Effects of intravenous single-bolus lidocaine infusion versus intravenous single-bolus magnesium sulfate infusion on postoperative pain, emotional status, and quality of life in patients undergoing spine fusion surgery: a randomized study

BACKGROUND

We assessed the efficiency of intravenous adjuvants in decreasing opioid intake and pain scores after spine fusion surgery.

METHODS

This study included 120 patients aged 18-60 listed for spine fusion surgery under general anesthesia. Patients were randomly assigned to four groups: Group (Lidocaine): received IV lidocaine 4 mg/kg in 50 mL volume over 30 min. Group (Magnesium): received IV magnesium sulfate 30mg/kg in 50 mL volume over 30 min. Group (combined Lidocaine and Magnesium): received IV lidocaine 4 mg/kg in 50 mL volume over 30 min.+IV magnesium sulfate 30mg/kg in 50 mL volume over 30 min. Group (Control): received IV saline 50 mL. The time to the first request analgesia, the postoperative pain score, total analgesic use, patient satisfaction, anxiety, depression, mental state, quality of life, and side effects were measured.

RESULTS

The combined group had more extended time for the first analgesic request and fewer rescue analgesia doses than the other groups. NRS scores at rest or movement were statistically significantly lower in the lidocaine group and the combined group compared to the control group (P1, P3<0.05) at almost all times. This combination reduces anxiety and depression and improves overall health up to three months after a single infusion. The combined group had higher patient satisfaction.

CONCLUSIONS

A synergistic effect of a combination of lidocaine and magnesium sulfate on perioperative pain was found. It reduces analgesic consumption, depression, and anxiety and improves overall health up to three months after a single infusion dose.

Intravenous lidocaine on postoperative pain and opioid consumption during gynecological surgery: a meta-analysis of randomized controlled trials

INTRODUCTION

This study aimed to evaluate the role of intravenous lidocaine as a adjuvant anesthetics in patients undergoing gynecological surgery.

EVIDENCE ACQUISITION

We conducted a meta-analysis of randomized controlled trials (RCTs) from PubMed/Medline, Embase and clinic trails.gov involving the use of intravenous lidocaine in gynecological surgery. We used a more comprehensive search strategy to adequately screen for randomized controlled trials involving intravenous lidocaine infusion in gynecological surgery. First outcomes were postoperative pain scores. And secondary outcomes included 24 h postoperative opioids consumption, time to first flatus, and incidence of postoperative nausea and vomiting.

EVIDENCE SYNTHESIS

A total of 6 RCTs comprising 375 patients were included in the meta-analysis. There were statistically significant between postoperative pain scores. The consumption of opioids and anesthetics during surgery and 24 hours after surgery was statistically significant when compared with the control group. Postoperative pain scores were similar at 2, 4, 6, 8, 10, 12, 24, 48 hours between groups. No statistical differences were found in postoperative complications including nausea, vomiting and restoration of the intestinal function.

CONCLUSIONS

Our results indicated that the current literature supports the perioperative use of intravenous lidocaine as part of multimodal analgesia and beneficial to patients in early postoperative analgesia, reduced opioid consumption.

The Role of Cytokines in Acute and Chronic Postsurgical Pain in Pediatric Patients after Major Musculoskeletal Surgeries

Study Objective

To determine if baseline cytokines and their changes over postoperative days 0-2 (POD0-2) predict acute and chronic postsurgical pain (CPSP) after major surgery.

Design

Prospective, observational, longitudinal nested study.

Setting

University-affiliated quaternary children's hospital.

Patients

Subjects (≥8 years old) with idiopathic scoliosis undergoing spine fusion or pectus excavatum undergoing Nuss procedure.

Measurements

Demographics, surgical, psychosocial measures, pain scores, and opioid use over POD0-2 were collected. Cytokine concentrations were analyzed in serial blood samples collected before and after (up to two weeks) surgery, using Luminex bead arrays. After data preparation, relationships between pre- and post-surgical cytokine concentrations with acute (% time in moderate-severe pain over POD0-2) and chronic (pain score>3/10 beyond 3 months post-surgery) pain were analyzed. After adjusting for covariates, univariate/multivariate regression analyses were conducted to associate baseline cytokine concentrations with postoperative pain, and mixed effects models were used to associate longitudinal cytokine concentrations with pain outcomes.

Main Results

Analyses included 3,164 measures of 16 cytokines from 112 subjects (median age 15.3, IQR 13.5-17.0, 54.5% female, 59.8% pectus). Acute postsurgical pain was associated with higher baseline concentrations of GM-CSF (β=0.95, SE 0.31; p=.003), IL-1β (β=0.84, SE 0.36; p=.02), IL-2 (β=0.78, SE 0.34; p=.03), and IL-12 p70 (β=0.88, SE 0.40; p=.03) and longitudinal postoperative elevations in GM-CSF (β=1.38, SE 0.57; p=.03), IFNγ (β=1.36, SE 0.6; p=.03), IL-1β (β=1.25, SE 0.59; p=.03), IL-7 (β=1.65, SE 0.7, p=.02), and IL-12 p70 (β=1.17, SE 0.58; p=.04). In contrast, CPSP was associated with lower baseline concentration of IL-8 (β= -0.39, SE 0.17; p=.02), and the risk of developing CPSP was elevated in patients with lower longitudinal postoperative concentrations of IL-6 (β= -0.57, SE 0.26; p=.03), IL-8 (β= -0.68, SE 0.24; p=.006), and IL-13 (β= -0.48, SE 0.22; p=.03). Furthermore, higher odds for CPSP were found for females (vs. males) for IL-2, IL-4, IL-5, IL-6, IL-8, IL-10, and TNFα, and for pectus (vs. spine) surgery for IL-8 and IL-10.

Conclusion

We identified pro-inflammatory cytokines associated with increased acute postoperative pain and anti-inflammatory cytokines associated with lower CPSP risk, with potential to serve as predictive and prognostic biomarkers.

Ultrasound-guided erector spinae plane blocks for pain management after open lumbar laminectomy

PURPOSE

Lumbar spine surgery is associated with significant postoperative pain. The benefits of erector spinae plane blocks (ESPBs) combined with multimodal analgesia has not been adequately studied. We evaluated the analgesic effects of bilateral ESPBs as a component of multimodal analgesia after open lumbar laminectomy.

METHODS

Analgesic effects of preoperative, bilateral, ultrasound-guided ESPBs combined with standardized multimodal analgesia (n = 25) was compared with multimodal analgesia alone (n = 25) in patients undergoing one or two level open lumbar laminectomy. Other aspects of perioperative care were similar. The primary outcome measure was cumulative opioid consumption at 24 h. Secondary outcomes included opioid consumption, pain scores, and nausea and vomiting requiring antiemetics on arrival to the post-anesthesia care unit (PACU), at 24 h, 48 h, and 72 h after surgery, as well as duration of the PACU and hospital stay.

RESULTS

Opioid requirements at 24 h were significantly lower with ESPBs (31.9 ± 12.3 mg vs. 61.2 ± 29.9 mg, oral morphine equivalents). Pain scores were significantly lower with ESPBs in the PACU and through postoperative day two. Patients who received ESPBs required fewer postoperative antiemetic therapy (n = 3, 12%) compared to those without ESPBs (n = 12, 48%). Furthermore, PACU duration was significantly shorter with ESPBs (49.7 ± 9.5 vs. 79.9 ± 24.6 min).

CONCLUSIONS

Ultrasound-guided, bilateral ESPBs, when added to an optimal multimodal analgesia technique, reduce opioid consumption and pain scores, the need for antiemetic therapy, and the duration of stay in the PACU after one or two level open lumbar laminectomy.

Postoperative use and early discontinuation of intravenous lidocaine in spine patients

PURPOSE

Our institution employs a multimodal approach to manage postoperative pain after spine surgery. It involves continuous intravenous (IV) lidocaine until the morning of postoperative day two. This study aimed to determine the rate and reasons for early discontinuation of IV lidocaine in our spine patients.

METHODS

We conducted a retrospective chart review and included pediatric patients who underwent ≥ 3-level spine surgery and received postoperative IV lidocaine from November 2019 to September 2022. For each case, we recorded the side effects of IV lidocaine, adverse events, time to discontinuation, and discontinuation rate. Subsequently, we used the same methodology to generate an adult cohort for comparison.

RESULTS

We included 52 pediatric (18M:34F) and 50 (21M:29F) adult patients. The pediatric cohort's mean age was 14 years (8-18), and BMI 23.9 kg/m2 (13.0-42.8). The adult cohort's mean age was 61 years (29-82), and BMI 28.8 kg/m2 (17.2-44.1). IV lidocaine was discontinued prematurely in 21/52 (40.4%) of the pediatric cases and 26/50 (52.0%) of the adult cases (RR = 0.78, p = 0.2428). The side effects noted in the pediatric cases vary, including numbness, visual disturbance, and obtundation, but no seizures. The most common adverse events were fever and motor dysfunction.

CONCLUSION

The early discontinuation rate of IV lidocaine use after spine surgery for children in our institution does not differ significantly from that of adults. The nature of the side effects and the reasons for discontinuation between the groups were similar. Thus, the safety profile of IV lidocaine for pediatric spine patients is comparable to adults.

Nausea and Vomiting After Posterior Spinal Fusion in Adolescent Idiopathic Scoliosis: A Systematic and Critical Analysis Review

BACKGROUND

Postoperative nausea and vomiting (PONV) affects patient satisfaction, health care costs, and hospital stay by complicating the postoperative recovery period after adolescent idiopathic scoliosis (AIS) spinal fusion surgery. Our goal was to identify recommendations for optimal management of PONV in AIS patients undergoing posterior spinal fusion (PSF).

METHODS

We performed a systematic review in June 2022, searching the PubMed and Embase electronic databases using search terms "(Adolescent idiopathic scoliosis) AND (Postoperative) AND (Nausea) AND (Vomiting)." Three authors reviewed the 402 abstracts identified from January 1991 to June 2022. Studies that included adolescents or young adults (<21 years) with AIS undergoing PSF were selected for full-text review by consensus. We identified 34 studies reporting on incidence of PONV. Only 6 studies examined PONV as the primary outcome, whereas remaining were reported PONV as a secondary outcome. Journal of Bone and Joint Surgery Grades of recommendation were assigned to potential interventions or clinical practice influencing incidence of PONV with respect to operative period (preoperative, intraoperative, and postoperative period) on the basis that potential guidelines/interventions for PONV can be targeted at those periods.

RESULTS

A total of 11 factors were graded, 5 of which were related to intervention and 6 were clinical practice-related. Eight factors could be classified into the operative period-1 in the intraoperative period and 7 in the postoperative period, whereas the remaining 3 recommendations had overlapping periods. The majority of grades of recommendations given were inconclusive or conflicting. The statement that neuraxial and postoperative systemic-only opioid therapy have a similar incidence of PONV was supported by good (Grade A) evidence. There was fair (Grade B) and poor evidence (Grade C) to avoid opioid antagonists and nonopioid local analgesia using wound catheters as PONV-reducing measures.

CONCLUSION

Although outcomes after spinal fusion for AIS have been studied extensively, the literature on PONV outcomes is scarce and incomplete. PONV is most commonly included as a secondary outcome in studies related to pain management. This study is the first to specifically identify evidence and recommendations for interventions or clinical practice that influence PONV in AIS patients undergoing PSF. Most interventions and clinical practices have conflicting or limited data to support them, whereas others have low-level evidence as to whether the intervention/clinical practice influences the incidence of PONV. We have identified the need for expanded research using PONV as a primary outcome in patients with AIS undergoing spinal fusion surgery.

Error traps and preventative strategies for adolescent idiopathic scoliosis spinal surgery

Anesthesia for posterior spinal fusion for adolescent idiopathic scoliosis remains one of the most common surgeries performed in adolescents. These procedures have the potential for significant intraprocedural and postoperative complications. The potential for pressure injuries related to prone positioning must be understood and addressed. Additionally, neuromonitoring remains a mainstay for patient care in order to adequately assess patient neurologic integrity and alert the providers to a reversible action. As such, causes of neuromonitoring signal loss must be well understood, and the provider should have a systematic approach to signal loss. Further, anesthetic design must facilitate intraoperative wake-up to allow for a definitive assessment of neurologic function. Perioperative bleeding risk is high in posterior spinal fusion due to the extensive surgical exposure and potentially lengthy operative time, so the provider should undertake strategies to reduce blood loss and avoid coagulopathy. Pain management for adolescents undergoing spinal fusion is also challenging, and inadequate analgesia can delay recovery, impede patient/family satisfaction, increase the risk of chronic postsurgical pain/disability, and lead to prolonged opioid use. Many of the significant complications associated with this procedure, however, can be avoided with intentional and evidence-based approaches covered in this review.

Guidelines on perioperative optimization protocol for the adult patient 2023

OBJECTIVE

The French Society of Anesthesiology and Intensive Care Medicine [Société Française d'Anesthésie et de Réanimation (SFAR)] aimed at providing guidelines for the implementation of perioperative optimization programs.

DESIGN

A consensus committee of 29 experts from the SFAR was convened. A formal conflict-of-interest policy was developed at the outset of the process and enforced throughout. The entire guidelines process was conducted independently of any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence.

METHODS

Four fields were defined: 1) Generalities on perioperative optimization programs; 2) Preoperative measures; 3) Intraoperative measures and; 4) Postoperative measures. For each field, the objective of the recommendations was to answer a number of questions formulated according to the PICO model (population, intervention, comparison, and outcomes). Based on these questions, an extensive bibliographic search was carried out using predefined keywords according to PRISMA guidelines and analyzed using the GRADE® methodology. The recommendations were formulated according to the GRADE® methodology and then voted on by all the experts according to the GRADE grid method. As the GRADE® methodology could have been fully applied for the vast majority of questions, the recommendations were formulated using a "formalized expert recommendations" format.

RESULTS

The experts' work on synthesis and application of the GRADE® method resulted in 30 recommendations. Among the formalized recommendations, 19 were found to have a high level of evidence (GRADE 1±) and ten a low level of evidence (GRADE 2±). For one recommendation, the GRADE methodology could not be fully applied, resulting in an expert opinion. Two questions did not find any response in the literature. After two rounds of rating and several amendments, strong agreement was reached for all the recommendations.

CONCLUSIONS

Strong agreement among the experts was obtained to provide 30 recommendations for the elaboration and/or implementation of perioperative optimization programs in the highest number of surgical fields.

Efficacy of prolonged intravenous lidocaine infusion for postoperative movement-evoked pain following hepatectomy: a double-blinded, randomised, placebo-controlled trial

BACKGROUND

The analgesic effect of intravenous lidocaine varies with the duration of lidocaine infusion and surgery type. We tested the hypothesis that prolonged lidocaine infusion alleviates postoperative pain in patients recovering from hepatectomy over the first 3 postoperative days.

METHODS

Patients undergoing elective hepatectomy were randomly assigned to receive prolonged i.v. lidocaine treatment or placebo. The primary outcome was incidence of moderate-to-severe movement-evoked pain at 24 h postoperatively. The secondary outcomes included incidence of moderate-to-severe pain during movement and at rest throughout the first 3 postoperative days, postoperative opioid consumption, and pulmonary complications. Plasma lidocaine concentration was also monitored.

RESULTS

We enrolled 260 subjects. Intravenous lidocaine lowered the incidence of moderate-to-severe movement-evoked pain at 24 h and 48 h postoperatively (47.7% vs 67.7%, P=0.001; 38.5% vs 58.5%, P=0.001) and reduced movement-evoked pain scores (3.7 [1.7] vs 4.2 [1.6]; mean difference 0.5 [95% confidence interval {CI}: 0.1-0.9]; P=0.018) and morphine equivalent consumption (47.2 [16.7] mg vs 52.6 [19.2] mg; mean difference 5.4 mg [95% CI: 1.0-9.8]; P=0.016) at 24 h postoperatively. Lidocaine also lowered the incidence of postoperative pulmonary complications (23.1% vs 38.5%; P=0.007). Median plasma lidocaine concentrations were 1.5, 1.9, and 1.1 μg ml^-1 (inter-quartile ranges: 1.1-2.1, 1.4-2.6, and 0.8-1.6, respectively) after bolus injection, at the end of the surgery, and 24 h postoperatively.

CONCLUSIONS

Prolonged intravenous lidocaine infusion reduced the incidence of moderate-to-severe movement-evoked pain for 48 h after hepatectomy. However, the reduction in pain scores and opioid consumption by lidocaine was below the minimal clinically important difference.

CLINICAL TRIAL REGISTRATION

NCT04295330.

Intravenous lidocaine simultaneously infused with sufentanil to accelerate gastrointestinal function recovery in patients after thoracolumbar surgery: a prospective, randomized, double-blind controlled study

PURPOSE

Postoperative gastrointestinal dysfunction is one of the common complications of surgery, especially after surgery for a thoracolumbar spinal fracture. Intravenous lidocaine is a potential method to improve postoperative gastrointestinal function in surgical patients, reduce opioid use and shorten hospital stays. The purpose of this study is to explore the effect of intravenous lidocaine on the recovery of gastrointestinal function in patients after thoracolumbar surgery.

METHODS

In this study, 48 eligible patients undergoing elective thoracolumbar spine fractures resection and internal fixation surgery were enrolled to receive intravenous injections of lidocaine in different concentrations during the perioperative period. Patients were randomly divided into three groups: control group (group A), low concentration of lidocaine group (group B) and high concentration of lidocaine group (group C), 16 patients in each group. First postoperative exhaust time, numbers of bowel sound at preoperative and postoperative 3, 6, 12, 24 h, pain scores at postoperative 0, 3, 6, 12, 24, 48 h, total sufentanil use in PACU and perioperative periods, postoperative hospital stay and analgesic remedy within postoperative 48 h were recorded and compared. The primary endpoints include: the time of first flatus passage after the operation, the number of bowel sounds per minute counted with stethoscope at 30 min before anesthesia induction and at 3, 6, 12 and 24 h postoperative. The secondary endpoints included: the pain scores at PACU (after entering into PACU), 3, 6, 12, 24 and 48 h postoperative, the amount of sufentanil administrated by intravenous push during operation and the numbers of patients needed rescuing sufentanil in PACU, and the numbers of patients needed administration of gastric motility drugs or non-steroidal analgesics at ward within 48 h postoperation, length of hospital stay (from the first day after surgery to discharge from hospital) and the incidence of adverse reactions.

RESULTS

Compared with group A, the first postoperative exhaust time in group B and C occurred much earlier (23.3 ± 11.0 h vs. 16.0 ± 6.6 h, 16.6 ± 5.1 h, P < 0.05). Compared with preoperation, the numbers of bowel sound significantly increased at 24 h postoperatively in group B, while group B at 6 h and group C at 6 and 24 h postoperatively had significantly more active bowel sounds compared to group A (P < 0.05). There were no remarkable differences in VAS scores within 12 h postoperatively among three groups, and however, significantly lower VAS scores were found at 12, 24 and 48 h postoperatively in group C when comparing to Group A (p < 0.05). There was no statistical significance in the incidence of postoperative flatulence and nausea and vomiting, the number of patients needed rescuing sufentanil in PACU, the length of postoperative hospital stay and the number of patients requiring non-steroidal analgesics at ward within 48 h postoperation.

CONCLUSIONS

Intravenous lidocaine infusion together with patient-controlled analgesia of sufentanil expedited the early recovery of gastrointestinal function and improved analgesic quality of sefentanyl in patients undergoing thoracolumbar surgeries.

Perioperative intravenous lidocaine use in children

Perioperative pain management impacts patient morbidity, quality of life, and hospitalization cost. In children, it impacts not only the child, but the whole family. Adjuncts for improved perioperative analgesia continue to be sought to minimize adverse side effects associated with opioids and for those in whom regional or neuraxial anesthesia is not suitable. The use of ketamine and alpha agonists may be useful in these settings but have noted adverse effects including hallucinations, hemodynamic instability, and excessive sedation. One alternative is intravenous lidocaine. Despite its off-label use, intravenous lidocaine has demonstrated anti-neuropathic, anti-hyperalgesic, and anti-inflammatory actions and is an emerging technique. Multiple studies in adults have demonstrated beneficial effects of perioperative intravenous lidocaine including improved perioperative analgesia with reduced postoperative opioid use, improved gastrointestinal function, earlier mobilization, and reduction in hospital length of stay. Despite the limited pediatric literature, some of these findings have been replicated. Large-scale trials providing evidence for the pediatric pharmacokinetics and high-quality safety data with respect to intravenous lidocaine are still however lacking. To date, dose ranges studied in the pediatric population have not been associated with serious side effects and current data suggests perioperative intravenous lidocaine in a subgroup of pediatric surgical patients seems well-tolerated and beneficial.

Postoperative analgesia for complex spinal surgery

PURPOSE OF REVIEW

Complex spinal surgery is associated with significant postoperative pain. The purpose of this paper is to review recent literature on postoperative pain management in adult and adolescent patients having complex spinal surgery.

RECENT FINDINGS

We conducted a literature search using the Medline database for relevant publications from 2020 to 2022 on postoperative pain after complex spinal surgery. Although opioids remain the mainstay to manage pain after complex spinal surgery, they are associated with adverse effects. Multimodal analgesia may be used to reduce these adverse effects by combining different drugs targeting different parts of the pain pathway. Recent publications suggest continuous low dose fentanyl or morphine infusion, methadone, intravenous paracetamol and ibuprofen, ketorolac, ketamine, magnesium infusion, lidocaine infusion and dexmedetomidine appear to be effective and safe to manage pain after complex spinal surgery. Regional techniques including bilateral erector spinae block, interfascial plane block and intrathecal morphine also appear to be effective and safe.

SUMMARY

Pain management after complex spinal surgery remains challenging. Therefore, further studies are still required to determine the optimal multimodal analgesic regimen for these patients.

Opioid-Sparing Techniques in Orthopedic Anesthesia-One Step to Opioid-Free Anesthesia?

Opioid-free anesthesia is a multimodal anesthesia aimed at avoiding the negative impact of intraoperative opioid on patient's postoperative outcomes. It is based on the physiology of pathways involved in intraoperative nociception. It has been shown to be feasible but the literature is still scarce on the clinically meaningful benefits as well as on the side effects and/or complications that might be associated with it. Moreover, most studies involved abdominal and/or bariatric surgery. Procedure-specific studies are lacking, especially in orthopedics.

Effect of intravenous lidocaine on pain after head and neck cancer surgery (ELICO trial): A randomised controlled trial

BACKGROUND

Treatment of postoperative pain after ear, nose and throat (ENT) cancer surgery is mainly morphine administration. Additional systemic lidocaine has shown promising results in some surgical procedures.

OBJECTIVE

The main objective was to evaluate morphine consumption in the first 48 postoperative hours after intra-operative lidocaine infusion during major ENT cancer surgery.

DESIGN

A randomised, double-blind, placebo-controlled trial.

SETTING

Bicentric study including a university hospital and a major cancer centre, conducted from December 2016 to December 2019.

PATIENTS

A total of 144 patients undergoing major ENT cancer surgery were included.

INTERVENTION

The patients were randomly assigned to receive intravenous lidocaine or placebo during surgery and in the recovery room.

MAIN OUTCOME MEASURES

Endpoints were postoperative morphine consumption in the first 24 and 48 h postoperatively, intra-operative remifentanil consumption, adverse events occurrence and assessment 3 to 6 months after surgery with the McGill pain questionnaire.

RESULTS

A total of 118 patients were included (lidocaine n  = 57; placebo n  = 61, 26 patients were excluded). There was no significant difference in morphine consumption during the first 48 postoperative hours in the lidocaine group compared with the placebo group with a median [IQR] of 0.60 [0.30 to 1.03] mg kg -1 vs. 0.57 [0.37 to 0.96] mg kg -1 , total dose 44 [21 to 73.3] mg vs. 38 [23.3 to 56.5] mg, P  = 0.92.There was no significant difference between the two groups in any of the other endpoints, including at follow up 3 to 6 months after surgery.

CONCLUSION

Intravenous lidocaine in ENT cancer surgery did not show any additional analgesic or morphine-sparing effect 48 h after surgery. Three to six months after surgery, there was no significant difference in pain scores or consumption of analgesics. Patients treated pre-operatively with opioids were not evaluated in the study.

TRIAL REGISTRATION

Clinicaltrials.gov identifier: NCT02894710 and EUDRACT number 2015-005799-90.

Effect of Intravenous Infusion of Lidocaine Compared with Ultrasound-Guided Transverse Abdominal Plane Block on the Quality of Postoperative Recovery in Patients Undergoing Laparoscopic Bariatric Surgery

Purpose

To investigate the effect of intravenous infusion of lidocaine compared with ultrasound-guided transverse abdominal plane (TAP) block on the quality of postoperative recovery and analgesic effect in patients undergoing bariatric surgery.

Patients and Methods

Ninety-nine ASA II-III patients scheduled for elective laparoscopic bariatric surgery were randomized into the lidocaine group (group L), transverse abdominal plane block group (group T), and control group (group C). Group L: a loading dose of 1.5 mg/kg lidocaine was given at induction, followed by 2 mg·kg^-1·h^-1 maintenance until the end of surgery. Group T: ultrasound-guided bilateral administration of 0.25% ropivacaine in the transverse abdominal plane was given after induction of general anesthesia. Group C: no additional treatment was performed. Quality of recovery-40 (QoR-40) was assessed at 24 h after surgery. Consumption of propofol and remifentanil, visual analog scale (VAS) pain scores at rest at 0, 6, 12, and 24 h postoperatively, time to return of intestinal function, use of remedial analgesics within 24 h after surgery, adverse reactions were recorded.

Results

Compared with Group C, Group L and Group T had higher QoR-40 scores at 24 h postoperatively, and the difference was statistically significant (P=0.002 and P=0.003, respectively). However, there was no difference between Group L and Group T (P=0.128). In addition, compared with those of Group T and Group C, VAS scores at 12 h and 24 h postoperatively were lower in Group L (P <0.0166).

Conclusion

Both intravenous infusion of lidocaine and ultrasound-guided TAP block provided good postoperative recovery and postoperative analgesia for patients with bariatric surgery, and intravenous infusion of lidocaine provided better analgesia at 12 h and 24 h postoperatively compared with TAP block.

Perioperative Pain Management for Elective Spine Surgery: Opioid Use and Multimodal Strategies

In recent years, physicians and institutions have come to recognize the increasing opioid epidemic in the United States, thus prompting a dramatic shift in opioid prescribing patterns. The lack of well-studied alternative treatment regimens has led to a substantial burden of opioid addiction in the United States. These forces have led to a huge economic burden on the country. The spine surgery population is particularly high risk for uncontrolled perioperative pain, because most patients experience chronic pain preoperatively and many patients continue to experience pain postoperatively. Overall, there is a large incentive to better understand comprehensive multimodal pain management regimens, particularly in the spine surgery patient population. The goal of this review is to explore trends in pain symptoms in spine surgery patients, overview the best practices in pain medications and management, and provide a concise multimodal and behavioral treatment algorithm for pain management, which has since been adopted by a high-volume tertiary academic medical center.

Efficacy of Intravenous Lidocaine for Pain Relief in the Emergency Department: A Systematic Review and Meta-Analysis

Objective

To compare the efficacy of intravenous (IV) lidocaine with standard analgesics (NSAIDS, opioids) for pain control due to any cause in the emergency department.

Methods

The electronic databases of PubMed, Embase, ScienceDirect, CENTRAL, and Google Scholar were explored from 1st January 2000 to 30th March 2021 and randomized controlled trials (RCTs) comparing IV lidocaine with a control group of standard analgesics were included.

Results

Twelve RCTs including 1,351 patients were included. The cause of pain included abdominal pain, renal or biliary colic, traumatic pain, radicular low back pain, critical limb ischemia, migraine, tension-type headache, and pain of unknown origin. On pooled analysis, we found no statistically significant difference in pain scores between IV lidocaine and control group at 15 min (MD: −0.24 95% CI: −1.08, 0.61 I2 = 81% p = 0.59), 30 min (MD: −0.24 95% CI: −1.03, 0.55 I2 = 86% p = 0.55), 45 min (MD: 0.31 95% CI: −0.66, 1.29 I2 = 66% p = 0.53), and 60 min (MD: 0.59 95% CI: −0.26, 1.44 I2 = 75% p = 0.18). There was no statistically significant difference in the need for rescue analgesics between the two groups (OR: 1.45 95% CI: 0.82, 2.56 I2 = 41% p = 0.20), but on subgroup analysis, the need for rescue analgesics was significantly higher with IV lidocaine in studies on abdominal pain but not for musculoskeletal pain. On meta-analysis, there was no statistically significant difference in the incidence of side-effects between the two study groups (OR: 1.09 95% CI: 0.59, 2.02 I2 = 48% p = 0.78).

Conclusion

IV lidocaine can be considered as an alternative analgesic for pain control in the ED. However, its efficacy may not be higher than standard analgesics. Further RCTs with a large sample size are needed to corroborate the current conclusions.

Perioperative Intravenous Lidocaine Infusion on Postoperative Recovery in Patients Undergoing Arthroscopic Rotator Cuff Repair Under General Anesthesia - A Randomized Controlled Trial

OBJECTIVE

Arthroscopic rotator cuff repair (ARCR) is known to cause severe postoperative pain which may interfere with recovery. Intravenous (IV) lidocaine has analgesic, anti-inflammatory, and anti-hyperalgesic effects, and is being used in various types of surgeries. However, the effect of IV lidocaine in ARCR is not well known.

MATERIALS AND METHODS

Ninety patients undergoing ARCR were randomly allocated to receive IV lidocaine (1.5▒mg/kg bolus of 1% lidocaine after anesthesia induction followed by a continuous infusion of 2▒mg/kg/h up to 1▒h after surgery) or an equal volume of saline. In both groups, an IV patient-controlled analgesia (PCA) device was used which contained fentanyl 10▒µg/mL, infused at 1▒mL/h with a 1▒mL bolus dose. The primary outcome was fentanyl requirements given via IV PCA during the first 24 hours after surgery. Perioperative pain scores and functional recovery were assessed as secondary outcomes.

RESULTS

The amount of fentanyl administered via IV PCA up to 24 hours after surgery was significantly lower in the Lidocaine group compared to the Control group (329 [256.2-428.3] vs. 394.5 [287.0-473.0], P=0.037) The number of PCA bolus attempts were lower in the Lidocaine group without statistical significance. There were no differences in postoperative pain scores or functional shoulder scores between the two groups.

DISCUSSION

IV lidocaine appears to be helpful in reducing opioid requirements during the acute postoperative period in patients undergoing ARCR. IV lidocaine may be a viable option as a component of multimodal analgesia in ARCR when regional analgesia is not possible.

Perioperative Care of Patients Undergoing Major Complex Spinal Instrumentation Surgery: Clinical Practice Guidelines From the Society for Neuroscience in Anesthesiology and Critical Care

Evidence-based standardization of the perioperative management of patients undergoing complex spine surgery can improve outcomes such as enhanced patient satisfaction, reduced intensive care and hospital length of stay, and reduced costs. The Society for Neuroscience in Anesthesiology and Critical Care (SNACC) tasked an expert group to review existing evidence and generate recommendations for the perioperative management of patients undergoing complex spine surgery, defined as surgery on 2 or more thoracic and/or lumbar spine levels. Institutional clinical management protocols can be constructed based on the elements included in these clinical practice guidelines, and the evidence presented.

Intravenous lidocaine in spine surgery: A meta-analysis of randomized controlled trials

Background

Methods

Results

Conclusion

Perioperative Intravenous Lidocaine and Metastatic Cancer Recurrence - A Narrative Review

Cancer is a major global health problem and the second leading cause of death worldwide. When detected early, surgery provides a potentially curative intervention for many solid organ tumours. Unfortunately, cancer frequently recurs postoperatively. Evidence from laboratory and retrospective clinical studies suggests that the choice of anaesthetic and analgesic agents used perioperatively may influence the activity of residual cancer cells and thus affect subsequent recurrence risk. The amide local anaesthetic lidocaine has a well-established role in perioperative therapeutics, whether used systemically as an analgesic agent or in the provision of regional anaesthesia. Under laboratory conditions, lidocaine has been shown to inhibit cancer cell behaviour and exerts beneficial effects on components of the inflammatory and immune responses which are known to affect cancer biology. These findings raise the possibility that lidocaine administered perioperatively as a safe and inexpensive intravenous infusion may provide significant benefits in terms of long term cancer outcomes. However, despite the volume of promising laboratory data, robust prospective clinical evidence supporting beneficial anti-cancer effects of perioperative lidocaine treatment is lacking, although trials are planned to address this. This review provides a state of the art summary of the current knowledge base and recent advances regarding perioperative lidocaine therapy, its biological effects and influence on postoperative cancer outcomes.

Effect of Intravenous Lidocaine on Serum Interleukin-17 After Video-Assisted Thoracic Surgery for Non-Small-Cell Lung Cancer: A Randomized, Double-Blind, Placebo-Controlled Trial

Purpose

Surgical stress promotes tumor metastasis. Interleukin (IL)-17 plays a pivotal role in cancer progression, and high IL-17 expression predicts poor prognosis of non-small-cell lung cancer (NSCLC). Lidocaine may exert tumor-inhibiting effects. We hypothesize that intravenous lidocaine attenuates surgical stress and reduces serum IL-17 levels during video-assisted thoracic surgery (VATS) for NSCLC.

Methods

This randomized, double-blind, placebo-controlled trial included 60 early-stage NSCLC patients undergoing VATS, into a lidocaine group (n = 30; intravenous lidocaine bolus 1.0 mg/kg, and 1.0 mg/kg/h until the end of surgery) or a normal saline control group (n = 30). The primary outcome was serum IL-17 level at 24 hours postoperatively. The secondary outcomes included serum IL-17 level at the time of post-anesthesia care unit (PACU) discharge, serum cortisol level at PACU discharge and postoperative 24 hours, pain scores (0–10) from PACU discharge to 48 hours postoperatively, incidences of postoperative nausea and vomiting, dizziness, and arrhythmia during 0–48 hours postoperatively, and 30-day mortality. Long-term outcomes included chemotherapy, cancer recurrence, and mortality.

Results

The lidocaine group had lower serum IL-17 at 24 hours postoperatively compared with the control group (23.0 ± 5.8 pg/mL vs 27.3 ± 8.2 pg/mL, difference [95% CI] = −4.3 [−8.4 to −0.2] pg/mL; P = 0.038). The lidocaine group also had reduced serum IL-17 (difference [95% CI] = −4.6 [−8.7 to −0.5] pg/mL), serum cortisol (difference [95% CI] = −37 [−73 to −2] ng/mL), and pain scores (difference [95% CI] = −0.7 [−1.3 to −0.1] points) at PACU discharge. During a median follow-up of 10 (IQR, 9–13) months, 2 patients in the lidocaine group and 6 patients in the control group received chemotherapy, one patient in the control group had cancer recurrence, and no death event occurred.

Conclusion

Intravenous lidocaine was associated with reduced serum IL-17 and cortisol following VATS procedures in early-stage NSCLC patients.

Trial Registration

ChiCTR2000030629.

Perioperative Intravenous Lidocaine Infusion for Post-operative Analgesia in Patients undergoing Surgery of the Spine Systematic Review and Meta-analysis

OBJECTIVE

We conducted a systematic review and meta-analysis to examine the impact of perioperative intravenous lidocaine infusion on pain management scores, opioid consumption, adverse events and hospital length of stay in patients undergoing spinal surgery.

METHODS

We included randomized controlled trials (RCT's) evaluating the use of perioperative intravenous lidocaine in adult and paediatric patients undergoing spinal surgery. Primary outcomes were post-operative pain scores at rest, at two, four- six, twenty-four and forty-eight hours and adverse events attributable to lidocaine administration. We searched electronic databases from inception to present. We used Cochrane's standard methods. We used a random-effects model to synthetize data. We conducted three subgroup analysis: major versus minor surgery, patients with chronic pain conditions versus patients without, and adult versus paediatric.

RESULTS

A total of eight studies were included comparing patients having intravenous lidocaine (n = 349) to controls (n = 343). Intravenous lidocaine administration was associated with significantly reduced visual analogue pain scores at two MD= -1.13, four-six MD =-0.79 and twenty-four hours MD= -0.50 post-operatively. In the adults, efficacy of treatment was extended to forty-eight hours MD= -0.72. Perioperative intravenous lidocaine administration was associated with reduced peri-operative opioid consumption at twenty-four and forty-eight as well as decreased hospital length of stay.

CONCLUSION

Perioperative intravenous lidocaine infusion consistently improves analgesic measures in adult and paediatric population in the first twenty-four hours, with an effective decrease in opioid consumption noted to forty-eight hours. These results are most generalizable in the adult population in the first four-six to twenty four post-operative hours.

Comparative effectiveness of pharmacological interventions to prevent postoperative delirium: a network meta-analysis

Many pharmacologic agents were investigated for the effect to prevent delirium. We aimed to comprehensively compare the effect of the pharmacological interventions to prevent postoperative delirium. A Bayesian network meta-analysis of randomized trials was performed using random effects model. PubMed, the Cochrane Central Register of Controlled Trials, and Embase were searched on 20 January 2021. Randomized trials comparing the effect of a drug to prevent postoperative delirium with another drug or placebo in adult patients undergoing any kind of surgery were included. Primary outcome was the postoperative incidence of delirium. Eighty-six trials with 26,992 participants were included. Dexmedetomidine, haloperidol, and atypical antipsychotics significantly decreased the incidence of delirium than placebo [dexmedetomidine: odds ratio 0.51, 95% credible interval (CrI) 0.40-0.66, moderate quality of evidence (QOE); haloperidol: odds ratio 0.59, 95% CrI 0.37-0.95, moderate QOE; atypical antipsychotics: odds ratio 0.27, 95% CrI 0.14-0.51, moderate QOE]. Dexmedetomidine and atypical antipsychotics had the highest-ranking probabilities to be the best. However, significant heterogeneity regarding diagnostic time window as well as small study effects precludes firm conclusion.

Effects of Systemic Lidocaine on Postoperative Recovery Quality and Immune Function in Patients Undergoing Laparoscopic Radical Gastrectomy

Objective

This study aimed to explore the effects of lidocaine on postoperative quality of recovery (QoR) and immune function in patients undergoing laparoscopic radical gastrectomy.

Methods

In total, 135 patients were enrolled and were equally randomized to receive low-dose lidocaine (Group LL: 1.5 mg/kg bolus followed by an infusion at 1.0 mg/kg/hour) or high-dose lidocaine (Group HL: 1.5 mg/kg bolus followed by an infusion at 2.0 mg/kg/hour) or Controls (Group C: received a volume-matched normal saline at the same rate). The primary outcome was a QoR-40 score on postoperative day (POD) 1. Secondary outcomes were a QoR-40 score on POD 3, levels of inflammatory factors (IL-6, IL-10, TNF-α) and CD4⁺T cells, CD8⁺T cells proportions, and CD4⁺/CD8⁺ cell ratios and postoperative recovery of bowel function.

Results

There were no statistically significant differences in patient characteristics at baseline. The total QoR-40 scores on POD 1 in Group HL (171.4±3.89) were higher than those in Group LL (166.20±4.05) and in Group C (163.40±4.38) (adjusted P<0.001). Differences in the dimension scores of QoR-40 for pain, physical comfort, and emotional state were significant across the three groups. Lidocaine administration significantly reduced the release of IL-6, IL-10, TNF-α, and attenuated immune changes induced by trauma. Kaplan–Meier curves showed that the median time to the first exhaust and defecation were shorter in the Group HL than in Groups LL and C (1.55 days vs 2.4 days vs 2.6 days, log rank P<0.0001; and 2.86 days vs 3.22 days vs 3.46 days, log rank P=0.002, respectively). Additionally, patients in lidocaine groups required less remifentanil consumption and experienced lower pain intensity, compared with the control group.

Conclusion

Systemic lidocaine improved postoperative recovery, alleviated inflammation and immunosuppression, and accelerated the return of bowel function, and is thus, worthy of clinical application.

Clinical Trials Registration

ChiCTR2000028934.

Perioperative Pain Management and Opioid Stewardship: A Practical Guide

Surgical procedures are key drivers of pain development and opioid utilization globally. Various organizations have generated guidance on postoperative pain management, enhanced recovery strategies, multimodal analgesic and anesthetic techniques, and postoperative opioid prescribing. Still, comprehensive integration of these recommendations into standard practice at the institutional level remains elusive, and persistent postoperative pain and opioid use pose significant societal burdens. The multitude of guidance publications, many different healthcare providers involved in executing them, evolution of surgical technique, and complexities of perioperative care transitions all represent challenges to process improvement. This review seeks to summarize and integrate key recommendations into a "roadmap" for institutional adoption of perioperative analgesic and opioid optimization strategies. We present a brief review of applicable statistics and definitions as impetus for prioritizing both analgesia and opioid exposure in surgical quality improvement. We then review recommended modalities at each phase of perioperative care. We showcase the value of interprofessional collaboration in implementing and sustaining perioperative performance measures related to pain management and analgesic exposure, including those from the patient perspective. Surgery centers across the globe should adopt an integrated, collaborative approach to the twin goals of optimal pain management and opioid stewardship across the care continuum.

Pathway for enhanced recovery after spinal surgery-a systematic review of evidence for use of individual components

Background

Enhanced recovery in spinal surgery (ERSS) has shown promising improvements in clinical and economical outcomes. We have proposed an ERSS pathway based on available evidence. We aimed to delineate the clinical efficacy of individual pathway components in ERSS through a systematic narrative review.

Methods

We included systematic reviews and meta-analysis, randomized controlled trials, non-randomized controlled studies, and observational studies in adults and pediatric patients evaluating any one of the 22 pre-defined components. Our primary outcomes included all-cause mortality, morbidity outcomes (e.g., pulmonary, cardiac, renal, surgical complications), patient-reported outcomes and experiences (e.g., pain, quality of care experience), and health services outcomes (e.g., length of stay and costs). Following databases (1990 onwards) were searched: MEDLINE, EMBASE, and Cochrane Library (Cochrane Database of Systematic Reviews and CENTRAL). Two authors screened the citations, full-text articles, and extracted data. A narrative synthesis was provided. We constructed Evidence Profile (EP) tables for each component of the pathway, where appropriate information was available. Due to clinical and methodological heterogeneity, we did not conduct a meta-analyses. GRADE system was used to classify confidence in cumulative evidence for each component of the pathway.

Results

We identified 5423 relevant studies excluding duplicates as relating to the 22 pre-defined components of enhanced recovery in spinal surgery. We included 664 studies in the systematic review. We identified specific evidence within the context of spinal surgery for 14/22 proposed components. Evidence was summarized in EP tables where suitable. We performed thematic synthesis without EP for 6/22 elements. We identified appropriate societal guidelines for the remainder of the components.

Conclusions

We identified the following components with high quality of evidence as per GRADE system: pre-emptive analgesia, peri-operative blood conservation (antifibrinolytic use), surgical site preparation and antibiotic prophylaxis. There was moderate level of evidence for implementation of prehabilitation, minimally invasive surgery, multimodal perioperative analgesia, intravenous lignocaine and ketamine use as well as early mobilization. This review allows for the first formalized evidence-based unified protocol in the field of ERSS.

Further studies validating the multimodal ERSS framework are essential to guide the future evolution of care in patients undergoing spinal surgery.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12871-021-01281-1.

Efficacy of systemic lidocaine on postoperative quality of recovery and analgesia after video-assisted thoracic surgery: A randomized controlled trial

STUDY OBJECTIVE

Intraoperative systemic lidocaine has become widely accepted as an adjunct to general anesthesia, associated with opioid-sparing and enhanced recovery. We hypothesized that perioperative systemic lidocaine improves postoperative pain and enhances the quality of recovery (QoR) in patients following video-assisted thoracic surgery (VATS).

DESIGN

Prospective, single-center, double-blind, randomized placebo-controlled clinical trial.

SETTING

Single institution, tertiary university hospital.

PATIENTS

Adult patients aged 18 to 65 undergoing VATS were eligible for participation.

INTERVENTIONS

Patients enrolled in this study were randomized to receive either system lidocaine (a bolus of 1.5 mg kg^-1, followed by an infusion of 2 mg kg^-1 h^-1 until the end of the surgical procedure) or identical volumes and rates of 0.9% saline.

MEASUREMENTS

The primary outcome was a global QoR-15 score 24 h after surgery. Secondary outcomes included postoperative pain score, cumulative opioid consumption, emergence time, length of PACU stay, adverse events, and patient satisfaction.

MAIN RESULTS

There was no difference in the global QoR-15 scores at 24 h postoperatively between the lidocaine and saline groups (median 117, IQR 113.5-124, vs. median 116, IQR 111-120, P = 0.067), with a median difference of 3 (95% CI 0 to 6, P = 0.507). Similarly, postoperative pain scores, postoperative cumulative opioid consumption, PACU length of stay, the occurrence of PONV, and patient satisfaction were comparable between the two groups (all P > 0.05).

CONCLUSIONS

Our current findings do not support using perioperative systemic lidocaine as a potential strategy to improve postoperative pain and enhance QoR in patients undergoing VATS.

TRIAL REGISTRATION

Chinese Clinical Trial Registry (identifier: ChiCTR1900027515).

Superficial cervical plexus block alone or combined with interscalene brachial plexus block in surgery for clavicle fractures: a randomized clinical trial

BACKGROUND

The regional anesthesia technique which is suitable for fracture clavicle is a matter of debate. This study aimed to compare the use of superficial cervical plexus alone or in combination with interscalene block in patients undergoing internal fixation of fractured clavicle.

METHODS

Seventy patients undergoing internal fixation of fractured clavicle were enrolled in this clinical trial and randomly distributed into two groups; superficial cervical plexus block (CPB) group and combined superficial cervical plexus block and interscalene block (ISB) group. The regional anesthesia techniques were performed before induction of general anesthesia. The intraoperative fentanyl and isoflurane consumption, the postoperative morphine consumption, the postoperative pain score, the duration of postoperative analgesia, the incidence of perioperative complications, and the patient's satisfaction were recorded.

RESULTS

In comparison to the use of combined CPB and ISB, the use of CPB alone did not significantly change the postoperative morphine consumption (8.4±3.3 mg versus 7.3±3.2 mg [P=0.2]), the time to the first request of postoperative analgesia (396.7 193.4 min versus 407.7±150.0 min [P=0.8]), or the postoperative pain score (P˃0.05). Also, it did not change the intraoperative fentanyl consumption (P=0.3), the intraoperative isoflurane consumption (P=0.7), the incidence of perioperative complication, or the degree of patient's satisfaction (P˃0.05). It significantly decreased the incidence of phrenic nerve palsy (P=0.03).

CONCLUSIONS

In patients undergoing internal fixation of clavicular fracture, the perioperative analgesic effect of SCP alone is equally effective to its use in combination with ISB.

Perioperative and Anesthetic Considerations for Patients with Degenerative Spine Disease

The demand for spine surgery has dramatically increased over the last 2 decades. As the population ages and surgical and anesthetic techniques advance, the perioperative care of spine surgery patients poses challenges to anesthesiologists. Perioperative outcomes in terms of a decrease in complication rates and total health care expenditures have directed perioperative care to focus on enhanced recovery after surgery protocols, which many institutions have adopted. The role of anesthesiologists in the care of patients undergoing spine surgery is expanding beyond intraoperative care; consequently, a multidisciplinary approach is the best direction for optimal patient care.

The analgesic effect of intravenous lidocaine versus intrawound or epidural bupivacaine for postoperative opioid reduction in spine surgery: A systematic review and meta-analysis

BACKGROUND

Pain management following spine surgery remains a challenge. The significant use of opioids may lead to opioid-related adverse events. These complications can increase perioperative morbidity and rapidly expend health care resources by developing chronic pain. Although intraoperative pain control for surgery has been studied in the literature, a thorough assessment of the effect in spine surgery is rarely reported. The objective of the present study was to examine the outcomes of intraoperative intravenous lidocaine and intrawound or epidural bupivacaine use in spine surgery.

METHODS

An electronic literature search was conducted for studies on the use of lidocaine and bupivacaine in spine surgery for all years available. Only articles in English language were included. Postoperative opioid consumption, VAS score, nausea/vomiting, and length of hospital stay comprised the outcomes of interest. Pooled descriptive statistics with Risk Ratios (RR), Mean Differences (MD) and 95 % confidence interval were used to synthesize the outcomes for each medication.

RESULTS

A total of 10 studies (n = 579) were included in the analysis. Comparison of the opioid consumption revealed a significant mean difference between lidocaine and bupivacaine (MD: -12.25, and MD: -0.4, respectively, p = 0.01), favoring lidocaine. With regard to postoperative VAS, the pooled effect of both groups decreased postoperative pain (MD: -0.61 (95 % CI: -1.14, -0.08)), with a more significant effect in the lidocaine group (MD: -0.84, (95 % CI: -1.21, -0.48)). There was no significant effect in length of stay, and postoperative nausea/vomiting.

CONCLUSIONS

The results of the present meta-analysis indicate that lidocaine and bupivacaine use may decrease postoperative pain and opioid consumption. Lidocaine had a stronger effect on the reduction of opioid consumption compared to bupivacaine.

Postoperative Pain Management in Pediatric Spinal Fusion Surgery for Idiopathic Scoliosis

This article reviews and summarizes current evidence and knowledge gaps regarding postoperative analgesia after pediatric posterior spine fusion for adolescent idiopathic scoliosis, a common procedure that results in severe acute postoperative pain. Inadequate analgesia may delay recovery, cause patient dissatisfaction, and increase chronic pain risk. Despite significant adverse effects, opioids are the analgesic mainstay after scoliosis surgery. However, growing emphasis on opioid minimization and enhanced recovery has increased adoption of multimodal analgesia (MMA) regimens. While opioid adverse effects remain a concern, MMA protocols must also consider risks and benefits of adjunct medications. We discuss use of opioids via different administration routes and elaborate on the effect of MMA components on opioid/pain and recovery outcomes including upcoming regional analgesia. We also discuss risk for prolonged opioid use after surgery and chronic post-surgical pain risk in this population. Evidence supports use of neuraxial opioids at safe doses, low-dose ketorolac, and methadone for postoperative analgesia. There may be a role for low-dose ketamine in those who are opioid-tolerant or have chronic pain, but the evidence for preoperative gabapentinoids and intravenous lidocaine is currently insufficient. There is a need for further studies to evaluate pediatric-specific optimal MMA dosing regimens after scoliosis surgery. Questions remain regarding how best to prevent acute opioid tolerance, opioid-induced hyperalgesia, and chronic postsurgical pain. We anticipate that this timely update will enable clinicians to develop efficient pain regimens and provide impetus for future research to optimize recovery outcomes after spine fusion.

Effect of perioperative intravenous lidocaine for patients undergoing spine surgery: A meta-analysis and systematic review

BACKGROUND

Perioperative intravenous lidocaine has been reported to have analgesic and opioid-sparing effects in many kinds of surgery. Several studies have evaluated its use in the settings of spine surgery. The aim of the study is to examine the effect of intravenous lidocaine in patients undergoing spine surgery.

METHODS

We performed a quantitative systematic review. Databases of PubMed, Medline, Embase database and Cochrane library were investigated for eligible literatures from their establishments to June, 2019. Articles of randomized controlled trials that compared intravenous lidocaine to a control group in patients undergoing spine surgery were included. The primary outcome was postoperative pain intensity. Secondary outcomes included postoperative opioid consumption and the length of hospital stay.

RESULT

Four randomized controlled trials with 275 patients were included in the study. postoperative pain compared with control was reduced at 6 hours after surgery (WMD -0.50, 95%CI, -0.76 to -0.25, P < .001), at 24 hours after surgery (WMD -0.50, 95%CI, -0.70 to -0.29, P < .001) and at 48 hours after surgery (WMD -0.57, 95%CI, -0.96 to -0.17, P = .005). The effect of intravenous lidocaine on postoperative opioid consumption compared with control revealed a significant effect (WMD -15.36, 95%CI, -21.40 to -9.33 mg intravenous morphine equivalents, P < .001).

CONCLUSION

This quantitative analysis of randomized controlled trials demonstrated that the perioperative intravenous lidocaine was effective for reducing postoperative opioid consumption and pain in patients undergoing spine surgery. The intravenous lidocaine should be considered as an effective adjunct to improve analgesic outcomes in patients undergoing spine surgery. However, the quantity of the studies was very low, more research is needed.

Management strategies for the treatment and prevention of postoperative/postdischarge nausea and vomiting: an updated review

Postoperative nausea and vomiting (PONV) and postdischarge nausea and vomiting (PDNV) remain common and distressing complications following surgery. The routine use of opioid analgesics for perioperative pain management is a major contributing factor to both PONV and PDNV after surgery. PONV and PDNV can delay discharge from the hospital or surgicenter, delay the return to normal activities of daily living after discharge home, and increase medical costs. The high incidence of PONV and PDNV has persisted despite the introduction of many new antiemetic drugs (and more aggressive use of antiemetic prophylaxis) over the last two decades as a result of growth in minimally invasive ambulatory surgery and the increased emphasis on earlier mobilization and discharge after both minor and major surgical procedures (e.g. enhanced recovery protocols). Pharmacologic management of PONV should be tailored to the patient’s risk level using the validated PONV and PDNV risk-scoring systems to encourage cost-effective practices and minimize the potential for adverse side effects due to drug interactions in the perioperative period. A combination of prophylactic antiemetic drugs with different mechanisms of action should be administered to patients with moderate to high risk of developing PONV. In addition to utilizing prophylactic antiemetic drugs, the management of perioperative pain using opioid-sparing multimodal analgesic techniques is critically important for achieving an enhanced recovery after surgery. In conclusion, the utilization of strategies to reduce the baseline risk of PONV (e.g. adequate hydration and the use of nonpharmacologic antiemetic and opioid-sparing analgesic techniques) and implementing multimodal antiemetic and analgesic regimens will reduce the likelihood of patients developing PONV and PDNV after surgery.

Neuroanesthesia Guidelines for Optimizing Transcranial Motor Evoked Potential Neuromonitoring During Deformity and Complex Spinal Surgery: A Delphi Consensus Study

STUDY DESIGN

Expert opinion-modified Delphi study.

OBJECTIVE

We used a modified Delphi approach to obtain consensus among leading spinal deformity surgeons and their neuroanesthesiology teams regarding optimal practices for obtaining reliable motor evoked potential (MEP) signals.

SUMMARY OF BACKGROUND DATA

Intraoperative neurophysiological monitoring of transcranial MEPs provides the best method for assessing spinal cord integrity during complex spinal surgeries. MEPs are affected by pharmacological and physiological parameters. It is the responsibility of the spine surgeon and neuroanesthesia team to understand how they can best maintain high-quality MEP signals throughout surgery. Nevertheless, varying approaches to neuroanesthesia are seen in clinical practice.

METHODS

We identified 19 international expert spinal deformity treatment teams. A modified Delphi process with two rounds of surveying was performed. Greater than 50% agreement on the final statements was considered "agreement"; >75% agreement was considered "consensus."

RESULTS

Anesthesia regimens and protocols were obtained from the expert centers. There was a large amount of variability among centers. Two rounds of consensus surveying were performed, and all centers participated in both rounds of surveying. Consensus was obtained for 12 of 15 statements, and majority agreement was obtained for two of the remaining statements. Total intravenous anesthesia was identified as the preferred method of maintenance, with few centers allowing for low mean alveolar concentration of inhaled anesthetic. Most centers advocated for <150 μg/kg/min of propofol with titration to the lowest dose that maintains appropriate anesthesia depth based on awareness monitoring. Use of adjuvant intravenous anesthetics, including ketamine, low-dose dexmedetomidine, and lidocaine, may help to reduce propofol requirements without negatively effecting MEP signals.

CONCLUSION

Spine surgeons and neuroanesthesia teams should be familiar with methods for optimizing MEPs during deformity and complex spinal cases. Although variability in practices exists, there is consensus among international spinal deformity treatment centers regarding best practices.

LEVEL OF EVIDENCE

5.

Opioid Alternatives in Spine Surgery: A Narrative Review

Adequate analgesia is known to improve outcomes after spine surgery. Despite recent attention highlighting the negative effects of narcotics and their addiction potential, opioids have been the mainstay of management for providing analgesia following spine surgeries. However, side effects including hyperalgesia, tolerance, and subsequent dependence restrict the generous usage of opioids. Multimodal analgesia regimens acting through different mechanisms offer significant opioid sparing and minimize the side effects of individual drugs. Hence, they are being increasingly incorporated into enhanced recovery protocols. Multimodal analgesia includes drugs such as N-methyl-D-aspartate antagonists, nonsteroidal anti-inflammatory drugs and membrane-stabilizing agents, neuraxial opioids, local anesthetic infiltration, and fascial compartment blocks. Analgesia started before the painful stimulus, termed preemptive analgesia, facilitates subsequent pain management. Both nonsteroidal anti-inflammatory drugs and neuraxial analgesia have been conclusively shown to reduce opioid requirements after spine surgery, and there is a resurgence of interest in the use of low-dose ketamine or methadone. Neuraxial narcotics offer enhanced analgesia for a longer duration with lower dosage and side effect profiles compared with systemic opioid administration. Fascial compartment blocks are increasingly used as they provide effective analgesia with fewer adverse effects. In this narrative review, we will discuss multimodality analgesic regimens incorporating opioid-sparing adjuvants to manage pain after spine surgery.

Lidocaine as an element of multimodal analgesic therapy in major spine surgical procedures in children: a prospective, randomized, double-blind study

Background

Introducing the principles of multimodal analgesic therapy is necessary to provide appropriate comfort for the patient after surgery. The main objective of the study was evaluating the influence of perioperative intravenous (i.v.) lidocaine infusion on postoperative morphine requirements during the first 48 h postoperatively in children undergoing major spine surgery.

Materials and methods

Prospective, randomized, double-blind study: 41 children, qualified to multilevel spine surgery, were randomly divided into two treatment groups: lidocaine and placebo (control). The lidocaine group received lidocaine as a bolus of 1.5 mg/kg over 30 minutes, followed by a continuous infusion at 1 mg/kg/h to 6 hours after surgery. The protocol of perioperative management was identical for all patients. Measurements: morphine demand, intensity of postoperative pain (the Numerical Rating Scale), oral feeding initiation time, first attempts at assuming erect position, postoperative quality of life (the Acute Short-form /SF-12/ health survey).

Results

Patient data did not differ demographically. Compared to the control group, lidocaine treatment reduced the demand for morphine during the first 24h [95% CI 0.13 (0.11-0.28) mg/kg, p = 0.0122], 48h [95% CI 0.46 (0.22-0.52) mg/kg, p = 0.0299] after surgery and entire hospitalization [95% CI 0.58 (0.19-0.78) mg/kg, p = 0.04]; postoperative pain intensity; nutritional withdrawal period [introduction of liquid diet (p = 0.024) and solid diet (p = 0.012)], and accelerated the adoption of an upright position [sitting (p = 0.048); walking (p = 0.049)]. The SF-12 generic health survey did not differ between groups before operation, 2 months and 4 years after surgery.

Conclusions

Perioperative lidocaine administration, as a part of the applied analgesic therapy regimen, may decrease postoperative opioid demand and accelerates convalescence of children undergoing major surgery.

A prospective randomized double-blind trial of the efficacy of a bilateral lumbar erector spinae block on the 24h morphine consumption after posterior lumbar inter-body fusion surgery

BACKGROUND

Spine surgery is associated with considerable postoperative pain and can be challenging to treat. A loco-regional technique suitable for spine surgery should cover the dorsal root of the spinal nerves at the levels where surgery is performed. The erector spinae block is a loco-regional technique with promising results and was recently described at the thoracic level. There are no randomized trials of this technique on a lumbar level. This study tests the hypothesis that the 24-h postoperative morphine consumption is significantly lower in patients undergoing posterior lumbar inter-body fusion surgery with a lumbar erector spinae (LUMBES) block when compared with a sham block.

METHODS

This prospective randomized double-blind multicenter study will randomly allocate 80 adult patients undergoing elective posterior lumbar inter-body fusion surgery during general anesthesia to one of two groups as follows: (1) bilateral erector spinae block (20 mL 0.25% levobupivacaine) or (2) bilateral sham block (20 mL NaCl 0.9%). Our primary endpoint is 24-h postoperative morphine consumption. Secondary endpoints include 72-h morphine consumption, intraoperative sufentanil dosage, postoperative pain scores at regular time intervals both at rest and during movement, time to first postoperative mobilization, and the Quality of Recovery 40 survey score.

DISCUSSION

The LUMBES trial is a pragmatic clinical study that will provide evidence of whether a bilateral lumbar erector spinae block is effective in reducing 24-h postoperative morphine consumption in patients undergoing lumbar inter-body fusion surgery. If this hypothesis is confirmed, this finding could contribute to more widespread implementation of this technique.

TRIAL REGISTRATION

Local ethics committee B300201837508, ClinicalTrials.gov identifier: NCT03825198 . Registered on 31 Jan 2019.

Adjuvant analgesics in spinal surgery

Peri- and postoperative pain control can present a challenge to any doctor, particularly in the setting of spinal surgery. The use of adjuvant pain agents and multimodal analgesia is changing the face of modern anaesthesia and offering clinicians more avenues to control perioperative pain. This article discusses the use of adjuvant medications and some of the evidence surrounding their use in spinal surgery.

Continuous intravenous perioperative lidocaine infusion for postoperative pain and recovery in adults

BACKGROUND

The management of postoperative pain and recovery is still unsatisfactory in a number of cases in clinical practice. Opioids used for postoperative analgesia are frequently associated with adverse effects, including nausea and constipation, preventing smooth postoperative recovery. Not all patients are suitable for, and benefit from, epidural analgesia that is used to improve postoperative recovery. The non-opioid, lidocaine, was investigated in several studies for its use in multimodal management strategies to reduce postoperative pain and enhance recovery. This review was published in 2015 and updated in January 2017.

OBJECTIVES

To assess the effects (benefits and risks) of perioperative intravenous (IV) lidocaine infusion compared to placebo/no treatment or compared to epidural analgesia on postoperative pain and recovery in adults undergoing various surgical procedures.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL, and reference lists of articles in January 2017. We searched one trial registry contacted researchers in the field, and handsearched journals and congress proceedings. We updated this search in February 2018, but have not yet incorporated these results into the review.

SELECTION CRITERIA

We included randomized controlled trials comparing the effect of continuous perioperative IV lidocaine infusion either with placebo, or no treatment, or with thoracic epidural analgesia (TEA) in adults undergoing elective or urgent surgery under general anaesthesia. The IV lidocaine infusion must have been started intraoperatively, prior to incision, and continued at least until the end of surgery.

DATA COLLECTION AND ANALYSIS

We used Cochrane's standard methodological procedures. Our primary outcomes were: pain score at rest; gastrointestinal recovery and adverse events. Secondary outcomes included: postoperative nausea and postoperative opioid consumption. We used GRADE to assess the quality of evidence for each outcome.

MAIN RESULTS

We included 23 new trials in the update. In total, the review included 68 trials (4525 randomized participants). Two trials compared IV lidocaine with TEA. In all remaining trials, placebo or no treatment was used as a comparator. Trials involved participants undergoing open abdominal (22), laparoscopic abdominal (20), or various other surgical procedures (26). The application scheme of systemic lidocaine strongly varies between the studies related to both dose (1 mg/kg/h to 5 mg/kg/h) and termination of the infusion (from the end of surgery until several days after).The risk of bias was low with respect to selection bias (random sequence generation), performance bias, attrition bias, and detection bias in more than 50% of the included studies. For allocation concealment and selective reporting, the quality assessment yielded low risk of bias for only approximately 20% of the included studies.IV Lidocaine compared to placebo or no treatment We are uncertain whether IV lidocaine improves postoperative pain compared to placebo or no treatment at early time points (1 to 4 hours) (standardized mean difference (SMD) -0.50, 95% confidence interval (CI) -0.72 to -0.28; 29 studies, 1656 participants; very low-quality evidence) after surgery. Due to variation in the standard deviation (SD) in the studies, this would equate to an average pain reduction of between 0.37 cm and 2.48 cm on a 0 to 10 cm visual analogue scale . Assuming approximately 1 cm on a 0 to 10 cm pain scale is clinically meaningful, we ruled out a clinically relevant reduction in pain with lidocaine at intermediate (24 hours) (SMD -0.14, 95% CI -0.25 to -0.04; 33 studies, 1847 participants; moderate-quality evidence), and at late time points (48 hours) (SMD -0.11, 95% CI -0.25 to 0.04; 24 studies, 1404 participants; moderate-quality evidence). Due to variation in the SD in the studies, this would equate to an average pain reduction of between 0.10 cm to 0.48 cm at 24 hours and 0.08 cm to 0.42 cm at 48 hours. In contrast to the original review in 2015, we did not find any significant subgroup differences for different surgical procedures.We are uncertain whether lidocaine reduces the risk of ileus (risk ratio (RR) 0.37, 95% CI 0.15 to 0.87; 4 studies, 273 participants), time to first defaecation/bowel movement (mean difference (MD) -7.92 hours, 95% CI -12.71 to -3.13; 12 studies, 684 participants), risk of postoperative nausea (overall, i.e. 0 up to 72 hours) (RR 0.78, 95% CI 0.67 to 0.91; 35 studies, 1903 participants), and opioid consumption (overall) (MD -4.52 mg morphine equivalents , 95% CI -6.25 to -2.79; 40 studies, 2201 participants); quality of evidence was very low for all these outcomes.The effect of IV lidocaine on adverse effects compared to placebo treatment is uncertain, as only a small number of studies systematically analysed the occurrence of adverse effects (very low-quality evidence).IV Lidocaine compared to TEAThe effects of IV lidocaine compared with TEA are unclear (pain at 24 hours (MD 1.51, 95% CI -0.29 to 3.32; 2 studies, 102 participants), pain at 48 hours (MD 0.98, 95% CI -1.19 to 3.16; 2 studies, 102 participants), time to first bowel movement (MD -1.66, 95% CI -10.88 to 7.56; 2 studies, 102 participants); all very low-quality evidence). The risk for ileus and for postoperative nausea (overall) is also unclear, as only one small trial assessed these outcomes (very low-quality evidence). No trial assessed the outcomes, 'pain at early time points' and 'opioid consumption (overall)'. The effect of IV lidocaine on adverse effects compared to TEA is uncertain (very low-quality evidence).

AUTHORS' CONCLUSIONS

We are uncertain whether IV perioperative lidocaine, when compared to placebo or no treatment, has a beneficial impact on pain scores in the early postoperative phase, and on gastrointestinal recovery, postoperative nausea, and opioid consumption. The quality of evidence was limited due to inconsistency, imprecision, and study quality. Lidocaine probably has no clinically relevant effect on pain scores later than 24 hours. Few studies have systematically assessed the incidence of adverse effects. There is a lack of evidence about the effects of IV lidocaine compared with epidural anaesthesia in terms of the optimal dose and timing (including the duration) of the administration. We identified three ongoing studies, and 18 studies are awaiting classification; the results of the review may change when these studies are published and included in the review.

Poorly controlled postoperative pain: prevalence, consequences, and prevention

This review provides an overview of the clinical issue of poorly controlled postoperative pain and therapeutic approaches that may help to address this common unresolved health-care challenge. Postoperative pain is not adequately managed in greater than 80% of patients in the US, although rates vary depending on such factors as type of surgery performed, analgesic/anesthetic intervention used, and time elapsed after surgery. Poorly controlled acute postoperative pain is associated with increased morbidity, functional and quality-of-life impairment, delayed recovery time, prolonged duration of opioid use, and higher health-care costs. In addition, the presence and intensity of acute pain during or after surgery is predictive of the development of chronic pain. More effective analgesic/anesthetic measures in the perioperative period are needed to prevent the progression to persistent pain. Although clinical findings are inconsistent, some studies of local anesthetics and nonopioid analgesics have suggested potential benefits as preventive interventions. Conventional opioids remain the standard of care for the management of acute postoperative pain; however, the risk of opioid-related adverse events can limit optimal dosing for analgesia, leading to poorly controlled acute postoperative pain. Several new opioids have been developed that modulate μ-receptor activity by selectively engaging intracellular pathways associated with analgesia and not those associated with adverse events, creating a wider therapeutic window than unselective conventional opioids. In clinical studies, oliceridine (TRV130), a novel μ-receptor G-protein pathway-selective modulator, produced rapid postoperative analgesia with reduced prevalence of adverse events versus morphine.