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Bugada D, Compagnone C, Bettinelli S, Grimaldi S, DE Gregori M, Muscoli C, Berretta R, Cobianchi L, Peloso A, Lorini L, Lavand'homme P, Allegri M. Prolonged continuous wound infusion of local anesthetic and steroid after major abdominal surgery to reduce opioid consumption: a randomized, double-blind trial. Minerva Anestesiol 2023; 89:625-635. [PMID: 37194239 DOI: 10.23736/s0375-9393.23.16547-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Abstract
BACKGROUND Continuous wound infusion (CWI) is effective for post-operative pain management, but the effect of prolonged infusions and the use of steroids in the infused mixture have never been addressed. We investigate the effect of prolonged CWI with ropivacaine 0.2% (R) over seven days and methylprednisolone (Mp) 1 mg/kg infused in the wound in the first 24 hours. METHODS This is a randomized, double blind, phase III trial (RCT) in major abdominal surgery with laparotomy. After a 24-hours pre-peritoneal CWI of R-Mp, patients were randomized to receive either R-Mp or placebo for the next 24 hours. Then, patient-controlled CWI with only ropivacaine 0.2% or placebo (according to the randomization group) was planned between 48 hours and seven days after surgery. Morphine equivalents at seven days were analyzed, together with any catheter- or drug-related side effect and PPSP at 3 months. RESULTS We enrolled 120 patients (63 in the CWI group, 57 in the placebo group). Prolonged CWI did not reduce opioid consumption in the first seven postoperative days (P=0.08). CWI was associated with reduced consumption of non-opioid analgesics (P=0.03). Most of the patients continued to require bolus in the surgical wound beyond 48 hours. PPSP prevalence was not different between groups. CONCLUSIONS Prolonged infusion with R-Mp is safe and effective but did not reduce opioid consumption in the seven days after surgery or PPSP prevalence.
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Affiliation(s)
- Dario Bugada
- Department of Emergency and Critical Care Medicine, ASST Papa Giovanni XXIII, Bergamo, Italy -
| | - Christian Compagnone
- Service of Anesthesia, Intensive Care and Pain Therapy, University Hospital of Parma, Parma, Italy
| | - Silvia Bettinelli
- Department of Emergency and Critical Care Medicine, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Stefania Grimaldi
- Department of Anesthesia and Intensive Care Medicine, Humanitas Clinical and Research Center IRCCS, Rozzano, Milan, Italy
| | - Manuela DE Gregori
- Clinical and Experimental Pharmacokinetics Unit, San Matteo IRCCS Foundation, Pavia, Italy
| | - Carolina Muscoli
- Institute of Research for Food Safety & Health (IRC-FSH), Department of Health Science, Magna Graecia University, Catanzaro, Italy
| | - Roberto Berretta
- Department of Gynecology and Obstetrics, University of Parma, Parma, Italy
| | - Lorenzo Cobianchi
- Department of General Surgery, San Matteo IRCCS Foundation, Pavia, Italy
- Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Andrea Peloso
- Department of General Surgery and Transplantation, University Hospital of Geneva, University of Geneva, Geneva, Switzerland
| | - Luca Lorini
- Department of Emergency and Critical Care Medicine, ASST Papa Giovanni XXIII, Bergamo, Italy
| | | | - Massimo Allegri
- Pain Therapy Service, Policlinico di Monza Hospital, Monza, Monza-Brianza, Italy
- Centre Lemanique d'antalgie et neuromodulation, Ensemble Hospitalier de la Côte, Morges, Switzerland
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Parisien M, van Reij RRI, Khoury S, Koseli E, Karaky M, van den Hoogen NJ, Peng G, Allegri M, de Gregori M, Chelly JE, Rakel BA, Aasvang EK, Kehlet H, Buhre WFFA, Bryant CD, Damaj MI, King IL, Mogil JS, Joosten EAJ, Diatchenko L. Genome-wide association study suggests a critical contribution of the adaptive immune system to chronic post-surgical pain. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.01.24.23284520. [PMID: 36945481 PMCID: PMC10029026 DOI: 10.1101/2023.01.24.23284520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Chronic post-surgical pain affects a large proportion of people undergoing surgery, delaying recovery time and worsening quality of life. Although many environmental variables have been established as risk factors, less is known about genetic risk. To uncover genetic risk factors we performed genome-wide association studies in post-surgical cohorts of five surgery types- hysterectomy, mastectomy, abdominal, hernia, and knee- totaling 1350 individuals. Genetic associations between post-surgical chronic pain levels on a numeric rating scale (NRS) and additive genetic effects at common SNPs were evaluated. We observed genome-wide significant hits in almost all cohorts that displayed significance at the SNP, gene, and pathway levels. The cohorts were then combined via a GWAS meta-analysis framework for further analyses. Using partitioned heritability, we found that loci at genes specifically expressed in the immune system carried enriched heritability, especially genes related to B and T cells. The relevance of B cells in particular was then demonstrated in mouse postoperative pain assays. Taken altogether, our results suggest a role for the adaptive immune system in chronic post-surgical pain.
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van Reij RRI, Voncken JW, Joosten EAJ, van den Hoogen NJ. Polygenic risk scores indicates genetic overlap between peripheral pain syndromes and chronic postsurgical pain. Neurogenetics 2020; 21:205-215. [PMID: 32377986 PMCID: PMC7283206 DOI: 10.1007/s10048-020-00614-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 04/21/2020] [Indexed: 02/08/2023]
Abstract
Chronic postsurgical pain (CPSP) is a debilitating chronic pain condition that has a substantial effect on quality of life. CPSP shows considerable clinical overlap with different chronic peripheral pain syndromes, suggesting a shared aetiology. This study aims to assess the genetic overlap between different chronic pain syndromes and CPSP, providing relevant biological context for potential chronic pain markers of CPSP. To analyse the genetic overlap between CPSP and chronic peripheral pain syndromes, recent GWAS studies were combined for polygenic risk scores (PRS) analysis, using a cohort of CPSP patients as starting point. Biological contextualisation of genetic marker, overlap between CPSP and chronic pain syndromes, was assessed through Gene Ontology (GO), using Pathway Scoring Algorithm (PASCAL) and REVIGO. PRS analyses suggest a significant genetic overlap between CPSP and 3 chronic pain disorders: chronic widespread pain (CWP, p value threshold = 0.003, R2 0.06, p = 0.003), rheumatoid arthritis (RA, p value threshold = 0.0177, R2 = 0.04, p = 0.017) and possibly sciatica (p value threshold = 0.00025, R2 = 0.03, p = 0.045). Whereas no significant genetic overlap was found with cluster headache and migraine, the outcome for osteoarthritis (OA) was inconsistent between the cohorts. This is likely related to cohort composition, as repeated random reallocation of patients' nullified CPSP/OA outcome variation between the discovery and replication cohorts. GO analyses suggested an aetiological involvement of genetic markers that control neurological signalling (specifically sodium channels) and inflammatory response. The current study reaffirms the impact of sample size, cohort composition and open data accessibility on the unbiased identification of genetic overlap across disorders. In conclusion, this study is the first to report genetic overlap between regulatory processes implicated in CPSP and chronic peripheral pain syndromes. Interaction between neurological signalling and inflammatory response may explain the genetic overlap between CPSP, CWP and RA. Enhanced understanding of mechanisms underlying chronification of pain will aid the development of new therapeutic strategies for CPSP with sodium channel biochemistry as a potential candidate.
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Affiliation(s)
- Roel R I van Reij
- Department of Anaesthesiology and Pain Management, Maastricht University Medical Center+, 6200, MD, Maastricht, The Netherlands.
- Department of Translational Neuroscience, School for Mental Health and Neuroscience (MHeNs), University of Maastricht, 6200, MD, Maastricht, The Netherlands.
| | - Jan Willem Voncken
- Department of Molecular Genetics, Maastricht University Medical Center+, 6200, MD, Maastricht, The Netherlands
| | - Elbert A J Joosten
- Department of Anaesthesiology and Pain Management, Maastricht University Medical Center+, 6200, MD, Maastricht, The Netherlands
- Department of Translational Neuroscience, School for Mental Health and Neuroscience (MHeNs), University of Maastricht, 6200, MD, Maastricht, The Netherlands
| | - Nynke J van den Hoogen
- Department of Anaesthesiology and Pain Management, Maastricht University Medical Center+, 6200, MD, Maastricht, The Netherlands
- Department of Translational Neuroscience, School for Mental Health and Neuroscience (MHeNs), University of Maastricht, 6200, MD, Maastricht, The Netherlands
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4
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van Reij RRI, Hoofwijk DMN, Rutten BPF, Weinhold L, Leber M, Joosten EAJ, Ramirez A, van den Hoogen NJ. The association between genome-wide polymorphisms and chronic postoperative pain: a prospective observational study. Anaesthesia 2020; 75 Suppl 1:e111-e120. [PMID: 31903573 PMCID: PMC6973279 DOI: 10.1111/anae.14832] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/17/2019] [Indexed: 12/19/2022]
Abstract
Chronic postoperative pain is common and can have a negative impact on quality of life. Recent studies show that genetic risk factors are likely to play a role, although only gene‐targeted analysis has been used to date. This is the first genome‐wide association study to identify single‐nucleotide polymorphisms associated with the development of chronic postoperative pain based on two independent cohorts. In a discovery cohort, 330 women scheduled for hysterectomy were genotyped. A case–control association analysis compared patients without chronic postoperative pain and the 34 who had severe chronic postoperative pain 3 months after surgery. No single‐nucleotide polymorphisms reached genome‐wide significance, but several showed suggestive associations with chronic postoperative pain (p < 1 × 10−5). Single‐nucleotide polymorphisms with significance p < 1 × 10−5 were followed up in a replication cohort consisting of 203 men and women scheduled for orthopaedic or abdominal surgery. Ten of these patients developed severe chronic postoperative pain. A single‐nucleotide polymorphism in NAV3 was significantly replicated with chronic postoperative pain in the replication cohort (p = 0.009). Meta‐analysis revealed that two loci (IQGAP1 and CRTC3) were significantly associated with chronic postoperative pain at 3 months (IQGAP1 p = 3.93 × 10−6 β = 2.3863, CRTC3 p = 2.26 × 10−6, β = 2.4209). The present genome‐wide association study provides initial evidence for genetic risk factors of chronic postoperative pain and supports follow‐up studies.
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Affiliation(s)
- R R I van Reij
- Department of Anaesthesiology and Pain Management, Maastricht University Medical Center, Maastricht, the Netherlands
| | - D M N Hoofwijk
- School for Mental Health and Neuroscience, Faculty of Health, Medicine and Life Sciences, University of Maastricht, the Netherlands
| | - B P F Rutten
- Department of Psychiatry and Neuropsychology, Faculty of Health, Medicine and Life Sciences, University of Maastricht, the Netherlands
| | - L Weinhold
- Department of Medical Biometry, Informatics and Epidemiology, University Hospital Bonn, Germany
| | - M Leber
- Department of Psychiatry and Psychotherapy, University of Cologne, Germany
| | - E A J Joosten
- Department of Anaesthesiology and Pain Management, Maastricht University Medical Center, Maastricht, the Netherlands
| | - A Ramirez
- Department of Psychiatry and Psychotherapy, University of Bonn, Germany
| | - N J van den Hoogen
- Department of Anaesthesiology and Pain Management, Maastricht University Medical Center, Maastricht, the Netherlands
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Comparing human peritoneal fluid and phosphate-buffered saline for drug delivery: do we need bio-relevant media? Drug Deliv Transl Res 2018; 8:708-718. [PMID: 29582351 DOI: 10.1007/s13346-018-0513-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
An understanding of biological fluids at the site of administration is important to predict the fate of drug delivery systems in vivo. Little is known about peritoneal fluid; therefore, we have investigated this biological fluid and compared it to phosphate-buffered saline, a synthetic media commonly used for in vitro evaluation of intraperitoneal drug delivery systems. Human peritoneal fluid samples were analysed for electrolyte, protein and lipid levels. In addition, physicochemical properties were measured alongside rheological parameters. Significant inter-patient variations were observed with regard to pH (p < 0.001), buffer capacity (p < 0.05), osmolality (p < 0.001) and surface tension (p < 0.05). All the investigated physicochemical properties of peritoneal fluid differed from phosphate-buffered saline (p < 0.001). Rheological examination of peritoneal fluid demonstrated non-Newtonian shear thinning behaviour and predominantly exhibited the characteristics of an entangled network. Inter-patient and inter-day variability in the viscosity of peritoneal fluid was observed. The solubility of the local anaesthetic lidocaine in peritoneal fluid was significantly higher (p < 0.05) when compared to phosphate-buffered saline. Interestingly, the dissolution rate of lidocaine was not significantly different between the synthetic and biological media. Importantly, and with relevance to intraperitoneal drug delivery systems, the sustained release of lidocaine from a thermosensitive gel formulation occurred at a significantly faster rate into peritoneal fluid. Collectively, these data demonstrate the variation between commonly used synthetic media and human peritoneal fluid. The differences in drug release rates observed illustrate the need for bio-relevant media, which ultimately would improve in vitro-in vivo correlation.
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6
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Amodeo G, Bugada D, Franchi S, Moschetti G, Grimaldi S, Panerai A, Allegri M, Sacerdote P. Immune function after major surgical interventions: the effect of postoperative pain treatment. J Pain Res 2018; 11:1297-1305. [PMID: 30022848 PMCID: PMC6044362 DOI: 10.2147/jpr.s158230] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
INTRODUCTION Impaired immune function during the perioperative period may be associated with worse short- and long-term outcomes. Morphine is considered a major contributor to immune modulation. PATIENTS AND METHODS We performed a pilot study to investigate postoperative immune function by analyzing peripheral blood mononuclear cells' functionality and cytokine production in 16 patients undergoing major abdominal surgery. All patients were treated with intravenous (i.v.) patient-controlled analgesia with morphine and continuous wound infusion with ropivacaine+methylprednisolone for 24 hours. After 24 hours, patients were randomized into two groups, one continuing intrawound infusion and the other receiving only i.v. analgesia. We evaluated lymphoproliferation and cytokine production by peripheral blood mononuclear cells at the end of surgery and at 24 and 48 hours postoperatively. RESULTS A significant reduction in TNF-α, IL-2, IFN-γ and lymphoproliferation was observed immediately after surgery, indicating impaired cell-mediated immunity. TNF-α and IFN-γ remained suppressed up to 48 hours after surgery, while a trend to normalization was observed for IL-2 and lymphoproliferation, irrespective of the treatment group. A significant inverse correlation was present between age and morphine and between age and lymphoproliferation. No negative correlation was present between morphine and cytokine production. We did not find any differences within the two groups between 24 and 48 hours in terms of morphine consumption and immune responses. CONCLUSION A relevant depression of cell-mediated immunity is associated with major surgery and persists despite optimal analgesia. Even though morphine may participate in immunosuppression, we did not retrieve any dose-related effect.
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Affiliation(s)
- Giada Amodeo
- Department of Pharmacological and Biomolecular Sciences, University of Milano, Milano, Italy,
| | - Dario Bugada
- Study In Multidisciplinary Pain Research Group
- Department of Anesthesia and ICU, ASST Papa Giovanni XXIII, Bergamo, Italy
- Department of Anesthesia and ICU, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Silvia Franchi
- Department of Pharmacological and Biomolecular Sciences, University of Milano, Milano, Italy,
| | - Giorgia Moschetti
- Department of Pharmacological and Biomolecular Sciences, University of Milano, Milano, Italy,
| | - Stefania Grimaldi
- Department of Anesthesia, IRCCS Humanitas Research Center, Rozzano, Italy
| | - Alberto Panerai
- Department of Pharmacological and Biomolecular Sciences, University of Milano, Milano, Italy,
| | | | - Paola Sacerdote
- Department of Pharmacological and Biomolecular Sciences, University of Milano, Milano, Italy,
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7
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Weinstein EJ, Levene JL, Cohen MS, Andreae DA, Chao JY, Johnson M, Hall CB, Andreae MH. Local anaesthetics and regional anaesthesia versus conventional analgesia for preventing persistent postoperative pain in adults and children. Cochrane Database Syst Rev 2018; 6:CD007105. [PMID: 29926477 PMCID: PMC6377212 DOI: 10.1002/14651858.cd007105.pub4] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Regional anaesthesia may reduce the rate of persistent postoperative pain (PPP), a frequent and debilitating condition. This review was originally published in 2012 and updated in 2017. OBJECTIVES To compare local anaesthetics and regional anaesthesia versus conventional analgesia for the prevention of PPP beyond three months in adults and children undergoing elective surgery. SEARCH METHODS We searched CENTRAL, MEDLINE, and Embase to December 2016 without any language restriction. We used a combination of free text search and controlled vocabulary search. We limited results to randomized controlled trials (RCTs). We updated this search in December 2017, but these results have not yet been incorporated in the review. We conducted a handsearch in reference lists of included studies, review articles and conference abstracts. We searched the PROSPERO systematic review registry for related systematic reviews. SELECTION CRITERIA We included RCTs comparing local or regional anaesthesia versus conventional analgesia with a pain outcome beyond three months after elective, non-orthopaedic surgery. DATA COLLECTION AND ANALYSIS At least two review authors independently assessed trial quality and extracted data and adverse events. We contacted study authors for additional information. We presented outcomes as pooled odds ratios (OR) with 95% confidence intervals (95% CI), based on random-effects models (inverse variance method). We analysed studies separately by surgical intervention, but pooled outcomes reported at different follow-up intervals. We compared our results to Bayesian and classical (frequentist) models. We investigated heterogeneity. We assessed the quality of evidence with GRADE. MAIN RESULTS In this updated review, we identified 40 new RCTs and seven ongoing studies. In total, we included 63 RCTs in the review, but we were only able to synthesize data on regional anaesthesia for the prevention of PPP beyond three months after surgery from 39 studies, enrolling a total of 3027 participants in our inclusive analysis.Evidence synthesis of seven RCTs favoured epidural anaesthesia for thoracotomy, suggesting the odds of having PPP three to 18 months following an epidural for thoracotomy were 0.52 compared to not having an epidural (OR 0.52 (95% CI 0.32 to 0.84, 499 participants, moderate-quality evidence). Simlarly, evidence synthesis of 18 RCTs favoured regional anaesthesia for the prevention of persistent pain three to 12 months after breast cancer surgery with an OR of 0.43 (95% CI 0.28 to 0.68, 1297 participants, low-quality evidence). Pooling data at three to 8 months after surgery from four RCTs favoured regional anaesthesia after caesarean section with an OR of 0.46, (95% CI 0.28 to 0.78; 551 participants, moderate-quality evidence). Evidence synthesis of three RCTs investigating continuous infusion with local anaesthetic for the prevention of PPP three to 55 months after iliac crest bone graft harvesting (ICBG) was inconclusive (OR 0.20, 95% CI 0.04 to 1.09; 123 participants, low-quality evidence). However, evidence synthesis of two RCTs also favoured the infusion of intravenous local anaesthetics for the prevention of PPP three to six months after breast cancer surgery with an OR of 0.24 (95% CI 0.08 to 0.69, 97 participants, moderate-quality evidence).We did not synthesize evidence for the surgical subgroups of limb amputation, hernia repair, cardiac surgery and laparotomy. We could not pool evidence for adverse effects because the included studies did not examine them systematically, and reported them sparsely. Clinical heterogeneity, attrition and sparse outcome data hampered evidence synthesis. High risk of bias from missing data and lack of blinding across a number of included studies reduced our confidence in the findings. Thus results must be interpreted with caution. AUTHORS' CONCLUSIONS We conclude that there is moderate-quality evidence that regional anaesthesia may reduce the risk of developing PPP after three to 18 months after thoracotomy and three to 12 months after caesarean section. There is low-quality evidence that regional anaesthesia may reduce the risk of developing PPP three to 12 months after breast cancer surgery. There is moderate evidence that intravenous infusion of local anaesthetics may reduce the risk of developing PPP three to six months after breast cancer surgery.Our conclusions are considerably weakened by the small size and number of studies, by performance bias, null bias, attrition and missing data. Larger, high-quality studies, including children, are needed. We caution that except for breast surgery, our evidence synthesis is based on only a few small studies. On a cautionary note, we cannot extend our conclusions to other surgical interventions or regional anaesthesia techniques, for example we cannot conclude that paravertebral block reduces the risk of PPP after thoracotomy. There are seven ongoing studies and 12 studies awaiting classification that may change the conclusions of the current review once they are published and incorporated.
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Affiliation(s)
- Erica J Weinstein
- Albert Einstein College of Medicine of Yeshiva University1300 Morris Park AveBronxNYUSA10461
| | - Jacob L Levene
- Albert Einstein College of Medicine of Yeshiva University1300 Morris Park AveBronxNYUSA10461
| | - Marc S Cohen
- Montefiore Medical Center, Albert Einstein College of MedicineDepartment of Anesthesiology111 E 210 StreetBronxNYUSA#N4‐005
| | - Doerthe A Andreae
- Milton S Hershey Medical CenterDepartment of Allergy/ Immunology500 University DrHersheyPAUSA17033
| | - Jerry Y Chao
- Montefiore Medical Center, Albert Einstein College of MedicineDepartment of Anesthesiology111 E 210 StreetBronxNYUSA#N4‐005
| | - Matthew Johnson
- Teachers College, Columbia UniversityHuman DevelopmentNew YorkNYUSA10027
| | - Charles B Hall
- Albert Einstein College of MedicineDivision of Biostatistics, Department of Epidemiology and Population Health1300 Morris Park AvenueBronxNYUSA10461
| | - Michael H Andreae
- Milton S Hershey Medical CentreDepartment of Anesthesiology & Perioperative Medicine500 University DriveH187HersheyPAUSA17033
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Weinstein EJ, Levene JL, Cohen MS, Andreae DA, Chao JY, Johnson M, Hall CB, Andreae MH. Local anaesthetics and regional anaesthesia versus conventional analgesia for preventing persistent postoperative pain in adults and children. Cochrane Database Syst Rev 2018; 4:CD007105. [PMID: 29694674 PMCID: PMC6080861 DOI: 10.1002/14651858.cd007105.pub3] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Regional anaesthesia may reduce the rate of persistent postoperative pain (PPP), a frequent and debilitating condition. This review was originally published in 2012 and updated in 2017. OBJECTIVES To compare local anaesthetics and regional anaesthesia versus conventional analgesia for the prevention of PPP beyond three months in adults and children undergoing elective surgery. SEARCH METHODS We searched CENTRAL, MEDLINE, and Embase to December 2016 without any language restriction. We used a combination of free text search and controlled vocabulary search. We limited results to randomized controlled trials (RCTs). We updated this search in December 2017, but these results have not yet been incorporated in the review. We conducted a handsearch in reference lists of included studies, review articles and conference abstracts. We searched the PROSPERO systematic review registry for related systematic reviews. SELECTION CRITERIA We included RCTs comparing local or regional anaesthesia versus conventional analgesia with a pain outcome beyond three months after elective, non-orthopaedic surgery. DATA COLLECTION AND ANALYSIS At least two review authors independently assessed trial quality and extracted data and adverse events. We contacted study authors for additional information. We presented outcomes as pooled odds ratios (OR) with 95% confidence intervals (95% CI), based on random-effects models (inverse variance method). We analysed studies separately by surgical intervention, but pooled outcomes reported at different follow-up intervals. We compared our results to Bayesian and classical (frequentist) models. We investigated heterogeneity. We assessed the quality of evidence with GRADE. MAIN RESULTS In this updated review, we identified 40 new RCTs and seven ongoing studies. In total, we included 63 RCTs in the review, but we were only able to synthesize data on regional anaesthesia for the prevention of PPP beyond three months after surgery from 41 studies, enrolling a total of 3143 participants in our inclusive analysis.Evidence synthesis of seven RCTs favoured epidural anaesthesia for thoracotomy, suggesting the odds of having PPP three to 18 months following an epidural for thoracotomy were 0.52 compared to not having an epidural (OR 0.52 (95% CI 0.32 to 0.84, 499 participants, moderate-quality evidence). Simlarly, evidence synthesis of 18 RCTs favoured regional anaesthesia for the prevention of persistent pain three to 12 months after breast cancer surgery with an OR of 0.43 (95% CI 0.28 to 0.68, 1297 participants, low-quality evidence). Pooling data at three to 8 months after surgery from four RCTs favoured regional anaesthesia after caesarean section with an OR of 0.46, (95% CI 0.28 to 0.78; 551 participants, moderate-quality evidence). Evidence synthesis of three RCTs investigating continuous infusion with local anaesthetic for the prevention of PPP three to 55 months after iliac crest bone graft harvesting (ICBG) was inconclusive (OR 0.20, 95% CI 0.04 to 1.09; 123 participants, low-quality evidence). However, evidence synthesis of two RCTs also favoured the infusion of intravenous local anaesthetics for the prevention of PPP three to six months after breast cancer surgery with an OR of 0.24 (95% CI 0.08 to 0.69, 97 participants, moderate-quality evidence).We did not synthesize evidence for the surgical subgroups of limb amputation, hernia repair, cardiac surgery and laparotomy. We could not pool evidence for adverse effects because the included studies did not examine them systematically, and reported them sparsely. Clinical heterogeneity, attrition and sparse outcome data hampered evidence synthesis. High risk of bias from missing data and lack of blinding across a number of included studies reduced our confidence in the findings. Thus results must be interpreted with caution. AUTHORS' CONCLUSIONS We conclude that there is moderate-quality evidence that regional anaesthesia may reduce the risk of developing PPP after three to 18 months after thoracotomy and three to 12 months after caesarean section. There is low-quality evidence that regional anaesthesia may reduce the risk of developing PPP three to 12 months after breast cancer surgery. There is moderate evidence that intravenous infusion of local anaesthetics may reduce the risk of developing PPP three to six months after breast cancer surgery.Our conclusions are considerably weakened by the small size and number of studies, by performance bias, null bias, attrition and missing data. Larger, high-quality studies, including children, are needed. We caution that except for breast surgery, our evidence synthesis is based on only a few small studies. On a cautionary note, we cannot extend our conclusions to other surgical interventions or regional anaesthesia techniques, for example we cannot conclude that paravertebral block reduces the risk of PPP after thoracotomy. There are seven ongoing studies and 12 studies awaiting classification that may change the conclusions of the current review once they are published and incorporated.
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Affiliation(s)
- Erica J Weinstein
- Albert Einstein College of Medicine of Yeshiva University1300 Morris Park AveBronxUSA10461
| | - Jacob L Levene
- Albert Einstein College of Medicine of Yeshiva University1300 Morris Park AveBronxUSA10461
| | - Marc S Cohen
- Montefiore Medical Center, Albert Einstein College of MedicineDepartment of Anesthesiology111 E 210 StreetBronxUSA#N4‐005
| | - Doerthe A Andreae
- Milton S Hershey Medical CenterDepartment of Allergy/ Immunology500 University DrHersheyUSA17033
| | - Jerry Y Chao
- Montefiore Medical Center, Albert Einstein College of MedicineDepartment of Anesthesiology111 E 210 StreetBronxUSA#N4‐005
| | - Matthew Johnson
- Teachers College, Columbia UniversityHuman DevelopmentNew YorkUSA10027
| | - Charles B Hall
- Albert Einstein College of MedicineDivision of Biostatistics, Department of Epidemiology and Population Health1300 Morris Park AvenueBronxUSA10461
| | - Michael H Andreae
- Milton S Hershey Medical CentreDepartment of Anesthesiology & Perioperative Medicine500 University DriveH187HersheyUSA17033
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9
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Allegri M, Bugada D, De Gregori M, Avanzini MA, De Silvestri A, Petroni A, Sala A, Filisetti C, Icaro Cornaglia A, Cobianchi L. Continuous wound infusion with chloroprocaine in a pig model of surgical lesion: drug absorption and effects on inflammatory response. J Pain Res 2017; 10:2515-2524. [PMID: 29184436 PMCID: PMC5673045 DOI: 10.2147/jpr.s139856] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Continuous wound infusion (CWI) may protect from inflammation, hyperalgesia and persistent pain. Current local anesthetics display suboptimal pharmacokinetic profile during CWI; chloroprocaine (CP) has ideal characteristics, but has never been tested for CWI. We performed an animal study to investigate the pharmacokinetic profile and anti-inflammatory effect of CP during CWI. A total of 14 piglets received an infusion catheter after pararectal laparotomy and were randomly allocated to one of three groups: 5 mL/h infusion of saline (group A), CP 1.5% (group B) and CP 0.5% (group C). Blood sampling was performed to assess absorption and systemic inflammation at 0, 3, 6, 12, 24, 48, 72, 96, 102 and 108 hours. The wound and contralateral healthy abdominal wall were sampled for histological analyses. Absorption of CP from the site of infusion, evaluated as the plasmatic concentrations of CP and its metabolite, 4-amino-2-chlorobenzoic acid (CABA), showed a peak during the first 6 hours, but both CP and its metabolite rapidly disappeared after stopping CP infusion. Local inflammation was reduced in groups B and C (CP-treated p < 0.001), in a CP dose-dependent fashion. While CP inhibited in a dose-dependent manner pig mononuclear cells (MNCs) in vitro proliferation to a polyclonal activator, no effect on systemic cytokines’ concentrations or on ex vivo monocytes’ responsiveness was observed, suggesting the lack of systemic effects, in line with the very short half-life of CP in plasma. CP showed a very good profile for use in CWI, with dose-dependent local anti-inflammatory effects, limited absorption and rapid clearance from the bloodstream upon discontinuation. No cytotoxicity or side effects were observed. CP, therefore, may represent an optimal choice for clinical CWI, adaptable to each patient’s need, and protective on wound inflammatory response (and hyperalgesia) after surgery.
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Affiliation(s)
- Massimo Allegri
- Department of Medicine and Surgery, University of Parma, Parma.,SIMPAR Group (Study in Multidisciplinary PAin Research)
| | - Dario Bugada
- Department of Medicine and Surgery, University of Parma, Parma.,SIMPAR Group (Study in Multidisciplinary PAin Research).,Department of Anaesthesia and ICU, ASST Papa Giovanni XXIII, Bergamo
| | - Manuela De Gregori
- SIMPAR Group (Study in Multidisciplinary PAin Research).,Pain Therapy Service, Fondazione IRCCS Policlinico San Matteo
| | - Maria A Avanzini
- Laboratory of Transplant Immunology/Cell Factory, IRCCS Foundation Policlinico San Matteo
| | - Annalisa De Silvestri
- Clinical epidemiology and Biometrics Unit, Fondazione IRCCS Policlinico San Matteo, Pavia
| | - Anna Petroni
- Department of Pharmacological and Biomolecular Sciences, University of Milan, Milan
| | - Angelo Sala
- Department of Pharmacological and Biomolecular Sciences, University of Milan, Milan.,I.B.I.M., C.N.R., Palermo
| | - Claudia Filisetti
- PhD School, University of Pavia.,Department of Pediatric Surgery, Fondazione IRCCS Policlinico San Matteo, Pavia.,Department of Pediatric Surgery, "V. Buzzi" Children's Hospital, Milan
| | | | - Lorenzo Cobianchi
- Department of Surgical, Clinical, Paediatric and Diagnostic Science, University of Pavia.,General Surgery 1, IRCCS Fondazione Policlinico San Matteo, Pavia, Italy
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