The analgesic effectiveness of perioperative lidocaine infusions for acute and chronic persistent postsurgical pain in patients undergoing breast cancer surgery: a systematic review and meta-analysis.

BACKGROUND: Breast cancer is the most common cancer among women and tumour resection carries a high prevalence of chronic persistent postsurgical pain (CPSP). Perioperative i.v. lidocaine infusion has been proposed as protective against CPSP; however, evidence of its benefits is conflicting. This review evaluates the effectiveness of perioperative lidocaine infusions for breast cancer surgery. METHODS: Randomised trials comparing perioperative lidocaine infusions with parenteral analgesia in breast cancer surgery patients were sought. The two co-primary outcomes were the odds of CPSP at 3 and 6 months after operation. Secondary outcomes included rest pain at 1, 6, 12, and 24 h; analgesic consumption at 0-24 and 25-48 h; quality of recovery; opioid-related side-effects; and lidocaine infusion side-effects. Hartung-Knapp-Sidik-Jonkman (HKSJ) random effects modelling was used. RESULTS: Thirteen trials (1039 patients; lidocaine: 518, control: 521) were included. Compared with control, perioperative lidocaine infusion did not decrease the odds of developing CPSP at 3 and 6 months. Lidocaine infusion improved postoperative pain at 1 h by a mean difference (95% confidence interval) of -0.65 cm (-0.73 to -0.57 cm) (P<0.0001); however, this difference was not clinically important (1.1 cm threshold). Similarly, lidocaine infusion reduced oral morphine consumption by 7.06 mg (-13.19 to -0.93) (P=0.029) over the first 24 h only; however, this difference was not clinically important (30 mg threshold). The groups were not different for any of the remaining outcomes. CONCLUSIONS: Our results provide moderate-quality evidence that perioperative lidocaine infusion does not reduce CPSP in patients undergoing breast cancer surgery. Routine use of lidocaine infusions for perioperative analgesia and CPSP prevention is not supported in this population. SYSTEMATIC REVIEW PROTOCOL: PROSPERO CRD42023420888.

Rare Case of Tongue Ischemia Following Cardiopulmonary Bypass.

Tongue ischemia is a devastatingly rare disease complication that is typically attributed to cranial arteritis, vasculitis, or prolonged oral intubation that manifests in a patient as a phenotypically black or discolored tongue. There have been less than 10 cases reported in the literature, however, documenting tongue ischemia secondary to shock states requiring high-dose vasopressor support. In these cases, the ischemia or necrosis has typically been limited to the tip of the tongue or has been associated with unilateral disease as bilateral tongue involvement is unlikely given the collateral blood supply of the tongue. To date, the use of imaging modalities to confirm lingual artery disease as the etiology for the presentation of tongue ischemia has been limited. We present a unique case of bilateral tongue ischemia following the use of cardiopulmonary bypass which was confirmed with radiographic evidence demonstrating bilateral lingual artery disease. The nature of case is presented, previous reports of similar cases are reviewed, and potential etiologies of this rare manifestation are discussed.

Remimazolam for Sedation During Upper Gastrointestinal Endoscopy in an Adolescent.

Remimazolam is a short-acting benzodiazepine that has recently received approval from the US Food and Drug Administration (FDA) for procedural sedation in adults. Similar to other benzodiazepines such as midazolam, remimazolam has sedative, anxiolytic, and amnestic properties. Rapid metabolism by plasma esterases results in a half-life of 5 - 10 min and a limited context sensitive half-life. Preliminary data from adult studies have demonstrated favorable hemodynamic stability, no pain on injection, and limited impact on ventilatory function. To date, its use as the primary agent for procedural sedation in pediatric-aged patients has been limited, as previous published reports of its use have detailed its administration as an adjunct to general anesthesia. We report anecdotal experience with the use of remimazolam for procedural sedation during an upper gastrointestinal endoscopy in a 15-year-old adolescent with multiple drug and food allergies. The role of remimazolam in procedural sedation is discussed, previous reports of its use in pediatric-aged patients are reviewed, and dosing algorithms are presented.