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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)
 

Psai

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Lot of suspicious sources like the middle east and Canada
 
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Ezekiel2517

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Lot of suspicious sources like the middle east and Canada
Not to mention any anesthesia journal. Anyone can find a bad study published in some crap journal to "support" anything. Doesn't make it evidence. Unfortunately most people don't know how to evaluate the quality of a study.
 
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fakin' the funk

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Lot of suspicious sources like the middle east and Canada
Not to mention any anesthesia journal. Anyone can find a bad study published in some crap journal to "support" anything. Doesn't make it evidence. Unfortunately most people don't know how to evaluate the quality of a study.
Eagerly awaiting your detailed evaluation of the 20+ studies cited above
 
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algosdoc

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It is interesting that the yardstick of how to evaluate a study has been in constant flux since the 1800s. Certainly one cannot use the measuring devices of today to be applied to the 1950s, 1960s, or 1970s. EBM did not come about until the 1980s (1985 with a series of books about the critical appraisal of medicine) and since then has evolved significantly, not always in a good way. I presented a brief review, not an exhaustive analysis, since that would entail using the standards of the day for older studies. SO...does the lack of publication of the articles in Anesthesiology or A&A necessarily negate the significance or the validity of the studies? I don't think so. There were no studies published in Anesthesiology or A&A to support or contradict the above studies published in other journals. EBM is just that- using the best data available to make a decision. EBM is not relegated to the presence of a series of confluent-result high-quality low-drop out rate-unbiased-clinically and statistically significant double blinded placebo controlled randomized trials in order to prove a hypothesis, and neither is the absence of such lofty proof a declaration that the hypothesis is invalid. Of course if you are a policy hack for a medical insurance company, this is exactly the line of logic employed to deny coverage and claims. Also, of importance, EBM does not take into account the exalted or lowly status of the journal. The journals of the NLM are all peer reviewed journals with standards that include both readership and the use of evolving standards for studies, such as IRB approval. But all the older journals in the National Library of Medicine pubmed database did not meet virtually any of todays standards, including NEJM, JAMA, Anesthesiology, and A&A. As the science evolved, so have the journals. But for the time periods when the research was performed, the research met the scientific standards of the day. It is historically naive and inaccurate to use today's yardstick to measure the validity of yesterday's science, and to determine a study's worth only by todays standards. Unless you work for a health insurance company.
 
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Psai

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Of course you should use today's yardstick to evaluate yesterday's science. The lack of critical evaluation of "ebm" has everyone in this country giving people kayexalate for hyperkalemia even though the articles published are from 60 years ago and are so poorly designed that they wouldn't even be fit for a junior high school science fair today. Now we risk colonic necrosis even time we prescribe it for an ineffectual treatment because of poor quality data.

I do understand that a study being in a prestigious journal does not make it legitimate by default but it does add a certain amount of credence to it. There's no time to read every journal article published and when you're trying to evaluate data, you know that it's easier to publish in some journals than others.

I do find it interesting that I've been told that a toxic dose of lido is 4.5 mg/kg but people seemed to do okay with 6.
 
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Since yardsticks are in flux, it is very likely the EBM that is so revered now will be scoffed at in a few years, and current studies will also be discounted. But that is not how science works. It has been a gradual progression of thought and development. The scientists of the 1960s were not incompetent, and neither is their research. One can glean much from their work, especially considering many of the studies presented above were controlled. And some of their numbers are very impressive- hundreds and thousands of patients- studies that would be impossible to replicate today due to their very cost. So take the science, read it, and understand its limitations.
 
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T-burglar

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Have any of you ever injected 80 mg of lidocaine IVP into your AC vein to see what it feels like? You get pre-toxic symptoms, agitation, loss of coordination and do not feel relaxed or sedated AT ALL.
 

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Yes before my egd/colon the anesthesia dr gave me lidocaine first. Man I felt dizzy/****ty for a little before he pushed the propofol :/
 
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I mix it with the prop. Seems to kill the sting better this way than giving it separately up front. That's been my first hand experience anyways having done it both ways a lot.
 

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Of course you should use today's yardstick to evaluate yesterday's science. The lack of critical evaluation of "ebm" has everyone in this country giving people kayexalate for hyperkalemia even though the articles published are from 60 years ago and are so poorly designed that they wouldn't even be fit for a junior high school science fair today. Now we risk colonic necrosis even time we prescribe it for an ineffectual treatment because of poor quality data.

I do understand that a study being in a prestigious journal does not make it legitimate by default but it does add a certain amount of credence to it. There's no time to read every journal article published and when you're trying to evaluate data, you know that it's easier to publish in some journals than others.

I do find it interesting that I've been told that a toxic dose of lido is 4.5 mg/kg but people seemed to do okay with 6.

Not necessarily saying it causes bad outcomes but are you okay with it when lawyers are looking through your anesthesia record after you dosed higher than recommended for converting a labor epidural for a semiurgent c section in a 70kg mother and the baby has a bad outcome?
 

Ezekiel2517

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Eagerly awaiting your detailed evaluation of the 20+ studies cited above
Not gonna waste my time since I couldn't give two ****s about the topic. I use lido to mix with prop so patients stay quiet. Perhaps algosdoc can enlighten us with a detailed analysis of the throng of studies he regurgitated up there and demonstrate to us why they are meaningful. Based on the length and verbosity of his posts, he seems to have some time on his hands.
 
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My interest was in using lidocaine to reduce postop opioid load, thus prompting a review of the lit. It is just info. Feel free to ignore it.
 
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AdmiralChz

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Interesting review, some old data here! At some of these doses I would be worried about overdose... many text reference a maximum dose of lidocaine 4 mg/kg (package insert for 2% by quick Google search - 4.5 mg/kg) or a max dose of 300 mg. Well below the 6 mg/kg to prevent post-operative myalgias and other applications of high-dose lidocaine. Did those studies address that?
 

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Let me just say this. I use lidocaine nearly every case. I give it for extubation nearly every case. I give it for intubation nearly every time. I give it for LMA insertion nearly every time.

You get the point I'm sure.

If you want smooth anesthestics, then get used to lidocaine.

I also spray the crap out of nearly every trachea I put a tube in no matter how long the case it.
 
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fakin' the funk

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Let me just say this. I use lidocaine nearly every case. I give it for extubation nearly every case. I give it for intubation nearly every time. I give it for LMA insertion nearly every time.

I also spray the crap out of nearly every trachea I put a tube in no matter how long the case it.
I *love* the LMA MADgic. It is a great way to get the benefit of an ETT without the need or possible need for NMB, extra opioids, extra volatile, etc.

Really, really different way to use the same drug, but I am not 100% sold on the benefit of IV lidocaine infusions for postop analgesia/opioid reduction, ileus reduction, etc. I think the doses you have to run to really get these benefits (2+ mg/kg/hr) can burn you big time. Bradycardia, prolonged sedation, etc.
 

GA8314

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Would be worth reading if the studies from the few legit journals included weren't 30+ years old
Perhaps but a lot of studies were conducted at that time, no? Why must they be bad just because they are old?
 
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algosdoc

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Published maximum recommended doses are derived from animal models since it would be rare to find human volunteers who would submit to cardiac toxicity produced by tissue or intravenous lidocaine. It should be remembered, some of these dosages are designed to specifically avoid some of the effects produced intentionally in early studies (such as general anesthesia). In a mouse study of IV lidocaine (A comparison of the systemic toxicity of lidocaine versus its quaternary derivative QX-314 in mice. - PubMed - NCBI), CNS toxicity occurred at an ED50 of 19.5mg/kg (range 17.7-21.3) whereas cardiovascular toxicity occurred at 21.2mg/kg (range 19.0-23.4). Published maximum infiltration dosages of lidocaine without epinephrine is 4.5mg/kg.

The closest info I could find in humans to direct IV lidocaine toxicity is in a review of Bier blocks in human patients (Adverse events associated with intravenous regional anesthesia (Bier block): a systematic review of complications. - PubMed - NCBI): the lowest dosage reported that caused a seizure was 1.4mg/kg and the lowest dosage reported to cause a cardiac arrest was 2.5mg/kg.
 
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I *love* the LMA MADgic. It is a great way to get the benefit of an ETT without the need or possible need for NMB, extra opioids, extra volatile, etc.

Really, really different way to use the same drug, but I am not 100% sold on the benefit of IV lidocaine infusions for postop analgesia/opioid reduction, ileus reduction, etc. I think the doses you have to run to really get these benefits (2+ mg/kg/hr) can burn you big time. Bradycardia, prolonged sedation, etc.
can you elaborate on how you use LMA MADgic?? I'm assuming you spray in the trachea with 4% lido? This really replaces NMB for intubation?
 

fakin' the funk

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can you elaborate on how you use LMA MADgic?? I'm assuming you spray in the trachea with 4% lido? This really replaces NMB for intubation?
5ml 4% total: some to the cords, then intubate and spray some in the proximal/mid trachea. Doesn't replace NMB used for intubation itself. But then you can use sux for intubation and then use the ETT like an LMA. My anecdotal opinion is that this generally makes the patient pretty insensate to the tube in the larynx/trachea, at least for a period of time (30? 60? minutes). It's definitely very variable between patients both in efficacy and duration.
 
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