Perioperative pain control lidocaine infusions

PACU resident presentation

Shelly Pecorella

10/19/12

Definition
- One of the local anesthetics - Amide class

- Na+ channel blockers

- Blocks both initiation and propagation of nerve impulses

Where we normally use lidocaine

- Subcutaneous - Peripheral nerve blocks - Surgical field (usually other LAs) - Epidural - Spinal* - For all, work to avoid accidental intravascular injections
- Test doses with epi

Alternative approach- IV lidocaine

- Demonstrated benefits with intraoperative infusions of intravenous lidocaine
- Improved post-op pain (better pain scores) - Decreased opiate requirement - Quicker return of bowel fxn

Alternative approach- IV lidocaine

- Postulated to work as a preventative analgesic, blocking the induction of central hyperalgesia that can be seen after surgical insult - Inflammatory reactions are seen postoperatively
- Lidocaine shown to lessen the typical increase of

pro-inflammatory cytokines when given perioperatively

Intraop Infusions

- Most studies start with 1-1.5mg/kg bolus - Infusion of 1-1.5mg/kg/hr continuing through surgical closure
- can continue postoperatively (PACU and floor)

- These plasma levels are lower than the potential levels we worry about from accidental intravascular injections with relatively larger doses for peripheral blocks

Post-op/Floor (Stanford)
- Continuation from OR or new start for pain control (more often seen with chronic pain patients or large incisions not amenable to neuraxial technique) - Generally start at 1mg/kg/hr
- Can start with bolus dose of 0.75-1mg/kg (more common to see side effects with this) - Check lidocaine levels q8h until stabilized, then q12h - Working for therapeutic levels (quantitative or qualitative)
- Goal 2.5-5 mcg/ml - Potentially toxic at >6 mcg/ml - Toxic at >9 mcg/ml

Chronic Pain
- IV lidocaine also shown to have benefits
- CRPS pts had decreased allodynia and decreased inflammatory components - variable results with neuropathic pain, improvement more common in targeted populations - at Stanford, used for chronic abdominal pain inpatients where narcotics have unacceptable side effects

- Short term infusions demonstrated improved pain control in some studies for up to 3 months - Minimal side effects in studies

Risks/What to watch for

- Toxicity/Adverse reactions
- Cardiac
- Hypotension, conduction block, arrhythmias (especially bradycardic rhythms), CV collapse, cardiac arrest

- CNS
- Dizziness, ringing in ears, blurry vision, agitation/lethargy, seizures, hallucinations, slurred speech, disorientation

- GI
- Metallic taste, N/V, perioral numbness

- Allergic reactions are rare

Where does this go?

- Often can wean off
- Either after short term improvement (such as after a few days post op for large spinal surgeries) - May have had planned short trial of lidocaine

- Transition to mexiletine
- Oral sodium channel blocker - Frequently discontinued due to intolerable side effects (most commonly nausea and dizziness) - In one study, less than 20% of pts started on mexiletine continued at one year
- However, it may provide longer term relief in patients who demonstrate the most significant response to IV lidocaine trials

References
Efficacy of 5-day continuous lidocaine infusion for the treatment of refractory complex regional pain syndrome. Pain Medicine. Vol 10 Issue 2, p 401-412. Mar 2009. Schwartzman R, Patel M, Grothusen J, Alexander G. Mexiletine therapy for chronic pain: survival analysis identifities factors predicting clinical success. Carroll IR, Kaplan KM, Mackey SC. Pain Symptom Management. 2008 Mar; 35(3):321-6 Multivariate analysis of chronic pain patients undergoing lidocaine infusions: increasing pain severity and advancing age predict likelihood of clinically meaningful analgesia. Carroll L, Gaeta R, Mackey S. Clincal Journal of Pain. 2007. Oct; 23(8): 702-6 A randomized, double-masked, placebo-controlled pilot trial of extended IV lidocaine infusion for relief of ongoing neuropathic pain. Tremont-Lukats IW, Hutson PR, Backonja MM. Clin J Pain. 2006 MarApr;22(3):266-71. The effect of perioperative intravenous lidocaine on postoperative pain and immune function. Yardeni IZ, Beilin B, Mayburd E, Levinson Y, and Bressler H. Anesthesia & Analgesia. Nov 2009. Vol 109 no5. 1464-1469. Miller 7th edition. Chapter 30, Local Anesthetics Perioperative Intravenous Lidocaine Has Preventive Effects on Postoperative Pain and Morphine Consumption After Major Abdominal Surgery. Koppert W, et al. Anesthesia and Analgesia. Apr 2004. Vol 98 no 4. 1050-1055. Stanford Acute Pain Management: Resident rotation syllabus. Version 2009-10.