Systemic lidocaine shortens length of hospital stay after colorectal surgery: a double-blinded, randomized, placebo-controlled trial

Lidocaine enhances the effects of chemotherapeutic drugs against bladder cancer

This study aimed to investigate whether lidocaine, alone or in combination with other chemotherapeutic agents, inhibits the growth of human bladder cancer cells in vitro and orthotopically transplanted bladder tumors in vivo. The effects of lidocaine (1.25, 2.5 or 5 mg/mL), mitomycin C (MMC, 0.66 mg/mL), pirarubicin (0.75 mg/mL) and Su Fu’ning lotion (SFN, 0.0625 mg/mL) on the proliferation of human bladder cancer (BIU-87) cells were studied using the MTT assay. A Balb/c nude mouse model of bladder cancer was developed by orthotopic transplantation of BIU-87 cells, and the effects of intravesical instillation of lidocaine and MMC on bladder wet weight (a measure of tumor size) and survival (over 60 days) were studied. Lidocaine inhibited proliferation of BIU-87 cells in a concentration-dependent manner and (when given in combination) enhanced the actions of each of the other antiproliferative agents. In tumor-bearing mice, MMC alone had no effect on mean survival or bladder wet weight. However, the combination of 0.66 mg/mL MMC and 5 mg/mL lidocaine prolonged survival (from 34.62 ± 6.49 to 49.30 ± 6.72 days; n = 8, P < 0.05) and reduced bladder wet weight (from 68.94 ± 53.61 to 20.26 ± 6.07; n = 8, P < 0.05). Intravesical instillation of lidocaine combined with other chemotherapeutic agents potentially could be an effective therapy for bladder cancer.

Effect of intravenous lidocaine on the incidence of postextubation laryngospasm: A double-blind, placebo-controlled randomized trial

Objectives

The study aimed to test the effect of intraoperative intravenous (IV) lidocaine on the incidence of postextubation laryngospasm in adult patients.

Methods

The prospective randomized clinical trial was conducted at tertiary care hospital in Riyadh, between January and December 2012. Seventy-two patients undergoing laparoscopic cholecystectomy were randomly assigned to receive either placebo (n = 36) or IV lidocaine (n = 36), 1 mg/kg bolus after desflurane was discontinued. Laryngospasm was graded from 0 to 3 based on the absence or presence of signs and the severity of postextubation laryngospasm.

Results

The study was terminated early by the data monitoring committee because of safety concerns due to an increased incidence of postextubation laryngospasm. Patient demographics were similar for both groups. The incidence of postextubation laryngospasm was 19.5% in the placebo group and 0% in the treatment (lidocaine) group; this difference was statistically significant (P = 0.017; 95% confidence interval, 4.6% to 36.0%).

Conclusions

The cause of laryngospasm in our study was most likely the rapid increase in the concentration of inspired desflurane, which might have caused airway irritation. Therefore, we believe that pretreating patients at risk of developing laryngospasm with IV lidocaine could be effective.

The Amide Local Anesthetic Lidocaine in Cancer Surgery-Potential Antimetastatic Effects and Preservation of Immune Cell Function? A Narrative Review

Surgical removal of the primary tumor in solid cancer is an essential component of the treatment. However, the perioperative period can paradoxically lead to an increased risk of cancer recurrence. A bimodal dynamics for early-stage breast cancer recurrence suggests a tumor dormancy-based model with a mastectomy-driven acceleration of the metastatic process and a crucial role of the immunosuppressive state during the perioperative period. Recent evidence suggests that anesthesia could also influence the progress of the disease. Local anesthetics (LAs) have long been used for their properties to block nociceptive input. They also exert anti-inflammatory capacities by modulating the liberation or signal propagation of inflammatory mediators. Interestingly, LAs can reduce viability and proliferation of many cancer cells in vitro as well. Additionally, retrospective clinical trials have suggested that regional anesthesia for cancer surgery (either with or without general anesthesia) might reduce the risk of recurrence. Lidocaine, a LA, which can be administered intravenously, is widely used in clinical practice for multimodal analgesia. It is associated with a morphine-sparing effect, reduced pain scores, and in major surgery probably also with a reduced incidence of postoperative ileus and length of hospital stay. Systemic delivery might therefore be efficient to target residual disease or reach cells able to form micrometastasis. Moreover, an in vitro study has shown that lidocaine could enhance the activity of natural killer (NK) cells. Due to their ability to recognize and kill tumor cells without the requirement of prior antigen exposure, NKs are the main actor of the innate immune system. However, several perioperative factors can reduce NK activity, such as stress, pain, opioids, or general anesthetics. Intravenous lidocaine as part of the perioperative anesthesia regimen would be of major interest for clinicians, as it might bear the potential to reduce the risk of cancer recurrence or progression patients undergoing cancer surgery. As a well-known pharmaceutical agent, lidocaine might therefore be a promising candidate for oncological drug repurposing. We urgently need clinical randomized trials assessing the protective effect of lidocaine on NKs function and against recurrence after cancer surgery to achieve a “proof of concept.”

A Meta-Analysis: Postoperative Pain Management in Colorectal Surgical Patients and the Effects on Length of Stay in an Enhanced Recovery After Surgery (ERAS) Setting

INTRODUCTION

Enhanced Recovery After Surgery (ERAS) aims to minimize the length of a negative physiological response to surgical intervention. There are a number of aspects involved in ERAS protocols, one of which is postoperative pain relief. This meta-analysis investigates the current evidence for postoperative pain relief and its effect on patient pain and the length of stay after colorectal surgery.

METHOD/RESULTS

Medline, PubMed, and EMBASE databases were searched for relevant studies between January 1966 and February 2016. All randomized controlled trials comparing postoperative pain management strategies in an ERAS setting with the length of stay as an outcome measure were selected. In addition to the length of stay, other outcomes analyzed were pain scores at 24 hours postoperatively, nausea, vomiting, and the time to the first bowel motion.

RESULTS

There was a decrease in vomiting in the ERAS group compared with the control groups (relative risk=0.82; 95% confidence interval, 0.52-1.27). Mean differences in the length of stay (P=0.879), pain visual analogue scales (P=0.120), the time to the first bowel motion in hours (P=0.371), and nausea (P=0.083) were not statistically significant.

CONCLUSIONS

In an ERAS setting with regard to a colorectal patient population, the choice of modality for postoperative pain relief does not impact the length of hospital stay, pain, the time to the first bowel motion, or nausea.

Effect of perioperative intravenous lidocaine infusion on postoperative recovery following laparoscopic Cholecystectomy-A randomized controlled trial

BACKGROUND AND OBJECTIVE

Intravenous lidocaine infusion has been shown to facilitate postoperative recovery after major abdominal surgery. The current randomized controlled study was performed to assess the effect of perioperative intravenous lidocaine infusion on pain intensity, bowel function and cytokine response after larparoscopic cholecystectomy.

METHODS

Eighty patients undergoing laparoscopic cholecystectomy were randomly allocated to receive intravenous lidocaine (bolus injection of 1.5 mg/kg lidocaine at induction of anesthesia, then a continuous infusion of 2 mg/kg/h until the end of surgery) or an equal volume of saline. Patients, anesthesiologists, and study personnel were blinded, and anesthesia and multimodal perioperative analgesia were standardized. Blood cytokines were measured at scheduled times within 48 h. Pain scores, opioid consumption, time to first flatus and time to first bowel movement were also measured after surgery.

RESULTS

Seventy-one of the 80 patients who were recruited completed the study protocol. Patient demographics were similar in the two groups. Lidocaine significantly reduced pain intensity [visual analogue scale (VAS), 0-10 cm] at 2 h (lidocaine 3.01 ± 0.65 cm vs. placebo 4.27 ± 0.58 cm, p = 0.01) and 6 h (lidocaine 3.38 ± 0.42 cm vs. placebo 4.22 ± 0.67 cm, p = 0.01) and total fentanyl consumption 24 h after surgery (lidocaine 98.27 ± 16.33 μg vs. placebo 187.49 ± 19.76 μg, p = 0.005). Time to first flatus passage (lidocaine 20 ± 11 h vs. placebo 29 ± 10 h, p = 0.01) and time to first bowel movement (lidocaine 41 ± 16 h vs. placebo 57 ± 14 h, p = 0.01) were also significantly shorter in patients who received lidocaine. Intravenous lidocaine infusion experienced less cytokine release than the control group.

CONCLUSIONS

This study indicates that perioperative systemic lidocaine improves postoperative recovery and attenuates the initiation of excessive inflammatory response following laparoscopic cholecystectomy.

Intravenous lignocaine in colorectal surgery: a systematic review

BACKGROUND

Colorectal surgery leads to morbidity during recovery including pain and fatigue. Intravenous (IV) lignocaine (IVL) has both analgesic and anti-inflammatory effects that may improve post-operative pain and recovery. The aim of this review is to compare the effectiveness of IVL to other perioperative analgesia regimens for reducing pain and opioid consumption following colorectal surgery.

METHODS

Using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement, a literature search was conducted to identify randomized clinical trials that compared IVL with IV placebo or epidural anaesthesia in open or laparoscopic colorectal surgery. The primary outcomes were opioid requirements and pain scores assessed by visual analogue score. Data were entered into pre-designed electronic spreadsheets.

RESULTS

The literature search identified 2707 studies. A total of nine randomized clinical trials met the inclusion criteria. Five studies investigated IVL compared with IV placebo and four studies investigated IVL compared with epidural anaesthesia. Two out of the five studies comparing IVL and placebo showed statistically significant reductions in opioid consumption with IVL. There was a variable degree of improvement in pain scores when IVL was compared with epidural. Two studies showed a significant difference, with lower opioid consumption and pain scores in the epidural group. Laparoscopic and open procedures could not be compared between the IVL and placebo group.

CONCLUSION

IVL has shown limited benefit towards reducing early pain and morphine consumption when compared with placebo in colorectal surgery. However, IVL did not show any significant reduction in pain or opioid consumption when compared with epidural. Further research investigating IVL combined with intraperitoneal local anaesthetic is warranted.

The Effects of Anesthetics on Recurrence and Metastasis of Cancer, and Clinical Implications

Surgical resection of the primary tumor may enhance the metastasis and recurrence of cancer. The reaction of patients to surgery includes changes of the immune system, the inflammatory system and the neuroendocrine system. In the perioperative period, anesthetics are used both for anesthesia and analgesia. There are several studies showing that the progression of cancer can be influenced by many kinds of anesthetics, although most of these studies are preclinical and thus have not yet influenced clinical recommendations. This review summarizes recent studies regarding the effects of anesthetics on metastasis and recurrence of cancer.

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.

Continuous Lidocaine Infusion as Adjunctive Analgesia in Intensive Care Unit Patients

Despite a paucity of data, the role of intravenous lidocaine (IVLI) as adjunctive analgesia in the intensive care unit (ICU) seems promising due to a low potential to contribute to respiratory depression. A retrospective chart review was conducted to evaluate the safety and effectiveness of IVLI for the treatment of pain in ICU patients with varying degrees of organ dysfunction from March 2014 to March 2016. The primary outcomes included the time to a ≥20% reduction in pain scores after the initiation of IVLI and the difference in opioid requirements as well as pain scores prior to and during IVLI therapy. Other variables included the presence of IVLI-related adverse events and the dosage and duration of IVLI. A total of 21 ICU patients were included from 2 different hospitals. The mean time to a ≥20% reduction in pain scores from the start of IVLI was 3.3 hours (SD = 2.2). The median morphine dose equivalents required during 6, 12, and 24 hours pre-IVLI were significantly higher compared to the same time periods after IVLI (18.3 vs 10 mg, P = .002; 41.8 vs 18.3 mg, P = .002; 93.5 vs 30.5 mg, P = .037). Neurological adverse effects of lidocaine were noted in 3 patients, but the effects were reversed on IVLI discontinuation. This report suggests that IVLI as an adjunctive agent in the treatment of acute pain may be a potential option in ICU patients who are refractory to opioids or those in whom opioid-induced respiratory depression is a concern.

Intravenous lidocaine for effective pain relief after bimaxillary surgery

OBJECTIVES

The aim of this prospective, randomized, double-blind, placebo-controlled study was to evaluate the analgesic effect of intravenous lidocaine on postoperative pain in bimaxillary surgery.

MATERIALS AND METHODS

Between July 2015 and November 2015, 52 consecutive patients that underwent bimaxillary surgery were recruited to the present study. The patients were randomly divided into two groups: group L (1.5 mg/kg bolus and 2 mg/kg/h continuous infusion during the operation) and group C (normal saline). To measure pain intensity, a visual analog scale (VAS) was used at 2, 4, 8, 12, 24, and 48 h after surgery. Rescue ketorolac use was measured in the first 4, 4-8, 8-24, and 24-48 h after surgery. Total ketorolac consumption (the sum of rescue and eight-hourly fixed schedule ketorolac injection), WBC count, neutrophil count, and postoperative swelling were recorded.

RESULTS

There were no significant differences between the two groups with respect to demographics. VAS pain scores were significantly lower in group L compared with group C up to 8 h after surgery. Rescue ketorolac use up to 8 h after surgery and total ketorolac consumption were significantly lower in group L than in group C. Postoperative WBC and neutrophil counts were significantly decreased in group L. Compared with group C, the amount of calibrated postoperative swelling was lower in group L.

CONCLUSIONS

Systemic lidocaine infusion during bimaxillary surgery reduces postoperative pain, analgesic consumption, and facial swelling.

CLINICAL RELEVANCE

Systemic lidocaine is simple, economic, and a safe procedure reducing pain and soft tissue swelling after bimaxillary surgery.

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.

Perioperative regional anaesthesia and postoperative longer-term outcomes

Regional anaesthesia provides effective anaesthesia and analgesia in the perioperative setting. Central neuraxial blocks-that is, spinal and epidural blocks-are well established as an alternative or adjunct to general anaesthesia. Peripheral blocks may be used as part of multimodal anaesthesia/analgesia in perioperative practice, reducing the need for opioid analgesics and enhancing early recovery. Furthermore, regional anaesthesia has increased in popularity and may be done with improved ease and safety with the introduction of ultrasound-guided techniques. The effects of local anaesthetics and regional anaesthesia on long-term outcomes such as morbidity, mortality, the quality of recovery beyond the duration of analgesia, and whether it can expedite the resumption of activities of daily living are less clear. It has also been suggested that regional anaesthesia may impact the risk of metastasis after cancer surgery. This article provides an overview of current evidence around quality of recovery, risk for delirium, long-term effects, and possible impact on cancer disease progression associated with the clinical use of local and regional anaesthetic techniques. In summary, there is still a lack of robust data that regional anaesthesia has a clinical impact beyond its well-acknowledged beneficial effects of reducing pain, reduced opioid consumption, and improved quality of early recovery. Further high-quality prospective studies on long-term outcomes are warranted.

A Clinical Comparison of Intravenous and Epidural Local Anesthetic for Major Abdominal Surgery

BACKGROUND

Epidural analgesia provides good pain control after many postoperative procedures, but it can lead to complications, has some contraindications, and occasionally fails. Intravenous lidocaine infusion has been suggested as an alternative. We assessed, in our clinical practice, the effects of perioperative intravenous lidocaine infusion compared with epidural analgesia for major abdominal surgery.

METHODS

We conducted a retrospective review of patients who had received intravenous lidocaine (1 mg/kg per hour) perioperatively after a major abdominal surgery. We matched them with patients who had received epidural analgesia. We tested a joint hypothesis of noninferiority of lidocaine infusion to epidural analgesia 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 (epidural)] of 1.2 in opioid consumption, respectively.

RESULTS

Two hundred sixteen patients (108 in each group) were analyzed. Intravenous lidocaine was not inferior to epidural analgesia with respect to pain scores. Lidocaine infusion was inferior to epidural analgesia with respect to opioid consumption. Patients in the lidocaine group had fewer episodes of hypotension and less postoperative nausea and vomiting, pruritus, and urinary retention. Patients receiving lidocaine also had earlier urinary catheter removal and earlier first gastrointestinal function. Daily mental status assessment was similar between the 2 groups.

CONCLUSIONS

Patients who received systemic lidocaine infusions with the addition of PRN (as needed) opioids administered for breakthrough pain did not have clinically significant differences in pain scores on postoperative day 2 and beyond. Intravenous lidocaine infusion in major abdominal surgery was inferior to epidural analgesia with respect to opioid consumption. However, lidocaine was associated with improvements in several important aspects of recovery.

Inflammation and Epidural-Related Maternal Fever: Proposed Mechanisms

Intrapartum fever is associated with excessive maternal interventions as well as higher neonatal morbidity. Epidural-related maternal fever (ERMF) contributes to the development of intrapartum fever. The mechanism(s) for ERMF has remained elusive. Here, we consider how inflammatory mechanisms may be modulated by local anesthetic agents and their relevance to ERMF. We also critically reappraise the clinical data with regard to emerging concepts that explain how anesthetic drug-induced metabolic dysfunction, with or without activation of the inflammasome, might trigger the release of nonpathogenic, inflammatory molecules (danger-associated molecular patterns) likely to underlie ERMF.

Intraperitoneal ropivacaine and early postoperative pain and postsurgical outcomes after laparoscopic herniorrhaphy in toddlers: a randomized clinical trial

BACKGROUND

Postoperative pain can cause physiological distress, postoperative complications, and extended lengths of hospitalized stay. In children, management of postoperative pain is still recognized as being inadequate.

OBJECTIVE

The aim of this trial was to investigate the effects of intraperitoneal ropivacaine on postoperative pain, and recovery of bowel function and emetic events after laparoscopic herniorrhaphy in toddlers.

METHODS

Seventy-six children aged from 9 months to 3 years were recruited between August 2013 and June 2014 at Tongji Hospital and randomly assigned into two groups. One group received intraperitoneal ropivacaine right before surgery and the control group received intraperitoneal saline. A standard combined general anesthesia procedure was performed under regular monitoring. Postoperative pain was assessed by the FLACC scale. Postoperative analgesic consumption, time to flatus, time to first stool, and postoperative emetic events were also recorded.

RESULTS

When compared with the control group, children who received intraperitoneal ropivacaine experienced less pain 0-4 h after surgery [P < 0.001, difference in median FLACC (95% CI) for 2 h time point is 2.00 (0.87-3.13), for 4 h time point is 1.00 (0.55-1.45)]. In addition, the number of toddlers who received analgesia 0-24 h after surgery in the ropivacaine group was lower than that in the control group [P < 0.001, difference in proportions (95% CI) is 0.575 (0.3865-0.7638)]. Compared with the control group, time to flatus in ropivacaine group was also much shorter [21.1 h vs 16.7 h, P = 0.04, difference in mean (95% CI) is 4.4 (1.49-7.28)], and the time to first stool after surgery was earlier in the ropivacaine group [30.7 h vs 25.6 h, P = 0.003, difference in mean (95% CI) is 5.1 (1.78-8.45)]. Furthermore, the incidence of emetic events in the ropivacaine group was significantly lower than the control group [32.4% vs 11.1%, P = 0.03, difference in proportions (95% CI) is 0.212 (0.0246-0.4002)].

CONCLUSION

The present results indicate that intraperitoneal ropivacaine reduces early postoperative pain and improves recovery after laparoscopic herniorrhaphy in toddlers. Therefore, IPLA is a good stratagem for postoperative pain management after laparoscopic surgery in toddlers.

Efficacy and cost-effectiveness of intradiscal methylene blue injection for chronic discogenic low back pain: study protocol for a randomized controlled trial

BACKGROUND

Low back pain (LBP) is a common health problem and a substantial part of LBP is presumed to be attributable to degeneration of the intervertebral disc. For patients suffering from intractable discogenic LBP, there are few evidence-based effective interventional treatment options available. In 2010, the results of a randomized controlled trial (RCT) were published concerning "intradiscal methylene blue injection" (IMBI), in which this intervention appeared to be very successful in relieving discogenic pain. Therefore, we decided to repeat this study to investigate whether we could replicate the published results. The results of our preliminary feasibility study gave reason to set up an RCT. The aim of this RCT is to evaluate if IMBI is a more effective treatment of discogenic low back pain as an intradiscal placebo intervention, and furthermore, to assess the cost-effectiveness of this intervention.

METHODS/DESIGN

Consecutive discogenic low back pain patients referred to four specialized pain treatment facilities are being screened for eligibility. After a positive standardized provocation discography and informed consent, patients are randomized into two groups. The treatment group receives an intradiscal injection with methylene blue, lidocaine, and contrast, and the control group receives intradiscal isotonic saline with lidocaine and contrast. Main outcome measures are pain at the 6-month follow-up, patient's global impression of change, cost-effectiveness, quality of life, disability, and analgesic intake.

DISCUSSION

The importance of this study is emphasized by the fact that for intractable discogenic low back pain patients, evidence-based effective pain treatments are rare. If this study establishes clinical success and cost-effectiveness, IMBI could become the "pain treatment of choice" for a selected group of patients with chronic discogenic low back pain for whom noninvasive treatment options have failed.

TRIAL REGISTRATION

National Trial register NTR2547 Registered at 29 September 2010 and 31 March 2014.

An estimation for an appropriate end time for an intraoperative intravenous lidocaine infusion in bowel surgery: a comparative meta-analysis

STUDY OBJECTIVE

There exists no commonly accepted regimen for an intravenous lidocaine infusion (IVLI). This study aims to determine an appropriate end time for an IVLI during bowel surgery.

DESIGN

A systematic search for randomized controlled trials assessing IVLI for bowel surgery was conducted using Ovid MEDLINE, EMBASE, CINAHL, Cochrane CENTRAL, Google Scholar, hand-searching references, and grey literature. Data were pooled for studies that stopped IVLI ≤60 minutes (intraoperative IVLI) after skin closure and where IVLI continued >60 minutes after surgery (postoperative continued IVLI). Quantitative analysis was done using the random-effects model.

MAIN RESULTS

Seven studies (n = 362) were identified after the systematic search. Three studies (n = 160) and 4 studies (n = 202) used an intraoperative and postoperative continued IVLI, respectively. An intraoperative IVLI significantly reduced pain scores at rest for 48 hours (standardized mean difference on a 0-10 scale, -1.24; 95% confidence interval, -1.93 to -0.56) and 72 hours (standardized mean difference, -1.12; 95% confidence interval, -1.79 to -0.44) compared with postoperative IVLI (test for interaction: P < .001 and P = .003, respectively). Although intraoperative IVLI reduced 24-hour pain scores on movement, this was not statistically different than pain scores in the postoperative IVLI group (test of interaction: P = 0.68). There were no differences between intraoperative IVLI and postoperative IVLI for postoperative in-hospital nausea, vomiting, time to bowel movement, and length of hospital stay.

CONCLUSION

Continuing an IVLI beyond 60 minutes after surgery has no added analgesic or gastrointestinal benefit. Further research is needed to clarify an optimal IVLI regimen and end time.

Continuous intravenous perioperative lidocaine infusion for postoperative pain and recovery

BACKGROUND

The management of postoperative pain and recovery is still unsatisfactory in clinical practice. Opioids used for postoperative analgesia are frequently associated with adverse effects including nausea and constipation. These adverse effects prevent smooth postoperative recovery. On the other hand not all patients may be suited to, and take benefit from, epidural analgesia used to enhance postoperative recovery. The non-opioid lidocaine was investigated in several studies for its use in multi-modal management strategies to reduce postoperative pain and enhance recovery.

OBJECTIVES

The aim of this review was to assess the effects (benefits and risks) of perioperative intravenous 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 the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 5 2014), MEDLINE (January 1966 to May 2014), EMBASE (1980 to May 2014), CINAHL (1982 to May 2014), and reference lists of articles. We searched the trial registry database ClinicalTrials.gov, contacted researchers in the field, and handsearched journals and congress proceedings. We did not apply any language restrictions.

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

Trial quality was independently assessed by two authors according to the methodological procedures specified by the Cochrane Collaboration. Data were extracted by two independent authors. We collected trial data on postoperative pain, recovery of gastrointestinal function, length of hospital stay, postoperative nausea and vomiting (PONV), opioid consumption, patient satisfaction, surgical complication rates, and adverse effects of the intervention.

MAIN RESULTS

We included 45 trials involving 2802 participants. Two trials compared intravenous lidocaine versus epidural analgesia. In all the remaining trials placebo or no treatment was used as a comparator. Trials involved participants undergoing open abdominal (12), laparoscopic abdominal (13), or various other surgical procedures (20).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.We found evidence of effect for intravenous lidocaine on the reduction of postoperative pain (visual analogue scale, 0 to 10 cm) compared to placebo or no treatment at 'early time points (one to four hours)' (mean difference (MD) -0.84 cm, 95% confidence interval (CI) -1.10 to -0.59; low-quality evidence) and at 'intermediate time points (24 hours)' (MD -0.34 cm, 95% CI -0.57 to -0.11; low-quality evidence) after surgery. However, no evidence of effect was found for lidocaine to reduce pain at 'late time points (48 hours)' (MD -0.22 cm, 95% CI -0.47 to 0.03; low-quality evidence). Pain reduction was most obvious at 'early time points' in participants undergoing laparoscopic abdominal surgery (MD -1.14, 95% CI -1.51 to -0.78; low-quality evidence) and open abdominal surgery (MD -0.72, 95% CI -0.96 to -0.47; moderate-quality evidence). No evidence of effect was found for lidocaine to reduce pain in participants undergoing all other surgeries (MD -0.30, 95% CI -0.89 to 0.28; low-quality evidence). Quality of evidence is limited due to inconsistency and indirectness (small trial sizes).Evidence of effect was found for lidocaine on gastrointestinal recovery regarding the reduction of the time to first flatus (MD -5.49 hours, 95% CI -7.97 to -3.00; low-quality evidence), time to first bowel movement (MD -6.12 hours, 95% CI -7.36 to -4.89; low-quality evidence), and the risk of paralytic ileus (risk ratio (RR) 0.38, 95% CI 0.15 to 0.99; low-quality evidence). However, no evidence of effect was found for lidocaine on shortening the time to first defaecation (MD -9.52 hours, 95% CI -23.24 to 4.19; very low-quality evidence).Furthermore, we found evidence of positive effects for lidocaine administration on secondary outcomes such as reduction of length of hospital stay, postoperative nausea, intraoperative and postoperative opioid requirements. There was limited data on the effect of IV lidocaine on adverse effects (e.g. death, arrhythmias, other heart rate disorders or signs of lidocaine toxicity) compared to placebo treatment as only a limited number of studies systematically analysed the occurrence of adverse effects of the lidocaine intervention.The comparison of intravenous lidocaine versus epidural analgesia revealed no evidence of effect for lidocaine on relevant outcomes. However, the results have to be considered with caution due to imprecision of the effect estimates.

AUTHORS' CONCLUSIONS

There is low to moderate evidence that this intervention, when compared to placebo, has an impact on pain scores, especially in the early postoperative phase, and on postoperative nausea. There is limited evidence that this has further impact on other relevant clinical outcomes, such as gastrointestinal recovery, length of hospital stay, and opioid requirements. So far there is a scarcity of studies that have systematically assessed the incidence of adverse effects; the optimal dose; timing (including the duration of the administration); and the effects when compared with epidural anaesthesia.

The effects of preoperative oral pregabalin and perioperative intravenous lidocaine infusion on postoperative morphine requirement in patients undergoing laparatomy

For the treatment of postoperative pain, multimodal analgesia can reduce the side effects and required dose of opioids by combining drugs and methods with different modes of action. This study evaluated the efficacy of preoperative oral pregabalin and perioperative intravenous lidocaine in patients undergoing laparotomy.

OBJECTIVES:

To evaluate and compare the effects of preoperative oral pregabalin and perioperative intravenous lidocaine infusion on postoperative morphine requirement, adverse effects, patients’ satisfaction, mobilization, time to first defecation and time to discharge in patients undergoing laparotomy.

METHODS:

Eighty patients (18 to 65 years of age) undergoing elective laparotomy were randomly divided into four groups (n=20 in each group): group C, placebo capsules and normal saline infusion perioperatively (control); group L, placebo capsules and lidocaine 1 mg/kg intravenous bolus dose followed by 2 mg/kg/h infusion until skin closure; group P, 150 mg oral pregabalin and normal saline infusion perioperatively; and group PL, 150 mg oral pregabalin and lidocaine 2 mg/kg/h infusion until skin closure. Hemodynamic parameters, visual analogue scale (VAS) scores, analgesic consumption, side effects, time to mobilization, time to first defecation, time to discharge and patients’ satisfaction were recorded.

RESULTS:

VAS scores of group L, group P and group PL were lower than group C (P<0.05). Morphine consumption of group P and group PL was lower than group C (P<0.05). Incidence of nausea in group C was higher than group L and group PL. Time to first defecation and mobilization were shorter in group L and group PL compared with group C (P<0.05).

CONCLUSION:

Preoperative oral pregabalin and perioperative intravenous lidocaine infusion decreased postoperative VAS scores. Preoperative oral pregabalin decreased morphine requirement and perioperative intravenous lidocaine infusion hastened gastrointestinal motility and mobilization, and decreased the incidence of nausea in patients undergoing laparotomy. Therefore, preoperative pregabalin with or without lidocaine provides superior pain relief in patients undergoing laparatomy.

Epigenetics in the perioperative period

The perioperative period is characterized by profound changes in the body's homoeostatic processes. This review seeks to address whether epigenetic mechanisms may influence an individual's reaction to surgery and anaesthesia. Evidence from animal and human studies suggests that epigenetic mechanisms can explain many facets of susceptibility to acute and chronic pain, making them potential therapeutic targets. Modern pain management is still based upon opiates, and both the developmental expression of opioid receptors and opioid-induced hyperalgesia have been linked to epigenetic mechanisms. In general, opiates seem to increase global DNA methylation levels. This is in contrast to local anaesthetics, which have been ascribed a global demethylating effect. Even though no direct investigations have been carried out, the potential influence of epigenetics on the inflammatory response that follows surgery seems a promising area for research. There is a considerable body of evidence that supports the involvement of epigenetics in the complex process of wound healing. Epigenetics is an important emerging research topic in perioperative medicine, with a huge potential to positively influence patient outcome.

Is lidocaine patch as effective as intravenous lidocaine in pain and illus reduction after laparoscopic colorectal surgery? A randomized clinical trial

Objective:

To evaluate the efficacy of lidocaine patch applied around wound in laparoscopic colorectal surgery in reduction of postoperative pain and illus compared to intravenous lidocaine infusion and placebo.

Background:

Postoperative illus and pain after colorectal surgery is a challenging problem associated with increased morbidity and cost. Inflammatory response to surgery plays crucial rule in inducing postoperative illus. Systemic local anesthetics proved to have anti-inflammatory properties that may be beneficial in preventing ileus added to its analgesic actions. The lidocaine patch evaluated in many types of pain with promising results. We try to evaluate the patch in perioperative field as a more simple and safe technique than the intravenous route.

Materials and Methods:

Prospective, randomized, controlled study was conducted, comparing three groups. Group 1 (placebo) received saline infusion, group 2 received i.v. lidocaine infusion after induction of anesthesia, 2 mg/min if body weight >70 kg or 1 mg/min if body weight <70 kg, group 3 received lidocaine patch 5%, three patches each one divided into two equal parts and applied around the three wounds just before induction. Data collected were, pain scores (VAS), morphine consumption, return of bowel function, pro-inflammatory cytokines plasma levels and plasma lidocaine level.

Results:

Pain intensity (VAS) scores at rest and during coughing were significantly lower during the first 72 h postoperative in i.v. lidocaine group and patch group compared to the placebo group. Mean morphine consumption were significantly lower in the i.v. lidocaine group and patch group compared to placebo group. Return of the bowel function was significantly earlier in i.v. lidocaine group in comparison to the other groups. Proinflammatory cytokines (IL6, IL8, and C3a) were significantly lower in i.v. lidocaine group compared to the other two groups.

Conclusion:

The lidocaine patch was equal to i.v. lidocaine infusion in decreasing pain scores and morphine consumption but not in acceleration of bowel function return.

Time to readiness for discharge is a valid and reliable measure of short-term recovery after colorectal surgery

BACKGROUND

Short-term recovery after colorectal surgery has been traditionally investigated through length of stay (LOS). However, this measure is influenced by several confounding factors. This study aimed to investigate the construct validity and reliability of assessing the time to achieve standardized discharge criteria (time to readiness for discharge, or TRD) as a measure of short-term recovery. In a secondary analysis, we compared sample size requirements for randomized controlled trials (RCTs) using TRD or LOS as outcome measures.

METHODS

Seventy patients participated in the construct validity study and 21 patients participated in the reliability study. TRD was defined as the number of days to achieve discharge criteria previously defined by consensus. Construct validity was investigated by testing six hypothesis based on the assumption that TRD measures short-term recovery. Reliability was calculated by comparing measures of TRD by two independent assessors. Variability estimates (standard deviations) of LOS and TRD were used for sample size calculations.

RESULTS

Five of the six hypotheses were supported by the data (p < 0.05). Interobserver reliability was excellent (ICC2.1 = 0.99). Sample size estimations showed that RCTs using TRD as an outcome measure require approximately 23 % less participants compared to RCTs using LOS.

CONCLUSIONS

The results of this research support the construct-validity and reliability of TRD as a measure of short-term recovery. Using TRD as an alternative to LOS may reduce sample size requirements in future RCTs.

Lidocaine increases the anti-inflammatory cytokine IL-10 following mechanical ventilation in healthy mice

BACKGROUND

Mechanical ventilation (MV) induces an inflammatory response that may result in (acute) lung injury. Lidocaine, an amide local anesthetic, has anti-inflammatory properties in vitro and in vivo, possibly due to an attenuation of pro-inflammatory cytokines, intracellular adhesion molecule-1 (ICAM-1), and reduction of neutrophils influx. We hypothesized an attenuation of MV-induced inflammatory response with intravenously administered lidocaine.

METHODS

Lidocaine (Lido) (2, 4, and 8 mg/kg/h) was intravenously administered during 4 h of MV with a tidal volume of 8 ml/kg, positive end expiratory pressure 1,5 cmH2O and FiO2 0.4. We used one ventilated control (CON) group receiving vehicle. After MV, mice were euthanized, and lungs and blood were immediately harvested, and cytokine levels and ICAM-1 levels were measured in plasma and lung homogenates. Pulmonary neutrophils influx was determined in LEDER-stained slices of lungs. Anesthetic need was determined by painful hind paw stimulation.

RESULTS

Lidocaine-treated animals (Lido 2, 4 and 8 mg/kg/h) showed higher interleukin (IL)-10 plasma levels compared to control animals. Lidocaine treatment with 8 mg/kg/h (Lido 8) resulted in higher IL-10 in lung homogenates. No differences were observed in pro-inflammatory cytokines, ICAM-1, and pulmonary influx between the different ventilated groups.

CONCLUSIONS

Intravenously administered lidocaine increases levels of plasma IL-10 with infusion from 2, 4, and 8 mg/kg/h and pulmonary levels of IL-10 with 8 mg/kg/h in a murine mechanical ventilation model. Intravenously administered lidocaine appears to reduce anesthetic need in mice.

[Effect of intraoperative intravenous lidocaine on pain and plasma interleukin-6 in patients undergoing hysterectomy]

BACKGROUND AND OBJECTIVES

Interleukin-6 (IL-6) is a predictor of trauma severity. The purpose of this study was to evaluate the effect of intravenous lidocaine on pain severity and plasma IL-6 after hysterectomy.

METHOD

A prospective, randomized, comparative, double-blind study with 40 patients, aged 18-60 years. G1 received lidocaine (2mg.kg(-1).h(-1)) or G2 received 0.9% saline solution during the operation. Anesthesia was induced with O2/isoflurane. Pain severity (T0: awake and 6, 12, 18 and 24hours), first analgesic request, and dose of morphine in 24hours were evaluated. IL-6 was measured before starting surgery (T0), five hours after the start (T5), and 24hours after the end of surgery (T24).

RESULTS

There was no difference in pain severity between groups. There was a decrease in pain severity between T0 and other measurement times in G1. Time to first supplementation was greater in G2 (76.0±104.4min) than in G1 (26.7±23.3min). There was no difference in supplemental dose of morphine between G1 (23.5±12.6mg) and G2 (18.7±11.3mg). There were increased concentrations of IL-6 in both groups from T0 to T5 and T24. There was no difference in IL-6 dosage between groups. Lidocaine concentration was 856.5±364.1 ng.mL(-1) in T5 and 30.1±14.2 ng.mL(-1) in T24.

CONCLUSION

Intravenous lidocaine (2mg.kg(-1).h(-1)) did not reduce pain severity and plasma levels of IL-6 in patients undergoing abdominal hysterectomy.

Intraperitoneal local anesthetics have predominant local analgesic effect: a randomized, double-blind study

BACKGROUND

It remains unclear whether analgesia from intraperitoneal local anesthetics is via local or central mechanisms. This double-blind clinical trial tests the hypothesis that intraperitoneal local anesthetic is superior to continuous IV infusion for pain management. Primary outcome was morphine consumption during 0 to 24 h.

METHODS

Informed consent was obtained from 60 patients, age 30 to 75 yr, American Society of Anesthesiologists physical status I to II, undergoing abdominal hysterectomy. A computer-generated program randomized patients in parallel arms to group IV: continuous infusion of lidocaine 50 mg/h (10 ml) IV and saline 10 ml/h intermittently intraperitoneal; group IP: injection of lidocaine 50 mg/h (10 ml) once every hour intraperitoneally and continuous infusion of saline 10 ml/h intravenously; and group P (placebo): saline 10 ml/h both intravenously and intermittent intraperitoneal injection. Postoperative morphine consumption, pain intensity, recovery, home discharge, and lidocaine concentrations were measured.

RESULTS

Morphine consumption during 0 to 24 h was lower in group IP versus group IV, mean difference -22.6 mg (95% CI, 11.4 to 33.8; P < 0.01). No difference was seen between group IV and group P. The total mean plasma concentration of lidocaine in group IP was significantly lower than group IV, 0 to 4.5 h postoperatively (P = 0.03) with no evidence of systemic toxicity. Pain intensity and other recovery parameters were similar between the groups.

CONCLUSION

The lower supplemental morphine consumption and plasma lidocaine concentration in group IP would confirm that the effects of local anesthetics are likely to be predominant via local intraperitoneal receptors or anti-inflammatory effects and not via central mechanisms alone.

Recovery of gastrointestinal function with thoracic epidural vs. systemic analgesia following gastrointestinal surgery

The objective of this review was to systematically assess the effect of thoracic epidural analgesia (TEA) vs. systemic analgesia (SA) on the recovery of gastrointestinal (GI) function in patients following GI surgery. We performed a comprehensive literature search to identify randomized controlled trials of adult patients undergoing GI surgery, comparing the effect of two postoperative analgesia regimens. Patients postoperatively receiving local anesthesia-based TEA with or without opioids were compared to patients receiving opioid-based SA. The outcomes considered were times to GI function recovery, GI complications, and specific side effects. Twelve studies with 331 patients in the TEA group and 319 in the SA group were included. Compared to SA, TEA improved the GI recovery after GI procedures by shortening the time to first passage of flatus by 31.3 h, 95% confidence intervals (CIs): -33.2 to -29.4, P < 0.01; and shortening the time to first passage of stool by 24.1 h, 95% CIs: -27.2 to -20.9, P < 0.001. There was no difference between the groups in the incidence of anastomotic leakage and ileus. The occurrence of postoperative hypotension was relatively higher in the TEA group, risk ratio: 7.9, 95% CIs: 2.4 to 26.5, P = 0.001; other side effects (such as pruritus and vomiting) were similar in the two groups. There is evidence that TEA (compared to SA) improves the recovery of GI function after GI procedures without any increased risk of GI complications. To further confirm these effects, larger, better quality randomized controlled trials with standard outcome measurements are needed.

Intraoperative systemic infusion of lidocaine reduces postoperative pain after lumbar surgery: a double-blinded, randomized, placebo-controlled clinical trial

BACKGROUND CONTEXT

Analgesic effect of lidocaine infusion on postoperative pain.

PURPOSE

The aim of this study was to evaluate the analgesic effect of lidocaine infusion on postoperative pain after lumbar microdiscectomy.

STUDY DESIGN

This study used a prospective, randomized, double-blinded, and placebo-controlled clinical trial.

PATIENT SAMPLE

Fifty-one patients participated in this randomized, double-blinded study.

OUTCOME MEASURES

The primary outcome was the visual analog scale (VAS) (0-100 mm) pain score at 4 hours after surgery. The secondary outcomes were the VAS pain score at 2, 8, 12, 24, and 48 hours after surgery, the frequency with which patients pushed the button (FPB) of the patient-controlled analgesia system, and the fentanyl consumption at 2, 4, 8, 12, 24, and 48 hours after surgery. Other outcomes were satisfaction scores regarding pain control and the overall recovery process, incidence of postoperative nausea and vomiting (PONV), and length of hospital stay (HS).

METHODS

Preoperatively and throughout the surgery, Group L received intravenous lidocaine infusion (a 1.5-mg/kg bolus followed by a 2-mg/kg/h infusion until the end of the surgical procedure) and Group C received normal saline infusion as a placebo.

RESULTS

The VAS scores and fentanyl consumption were significantly lower in Group L compared with Group C except at 48 h after surgery (p<.05). Total fentanyl consumption, total FPB, length of HS, and satisfaction scores were also significantly lower in Group L compared with Group C (p<.05).

CONCLUSIONS

Intraoperative systemic infusion of lidocaine decreases pain perception during microdiscectomy, thus reducing the consumption of opioid and the severity of postoperative pain. This effect contributes to reduce the length of HS.

Perioperative protocols in colorectal surgery

The reduction in health-care expenditures and more efficient use of medical resources are now overriding health policy priorities with the two-pronged goal of improving patient outcomes while decreasing overall cost. Current reports show colorectal surgery accounting for 25% of all operative complications and an average length of stay of 8 to 12 days for a standard elective colon resection. To combat this, Kehlet and colleagues introduced a concept of enhanced recovery after surgery (ERAS) or fast-track pathways, with the goal of using current evidence and multimodal therapies to decrease surgical stress, enhance postoperative recovery, and reduce length of stay. The benefits, safety, and cost-effectiveness of fast-track protocols are validated in multiple randomized controlled trials. In this review, the authors focus on the evidence regarding fast-track pathways, use of minimally invasive surgery and its role in fast-track pathways, newer perioperative interventions, and future directions.