A combination of levobupivacaine and lidocaine for paravertebral block in breast cancer patients undergoing quadrantectomy causes greater hemodynamic oscillations than levobupivacaine alone

Comparing block characteristics of mixtures of short/intermediate- and long-acting local anesthetics for peripheral nerve block: a systematic review and meta-analysis

INTRODUCTION

Results from Randomized Controlled Trials (RCTs) on mixed Local Anesthetics (LA) are conflicting. We conducted a systematic review and meta-analysis on whether using mixed LA leads to faster onset of surgical block.

METHOD

We conducted systemic review and meta-analysis of RCTs. Medline and Embase without language restriction from inception to June 15, 2024, were searched. Included RCTs had to compare mixed LA to long-acting LA in adult surgical patients for onset or duration of nerve blocks. Onset time to surgical block was the primary outcome. The Cochrane Risk of Bias Tool with GRADE methodology was utilized to assess evidence quality.

RESULTS

Nineteen trials including 1060 participants met the inclusion criteria. Mixed LA modestly reduced time to surgical block (-8.4 minutes; 95% CI -12.0 to -4.8 minutes; p = 0.0001; I2 = 0.99), sensory block duration (-226.2 minutes; 95% CI -352.2 to -100.1 minutes; p = 0.002; I2 = 0.98) and motor block duration (-259.2 minutes; 95% CI -399.5 to -119.0 minutes; p = 0.003; I2 = 0.98) but not time to analgesic request duration (-130.5 minutes; 95% CI -265.9 to 4.9 minutes; p = 0.057; I2 = 0.98). GRADE scoring ranged from low to very low.

CONCLUSION

The existing evidence showed mixed LA led to a modest reduction in surgical block latency but also shortened block duration. Future studies should evaluate the role of mixed LA in lower limb blocks and optimal dosing of long-acting LA to balance onset latency and analgesic duration.

PROSPERO REGISTRATION

CRD42024552801.

Efficacy of long-acting local anesthetics versus their mixture with shorter-acting local anesthetics for peripheral nerve blocks guided by ultrasound: a systematic review with meta-analysis of randomized controlled trials

BACKGROUND/IMPORTANCE

Local anesthetic (LA) mixtures are used in peripheral nerve blocks (PNB) to improve onset, though study results remain conflicting.

OBJECTIVE

This systematic review and meta-analysis compared the efficacy outcomes of long-acting LA to their mixture with shorter-acting LA in ultrasound-guided PNB. The primary outcome was sensory block onset.

EVIDENCE REVIEW

We searched WoS, Scopus, MEDLINE, EMBASE, BVS/LILACS, and Cochrane databases from 1998 to 2024 for randomized controlled trials (RCTs). We conducted a random-effects meta-analysis, evaluated the risk of bias (RoB) with RoB 2.0, performed sensitivity analyses, assessed non-reporting bias with DOI plots and Luis Furuya-Kanamori index, and evaluated strength of evidence with Grading of Recommendations Assessment, Development and Evaluations.

FINDINGS

We included 10 RCTs (516 participants). Mixture of LA may have no effect on sensory block onset (mean difference (MD) -1.62 min, 95% CI: -4.04 to 0.81; I2=81.50%, 95% CI: 62.82% to 90.80%; prediction interval (PI)=-7.78 to 4.55; very low certainty) and motor block onset (MD -5.60 min; 95% CI: -14.54 to 3.33, I2=98.89%, 95% CI: 98.50% to 99.18%; PI=-31.90 to 20.69; very low certainty), while it may reduce the duration of sensory block (MD -2.16 hours, 95% CI: -4.16 to -0.17; I2=90.77%, 95% CI: 84.22% to 94.60%; PI=-7.24 to 2.92; very low certainty).

CONCLUSIONS

LA mixtures may not affect sensory and motor block onset in ultrasound-guided PNB but could shorten the duration of sensory blockade.

Bupivacaine inhibits the malignant biological behavior of oral squamous cell carcinoma cells by inhibiting the activation of ERK1/2 and STAT3

Background

Oral squamous cell carcinoma (OSCC) is an aggressive malignant tumor. Bupivacaine (Bupi), a local anesthetic drug, has been shown to display anti-tumor activity against a variety of tumors.

Methods

We selected OSCC CAL-27 cells as the in vitro model. Cell toxicity, proliferation, apoptosis, and stemness were conducted, respectively. The protein levels of Ki67, PCNA, caspase-3, caspase-9, survivin, SOX2, NANOG, OCT4, STAT3, p-STAT3, ERK1/2, and p-ERK1/2 were evaluated by western blotting. Male BALB/c nude mice xenograft model was used to evaluate the effect of Bupi on tumor growth in vivo.

Results

Compared with the control group, Bupi (0.2, 0.5, or 1 µm) significantly decreased the cell viability and the proliferation of CAL-27 cells. Meanwhile, Bupi significantly promoted apoptosis of CAL-27 cells compared with the control group. Additionally, Bupi inhibited the stemness of CAL-27 cells which was evidenced by a sphere formation assay. Bupi decreased the phosphorylation level of STAT3 and ERK1/2 in a dose-dependent manner. The addition of interferon-γ (IFN-γ, 20 ng/mL) in the experiment verified the role of Bupi on STAT3 and ERK1/2 signaling. In vivo, Bupi (40 µmol/kg) obviously suppressed the weight and size of the xenograft tumor, the number of apoptotic cells and Ki67+ decreased. Also, Bupi treatment inhibited the expression of stem-like marker proteins.

Conclusions

Bupi could be used as an anticancer drug against the growth and stemness ability of OSCC. The underlying mechanism may be due to down-regulation of STAT3 and ERK1/2 signaling. This study provides a new insight for the application of Bupi.

A possible future for anaesthesia in breast surgery: thoracic paravertebral block and awake surgery. A prospective observational study

INTRODUCTION

Quadrantectomy is a surgical procedure traditionally performed under general anaesthesia with intraoperative and postoperative opioid-based analgesia. The use of locoregional anaesthesia techniques in breast surgery has become widespread and allows excellent management of intraoperative and postoperative pain with reduced opioid consumption. We chose thoracic paravertebral block as regional anaesthesia technique in breast surgery to investigate the possibility of carrying out this surgery with the patient awake.

METHODS

A prospective observational study on 50 patients was designed. The primary outcome for this study was the possibility to carry out the surgery with only the paravertebral block associated with mild sedation without general anaesthesia. Forty minutes before the start of the surgery, an ultrasound-guided thoracic paravertebral block was performed at two thoracic levels, and for each level, 7 mL of ropivacaine 0.7% was injected. Sedation was obtained with target-controlled infusion of propofol.

RESULTS

Forty-nine patients underwent the operation awake; in one case, we had to place an I-gel and perform general anaesthesia. No patient needed intraoperative or postoperative opioids. The numeric rating scale, recorded at 0, 2, 6, 12, 24, and 36 hours, was greater than 3 in only five patients.

CONCLUSIONS

We believe that if in the future we try to make quadrantectomy an intervention in which the anaesthesia is exclusively regional, therefore with a patient awake and collaborating, it will not be possible to ignore the use of thoracic paravertebral block.

A Randomized Controlled Trial Comparing Analgesic Efficacies of an Ultrasound-Guided Approach with and without a Combined Pressure Measurement Technique for Thoracic Paravertebral Blocks After Open Thoracotomy

Purpose

Ultrasound-guided thoracic paravertebral block (TPVB) is an established means for providing postoperative analgesia in thoracic surgery. However, there are conflicting results regarding the efficacy of post-thoracotomy pain management of ultrasound-guided TPVB when compared with that using traditional landmark approach. We therefore conducted a comparative study to evaluate the analgesic efficacy of TPVB when pressure measurement during needle advancement is combined with an ultrasound-guided approach.

Patients and Methods

The patients scheduled for lobectomy through thoracotomy were randomly allocated to receive either the ultrasound-guided approach only group (U group) or the ultrasound-guided approach combined with pressure measurement group (UP group) (n = 36 per group). Before thoracic muscle closure, 0.375% ropivacaine (20 mL) was administered as a bolus, followed by a continuous infusion of 0.2% ropivacaine (0.1 mL/kg/hr) in both groups. Postoperative pain was assessed using the visual analogue scale (VAS) pain score while resting and coughing. Local anesthetics and pethidine usage and sensory block area were also evaluated.

Results

The UP group showed significantly lower VAS scores, local anesthetics and pethidine usage, and a wider sensory block area than the U group.

Conclusion

A combined technique with ultrasound guidance and pressure measurement provided a superior analgesic effect over that of an ultrasound-guided approach alone for the management of post-thoracotomy pain.

PROSPECT guideline for oncological breast surgery: a systematic review and procedure-specific postoperative pain management recommendations

Analgesic protocols used to treat pain after breast surgery vary significantly. The aim of this systematic review was to evaluate the available literature on this topic and develop recommendations for optimal pain management after oncological breast surgery. A systematic review using preferred reporting items for systematic reviews and meta-analysis guidance with procedure-specific postoperative pain management (PROSPECT) methodology was undertaken. Randomised controlled trials assessing postoperative pain using analgesic, anaesthetic or surgical interventions were identified. Seven hundred and forty-nine studies were found, of which 53 randomised controlled trials and nine meta-analyses met the inclusion criteria and were included in this review. Quantitative analysis suggests that dexamethasone and gabapentin reduced postoperative pain. The use of paravertebral blocks also reduced postoperative pain scores, analgesia consumption and the incidence of postoperative nausea and vomiting. Intra-operative opioid requirements were documented to be lower when a pectoral nerves block was performed, which also reduced postoperative pain scores and opioid consumption. We recommend basic analgesics (i.e. paracetamol and non-steroidal anti-inflammatory drugs) administered pre-operatively or intra-operatively and continued postoperatively. In addition, pre-operative gabapentin and dexamethasone are also recommended. In major breast surgery, a regional anaesthetic technique such as paravertebral block or pectoral nerves block and/or local anaesthetic wound infiltration may be considered for additional pain relief. Paravertebral block may be continued postoperatively using catheter techniques. Opioids should be reserved as rescue analgesics in the postoperative period. Research is needed to evaluate the role of novel regional analgesic techniques such as erector spinae plane or retrolaminar plane blocks combined with basic analgesics in an enhanced recovery setting.

Lidocaine protects H9c2 cells from hypoxia-induced injury through regulation of the MAPK/ERK/NF-κB signaling pathway

The aim of the present study was to investigate the effect of Lidocaine on hypoxia-induced injury in cardiomyoblasts whilst exploring the associated molecular mechanism. In the present study, hypoxia was induced in H9c2 cells to establish an in vitro model of myocardial infarction. The cells were treated with lidocaine (0.5, 1, 5, 10 mM) for 48 h under hypoxic conditions. Cell viability and apoptosis levels were determined by MTT assay and flow cytometry, and ELISA was used to measure the levels of inflammatory cytokines released. A creatine kinase isoenzyme/cardiac troponin I detection kit was used to show that lidocaine significantly reduced hypoxia-induced cardiac troponin 1 and creatine kinase-muscle/brain release in a dose-dependent manner. Mitochondrial viability staining suggested that lidocaine significantly enhanced mitochondrial viability under hypoxic conditions. Lidocaine also significantly reduced hypoxia-induced apoptosis and increased H9c2 viability in a dose-dependent manner. Additionally, under hypoxic conditions, lidocaine dose-dependently promoted Bcl-2 expression, while decreasing Bax and caspase-3 expression in H9c2 cells. ELISA and reverse transcription quantitative PCR were used to detect the levels of tumor necrosis factor (TNF-α), interleukin (IL)-1β and IL-6 released by H9c2 cells. Results showed that lidocaine markedly reduced the hypoxia-induced expression levels of IL-1β, TNF-α and IL-6 in a dose-dependent manner. In addition, protein levels of phosphorylated (p)-ERK1/2 and NF-κB p-p65 were analyzed by western blotting, and results indicated that lidocaine significantly increased the protein levels of p-ERK1/2 and decreased the protein level of NF-κB p-p65 in a dose-dependent manner under hypoxic conditions. These data suggested that lidocaine might protect cardiomyoblasts from hypoxia-induced injury via activation of the mitogen activated protein kinase/ERK/NF-κB signaling pathway.

THE ROLE OF PARAVERTEBRAL BLOCKS IN AMBULATORY SURGERY: REVIEW OF THE LITERATURE

Ambulatory surgery often involves surgical procedures on the thorax, abdomen and limbs, which can be associated with substantial postoperative pain. The aim of this narrative review is to provide an analysis of the effectiveness of paravertebral block (PVB) alone or in combination with general anaesthesia, in this setting, with an emphasis on satisfactory postoperative analgesia in comparison to other modalities. We have conducted a search of current medical literature written in English through PubMed, Google Scholar and Ovid Medline®. Peer-reviewed professional articles, review articles, retrospective and prospective studies, case reports and case series were systematically searched for during the time period between November 2003 and February 2019. The literature used for the purpose of creating this review showed that utilisation of paravertebral block either alone or in combination with general anaesthesia, has a positive effect on satisfactory analgesia in ambulatory surgery. With a multimodal analgesic approach of PVB and other techniques of anaesthesia and analgesia there is a reduction in postoperative opioid consumption, fewer side effects, lower pain scores, decreased mortality, earlier mobilisation of patients and reduced hospital stay.

Effect of clonidine on the cutaneous silent period during spinal anesthesia

AIM

To investigate the effect of clonidine on the cutaneous silent period (CSP) during spinal anesthesia.

METHODS

A total of 67 adult patients were included in this randomized, prospective, single-center, double-blind trial. They did not have neurological disorders and were scheduled for inguinal hernia repair surgery. This trial was registered on ClinicalTrials.gov (NTC03121261). The patients were randomized into two groups with regards to the intrathecally administered solution: (1) 15 mg of 0.5% levobupivacaine with 50 µg of 0.015% clonidine, or (2) 15 mg of 0.5% levobupivacaine alone. There were 34 patients in the levobupivacaine-clonidine (LC) group and 33 patients in the levobupivacaine (L) group. CSP and its latency were measured four times: prior to the subarachnoid block (SAB), after motor block regression to the 0 level of the Bromage scale, with ongoing sensory blockade, and both 6 and 24 h after SAB.

RESULTS

Only data from 30 patients in each group were analyzed. There were no significant differences between the groups investigated preoperatively and after 24 h. The CSP of the L group at the time point when the Bromage scale was 0 was 44.8 ± 8.1 ms, while in the LC group it measured 40.2 ± 3.8 ms (P = 0.007). The latency in the L group at the time point when the Bromage scale was 0 was 130.3 ± 10.2 ms, and in the LC group it was 144.7 ± 8.3 ms (P < 0.001). The CSP of the L group after 6 h was 59.6 ± 9.8 ms, while in the LC group it was 44.5 ± 5.0 ms (P < 0.001). The latency in the L group after 6 h was 110.4 ± 10.6 ms, while in LC group it was 132.3 ± 9.7 ms (P < 0.001).

CONCLUSION

Intrathecal addition of clonidine to levobupivacaine for SAB in comparison with levobupivacaine alone results in a diminished inhibitory tonus and shortened CSP.