Acute Cytokine Response During Breast Cancer Surgery: Potential Role of Dexamethasone and Lidocaine and Relationship with Postoperative Pain and Complications - Analysis of Three Pooled Pilot Randomized Controlled Trials

Purpose

An imbalance in perioperative cytokine response may cause acute pain and postoperative complications. Anesthetic drugs modulate this cytokine response, but their role in non-major breast cancer surgery is unclear. In an exploratory study, we investigated whether intravenous lidocaine and dexamethasone could modulate the cytokine response into an anti-inflammatory direction. We also evaluated interrelationships between cytokine levels, pain scores and postoperative complications. Our goal is to develop multimodal analgesia regimens optimizing outcome after breast cancer surgery.

Patients and Methods

Forty-eight patients undergoing a lumpectomy were randomly assigned to placebo or lidocaine (1.5 mg⋅kg⁻¹ followed by 2 mg⋅kg⁻¹⋅hour⁻¹) supplemented by dexamethasone zero, 4 or 8 mg, yielding six groups of eight patients. Interleukin (IL)-1β, IL-1Ra, IL-6, IL-10 levels and pain scores were measured at baseline and four hours postoperatively. We assessed postoperative complications occurring within 30 days. We noted persistent pain and infections as potential immune-related complications (PIRC). We used multiple regression to disentangle the effects of the individual study drugs (given by their partial regression coefficients (b)). Odds ratios (OR) estimated the link between pain scores and complications.

Results

Dexamethasone 8 mg increased IL-10 (b=12.70 (95% CI=8.06–17.34), P<0.001). Dexamethasone 4 mg and 8 mg decreased the ratio IL-6/IL-10 (b=−2.60 (−3.93 to −1.26), P<0.001 and b=−3.59 (−5.04 to −2.13), P<0.001, respectively). We could not show modulatory effects of lidocaine on cytokines. High pain scores were linked to the occurrence of PIRC’s (OR=2.028 (1.134–3.628), P=0.017). Cytokine levels were not related either to acute pain or PIRC.

Conclusion

Dexamethasone modulated the perioperative cytokine response into an anti-inflammatory direction. An overall lidocaine effect was not found. Patients with higher pain scores suffered from more 30-day PIRCs. Cytokine levels were not associated with pain or more postoperative complications, even not with PIRC. Larger studies in breast cancer surgery are needed to confirm these explorative results.

[Unexpected movements in a brain-dead patient]

In a brain-dead patient, a 42-year-old woman who went into a coma after a cervical foraminotomy, spinal automatisms were seen which cast doubt on the diagnosis of brain death. The procedure which was to lead to organ transplantation was seriously disturbed. In brain-dead patients spinal automatisms appear earlier and are more often present than deep tendon reflexes. Due to the developing hyperreflexia spinal automatisms can be elicited more easily and from a larger skin area as the period of brain death lasts longer. Spinal automatisms can also appear spontaneously and can be generated by hypercapnia. If criteria for brain death are met, these movements are no reason to reconsider the diagnosis of brain death.

Disconnection of the ventilatory system does not prevent pleural lesions during sternotomy

In previous studies pleurotomy has seldom been reported as a complication of sternotomy and, therefore, the incidence is unknown. Factors increasing or decreasing the risk of pleurotomy also have not been studied properly. In a prospective, randomized trial, performed during 14 consecutive months from 1988 until 1989, the incidence of pleurotomy and its possible risk factors were studied in 712 patients undergoing median sternotomy for cardiac and mediastinal procedures. The overall incidence of pleurotomy was 14.7%. Chronic obstructive pulmonary disease, the use of positive end-expiratory pressure, and continuation or discontinuation of the ventilatory system did not affect the incidence. A surgeon-related risk factor could be significantly identified (P < 0.001). In conclusion, disconnection of the ventilatory system during sternotomy has been shown to have no influence on the pleurotomy rate and its continued use is no longer valid.

Parasitological, clinical and haematological response of children with Plasmodium falciparum to 4-aminoquinolines and to pyrimethamine-sulfadoxine with quinine in western Kenya

Children with Plasmodium falciparum infections in Western Province, Kenya, were studied in 1987 for their parasitological, clinical and haematological response to chloroquine, to amodiaquine and to pyrimethamine-sulfadoxine plus quinine. Ninety-eight children under 5 years of age were treated in 1 of 2 hospitals. Of the 56 patients treated with chloroquine base 25 mg/kg, 91% had resistant infections, with 36% having no significant decrease in parasitaemia (RIII resistance); however, 69% responded clinically within a week. Of the 27 patients treated with amodiaquine base 25 mg/kg, 67% had resistant infections, with 7% RIII resistant; 81% responded clinically. The parasites cleared in all 15 children given pyrimethamine-sulfadoxine plus 3 days of quinine. Only when parasites cleared did patients have improved haemoglobins and haematocrits. This study shows that parasitaemia in children hospitalized in western Kenya responds poorly to 4-aminoquinolines, although the patients improve clinically, at least during the first 7 days. Young children may need to clear parasites to avoid the risk of severe anemia and the need for blood transfusions.