Regional anaesthesia and cancer metastases: the implication of local anaesthetics

E. G. VOTTA-VELIS et al.

Acta Anaesthesiologica Scandinavica

Volume 57, Issue 10, pages 1211–1229, November 2013

Clinical and basic science studies have demonstrated the anti-inflammatory properties of local anaesthetics. Recent studies have begun to unravel molecular pathways linking inflammation and cancer. Regional anaesthesia is associated in some retrospective clinical studies with reduced risk of metastasis and increased long-term survival. The potential beneficial effects of regional anaesthesia have been attributed mainly to the inhibition of the neuroendocrine stress response to surgery and to the reduction in the requirements of volatile anaesthetics and opioids. Because cancer is linked to inflammation and local anaesthetics have anti-inflammatory effects, these agents may participate in reducing the risk of metastasis, but their mechanism of action is unknown. We demonstrated in vitro that amide local anaesthetics attenuate tumour cell migration as well as signalling pathways enhancing tumour growth and metastasis. This has provided the first evidence of a molecular mechanism by which regional anaesthesia might inhibit or reduce cancer metastases.

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A Randomized Trial of Epidural Glucocorticoid Injections for Spinal Stenosis

 Janna L. Friedly, M.D et al.

 N Engl J Med 2014; 371:11-21July 3, 2014

 In a double-blind, multisite trial, they randomly assigned 400 patients who had lumbar central spinal stenosis and moderate-to-severe leg pain and disability to receive epidural injections of glucocorticoids plus lidocaine or lidocaine alone. The patients received one or two injections before the primary outcome evaluation, performed 6 weeks after randomization and the first injection. 

 At 6 weeks, there were no significant between-group differences in the RMDQ score (adjusted difference in the average treatment effect between the glucocorticoid–lidocaine group and the lidocaine-alone group).

In the treatment of lumbar spinal stenosis, epidural injection of glucocorticoids plus lidocaine offered minimal or no short-term benefit as compared with epidural injection of lidocaine alone.

Anesthesia Technique, Mortality, and Length of Stay After Hip Fracture Surgery

Mark D. Neuman, MD, MSc; Paul R. Rosenbaum, PhD; Justin M. Ludwig, MA; Jose R. Zubizarreta, PhD; Jeffrey H. Silber, MD, PhD

JAMA. 2014;311(24):2508-2517

The investigators conducted a matched retrospective cohort study involving patients 50 years or older who were undergoing surgery for hip fracture at general acute care hospitals Of 56 729 patients, 15 904 (28%) received regional anesthesia and 40 825 (72%) received general anesthesia. Overall, 3032 patients (5.3%) died in New York State between July 1, 2004, and December 31, 2011.

To go beyond prior observational studies, they used 2 statistical techniques intended to address selection bias, multivariable matching, and instrumental variable analysis. They hypothesized that regional anesthesia would be associated with improved outcomes compared with general anesthesia.

The near-far matched analysis showed no significant difference in 30-day mortality by anesthesia type among the 21 514 patients included in this match

Regional anesthesia was associated with a 0.6-day shorter length of stay than general anesthesia

Asleep Versus Awake: Does It Matter?: Pediatric Regional Block Complications by Patient State: A Report From the Pediatric Regional Anesthesia Network.

Reg Anesth Pain Med. 2014 Jun 10.

Taenzer AH, Walker BJ, Bosenberg AT, Martin L, Suresh S, Polaner DM, Wolf C, Krane EJ

The investigators analized  more than 50,000 pediatric regional anesthesia blocks from an observational prospective database, and determined  the rate of adverse events in relation to the patient's state at the time of block placement. Primary outcomes considered were postoperative neurologic symptoms (PONSs) and local anesthetic systemic  toxicity (LAST). Secondary outcome was extended hospital stay due to a block complication.

Postoperative neurological symptoms occurred at a rate of 0.93/1000 (confidence interval [CI], 0.7-1.2) under GA and 6.82/1000 (CI, 4.2-10.5) in sedated and awake patients.

The only occurrence of PONSs lasting longer than 6 months (PONSs-L) was a small sensory deficit in a sedated patient (0.019/1000 [CI, 0-0.1] for all, 0.48/1000 [CI, 0.1-2.7] for sedated patients).

 There were no cases of paralysis.

There were 5 cases of LAST or 0.09/1000 (CI, 0.03-0.21). The incidence of LAST in patients under GA (both with and without NMB) was 0.08/1000 (CI, 0.02-0.2) and 0.34/1000 (CI, 0-1.9) in awake/sedated patients.

Extended hospital stays were described 18 times (0.33/1000 [CI, 0.2-0.53]). The rate for patients under GA without NMB was 0.29/1000 (CI, 0.13-0.48); GA with NMB, 0.29/1000 (CI, 0.06-0.84); sedated, 1.47/1000 (CI, 0.3-4.3); and awake, 1.15/1000 (CI, 0.02-6.4).

They conclude that  the placement of regional anesthetic blocks in pediatric patients under GA is as safe as placement in sedated and awake children.

Effects of a head elevated ramped position during elective caesarean delivery after combined spinal-epidural anaesthesia.

Cheesman K, Massey S, Preston R, Albert A, Douglas J.

Int J Obstet Anesth.     2014 May;23(2):106-12.

Elevating the parturient undergoing elective caesarean delivery into the Head Elevated Ramped Position immediately or once the block had been established did not appear to significantly alter time to an adequate block height of T4; however, the need for epidural supplementation was greater in the intervention groups. Cautious use of this novel position change can provide a more comfortable experience and provide a better airway position should conversion to general anaesthesia be required.

Carotid endarterectomy under local and/or regional anesthesia has less risk of myocardial infarction compared to general anesthesia: An analysis of national surgical quality improvement program database.

Kfoury E, Dort J, Trickey A, Crosby M, Donovan J, Hashemi H, Mukherjee D

.

Vascular. 2014 May 29. 

Our study compared 30-day postoperative myocardial infarction, stroke, and mortality between carotid endarterectomy under local or regional anesthesia and carotid endarterectomy under general anesthesia utilizing National Surgical Quality Improvement Program database

Carotid endarterectomy under local or regional anesthesia had a significantly decreased risk of 30-day postoperative myocardial infarction when compared to carotid endarterectomy under general anesthesia (0.4% vs 0.86%, p = 0.012). No statistically significant differences were found in postoperative stroke or mortality.