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Journal of Pain Research 2017Dexamethasone is a common adjuvant for local anesthetics in regional anesthesia, but the optimal route of administration is controversial. Therefore, we did a systematic... (Review)
Review
BACKGROUND
Dexamethasone is a common adjuvant for local anesthetics in regional anesthesia, but the optimal route of administration is controversial. Therefore, we did a systematic review and meta-analysis of randomized controlled trials to assess the effect of perineural versus intravenous dexamethasone on local anesthetic regional nerve-blockade outcomes.
MATERIALS AND METHODS
Medline (through PubMed), Embase, Cochrane, Web of Science, and Biosis Previews databases were systematically searched (published from inception of each database to January 1, 2017) to identify randomized controlled trials. The data of the selected trials were statistically analyzed to find any significant differences between the two modalities. The primary outcome was the duration of analgesia. Secondary outcomes included duration of motor block, postoperative nausea and vomiting, and postoperative analgesic dose at 24 hours. We conducted a planned subgroup analysis to compare the effects between adding epinephrine or not.
RESULTS
Ten randomized controlled trials met the inclusion criteria of our analysis, with a total of 749 patients. Without the addition of epinephrine, the effects of perineural and intravenous dexamethasone were equivalent concerning the duration of analgesia (mean difference 0.03 hours, 95% CI -0.17 to 0.24). However, with the addition of epinephrine, the analgesic duration of perineural dexamethasone versus intravenous dexamethasone was prolonged (mean difference 3.96 hours, 95% CI 2.66-5.27). Likewise, the impact of epinephrine was the same on the duration of motor block. The two routes of administration did not show any significant differences in the incidence of postoperative nausea and vomiting, nor on postoperative analgesic consumption at 24 hours.
CONCLUSION
Our results show that perineural dexamethasone can prolong the effects of analgesic duration when compared to the intravenous route, only when epinephrine is coadministered. Without epinephrine, the two modalities show equivalent effect as adjuvants on regional anesthesia.
PubMed: 28740419
DOI: 10.2147/JPR.S138212 -
Journal of Perianesthesia Nursing :... Apr 2021Pain control during and after breast surgery is still a challenging task. Dexmedetomidine (DEX) is considered as a sedative agent that is widely used perineurally or... (Meta-Analysis)
Meta-Analysis
PURPOSE
Pain control during and after breast surgery is still a challenging task. Dexmedetomidine (DEX) is considered as a sedative agent that is widely used perineurally or intravenously as an adjuvant in general anesthesia and critical care medicine practice. The aim of this study is to evaluate the efficacy of perineural DEX and intravenous (IV) DEX and their effects on postoperative complications in breast surgeries.
DESIGN
Systematic review and meta-analysis.
METHODS
The present study systematically reviewed all identified randomized controlled trials for efficacy and safety of IV and perineural use of DEX in breast surgeries. Databases were searched for articles published before October 2019.
FINDINGS
Twelve trials were identified including 803 patients undergoing breast surgery. Although administration of IV DEX and its use with pectoral nerve (Pecs) block significantly postponed time for first analgesic request and decreased pain score at 1 and 12 hours after surgery, paravertebral use of DEX had no statistically significant effect. Pooled data about perineural DEX showed no significant effect on postoperative nausea and vomiting (PONV), whereas IV DEX significantly reduced PONV. Pooled analysis also showed that DEX administration did not significantly affect postoperative complications, such as postoperative itching, bradycardia, and pneumothorax in patients undergoing breast surgery.
CONCLUSIONS
The results showed that unlike paravertebral DEX, both DEX use with Pecs blocks and IV DEX were effective in control of postoperative pain in patients undergoing breast surgeries. Unlike perineural DEX, IV DEX significantly reduced PONV.
Topics: Dexmedetomidine; Humans; Hypnotics and Sedatives; Pain Management; Pain, Postoperative; Postoperative Nausea and Vomiting
PubMed: 33303343
DOI: 10.1016/j.jopan.2020.09.011 -
European Journal of Surgical Oncology :... Apr 2022The hepatic flexure and transverse colon have a complex intermingled lymphovascular anatomy crossing between mesocolon and mesogastrium. Few studies have investigated... (Review)
Review
INTRODUCTION
The hepatic flexure and transverse colon have a complex intermingled lymphovascular anatomy crossing between mesocolon and mesogastrium. Few studies have investigated the oncological relevance of metastatic infrapyloric and gastroepiploic lymph nodes (IGLN) from hepatic flexure and transverse colon tumors. This study aimed to evaluate the incidence and risk factors for IGLN metastases, and the indications, surgical morbidities, and oncological outcome following extended lymphadenectomy.
MATERIALS AND METHODS
According to the PRISMA statement, a systematic review on IGLN lymphadenectomy for colon cancer was conducted into PubMed, Embase, and Cochrane databases. A critical appraisal of study was performed according to the Joanna Briggs Institute Tools.
RESULTS
Nine studies were included. IGLN metastases incidence ranged 0.7-22%. IGLN positivity for patients with metastatic mesocolic lymph nodes ranged 1.7-33.3%. Postoperative complication rate ranged 8.5-36.9%, mostly low grade according to Clavien-Dindo's classification. Postoperative mortality rate ranged 0-5.4% at 30-days. IGLN metastases were associated with advanced disease with a 5-year progression-free survival rate up to 33.9%. Two authors reported perineural invasion and N stage as risk factors, while another reported endoscopic obstruction, signet ring adenocarcinoma, CEA level ≥17 ng/ml, and M1 stage to be risk factors for IGLN involvement. Apart from one study, all other studies were of moderate/high quality.
CONCLUSIONS
Metastatic IGLNs are not uncommon and should be highly considered. IGLN metastases could be potentially associated with an aggressive disease. IGLN dissection is not associated with higher morbidity and mortality than standard CME. Preoperative risk factors of IGLN involvement could guide surgical indication for extended lymphadenectomy.
Topics: Colectomy; Colon, Ascending; Colon, Transverse; Colonic Neoplasms; Humans; Laparoscopy; Lymph Node Excision; Lymph Nodes; Mesocolon
PubMed: 34893366
DOI: 10.1016/j.ejso.2021.12.005 -
Techniques in Coloproctology Feb 2021In recent years, there has been growing concern about the potential association of stent placement as a bridge to surgery in malignant colon obstruction and some... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
In recent years, there has been growing concern about the potential association of stent placement as a bridge to surgery in malignant colon obstruction and some anatomopathological findings that could lead to worsening long-term cancer outcomes, such as perineural, vascular and lymphatic invasion. The aim of the present review was to assess the pathological changes found in surgical specimens after stent placement for obstructing colon cancer vs. emergency surgery, and the impact of perineural invasion on survival rates METHODS: MEDLINE, Cochrane Library, Ovid and ISRCTN Registry were searched, with no restrictions. We performed four meta-analyses to estimate the pooled effect sizes using a random effect model. The outcomes were perineural, vascular and lymphatic invasion rates, and 5-year overall survival rate in patients with obstructive colon cancer, depending on the presence or absence of perineural invasion.
RESULTS
Ten studies with a total of 1273 patients were included in the meta-analysis. We found that patients in the stent group had a significantly higher risk of perineural (OR 1.98, 95% CI 1.22-3.21; p = 0.006) and lymphatic invasion (OR 1.45, 95% CI 1.10-1.90; p = 0.008). Furthermore, patients with positive perineural invasion had almost twice the risk of dying compared to those with no perineural invasion (HR 1.92, 95% CI 1.22-3.02; p = 0.005).
CONCLUSIONS
Stent placement as a bridge to surgery in colorectal cancer patients modifies the pathological characteristics such as perineural and lymphatic invasion, and this may worsen the long-term prognosis of patients. The presence of perineural infiltration in obstructed colon cancer decreases the long-term survival of patients.
Topics: Colonic Neoplasms; Colorectal Neoplasms; Humans; Intestinal Obstruction; Stents
PubMed: 33200308
DOI: 10.1007/s10151-020-02350-2 -
Bioscience Reports Oct 2018The significance of perineural invasion (PNI) present in penile cancer (PC) is controversial. In order to clarify the predictive role of PNI in the inguinal lymph node... (Meta-Analysis)
Meta-Analysis
The significance of perineural invasion (PNI) present in penile cancer (PC) is controversial. In order to clarify the predictive role of PNI in the inguinal lymph node (ILN) metastases (ILNM) and oncologic outcome of patients, we performed this meta-analysis and systematic review. The search of PubMed, Embase, and Web of Science was conducted for appropriate studies, up to 20 January 2018. The pooled odds ratio (OR) and hazard ratio (HR) with their 95% confidence interval (CI) were applied to evaluate the difference in ILNM and oncologic outcome between patients present with PNI and those who were absent. A total of 298 in 1001 patients present with PNI were identified in current meta-analysis and systematic review. Significant difference was observed in ILNM between PNI present and absent from patients with PC (OR = 2.98, 95% CI = 2.00-4.45). Patients present with PNI had a worse cancer-specific survival (CSS) (HR = 3.58, 95% CI = 1.70-7.55) and a higher cancer-specific mortality (CSM) (HR = 2.20, 95% CI = 1.06-3.82) than those cases without PNI. This meta-analysis and systematic review demonstrated the predictive role of PNI in ILNM, CSS, and CSM for PC patients.
Topics: Aged; Aged, 80 and over; Humans; Inguinal Canal; Lymph Nodes; Lymphatic Metastasis; Male; Middle Aged; Neoplasm Invasiveness; Odds Ratio; Penile Neoplasms; Penis; Prognosis; Proportional Hazards Models; Retrospective Studies; Treatment Outcome
PubMed: 30279203
DOI: 10.1042/BSR20180333 -
Anesthesia and Analgesia Jan 2018Perineural dexamethasone has gained popularity in regional anesthesia to prolong analgesia duration. However, uncertainty remains regarding the optimal perineural dose.... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Perineural dexamethasone has gained popularity in regional anesthesia to prolong analgesia duration. However, uncertainty remains regarding the optimal perineural dose. Clarification of this characteristic is of significant importance as the administration of dexamethasone may lead to dose-dependent complications. The objective of this meta-analysis was to define the optimal perineural dexamethasone dose to prolong analgesia after brachial plexus blockade for adult patients undergoing upper limb surgery.
METHODS
We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement guidelines and searched databases including MEDLINE, PubMed, and EMBASE until January 2017, without language restriction. Only trials comparing perineural dexamethasone and local anesthetics with local anesthetics alone for brachial plexus blocks were included in the present meta-analysis. The Cochrane Collaboration's Risk of Bias Tool was used to assess the methodological quality of each trial and meta-analyses were performed following a random effects model. The primary outcome was duration of analgesia for each type of local anesthetic (short-/intermediate-acting and long-acting local anesthetics). A meta-regression followed by a subgroup analysis were performed to assess the impact of different perineural dexamethasone doses on duration of analgesia; for the latter analysis, trials were grouped in low (1-4 mg) and moderate (5-10 mg) dexamethasone doses. Secondary outcomes included the rate of neurologic complication and resting pain scores and morphine consumption within the first 24 hours.
RESULTS
Thirty-three controlled trials, including 2138 patients, were identified. The meta-regression revealed a ceiling effect with a perineural dexamethasone dose of 4 mg when combined with short-/intermediate-acting (8 trials; 366 participants) or long-acting local anesthetics (23 trials; 1869 participants). This finding was confirmed by subgroup analyses comparing low and moderate dexamethasone doses. With short-/intermediate-acting local anesthetics, the mean difference (95% confidence interval) of analgesia duration with low and moderate doses was 277 (234-322) minutes and 229 (161-297) minutes, respectively. With long-acting local anesthetics, the mean differences with low and moderate doses were 505 (342-669) minutes and 509 (443-575) minutes. Perineural dexamethasone did not increase the rate of neurologic complications (risk ratio [95% confidence interval], 1.40 [0.54-3.63]). The Grades of Recommendation, Assessment, Development, and Evaluation quality of evidence for the primary and secondary outcomes were very low, due mainly to limitations, inconsistency, indirectness, and publication bias.
CONCLUSIONS
There is currently very low quality evidence that 4 mg of perineural dexamethasone represents a ceiling dose that prolongs analgesia duration by a mean period of 6 and 8 hours when combined with short-/intermediate- or long-acting local anesthetics, respectively. Additional data are needed to explore the threshold for this effect, particularly with doses below 4 mg. The risk of neurologic complications is probably not increased (very low evidence).
Topics: Analgesia; Anti-Inflammatory Agents; Brachial Plexus Block; Dexamethasone; Dose-Response Relationship, Drug; Drug Administration Schedule; Humans; Randomized Controlled Trials as Topic
PubMed: 28922230
DOI: 10.1213/ANE.0000000000002488 -
Oral Surgery, Oral Medicine, Oral... Dec 2016We performed a systematic review to assess the prognostic value of perineural invasion (PNI) for patients with head and neck adenoid cystic carcinoma. (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
We performed a systematic review to assess the prognostic value of perineural invasion (PNI) for patients with head and neck adenoid cystic carcinoma.
STUDY DESIGN
A literature search of MEDLINE and EMBASE was used to identify relevant literature up to December 2015. The primary outcomes of interest were overall survival, disease-free survival, and locoregional control. Study information and hazard ratios (HRs) were extracted, and HRs were pooled using the Mantel-Haenszel fixed-effects model and the DerSimonian and Laird random-effects model according to heterogeneity.
RESULTS
Twenty-two studies and 1332 patients were included in this study. The PNI ratio was 43.2%. PNI was at increasing risk for overall survival (HR = 2.98; 95% confidence interval [CI] 2.00-4.46), disease-free survival (HR = 1.88; 95% CI, 1.42-2.49), and locoregional control (HR = 2.15; 95% CI, 1.48-3.13) with statistical significance.
CONCLUSIONS
PNI is an independent factor for poor prognosis in patients with head and neck adenoid cystic carcinoma. Moreover, PNI poses a significantly higher threat to male patients and younger patients.
Topics: Carcinoma, Adenoid Cystic; Head and Neck Neoplasms; Humans; Neoplasm Invasiveness; Peripheral Nervous System Neoplasms; Prognosis; Risk Factors
PubMed: 27727107
DOI: 10.1016/j.oooo.2016.08.008 -
Pain Physician Sep 2021Perineural (PN) dexamethasone (DEX) administration can prolong the analgesic time of a brachial plexus block. However, its efficacy and safety are controversial due to... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Perineural (PN) dexamethasone (DEX) administration can prolong the analgesic time of a brachial plexus block. However, its efficacy and safety are controversial due to its off-label use and different routes of administration.
OBJECTIVES
This meta-analysis aimed to assess the safety and efficacy of PN versus intravenous (IV) dexamethasone.
STUDY DESIGN
Systematic review and meta-analysis of randomized controlled trials (RCTs).
SETTING
Relevant studies were found through a comprehensive literature search of PubMed, Web of Science, Ovid, EMBASE, and the Cochrane Library (from the inception until January 2020).
METHODS
According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, this meta-analysis was conducted to identify RCTs comparing PN and IV dexamethasone in brachial plexus block. A randomized effect model was used in the meta-analysis and the subgroup analysis was performed with adrenaline stratification. The quality of evidence and the strength of recommendations were graded by GradePro version 3.6.1.
RESULTS
Twelve RCTs with a total of 1,345 subjects were included. We found that PN dexamethasone could prolong the duration of analgesia (mean difference [MD]: 131.82 minutes, 95% confidence interval [CI] [38.96, 224.68], I2 = 82%, P = 0.005), motor block (MD: 218.85 minutes, 95% CI [113.65,324.05], I2 = 72%, P < 0.0001) and sensory block (MD: 209.57 minutes, 95% CI [72.64, 346.50], I2 = 87%, P = 0.003) in the main analysis with significant difference. In the absence of epinephrine, there were no significant differences between PN dexamethasone and IV dexamethasone. Except for adverse-effects, no significant differences were observed in secondary outcomes. PN dexamethasone had slightly higher adverse-effects; however, these could be altered if a sensitivity analysis was conducted.
LIMITATIONS
There was high heterogeneity among included studies.
CONCLUSIONS
PN dexamethasone can prolong the duration of analgesia, sensory block, and motor block, when compared with IV dexamethasone. In a subgroup analysis without epinephrine, the 2 routes of administration were equivalent to topical anesthesia. There were no differences in secondary outcomes, except for adverse effects, which could be altered if a sensitivity analysis was conducted. Therefore, despite the advantages of PN dexamethasone, caution is needed due to its off-label character. While the results of this study are promising, additional large and well-designed RCTs are needed to validate these initial findings and their implications.
Topics: Administration, Intravenous; Analgesia; Brachial Plexus Block; Dexamethasone; Humans; Randomized Controlled Trials as Topic
PubMed: 34554686
DOI: No ID Found -
Neurobiology of Pain (Cambridge, Mass.) 2021Obesity has been associated with increased chronic pain susceptibility but causes are unclear. In this review, we systematize and analyze pain outcomes in rodent models... (Review)
Review
Obesity has been associated with increased chronic pain susceptibility but causes are unclear. In this review, we systematize and analyze pain outcomes in rodent models of obesity as these can be important tools for mechanistic studies. Studies were identified using MEDLINE/PubMed and Scopus databases using the following search query: (((pain) OR (nociception)) AND (obesity)) AND (rat OR (mouse) OR (rodent))). From each eligible record we extracted the following data: species, strain, sex, pain/obesity model and main behavioral readouts. Out of 695 records 33 were selected for inclusion. 27 studies assessed nociception/acute pain and 17 studies assessed subacute or chronic pain. Overall genetic and dietary models overlapped in pain-related outcomes. Most acute pain studies reported either decreased or unaltered responses to noxious painful stimuli. However, decreased thresholds to mechanical innocuous stimuli, i.e. allodynia, were frequently reported. In most studies using subacute and chronic pain models, namely of subcutaneous inflammation, arthritis and perineural inflammation, decreased thresholds and/or prolonged pain manifestations were reported in obesity models. Strain comparisons and longitudinal observations indicate that genetic factors and the time course of the pathology might account for some of the discrepancies observed across studies. Two studies reported increased pain in animals subjected to high fat diet in the absence of weight gain. Pain-related outcomes in experimental models and clinical obesity are aligned indicating that the rodent can be an useful tool to study the interplay between diet, obesity and pain. In both cases weight gain might represent only a minor contribution to abnormal pain manifestation.
PubMed: 34195483
DOI: 10.1016/j.ynpai.2021.100066 -
Anesthesia and Analgesia Jun 2017Clonidine, an α-2 agonist, has long been used as a local anesthetic adjunct with proven efficacy to prolong peripheral nerve block duration. Dexmedetomidine, a newer... (Meta-Analysis)
Meta-Analysis Review
Perineural Dexmedetomidine Is More Effective Than Clonidine When Added to Local Anesthetic for Supraclavicular Brachial Plexus Block: A Systematic Review and Meta-analysis.
BACKGROUND
Clonidine, an α-2 agonist, has long been used as a local anesthetic adjunct with proven efficacy to prolong peripheral nerve block duration. Dexmedetomidine, a newer α-2 agonist, has a more favorable pharmacodynamic and safety profile; however, data comparing its efficacy as an adjunct to that of clonidine are inconsistent. We sought to compare the clinical efficacy of these 2 α-2 agonists by examining their effects on peripheral nerve block characteristics for upper extremity surgery.
METHODS
A preliminary search found that the overwhelming majority of randomized controlled trials comparing perineural dexmedetomidine to clonidine for upper extremity surgery were in the setting of supraclavicular brachial plexus block (SCB). Therefore, we performed a systematic review and meta-analysis of randomized controlled trials comparing dexmedetomidine with clonidine as perineural adjuncts to single-injection SCB. Sensory and motor block duration and onset, analgesic duration, α-2 agonist side effects, and block complications were analyzed. Sensory block duration was designated as a primary outcome. Data were combined using random-effects modeling, and ratio-of-means was used to analyze the results.
RESULTS
A total of 868 patients from 14 clinical studies were included in the analysis. Compared with clonidine, dexmedetomidine prolonged the duration (ratio of means [95% confidence interval {CI}]) of sensory block by an estimate of 1.2 (1.2-1.3; P< .00001). It also prolonged the duration (ratio of means [99% CI]) of motor block by an estimate of 1.2 (1.1-1.3; P < .00001), and analgesia by an estimate of 1.2 (1.1-1.3; P < .00001). It also hastened the onset of sensory block by an estimate of 0.9 (0.8-1.0; P < .00001) and motor block by an estimate of 0.9 (0.9-1.0; P = .002). Dexmedetomidine was associated with an increased odds ratio (99% CI) of transient bradycardia by an estimate of 7.4 (1.3-40.8; P = .003) and postoperative sedation by an estimate of 11.8 (1.9-73.6; P = .0005). There were no differences in other α-2 agonist-related side effects or block-related complications.
CONCLUSIONS
Compared with clonidine as a local anesthetic adjunct for single-injection SCB, perineural dexmedetomidine enhances sensory, motor, and analgesic block characteristics. These benefits should be weighed against the increased risk of transient bradycardia.
Topics: Adrenergic alpha-2 Receptor Agonists; Anesthetics, Local; Brachial Plexus Block; Bradycardia; Chi-Square Distribution; Clonidine; Dexmedetomidine; Humans; Motor Activity; Odds Ratio; Pain Threshold; Risk Assessment; Risk Factors; Time Factors; Treatment Outcome; Upper Extremity
PubMed: 28525514
DOI: 10.1213/ANE.0000000000002014