Systemic Lidocaine infusion
Dr. Moutasem
Lidocaine
Operative
pain
None Operative
pain
Guidelines
LidocaineLidocaine, the first amino amide-type local anesthetic,
was first synthesized under the name Xylocaine by
Swedish chemist Nils Löfgren in 1943.
IndicationsRapid acting local anesthetic for procedures
ranging from infiltration to regional nerve block
Antiarrhythmic in the treatment of vent.
arrhythmias
Treatment of status epilepticus (INVESTIGATIONAL)
Treatment of pain
Operative
Neuropathic pain
PharmacologyHalf life: 90-120 min.
Time to steady state: 8-10 hours
Distribution: Lipo-philic, widely distributed into
body
Protein binding: 60-80 %
Metabolism:
90% metabolite in the liver,
10 % unchanged drug excreted by kidney.
Mao & Chen, 2000
Active metabolites:Active metabolites: 90% in the liver
monoethylglycinexylidide(MEDX), half life 2 hrs, 60-80% as potent as lidocaine
glycinexylidine(GX), half life 10 hrs
Half-life of lidocaine is approximately 90–120 min.
hepatic impairment (average 343 min.) or
Congestive heart failure (average 136 min.)
Pharmacology
Mechanism of action:Intravenous lidocaine is analgesic,
antihyperalgesic, and antiinflammatory.
* * Acta Anaesthesiol Scand.2006 * * Int Anesthesiol Clin. 2003 * Mao & Chen, 2000
These properties are mediated by a variety ofmechanisms, including sodium channel blockade,as well as inhibition of G protein–coupled receptors and N-methyl-D-aspartate receptors. * *
In sub-anesthetic dose, it blocks spontaneous ectopic discharge of the injured nerve without blocking normal nerve conduction*
Toxicity Ferrini,2000
Contraindications for the use of lidocaine
• Heart block, second or third degree (without pacemaker)
• Severe sinoatrial block (without pacemaker)• Serious adverse drug reaction to amide local
anaesthetics• Concurrent treatment with quinidine, flecainide,
disopyramide, procainamide (Class I agents)• Prior use of Amiodarone hydrochloride• Hypotension not due to Arrhythmia• Bradycardia• Accelerated idioventricular rhythm• Pacemaker• Porphyria, especially acute porphyria (AIP);
Sodium Channel
• The sodium channel is a voltage gated channel (Nav) is grouped into 9 classifications dependant upon there location and action.
• The therapeutic goal would be to develop one that could specifically block the four channels (1.3, 1.7, 1.8 and 1.9) that have been shown to be in use for the proliferation of neuropathic and other pain signals.
Sodium Channels role in neuropathic pain
A Theory suggests that the fast activation,
inactivation and rapid re-priming kinetics
and persistent current component of The
sodium channel 1.3 contribute to the
development of spontaneous ectopic
discharges and sustained firing
characteristics of injured sensory nerves,
leading to neuropatheic pain.
Rogers M, et al.2006
Its mode of action is the attenuation of
peripheral nociceptors sensitisation and CNS
hyperexcitability, it achieves this by
stablaising the open state of the sodium
channel, this will lead to the sodium channel
effectively being deactivated.
Rogers M, et al., Semin Cell Dev Biol (2006)
LidocaineBartlett et al. 1961
First study suggesting there is a role for systemic lidocaine for relief of post-op pain
Boas et al. 1982Clinical role for lidocaine for treatment of
peripheral and central pain
Inhibition of Postoperative Pain by Continuous Low-Dose intravenous Infusion
of LidocaineJean Cassuto, Anesthesia and Analgesia
low-dose continuous infusion of lidocaine is devoid of side effects and can be used to decrease the severity of postoperative pain,
thus reducing the need for potent morphinomimetic drugs in the postoperative period
Treatment of Postoperative Paralytic ileus by Intravenous Lidocaine Infusion
Gunnar Rimback, Md, Anesth Analg,1990 lidocaine or saline placebo.
Thirty patients scheduled for elective cholecystectomy were studied
Continuous IV infusion of lidocaine during the first postoperative day after cholecystectomy can reduce the need for narcotics and shorten the period of postoperative colonic inhibition in patients undergoing major abdominal surgery.
Secondary to the inhibition of peritoneal irritation followed by reduced activation of inhibitory gastrointestinal reflexes.
Intravenous Lidocaine Infusion Facilitates Acute Rehabilitation after Laparoscopic
ColectomyAbdourahamane Kaba, M.D.,*Anesthesiology 2007
45 patients enrolled
Conclusions: Intravenous lidocaine improves postoperative
analgesia, fatigue, and bowel function after laparoscopic colectomy.
These benefits are associated with a significant reduction in hospital stay.
Perioperative Intravenous Lidocaine Has Preventive Effects on Postoperative Pain and
Morphine Consumption After Major Abdominal Surgery
Wolfgang Koppert, Germany ,Anesth Analg 2004
A prospective, randomized, and double-blinded study of 40 patients undergoing major abdominal surgery
The perioperative administration of systemic lidocaine is most effective in surgery associated with the development of pronounced central hyperalgesia, i.e., intestinal and bowel surgery.
The pain experience after these types of surgery can be attenuated by lidocaine in a clinically relevant manner.
Intravenous Lidocaine for AmbulatoryAnesthesia
Christopher L. Wu, MD ,Inter Anes Research Society,Dec. 2009
Using 1.5–3 mg kg\ hlidocaine significantly reduced the incidence of nausea and vomiting (32% vs 52%), Marginally reduced pain scores , Decreased duration of postoperative ileus (8.4 h) and hospital stay (0.84 days).
Systemic Lidocaine Shortens Length
of Hospital Stay After Colorectal
SurgeryA Double-blinded, Randomized, Placebo-controlled Trial
Susanne Herroeder, MD Annals of Surgery, August 2007
60 patients of ASA physical status I to III,
between 18 and 75 years of age, scheduled
for elective colorectal surgery
Study Drug Administration
Patients in the lidocaine group received 1.5 mg/kglidocaine intravenously as a loading dose before
induction of general anesthesia.
Immediately after tracheal intubation, a continuous systemic lidocaine infusion (2 mg/min) was initiated and terminated 4 hours after skin closure.
Patients in the control group were treated likewise using NaCl 0.9% in a double-blinded fashion.
Outcome Measures
The primary outcome measure• length of hospital stay.
Secondary outcome measures • Length of PACU stay,• Time until return of bowel function,• Postoperative pain and opioid
consumption, • Plasma levels of several pro- and anti-
inflammatory interleukins .
Length of hospital stay
Visual analog scale (VAS)
Gastrointestinal motility
Conclusions:
Systemic lidocaine may thus provide a convenient and inexpensive approach to improve outcome for patients not suitable for epidural anesthesia.
Comparison of the effects of thoracic epidural analgesia and i.v. infusion with
lidocaine on cytokine response, postoperative pain and bowel function in patients
undergoing colonic surgeryC. P. Kuo ,British Journal of Anaesthesia Sept, 2006
Conclusions The TEA lidocaine had better pain relief, lower opioid consumption, earlier return of bowel function and lesser production of cytokines than IV lidocaine during 72 h after colonic surgery; IV group was better than the control group.
Systemic administration of local anesthetics to relieve neuropathic pain : a systemic review and meta-
analysis
Tremont-Lukats, 2005
conclude “Lidocaine and mexiletine produced no major
adverse events in controlled clinical trials, were superior to placebo to relieve neuropathic pain, and were as effective as other analgesics used for this condition.”
Tremont-Lukats, 2005
The Analgesic Response to Intravenous Lidocaine in the Treatment of
Neuropathic PainF. Michael Ferrante, Anesth A nalg 1996
13 patients were enrolled in the study,with neuropathic pain for at least 6 months .
Lidocaine was administered IV at a rate of 8.35 mg/min over 60 min.
In conclusion, the results of this study suggest that the
analgesic response to IV lidocaine is best characterized by a precipitous ‘break in pain” over a narrow dosage and concentration range.
Topical Lidocaine Patch Relieves a Variety of Neuropathic Pain Conditions
Devers, Clinical Journal of Pain: Sept 2000
Results: Moderate or better pain relief was reported by
13 of the 16 participants (81%). Patients had a mean duration of patch use of
6.2 weeks with continued relief.
Chronic pain treatment with intravenous lidocaine Petersen P, Neurol Res., Sep,1986
18 patients with severe chronic pain states due neurological diseases.
After the infusion of lidocaine 14 patients (78%) had significant pain relief ranging from 2 hours to 25 days.
Efficacy of 5-Day Infusion Continuous Lidocaine for the
Treatment of Refractory C R P SRobert . schwartzman, md,pain medicine, 2009
The majority of patients demonstrated a significant decrease in pain parameters and other symptoms and signs of CRPS. The pain reduction lasted an average of 3 months.
Lidocaine may be particularly effective for thermal and mechanical allodynia. Less clinically significant effects were documented on the motor aspects of the syndrome.
Diabetic Polyneuropathy (DPN)Viola et al., Journal of Diabetes and Complications, 2006
15 pat. with intractable painful DPN Double-blind, placebo-controlled crossover trial Two doses: 5mg/kg and 7.5mg/kg vs. saline Infusion during 4h and every 4 weeks
Both doses ↓↓ severity of pain Dose-response effect !
Reduction present at 14 and 28 days after Decrease in qualitative nature of pain up to 28d
Guidelines
Pre infusion assessment and preperation
Lidocaine testLidocaine infusion Home infusion
Pre infusion assessment
Complete history and physical examinationQuantitative pain assessment Any history of allergy from lidocaineAny history of Heart or liver diseasesECG
Ferrini& Paice, 2004
Patient preperation
Patients are required to have nothing by mouth for 4 hours prior to the procedures
Written consentVital signs are monitored including heart
rhythm, heart rate, blood pressure and oxygen saturation
Lidocaine test Dose: 1-3 mg/kg (average 100 mg)
Concentration: 8 mg/ml IV over 20-30 min. OR 40 mg/ml SC over 30-60 min (2-3 ml/hr)
Monitor pain relief, vital signs and side effects q15 min.
50% of the dose in elderly patients >70 year, patients with heart or liver disease
Ferrini& Paice, 2004
Lidocaine infusion
If pain relief > 50% and no side effects Dose 0.5 -2 mg/kg/hr IV OR SC Monitor pain, V/S and side effect after 15
min then 60 min then q 8 hr then prn Titrate up based on pain relief If any side effects occurred, stop infusion,
reassess after 30-60 min then resume with 20% Or last safe dose
Home infusion
Patient must have a stable caregiver situation, with 24-hour supervision by a competent adult
Patient must consent to being visited by a registered nurse 2–7 times a week
Patient/caregiver should be provided with a lidocaine patient information sheet
Home Massages
• Lidocaine infusion is safe and effective intervention for operative and chronic pain
• Lidocaine infusion has narrow therapeutic index. So, it needs clear guidelines to demonstrate how we use it safely