Anesthesiology
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Randomized Controlled Trial Multicenter Study
Intravenous Lidocaine Does Not Improve Neurologic Outcomes after Cardiac Surgery: A Randomized Controlled Trial.
Why is this interesting?
Lidocaine/lignocaine has been increasingly used intra- and perioperatively as an analgesic adjunct, with further research suggesting a potential neuroprotective effect. Cognitive decline is a common problem following cardiac surgery (40-50%), with lidocaine potentially offering a simple and safe intervention to reduce this complication. Past studies have showed conflicting results.
What did they do?
This Duke University team randomized 478 cardiac surgery patients across multiple centres to lidocaine intraoperatively (1 mg/kg bolus then decreasing infusions across 2.9 / 1.5 / 0.6 mg/kg/h over 48 hours) or blinded control. Cognitive function was assessed at 6 weeks and 1 year.
They found...
No difference in cognitive deficit between lidocaine infusion and saline control at either 6 weeks or 1 year.
Be smart
Intravenous lidocaine infusion remains relatively safe, practical and is still likely a useful analgesic adjunct. Similar to magnesium, which has been shown to be neuroprotective in premature infants but not adult cardiac patients, the problem for lidocaine may well be context rather than physiological benefit itself.
summary -
Opioids are a mainstay of perioperative analgesia. Opioid use in children with obstructive sleep apnea is challenging because of assumptions for increased opioid sensitivity and assumed risk for opioid-induced respiratory depression compared to children without obstructive sleep apnea. These assumptions have not been rigorously tested. This investigation tested the hypothesis that children with obstructive sleep apnea have an increased pharmacodynamic sensitivity to the miotic and respiratory depressant effects of the prototypic μ-opioid agonist remifentanil. ⋯ No differences in the remifentanil concentration-miosis relation were seen in children with or without obstructive sleep apnea. The dose and duration of remifentanil administered did not alter ventilatory parameters in either group.
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Opioid analgesics are widely used for treatment of acute, postoperative, and chronic pain. However, activation of opioid receptors can result in severe respiratory depression. There is an unmet clinical need to develop a pharmacologic therapy to counter opioid-induced respiratory depression without interfering with analgesia. Further, additional advances to confront accidental lethal overdose with the use of fentanyl and other opioids are needed. Here, the authors test the hypothesis that activation of nicotinic receptors expressed within respiratory rhythm-generating networks would counter opioid-induced respiratory depression without compromising analgesia. ⋯ The novel strategy of targeting α4β2 nicotinic acetylcholine receptors has the potential for advancing pain control and reducing opioid-induced respiratory depression and overdose.
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Comment Letter
Intubation in Operating Room versus Intensive Care: Comment.