Regional vitamin C in Bier block reduces the incidence of CRPS-1 following distal radius fracture surgery

Alimian, Mahzad; Eraghi, Amir Sobhani; Chavoshizadeh, Seyyed Alireza; Mohseni, Masood; Mousavi, Elham; Movassaghi, Shima

doi:10.1007/s00590-020-02821-0

Cited by 7 publications

(6 citation statements)

References 24 publications

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“…However, even among those selected 24 articles, the research quality differs a lot. Six studies are of high quality [ 28 , 34 , 39 , 42 – 44 ], 13 studies are of adequate quality [ 29 – 31 , 33 , 35 – 37 , 40 , 41 , 45 , 47 – 49 ], and five of low quality [ 32 , 38 , 46 , 50 , 51 ].…”

Section: Resultsmentioning

confidence: 99%

“…lower pain score: SMD = − 0.65, 95% CI [− 1.11, − 0.19], p = 0.005; I 2 = 81% and lower morphine consumption: WMD = − 6.74 mg, 95% CI [− 9.63, − 3.84], p < 0.00001; I 2 = 85% Subgroup analyses demonstrated significant reductions in pain severity and morphine requirement only for patients receiving iv ascorbate/ascorbic acid but not in the oral subgroup No notable increase in side effects among surgical patients Suter et al [ 34 ] Meta-analysis, 8 trials on pain and morphine consumption ( n = 782), 6 trials ( n = 863) on CRPS; high quality Note: pain intensity, cumulative iv morphine consumption, and incidence of CRPS were secondary parameter CRPS: five trials 200–1500 mg, oral for 28–50 days One trial 500 mg once as Bier block; note: both groups received additionally 500 mg orally for 6 weeks Lower postoperative VAS score: At 1–2 h (six trials, n = 642; MD = − 0.68, 95% CI [− 1.21, − 0.15], I 2 = 70%) At 6 h (five trials, n = 442; MD = − 0.71, 95% CI [− 1.20, − 0.23], I 2 = 70%) At 24 h (six trials, n = 502; MD = − 0.77, 95% CI [− 1.21, − 0.33], I 2 = 77%) Lower cumulative iv morphine consumption: At 1–2 h two trials, n = 197; MD = − 0.96 mg, 95% CI [− 1.64, − 0.28], I 2 = 0% At 24 h six trials, n = 470; MD = − 3.54 mg, 95% CI [− 5.30, − 1.77], I 2 = 90% At 48 h two trials, n = 123; MD = − 6.63 mg, 95% CI [− 9.15, − 4.11], I 2 = 0%; The exclusion of the only trial performed in intermediate/high risk surgery decreased statistical heterogeneity drastically MD = − 4.00 mg 95% CI [− 4.06, − 3.94], I 2 = 0% Reduced risk for CRPS: RR = 0.42, 95% CI [0.27, 0.65], p = 0.0001, I 2 = 0% AE were present in three RCTs ( n = 157), absent in 10 RCTs ( n = 957), and not reported in 25 RCTs ( n = 1570). One trial ( n = 20) in kidney transplantation surgery was stopped early because of safety concerns Jacques et al [ 42 ] Prospective, randomized, placebo-controlled trial; n = 74; total knee arthroplasty; high quality 1 g oral for 40 days after surgery Reduced risk for CRPS: RR = 0.27; 95% CI [0.1–0.8], p = 0.015) No AE was noted Alimian et al [ 31 ] Prospective, double-blinded, randomized placebo-controlled trial; n = 68; isolated extra-articular distal radius fra...…”

Section: Resultsmentioning

confidence: 99%

“…There is one prospective, double-blinded, randomized placebo-controlled trial ( n = 68, evidence level 1b) so far that has investigated the effects of parenteral ascorbate [ 31 ]. Although both groups received ascorbate/ascorbic acid orally for 6 weeks, local injection of 500 mg ascorbate (adjuvant in Bier block) significantly reduced the incidence of CRPS 12 weeks after surgery (22.9 vs. 45.5%, p = 0.04).…”

Section: Resultsmentioning

confidence: 99%

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The Use of High-Dose Intravenous l-Ascorbate in Pain Therapy: Current Evidence from the Literature

Likar,

Poglitsch,

Bejvančický

et al. 2024

Pain Ther

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Introduction Pain is the most common reason for seeking medical treatment. Despite extensive research efforts and effective analgesics modulating pain, there is still a major therapeutic gap in addressing the root causes of pain. Pain is associated with tissue damage induced by oxidative stress and induction of inflammatory mediators following high consumption of antioxidants. The role of antioxidants in general, and the administration of l -ascorbate in particular, is still controversially discussed and underestimated in the daily clinical practice. Methods The current literature on the therapeutic effect of l -ascorbate, ascorbic acid, and vitamin C on various pain conditions was evaluated against the background of evidence-based medicine. Those articles, obtained from systematic search in PubMed, were critically assessed and rated in terms of evidence level and methodological quality by two independent experts. The primary purpose of this work was to establish specific pain therapy guidance for intravenous l -ascorbate. Results A PubMed search revealed 14 suitable articles comprising controlled clinical trials and meta-analyses. An additional ten publications could be identified via secondary literature. There is supporting evidence for the efficacy of ascorbate treatment in inflammatory pain conditions, in the complex regional pain syndrome, in post zoster neuralgia, in neuropathic pain, in post-operative pain conditions, and in tumor-related pain. However, the considered studies differ in the type of administration, in dosage, in duration of treatment, as well as in quality of research. Despite all study heterogeneity, it became evident that research of high scientific quality is in support of the efficacy of l -ascorbate in pain treatment. Discussion Oxidative stress is present in almost all pain conditions. Because oral administration of most magistral formulas of vitamin C does not provide biological availability, parenteral administration should be preferred and can be supported by an oral dose with high bioavailability on days without intravenous treatment. l -ascorbate should be preferred for parenteral high dosage, rather than ascorbic acid, as it does not release acid valences under physiological conditions. Conclusions l -ascorbate is an effective, safe, and economically favorable integrative treatment option for various pain conditions, addressing the root cause of tissue damage and inflammatory mediator burst. Graphical Abstract

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Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

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The Use of High-Dose Intravenous l-Ascorbate in Pain Therapy: Current Evidence from the Literature

Likar,

Poglitsch,

Bejvančický

et al. 2024

Pain Ther

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“…Consistent with this idea, emerging evidence suggests that antioxidant therapy using multiple combined antioxidants reduce migraine headache frequency and intensity, 80 and may reduce pain in individuals with chronic pelvic pain, 65 pancreatitis, 14 and osteoarthritis. 66 In addition, some trials suggest that vitamin C, which has antioxidant effects, may reduce the risk of complex regional pain syndrome after surgery 2,36,45 and fracture. 1 Findings such as these that antioxidant interventions which reduce OS also decrease pain intensity and may in some contexts prevent development of CP provide tentative support for a causal role for OS in CP.…”

Section: Discussionmentioning

confidence: 99%

Oxidative stress is associated with characteristic features of the dysfunctional chronic pain phenotype

Bruehl¹,

Milne²,

Schildcrout

et al. 2021

Pain

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The dysfunctional chronic pain (Dysfunctional CP) phenotype is an empirically identifiable CP subtype with unclear pathophysiological mechanisms that cuts across specific medical CP diagnoses. This study tested whether the multidimensional pain and psychosocial features that characterize the dysfunctional CP phenotype are associated broadly with elevated oxidative stress (OS). Measures of pain intensity, bodily extent of pain, catastrophizing cognitions, depression, anxiety, sleep disturbance, pain interference, and function were completed by 84 patients with chronic osteoarthritis before undergoing total knee arthroplasty. Blood samples were obtained at the initiation of surgery before incision or tourniquet placement. Plasma levels of F2-isoprostanes and isofurans, the most highly specific measures of in vivo OS, were quantified using gas chromatography/negative ion chemical ionization mass spectrometry. The results indicated that controlling for differences in age, sex, and body mass index, higher overall OS (mean of isoprostanes and isofurans) was associated with significantly (P , 0.05) greater pain intensity, more widespread pain, greater depressive symptoms and pain catastrophizing, higher pain interference, and lower function. OS measures were not significantly associated with sleep disturbance or anxiety levels (P .0.10). The results build on prior case-control findings suggesting that presence of a CP diagnosis is associated with elevated OS, highlighting that it may specifically be individuals displaying characteristics of the dysfunctional CP phenotype who are characterized by elevated OS. Clinical implications of these findings remain to be determined.

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“…Five studies (n¼795) administered enteral ascorbic acid (200e1500 mg) for 28e50 days, whereas one study (n¼68) administered intravenous vitamin C once as Bier block adjuvant. 22 The use of ascorbic acid was associated with a lower incidence of CPRS type I at longest follow-up available (22 of 420 [5.24%] with vitamin C vs 59 of 443 [13.32%] with control, RR¼0.42 [95% CI, 0.27 to 0.65], P¼0.0001, I 2 ¼0%) (Supplementary Fig. 5).…”

Section: Complex Regional Pain Syndromementioning

confidence: 95%

Efficacy and safety of perioperative vitamin C in patients undergoing noncardiac surgery: a systematic review and meta-analysis of randomised trials

Suter

Pinto

Belletti

et al. 2022

British Journal of Anaesthesia

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Regional vitamin C in Bier block reduces the incidence of CRPS-1 following distal radius fracture surgery

Cited by 7 publications

References 24 publications

The Use of High-Dose Intravenous l-Ascorbate in Pain Therapy: Current Evidence from the Literature

The Use of High-Dose Intravenous l-Ascorbate in Pain Therapy: Current Evidence from the Literature

Oxidative stress is associated with characteristic features of the dysfunctional chronic pain phenotype

Efficacy and safety of perioperative vitamin C in patients undergoing noncardiac surgery: a systematic review and meta-analysis of randomised trials

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