the prevalence of long-term opioid use following surgery, the concurrent crisis of drug shortages presents an additional challenge. Anesthesiologists and acute pain medicine specialists will need to advocate locally and nationally to ensure a steady supply of analgesic medications and in-class alternatives for their patients’ perioperative pain management.

Local anaesthetics and regional anaesthesia versus conventional analgesia for preventing persistent postoperative pain in adults and children

BACKGROUND

Regional anaesthesia may reduce the rate of persistent postoperative pain (PPP), a frequent and debilitating condition. This review was originally published in 2012 and updated in 2017.

OBJECTIVES

To compare local anaesthetics and regional anaesthesia versus conventional analgesia for the prevention of PPP beyond three months in adults and children undergoing elective surgery.

SEARCH METHODS

We searched CENTRAL, MEDLINE, and Embase to December 2016 without any language restriction. We used a combination of free text search and controlled vocabulary search. We limited results to randomized controlled trials (RCTs). We updated this search in December 2017, but these results have not yet been incorporated in the review. We conducted a handsearch in reference lists of included studies, review articles and conference abstracts. We searched the PROSPERO systematic review registry for related systematic reviews.

SELECTION CRITERIA

We included RCTs comparing local or regional anaesthesia versus conventional analgesia with a pain outcome beyond three months after elective, non-orthopaedic surgery.

DATA COLLECTION AND ANALYSIS

At least two review authors independently assessed trial quality and extracted data and adverse events. We contacted study authors for additional information. We presented outcomes as pooled odds ratios (OR) with 95% confidence intervals (95% CI), based on random-effects models (inverse variance method). We analysed studies separately by surgical intervention, but pooled outcomes reported at different follow-up intervals. We compared our results to Bayesian and classical (frequentist) models. We investigated heterogeneity. We assessed the quality of evidence with GRADE.

MAIN RESULTS

In this updated review, we identified 40 new RCTs and seven ongoing studies. In total, we included 63 RCTs in the review, but we were only able to synthesize data on regional anaesthesia for the prevention of PPP beyond three months after surgery from 39 studies, enrolling a total of 3027 participants in our inclusive analysis.Evidence synthesis of seven RCTs favoured epidural anaesthesia for thoracotomy, suggesting the odds of having PPP three to 18 months following an epidural for thoracotomy were 0.52 compared to not having an epidural (OR 0.52 (95% CI 0.32 to 0.84, 499 participants, moderate-quality evidence). Simlarly, evidence synthesis of 18 RCTs favoured regional anaesthesia for the prevention of persistent pain three to 12 months after breast cancer surgery with an OR of 0.43 (95% CI 0.28 to 0.68, 1297 participants, low-quality evidence). Pooling data at three to 8 months after surgery from four RCTs favoured regional anaesthesia after caesarean section with an OR of 0.46, (95% CI 0.28 to 0.78; 551 participants, moderate-quality evidence). Evidence synthesis of three RCTs investigating continuous infusion with local anaesthetic for the prevention of PPP three to 55 months after iliac crest bone graft harvesting (ICBG) was inconclusive (OR 0.20, 95% CI 0.04 to 1.09; 123 participants, low-quality evidence). However, evidence synthesis of two RCTs also favoured the infusion of intravenous local anaesthetics for the prevention of PPP three to six months after breast cancer surgery with an OR of 0.24 (95% CI 0.08 to 0.69, 97 participants, moderate-quality evidence).We did not synthesize evidence for the surgical subgroups of limb amputation, hernia repair, cardiac surgery and laparotomy. We could not pool evidence for adverse effects because the included studies did not examine them systematically, and reported them sparsely. Clinical heterogeneity, attrition and sparse outcome data hampered evidence synthesis. High risk of bias from missing data and lack of blinding across a number of included studies reduced our confidence in the findings. Thus results must be interpreted with caution.

AUTHORS' CONCLUSIONS

We conclude that there is moderate-quality evidence that regional anaesthesia may reduce the risk of developing PPP after three to 18 months after thoracotomy and three to 12 months after caesarean section. There is low-quality evidence that regional anaesthesia may reduce the risk of developing PPP three to 12 months after breast cancer surgery. There is moderate evidence that intravenous infusion of local anaesthetics may reduce the risk of developing PPP three to six months after breast cancer surgery.Our conclusions are considerably weakened by the small size and number of studies, by performance bias, null bias, attrition and missing data. Larger, high-quality studies, including children, are needed. We caution that except for breast surgery, our evidence synthesis is based on only a few small studies. On a cautionary note, we cannot extend our conclusions to other surgical interventions or regional anaesthesia techniques, for example we cannot conclude that paravertebral block reduces the risk of PPP after thoracotomy. There are seven ongoing studies and 12 studies awaiting classification that may change the conclusions of the current review once they are published and incorporated.

Continuous intravenous perioperative lidocaine infusion for postoperative pain and recovery in adults

BACKGROUND

The management of postoperative pain and recovery is still unsatisfactory in a number of cases in clinical practice. Opioids used for postoperative analgesia are frequently associated with adverse effects, including nausea and constipation, preventing smooth postoperative recovery. Not all patients are suitable for, and benefit from, epidural analgesia that is used to improve postoperative recovery. The non-opioid, lidocaine, was investigated in several studies for its use in multimodal management strategies to reduce postoperative pain and enhance recovery. This review was published in 2015 and updated in January 2017.

OBJECTIVES

To assess the effects (benefits and risks) of perioperative intravenous (IV) lidocaine infusion compared to placebo/no treatment or compared to epidural analgesia on postoperative pain and recovery in adults undergoing various surgical procedures.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL, and reference lists of articles in January 2017. We searched one trial registry contacted researchers in the field, and handsearched journals and congress proceedings. We updated this search in February 2018, but have not yet incorporated these results into the review.

SELECTION CRITERIA

We included randomized controlled trials comparing the effect of continuous perioperative IV lidocaine infusion either with placebo, or no treatment, or with thoracic epidural analgesia (TEA) in adults undergoing elective or urgent surgery under general anaesthesia. The IV lidocaine infusion must have been started intraoperatively, prior to incision, and continued at least until the end of surgery.

DATA COLLECTION AND ANALYSIS

We used Cochrane's standard methodological procedures. Our primary outcomes were: pain score at rest; gastrointestinal recovery and adverse events. Secondary outcomes included: postoperative nausea and postoperative opioid consumption. We used GRADE to assess the quality of evidence for each outcome.

MAIN RESULTS

We included 23 new trials in the update. In total, the review included 68 trials (4525 randomized participants). Two trials compared IV lidocaine with TEA. In all remaining trials, placebo or no treatment was used as a comparator. Trials involved participants undergoing open abdominal (22), laparoscopic abdominal (20), or various other surgical procedures (26). The application scheme of systemic lidocaine strongly varies between the studies related to both dose (1 mg/kg/h to 5 mg/kg/h) and termination of the infusion (from the end of surgery until several days after).The risk of bias was low with respect to selection bias (random sequence generation), performance bias, attrition bias, and detection bias in more than 50% of the included studies. For allocation concealment and selective reporting, the quality assessment yielded low risk of bias for only approximately 20% of the included studies.IV Lidocaine compared to placebo or no treatment We are uncertain whether IV lidocaine improves postoperative pain compared to placebo or no treatment at early time points (1 to 4 hours) (standardized mean difference (SMD) -0.50, 95% confidence interval (CI) -0.72 to -0.28; 29 studies, 1656 participants; very low-quality evidence) after surgery. Due to variation in the standard deviation (SD) in the studies, this would equate to an average pain reduction of between 0.37 cm and 2.48 cm on a 0 to 10 cm visual analogue scale . Assuming approximately 1 cm on a 0 to 10 cm pain scale is clinically meaningful, we ruled out a clinically relevant reduction in pain with lidocaine at intermediate (24 hours) (SMD -0.14, 95% CI -0.25 to -0.04; 33 studies, 1847 participants; moderate-quality evidence), and at late time points (48 hours) (SMD -0.11, 95% CI -0.25 to 0.04; 24 studies, 1404 participants; moderate-quality evidence). Due to variation in the SD in the studies, this would equate to an average pain reduction of between 0.10 cm to 0.48 cm at 24 hours and 0.08 cm to 0.42 cm at 48 hours. In contrast to the original review in 2015, we did not find any significant subgroup differences for different surgical procedures.We are uncertain whether lidocaine reduces the risk of ileus (risk ratio (RR) 0.37, 95% CI 0.15 to 0.87; 4 studies, 273 participants), time to first defaecation/bowel movement (mean difference (MD) -7.92 hours, 95% CI -12.71 to -3.13; 12 studies, 684 participants), risk of postoperative nausea (overall, i.e. 0 up to 72 hours) (RR 0.78, 95% CI 0.67 to 0.91; 35 studies, 1903 participants), and opioid consumption (overall) (MD -4.52 mg morphine equivalents , 95% CI -6.25 to -2.79; 40 studies, 2201 participants); quality of evidence was very low for all these outcomes.The effect of IV lidocaine on adverse effects compared to placebo treatment is uncertain, as only a small number of studies systematically analysed the occurrence of adverse effects (very low-quality evidence).IV Lidocaine compared to TEAThe effects of IV lidocaine compared with TEA are unclear (pain at 24 hours (MD 1.51, 95% CI -0.29 to 3.32; 2 studies, 102 participants), pain at 48 hours (MD 0.98, 95% CI -1.19 to 3.16; 2 studies, 102 participants), time to first bowel movement (MD -1.66, 95% CI -10.88 to 7.56; 2 studies, 102 participants); all very low-quality evidence). The risk for ileus and for postoperative nausea (overall) is also unclear, as only one small trial assessed these outcomes (very low-quality evidence). No trial assessed the outcomes, 'pain at early time points' and 'opioid consumption (overall)'. The effect of IV lidocaine on adverse effects compared to TEA is uncertain (very low-quality evidence).

AUTHORS' CONCLUSIONS

We are uncertain whether IV perioperative lidocaine, when compared to placebo or no treatment, has a beneficial impact on pain scores in the early postoperative phase, and on gastrointestinal recovery, postoperative nausea, and opioid consumption. The quality of evidence was limited due to inconsistency, imprecision, and study quality. Lidocaine probably has no clinically relevant effect on pain scores later than 24 hours. Few studies have systematically assessed the incidence of adverse effects. There is a lack of evidence about the effects of IV lidocaine compared with epidural anaesthesia in terms of the optimal dose and timing (including the duration) of the administration. We identified three ongoing studies, and 18 studies are awaiting classification; the results of the review may change when these studies are published and included in the review.

Local anaesthetics and regional anaesthesia versus conventional analgesia for preventing persistent postoperative pain in adults and children

BACKGROUND

Regional anaesthesia may reduce the rate of persistent postoperative pain (PPP), a frequent and debilitating condition. This review was originally published in 2012 and updated in 2017.

OBJECTIVES

To compare local anaesthetics and regional anaesthesia versus conventional analgesia for the prevention of PPP beyond three months in adults and children undergoing elective surgery.

SEARCH METHODS

We searched CENTRAL, MEDLINE, and Embase to December 2016 without any language restriction. We used a combination of free text search and controlled vocabulary search. We limited results to randomized controlled trials (RCTs). We updated this search in December 2017, but these results have not yet been incorporated in the review. We conducted a handsearch in reference lists of included studies, review articles and conference abstracts. We searched the PROSPERO systematic review registry for related systematic reviews.

SELECTION CRITERIA

We included RCTs comparing local or regional anaesthesia versus conventional analgesia with a pain outcome beyond three months after elective, non-orthopaedic surgery.

DATA COLLECTION AND ANALYSIS

At least two review authors independently assessed trial quality and extracted data and adverse events. We contacted study authors for additional information. We presented outcomes as pooled odds ratios (OR) with 95% confidence intervals (95% CI), based on random-effects models (inverse variance method). We analysed studies separately by surgical intervention, but pooled outcomes reported at different follow-up intervals. We compared our results to Bayesian and classical (frequentist) models. We investigated heterogeneity. We assessed the quality of evidence with GRADE.

MAIN RESULTS

In this updated review, we identified 40 new RCTs and seven ongoing studies. In total, we included 63 RCTs in the review, but we were only able to synthesize data on regional anaesthesia for the prevention of PPP beyond three months after surgery from 41 studies, enrolling a total of 3143 participants in our inclusive analysis.Evidence synthesis of seven RCTs favoured epidural anaesthesia for thoracotomy, suggesting the odds of having PPP three to 18 months following an epidural for thoracotomy were 0.52 compared to not having an epidural (OR 0.52 (95% CI 0.32 to 0.84, 499 participants, moderate-quality evidence). Simlarly, evidence synthesis of 18 RCTs favoured regional anaesthesia for the prevention of persistent pain three to 12 months after breast cancer surgery with an OR of 0.43 (95% CI 0.28 to 0.68, 1297 participants, low-quality evidence). Pooling data at three to 8 months after surgery from four RCTs favoured regional anaesthesia after caesarean section with an OR of 0.46, (95% CI 0.28 to 0.78; 551 participants, moderate-quality evidence). Evidence synthesis of three RCTs investigating continuous infusion with local anaesthetic for the prevention of PPP three to 55 months after iliac crest bone graft harvesting (ICBG) was inconclusive (OR 0.20, 95% CI 0.04 to 1.09; 123 participants, low-quality evidence). However, evidence synthesis of two RCTs also favoured the infusion of intravenous local anaesthetics for the prevention of PPP three to six months after breast cancer surgery with an OR of 0.24 (95% CI 0.08 to 0.69, 97 participants, moderate-quality evidence).We did not synthesize evidence for the surgical subgroups of limb amputation, hernia repair, cardiac surgery and laparotomy. We could not pool evidence for adverse effects because the included studies did not examine them systematically, and reported them sparsely. Clinical heterogeneity, attrition and sparse outcome data hampered evidence synthesis. High risk of bias from missing data and lack of blinding across a number of included studies reduced our confidence in the findings. Thus results must be interpreted with caution.

AUTHORS' CONCLUSIONS

We conclude that there is moderate-quality evidence that regional anaesthesia may reduce the risk of developing PPP after three to 18 months after thoracotomy and three to 12 months after caesarean section. There is low-quality evidence that regional anaesthesia may reduce the risk of developing PPP three to 12 months after breast cancer surgery. There is moderate evidence that intravenous infusion of local anaesthetics may reduce the risk of developing PPP three to six months after breast cancer surgery.Our conclusions are considerably weakened by the small size and number of studies, by performance bias, null bias, attrition and missing data. Larger, high-quality studies, including children, are needed. We caution that except for breast surgery, our evidence synthesis is based on only a few small studies. On a cautionary note, we cannot extend our conclusions to other surgical interventions or regional anaesthesia techniques, for example we cannot conclude that paravertebral block reduces the risk of PPP after thoracotomy. There are seven ongoing studies and 12 studies awaiting classification that may change the conclusions of the current review once they are published and incorporated.

Anesthesia and fast-track in video-assisted thoracic surgery (VATS): from evidence to practice

In thoracic surgery, the introduction of video-assisted thoracoscopic techniques has allowed the development of fast-track protocols, with shorter hospital lengths of stay and improved outcomes. The perioperative management needs to be optimized accordingly, with the goal of reducing postoperative complications and speeding recovery times. Premedication performed in the operative room should be wisely administered because often linked to late discharge from the post-anesthesia care unit (PACU). Inhalatory anesthesia, when possible, should be preferred based on protective effects on postoperative lung inflammation. Deep neuromuscular blockade should be pursued and carefully monitored, and an appropriate reversal administered before extubation. Management of one-lung ventilation (OLV) needs to be optimized to prevent not only intraoperative hypoxemia but also postoperative acute lung injury (ALI): protective ventilation strategies are therefore to be implemented. Locoregional techniques should be favored over intravenous analgesia: the thoracic epidural, the paravertebral block (PVB), the intercostal nerve block (ICNB), and the serratus anterior plane block (SAPB) are thoroughly reviewed and the most common dosages are reported. Fluid therapy needs to be administered critically, to avoid both overload and cardiovascular compromisation. All these practices are analyzed singularly with the aid of the most recent evidences aimed at the best patient care. Finally, a few notes on some of the latest trends in research are presented, such as non-intubated video-assisted thoracoscopic surgery (VATS) and intravenous lidocaine.

Effect of intravenous lidocaine infusion on long-term postoperative pain after spinal fusion surgery

BACKGROUND

Intravenous lidocaine infusion is known to reduce postoperative pain for days or weeks beyond the infusion time, and plasma half-life in several types of surgical procedures.

OBJECTIVES

To evaluate the effect of intravenous (IV) lidocaine infusion on long term postoperative pain intensity for 3 months in patients undergoing spinal fusion surgery.

STUDY DESIGN

Prospective randomized, double-blinded study.

SETTING

Assiut University Hospital, Assiut, Egypt.

METHODS

Forty patients undergoing spinal fusion surgery were randomized into 2 equal groups (n = 20 in each). Patients in the lidocaine group received IV lidocaine at a dosage of 2.0 mg/kg slowly before induction of anesthesia, followed by lidocaine IV infusion at a rate of 3.0 mg/kg/h until the end of surgery. Patients in the control group received an equal volume of normal saline. The following data were assessed: pain by Visual Analog Score (VAS) at 1 hour, 6 hours, 12 hours, 24 hours, 48 hours, at discharge time, and at 1 month, 2 months, and 3 months post-operation, time to first request for additional analgesia, and total morphine consumption in 24 hours.

RESULTS

Lidocaine significantly reduced the postoperative pain score (VAS) for up to 3 months (P < .05), and significantly reduced morphine consumption (4.5 mg vs. 19.85 mg) in the 1st 24 hours postoperative. Lidocaine also significantly, prolonged (P < .05) the time to first request for additional analgesia (9.56 ± 2.06 hours vs 1.82 ± 0.91 hours).

CONCLUSION

Intra-operative lidocaine, when given intravenously as a bolus followed by an infusion, significantly decreased long term postoperative back pain intensity in patients undergoing spinal fusion surgery.

A randomized crossover study of the effects of lidocaine on motor- and sensory-evoked potentials during spinal surgery

BACKGROUND CONTEXT

Lidocaine has emerged as a useful adjuvant anesthetic agent for cases requiring intraoperative monitoring of motor-evoked potentials (MEPs) and somatosensory-evoked potentials (SSEPs). A previous retrospective study suggested that lidocaine could be used as a component of propofol-based intravenous anesthesia without adversely affecting MEP or SSEP monitoring, but did not address the effect of the addition of lidocaine on the MEP and SSEP signals of individual patients.

PURPOSE

The purpose of this study was to examine the intrapatient effects of the addition of lidocaine to balanced anesthesia on MEPs and SSEPs during multilevel posterior spinal fusion.

STUDY DESIGN

This is a prospective, two-treatment, two-period crossover randomized controlled trial with a blinded primary outcome assessment.

PATIENT SAMPLE

Forty patients undergoing multilevel posterior spinal fusion were studied.

OUTCOME MEASURES

The primary outcome measures were MEP voltage thresholds and SSEP amplitudes. Secondary outcome measures included isoflurane concentrations and hemodynamic parameters.

METHODS

Each participant received two anesthetic treatments (propofol 50 mcg/kg/h and propofol 25 mcg/kg/h+lidocaine 1 mg/kg/h) along with isoflurane, ketamine, and diazepam. In this manner, each patient served as his or her own control. The order of administration of the two treatments was determined randomly.

RESULTS

There were no significant within-patient differences between MEP threshold voltages or SSEP amplitudes during the two anesthetic treatments.

CONCLUSIONS

Lidocaine may be used as a component of balanced anesthesia during multilevel spinal fusions without adversely affecting the monitoring of SSEPs or MEPs in individual patients.

Does smoking affect the outcomes of lumbar decompression surgery?

Introduction: Lumbar decompressions and micro-discectomies are commonly performed non-complex spinal surgeries that do not involve the insertion of metalwork into the spine and are done for symptomatic disc prolapse and lumbar spinal stenosis, whereas complex-spinal surgery does require metalwork [1]. Studies of complex-spinal surgeries show that smoking has a significant negative impact on the outcome of the surgery [2] therefore, the cessation of smoking is advised prior to surgery [3]. There are evidences in the literature supportive as well as opposing this statement about continued smoking and poor outcome of decompressive spinal surgeries.

Methods: We retrospectively reviewed 143 consecutive patients who have had either a micro-discectomy or a micro-decompression.

Results: We found no statistical difference between smokers and non-smokers in the outcomes of lumbar decompression surgery. Both groups improved equally and significantly in terms of back pain, leg pain and functions. Out of 143 patients, only 2% more non-smokers had improved leg pain compared to smokers, 1% less non-smokers had improved back pain and 2% more non-smokers had an improved Oswestry Disability Index (ODI) score.

Discussion: We recommend that it is important to surgically treat both smokers and non-smokers in need of a lumbar spinal decompression.

Influence of catastrophizing, anxiety, and depression on in-hospital opioid consumption, pain, and quality of recovery after adult spine surgery

OBJECTIVE Perception of perioperative pain is influenced by various psychological factors. The aim of this study was to determine the impact of catastrophizing, anxiety, and depression on in-hospital opioid consumption, pain scores, and quality of recovery in adults who underwent spine surgery. METHODS Patients undergoing spine surgery were enrolled in this study, and the preoperatively completed questionnaires included the verbal rating scale (VRS), Pain Catastrophizing Scale (PCS), Hospital Anxiety and Depression Scale (HADS), and Oswestry Disability Index (ODI). Quality of recovery was assessed using the 40-item Quality of Recovery questionnaire (QoR40). Opioid consumption and pain scores according to the VRS were recorded daily until discharge. RESULTS One hundred thirty-nine patients were recruited for the study, and 101 completed the QoR40 assessment postoperatively. Patients with higher catastrophizing scores were more likely to have higher maximum pain scores postoperatively (estimate: 0.03, SE: 0.01, p = 0.02), without increased opioid use (estimate: 0.44, SE: 0.27, p = 0.11). Preoperative anxiety (estimate: 1.18, SE: 0.65, p = 0.07) and depression scores (estimate: 1.06, SE: 0.71, p = 0.14) did not correlate with increased postoperative opioid use; however, patients with higher preoperative depression scores had lower quality of recovery after surgery (estimate: -1.9, SE: 0.56, p < 0.001). CONCLUSIONS Catastrophizing, anxiety, and depression play important roles in modulating postoperative pain. Preoperative evaluation of these factors, utilizing a validated tool, helps to identify patients at risk. This might allow for earlier psychological intervention that could reduce pain severity and improve the quality of recovery.

Chronic Opioid Use After Surgery: Implications for Perioperative Management in the Face of the Opioid Epidemic

Physicians, policymakers, and researchers are increasingly focused on finding ways to decrease opioid use and overdose in the United States both of which have sharply increased over the past decade. While many efforts are focused on the management of chronic pain, the use of opioids in surgical patients presents a particularly challenging problem requiring clinicians to balance 2 competing interests: managing acute pain in the immediate postoperative period and minimizing the risks of persistent opioid use after the surgery. Finding ways to minimize this risk is particularly salient in light of a growing literature suggesting that postsurgical patients are at increased risk for chronic opioid use. The perioperative care team, including surgeons and anesthesiologists, is poised to develop clinical- and systems-based interventions aimed at providing pain relief in the immediate postoperative period while also reducing the risks of opioid use longer term. In this paper, we discuss the consequences of chronic opioid use after surgery and present an analysis of the extent to which surgery has been associated with chronic opioid use. We follow with a discussion of the risk factors that are associated with chronic opioid use after surgery and proceed with an analysis of the extent to which opioid-sparing perioperative interventions (eg, nerve blockade) have been shown to reduce the risk of chronic opioid use after surgery. We then conclude with a discussion of future research directions.

Poorly controlled postoperative pain: prevalence, consequences, and prevention

This review provides an overview of the clinical issue of poorly controlled postoperative pain and therapeutic approaches that may help to address this common unresolved health-care challenge. Postoperative pain is not adequately managed in greater than 80% of patients in the US, although rates vary depending on such factors as type of surgery performed, analgesic/anesthetic intervention used, and time elapsed after surgery. Poorly controlled acute postoperative pain is associated with increased morbidity, functional and quality-of-life impairment, delayed recovery time, prolonged duration of opioid use, and higher health-care costs. In addition, the presence and intensity of acute pain during or after surgery is predictive of the development of chronic pain. More effective analgesic/anesthetic measures in the perioperative period are needed to prevent the progression to persistent pain. Although clinical findings are inconsistent, some studies of local anesthetics and nonopioid analgesics have suggested potential benefits as preventive interventions. Conventional opioids remain the standard of care for the management of acute postoperative pain; however, the risk of opioid-related adverse events can limit optimal dosing for analgesia, leading to poorly controlled acute postoperative pain. Several new opioids have been developed that modulate μ-receptor activity by selectively engaging intracellular pathways associated with analgesia and not those associated with adverse events, creating a wider therapeutic window than unselective conventional opioids. In clinical studies, oliceridine (TRV130), a novel μ-receptor G-protein pathway-selective modulator, produced rapid postoperative analgesia with reduced prevalence of adverse events versus morphine.

Enhanced Recovery After Surgery in Laparoscopic Surgery

BACKGROUND

As part of an effort to maximize value in the perioperative setting, a paradigm shift is underway in the way that patients are cared for preoperatively, on the day of surgery, and postoperatively-a setting collectively known as the perioperative care. Enhanced Recovery After Surgery (ERAS^®) is an evidence-based, patient-centered team approach to delivering high-quality perioperative care to surgical patients.

METHODS

This review focuses on anesthesiologists, with their unique purview of perioperative setting, who are important drivers of change in the delivery of valuable perioperative care. ERAS care pathways begin in the preoperative setting by both preparing the patient for the psychological stress of surgery and optimizing the patient's medical and physiologic status so the body is ready for the physical demands of surgery.

RESULTS

Minimization of perioperative fasting is important to maintain volume status-decreasing reliance on intravenous fluid administration, and to reduce protein catabolism around the time of surgery. Intraoperative management in ERAS pathways relies on goal-directed fluid therapy and opioid-sparing multimodal analgesia. Postoperatively, early feeding and ambulation, as well as discontinuation of extraneous lines and catheters facilitate patients' functional recovery.

CONCLUSION

The laparoscopic approach to surgery, when possible, compliments ERAS techniques by reducing abdominal wall trauma and the resultant milieu of inflammatory, neurohumoral, and pain responses. Anesthesiologists driving change in the perioperative setting, in collaboration with surgeons and other disciplines, can improve value in healthcare and provide optimal outcomes that matter most to patients and healthcare providers alike.

The Efficacy of Systemic Lidocaine in the Management of Chronic Pain: A Literature Review

Context

Despite recent advances in the understanding of the chronic pain concept, its diagnosis and management remains a daily challenge for clinicians and patients. Based on the published literature, this review discusses and tries to organize the current knowledge and the up-to-date clinical experience about the efficacy and safety of the use of intravenous lidocaine in treatment and prevention of chronic pain.

Evidence Acquisition

To prepare this narrative review, we performed an in depth literature review using the PubMed searching engine. We extracted all relevant articles published in English, up to April 2016.

Results

Lidocaine, administered as transdermal patch or intravenous lidocaine, is a safe and effective modality in the treatment of post-herpetic neuralgia (PHN), complex regional pain syndrome, as well and for prevention of chronic pain. It may be effective in the management of neuropathic pain syndromes, chronic pain, post-operative pain, and refractory cancer pain.

Conclusions

Intravenous lidocaine and lidocaine patch are effective and safe for the treatment of several chronic or neuropathic pain syndromes. The use of lidocaine during surgery could prevent the development of some chronic post-surgical pain syndromes.

Perioperative Use of Intravenous Lidocaine

Perioperative lidocaine infusion improves analgesia and recovery after some surgical procedures, possibly through systemic antiinflammatory effects. This commentary provides the clinician with evidence for rational use of perioperative lidocaine infusion in procedures where it is of demonstrated benefit.

Chronic Pain in Neurosurgery

This review includes a summary of contemporary theories of pain processing and advocates a multimodal analgesia approach for providing perioperative care. A summary of various medication classes and anesthetic techniques is provided that highlights evidence emerging from neurosurgical literature. This summary covers opioid management, acetaminophen, nonsteroidal antiinflammatories, ketamine, lidocaine, dexmedetomidine, corticosteroids, gabapentin, and regional anesthesia for neurosurgery. At present, there is not enough investigation into these areas to describe best practices for treating or preventing chronic pain in neurosurgery; but providers can identify a wider range of options available to personalize perioperative care strategies.

Retrospective case-control non-inferiority analysis of intravenous lidocaine in a colorectal surgery enhanced recovery program

BACKGROUND

Enhanced recovery after surgery (ERAS) programs typically utilizes multi-modal analgesia to reduce perioperative opioid consumption. Systemic lidocaine is used in several of these ERAS algorithms and has been shown to reduce opioid use after colorectal surgery. However it is unclear how much the other components of an ERAS protocol contribute to the final outcome. Using a noninferiority analysis we sought to assess the role of perioperative lidocaine in an ERAS program for colorectal surgery, using pain and opioid consumption as outcomes.

METHODS

We conducted a retrospective review of patients who had received intravenous lidocaine perioperatively during colorectal surgery. We matched them with patients who were managed using a multi-component ERAS protocol, which included perioperative lidocaine. We tested a joint hypothesis of noninferiority of lidocaine infusion to ERAS protocol in postoperative pain scores and opioid consumption. We assigned a noninferiority margin of 1 point (on an 11-point numerical rating scale) difference in pain and a ratio [mean (lidocaine) / mean (ERAS)] of 1.2 in opioid consumption, respectively.

RESULTS

Fifty-two patients in the lidocaine group were matched with patients in the ERAS group. With regards to opioid consumption, in the overall [1.68 (1.43-1.98)] [odds ratio (95% confidence interval)] analysis and on postoperative day (POD) 1 [2.38 (1.74-3.31)] lidocaine alone was inferior to multi-modal analgesia. On POD 2 and beyond, although the mean odds ratio for opioid consumption was 1.43 [1.43 (1.17-1.73)], the lower limit extended beyond the pre-defined cut-off of 1.2, rendering the outcome inconclusive. For pain scores lidocaine is non-inferior to ERAS [-0.17 (-1.08-0.74)] on POD 2 and beyond. Pain scores on POD 1 and in the overall cohort were inconclusive based on the noninferiority analysis.

CONCLUSIONS

The addition of a multi-component ERAS protocol to intravenous lidocaine incrementally reduces opioid consumption, most evident on POD 1. For pain scores the data is inconclusive on POD 1, however on POD 2 and beyond lidocaine alone is non-inferior to an ERAS program with lidocaine. Opioid-related complications, including return of bowel function, were not different between the groups despite reduced opioid use in the ERAS group.

Lidocaine Infusion: A Promising Therapeutic Approach for Chronic Pain

Opioid abuse is a national epidemic in the United States, where it is estimated that a prescription drug overdose death occurs every 19 minutes. While opioids are highly effective in acute and subacute pain control, their use for treatment of chronic pain is controversial. Chronic opioids use is associated with tolerance, dependency, hyperalgesia. Although there are new strategies and practice guidelines to reduce opioid dependence and opioid prescription drug overdose, there has been little focus on development of opioid-sparing therapeutic approaches. Lidocaine infusion has been shown to be successful in controlling pain where other agents have failed. The opioid sparing properties of lidocaine infusion added to its analgesic and antihyperalgesic properties make lidocaine infusion a viable option for pain control in opioid dependent patients. In this review, we provide an overview of the opioid abuse epidemic, and we outline current evidence supporting the potential use of lidocaine infusion as an adjuvant therapeutic approach for management of chronic pain.

Cytotoxicity and cellular response mechanisms of water-soluble platinum(II) complexes of lidocaine and phenylcyanamide derivatives

Three new platinum(II) complexes of lidocaine and phenylcyanamide derivative ligands of formula K[Pt(3,5-(NO₂)₂pcyd)₂(LC)], 1, K[Pt(3,5-(CF₃)₂pcyd)₂(LC)], 2, K[Pt(3,5-Cl₂pcyd)₂(LC)], 3 (LC: lidocaine, 3,5-(NO₂)₂pcyd: 3,5-dinitro phenylcyanamide, 3,5-(CF₃)₂pcyd: 3,5-bis(trifluoromethyl) phenylcyanamide, 3,5-Cl₂pcyd: 3,5-dichloro phenylcyanamide) have been synthesized and fully characterized. Cellular uptake, DNA platination and cytotoxicity against a panel of human tumor cell lines were evaluated. The complexes 1-3 revealed a significant in vitro antiproliferative activity against human ovarian carcinoma (A2780), colorectal adenocarcinoma (HT29), breast (MCF-7), liver hepatocellular carcinoma (HepG-2) and lung adenocarcinoma (A549) cancer cell lines. All the complexes are more active than cisplatin and follow the trend 1 > 2 > 3. Mechanistic studies showed that the trend in cytotoxicity of the Pt(II) complexes is mainly consistent with their ability to accumulate into cancer cells and to increase intracellular basal reactive oxygen species levels, which consequently results in the loss of mitochondrial membrane potential and apoptosis induction. The complex 1 caused to approximately 80-fold higher DNA platination level with respect to cisplatin. The complexes 1-3 can considerably stimulate the production of hydrogen peroxide in a time-dependent manner. Also, the complexes 1-3 induced an increase in reactive oxygen species (ROS) production that was superior to that induced by antimycin. The complex 1 had the most effect on ROS production in comparison with other complexes.

Management of Postoperative Pain: A Clinical Practice Guideline From the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists' Committee on Regional Anesthesia, Executive Committee, and Administrative Council

Most patients who undergo surgical procedures experience acute postoperative pain, but evidence suggests that less than half report adequate postoperative pain relief. Many preoperative, intraoperative, and postoperative interventions and management strategies are available for reducing and managing postoperative pain. The American Pain Society, with input from the American Society of Anesthesiologists, commissioned an interdisciplinary expert panel to develop a clinical practice guideline to promote evidence-based, effective, and safer postoperative pain management in children and adults. The guideline was subsequently approved by the American Society for Regional Anesthesia. As part of the guideline development process, a systematic review was commissioned on various aspects related to various interventions and management strategies for postoperative pain. After a review of the evidence, the expert panel formulated recommendations that addressed various aspects of postoperative pain management, including preoperative education, perioperative pain management planning, use of different pharmacological and nonpharmacological modalities, organizational policies, and transition to outpatient care. The recommendations are based on the underlying premise that optimal management begins in the preoperative period with an assessment of the patient and development of a plan of care tailored to the individual and the surgical procedure involved. The panel found that evidence supports the use of multimodal regimens in many situations, although the exact components of effective multimodal care will vary depending on the patient, setting, and surgical procedure. Although these guidelines are based on a systematic review of the evidence on management of postoperative pain, the panel identified numerous research gaps. Of 32 recommendations, 4 were assessed as being supported by high-quality evidence, and 11 (in the areas of patient education and perioperative planning, patient assessment, organizational structures and policies, and transitioning to outpatient care) were made on the basis of low-quality evidence.

PERSPECTIVE

This guideline, on the basis of a systematic review of the evidence on postoperative pain management, provides recommendations developed by a multidisciplinary expert panel. Safe and effective postoperative pain management should be on the basis of a plan of care tailored to the individual and the surgical procedure involved, and multimodal regimens are recommended in many situations.

Intravenous lidocaine for effective pain relief after a laparoscopic colectomy: a prospective, randomized, double-blind, placebo-controlled study

A perioperative intravenous lidocaine infusion has been reported to decrease postoperative pain. The goal of this study was to evaluate the effectiveness of intravenous lidocaine in reducing postoperative pain for laparoscopic colectomy patients. Fifty-five patients scheduled for an elective laparoscopic colectomy were randomly assigned to 2 groups. Group L received an intravenous bolus injection of lidocaine 1.5 mg/kg before intubation, followed by 2 mg/kg/h continuous infusion during the operation. Group C received the same dosage of saline at the same time. Postoperative pain was assessed at 2, 4, 8, 12, 24, and 48 hours after surgery by using the visual analog scale (VAS). Fentanyl consumption by patient-controlled plus investigator-controlled rescue administration and the total number of button pushes were measured at 2, 4, 8, 12, 24, and 48 hours after surgery. In addition, C-reactive protein (CRP) levels were checked on the operation day and postoperative days 1, 2, 3, and 5. VAS scores were significantly lower in group L than group C until 24 hours after surgery. Fentanyl consumption was lower in group L than group C until 12 hours after surgery. Moreover, additional fentanyl injections and the total number of button pushes appeared to be lower in group L than group C (P < 0.05). The CRP level tended to be lower in group L than group C, especially on postoperative day 1 and 2 and appeared to be statistically significant. The satisfaction score was higher in group L than group C (P = 0.024). Intravenous lidocaine infusion during an operation reduces pain after a laparoscopic colectomy.