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Intravenous Lidocaine: When to Use it in Anesthesiology- the Medical Literature Reviewed Sept 2017
PREVENTING FASCICULATIONS FROM SCH: At a dose of 6mg/kg it prevents fasciculations from SCH 100% of the time (Anesthesiology. 1965 Jan-Feb;26:3-7).
PREVENTING POSTOP MYALGIAS: At a dosage of 6mg/kg it, IV lidocaine reduces post op myalgias from 40% to 4% (Anesth Analg. 1967 Mar-Apr;46(2):225-30), but does not work at 1.5mg/kg (Anaesthesia. 1987 May;42(5):503-10.)
RAPID REDUCTION OF INTRACRANIAL PRESSURE: IV lidocaine rapidly reduces intracranial pressure with a 3mg/kg dosage without altering systemic pressures (Anesth Analg. 1980 Jun;59(6):435-7.)
INTRACTABLE SEIZURE TREATMENT: Lidocaine requires a relatively high dosage to produce seizures (22mg/kg in monkeys- Anesthesiology. 1975 Apr;42(4):471-8.) Lidocaine infusion with a progressive decrease from 4 to 1mg/kg/hr over 4 days eliminates seizures in newborns in 11 out of 13 (Ther Drug Monit. 1990 Jul;12(4):316-20.) and boluses of 1.5-2mg/kg in adults help manage status epilepticus unresponsive to benzodiazepines and without any respiratory compromise from the lidocaine (J Neurol Neurosurg Psychiatry. 1992 Jan;55(1):49-51.). A later study confirmed the utility of a lidocaine infusion in reducing seizures in the vast majority of neonates with encephalopathy (J Child Neurol. 2007 Mar;22(3):255-9.)
REDUCTION OF PROPOFOL INDUCED INJECTION PAIN: Lidocaine but not fentanyl reduces propofol injection pain (Middle East J Anaesthesiol. 1996 Oct;13(6):613-9, Anesth Analg. 1998 Feb;86(2):382-6.). The manner of injection of lidocaine in producing less pain with propofol is important. A study found 70% of patients with propofol alone, 52% with propofol plus lidocaine premix, 46% of those given IV lidocaine 60 sec before propofol, and 14% of those given IV lidocaine with venous occlusion for 60 sec before propofol experienced pain (Saudi Med J. 2006 Jul;27(7):997-1000.) Another study showed only a 3% incidence of pain with lidocaine injected into a 60sec occluded vein followed by proporol (Eur J Anaesthesiol. 2007 Mar;24(3):235-8. Epub 2007 Jan 4.)
REDUCTION OF ROCURONIUM INDUCED PAIN: Lidocaine IV pretreatment also reduces the pain on rocuronium injection (J Anesth. 2014 Dec;28(6):886-90.)
REDUCTION OF COUGH AND AIRWAY OBSTRUCTION DURING LMA INSERTION: During insertion of a LMA, coughing and airway obstruction were significantly reduced with lidocaine 1.5mg/kg plus propofol vs propofol alone (Anaesthesia. 1995 May;50(5):464-6.).
REDUCTION OF OPIOID INDUCED COUGH: IV Lidocaine reduces the incidence of IV opioid induced cough (J Anesth. 2014 Jun;28(3):325-33) with a minimum dose of 0.5mg/kg in a meta-analysis.
REDUCTION OF INTRAOPERATIVE ANESTHESIA REQUIREMENTS: Mixed results. Lidocaine IV enhances propofol sedation- a dose of 3mg/kg reduces the propofol requirement by 34% (Br J Anaesth. 1997 Apr;78(4):375-7.) however in a later dog study, lidocaine as a 1.5mg/kg bolus followed by 0.25mg/kg/min as an infusion did not reduce propofol infusion requirements (Vet Anaesth Analg. 2012 Mar;39(2):160-73). Lidocaine IV bolus 1.5mg/kg followed by 50mcg/kg/min infusion reduces isoflurane requirements by 25% in horses (J Vet Med A Physiol Pathol Clin Med. 2003 May;50(4):190-5.) with no deleterious effect on hemodynamic parameters and sevofluorane requirements by 26% (J Vet Med Sci. 2014 Jun;76(6):847-53). Lidocaine 1.5mg/kg bolus before skin incision, reduced the amount of propofol required for skin incision by 42% (Acta Anaesthesiol Scand. 2015 Mar;59(3):310-8.). In a review paper, IV lidocaine was opioid sparing and produced less ileus after general anesthesia (Acta Anaesthesiol Belg. 2006;57(2):113-20.), however remifentanil infusion study found lidocaine bolus 1.5mg/kg then 1.5mg/kg/hr did not reduce remifentanil infusion requirements during human surgery (Eur Rev Med Pharmacol Sci. 2014;18(4):559-65.).
LIDOCAINE HAS NO EFFECT: Lidocaine does not reduce the bispectral index (J Clin Anesth. 2012 Mar;24(2):121-5.) Lidocaine reduces the incidence of IV opioid induced cough (J Anesth. 2014 Jun;28(3):325-33) with a minimum dose of 0.5mg/kg in a meta-analysis.
PRE-EMPTIVE ANALGESIA: Mixed results
Intraoperative lidocaine infusion reduced the post operative pain from 6.1 to 4.6 and significantly reduced opioid use by 30-50% for 48 hours after surgery (Can J Surg. 2014 Jun;57(3):175-82.) A study of lidocaine infusion 33mcg/kg/min during surgery significantly reduced post operative pain and morphine requirements (Eur J Anaesthesiol. 2010 Jan;27(1):41-6). Another study showed a bolus of 1.5mg/kg on induction followed by an infusion of 2mg/kg/hr throughout surgery reduced post op pain from 4.3 to 3 after a cholecystectomy and fentanyl requirements from 187 to 98 mcg during the first 24 hours after surgery (Int J Surg. 2017 Sep;45:8-13). After lumbar microdiscectomy with lidocaine bolus 1.5mg/kg then infusion intraoperatively 2mg/kg/hr, pain and opioid consumption was significantly reduced (Spine J. 2014 Aug 1;14(8):1559-66) for 24 hours after surgery and the hospital stay was reduced. After thyroidectomy that had employed a lidocaine bolus plus intraoperative infusion, there was a significant reduction in pain and opioid consumption after surgery (World J Surg. 2016 Dec;40(12):2941-2947.) After open nephrectomy with a lidocaine infusion 1mg/kg/hr during surgery and for 24 hours afterwards, the morphine consumption postoperatively fell by 42% and VAS fell significantly (Saudi J Anaesth. 2017 Apr-Jun;11(2):177-184.) After bowel surgery, one study found significant reduction in post op ileus, opioid consumption, and pain using a lidocaine bolus plus infusion lasting until 1 hour after surgery (ANZ J Surg. 2015 Jun;85(6):425-9.). One study found postoperative pain and opioid use was less at least 12 hours after surgery in inguinal herniorrhaphy patients receiving a bolus of 1.5mg/kg lidocaine plus infusion of 2mg/kg/hr during surgery (J Int Med Res. 2011;39(2):435-45.) A study of major bowel surgery with IV lidocaine bolus plus infusion found short term reduction in pain for 4 hours after surgery, but the 48 hour opioid consumption and ileus was no different compared to controls (J Gastrointest Surg. 2014 Dec;18(12):2155-62).
Several studies had negative outcomes using a lidocaine bolus at induction followed by intraoperative and postoperative lidocaine infusions for 24 hours after surgery with no significant reduction in opioid consumption or pain after laparoscopic fundoplication (Local Reg Anesth. 2016 Dec 2;9:87-93), laparoscopic cholecystectomy (Reg Anesth Pain Med. 2016 May-Jun;41(3):362-7), breast surgery (Korean J Anesthesiol. 2012 May;62(5):429-34.), abdominal hysterectomy (Can J Anaesth. 2010 Aug;57(8):759-66), or posterior spinal arthrodesis ( Br J Anaesth. 2017 Apr 1;118(4):576-585). A single bolus of lidocaine 1.5mg/kg failed to provide any reduction in post operative pain or opioid consumption in gynecological laparotomy surgery (Farm Hosp. 2016 Jan 1;40(1):44-51)
PREVENTING FASCICULATIONS FROM SCH: At a dose of 6mg/kg it prevents fasciculations from SCH 100% of the time (Anesthesiology. 1965 Jan-Feb;26:3-7).
PREVENTING POSTOP MYALGIAS: At a dosage of 6mg/kg it, IV lidocaine reduces post op myalgias from 40% to 4% (Anesth Analg. 1967 Mar-Apr;46(2):225-30), but does not work at 1.5mg/kg (Anaesthesia. 1987 May;42(5):503-10.)
RAPID REDUCTION OF INTRACRANIAL PRESSURE: IV lidocaine rapidly reduces intracranial pressure with a 3mg/kg dosage without altering systemic pressures (Anesth Analg. 1980 Jun;59(6):435-7.)
INTRACTABLE SEIZURE TREATMENT: Lidocaine requires a relatively high dosage to produce seizures (22mg/kg in monkeys- Anesthesiology. 1975 Apr;42(4):471-8.) Lidocaine infusion with a progressive decrease from 4 to 1mg/kg/hr over 4 days eliminates seizures in newborns in 11 out of 13 (Ther Drug Monit. 1990 Jul;12(4):316-20.) and boluses of 1.5-2mg/kg in adults help manage status epilepticus unresponsive to benzodiazepines and without any respiratory compromise from the lidocaine (J Neurol Neurosurg Psychiatry. 1992 Jan;55(1):49-51.). A later study confirmed the utility of a lidocaine infusion in reducing seizures in the vast majority of neonates with encephalopathy (J Child Neurol. 2007 Mar;22(3):255-9.)
REDUCTION OF PROPOFOL INDUCED INJECTION PAIN: Lidocaine but not fentanyl reduces propofol injection pain (Middle East J Anaesthesiol. 1996 Oct;13(6):613-9, Anesth Analg. 1998 Feb;86(2):382-6.). The manner of injection of lidocaine in producing less pain with propofol is important. A study found 70% of patients with propofol alone, 52% with propofol plus lidocaine premix, 46% of those given IV lidocaine 60 sec before propofol, and 14% of those given IV lidocaine with venous occlusion for 60 sec before propofol experienced pain (Saudi Med J. 2006 Jul;27(7):997-1000.) Another study showed only a 3% incidence of pain with lidocaine injected into a 60sec occluded vein followed by proporol (Eur J Anaesthesiol. 2007 Mar;24(3):235-8. Epub 2007 Jan 4.)
REDUCTION OF ROCURONIUM INDUCED PAIN: Lidocaine IV pretreatment also reduces the pain on rocuronium injection (J Anesth. 2014 Dec;28(6):886-90.)
REDUCTION OF COUGH AND AIRWAY OBSTRUCTION DURING LMA INSERTION: During insertion of a LMA, coughing and airway obstruction were significantly reduced with lidocaine 1.5mg/kg plus propofol vs propofol alone (Anaesthesia. 1995 May;50(5):464-6.).
REDUCTION OF OPIOID INDUCED COUGH: IV Lidocaine reduces the incidence of IV opioid induced cough (J Anesth. 2014 Jun;28(3):325-33) with a minimum dose of 0.5mg/kg in a meta-analysis.
REDUCTION OF INTRAOPERATIVE ANESTHESIA REQUIREMENTS: Mixed results. Lidocaine IV enhances propofol sedation- a dose of 3mg/kg reduces the propofol requirement by 34% (Br J Anaesth. 1997 Apr;78(4):375-7.) however in a later dog study, lidocaine as a 1.5mg/kg bolus followed by 0.25mg/kg/min as an infusion did not reduce propofol infusion requirements (Vet Anaesth Analg. 2012 Mar;39(2):160-73). Lidocaine IV bolus 1.5mg/kg followed by 50mcg/kg/min infusion reduces isoflurane requirements by 25% in horses (J Vet Med A Physiol Pathol Clin Med. 2003 May;50(4):190-5.) with no deleterious effect on hemodynamic parameters and sevofluorane requirements by 26% (J Vet Med Sci. 2014 Jun;76(6):847-53). Lidocaine 1.5mg/kg bolus before skin incision, reduced the amount of propofol required for skin incision by 42% (Acta Anaesthesiol Scand. 2015 Mar;59(3):310-8.). In a review paper, IV lidocaine was opioid sparing and produced less ileus after general anesthesia (Acta Anaesthesiol Belg. 2006;57(2):113-20.), however remifentanil infusion study found lidocaine bolus 1.5mg/kg then 1.5mg/kg/hr did not reduce remifentanil infusion requirements during human surgery (Eur Rev Med Pharmacol Sci. 2014;18(4):559-65.).
LIDOCAINE HAS NO EFFECT: Lidocaine does not reduce the bispectral index (J Clin Anesth. 2012 Mar;24(2):121-5.) Lidocaine reduces the incidence of IV opioid induced cough (J Anesth. 2014 Jun;28(3):325-33) with a minimum dose of 0.5mg/kg in a meta-analysis.
PRE-EMPTIVE ANALGESIA: Mixed results
Intraoperative lidocaine infusion reduced the post operative pain from 6.1 to 4.6 and significantly reduced opioid use by 30-50% for 48 hours after surgery (Can J Surg. 2014 Jun;57(3):175-82.) A study of lidocaine infusion 33mcg/kg/min during surgery significantly reduced post operative pain and morphine requirements (Eur J Anaesthesiol. 2010 Jan;27(1):41-6). Another study showed a bolus of 1.5mg/kg on induction followed by an infusion of 2mg/kg/hr throughout surgery reduced post op pain from 4.3 to 3 after a cholecystectomy and fentanyl requirements from 187 to 98 mcg during the first 24 hours after surgery (Int J Surg. 2017 Sep;45:8-13). After lumbar microdiscectomy with lidocaine bolus 1.5mg/kg then infusion intraoperatively 2mg/kg/hr, pain and opioid consumption was significantly reduced (Spine J. 2014 Aug 1;14(8):1559-66) for 24 hours after surgery and the hospital stay was reduced. After thyroidectomy that had employed a lidocaine bolus plus intraoperative infusion, there was a significant reduction in pain and opioid consumption after surgery (World J Surg. 2016 Dec;40(12):2941-2947.) After open nephrectomy with a lidocaine infusion 1mg/kg/hr during surgery and for 24 hours afterwards, the morphine consumption postoperatively fell by 42% and VAS fell significantly (Saudi J Anaesth. 2017 Apr-Jun;11(2):177-184.) After bowel surgery, one study found significant reduction in post op ileus, opioid consumption, and pain using a lidocaine bolus plus infusion lasting until 1 hour after surgery (ANZ J Surg. 2015 Jun;85(6):425-9.). One study found postoperative pain and opioid use was less at least 12 hours after surgery in inguinal herniorrhaphy patients receiving a bolus of 1.5mg/kg lidocaine plus infusion of 2mg/kg/hr during surgery (J Int Med Res. 2011;39(2):435-45.) A study of major bowel surgery with IV lidocaine bolus plus infusion found short term reduction in pain for 4 hours after surgery, but the 48 hour opioid consumption and ileus was no different compared to controls (J Gastrointest Surg. 2014 Dec;18(12):2155-62).
Several studies had negative outcomes using a lidocaine bolus at induction followed by intraoperative and postoperative lidocaine infusions for 24 hours after surgery with no significant reduction in opioid consumption or pain after laparoscopic fundoplication (Local Reg Anesth. 2016 Dec 2;9:87-93), laparoscopic cholecystectomy (Reg Anesth Pain Med. 2016 May-Jun;41(3):362-7), breast surgery (Korean J Anesthesiol. 2012 May;62(5):429-34.), abdominal hysterectomy (Can J Anaesth. 2010 Aug;57(8):759-66), or posterior spinal arthrodesis ( Br J Anaesth. 2017 Apr 1;118(4):576-585). A single bolus of lidocaine 1.5mg/kg failed to provide any reduction in post operative pain or opioid consumption in gynecological laparotomy surgery (Farm Hosp. 2016 Jan 1;40(1):44-51)