Differential Pain Presentations Observed across Post-Traumatic Stress Disorder Symptom Trajectories after Combat Injury.

OBJECTIVE: This study evaluated the association between pain outcomes and post-traumatic stress disorder (PTSD) symptom trajectories after combat-related injury, while adjusting for receipt of regional anesthesia (RA) soon after injury. METHODS: The PTSD symptom trajectories of N = 288 combat-injured service members were examined from within a month of injury up to two-years after. Linear mixed-effects models evaluated the association between PTSD symptom trajectories and average pain and pain interference outcomes while adjusting for receipt of RA during combat casualty care. RESULTS: Four PTSD trajectories were characterized: resilient, recovering, worsening, and chronic. Differential pain presentations were associated with PTSD symptom trajectories, even after adjusting for receipt of RA. Compared to those with a resilient PTSD symptom trajectory, individuals presenting with chronic PTSD trajectories were estimated to experience average pain scores 2.61 points higher (95% CI: 1.71, 3.14). Participants presenting with worsening (ß = 1.42; 95% CI: 0.77, 1.78) and recovering PTSD trajectories (ß = 0.65; 95% CI: 0.09, 1.08) were estimated to experience higher average pain scores than participants with resilient PTSD trajectories. Significant differences in pain interference scores were observed across PTSD trajectories. Receiving RA was associated with improved pain up to two years after injury (ß = -0.31; 95% CI: -0.90, -0.04), however no statistically significant association was detected between RA and PTSD trajectories. CONCLUSIONS: Chronic and worsening PTSD trajectories were associated with greater pain intensity and interference following combat injury even when accounting for receipt of early RA for pain management. These findings underscore the need to jointly assess pain and PTSD symptoms across the trauma care continuum.

Technical effects of adding 1 % lidocaine to technetium sulfur colloid for sentinel lymphatic mapping in early breast cancer: analysis of data from a double-blind randomized controlled trial.

BACKGROUND: A practice standard in sentinel lymph node (SLN) mapping in breast cancer is intradermal injection of technetium-99m sulfur colloid (Tc-99m), resulting in significant patient discomfort and pain. A previous randomized controlled trial showed that adding lidocaine to Tc-99m significantly reduced radioisotope injection-related pain. We tested whether 1 % lidocaine admixed with Tc-99m affects feasibility of SLN mapping. METHODS: Between January 2006 and April 2009, 140 patients with early breast cancer were randomly assigned (1:1:1:1) to receive standard topical 4 % lidocaine cream and intradermal Tc-99m (control) or to one of three other study groups: topical placebo cream and injection of Tc-99m containing sodium bicarbonate (NaHCO3), 1 % lidocaine, or both. All SLN data were collected prospectively. RESULTS: Study groups were comparable for clinicopathological parameters. As previously reported, the addition of 1 % lidocaine to the radioisotope solution significantly improved patient comfort. Overall SLN identification rate in the trial was 93 %. Technical aspects of SLN biopsy were similar for all groups, including time from injection to operation, first SLN (SLN 1) gamma probe counts, ex vivo counts for SLN 1 and SLN 2, and axillary bed counts. SLN identification rates were comparable statistically: control (96 %), lidocaine (90 %), sodium bicarbonate (97 %), and sodium bicarbonate-lidocaine (90 %). The control group had a significantly higher SLN 2/SLN 1 ex vivo count ratio, and the number of SLNs detected was significantly reduced in the lidocaine versus no-lidocaine groups (p < 0.05). CONCLUSIONS: Addition of 1 % lidocaine to standard radioisotope solution for SLN mapping in breast cancer is associated with fewer SLNs detected, but it does not appear to compromise SLN identification.

Utilidad de los anestésicos locales en anestesia regional / Local anesthetics for regional anesthesia: an update

La anestesia regional en el siglo XXI, específicamente el bloqueos nervioso periférico y el bloqueo continuo de nervios periféricos, siguen gozando de una popularidad sin precedentes. A pesar de este resurgimiento de la popularidad, la investigación de un anestésico local nuevo y de acción más prolongada e inyectable con mejor perfil de seguridad sigue siendo un objetivo distante y difícil de lograr. Se han creado pocos anestésicos locales nuevos para uso clínico desde comienzos de la década de 1970. Los esfuerzos por mejorar la eficacia, la duración y la seguridad de los anestésicos locales inyectables incluyen aditivos y la nueva tecnología de localización de la aguja. Cualquier explicación convincente de los anestésicos locales de uso frecuente utilizados en la anestesia regional debe incluir un resumen detallado de la toxicidad de los anestésicos locales que incluya prevención, detección y tratamiento. Se plantea un enfoque específico sobre la aparición reciente de intralipid como tratamiento de la cardiotoxicidad inducida por anestésicos locales. Esta revisión de los anestésicos locales examinará la farmacología básica, explorará las tendencias actuales en la práctica de la anestesia regional y describirá los adelantos recientes en el uso clínico de los anestésicos locales y sus aditivos.

Regional anesthesia in the 21st century, specifically peripheral nerve blocks (PNBs) and continuous peripheralnerve blocks (CPNBs), continues to enjoy unparalleled popularity. Despite this resurgence in popularity, thesearch for a new, longer-acting local anesthetic (LA) forinjection with an improved safety profile remains anelusive and distant goal. A paucity of new local anestheticshas been developed for clinical use since the early 1970’s.Efforts to improve the efficacy, duration, and safety ofinjected LAs include drug additives to LAs and new need lelocalization technology. Any cogent discussion of the common LAs used with regional anesthesia must includea thorough summary of LA toxicity to include prevention,detection, and treatment. A specific focus on the recentemergence of Intralipid as a treatment for local anestheticinducedcardiac toxicity will ensue. This LA review willexamine basic pharmacology, explore current trends in regional anesthesia practice, and describe recent developments in the clinical use of LA and additives.