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Been here before on this topic. It's interesting how once again, guys, as I've said many times before, there's really nothing new under the sun and it's okay. We need to keep investigating this. As I've said many times before, also, the way that you do science is you keep checking the science. So while we're going to talk about this brand new publication out of the Pink journal, I do want to touch on, I mean super fast, I'm not going into any specific numbers and tell you the the big kind of conglomerate thought and results conclusions from these previous three reviews. And then we're going to get into this latest publication because the good news is, yeah, they all pretty much say the same thing. Yeah, sure, slap one of them bad boys on either above the fan and steel or on one side of the incision or the other. They seem to have a role. That's the good news. So if somebody asks you, does topical lidocaine patches, does that have a role for post cesarean pain control? Absolutely. There's no national guidance for it. It's not part of ACOG's multimodal or stepwise progressive algorithm. It's not on there, but sure. I mean, why not? As an adjuvant, it can be used, although of course we know it's got some limitations, can't be used by itself. And past a certain cutoff, which traditionally seems to be about 48 hours, there's really no difference in the patient's use of narcotics or satisfaction after that point. Okay, so that's the spoiler. Yes, these things definitely have a function. They definitely decrease VAS scores as visual analog score for pain. But it's short term. With the data showing 12 hours, check. They're going to feel better 24 hours. Yeah. Still working 36 hours. Yep, it's still good. But then it kind of falls down after that from 48 to 72 hours onward. Why? Because the initial discomfort is seems to be more localized and superficial and then as obviously the body heals kind of the pain may be not adequate control just by something topical and they need something else. Now it doesn't have to be narcotics just to be very clear. I mean we are big fans of progressive use and alternating doses of Tylenol and Motrin in most patients underdose their Motrin. So assuming that they don't have any kind of renal or hepatic dysfunction, you know, 600 milligrams of Motrin or a maximum of 800 milligrams every eight hours with food is okay, but most patients will take, you know, 200 milligrams of Motrin. Honey, that's not enough. You got a big old incision on your abdomen. You got to crank up those bad boys as long as you can tolerate that well. And there's no contraindication. So before we get into this new publication, let me just start with 2019 very quickly. That was the first systematic review that I want to dive into. This was actually published out of Current Pain and Medicine reports. Okay. Current Pain and Medicine. Sorry. And Headache Reports. It's a weird journal, I know, but. But it is a thing. It is Current Pain and Headache Reports. The title of this systematic review was Transdermal Lidocaine for perioperative pain. 2019. I don't want to dwell too much on this one because we got newer ones, but let me just give you the short term, the short answer. In the short term, post op pain control definitely improves with lidocaine patches. The problem, though, is that it was unclear. According to that 2019 systematic review, it was unclear if opioid reduction actually occurred and if there was any increase in patient ambulation function compared to those who did not use lidocaine. So in other words, yeah, sure, why not? It can help. And remember, our old motto and adage on the show is, hey, if it can possibly help and it doesn't hurt and there's some evidence for it, why not? So 2019, the emoji that summarizes lidocaine patches for post Caesarean pain control is meh. But it's not going to hurt. Nobody had had a complication from a lidocaine patch. So anyway, 2019, let's just check that little box. We covered that one and let's keep moving on. We go forward three years to 2022, and this is now a not just a systematic review, but a meta analysis of 11 RCTs. Keep these numbers in mind. 11 randomized clinical trials. This was Coo et al. That's K O O from 2022. And once again, yeah, lidocaine patches absolutely lowered pain scores up to 48 hours, but, quote, did not significantly reduce morphine consumption at 24 or 48 hours. The good news was, is that there was no increase in local or systemic side effects from the patches. End quote. So once again, very short term. Sure, why not? It could help me so that we're Back to the meh emoji. And again, I'm not trying to downplay this, but I'm just trying to. I want to show you how. It's interesting how people look at the same thing, but based on how they create their systematic review and meta analysis, whether they're going to include or exclude something, how you can still get the general vibe of it. But. But the numbers included are so different. Remember, 11 RCTs from coup in 2022. What? Oh, I forgot to tell you where that was. So, so sorry. So that was in the Journal of Clinical Anesthesia. Thank you, Michael. Journal of Clinical Anesthesia. So there you go. That's 2022. Let's go forward a year after that to 2023. Now, unlike the 2022 one that used 11 RCTs, this one now used 16 RCTs. You're like, wow, there was five more in that year. No, it depends on how. Once again, what they use for their inclusion and exclusion criteria. This is Wu et al. Wu, Wu et al. In 2023, 16 RCTs, total number of N for patients was 918. Now, these were various surgeries. Just to be clear, these were not just cesarean section, but they did include cesarean. All right, so it's a little bit more holistic. Exact same deal. 12 hours. Yeah. Pain scores much less. 24. Still good. 48 hours. Yeah, still good. And at that time, there was some decrease in opioid requirement. You're like, all right, this one showed it. Hey, in the first two days, they did reduce opioid requirements, specifically morphine. That's good news. Yeah. But however, overall, when they were asked, one group compared to the other, there was no real difference in patient satisfaction. So once again, yes, our goal should be to reduce narcotics. That's great. But overall, they're like, meh. So you all get this. How interesting is that? 2019 definitely showed some limited efficacy as a systematic review. 2022 said, yep, again, about 48 hours. And things kind of fall apart a little bit. Although the 2022 paper did not show any significant reduction in morphine consumption consumption. And then 2023, which showed pretty much the same thing. It works in the short term, really about 48 hours. But that one did show some decrease in morphine consumption, although overall patient satisfaction was not greatly improved. This publication from Woo et al was in the Clinical Journal of Pain, The Clinical Journal of Pain Reading. That sounds like it would be a pain. The Clinical Journal of Pain. My goodness. Well, that brings us now to this latest systematic review and meta analysis from the Pink Journal, which is lidocaine patches after cesarean delivery. A meta analysis of randomized control trials. Very quickly, because I want to knock this out because honestly, I'm kind of late to a meeting. I did not know that, Michael. I went over my. I mistimed this. Sorry. Let's get over. Let's get through this. So anyway, so I've got three. This is three RCTs, including 219 pregnancies. Now you're like, what happened to the others? That's how they designed this one. My point is, whenever you read a meta analysis, guys, that's good. That's a great way to take a lot of data, shuffle it through the mixer, put into the washing machine and see what it spits out. But it's still only as good as what you put into it. And that what you get out of it is what you put into it. I'm just saying this is not one of the larger RCTs, even though this was very lidocaine friendly. Because the biggest one yet is one that we just covered in 2023, which was 16. Okay, is that interesting or what? Again, just depends on how people dice it up. But this was three RCTs. The good news is. Surprise. No surprise. Exact Same thing at 12, 24 and 36 hours. Visual analog pain scores. VAs scores were significantly better. That's good. However, after that, the vas scores at 48 and 72 hours were similar. And there was similar opioid consumption between the two groups. Those with lidocaine and those without. So what's the quick take home message as we start wrapping this up? Maybe. Hey, why not? It doesn't seem to hurt. But according to this latest review, again, this is Pink Journal. Just, what, four days ago, from when we're doing this quote, based on this data. Remember, this is the one that they had put together on three RCTs. Based on this data, the use of lidocaine patches may be considered as part of a multimodal analgesia strategy after cesarean delivery. End quote. This is why you got to look at all the data gather. Because if you just read that conclusion, like, oh, hey, lidocaine patches should be considered based on this data. I'm going to do it just because that sentence says so. Again, you got to know what it can do and what it can't do in the first up to 48 hours. The first 48 hours. That's a good detective show, by the way. See, this is why these things take forever. Because in my brain, I said, First 48 hours. And this is something like me and my wife like to binge watch. Because one of the. One of the offices of those detectives on the first 48 hours is in our old previous town of Dallas. That's the Dallas PD headquarters that do that. Anyway, nothing to do with what we're talking about, but this is why it takes forever. Can you believe it? Geez Louise. Anyway, the first 48, yes, lidocaine patches do work, even though after that, it kind of falls apart a little bit. And that's why, if you're going to do this, that's fine. Maybe use this as a quality improvement project in your institution. Maybe get some data together. Talk with your anesthesia buddies or those in soap, the Society of Obstetrical Anesthesia and Perinatal Providers, and see what they think. I think it's a good idea to try. I'm all for it. Even though the benefit seems to be pretty short term. All right, everybody, I think I've done what I'm supposed to do. I think now that we've done all that, we can start to wrap this up. Am I done? It looks like I'm late for a meeting. All right, everyone. We've covered a new systematic review and meta analysis from the Pink Journal. And now that we've done all that, let's take it home. This has been Dr. Chapa Zobichyn. No Sweet Spin Podcast Podcast family, thank you for your support. Thank you for listening, and as always, we'll see you on another episode of the no Spin Podcast.