IV Lidocaine Infusion and Pain

Micah Scott: SRNA, RN, BSN, CCRN

&

Nina Weber: SRNA, RN, BSN, CCRN

Oregon Health & Science University

Class of 2012

Review

• Definition of Lidocaine

• Mechanism of Lidocaine

• Benefits/Disadvantages

• Who Benefits

• Case Studies

• Recommendations

Lidocaine • Local Anesthetic (Amide)

• Onset is fast (pka = 7.9) • 76% ionized at pH 7.4

• Duration is 90-200 min (Intermediate) • metabolism in liver

• 64% protein bound

• ½ life = 1.5 hours

• Reason for use • Antiarrhythmic, Analgesic

• Anti-inflammatory, Anti-hyperalgesic

• Reactive Airway

• Routes of Administration • IV, Epidural, Patch, Oral, Topical, Spinal

(Barash, Cullen, Stoelting, Cahalan, & Stock, 2009) (Nagelhout & Plaus, 2010)

Lidocaine MOA

• Blocks intracellular Na channels of neuron • Interrupts propagation of impulses in axons

• Inhibits NMDA signaling and activation

• Inhibiting glutamate/glycine • Inhibition of protein kinase C

• Attenuates IL-6, IL-8 and IL-1RA production

• Inhibition of spontaneous electrical activity in injured C nerve fibers and A – delta fibers

(Hahnenkamp, et al., 2006 ) (Kuo, Jao , Chen, Wong, Yeh, Sheen, & Wu, 2006 ) (Barash, Cullen, Stoelting, Cahalan, & Stock, 2009)

Benefits?

• Decrease LOS

• Reduction in narcotics

• Reduction in inhalation agent

• Decreased time to BM and flatulence

• Decreased N/V

• Decrease ileus

• Decreased rehab times

• Neuropathic pain

• Decreases inflammation

• Decreases pain

• Decreased respiratory depression

(Groudine, Fisher, Kaufman, Patel, Wilkins, Mehta, & Lumb, 1998) (Lauwick, Kim, Michelagnoli, Mistraletti, Feldman, Fried, & Carli, 2008) (Vigneault, et al, 2011) (Kuo, Jao, Chen, Wong, Yeh, Sheen, & Wu, 2006 )

Who Benefits?

• Surgeries with visceral pain

• Patients with neuropathic pain

• Patients with chronic pain?

• Cardiac surgery

• Patients with inflammatory problems

• Reactive airway disease

Disadvantages

• Toxicity, 5-10 mcg/ml, > 25 mcg/ml is deadly

• Meta-analysis of RCTs done by Vigneault stated that there are limited studies to prove toxicity with lidocaine drips

• Contraindications

• Heart block

• Allergies

(Barash, Cullen, Stoelting, Cahalan, & Stock, 2009) (Vigneault, et al, 2011) (Image retrieved from googleimages.com)

Lidocaine for Pain- Well Studied

(Lauwick, et al, 2008)

Lauwick et al Population

• 50 Lap Chole pts

• ASA I-II

• Excluded:

• Morbid Obesity

• DM

• Chronic Opioid

Users

(Lauwick, et al, 2008)

Lauwick et al- Protocol

Control Group – No Lidocaine

n=25

Lidocaine Group n=25

Preoperative 0.03mg/kg Midazolam

Opioids Pre-Induction

3 mcg/kg Fentanyl 1.5 mcg/kg Fentanyl

Lidocaine

1.5 mg/kg Lidocaine Bolus

2 mg/kg/hr Lidocaine gtt

Induction Propofol 2.5mg/kg & Rocuronium 0.8mg/kg Desflurane

Lauwick et al Protocol Control Group – No

Lidocaine Lidocaine Group

Maintenance -No Intraoperative Opioids

-Desflurane- titrated by BIS 35-50 & VS at 20% of baseline (HR/SBP)

-Treat MAP <60 with Phenylephrine 40mcg -Rocuronium 0.1mg/kg Supplemental

Pain Adjuncts -Acetaminophen 1.3g PR post induction -Ketorolac 15mg IV at Sx completion -Incisional Lidocaine

Lidocaine gtt Off at Last Suture

PACU RN Administration of Opioids

Lauwick et al Continued

Findings *Statistically

Significant

*Less Fentanyl in PACU Decrease In PONV?

=Post op Pain Scores

* 10% less Desflurane

= Readiness for PACU discharge scores

*10 Min. Quicker Surgical Time

Pooled Findings

• Opioid & Inhalation Agent Sparing

• Lower Pain Scores Immediate & Extended Postop

• Faster or equal time for PACU/Home Discharges

• Many Decreased Opioid Benefits

• PONV Prevention?

• LA from Epidural has similar effects

(Lauwick, et al, 2008)

Ideal Candidate

• Visceral Pain Expected-Abdominal/GYN sx • Longer/Traumatic Surgery or Difficult Laparoscopic

Sx Expected?

• Without Epidural: Contraindicated or Converted to Open

• NSAIDs Contraindicated

• Pt With Need for Decreased Opioids

• Concerned with PONV or Bowel Function

(Lauwick, et al, 2008)

Recommendations for Use

• Starting Infusion

• Bolus – 1.5mg/kg IV

• Lidocaine gtt – 2mg/kg/hr

• 30 min. Prior to

Noxious Stim/Incision

Rationale- Inflammation

• Use Combined with other Multimodal Therapies

• Ketorolac - Tylenol - Opioids

Ahmed + Lidocaine

(Lauwick, et al, 2008)

Recommendations Emergence

• Will Lidocaine Infusion Delay Emergence or Transfer from PACU?

• Stop 30 min. Prior to Emergence

• Correlate With:

• Opioid Amount Given

• Length of Surgery

• MAC Level During Case

(Lauwick, et al, 2008)

Recommendations Postop

• Titrate Opioids in PACU

• Written orders for titration

• Fentanyl 25mcg IV Bolus q 5 min max 200mcg/hr

• PO Meds- Smaller Dose/Less Frequent

(Lauwick, et al, 2008)

Lidocaine Comparison to Common Adjuncts

Vs. Toradol (Ketorolac)

• Elderly ? Renal Impaired? Coagulopathy? Surgeon Preference? Given Post Inflammation?

Vs. PO Meds (Tylenol, Celebrex, Neurontin)

• Unfamiliar/Limited IV Form

• Pills Preop?

Vs. Ketamine

• Many Real s/e, Need Benzo

• Limited Population Use

Vs. Precedex

• Bradycardia & Hypotension

• Severe Somnolence?

All the Other Reasons You Love Lidocaine… Cheapest of All Adjuncts!

Lido gtt!

Lido“pain” Infusion is Not VOODOO!!!

References

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