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Toner AJ, Bailey MA, Schug SA, Phillips M, Ungerer JP, Somogyi AA, Corcoran TB. Serum lidocaine (lignocaine) concentrations during prolonged perioperative infusion in patients undergoing breast cancer surgery: A secondary analysis of a randomised controlled trial. Anaesth Intensive Care 2023; 51:422-431. [PMID: 37802488 DOI: 10.1177/0310057x231194833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/10/2023]
Abstract
Perioperative lidocaine (lignocaine) infusions are being employed with increasing frequency. The determinants of systemic lidocaine concentrations during prolonged administration are unclear. In the Long-term Outcomes after Lidocaine Infusions for PostOperative Pain (LOLIPOP) pilot trial, the impact of infusion duration and body size metrics on serum lidocaine concentrations was examined with regression models in 48 women undergoing breast cancer surgery. Lidocaine was delivered as an intravenous bolus (1.5 mg/kg) and infusion (2 mg/kg per h) intraoperatively, followed by a 12-h subcutaneous infusion (1.33 mg/kg per h) postoperatively. Dosing was based on total body weight. Wound infiltration with other long-acting local anaesthetics was permitted. Protein binding and pharmacogenomic data were also collected. Lidocaine concentrations (median (interquartile range) (range)) during prolonged administration were in the safe and potentially therapeutic range: post-anaesthesia care unit 2.16 (1.73-2.82) (1.12-6.06) µg/ml; ward 1.41 (1.22-1.75) (0.64-2.81) µg/ml. Concentrations increased non-linearly during the early intravenous phase of administration (mean rise 1.21 µg/ml per hour of infusion, P = 0.007) but reached a pseudo steady-state during the later subcutaneous phase. Higher dose rates received per kilogram of lean (P = 0.004), adjusted (P = 0.006) and ideal body weight (P = 0.009) were associated with higher steady-state concentrations. The lidocaine free fraction was unaffected by the presence of ropivacaine, and phenotypes linked to slow metabolism were infrequent. Serum lidocaine concentrations reached a pseudo steady-state during a 12-h postoperative infusion. Greater precision in steady-state concentrations can be achieved by dosing on lean body weight versus adjusted or ideal body weight (equivalent lean body weight doses: intravenous bolus 2.5 mg/kg; intravenous infusion 3.33 mg/kg per h; subcutaneous infusion 2.22 mg/kg per h.
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Affiliation(s)
- Andrew J Toner
- Department of Anaesthesia and Pain Medicine, Royal Perth Hospital, Perth, Australia
- Medical School, University of Western Australia, Perth, Australia
| | - Martin A Bailey
- Department of Anaesthesia and Intensive Care Medicine, Taranaki Base Hospital, New Plymouth, New Zealand
| | - Stephan A Schug
- Medical School, University of Western Australia, Perth, Australia
| | - Michael Phillips
- Harry Perkins Institute of Medical Research, Nedlands, Australia
- Centre for Medical Research, University of Western Australia, Perth, Australia
| | - Jacobus Pj Ungerer
- Pathology Queensland, Royal Brisbane & Women's Hospital, Brisbane, Australia
- School of Biomedical Sciences, University of Queensland, Brisbane, Australia
| | - Andrew A Somogyi
- Discipline of Pharmacology, School of Biomedicine, University of Adelaide, Adelaide, Australia
| | - Tomas B Corcoran
- Department of Anaesthesia and Pain Medicine, Royal Perth Hospital, Perth, Australia
- Medical School, University of Western Australia, Perth, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
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Lee IWS, Schraag S. The Use of Intravenous Lidocaine in Perioperative Medicine: Anaesthetic, Analgesic and Immune-Modulatory Aspects. J Clin Med 2022; 11:jcm11123543. [PMID: 35743617 PMCID: PMC9224677 DOI: 10.3390/jcm11123543] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 06/12/2022] [Accepted: 06/16/2022] [Indexed: 12/14/2022] Open
Abstract
This narrative review provides an update on the applied pharmacology of lidocaine, its clinical scope in anaesthesia, novel concepts of analgesic and immune-modulatory effects as well as the current controversy around its use in perioperative opioid-sparing multi-modal strategies. Potential benefits of intravenous lidocaine in the context of cancer, inflammation and chronic pain are discussed against concerns of safety, toxicity and medico-legal constraints.
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Affiliation(s)
- Ingrid Wing-Sum Lee
- School of Medicine, University of Glasgow, Wolfson Medical School Building, University Avenue, Glasgow G12 8QQ, UK;
| | - Stefan Schraag
- Department of Perioperative Medicine, Golden Jubilee National Hospital, Agamemnon Street, Clydebank G81 4DY, UK
- Correspondence: ; Tel.: +44-7799878261
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Terblanche NC, Otahal P, Sharman JE. A survey of anaesthetists on uterotonic usage practices for elective caesarean section in Australia and New Zealand. Anaesth Intensive Care 2021; 49:440-447. [PMID: 34657486 DOI: 10.1177/0310057x211002838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Prophylactic administration of uterotonics ensures adequate uterine contraction at elective caesarean section to prevent substantial haemorrhage. Royal College of Obstetricians and Gynaecologists guidelines advise the administration of oxytocin 5 IU as a 'slow bolus' but there are variations in clinical practice. This study aimed to determine the beliefs and uterotonic usage practices at elective caesarean section by surveying anaesthetist members of the Obstetric Anaesthesia Special Interest Group in Australia and New Zealand. Questionnaires were emailed to Obstetric Anaesthesia Special Interest Group members and the response rate was 33%, with analysis of 279 completed reports. Oxytocin was the most commonly used first-line uterotonic, but extensive variation in oxytocin bolus use was identified. Thirty-eight percent of anaesthetists routinely administered Royal College of Obstetricians and Gynaecologists guideline-recommended 5 IU, whereas 38% favoured low dose (<5 IU), 10% high dose (≥10 IU) oxytocin, and 13% carbetocin (100 µg). More than 50% felt the evidence was weak for guideline-recommended 5 IU. Wide variation in the duration of oxytocin administration was also identified. Fifty-eight percent of anaesthetists routinely gave follow-up oxytocin infusions, most commonly at 40 IU over four hours, but there was significant variation in the dosage (10-40 IU) and administration duration (one hour to ≥six hours). In conclusion, there is significant variation in oxytocin usage practices at elective caesarean section among Australian and New Zealand anaesthetists. This variation may be due to a lack of strong evidence to guide practice. This emphasises the need for high quality trials in this clinically important area.
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Affiliation(s)
- Nico Cs Terblanche
- Department of Anaesthesia and Perioperative Medicine, Royal Hobart Hospital, Hobart, Australia.,Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia
| | - Petr Otahal
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia
| | - James E Sharman
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia
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Saka AK, Ferenbok J. Improving the Uptake of Transcatheter Aortic Valve Replacement in Ontario. Cureus 2021; 13:e16364. [PMID: 34395141 PMCID: PMC8360318 DOI: 10.7759/cureus.16364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/13/2021] [Indexed: 11/29/2022] Open
Abstract
Background The rising costs of healthcare delivery globally and the increasing research production rate create immense opportunities for implementing novel and more effective medical interventions that significantly benefit patient outcomes. However, the successful uptake of medical innovations is complex and often extremely contextual based on many sociopolitical and economic factors. These barriers to implementation can delay or derail new practices, procedures, products, and pharmaceuticals. Understanding the barriers to the successful implementation of medical innovations and the best practices and strategies to mitigate them is an extremely important area for translational research in health sciences. This study examines the barriers and potential challenges in implementing medical innovations and the possible preemptive measures that can be addressed early to increase the use of life-saving medical innovations. We consider the importance of appropriate, timely, and user-defined implementation techniques as a critical component of the successful uptake of medical innovations and use the uptake of transcatheter valve replacement therapy (TAVR), which is an alternative life-saving intervention for patients at risk for surgical complications, in Ontario, Canada as the practical case study of the challenges and potential instructive opportunities to establish best practices for systematic and effective innovation uptake. Methodology In addition to contextual and informal investigations, a small pilot survey of decision-makers across the University of Toronto-affiliated teaching hospitals helped compare and contrast the barriers to medical innovation uptake (in the literature) with the suggested barriers to the successful implementation of TAVR. This study looks primarily at the role of funding, physician preference, clinical guidelines, and patient comorbidities as decision-making factors contributing to TAVR uptake. The study also explores how the differences and similarities of TAVR uptake related to the decision-making factors above can help develop recommended strategies to address future implementation barriers. Results We observed that the decision-makers across the surveyed institutions refer patients with intermediate to high risk for surgery for TAVR. Funding and physician preference were identified as possible barriers to TAVR uptake, with underlying comorbidities of patients being a primary decision determinant for TAVR referral. Physician preferences were based on multiple factors such as clinical judgment, patient comorbidities, clinical guidelines, knowledge, TAVR, and surgical valve replacement skills. Conclusions To the best of our knowledge, this study is one of the first to use the Toronto Translational Thinking Framework to assess an innovative treatment uptake in the Ontario healthcare system. Although the study sample size was 11 and did not reflect the views of all decision-makers regarding TAVR use in Ontario, the survey reflected participants who directly make decisions regarding TAVR use, strengthening the credibility of the survey results. The insights from this study are intended to inform both the continued implementation of TAVR and to contribute to a broader field of investigation that aims to identify and operationalize the principles and best practices of translational research that may contribute to the efficacy of implementing other medical innovations in Ontario hospitals and beyond.
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Affiliation(s)
- Abimbola K Saka
- Institute of Medical Science, University of Toronto, Toronto, CAN
| | - Joseph Ferenbok
- Laboratory Medicine and Pathobiology, University of Toronto, Toronto, CAN
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Shanthanna H, Weinberg G. Intravenous lidocaine, regional blockade, or both: considerations for multiple interventions involving local anaesthetics. Br J Anaesth 2021; 127:497-501. [PMID: 34119313 DOI: 10.1016/j.bja.2021.04.024] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 04/09/2021] [Accepted: 04/28/2021] [Indexed: 01/04/2023] Open
Affiliation(s)
- Harsha Shanthanna
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada.
| | - Guy Weinberg
- Department of Anesthesiology, University of Illinois at Chicago, Jesse Brown VA Medical Center, Chicago, IL, USA
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Abstract
PURPOSE OF REVIEW Surgery remains integral to treating solid cancers. However, the surgical stress response, characterized by physiologic perturbation of the adrenergic, inflammatory, and immune systems, may promote procancerous pathways. Anesthetic technique per se may attenuate/enhance these pathways and thereby could be implicated in long-term cancer outcomes. RECENT FINDINGS To date, clinical studies have predominantly been retrospective and underpowered and, thus limit meaningful conclusions. More recently, prospective studies of regional anesthesia for breast and colorectal cancer surgery have failed to demonstrate long-term cancer outcome benefit. However, based on the consistent observation of protumorigenic effects of surgical stress and that of volatile anesthesia in preclinical studies, supported by in vivo models of tumor progression and metastasis, we await robust prospective clinical studies exploring the role of propofol-based total intravenous anesthesia (cf. inhalational volatiles). Additionally, anti-adrenergic/anti-inflammatory adjuncts, such as lidocaine, nonsteroidal anti-inflammatory drugs and the anti-adrenergic propranolol warrant ongoing research. SUMMARY The biologic perturbation of the perioperative period, compounded by the effects of anesthetic agents, renders patients with cancer particularly vulnerable to enhanced viability of minimal residual disease, with long-term outcome consequences. However, low level and often conflicting clinical evidence equipoise currently exists with regards to optimal oncoanesthesia techniques. Large, prospective, randomized control trials are urgently needed to inform evidence-based clinical practice guidelines.
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Toner AJ, Bailey MA, Schug SA, Corcoran TB. A pilot multicentre randomised controlled trial of lidocaine infusion in women undergoing breast cancer surgery. Anaesthesia 2021; 76:1326-1341. [PMID: 33651896 DOI: 10.1111/anae.15440] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/21/2021] [Indexed: 12/01/2022]
Abstract
Chronic postoperative pain is common after breast cancer surgery. Peri-operative lidocaine infusion may prevent the development of chronic postoperative pain, but a large-scale trial is required to test this hypothesis. It is unclear whether a pragmatic, multicentre trial design that is consistent with expert guidance, addresses the limitations of previous studies, and overcomes existing translational barriers is safe, effective and feasible. We conducted a double-blind, randomised controlled pilot study in 150 patients undergoing breast cancer surgery across three hospitals in Western Australia. Patients received lidocaine, or equivalent volumes of saline, as an intravenous bolus (1.5 mg.kg-1 ) and infusion (2 mg.kg-1 .h-1 ) intra-operatively, and a subcutaneous infusion (1.33 mg.kg-1 .h-1 ) postoperatively for up to 12 h on a standard surgical ward, with novel safety monitoring tools in place. The co-primary outcomes were: in-hospital safety events; serum levels of lidocaine during intravenous and subcutaneous infusion; and annualised enrolment rates per site with long-term data capture. In-hospital safety events were rare, and similar in the placebo and lidocaine arms (3% vs. 1%). Median (IQR [range]) serum lidocaine levels during intravenous (2.16 (1.74-2.83 [1.12-6.06]) µg.ml-1 , n = 41) and subcutaneous (1.52 (1.28-1.83 [0.64-2.85]) µg.ml-1 , n = 48) infusion were comparable with previous trials reporting improved pain outcomes. Annualised enrolment approximated 50 patients per site per year, with high levels of protocol adherence and ≥ 99% capture of outcomes at 3 and 6 months. The adjusted odds ratio (95%CI) for postoperative pain at 6 months in the lidocaine arm was 0.790 (0.370-1.684). We conclude that this trial, as designed, is safe, effective and feasible in patients undergoing breast cancer surgery, and a larger-scale trial is planned.
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Affiliation(s)
- A J Toner
- Department of Anaesthesia and Pain Medicine, Royal Perth Hospital, Perth, Australia
| | - M A Bailey
- Department of Anaesthesia and Intensive Care Medicine, Taranaki Base Hospital, New Plymouth, New Zealand
| | - S A Schug
- Department of Anaesthesia and Pain Medicine, Royal Perth Hospital, Perth, Australia
| | - T B Corcoran
- Department of Anaesthesia and Pain Medicine, Royal Perth Hospital, Perth, Australia
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