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