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Effects of anesthetic interventions on breast cancer behavior, cancer-related patient outcomes, and postoperative recovery.
Eden, C, Esses, G, Katz, D, DeMaria, S
Surgical oncology. 2018;(2):266-274
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Abstract
This narrative review will summarize our current understanding of the effects of perioperative interventions on patients undergoing surgical removal of breast malignancies. It will focus on how different anesthetic agents and perioperative interventions might affect both breast cancer behavior and/or tumor recurrence as well as postoperative recovery. The main objective of this study will be to describe the evidence and critically analyze preclinical and clinical studies on the use of intravenous versus inhaled anesthetic agents, opioids, regional anesthetics, and anesthetic adjuncts in patients undergoing breast cancer resection. We will look both at the evidence regarding cancer-related outcomes and postoperative recovery. A search of PubMed, from inception to May 2017 was performed using Mesh terms Breast Neoplasms [Mesh] OR cancer AND breast AND Anesthesia [Mesh]; "Anesthetics"[Mesh] AND "Breast Neoplasms/surgery"[Mesh]. Although no optimal anesthetic combination has been identified for patients undergoing breast cancer resection, it should be noted that based on the available evidence, an ideal anesthetic in this patient population would involve a combination of TIVA (propofol), regional anesthesia (paravertebral block)), non opioid sedatives (clonidine or dexmedetomidine), and COX-2 inhibition (ketorolac). Based on the current evidence, this combination of anesthetic and analgesic agents has the best chance of improving cancer-related outcomes and postoperative recovery.
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Efficacy of continuous in-wound infusion of levobupivacaine and ketorolac for post-caesarean section analgesia: a prospective, randomised, double-blind, placebo-controlled trial.
Wagner-Kovacec, J, Povalej-Brzan, P, Mekis, D
BMC anesthesiology. 2018;(1):165
Abstract
BACKGROUND In-wound catheters for infusion of local anaesthetic for post-caesarean section analgesia are well tolerated in parturients. Few studies have examined continuous in-wound infusion of a combination of local anaesthetic and non-steroidal anti-inflammatory drug for post-caesarean section analgesia. This single centre study evaluated post-operative analgesic efficacy and piritramide-sparing effects of continuous in-wound infusion of either local anaesthetic or non-steroidal anti-inflammatory agent, or the combination of both, versus saline placebo, when added to systemic analgesia with paracetamol. METHODS After National Ethical Board approval, 59 pregnant women scheduled for non-emergency caesarean section were included in this prospective, randomised, double-blind, placebo-controlled study. The parturients received spinal anaesthesia with levobupivacaine and fentanyl. Post-operative analgesia to 48 h included paracetamol 1000 mg intravenously every 6 h, with the studied agents as in-wound infusions. Rescue analgesia with piritramide was available as needed, titrated to 2 mg intravenously. Four groups were compared, using a subcutaneous multi-holed catheter connected to an elastomeric pump running at 5 mL/h over 48 h. The different in-wound infusions were: levobupivacaine 0.25% alone; ketorolac tromethamine 0.08% alone; levobupivacaine 0.25% plus ketorolac tromethamine 0.08%; or saline placebo. The primary outcome was total rescue piritramide used at 24 h and 48 h post-operatively, under maintained optimal post-caesarean section analgesia. RESULTS Compared to placebo in-wound infusions, ketorolac alone and levobupivacaine plus ketorolac in-wound infusions both significantly reduced post-operative piritramide consumption at 24 h (p = 0.003; p < 0.001, respectively) and 48 h (p = 0.001; p < 0.001). Compared to levobupivacaine, levobupivacaine plus ketorolac significantly reduced post-operative piritramide consumption at 24 h (p = 0.015) and 48 h (p = 0.021). For levobupivacaine versus ketorolac, no significant differences were seen for post-operative piritramide consumption at 24 h and 48 h (p = 0.141; p = 0.054). CONCLUSION Continuous in-wound infusion with levobupivacaine plus ketorolac provides greater opioid-sparing effects than continuous in-wound infusion with levobupivacaine alone. TRIAL REGISTRATION German Clinical Trials Register: retrospectively registered on 30 July, 2014, DRKS 00006559 .
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Comparing adductor canal block with local infiltration analgesia in total knee arthroplasty: A prospective, blinded and randomized clinical trial.
Tong, QJ, Lim, YC, Tham, HM
Journal of clinical anesthesia. 2018;:39-43
Abstract
STUDY OBJECTIVE Total knee arthroplasty (TKA) is associated with significant pain post-operatively. Our hypothesis is that adductor canal block (ACB) would be superior to local infiltration analgesia (LIA) in terms of providing analgesia, while still preserving quadriceps strength and enabling early postoperative rehabilitation. DESIGN A prospective, blinded and randomized clinical trial between LIA and ACB was conducted. SETTING Tertiary care urban hospital. PATIENTS 40 patients (ASA I to III) undergoing primary TKA under single-dose spinal anesthesia were prospectively randomized from January 2014 to October 2015. INTERVENTIONS The LIA group received local infiltration of Ropivacaine 150 mg, Ketorolac 30 mg, Morphine 10 mg, and Adrenaline 200 mcg in a total volume of 75 mls, administered intraoperatively by the surgeon. The ACB group was given an ACB postoperatively by one of the study investigators at the end of surgery with 30 mls of 0.5% Ropivacaine. MEASUREMENTS The primary outcome was total Morphine consumption in the first 24 h. Secondary outcomes included total Morphine consumption in the first 48 h, pain scores, quadriceps strength, the Timed Up and Go test (TUG), the 30 s Chair Stand Test (30s-CST) and length of hospital stay. MAIN RESULTS The median (interquartile range) 24 h Morphine consumption was 6 mg (2.3-18.3) in the ACB group and 17.5 mg (12-24.3) in the LIA group, p = 0.004. The 48 h Morphine consumption was 14.5 mg (7.5-28.5) in the ACB group as compared to 24 mg (14-33.8) in the LIA group, p = 0.03. There were no statistically significant differences in the other secondary outcomes. CONCLUSION ACB group had statistically significant reduced total Morphine consumption in the first 24 and 48 hours as compared to LIA group, with no statistically significant differences in functional outcomes of TKA patients.
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Effect of Topical Anesthetic Cream on Pain During Periareolar Injection of Technetium Tc99m Sulfur Colloid for Sentinel Lymph Node Biopsy in Breast Cancer: A Randomized Control Trial.
Canning, S, Bryson-Campbell, M, Suryavanshi, R
Journal of medical imaging and radiation sciences. 2018;(1):44-48
Abstract
BACKGROUND Injection of Tc99m to localize nodes for sentinel lymph node biopsy is reported by patients as very painful. The purpose of this study was to determine if anesthetic cream reduces pain associated with periareolar injection of Tc99m and to help elucidate conflicting literature regarding the efficacy of anesthetic cream for this procedure. METHODS A randomized, double-blind, placebo-controlled methodology was used for adult females with breast cancer undergoing periareolar injection of Tc99m for sentinel lymph node biopsy. Pain levels were compared using anesthetic cream (2.5% lidocaine/2.5% prilocaine) vs. placebo. Patient exclusion criteria included use of opioids or adjuvant pain medication or injecting Tc99m the day before surgery. The Numerical Rating Scale was used to assess pain levels immediately after the injections. RESULTS Comparing 23 experimental and 26 control patients, there was no significant difference between the experimental (median = 4) and the control group (median = 5) on level of pain experienced U= 0.492, P > .05. CONCLUSIONS The experimental group had a slightly lower median pain score; however, there was no statistically significant difference between those who used the cream compared with those who used a placebo, supporting the conclusion that anesthetic cream does not reduce pain during Tc99m injections. This study adds to the current literature to provide a stronger position that there is no benefit to using anesthetic cream for this procedure.
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Perineural Low-Dose Dexamethasone Prolongs Interscalene Block Analgesia With Bupivacaine Compared With Systemic Dexamethasone: A Randomized Trial.
Kahn, RL, Cheng, J, Gadulov, Y, Fields, KG, YaDeau, JT, Gulotta, LV
Regional anesthesia and pain medicine. 2018;(6):572-579
Abstract
BACKGROUND AND OBJECTIVES Perineural dexamethasone and intravenous (IV) dexamethasone have been shown to prolong peripheral nerve block duration. The effects of perineural and IV dexamethasone have only been compared at doses of 4 mg or greater. This triple-blind, randomized trial examined the effect of 1 mg IV versus perineural dexamethasone on interscalene block (ISB) analgesia duration. METHODS Patients undergoing ambulatory shoulder arthroscopy received an ultrasound-guided ISB with 15 mL bupivacaine 0.5% and 1 mg preservative-free dexamethasone that was administered perineurally (PeriD) or IV (IVDex). All patients received IV ketorolac and were discharged on naproxen 500 mg 2 times a day plus oxycodone/acetaminophen as needed. Peripheral nerve block duration, pain, opioid consumption, and block satisfaction were assessed via telephone follow-ups. RESULTS There were 63 PeriD patients and 62 IVDex patients who completed the primary outcome follow-up. The median time until analgesia from the ISB completely wore off was 3.5 hours (95% confidence interval, 1.0-6.0 hours) longer in the PeriD versus IVDex groups; P = 0.007). Time until the pain relief from the ISB began to wear off was also longer in the PeriD versus IVDex group (5.5 hours [95% confidence interval, 2.1-9.0 hours]; P = 0.002). Other secondary outcomes, including opioid consumption, satisfaction, and pain scores, were not different between groups. CONCLUSIONS In patients undergoing shoulder arthroscopy, low-dose perineural dexamethasone (1 mg) in combination with 15 mL of 0.5% bupivacaine prolonged the median time until pain relief from the ISB completely wore off compared with 1 mg IV dexamethasone. However, the degree of prolongation was smaller than the a priori-defined minimal clinically meaningful difference of 5 hours. CLINICAL TRIAL REGISTRATION This study was registered at Clinicaltrials.gov, identifier NCT02506660.
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Advances in Experimental Medicine and Biology: Intrafascicular Local Anesthetic Injection Damages Peripheral Nerve-Induced Neuropathic Pain.
Tseng, KY, Wang, HC, Chang, LL, Cheng, KI
Advances in experimental medicine and biology. 2018;:65-76
Abstract
Peripheral nerve blockade (PNB) is advantageous for patients undergoing surgery to decrease the perioperative opioid consumptions and enhance recovery after surgery.Inadvertent local anesthetic (LA) administration into nerve fiber intrafascicularly easily results in unrecognized nerve injury. Using nerve block guidance either by ultrasound, electrical nerve stimulator, or using pressure devices does not prevent nerve damage, even though most of the nerve injury is transiently. The incidence of neurologic symptoms or neuropathy is in the range of 0.02-2.2%, and no significant difference of postoperative neurologic symptoms is found as compared with using ultrasound or guided nerve stimulator technique. However, intrafascicular lidocaine brought about macrophage migration into the damaged fascicle, Schwann cell proliferation, increased intensity of myelin basic protein, and shorten withdrawal time to mechanical stimuli. In dorsal root ganglion (DRG), intrafascicular LA injection increased the activated transcriptional factor 3 (ATF-3) and downregulated Nav1.8 (Nav1.8). In spinal dorsal horn (SDH), the microglia and astrocytes located in SDH were activated and proliferated after intrafascicular LA injection and returned to baseline gradually at the end of the month. This is a kind of neuropathic pain, so low injection pressure should be maintained, the correct needle bevel used, nerve stimulator or ultrasound guidance applied, and careful and deliberately slow injection employed as important parts of the injection technique to prevent intrafascicular LA administration-induced neuropathic pain.
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The Analgesic Effect of Ultrasound-Guided Quadratus Lumborum Block After Cesarean Delivery: A Randomized Clinical Trial.
Krohg, A, Ullensvang, K, Rosseland, LA, Langesæter, E, Sauter, AR
Anesthesia and analgesia. 2018;(2):559-565
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Abstract
BACKGROUND Landmark and ultrasound-guided transversus abdominis plane blocks have demonstrated an opioid-sparing effect postoperatively after cesarean delivery. The more posterior quadratus lumborum (QL) might provide superior local anesthetic spread to the thoracolumbar fascia and paravertebral space. The aim of our study was to evaluate the efficacy of the QL block after cesarean delivery. METHODS A randomized, double-blind, controlled trial was performed. Forty parturients undergoing cesarean delivery received bilateral ultrasound-guided QL blocks with either 2 mg/mL ropivacaine or saline postoperatively. All patients received spinal anesthesia with bupivacaine and sufentanil and a postoperative analgesic regimen of paracetamol, ibuprofen, and ketobemidone administered by a patient-controlled analgesic pump. The ketobemidone consumption and time of each dose administered were recorded. The primary outcome was ketobemidone consumption during the first 24 hours postoperatively. Secondary and exploratory analyses compared repeated measures of pain scores, nausea, and fatigue, and total differences in time until patients were able to stand and able to walk 5 m, and the interaction between the effective analgesic score and time. RESULTS All 40 patients completed the trial, 20 in each group. The cumulative ketobemidone consumption in 24 hours was reduced in the active group compared with the control group (P = .04; ratio of means = 0.60; 95% confidence interval, 0.37-0.97). The effective analgesic scores were significantly better in the treatment group compared with the placebo group both at rest (P < .01) and during coughing (P < .01). CONCLUSIONS QL block with ropivacaine reduces the postoperative ketobemidone consumption and pain intensity as a part of a multimodal analgesic regimen that excludes neuraxial morphine.
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[Percutaneous endoscopic lumbar discectomy combined with epidural injection for prolapsed lumbar disc herniation].
Wu, HH, Tang, T, Pang, QJ, Wang, Y, Zhang, ZK
Zhongguo gu shang = China journal of orthopaedics and traumatology. 2017;(2):110-114
Abstract
OBJECTIVE To assess the effect of percutaneous endoscopic lumbar discectomy (PELD) combined with epidural injection for prolapsed lumbar disc herniation(PLDH). METHODS In this prospective randomized controlled study, the clinical data of 126 patients who had undergone a PELD because of a single-level PLDH from March 2014 to June 2015 were analyzed. There were 67 males and 59 females, ranging in age from 17 to 75 years old with an average of(41.0±13.5) years old, 9 cases were L₃,₄, 76 cases were L₄,₅ and 41 cases were L₅S₁. According to the random number table, the patients were randomized into two groups, with 63 patients in each group. Patients in group 1 were injected normal saline after PLED, patients in group 2 were subjected to an epidural injection of Diprospan, Lidocaine and Mecobalamine after PLED. All the patients were followed up from 6 to 20 months with the mean of 12.4 months. Complications, the postoperative hospital stay, the period of return to work, visual analogue scale (VAS) and Japanese Orthopedic Association (JOA) score were compared between two groups, and clinical outcomes were evaluated according to modified MacNab criteria. RESULTS All the operations were successful, and no complications were found. The mean postoperative hospital stay and the period of return to work in group 1 were (4.61±1.25) days and (4.31±0.47) weeks, respectively, and in group 2 were (2.53±0.69) days and (3.14±0.52) weeks, there was significant differences between two groups(P=0.000). Postoperative VAS and JOA scores in two groups were obviously improved (P=0.000). At 1 day, 1 week, 1 month after operation, VAS, JOA scores in group 2 were better than that of group 1(P=0.000), and after 6 months, there was no significant difference between two groups(P>0.05). According to the modified MacNab criteria, 39 cases got excellent results, 21 good, 3 fair in group 1, and which in group 2 were 41, 20, 2, respectively, there was no significant difference between two groups(P=0.087). CONCLUSIONS PELD is an mini-invasive technique for PLDH, it can fleetly reduce pain and improve function. And combination with epidural injection has the advantages of pain releasing and function improving in the short-term postoperative period, and it can decrease postoperative hospital stay and time of returning to work, and it is a safe and effective method.
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Reversal effects of local anesthetics on P-glycoprotein-mediated cancer multidrug resistance.
Hu, Y, Qin, X, Cao, H, Yu, S, Feng, J
Anti-cancer drugs. 2017;(3):243-249
Abstract
The existence of multidrug resistance (MDR) is the main reason for failure in cancer chemotherapy. The main mechanism of MDR is the overexpression of P-glycoprotein (P-gp). P-gp, a 170 kDa transmembrane phosphorylated glycoprotein encoded by ABCB1 belonging to a member of the ATP-binding cassette (ABC) super-family of the membrane transporters, is also known as the MDR protein. Local anesthetics (LAs) are a major contributor to medical practice. As a cornerstone of analgesia, LAs provides myriad benefits. Recent studies have shown that the LAs can interfere with receptors other than the traditional sodium channel. LA can suppress the proliferation of several cancer cells. The inhibition of P-gp could reverse MDR. Interestingly, the LAs, such as lidocaine, can repress ABCB1 (P-gp) expression and reverse MDR. Also, LAs can modulate the tumor necrosis factor/AKT pathway, the tumor necrosis factor/Src pathway, epidermal growth factor receptor, the Wnt pathway, and the RASSF1A/MDM2/p53 pathway to interfere with P-gp function. This means that LAs could be potentially useful in reversing cancer MDR. The aim of this review is to report the nonanesthetic functions of LAs, with a special focus on their anti-MDR effects and their potential beneficial implications in cancer chemotherapy.
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Effectiveness of Bupivacaine Liposome Injectable Suspension for Postoperative Pain Control in Total Knee Arthroplasty: A Prospective, Randomized, Double Blind, Controlled Study.
DeClaire, JH, Aiello, PM, Warritay, OK, Freeman, DC
The Journal of arthroplasty. 2017;(9S):S268-S271
Abstract
BACKGROUND We compared the effectiveness of liposomal bupivacaine to ropivacaine, each as part of multimodal pain management, in total knee arthroplasty (TKA) postoperative pain control. METHODS This prospective, double blind study randomized 96 TKA patients into a control group (periarticular injection of ropivacaine, ketorolac, morphine, and epinephrine in saline; 100cc) or an experimental group (periarticular injection of bupivacaine, ketorolac, morphine, and epinephrine in saline; 80cc plus 1.3% liposomal bupivacaine 20cc; total injection 100cc). The postoperative use of narcotics, visual analog pain scores, hours to ambulate 100 feet, and length of hospital stay were recorded. RESULTS There was no significant difference between the two groups (control N = 49, experiment N = 47) in mean narcotic use per hour, total narcotic use during hospital stay, time to ambulate 100 feet, length of hospital stay, or visual analog score for pain postoperatively. CONCLUSION There is no benefit in the use of liposomal bupivacaine compared with ropivacaine for postoperative pain control in TKA.