Local anaesthetics and regional anaesthesia versus conventional analgesia for preventing persistent postoperative pain in adults and children.
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ABSTRACT:
SUBMITTER: Weinstein EJ
PROVIDER: S-EPMC6080861 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description: Not available
| S-EPMC6377212 | biostudies-literature
Project description:BACKGROUND:Regional anaesthesia may reduce the rate of persistent (chronic) pain after surgery, a frequent and debilitating condition. OBJECTIVES:To compare local anaesthetics and regional anaesthesia versus conventional analgesia for the prevention of persistent pain six or 12 months after surgery. SEARCH METHODS:We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 4), PubMed (1966 to April 2012), EMBASE (1966 to May 2012) and CINAHL (1966 to May 2012) without any language restriction. We used a combination of free text search and controlled vocabulary search. The results were limited to randomized controlled clinical trials (RCTs). We conducted a handsearch in reference lists of included trials, review articles and conference abstracts. SELECTION CRITERIA:We included RCTs comparing local anaesthetics or regional anaesthesia versus conventional analgesia with a pain outcome at six or 12 months after surgery. DATA COLLECTION AND ANALYSIS:Two authors independently assessed trial quality and extracted data, including information on adverse events. We contacted study authors for additional information. Results are presented as pooled odds ratios (OR) with 95% confidence intervals (CI), based on random-effects models (inverse variance method). We grouped studies according to surgical interventions. We employed the Chi(2) test and calculated the I(2) statistic to investigate study heterogeneity. MAIN RESULTS:We identified 23 RCTs studying local anaesthetics or regional anaesthesia for the prevention of persistent (chronic) pain after surgery. Data from a total of 1090 patients with outcomes at six months and of 441 patients with outcomes at 12 months were presented. No study included children. We pooled data from 250 participants after thoracotomy, with outcomes at six months. Data favoured regional anaesthesia for the prevention of chronic pain at six months after thoracotomy with an OR of 0.33 (95% CI 0.20 to 0.56). We pooled two studies on paravertebral block for breast cancer surgery; the pooled data of 89 participants with outcomes at five to six months favoured paravertebral block with an OR of 0.37 (95% CI 0.14 to 0.94).The methodological quality of the included studies was intermediate. Adverse effects were not studied systematically and were reported sparsely. Clinical heterogeneity, attrition and sparse outcome data hampered the assessment of effects, especially at 12 months. AUTHORS' CONCLUSIONS:Epidural anaesthesia may reduce the risk of developing chronic pain after thoracotomy in about one patient out of every four patients treated. Paravertebral block may reduce the risk of chronic pain after breast cancer surgery in about one out of every five women treated. Our conclusions are significantly weakened by performance bias, shortcomings in allocation concealment, considerable attrition and incomplete outcome data. We caution that our evidence synthesis is based on only a few, small studies. More studies with high methodological quality, addressing various types of surgery and different age groups, including children, are needed.
| S-EPMC4004344 | biostudies-literature
Project description:BackgroundRegional anesthesia may mitigate the risk of persistent postoperative pain (PPP). This Cochrane review, published originally in 2012, was updated in 2017.MethodsWe updated our search of Cochrane CENTRAL, PubMed, EMBASE and CINAHL to December 2017. Only RCTs investigating local anesthetics (by any route) or regional anesthesia versus any combination of systemic (opioid or non-opioid) analgesia in adults or children, reporting any pain outcomes beyond three months were included. Data were extracted independently by at least two authors, who also appraised methodological quality with Cochrane 'Risk of bias' assessment and pooled data in surgical subgroups. We pooled studies across different follow-up intervals. As summary statistic, we reported the odds ratio (OR) with 95% confidence intervals and calculated the number needed to benefit (NNTB). We considered classical, Bayesian alternatives to our evidence synthesis. We explored heterogeneity and methodological bias.Results40 new and seven ongoing studies, identified in this update, brought the total included RCTs to 63. We were only able to synthesize data from 39 studies enrolling 3027 participants in a balanced design. Evidence synthesis favored regional anesthesia for thoracotomy (OR 0.52 [0.32 to 0.84], moderate-quality evidence), breast cancer surgery (OR 0.43 [0.28 to 0.68], low-quality evidence), and cesarean section (OR 0.46, [0.28 to 0.78], moderate-quality evidence). Evidence synthesis favored continuous infusion of local anesthetic after breast cancer surgery (OR 0.24 [0.08 to 0.69], moderate-quality evidence), but was inconclusive after iliac crest bone graft harvesting (OR 0.20, [0.04 to 1.09], low-quality evidence).ConclusionsRegional anesthesia reduces the risk of PPP. Small study size, performance, null, and attrition bias considerably weakened our conclusions. We cannot extrapolate to other interventions or to children.
| S-EPMC6461051 | biostudies-literature
Project description:Effective prevention of chronic postoperative pain is an important clinical goal, informed by a growing body of studies. Peri-operative regional anaesthesia remains one of the most important tools in the multimodal analgesic toolbox, blocking injury-induced activation and sensitisation of both the peripheral and central nervous system. We review the definition and taxonomy of chronic postoperative pain, its mechanistic basis and the most recent evidence for the preventative potential of multimodal analgesia, with a special focus on regional anaesthesia. While regional anaesthesia targets several important aspects of the mechanistic pathway leading to chronic postoperative pain, evidence for its efficacy is still mixed, possibly owing to the heterogeneity of risk profiles within the surgical patient, but also to variation in techniques and medications reported in the literature.
| S-EPMC8369227 | biostudies-literature
Project description:BACKGROUND:Previous studies suggest that truncal regional anaesthesia (TRA), including techniques such as paravertebral block, may contribute significantly to analgesia after mastectomy. However, the severity and impact of postoperative pain varies markedly amongst individuals, making the identification of patients who would benefit most from TRA a potentially important step toward personalised perioperative care. METHODS:In this prospective observational study, mastectomy patients (n=122) were recruited and systematically assessed for psychosocial characteristics including pain catastrophising before surgery, and either received preoperative TRA (n=57) or no block (n=65). RESULTS:Age, baseline pain, and psychosocial traits did not differ between these groups. TRA was associated with lower overall pain scores and opioid consumption perioperatively, with a larger proportion of patients without block (50% vs 28%) reporting moderate-severe pain (more than three/10) on the day of surgery. Mixed model analysis of variance revealed a significant interaction between catastrophising and TRA, such that amongst patients with high baseline catastrophising, TRA was associated with substantially lower pain severity score (58% lower), while amongst patients with low baseline catastrophising, TRA was associated with only 18% lower pain severity. At 2 weeks, this interaction between baseline catastrophising and TRA was also observed when examining surgical pain burden, with higher baseline catastrophising patients who had received TRA reporting lower pain and less frequent opioid use (40% vs 70% of patients). CONCLUSIONS:TRA provided immediate analgesic benefit for patients undergoing mastectomy on the day of surgery, but this effect appeared more pronounced and sustained amongst patients with higher baseline catastrophising. CLINICAL TRIAL REGISTRATION:NCT02329574.
| S-EPMC6676159 | biostudies-literature
Project description:A simple, safe, and effective technique of postop analgesia using wound perfusion with bupivacaine 0.25% via an indwelling intracatheter inserted in the depth of the wound was carried out on 25 ASA grade I/II patients of varying age groups reporting for a variety of surgical procedures. The first dose was given prior to shifting the patient from the OT. Subsequent doses were administered on patient demand basis. The intracatheter was kept in position for 48-72 hours postop. An analysis was made on the patients' pain relief using a visual analogue scale, dose/frequency of bupivacaine required, dose/type of supplemental analgesia needed, haemodynamic changes during infiltration, wound healing, and patient satisfaction. In this study only 12% of patients required opioids on Day One postoperatively. There were no adverse effects of infiltration either systemically or on wound healing, and all the patients had excellent postop analgesia.
| S-EPMC5532130 | biostudies-other
Project description: Not available
| S-EPMC6457860 | biostudies-literature
Project description:Postoperative pain relief in 40 children undergoing elective infraumbilical surgery was assessed after caudal epidural adminstration of either lignocaine or bupivacaine in the doses of 0.5 mL/kg body weight of a 1 per cent solution and 0.5 mL/kg body weight of a 0.25 per cent solution respectively. Pain free period was assessed by subjective pain scales. The pain free period was significantly prolonged in children who were given bupivacaine (14.75 ± 2.75 hours) as compared to lignocaine (7.25 ± 3.25 hours).
| S-EPMC5530789 | biostudies-other
Project description:There is a need to ensure that the care and welfare for fish maintained in the laboratory are to the highest standards. This extends to the use of anaesthetics for both scientific study, humane killing and euthanasia at end of life. An anaesthetic should not induce negative behaviours and fish should not seek to avoid the anaesthetic. Surprisingly little information is available to facilitate a humane choice of anaesthetic agent for fish despite over 100 years of use and the millions of fish currently held in thousands of laboratories worldwide. Using a chemotaxic choice chamber we found different species specific behavioural responses among four closely related fish species commonly held in the laboratory, exposed to three widely used anaesthetic agents. As previously found for zebrafish (Danio rerio), the use of MS-222 and benzocaine also appears to induce avoidance behaviours in medaka (Oryzias latipes); but etomidate could provide an alternative choice. Carp (Cyprinus carpio), although closely related to zebrafish showed avoidance behaviours to etomidate, but not benzocaine or MS-222; and rainbow trout (Oncorhynchus mykiss) showed no avoidance to the three agents tested. We were unable to ascertain avoidance responses in fathead minnows (Pimephales promelas) and suggest different test paradigms are required for that species.
| S-EPMC5541135 | biostudies-literature
Project description:BACKGROUND:This is an updated version of the original Cochrane review published in Issue 4, 2006. Patients may control postoperative pain by self administration of intravenous opioids using devices designed for this purpose (patient controlled analgesia or PCA). A 1992 meta-analysis by Ballantyne et al found a strong patient preference for PCA over non-patient controlled analgesia, but disclosed no differences in analgesic consumption or length of postoperative hospital stay. Although Ballantyne's meta-analysis found that PCA did have a small but statistically significant benefit upon pain intensity, a 2001 review by Walder et al did not find statistically significant differences in pain intensity or pain relief between PCA and groups treated with non-patient controlled analgesia. OBJECTIVES:To evaluate the efficacy and safety of patient controlled intravenous opioid analgesia (termed PCA in this review) versus non-patient controlled opioid analgesia of as-needed opioid analgesia for postoperative pain relief. SEARCH METHODS:We ran the search for the previous review in November 2004. For this update, we searched the Cochrane Central Register of Controlled Trials (CENTRAL 2014, Issue 12), MEDLINE (1966 to 28 January 2015), and EMBASE (1980 to 28 January 2015) for randomized controlled trials (RCTs) in any language, and reference lists of reviews and retrieved articles. SELECTION CRITERIA:We selected RCTs that assessed pain intensity as a primary or secondary outcome. These studies compared PCA without a continuous background infusion with non-patient controlled opioid analgesic regimens. We excluded studies that explicitly stated they involved patients with chronic pain. DATA COLLECTION AND ANALYSIS:Two review authors independently extracted data, which included demographic variables, type of surgery, interventions, efficacy, and adverse events. We graded each included study for methodological quality by assessing risk of bias and employed the GRADE approach to assess the overall quality of the evidence. We performed meta-analysis of outcomes that included pain intensity assessed by a 0 to 100 visual analog scale (VAS), opioid consumption, patient satisfaction, length of stay, and adverse events. MAIN RESULTS:Forty-nine studies with 1725 participants receiving PCA and 1687 participants assigned to a control group met the inclusion criteria. The original review included 55 studies with 2023 patients receiving PCA and 1838 patients assigned to a control group. There were fewer included studies in our updated review due to the revised exclusion criteria. For the primary outcome, participants receiving PCA had lower VAS pain intensity scores versus non-patient controlled analgesia over most time intervals, e.g., scores over 0 to 24 hours were nine points lower (95% confidence interval (CI) -13 to -5, moderate quality evidence) and over 0 to 48 hours were 10 points lower (95% CI -12 to -7, low quality evidence). Among the secondary outcomes, participants were more satisfied with PCA (81% versus 61%, P value = 0.002) and consumed higher amounts of opioids than controls (0 to 24 hours, 7 mg more of intravenous morphine equivalents, 95% CI 1 mg to 13 mg). Those receiving PCA had a higher incidence of pruritus (15% versus 8%, P value = 0.01) but had a similar incidence of other adverse events. There was no difference in the length of hospital stay. AUTHORS' CONCLUSIONS:Since the last version of this review, we have found new studies providing additional information. We reanalyzed the data but the results did not substantially alter any of our previously published conclusions. This review provides moderate to low quality evidence that PCA is an efficacious alternative to non-patient controlled systemic analgesia for postoperative pain control.
| S-EPMC7387354 | biostudies-literature