Postoperative pain and systemic inflammatory stress response after preoperative analgesia with clonidine or levobupivacaine: a randomized controlled trial

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.

Meta-analysis of the Diagnostic Accuracy of C-Reactive Protein for Infectious Complications in Laparoscopic Versus Open Colorectal Surgery

INTRODUCTION

C-reactive protein may predict anastomotic complications after colorectal surgery, but its predictive ability may differ between laparoscopic and open resection due to differences in stress response. Therefore, the objective of this study was to perform a systematic review and meta-analysis on the diagnostic characteristics of C-reactive protein to detect anastomotic leaks and infectious complications after laparoscopic and open colorectal surgery.

METHODS

A systematic review was performed according to PRISMA. Studies were included if they reported on the diagnostic characteristics of postoperative day 3-5 values of serum C-reactive protein to diagnose anastomotic leak or infectious complications specifically in patients undergoing elective laparoscopic and open colorectal surgery. The main outcome was a composite of anastomotic leak and infectious complications. A random-effects model was used to perform a meta-analysis of diagnostic accuracy.

RESULTS

A total of 13 studies were included (9 for laparoscopic surgery, 8 for open surgery). The pooled incidence of the composite outcome was 14.8% (95% CI 10.2-19.3) in laparoscopic studies and 21.0% (95% CI 11.9-30.0) for open. The pooled diagnostic accuracy characteristics were similar for open and laparoscopic studies. However, the C-reactive protein threshold cutoffs were lower in laparoscopic studies for postoperative days 3 and 4, but similar on day 5.

CONCLUSIONS

The diagnostic characteristics of C-reactive protein in the early postoperative period to detect infectious complications and leaks are similar after laparoscopic and open colorectal surgery. However, thresholds are lower for laparoscopic surgery, suggesting that the interpretation of serum CRP values needs to be tailored based on operative approach.

Hypothermia: Impact on plasticity following brain injury

Therapeutic hypothermia (TH) is a potent neuroprotectant against multiple forms of brain injury, but in some cases, prolonged cooling is needed. Such cooling protocols raise the risk that TH will directly or indirectly impact neuroplasticity, such as after global and focal cerebral ischemia or traumatic brain injury. TH, depending on the depth and duration, has the potential to broadly affect brain plasticity, especially given the spatial, temporal, and mechanistic overlap with the injury processes that cooling is used to treat. Here, we review the current experimental and clinical evidence to evaluate whether application of TH has any adverse or positive effects on postinjury plasticity. The limited available data suggest that mild TH does not appear to have any deleterious effect on neuroplasticity; however, we emphasize the need for additional high-quality preclinical and clinical work in this area.

Ultrasound-guided rectus sheath block for single-incision laparoscopic cholecystectomy

INTRODUCTION

Single-incision laparoscopic cholecystectomy (SILC) is increasingly applied for cholecystectomy and has been reported as safe and feasible, with short-term operative outcomes equivalent to four-port cholecystectomy. Although many investigators in randomized studies have noted the cosmetic advantages of SILC, the benefit of decreased pain in SILC remains controversial. Therefore, this study aimed to assess the efficacy of the rectus sheath block in SILC with respect to subjective pain.

METHODS

From April 2010 to March 2012, 75 patients with symptomatic gallstone or gallbladder polyps were assigned to one of three groups: (i) four-port laparoscopic cholecystectomy (n = 29); (ii) SILC (n = 15); and (iii) rectus sheath block in SILC (n = 30). We evaluated the operative details, length of hospital stay, and the need and usage of analgesia. Postoperative pain was recorded at 2, 6, 12, and 24 h after surgery based on a visual analog scale.

RESULTS

There was no difference with regard to age, ASA score, BMI, duration of operation, or length of hospital stay among the three groups. A significantly lower pain score was observed in the rectus sheath block in SILC group than in the SILC group at 2 and 6 h after operation. The pain score and need for analgesia were similar between the SILC group and the four-port cholecystectomy group.

CONCLUSION

SILC using an ultrasound-guided rectus sheath block significantly reduces postoperative pain.

Routine clinical markers of the magnitude of the systemic inflammatory response after elective operation: a systematic review

BACKGROUND

Operative injury to the body from all procedures causes a stereotypical cascade of neuroendocrine, cytokine, myeloid, and acute phase responses. This response has been examined commonly by the use of cortisol, interleukin-6 (IL-6), white cell count, and C-reactive protein (CRP). We aimed to determine which markers of the systemic inflammatory response were useful in determining the magnitude of injury after elective operations.

METHODS

A systematic review of the literature was performed using surgery, endocrine response, systemic inflammatory response, cortisol, IL-6, white cell count, and CRP. For each analyte the studies were grouped according to whether the operative injury was considered to be minor, moderate, or major and then by the operative procedure.

RESULTS

A total of 164 studies were included involving 14,362 patients. The IL-6 and CRP responses clearly were associated with the magnitude of operative injury and the invasiveness of the operative procedure. For example, the peak CRP response increased from 52 mg/L with cholecystectomy to 123 mg/L with colorectal cancer resection, 145 mg/L with hip replacement, 163 mg/L after abdominal aortic aneurysm repair, and 189 mg/L after open cardiac surgery. There also appeared to be a difference between minimally invasive/laparoscopic and open procedures such as cholecystectomy (27 vs 80 mg/L), colorectal cancer resection (97 vs 133 mg/L), and aortic aneurysm repair (132 vs 180 mg/L).

CONCLUSION

Peak IL-6 and CRP concentrations consistently were associated with the magnitude of operative injury and operative procedure. These markers may be useful in the objective assessment of which components of Enhanced Recovery after Surgery are likely to improve patient outcome and to assess the possible impact of operative injury on immune function.

Inflammatory Response in Patients under Coronary Artery Bypass Grafting Surgery and Clinical Implications: A Review of the Relevance of Dexmedetomidine Use

Despite the fact that coronary artery bypass grafting surgery (CABG) with cardiopulmonary bypass (CPB) prolongs life and reduces symptoms in patients with severe coronary artery diseases, these benefits are accompanied by increased risks. Morbidity associated with cardiopulmonary bypass can be attributed to the generalized inflammatory response induced by blood-xenosurfaces interactions during extracorporeal circulation and the ischemia/reperfusion implications, including exacerbated inflammatory response resembling the systemic inflammatory response syndrome (SIRS). The use of specific anesthetic agents with anti-inflammatory activity can modulate the deleterious inflammatory response. Consequently, anti-inflammatory anesthetics may accelerate postoperative recovery and better outcomes than classical anesthetics. It is known that the stress response to surgery can be attenuated by sympatholytic effects caused by activation of central (α-)2-adrenergic receptor, leading to reductions in blood pressure and heart rate, and more recently, that they can have anti-inflammatory properties. This paper discusses the clinical significance of the dexmedetomidine use, a selective (α-)2-adrenergic agonist, as a coadjuvant in general anesthesia. Actually, dexmedetomidine use is not in anesthetic routine, but this drug can be considered a particularly promising agent in perioperative multiple organ protection.

A randomized controlled double-blinded prospective study of the efficacy of clonidine added to bupivacaine as compared with bupivacaine alone used in supraclavicular brachial plexus block for upper limb surgeries

We compared the effects of clonidine added to bupivacaine with bupivacaine alone on supraclavicular brachial plexus block and observed the side-effects of both the groups. In this prospective, randomized, double-blinded, controlled trial, two groups of 25 patients each were investigated using (i) 40 ml of bupivacaine 0.25% plus 0.150 mg of clonidine and (ii) 40 ml of bupivacaine 0.25% plus 1 ml of NaCl 0.9, respectively. The onset of motor and sensory block and duration of sensory block were recorded along with monitoring of heart rate, non-invasive blood pressure, oxygen saturation and sedation. It was observed that addition of clonidine to bupivacaine resulted in faster onset of sensory block, longer duration of analgesia (as assessed by visual analogue score), prolongation of the motor block (as assessed by modified Lovett Rating Scale), prolongation of the duration of recovery of sensation and no association with any haemodynamic changes (heart rate and blood pressure), sedation or any other adverse effects. These findings suggest that clonidine added to bupivacaine is an attractive option for improving the quality and duration of supraclavicular brachial plexus block in upper limb surgeries.