Preventive skin analgesia with lidocaine patch for management of post-thoracotomy pain: Results of a randomized, double blind, placebo controlled study

Pain management after thoracic surgery or chest trauma

Accidental or surgically induced thoracic trauma is responsible for significant pain that can impact patient outcomes. One of the main objectives of its pain management is to promote effective coughing and early mobilization to reduce atelectasis and ventilation disorders induced by pulmonary contusion. The incidence of chronic pain can affect more than 35% of patients after both thoracotomy and thoracoscopy as well as after chest trauma. As the severity of acute pain is associated with the incidence of chronic pain, early and effective pain management is very important. In this narrative review, we propose to detail systemic and regional analgesia techniques to minimize postoperative pain, while reducing transitional pain, surgical stress response and opioid side effects. We provide the reader with practical recommendations based on both literature and clinical practice experience in a referral level III thoracic trauma center.

Is Lidocaine Patch Beneficial for Postoperative Pain?: A Meta-analysis of Randomized Clinical Trials

OBJECTIVES

The aim of this meta-analysis was to evaluate whether a lidocaine patch is beneficial for postoperative pain as an option for multimodal analgesia.

METHODS

Information was obtained from PubMed, Embase, and the Cochrane Central Register of Controlled Trials for clinical randomized controlled trials of lidocaine patches for postoperative pain (as of March 2022). Two researchers independently completed study screening, risk bias assessment, and data extraction. Review Manager (version 5.4, Cochrane Collaboration) was used to conduct the meta-analysis. The evaluation metrics were postoperative pain scores, opioid consumption, and patient satisfaction.

RESULTS

Sixteen randomized controlled trials were included, and data from 918 patients were available. Pain scores differed between the 2 groups at 12, 24, and 48 hours postoperatively, and the pain scores of the lidocaine patch group were significantly lower (mean difference [MD]=-1.32 [95% CI, -1.96 to -0.68], P <0.0001; I2 =92%) at 12 hours after the operation; (MD=-1.23 [95% CI, -1.72 to -0.75], P <0.00001; I2 =92%) at 24 hours after the operation; and (MD=-0.25 [95% CI,-0.29 to -0.21], P <0.00001; I2 =98%) at 48 hours after the operation. In addition, the lidocaine patch group had decreased opioid requirements (MD=-3.57 [95% CI, -5.06 to -2.09], P <0.00001; I2 =96%). The lidocaine patch group seemed to be more satisfied, but there was no statistically significant difference (risk ratio, 1.50 [95% CI, 0.74 to 3.05], P =0.26) between the groups.

DISCUSSION

Lidocaine patches are beneficial for postoperative pain and can be used in multimodal analgesia to reduce opioid use, but there is no significant increase in patient satisfaction with pain control. More data are needed to support this conclusion due to the large heterogeneity in the present study.

Placebo-controlled randomized double-blind comparison of the analgesic efficacy of lidocaine spray and etofenamate spray in pain control of rib fractures

BACKGROUND

As far as we could detect, we could not find any study in literature on the analgesic efficacy of spray forms of lidocaine and etofenamate in rib fractures. In this study, our aim is to empirically compare the analgesic efficacy of etofenamate spray, lidocaine 10% spray and placebo spray in the management of pain secondary to trauma secondary to isolated rib fractures.

METHODS

The study was designed according to a single-center, prospective, randomized, placebo-controlled double-blind study model. About 30 sealed envelopes were prepared for each of the 3 groups and 30 patients were included in each group. A total of 84 cases were included in the study (three groups: 27, 28, 29).

RESULTS

Numeric rating scale (NRS) grades at admission and at 15-30-60-120 min were similar between the three groups (P>0.05). Analysis findings of NRS perception differences between the initial NRS level and the 15-30-60-120th min NRS difference at the 0-120th min showed more lidocaine spray organs, and it was not clearly perceived that these four parameters went between the 3 groups for the outline.

CONCLUSION

The analgesic efficacy of lidocaine 10% spray, etofenamate spray, and placebo spray used together with standard dexketoprofen 50 mg intravenous treatment in the pain management of rib fractures were similar to each other and although there was a difference at the 120th min, this difference was not statistically significant.

Efficacy and Safety of Lidocaine Patch in the Management of Acute Postoperative Wound Pain: A Comprehensive Systematic Review and Meta-analysis of Randomized Controlled Trials

OBJECTIVE

This study sought to quantify the pooled effects of lidocaine patch (LP) on postoperative pain and side-effects through a comprehensive review and meta-analysis.

APPROACH

The study followed PRISMA, AMSTAR and the Cochrane Collaboration. Randomized controlled trials s comparing LP with placebo were retrieved from five electronic databases. Primary outcome in the study was cumulative intravenous morphine equivalent consumption (mg) within 24 hours postoperatively.

RESULTS

Twelve trials comprising 617 patients were included in the final analysis. Primary result indicated that the analgesic effects LP were only statistical but not clinically significant of postoperative intravenous morphine consumption within 24 hours (mean difference, -4.61 mg; 95% CI, -8.09, -1.14). Interestingly, the results of subgroup and meta-regression analysis indicated that preoperative administration of LP had potential advantages in postoperative wound pain management. It is also worthwhile to mention that LP provided a clinically important benefit in rest pain scores within 24-hour postoperatively. Apart from these, other secondary outcome analysis did not uncover any particularly significant analgesic or safety advantages to LP. Finally, LP also does not increase the risk of any local anesthetic-related side effects.

INNOVATION

This systematic review and meta-analysis provides moderate-to-high quality evidence undermining the role of LP for management of acute postoperative wound pain following surgical procedures and the justification for the associated extra costs.

CONCLUSION

Taken together, the current evidence does not support LP as part of a routine multimodal analgesia strategy to alleviate early postoperative acute pain. However, further studies should explore the clinical value of preoperative administration and the long-term effect of LP.

Comparative Study of the Effect of Lidocaine Spray and Ice Spray on the Pain Intensity During Intramuscular Injection: A Randomized Clinical Trial

BACKGROUND

Intramuscular injection is one of the most common, invasive, and painful ways to deliver medicine to the body.

AIM

Since one of the nurse's duties is to employ different methods to reduce pain caused by treatment procedures, this study was conducted to determine the effect of lidocaine spray and ice spray on pain intensity at the muscle injection site.

METHOD

A clinical trial was performed on 90 patients presenting to outpatient clinics of Neyshabur hospitals. The samples were selected using a computerized table of random numbers, and each participant was randomly assigned to one of the control, lidocaine spray, and ice spray groups. Pain severity was measured immediately after intramuscular injection using a numerical pain scale. Descriptive statistics along with statistical tests (chi-square, Fisher, etc.) were used to analyze the data in the R environment version 3.6.2. Ordinal logistic regression was used to compare pain intensity in the three groups by adjusting the effect of age variables and sensory disorders.

RESULTS

The mean pain intensity was 3.44 without intervention, 2.63 with lidocaine spray, and 2.27 with ice spray. Statistical tests indicated a significant difference in pain intensity of intramuscular injection between the ice group and the control group (p = .010). Although lidocaine spray reduced the pain intensity, its effect was insignificant compared with the control group.

CONCLUSIONS

Both ice and lidocaine spray can be effectively used to reduce the intensity of intramuscular injection pain; however, it seems that ice spray is a more effective, safe, and affordable method.

Regional anesthesia and acute perioperative pain management in thoracic surgery: a narrative review

Background and Objective

Thoracic surgery causes significant pain which can negatively affect pulmonary function and increase risk of postoperative complications. Effective analgesia is important to reduce splinting and atelectasis. Systemic opioids and thoracic epidural analgesia (TEA) have been used for decades and are effective at treating acute post-thoracotomy pain, although both have risks and adverse effects. The advancement of thoracoscopic surgery, a focus on multimodal and opioid-sparing analgesics, and the development of ultrasound-guided regional anesthesia techniques have greatly expanded the options for acute pain management after thoracic surgery. Despite the expansion of surgical techniques and analgesic approaches, there is no clear optimal approach to pain management. This review aims to summarize the body of literature regarding systemic and regional anesthetic techniques for thoracic surgery in both thoracotomy and minimally invasive approaches, with a goal of providing a foundation for providers to make individualized decisions for patients depending on surgical approach and patient factors, and to discuss avenues for future research.

Methods

We searched PubMed and Google Scholar databases from inception to May 2021 using the terms “thoracic surgery”, “thoracic surgery AND pain management”, “thoracic surgery AND analgesia”, “thoracic surgery AND regional anesthesia”, “thoracic surgery AND epidural”. We considered articles written in English and available to the reader.

Key Content and Findings

There is a wide variety of strategies for treating acute pain after thoracic surgery, including multimodal opioid and non-opioid systemic analgesics, regional anesthesia including TEA and paravertebral blocks (PVB), and a recent expansion in the use of novel fascial plane blocks especially for thoracoscopy. The body of literature on the effectiveness of different approaches for thoracotomy and thoracoscopy is a rapidly expanding field and area of active debate.

Conclusions

The optimal analgesic approach for thoracic surgery may depend on patient factors, surgical factors, and institutional factors. Although TEA may provide optimal analgesia after thoracotomy, PVB and emerging fascial plane blocks may offer effective alternatives. A tailored approach using multimodal systemic therapies and regional anesthesia is important, and future studies comparing techniques are necessary to further investigate the optimal approach to improve patient outcomes.

Pharmacologic Management of Persistent Pain in Cancer Survivors

Improvements in screening, diagnosis and treatment of cancer has seen cancer mortality substantially diminish in the past three decades. It is estimated there are almost 20 million cancer survivors in the USA alone, but some 40% live with chronic pain after completing treatment. While a broad definition of survivorship that includes all people living with, through and beyond a cancer diagnosis—including those with active cancer—is often used, this narrative review primarily focuses on the management of pain in people who are disease-free after completing primary cancer treatment as adults. Chronic pain in this population needs a different approach to that used for people with a limited prognosis. After describing the common chronic pain syndromes caused by cancer treatment, and the pathophysiologic mechanisms involved, the pharmacologic management of entities such as post-surgical pain, chemotherapy-induced neuropathy, aromatase inhibitor musculoskeletal syndrome and checkpoint inhibitor-related pain are described. The challenges  associated with opioid prescribing in this population are given special attention. Expert guidelines on pain management in cancer survivors now recommend a combination of pharmacologic and non-pharmacologic modalities, and these are also briefly covered.

Neuropathic agents in the management of pruritus in burn injuries: a systematic review and meta-analysis

Objectives

Pruritus is a common and often distressing complication after a burn injury. The purpose of this review is to explore the efficacy of drugs classically used to treat neuropathic pain in the management of pruritus after burn injury.

Methods

A systematic literature search of medical databases was conducted to find studies investigating drugs listed in the National Institute for Health and Care Excellence (NICE) guideline (CG173, "neuropathic pain in adults") for the management of pruritus after burn injury in patients of any age. Controlled studies were stratified by the drug class studied and their risk of bias before conducting meta-analysis. A narrative review of case series or observational studies was presented. Severity of pruritus at any time point, with all quantitative and qualitative measures, was included.

Results

Fifteen studies were included in the final analysis, 10 investigated the use of gabapentinoids, 4 studied doxepin, and 1 local anesthetic agents. Meta-analysis of three randomized controlled trials (RCTs) demonstrated that the use of gabapentinoids was associated with an improvement in mean VAS (Visual Analog Scale) 0-10 scores of 2.96 (95% confidence interval (95% CI) 1.20 to 4.73, p<0.001) when compared with placebo or antihistamine. A meta-analysis of four RCTs investigating topical doxepin showed an improvement in mean VAS scores of 1.82 (95% CI 0.55 to 3.09, p<0.001). However, when excluding two studies found to be at high risk of bias, no such improvement was found (-0.32, 95% CI -1.64 to -0.99, p=0.83).

Conclusion

This study suggests that gabapentinoids are beneficial in the management of burn-related pruritus. There is a lack of evidence to suggest that doxepin is an effective treatment. Topical local anesthetic agents may be safe and beneficial, but studies are scarce.

Level of evidence

Systematic review, level II.

Working towards an ERAS Protocol for Pancreatic Transplantation: A Narrative Review

Enhanced recovery after surgery (ERAS) initially started in the early 2000s as a series of protocols to improve the perioperative care of surgical patients. They aimed to increase patient satisfaction while reducing postoperative complications and postoperative length of stay. Despite these protocols being widely adopted in many fields of surgery, they are yet to be adopted in pancreatic transplantation: a high-risk surgery with often prolonged length of postoperative stay and high rate of complications. We have analysed the literature in pancreatic and transplantation surgery to identify the necessary preoperative, intra-operative and postoperative components of an ERAS pathway in pancreas transplantation.

Subxifoid versus transthoracic thoracoscopic lobectomy: Results of a retrospective analysis before and after matching analysis

Background

Here, we report our initial experience with subxifoid video‐assisted thoracoscopic surgery (SVATS) lobectomy for the management of primary lung cancer, and compared the outcomes of SVATS with those of conventional transthoracic VATS (CVATS) lobectomies to validate its feasibility and usefulness.

Methods

The clinical data of consecutive patients undergoing VATS lobectomy via SVATS or CVATS for lung cancer were retrospectively compared. The endpoints were to evaluate the statistical differences in surgical results, postoperative pain (measured with visual analog scale [VAS] scores at 8 hours, Day 1, Day 2, Day 3, at discharge, one month and three months after surgery) and paresthesia (measured at one‐ month, and three months after surgery). The two groups were compared before and after matching analysis.

Results

Our study population included 223 patients: 84 in the SVATS and 139 in the CVATS group. The two groups were not comparable for sex (P = 0.001), preoperative comorbidity as cardiopathy (P = 0.007), BMI value (P = 0.003), left‐sided procedure (P = 0.04), tumor stage (P = 0.04), and tumor size (P = 0.002). These differences were overcome by propensity score matching (PSM) analysis that yielded two well‐matched groups which included 61 patients in each group. Surgical outcomes including blood loss, hospital stay and complications were similar before and after matching analysis, but SVATS compared to CVATS was associated with longer operative time before (159 ± 13 vs. 126 ± 6.3, P < 0.0001), and after matching analysis (161 ± 23 vs. 119 ± 8.3; P < 0.0001) and significant reduction of postoperative pain during the different time‐points (P < 0.001), and paresthesia at one (P = 0.001), and three months (P < 0.0001).

Conclusions

SVATS lobectomy is a feasible and safe strategy with surgical outcomes similar to CVATS lobectomy but with less postoperative pain and paresthesia.

Key points

Significant findings of the study

Subxifoid thoracoscopic lobectomy is a feasible and safe procedure, with potential benefits in terms of postoperative pain and paresthesia compared to conventional thoracoscopic lobectomy

Our results showed that surgical outcomes including blood loss, hospital stay, morbidity and mortality are similar but subxifoid thoracoscopy was associated with significant reduction of postoperative pain and paresthesia.

What this study adds

Subxifoid thoracoscopy is a safe procedure; compared to conventional transthoracic thoracoscopy, it avoids intercostal incisions, and spares nerve trauma, resulting in a reduction of postoperative pain and paresthesia.

Does the length of uniportal video-assisted thoracoscopic lobectomy affect postoperative pain? Results of a randomized controlled trial

BACKGROUND

Uniportal video-assisted thoracoscopic surgery (VATS) lobectomy has become a common approach for the treatment of early stage lung cancer. Here, we aimed to establish whether the length of uniportal incision could affect postoperative pain and surgical outcomes in consecutive patients undergoing uniportal VATS lobectomy for early stage lung cancer.

METHODS

This was a unicenter Randomized Control Trial (NCT03218098). Consecutive patients undergoing uniportal VATS lobectomy for Stage I lung cancer were randomly assigned to a Small Incision group or Long Incision group in 1:1 ratio based on whether patients received a 4 cm or 8 cm incision. The endpoints were to compare the intergroup difference regarding (i) postoperative pain measured by brief pain inventory (BPI) questionnaire (first endpoint); (ii) operative time; (iii) length of chest drainage; (iv) length of hospital stay; (v) postoperative complications; and (vi) pulmonary functional status (secondary endpoints).

RESULTS

A total of 48 patients were eligible for the study. Four patients were excluded; the study population included 44 patients: 23 within the Small Incision group, and 21 within the Long Incision group. The 11 BPI scores between the two groups showed no significant difference. Small Incision group presented higher operative time than Long Incision group (138.69 vs. 112.14 minutes; P = 0.0001) while no significant differences were found regarding length of hospital stay (P = 0.95); respiratory complications (P = 0.92); FEV1% (P = 0.63), and 6-Minute Walking Test (P = 0.77).

CONCLUSIONS

A larger incision for uniportal VATS lobectomy significantly reduced the operative time due to better exposure of the anatomical structures without increasing postoperative pain or affecting the surgical outcome.

KEY POINTS

A larger incision for uniportal VATS lobectomy significantly reduced the operative time due to better exposure of the anatomical structures without increasing postoperative pain or affecting the surgical outcome. To perform a larger incision could be a valuable strategy, particularly in nonexpert hands or when the patient's anatomy or tumor size make exposure of anatomic structures through smaller incisions difficult.