Infiltration with ropivacaine plus lornoxicam reduces postoperative pain and opioid consumption

The analgetic effect of adjuvants in local infiltration analgesia - a systematic review with network meta-analysis of randomized trials

BACKGROUND

Local infiltration analgesia is commonly used for postoperative pain control after several surgical procedures including intra- and peri-articular as well as wound infiltration. Even though, various adjuvants injected with the local anesthetic have been studied in pairwise comparison or compared to peripheral nerve blocks, the question which adjuvant or combination of adjuvants is the most effective in prolonging the duration of different types of local infiltration analgesia (LIA) has not been answered conclusively.

OBJECTIVE

The objective of this network meta-analysis was to determine the analgesic effectiveness and safety of adjuvants in local infiltration analgesia.

DESIGN

Systematic review of randomized controlled trials with network meta-analyses.

DATA SOURCES

A comprehensive literature search in Embase, CENTRAL, MEDLINE and Web of Science was performed up to March 2023.

RESULTS

The best interventions to prolong the duration of analgesia were dexamethasone (Ratio of Means (ROM) 3.33) followed by the combinations of clonidine + morphine (ROM 3.35) and morphine + magnesium sulfate (ROM 2.92), fentanyl (ROM 2.27), ketorolac (ROM 2.26), buprenorphine (ROM 2.04), morphine (ROM 1.93), magnesium sulfate (ROM 1.91), clonidine (ROM 1.89), dexmedetomidine (ROM 1.74) and tramadol (ROM 1.58). Serious adverse events were not reported with either investigated adjuvant.

CONCLUSION

There is moderate evidence that dexamethasone is the most effective adjuvant to prolong the duration of analgesia in LIA. The evidence for the alpha-2 agonists dexmedetomidine and clonidine is also moderate, but their effectivity to prolong analgesia stays behind dexamethasone. Clonidine and dexmedetomidine had a small detectable effect on pain scores, yet below clinical relevance, but the largest effect on MEQ consumption. The effects of different opioids were homogenous for all endpoints. The prespecified subgroup analysis of LIA of the knee did not show significantly different results than the pooled analysis.

STUDY REGISTRATION

PROSPERO 2020 CRD42020176154 (28.04.2020).

Post-thyroidectomy pain relief is enhanced by wound infiltration. A systematic review of randomized controlled trials

INTRODUCTION

Thyroidectomy is a common surgical procedure. Traditional options for pain management, such as analgesics and nonsteroidal anti-inflammatory medications (NSAIDs), are limited by their side effects. Surgical wound infiltration with local anesthetics has the potential to reduce the need for analgesics in a number of surgical procedures. This systematic review and meta-analysis wanted to resolve these concerns and assess the efficacy of WI in the management of postoperative pain after thyroidectomy.

MATERIAL AND METHODS

The review adhered to Cochrane Collaboration and PRISMA standards. RCTs comparing WI with no infiltration or placebo were included. Patients with benign or malignant thyroid disease who underwent open thyroidectomy were eligible. Postoperative pain was assessed using a visual analogue scale (VAS) as the primary outcome. Time to first rescue dose, the need for analgesic rescue in the first 24 h, and total opioid analgesic consumption were secondary outcomes. Standardized mean difference (SMD) and odds ratio (OR) were used to analyze the data.

RESULTS

16 randomized controlled trials involving 1202 patients were included. At 6 and 8 h postoperatively, WI exhibited a statistically significant impact on pain management. In the WI group, the need for analgesic rescue was significantly reduced. At 4 h postoperatively, non-anesthetic medications demonstrated a significant analgesic effect.

CONCLUSIONS

This systematic review and meta-analysis support the use of WI with local anesthetics for postoperative pain management after thyroidectomy. These findings have significant implications for improving perioperative care, especially in ambulatory settings where effective pain management is essential.

Local Wound Infiltration for Thyroidectomized Patients in the Era of Multimodal Analgesia

The first few hours following thyroidectomy are the most crucial for pain management. Adequate postoperative pain control, reduction in opioid abuse and the possibility of implementing one-day operations are the considered parameters when developing the postoperative analgesic strategy. A study of the available literature was conducted, exploring the efficacy of (open) thyroidectomy wound infiltration. Seventeen full-text RCTs were extracted. Local anesthetics and non-steroidal anti-inflammatory drugs were infiltrated. Emphasis was given to postoperative pain scores and requirements for rescue analgesia with opioids. Most authors agree that local wound infiltration for thyroidectomized patients is effective in the management of postoperative pain parameters. In the era of multimodal analgesia, thyroidectomy wound infiltration could represent an essential adjunct contributing to lower VAS scores and reduced opioid requirements.

The Use of Wound Infiltration for Postoperative Pain Management after Breast Cancer Surgery: A Randomized Clinical Study

(1) Background: The present study aims to evaluate the reduction of postoperative pain in breast surgery using a series of local analgesics, which were infiltrated into the wound; (2) Methods: Envelopes containing allocation were prepared prior to the study. The patients involved were randomly assigned to the groups of local anesthesia infiltration (Group A) or normal pain management with intravenous analgesics (Group B). The random allocation sequence was generated using computer-generated random numbers. The normally distributed continuous data were expressed as the means (SD) and were assessed using the analysis of variance (ANOVA), independent-sample t-test, or paired t-test; (3) Results: The development of the postoperative pain stages was recorded using the VAS score. Therefore, for Group A, the following results were obtained: the VAS at 6 h postoperatively showed an average value of 0.63 and a maximum value of 3. The results for Group B were the following: the VAS score at 6 h postoperatively showed an average value of 4.92, a maximum of 8, and a minimum of 2; (4) Conclusions: We can confirm that there are favorable statistical indicators regarding the postoperative pain management process during the first 24-38 h after a surgical intervention for breast cancer using local infiltration of anesthetics.

Updates on Wound Infiltration Use for Postoperative Pain Management: A Narrative Review

Local anesthetic wound infiltration (WI) provides anesthesia for minor surgical procedures and improves postoperative analgesia as part of multimodal analgesia after general or regional anesthesia. Although pre-incisional block is preferable, in practice WI is usually done at the end of surgery. WI performed as a continuous modality reduces analgesics, prolongs the duration of analgesia, and enhances the patient’s mobilization in some cases. WI benefits are documented in open abdominal surgeries (Caesarean section, colorectal surgery, abdominal hysterectomy, herniorrhaphy), laparoscopic cholecystectomy, oncological breast surgeries, laminectomy, hallux valgus surgery, and radical prostatectomy. Surgical site infiltration requires knowledge of anatomy and the pain origin for a procedure, systematic extensive infiltration of local anesthetic in various tissue planes under direct visualization before wound closure or subcutaneously along the incision. Because the incidence of local anesthetic systemic toxicity is 11% after subcutaneous WI, appropriate local anesthetic dosing is crucial. The risk of wound infection is related to the infection incidence after each particular surgery. For WI to fully meet patient and physician expectations, mastery of the technique, patient education, appropriate local anesthetic dosing and management of the surgical wound with “aseptic, non-touch” technique are needed.

Perioperative pain management for thyroid and parathyroid surgery: A systematic review

INTRODUCTION

A growing body of evidence suggests that surgeons have historically over-prescribed opioid pain medications following thyroid and parathyroid surgery, thereby potentially contributing to the current US opioid epidemic. We reviewed the evidence supporting multimodal methods of pain control after cervical endocrine surgery.

METHODS

Fifty-one randomized clinical trials, 9 prospective cohort studies, 7 retrospective studies/reviews, and 1 survey regarding pain management for cervical endocrine surgery were include.

RESULTS

Most studies reported in-hospital pain scores and opioid consumption. Data on pain scores following discharge were limited. In several studies, the interventional dose was much greater than what is commonly used clinically.

CONCLUSION

Several evidence-based, non-opioid interventions can be incorporated into a standardized pain management protocol following cervical endocrine surgery. Little is known regarding the effects of these interventions on post-discharge pain scores and patient quality of life during recovery.

Adjuncts to local anesthetic wound infiltration for postoperative analgesia: a systematic review

Local anesthetics (LAs) are commonly infiltrated into surgical wounds for postsurgical analgesia. While many adjuncts to LA agents have been studied, it is unclear which adjuncts are most effective for co-infiltration to improve and prolong analgesia. We performed a systematic review on adjuncts (excluding epinephrine) to local infiltrative anesthesia to determine their analgesic efficacy and opioid-sparing properties. Multiple databases were searched up to December 2019 for randomized controlled trials (RCTs) and two reviewers independently performed title/abstract screening and full-text review. Inclusion criteria were (1) adult surgical patients and (2) adjunct and LA agents infiltration into the surgical wound or subcutaneous tissue for postoperative analgesia. To focus on wound infiltration, studies on intra-articular, peri-tonsillar, or fascial plane infiltration were excluded. The primary outcome was reduction in postoperative opioid requirement. Secondary outcomes were time-to-first analgesic use, postoperative pain score, and any reported adverse effects. We screened 6670 citations, reviewed 126 full-text articles, and included 89 RCTs. Adjuncts included opioids, non-steroidal anti-inflammatory drugs, steroids, alpha-2 agonists, ketamine, magnesium, neosaxitoxin, and methylene blue. Alpha-2 agonists have the most evidence to support their use as adjuncts to LA infiltration. Fentanyl, ketorolac, dexamethasone, magnesium and several other agents show potential as adjuncts but require more evidence. Most studies support the safety of these agents. Our findings suggest benefits of several adjuncts to local infiltrative anesthesia for postoperative analgesia. Further well-powered RCTs are needed to compare various infiltration regimens and agents.

Protocol registration

PROSPERO (CRD42018103851) (https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=103851)

Perioperative Analgesia for Patients Undergoing Thyroidectomy and Parathyroidectomy: An Evidence-Based Review

Objective:

To perform an evidence-based systematic review evaluating perioperative analgesia, including opioid alternatives, used for patients undergoing thyroidectomy and parathyroidectomy.

Methods:

A comprehensive literature search from 1997 to January 2018 of Pubmed, Cochrane, and EmBase libraries was performed for studies reporting analgesic administration following thyroid or parathyroid surgery. This systematic review was based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Studies were evaluated for level of evidence and given a Jadad score to assess for risk of bias. Outcomes gathered included postoperative pain scores, time to rescue analgesia, rescue analgesic consumption, and adverse events.

Results:

Thirty-eight randomized controlled trials met inclusion criteria. The GRADE criteria determined the overall evidence to be moderate-high. Studies utilizing NSAIDs reported reduced requirements for rescue analgesics. Acetaminophen studies presented with conflicting data on effectiveness. Gabapentinoid studies demonstrated lower pain scores and an increased time to rescue analgesic. Local anesthetics were effective at decreasing Visual Analogue Scale (VAS) and Numeric Rating Scale (NRS) pain scores while also reducing rescue analgesic consumption. Ketamine was shown to increased postoperative nausea and vomiting. NSAIDs and local anesthetic studies had an aggregate grade of evidence A, while all others had grade B evidence.

Conclusion:

There is significant evidence supporting the use of NSAIDs and local anesthetics in the perioperative period for pain management for thyroid and parathyroid surgeries. Acetaminophen, gabapentinoid and ketamine have some supporting evidence and may serve as adequate alternatives. Further multi-institutional RCTs are warranted to delineate optimal analgesic regimens.

Level of Evidence:

NA

Lack of Analgesic Effect Induced by Ropivacaine Wound Infiltration in Thyroid Surgery: A Randomized, Double-Blind, Placebo-Controlled Trial

BACKGROUND

Surgical site infiltration with local anesthetic reduces analgesic requests in various types of surgeries. Because thyroid surgery may induce severe postoperative pain, we tested the hypothesis that ropivacaine surgical site infiltration would significantly decrease postoperative administration of morphine in patients undergoing thyroid surgery.

METHODS

We performed a double-blind, placebo-controlled superiority trial to assess the efficacy of surgical site analgesia with ropivacaine (10 mL, 75 mg) performed at the end of thyroid surgery in adult patients. The primary end point was the proportion of patients not requiring IV morphine in the postanesthesia care unit.

RESULTS

One hundred sixty-three patients completed the study, 85 in the placebo group and 88 in the ropivacaine group. The proportion of patients requiring morphine administration in the postanesthesia care unit (55% vs 53%, P = 0.80), the dose of IV morphine administered (5.6 ± 6.1 vs 5.5 ± 6.0 mg, P = 0.90), the total dose of opioids administered (expressed as oral morphine equivalent dose: 64 ± 27 vs 69 ± 29 mg, P = 0.20), and the visual analog pain scale over the first 24 hours were not significantly different between groups. The incidence of adverse events (36% vs 39%, P = 0.88), morphine-related adverse events (19% vs 17%, P = 0.84), serious adverse events (0% vs 2%, P = 0.50), and the patient satisfaction scores (9 ± 1 vs 9 ± 1, P = 0.70) was not significantly different between the 2 groups.

CONCLUSIONS

Surgical site analgesia with ropivacaine at the end of thyroid surgery is not associated with any significant analgesic benefit.

Lornoxicam : pharmacology and usefulness to treat acute postoperative and musculoskeletal pain a narrative review

INTRODUCTION

Non-steroidal anti-inflammatory drugs (NSAIDS) are commonly used for acute pain management. Lornoxicam is a nonselective NSAID for oral and intravenous administration. It has been available for human use since two decades and there is a growing body of evidence supporting its efficacy and tolerability for management of acute pain.

AREAS COVERED

Public domain literature around the clinical use of lornoxicam for acute pain management has been reviewed.

EXPERT OPINION

There are a growing number of clinical studies documenting lornoxicam effects for short-term treatment of acute postoperative pain following various surgical procedures. It has in the majority of comparative studies been shown superior as compared to paracetamol, non-inferior compared to other NSAIDs, and commonly similarly effective as standard clinical doses of opioids, but associated with better tolerability. Its effect on other acute pain, for example, headache, back pain, or sports injury is not well studied. Lornoxicam 8 mg twice daily is a seemingly effective and tolerable alternative NSAID for use as sole agent or as part of multimodal analgesia in adults. Available data does however not show any outstanding benefits or special risk. The general precautions with regard to the use of NSAIDs, the potential risks, for example, gastrointestinal bleeding and or cardiovascular side effects must be acknowledged.

Analgesic efficacy of bilateral superficial cervical plexus block in robot-assisted endoscopic thyroidectomy using a transaxillary approach

BACKGROUND

Nerve blocks and infiltration with local anesthetics are commonly employed methods for postoperative pain control. This prospective, randomized trial was conducted to determine whether bilateral superficial cervical plexus block (BSCPB) is effective for reducing acute postoperative pain after robot-assisted endoscopic thyroidectomy (RAET) and to compare its effects with that of local wound infiltration (LWI).

METHODS

Ninety-seven patients who were to undergo RAET were randomly assigned to one of three groups to receive BSCPB with either 20 mL of 0.525% ropivacaine (BSCPB group, n=32) or 20 mL of isotonic sodium chloride solution (Control group, n=32) or LWI with 20 mL of 0.525% ropivacaine (LWI group, n=33). Postoperative pain scores were assessed at the postoperative anesthesia care unit (PACU) and at 6, 24, and 48 h postoperatively using a visual analog scale (VAS). Patients with VAS scores of ≥40 were administered rescue analgesics according to a standardized protocol. The main outcome variables were pain scores during the first postoperative 24 h and the number of patients requiring postoperative analgesic rescue.

RESULTS

The BSCBP and LWI groups showed lower pain scores compared with the Control group at the PACU. The BSCPB group continued to show significantly lower pain scores compared with the LWI and Control groups at postoperative 6 and 24 h. The number of patients requiring analgesic rescue at the PACU was lower in the BSCPB and LWI groups than in the Control group. The number of patients requiring additional rescue analgesics after discharge from the PACU until the first 24 postoperative h was lower in the BSCPB group than in the LWI group.

CONCLUSIONS

BSCPB and LWI are effective for reducing pain scores and analgesic requirements during the immediate postoperative period in patients who undergo RAET, with BSCPB being superior to LWI at postoperative 6-24 h.

Preoperative peritonsillar lornoxicam infiltration is not superior to intravenous lornoxicam for pain relief following tonsillectomy in adults

BACKGROUND AND OBJECTIVE

Nonsteroidal anti-inflammatory drugs have peripheral analgesic effects. We compared the efficacy of peritonsillar infiltration versus intravenous (i.v.) lornoxicam on pain relief after tonsillectomy in adults.

METHODS

Sixty adult patients scheduled for tonsillectomy were randomly assigned into three groups in a double-blind placebo-controlled study. In the control group, the patients received i.v. and peritonsillar saline infiltration; in the infiltration group, they received i.v. isotonic saline and peritonsillar lornoxicam infiltration, whereas in the i.v. group they received i.v. lornoxicam and peritonsillar saline infiltration. Pain verbal analogue scale at rest and on swallowing, the time to the first postoperative analgesic request, the total postoperative analgesic consumption during the first 24 h, intraoperative blood loss and postoperative bleeding were evaluated.

RESULTS

Preoperative lornoxicam administration resulted in a significant reduction in pain scores postoperatively in the infiltration and i.v. groups with no significant difference between them. The time to first postoperative analgesic request was 143 +/- 138 min in the control group compared with 684 +/- 328 and 750 +/- 316 min in the i.v. and infiltration groups, respectively; P value is less than 0.05. Similarly a higher total paracetamol consumption (2632 +/- 1065 mg) during the first postoperative day was recorded in the control group than in both the lornoxicam groups (1300 +/- 733 and 1600 +/- 754 mg), with no significant differences between the i.v. and infiltration groups. Comparable intraoperative blood losses with no posttonsillectomy bleeding were recorded in the three study groups.

CONCLUSION

Peritonsillar infiltration or i.v. lornoxicam enhanced postoperative analgesia after tonsillectomy in adults. However, the analgesic efficacy of locally applied lornoxicam is not superior to the i.v. administration.

Nicardipine is more effective than esmolol at preventing blood pressure increases during emergence from total intravenous anesthesia

BACKGROUND

This prospective, randomized, double-blind study was undertaken to compare prophylactic nicardipine infusion with esmolol infusion to determine their effects on the control of hemodynamic response during emergence from total intravenous anesthesia (TIVA) with propofol and remifentanil.

METHODS

One hundred and thirty two patients undergoing thyroidectomy were divided randomly into 3 groups. About 10 minutes before the end of surgery, propofol was stopped in all the patients and nicardipine group (n = 44) received a continuous infusion of 2 microgram/kg/min nicardipine during emergence from TIVA, esmolol group (n = 44) received 250 microgram/kg/min esmolol, and placebo group received 10-14 ml/hr of isotonic saline until 15 min after transfer to a postanesthesia care unit (PACU). Hemodynamic profiles were measured every minute throughout the study period.

RESULTS

MBP was significantly lower in the nicardipine group than in the esmolol group (P<0.05) from 10 min after PACU transfer until 10 min after study drug infusion stop. On the other hand, HR was significantly lower in the esmolol group than in the nicardipine group from 6 min after drug infusion.

CONCLUSIONS

Nicardipine infusion attenuated blood pressure increases more effectively than esmolol infusion during emergence from TIVA.

Recent advances in the pharmacological management of pain

Pain is an unpleasant sensation that originates from ongoing or impending tissue damage. Management of different types of pain (acute, postoperative, inflammatory, neuropathic or cancer) is the most frequent issue encountered by clinicians and pharmacological therapy is the first line of approach for the treatment of pain. This review presents and discusses recent clinical advances regarding both the improvements in delivery of analgesic drugs and improvements in the design of analgesic molecules. The new modalities of administration of analgesics used in the clinic are reviewed, including skin patches, oral and mucosal sprays, transdermal delivery systems and intranasal administration. New insights are then presented on standard drugs used to relieve pain, such as opioids (including tramadol), NSAIDs including selective cyclo-oxygenase-2 inhibitors, paracetamol (acetaminophen), local anaesthetics and adjuvant analgesics such as antidepressants, anticonvulsants (gabapentin and pregabalin), cannabinoids, ketamine and others (e.g. nefopam). Although the understanding of pain mechanisms has improved significantly recently, much more is yet to be discovered and awaited. Broadening of our knowledge is needed to improve basic and clinical research in this field in order to better alleviate pain in millions of people.

Non-opioid strategies for acute pain management

Subscribers to the Canadian Journal of Anesthesia are invited to read the following article to introduce them to a number of key articles cited in the bibliography. Reading at least the articles preceded by an asterisk (*) allows adequate preparation for the Self-Assessment Program, which can be completed by accessing the Continuing Medical Education (CME) link on the Journal site (http://www.cja-jca.org). Completion of the Self-Assessment Program will entitle subscribers to claim up to ten hours of Continuing Professional Development (CPD) under section 3 of CPD options, for a total of up to 20 Maintenance of Certification credits (note that section 3 hours are not limited to a maximum number of credits per five-year period). Obtaining CME credits for this module is not based upon attaining a specific score: the goal of participating is to define potential areas for improvement.

Preemptive analgesia with lidocaine prevents Failed Back Surgery Syndrome

Failed Back Surgery Syndrome (FBSS) is commonly encountered in pain-treatment settings in the United States. We tested whether potential key factors in this syndrome, such as extracellular concentrations of excitatory amino acids (EAAs), are increased in the dorsal horn by synaptic release due to unintentional stretch and/or deformation/compression/transection of dorsal spinal structures during surgery. We hypothesized that pharmacological nerve block as a form of preemptive analgesia prior to any insult to dorsal root neurons will prevent an abnormally high increase in extracellular concentrations of EAAs in the dorsal horn and ultimately the establishment of central sensitization during back surgery. The L4 and L5 dorsal roots were cut bilaterally near the spinal cord to provide an adequate model to test for preemptive analgesia. Amino acid concentrations were measured by dorsal horn microdialysis sampling; EAAs aspartate and glutamate were significantly increased by 80% and 65% respectively, as were other amino acids compared to sham control values. Topical application of 1% Lidocaine, a voltage-gated Na(+) channel blocker, for 10 min prior to L4 and L5 bilateral dorsal rhizotomy (BDR) significantly attenuated the increase in EAA concentrations such that their values were not different from sham controls. Behavioral tests demonstrated significant hindlimb mechanical allodynia after BDRs that was significantly attenuated by Lidocaine pretreatment. Thus, Lidocaine pretreatment could offer a safe measure for prevention of chronic pain for back surgical procedures if given by intramuscular injection, topical administration onto spinal nerves and/or the dorsal spinal surface during surgical procedures that include nerve entrapment release, intervertebral disc modification and laminectomies.

The analgesic effect of lornoxicam when added to lidocaine for intravenous regional anaesthesia

BACKGROUND

The aim of the study was to evaluate the effect of lornoxicam (L) on sensory and motor block onset time, tourniquet pain, and postoperative analgesia, when added to lidocaine in intravenous regional anaesthesia (IVRA).

METHODS

Forty-five patients undergoing hand surgery were randomly and blindly divided into three groups as to receive either i.v. saline and IVRA with lidocaine 0.5% (Control group, n=15), i.v. saline and IVRA lidocaine 0.5% with lornoxicam (L-IVRA group, n=15), or intravenous lornoxicam and IVRA lidocaine 0.5% (L-IV group, n=15). Sensory and motor blocks onset time, and tourniquet pain was measured after tourniquet application at 5, 10, 20, and 30 min, and analgesic use were recorded during operation. After the tourniquet deflation, at 1, 30 min, and 2, 4 h, visual analogue scales score, the time to first analgesic requirement, total analgesic consumption in first 24 h, and side effects were noted.

RESULTS

Sensory and motor block onset times were shorter and the recovery time prolonged in the Group L-IVRA compared with the other group (P=0.001). A decreased tourniquet pain, a prolonged time first analgesic requirement [229 (85) min vs 28 (20) and 95 (24) min, P=0.0038) and less postoperative analgesic requirements during 24 h were found in Group L-IVRA compared with the other groups (P<0.05).

CONCLUSIONS

The addition of lornoxicam to lidocaine for intravenous regional anaesthesia shortens the onset of sensory and motor block, decreases tourniquet pain and improves postoperative analgesia without causing any side effect.