Continuous intravenous lidocaine in the treatment of paralytic ileus due to severe spinal cord injury

Pain in Colorectal Surgery: How Does It Occur and What Tools Do We Have for Treatment?

Pain is a complex entity with deleterious effects on the entire organism. Poorly controlled postoperative pain impacts the patient outcome, being associated with increased morbidity, inadequate quality of life and functional recovery. In the current surgical environment with less invasive surgical procedures increasingly being used and a trend towards rapid discharge home after surgery, we need to continuously re-evaluate analgesic strategies. We have performed a narrative review consisting of a description of the acute surgical pain anatomic pathways and the connection between pain and the surgical stress response followed by reviewing methods of multimodal analgesia in colorectal surgery found in recent literature data. We have described various regional analgesia techniques and drugs effective in pain treatment, emphasizing their advantages and concerns. We have also tried to identify present knowledge gaps requiring future research. Our review concludes that surgical pain has peculiarities that make its management complex, implying a consistent, multimodal approach aiming to block both peripheral and central pain pathways.

Effect of perioperative lignocaine infusion on postoperative pain relief for laparoscopic intraperitoneal onlay mesh repair: A randomized controlled study

INTRODUCTION

The focus on enhanced recovery after surgery (ERAS) and opioid-free anesthesia has renewed interest in use of lignocaine. We evaluated postoperative pain relief following intravenous (IV) lignocaine administration in patients undergoing laparoscopic intraperitoneal onlay mesh repair (IPOM).

METHODS

Seventy patients were randomized into two groups. Group L patients were administered IV lignocaine infusion (1.5 mg/kg) at induction of anesthesia followed by infusion (1.5 mg/kg/h), until 1 hour in the post-anesthesia care unit (PACU). Group P patients received equal volumes of normal saline IV infusion. We recorded hemodynamics, perioperative analgesic consumption, postoperative visual analog scores (VAS), incidence of postoperative nausea and vomiting (PONV), bowel function, patient satisfaction and length of hospital stay (LOS).

RESULTS

The hemodynamics in both groups were maintained. Group L had lower VAS scores as compared to Group P (P < .05). Intraoperative fentanyl consumption in Group L was significantly less than Group P (P = .029). Group L patients scored lower on the Likert scale in comparison to the patients of Group P at 0 hour (P = .013). Recovery of bowel function as assessed by time to pass first flatus was significantly shortened by IV lignocaine (P = .001). The perioperative administration of IV lignocaine resulted in decreased postoperative analgesic requirement and greater patient satisfaction scores.

CONCLUSIONS

Perioperative IV lignocaine infusion provided good pain relief, hemodynamic stability and decreased perioperative analgesic consumption. PONV incidence decreased along with an early return of bowel function, reduced LOS and improved patient satisfaction in patients undergoing laparoscopic IPOM surgery.

Transversus abdominis plane block or intravenous lignocaine in open prostate surgery: a randomized controlled trial

BACKGROUND AND OBJECTIVES

Transversus abdominis plane block (TAP) and intravenous lignocaine are two analgesic techniques frequently used after abdominal surgery. We hypothesized that these two techniques improve post-operative analgesia after open prostate surgery and sought to compare their efficacy on immediate post-operative outcome after open prostate surgery.

METHODS

After ethics committee approval, 101 patients were enrolled in this prospective study and randomly allocated to receive bilateral ultrasound-guided TAP (n = 34), intravenous lignocaine (n = 33) or placebo (n = 34). In addition, intravenous paracetamol was given every 6 h. The primary endpoint was the cumulative opioid consumption during the first 48 post-operative hours (median[IQR]). Secondary endpoints included pain scores at rest and upon coughing, need for rescue tramadol, incidence of post-operative nausea and vomiting (PONV), recovery of bowel function and incidence of bladder catheter-related discomfort.

RESULTS

Cumulative piritramide consumption after 48 h was 28 [23] mg in the control group, 21 [29] mg in the TAP group and 21 [31] mg in the lignocaine group (P = 0.065). There was no significant difference in post-operative pain scores between groups. The proportions of patients requiring rescue tramadol, experiencing PONV or bladder catheter-related discomfort were similar in each group. Recovery of bowel function was also similar in the three groups.

CONCLUSIONS

Our study suggests that TAP block and intravenous lignocaine do not improve the post-operative analgesia provided by systematic administration of paracetamol after open prostatectomy.

[Update on the pharmacology and effects of local anesthetics]

Local anesthetics (LA) are broadly used in all disciplines and it could be considered that relatively little is reflected on the mechanisms of action of this old substance group. However, several molecular mechanisms of LAs mediating wanted and unwanted effects remain to be explored. Furthermore, the number of indications for application of LAs seems to be expanding. The local anesthetic effect of LAs is primarily mediated by a potent inhibition of voltage-gated sodium channels. However, this effect is due to much more than the interaction of LAs with one single molecule. Most recent studies indicated that the development of selective local anesthetics might be possible and LAs also interact with several other membrane molecules. Although the relevance of these effects is still unclear, they might play a role in systemic analgesia, tissue protection and anti-inflammatory effects of LA. The therapeutic index of systemically applied LA is very narrow. Systemic application is formally not permitted because the impending systemic toxicity is still a life-threatening complication. Although the cardiac and central nervous toxicity at least partly result from an unselective block of neuronal and cardiac sodium channels, preclinical studies suggest the involvement of several mechanisms. A local LA toxicity is less clinically impressive; however, all LAs induce a significant tissue toxicity for which the underlying mechanisms have been partly identified. This review reports on recent findings on mechanisms and on the clinical relevance of some LA-induced effects which are of relevance for anesthesiological activities.

Regional anaesthesia and cancer metastases: the implication of local anaesthetics

Clinical and basic science studies have demonstrated the anti-inflammatory properties of local anaesthetics. Recent studies have begun to unravel molecular pathways linking inflammation and cancer. Regional anaesthesia is associated in some retrospective clinical studies with reduced risk of metastasis and increased long-term survival. The potential beneficial effects of regional anaesthesia have been attributed mainly to the inhibition of the neuroendocrine stress response to surgery and to the reduction in the requirements of volatile anaesthetics and opioids. Because cancer is linked to inflammation and local anaesthetics have anti-inflammatory effects, these agents may participate in reducing the risk of metastasis, but their mechanism of action is unknown. We demonstrated in vitro that amide local anaesthetics attenuate tumour cell migration as well as signalling pathways enhancing tumour growth and metastasis. This has provided the first evidence of a molecular mechanism by which regional anaesthesia might inhibit or reduce cancer metastases.

Update on local anesthetics

PURPOSE OF REVIEW

Local anesthetics are not only used as drugs to block the sodium channel to provide analgesia and antiarrhythmic action. The purpose of this review is to highlight the new indications and limitations of this class of drugs.

RECENT FINDINGS

Recent research has focused on the use of intravenous local anesthetics to improve bowel function after surgery or trauma, to protect the central nervous system, to find new clues about local anesthetic effects in chronic neuropathic pain, and to investigate the long-term effect of anesthesia/analgesia provided by local anesthetics on cancer recurrence. Recent facts dealing with myotoxicity and chondrotoxicity are presented.

SUMMARY

There is growing evidence that local anesthetics have a broad spectrum of indications in addition to analgesia and antiarrhythmic effect. Most of them are still insufficiently known and investigated. These new indications will no doubt be intensively studied in the coming years.