Opioid reduction with systemic lidocaine during laparoscopic surgery

Jesse Hyde, Michael Murphy, & Kevin Yackley - Mount Marty College, Nurse Anesthesia

Table 1: Included study characteristics

Introduction
Level of
Researcher (Year) Study design Participants Inclusion Exclusion evidence *
Jadad score
• Laparoscopic abdominal surgery is associated with a high incidence
of postoperative incisional pain, which has traditionally relied Ahn (2015) Randomized double 55 total study; Laparoscopic colectomy Severe cardiovascular, renal, or hepatic Level I
blind comparison Group L Lidocaine (n=25) disease and allergic to local anesthesia
heavily on opioids for treatment.
Group C Placebo (n=25) Weight <45 kg or >100 kg Jadad = 5
• Uncontrolled pain can cause adverse symptoms such as
Opioid or NSAIDS during the prior week
hypoventilation, prolonged healing, hypercoagulation, immobility, or taking these drugs chronically
infection, and emotional stress, which can amplify morbidity, delay History of previous abdominal surgery
recovery, and impair rehabilitation, causing prolong hospital stays
and patient dissatisfaction. Kim (2011) Randomized double 68 total study; Age range 18-65 Body weight < 45 kg or >100 kg. History Level I
blind comparison Group IP Intraperitoneal (n=25) Laparoscopic of severe underlying cardiovascular,
• Opioids can cause respiratory depression, nausea, vomiting,
Group IV Intravenous (n=22) appendectomy for pulmonary, renal, or hepatic disease, and Jadad = 5
somnolence, ileus, depressed immune response, and cognitive Group C Control (n=21) unperforated appendicitis an allergic reaction to local anesthetics
dysfunction, which can also lead to prolonged hospital stays, patient
dissatisfaction, and accentuation of patient comorbidities.
• Medical professionals must carefully implement postoperative Kim (2012) Randomized double 34 total study; Laparoscopy assisted Advanced renal, pulmonary disease, Level I
analgesic regimens that control postoperative pain after abdominal blind comparison Group I Lidocaine (n=17) distal gastrectomy for heart failure, and hypersensitivity to
Group C Placebo (n=17) preoperatively diagnosed lidocaine; those required to convert to Jadad = 5
surgery, while limiting undesirable side effects of opioids.
early gastric cancer laparotomies
• Lidocaine is a drug of interest in postoperative abdominal patients
because it is a nonopioid analgesic that provides analgesia while
improving other outcomes such as patient satisfaction and shorter Ortiz (2016) Randomized double 44 total study; ASA I-II Heart disease, kidney failure, liver failure, Level I
hospital stays. blind comparison Lidocaine Group (n=22) Elective laparoscopic psychiatric disorder, chronic use of
Control Group (n=22) cholecystectomy opioids, medications that could cause Jadad = 5
• Lidocaine is safe, economical, and beneficial in treating postoperative
induction of liver enzymes
pain after abdominal surgery. Lidocaine likely works due to a
combination of blocking sodium channels within afferent pain fibers
and modulating the stress response with its anti-inflammatory Yang (2013) Randomized double 72 total study; ASA I-III Weight < 45 kg or > 100 kg Level I Results
blind comparison Group IV Intravenous (n=26) Elective laparoscopic
properties. • Sample consisted of 5 randomized control trials published between
Group IP Intraperitoneal (n=22) cholecystectomy Jadad = 5
Group C Control (n=24)
April 2013 and July 2016.

• Sample sizes of the studies ranged from 34 to 83 subjects.

Question
• In adult laparoscopic abdominal surgical patients, do perioperative
intravenous lidocaine infusions reduce patient controlled
postoperative opioid use when compared to placebo?
• We hypothesize that perioperative lidocaine infusions will reduce
postoperative opioid use, and in return, diminish unwanted side
effects of opioid analgesics.
* Hierarchy of knowledge scale from LoBiondo-Wood • Subjects were adults ranging from 18-65 years undergoing a
laparoscopic abdominal surgery.
Discussion
• Significance
Table 2: Lidocaine dosages • Lidocaine was found to reduce postoperative patient
controlled opioid consumption following laparoscopic

Methods
Lidocaine abdominal surgery
Researcher (Year) Comparison Results • Strengths
Bolus dose Infusion dose • High quality double blinded randomized control trials
• Primary search: PubMed, CINAHL, & Trip Database • Similar study method designs
• Secondary search: Google scholar and ancestry search • Homogeneity in outcome measurements
Ahn (2015) IV: 1.5 mg/kg 2 mg/kg/hr Placebo: Normal saline Group L was found to use less fentanyl by PCA than group
C which did not receive the intraoperative lidocaine • Weaknesses
• Randomized controlled trials • Variable opioid PCA settings
infusion.
• Published between 1/1/2011 and 6/20/2017 • Variable lidocaine administration protocols
• MeSH terms: “lidocaine”, “laparoscopy”, and “abdominal surgery” • Predominantly foreign studies
Kim (2011) IV: 1.5 mg/kg 2 mg/kg/hr Placebo: Normal saline Fentanyl consumption per PCA was highest in group C,
• Inclusion criteria: IP: 3.5 mg/kg and the groups that received either IV or IP lidocaine
• Adult human subjects
• English language
administration had less fentanyl consumption
postoperatively. Recommendations
• Intravenous lidocaine infusion
• Systemic lidocaine should be infused during laparoscopic abdominal
• PCA postoperative opioids
Kim (2012) IV: 1.5 mg/kg 2 mg/kg/hr Placebo: Normal saline Fentanyl consumption per PCA during the initial 12 hours surgeries to reduce postoperative opioid consumption. AHA/ACC
• Laparoscopic abdominal surgery
postoperatively was found to be significantly lower in recommendation Class I Level A.
• Exclusion criteria Group I that received lidocaine infusion intraoperatively
compared to patients that received placebo. • Further high level evidence studies should be done to expand the
• Case studies
scope of efficacy for systemic lidocaine infusions in surgical
• Open trials
procedures.
• Pediatric subjects

• Quality scale: Jadad scale Ortiz (2016) IV: 1.5 mg/kg 3 mg/kg/hr Placebo: Normal saline Patients received morphine PCA postoperatively and Additional References
patients that received intraoperative lidocaine infusion
Miler, R. D., Cohen, N. H., Eriksson, L. I., Fleisher, L. A., M., Wiener-
• Primary outcome was the usage of opioid via patient controlled were found to have decreased opioid consumption
Kronish, J. P., William, W. L. (2015). Miller’s anesthesia (8th ed.).
analgesia following laparoscopic abdominal surgery postoperatively.
Philadelphia, PA: Elsevier.
Barash, P. G, Cullen, B. F., Stoelting, R. K., Cahalan, M., Ortega, R.
Yang (2013) IV: 1.5 mg/kg 2 mg/kg/hr Placebo: Normal saline Significant reduction in fentanyl consumption (2015). Clinical anesthesia. Philadelphia, PA: Lippincott Williams &
IP: 3.5 mg/kg postoperatively in IV and IP groups vs control. Wilkins.
LoBiondo-Wood, G., & Haber, J. (2014). Nursing research: methods and
critical appraisal for evidence-based practice (8th ed.). St. Louis,
Missouri: Elsevier.