Local & regional anaesthesia at time of surgery to prevent l | Figure 1

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Local & regional anaesthesia at time of surgery to prevent longer-term persistent pain after surgery

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Can local anaesthetics at the time of surgery reduce the risk of having pain that persists for three months and more after surgery?

Cochrane Review; pooled results from 41 RCTs (3143 participants).

Key results

Regional anaesthesia reduced the number of people who experienced persistent pain after undergoing non-orthopaedic surgery. For open chest surgery, giving an epidural halved the odds of a person having persistent postoperative pain at 3 - 18 months after surgery (moderate-quality evidence). Seven people needed to be treated in this way for one to benefit.

For the prevention of persistent pain 3 - 12 months after breast cancer surgery, seven people needed regional anaesthesia for one to benefit (low-quality evidence). Infusion of local anaesthetic into a vein was shown to reduce the risk of persistent pain three to six months after breast surgery (moderate-quality evidence), with three people needing to be treated for one to benefit. Regional anaesthesia reduced the odds by more than half of a woman experiencing persistent pain after caesarean section (moderate-quality evidence). The number of women treated for one to benefit was 19.

Continuous local anaesthetic infusion of the site where bone tissue was obtained from the hip bone did not clearly reduce the number of people with persistent pain at three to 55 months (low-quality evidence).

Read the full Cochrane Review here

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\ \ The problem\ There is increasing evidence that people who have undergone brain surgery experience significant pain. This pain can have serious consequences including raised blood pressure, agitation, prolonged recovery time and an increased risk of long‐term headaches. Research studies have looked at different drugs in an attempt to reduce the risk of pain for these people. There is now more evidence about pain reduction options for adults undergoing brain surgery but there remains uncertainty as to which options work best.\ The question\ This review aimed to determine which drugs provide the best chance of reducing pain for adults undergoing brain surgery, by collecting and combining the results of studies that looked at pain‐relieving drugs for this patient group. To provide an accurate answer to this question, only studies conducted in accordance with an approved high standard were included. Studies published in different languages and countries were included in order to obtain as much information as possible.\ In addition to determining which drugs were best at preventing or reducing pain after brain surgery, this review attempted to determine additional information such as how much additional pain‐relieving treatment was required in addition to the treatment under study; whether participants' pain was adequately controlled or not; how drowsy the participants were; what side effects they experienced; and how long they needed to stay in intensive care and in hospital. This review also considered whether some treatments worked better when given before or after surgery or for people undergoing different approaches to brain surgery.\ The results\ A total of 43 eligible studies, (42 complete and one still in progress), were found. Of the 42 completed studies (3548 participants), 10 studied injections of local anaesthetic into the scalp, 12 studied injection of local anaesthetic around specific scalp nerves, 8 studied nonsteroidal anti‐inflammatory drugs (NSAIDs), 4 studied dexmedetomidine, 4 studied acetaminophen aka paracetamol), 2 studied opioid drugs, 3 studied gabapentin or pregabalin (anti‐seizure drugs that can also be used for pain relief) together with 1 study each of local anaesthetic injected into the veins, local anaesthetic injected into the jaw and the drug flupirtine.\ Sufficient information was abstracted to calculate the overall pain‐preventing effects of the following: local anaesthetic injections around the surgical wound, local anaesthetic injections around specific scalp nerves, NSAIDs, acetaminophen, dexmedetomidine and pregabalin or gabapentin. When only high‐quality studies were examined: NSAIDs reduced pain up to 24 hours after surgery, dexmedetomidine and local anaesthetics injected around specific scalp nerves reduced pain in the first 12 hours after surgery, pregabalin or gabapentin reduced pain in the first 6 hours after surgery and local anaesthetic injections around the surgical wound significantly reduced pain 48 hours after surgery, but did not affect pain at earlier time points.\ When the timing of injection of local anaesthetics was examined, local anaesthetics injected around specific scalp nerves provided better early pain relief (first 6 hours) when injected after surgery and better late pain relief (12 and 24 hours) when injected before surgery.\ The following interventions were also found to reduce the need for additional pain‐relieving drugs: local anaesthetics injected around specific scalp nerves and dexmedetomidine. Gabapentin or pregabalin was found to reduce the risk of nausea and vomiting after surgery.\ Acetaminophen was not found to prevent pain after brain surgery or reduce the need for additional pain‐relieving drugs.\ Insufficient evidence was found to determine whether any of these drugs made the participants more or less drowsy, affected how long they needed to stay in intensive care or whether different drugs worked better for adults undergoing different approaches to brain surgery.\ The overall quality of the evidence that contributed to the results of this review was assessed and judged to be 'high' for pain‐reducing effects of NSAIDs, 'moderate' to 'low' for pain‐reducing effects of dexmedetomidine, acetaminophen, pregabalin and gabapentin and local anaesthetics injected around specific scalp nerves and ' low' to ' very low' for pain‐reducing effects of local anaesthetic injections around the surgical wound, additional pain relief requirements and risk of nausea and vomiting after surgery .](https://app.figure1.com/case-detail/088b0039-4d3a-49d8-8f03-d7d69cd06669)

\ \ What is the issue?\ Breast cancer is one of the most common cancers in women. Surgical removal of the tumour is the main treatment; however, dissemination of cancer cells may occur due to tumour handling during surgery. The body's response to surgery (stress response or release of hormones and mediators) as well as drugs used to produce general anaesthesia (complete loss of consciousness), such as opioids and inhalational anaesthetics, can also depress immunity and promote cancer cell survival.\ Paravertebral anaesthesia acts by numbing the nerves on one side of the body and can allow surgery to be performed without general anaesthesia. The lightly sedated participant can report pain, cold, thirst, or hunger during or after surgery, allowing timely treatment. This, combined with pain relief produced by paravertebral anaesthesia, has the potential to improve immunity, reduce surgical stress, and improve quality of life and cancer‐free survival.\ Review question\ We collected and analysed data from all relevant studies to ascertain whether paravertebral anaesthesia would provide better quality of recovery and pain relief at rest and on movement, and to determine whether paravertebral anaesthesia would have any affect on mortality, compared to general anaesthesia.\ Study characteristics\ We included randomised controlled trials in which participants in one group received paravertebral anaesthesia with or without sedation and participants in the other group received general anaesthesia during breast cancer surgery. We did not include studies in which paravertebral anaesthesia was administered in addition to general anaesthesia and then this was compared to the use of general anaesthesia.\ Key results\ Nine studies involving 614 participants were included. Four studies were conducted in Europe, three in Asia, and one each in Africa and North America. All studies took place in medical college hospitals with no external funding.\ When reviewing evidence on the quality of recovery, these studies reported various outcomes. It was found that paravertebral anaesthesia:\ • may reduce 24‐hour postoperative analgesic use (61 per 1000 versus 480 per 1000 in the general anaesthesia group);\ • probably reduces the incidence of postoperative nausea and vomiting (72 per 1000 versus 340 per 1000 in the general anaesthesia group);\ • probably reduces pain at 2 hours (by 2.95 points on a 0 to 10 point scale) and may reduce pain at 24 hours at rest (0.21 points on a 0 to 10 point scale) compared to general anaesthesia; and\ • may reduce pain on movement at 6 hours and at 24 hours post surgery (at 6 hours by 2.57 points; at 24 hours by 2.12 points on a scale of 0 to 10) compared to general anaesthesia.\ No study reported on death with each anaesthetic technique. None of the included studies reported on disease‐free survival, chronic pain, or quality of life after breast cancer surgery, probably because these outcomes were not envisaged or planned.\ Reports of adverse events with paravertebral block were rare. Out of 290 participants who received paravertebral anaesthesia, two developed epidural spread, four had minor bleeding, and one had pleural puncture. Seventeen of 240 participants developed Horner's syndrome. All adverse events were self‐limited and resolved without treatment.\ Quality of the evidence\ Most evidence was judged to be of moderate certainty, meaning that we are moderately confident in the reported result. In some cases, evidence was seen to be of low certainty, meaning that our confidence in the reported result is limited.](https://app.figure1.com/case-detail/205ea2c7-ac00-409b-9260-f45b907ed58e)

\ \ Continuous delivery of a local anaesthetic around the wound to treat pain after bowel surgery through a vertical cut in the abdomen\ Background\ People with bowel disease can be treated with surgery to remove a part of the bowel (colorectal resection). A long vertical cut in the abdomen (midline laparotomy) is often required. Recovery after this type of surgery can be slow and painful. Continuous injection of a local anaesthetic (numbing a specific area of the body, e.g. around the wound) may reduce pain after this type of surgery. The local anaesthetic may also reduce the amount of morphine‐like pain killers required and side effects related to these medications. This could mean a shorter recovery time for the patient and earlier discharge from the hospital.\ Study characteristics\ We searched for clinical trials to January 2019 looking at the benefits and harms of continuous injection of a local anaesthetic after surgery to remove the bowel through a vertical cut in the abdomen. We looked for trials comparing local anaesthetic to an inactive substance (placebo) such as salty water (normal saline). We found six clinical trials including 541 participants. Most participants were aged 55 to 65 years, of varying health status from fit and healthy to having a severe systemic disease (a disease that affects the whole body).\ Key findings\ In people who received a local anaesthetic, pain at rest, pain on movement, and requirement for morphine‐like pain killers were reduced on the first day after surgery compared to people who received an inactive substance.\ People who received a local anaesthetic also opened their bowels about half a day earlier and were discharged from hospital about a day earlier compared to people who received an inactive substance.\ We did not find a difference between people who received a local anaesthetic and those who received an inactive substance in the rates of any serious complications after surgery until hospital discharge.\ Certainty of evidence\ We rated the certainty of the evidence from studies using four levels: high, moderate, low, very low. Reasons for downgrading the certainty of the evidence included limitations problems with the design of the studies, missing data, differences between trials and how the outcomes were measured, and the small number of participants. We need more high‐quality trials to evaluate this treatment, especially its effects on recovery after surgery, side effects and complications.\ We rated the certainty of the evidence for pain after surgery at rest and the length of hospital stay as high, meaning that we are very confident in the findings about the effects of the treatment on these outcomes. We rated the certainty of the evidence for the requirement for morphine‐like pain killers and the time until the first bowel movement as moderate. This means that we are moderately confident in the findings about the effects of the treatment on these outcomes. We rated the certainty of the evidence for pain after surgery on movement and the rates of any serious complications after surgery until hospital discharge as low, meaning that we have limited confidence in the findings about the effects of the treatment on these outcomes.](https://app.figure1.com/case-detail/22600875-5e69-42cc-83fa-54cd45658a2c)

\ \ Cochrane Review; seven studies (93 patients).\ Does local anaesthesia at the time of the operation (perioperative) reduce pain after surgery to the nasal septum and are there any adverse effects?\ Key finding\ The addition of local anaesthesia to nasal packs (if these are being used) following septal surgery may reduce postoperative pain within the first 12 hours postoperatively compared to nasal packing with a placebo added. However, this review revealed a lack of evidence on which to base comparisons of the various types of local anaesthesia.\ The quality of evidence for the use of local anaesthetic injection was low.](https://app.figure1.com/case-detail/415709bd-8b85-41a8-85b1-f6da7d2534f4)

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