Appropriate Duration of Perioperative Intravenous Administration of Lidocaine to Provide Satisfactory Analgesia for Adult Patients Undergoing Colorectal Surgery: A Meta-Analysis of Randomized Controlled Trials

Postoperative Multimodal Analgesia Strategy for Enhanced Recovery After Surgery in Elderly Colorectal Cancer Patients

Enhanced Recovery After Surgery (ERAS) protocols have substantially proven their merit in diminishing recuperation durations and mitigating postoperative adverse events in geriatric populations undergoing colorectal cancer procedures. Despite this, the pivotal aspect of postoperative pain control has not garnered the commensurate attention it deserves. Typically, employing a multimodal analgesia regimen that weaves together nonsteroidal anti-inflammatory drugs, opioids, local anesthetics, and nerve blocks stands paramount in curtailing surgical complications and facilitating reduced convalescence within hospital confines. Nevertheless, this integrative pain strategy is not devoid of pitfalls; the specter of organ dysfunction looms over the geriatric cohort, rooted in the abuse of analgesics or the complex interplay of polypharmacy. Revolutionary research is delving into alternative delivery and release modalities, seeking to allay the inadvertent consequences of analgesia and thereby potentially elevating postoperative outcomes for the elderly post-colorectal cancer surgery populace. This review examines the dual aspects of multimodal analgesia regimens by comparing their established benefits with potential limitations and offers insight into the evolving strategies of drug administration and release.

Intravenous lidocaine for postoperative analgesia management in paediatrics: A systematic review with meta-analysis of published studies

BACKGROUND

The administration of intravenous lidocaine during the peri-operative period may improve pain management after paediatric surgery.

OBJECTIVE

To explore the decrease in postoperative pain intensity and opioid consumption associated with peri-operative lidocaine administration in the paediatric population.

DESIGN

A systematic review with meta-analysis of randomised controlled trials and a Grading of Recommendations Assessment, Development and Evaluation (GRADE) analysis.

DATA SOURCES

Extensive literature review.

ELIGIBILITY CRITERIA

This study includes clinical trials conducted during surgery that examined the effect of intravenous lidocaine compared with placebo on postoperative pain management.

RESULTS

Lidocaine administration decreased pain intensity in PACU (standardised mean difference (SMD) = -1.89 [-3.75, -0.03], I2 = 97%, P of I2 < 0.001) and on postoperative day 1 (SMD = -2.02 [-3.37, -0.66], I2 = 96%, P of I2 < 0.001, number of studies = 5). Lidocaine was associated with a decrease in opioid consumption on postoperative day 1 (SMD = -1.2 [-2.19, -0.2], I2 = 93%, P of I2 < 0.001) but not on postoperative day 2 (SMD = -1.73 [-3.9, 0.44], I2 = 96%, P of I2 < 0.001). GRADE analyses resulted in low-quality results. Subgroup analyses revealed that pain intensity in PACU and opioid consumption on postoperative day 1 decreased when lidocaine was administered during both the intra-operative and postoperative periods.

CONCLUSIONS

The use of lidocaine is associated with improved pain management. However, further studies are needed to increase the level of evidence and determine the optimal administration regimen for pain management.

Adjuvant Analgesics in Acute Pain - Evaluation of Efficacy

PURPOSE OF THE REVIEW

Acute postoperative pain impacts a significant number of patients and is associated with various complications, such as a higher occurrence of chronic postsurgical pain as well as increased morbidity and mortality.

RECENT FINDINGS

Opioids are often used to manage severe pain, but they come with serious adverse effects, such as sedation, respiratory depression, postoperative nausea and vomiting, and impaired bowel function. Therefore, most enhanced recovery after surgery protocols promote multimodal analgesia, which includes adjuvant analgesics, to provide optimal pain control. In this article, we aim to offer a comprehensive review of the contemporary literature on adjuvant analgesics in the management of acute pain, especially in the perioperative setting. Adjuvant analgesics have proven efficacy in treating postoperative pain and reducing need for opioids. While ketamine is an established option for opioid-dependent patients, magnesium and α2-agonists have, in addition to their analgetic effect, the potential to attenuate hemodynamic responses, which make them especially useful in painful laparoscopic procedures. Furthermore, α2-agonists and dexamethasone can extend the analgesic effect of regional anesthesia techniques. However, findings for lidocaine remain inconclusive.

Effects of intravenous lidocaine on postoperative pain and gastrointestinal function recovery following gastrointestinal surgery: a meta-analysis

INTRODUCTION

The full extent of intravenous lidocaine's effectiveness in alleviating postoperative pain and enhancing gastrointestinal function recovery remains uncertain.

EVIDENCE ACQUISITION

We conducted an exhaustive search of databases to identify randomized controlled trials that compared intravenous lidocaine infusion's efficacy to that of a placebo or routine care in patients undergoing gastrointestinal surgery. The primary outcome measure was resting pain scores 24 h postoperatively. We utilized a random-effects model based on the intention-to-treat principle for the overall results.

EVIDENCE SYNTHESIS

This study included twenty-four trials with 1533 patients. Intravenous lidocaine significantly reduced resting pain scores 24 h after gastrointestinal surgery (twenty trials, SMD -0.67, 95% CI -1.09 to -0.24, P=0.002, I2 = 90%). This finding was consistent in subgroup analyses and sensitivity analyses. The benefit was also observed at other resting and moving time points (1, 2, 4, and 12 h) postoperatively. Intravenous lidocaine significantly decreased opioid consumption within 24 h after surgery (eleven trials, SMD: -1.19; 95% CI: -1.99 to -0.39; P=0.003). Intravenous lidocaine also shortened the time to bowel sound (MD: -8.51; 95% CI: -14.59 to -2.44; P=0.006), time to first flatus (MD: -6.00; 95% CI: -9.87 to -2.13; P=0.002), and time to first defecation (MD: -9.77; 95% CI: -17.19 to -2.36; P=0.01).

CONCLUSIONS

Perioperative intravenous lidocaine can alleviate acute pain and expedite gastrointestinal function recovery in patients undergoing gastrointestinal surgery. However, the results should be interpreted with caution due to substantial heterogeneity. Further large-scale studies are necessary to validate these findings.

Local anaesthetics and chemotherapeutic agents: a systematic review of preclinical evidence of interactions and cancer biology

Background

Local anaesthetics are widely used for their analgesic and anaesthetic properties in the perioperative setting, including surgical procedures to excise malignant tumours. Simultaneously, chemotherapeutic agents remain a cornerstone of cancer treatment, targeting rapidly dividing cancer cells to inhibit tumour growth. The potential interactions between these two drug classes have drawn increasing attention and there are oncological surgical contexts where their combined use could be considered. This review examines existing evidence regarding the interactions between local anaesthetics and chemotherapeutic agents, including biological mechanisms and clinical implications.

Methods

A systematic search of electronic databases was performed as per Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines. Selection criteria were designed to capture in vitro, in vivo, and clinical studies assessing interactions between local anaesthetics and a wide variety of chemotherapeutic agents. Screening and data extraction were performed independently by two reviewers. The data were synthesised using a narrative approach because of the anticipated heterogeneity of included studies.

Results

Initial searches yielded 1225 relevant articles for screening, of which 43 met the inclusion criteria. The interactions between local anaesthetics and chemotherapeutic agents were diverse and multifaceted. In vitro studies frequently demonstrated altered cytotoxicity profiles when these agents were combined, with variations depending on the specific drug combination and cancer cell type. Mechanistically, some interactions were attributed to modifications in efflux pump activity, tumour suppressor gene expression, or alterations in cellular signalling pathways associated with tumour promotion. A large majority of in vitro studies report potentially beneficial effects of local anaesthetics in terms of enhancing the antineoplastic activity of chemotherapeutic agents. In animal models, the combined administration of local anaesthetics and chemotherapeutic agents showed largely beneficial effects on tumour growth, metastasis, and overall survival. Notably, no clinical study examining the possible interactions of local anaesthetics and chemotherapy on cancer outcomes has been reported.

Conclusions

Reported preclinical interactions between local anaesthetics and chemotherapeutic agents are complex and encompass a spectrum of effects which are largely, although not uniformly, additive or synergistic. The clinical implications of these interactions remain unclear because of the lack of prospective trials. Nonetheless, the modulation of chemotherapy effects by local anaesthetics warrants further clinical investigation in the context of cancer surgery where they could be used together.

Clinical trial registration

Open Science Framework (OSF, project link: https://osf.io/r2u4z).

Impact of intravenous dexmedetomidine on postoperative gastrointestinal function recovery: an updated meta-analysis

BACKGROUND

Postoperative ileus (POI) is a complication that may occur after abdominal or nonabdominal surgery. Intravenous dexmedetomidine (Dex) has been reported to accelerate postoperative gastrointestinal function recovery; however, updated evidence is required to confirm its robustness.

METHODS

To identify randomized controlled trials examining the effects of perioperative intravenous Dex on gastrointestinal function recovery in patients undergoing noncardiac surgery, databases including MEDLINE, EMBASE, Google Scholar, and Cochrane Library were searched on August 2023. The primary outcome was time to first flatus. Secondary outcomes included time to oral intake and defecation as well as postoperative pain scores, postoperative nausea/vomiting (PONV), risk of hemodynamic instability, and length of hospital stay (LOS). To confirm its robustness, subgroup analyses and trial sequential analysis were performed.

RESULTS

The meta-analysis of 22 randomized controlled trials with 2566 patients showed that Dex significantly reduced the time to flatus [mean difference (MD):-7.19 h, P <0.00001), time to oral intake (MD: -6.44 h, P =0.001), time to defecation (MD:-13.84 h, P =0.008), LOS (MD:-1.08 days, P <0.0001), and PONV risk (risk ratio: 0.61, P <0.00001) without differences in hemodynamic stability and pain severity compared with the control group. Trial sequential analysis supported sufficient evidence favoring Dex for accelerating bowel function. Subgroup analyses confirmed the positive impact of Dex on the time to flatus across different surgical categories and sexes. However, this benefit has not been observed in studies conducted in regions outside China.

CONCLUSIONS

Perioperative intravenous Dex may enhance postoperative gastrointestinal function recovery and reduce LOS, thereby validating its use in patients for whom postoperative ileus is a significant concern.

PROcedure-SPECific postoperative pain management guideline for laparoscopic colorectal surgery: A systematic review with recommendations for postoperative pain management

Colorectal cancer is the second most common cancer diagnosed in women and third most common in men. Laparoscopic resection has become the standard surgical technique worldwide given its notable benefits, mainly the shorter length of stay and less postoperative pain. The aim of this systematic review was to evaluate the current literature on postoperative pain management following laparoscopic colorectal surgery and update previous procedure-specific pain management recommendations. The primary outcomes were postoperative pain scores and opioid requirements. We also considered study quality, clinical relevance of trial design, and a comprehensive risk-benefit assessment of the analgesic intervention. We performed a literature search to identify randomised controlled studies (RCTs) published before January 2022. Seventy-two studies were included in the present analysis. Through the established PROSPECT process, we recommend basic analgesia (paracetamol for rectal surgery, and paracetamol with either a nonsteroidal anti-inflammatory drug or cyclo-oxygenase-2-specific inhibitor for colonic surgery) and wound infiltration as first-line interventions. No consensus could be achieved either for the use of intrathecal morphine or intravenous lidocaine; no recommendation can be made for these interventions. However, intravenous lidocaine may be considered when basic analgesia cannot be provided.

Sixth Annual Enhanced Recovery After Surgery Symposium highlights: work in progress or standard care?

Enhanced Recovery After Surgery (ERAS) protocols have demonstrated effectiveness in accelerating patient recovery and improving outcomes. Since the systemwide implementation of ERAS protocols at Baylor Scott & White Health, an annual multidisciplinary conference has provided a review of outcomes and advancements in the ERAS program. This meeting, coined the ERAS symposium, allows providers who utilize recovery protocols to collaborate with national and international leaders in the field to improve the clinical care of patients. The sixth annual ERAS symposium was held on February 10, 2023, and provided key presentations that discussed the latest results from ERAS efforts across multiple surgical specialties along with updates in anesthesia, nursing, and nutrition. A summary of those presentations, which included perioperative glycemic control, misconceptions in pain management, and emerging ERAS protocols in different surgical specialties, is provided to document the system progress.