LIDO FOR BELLY (to much with a truncal block?)

[turnupthevapor]

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Question...If I run lido all day on a belly case do you all thing that would preclude me from doing a large volume truncal block? They are both amides and additive toxicity I am sure. The studies w lido infusion gives a blood level of 2-5 ucg so it is not insignificant. It would be a bummer to not do the blocks like a rectus sheath for midline etc? Anyone know of any work done with this?

Here is a summary if you haven't been following the lido lit

LIDOCAINE
The real benefit for lidocaine infusion seems to be in abdominal surgery and prostate surgery. The benefits HAVE NOT panned out in the literature for acute pain in GYN surgery, CT surgery, hip surgery, or breast surgery. There seems to be long term benefits if it is utilized in spine and breast surgery relating to quality of life and chronic pain.
First a word of caution, My biggest fear is that a innocent unassuming soul will program the pump wrong and give some poor patient 2 grams of lidocaine resulting in a death (keep the intralipid handy). Potentially we could limit the amount of lidocaine mixed in the bag? Also this drug also has extensively renal clearance so I opt out as the CrCl drops and sometimes in the elderly.

So back to abdominal surgery where the best evidence is. Perioperative lidocaine infusion, in doses ranging from 1.5 to 3mg/kg/hr ideal body weight (after a bolus of 1 mg/kg), consistently improved postoperative pain scores in patients undergoing open or laparoscopic abdominal surgery. The goal of an infusion is to achieve a steady state concentration within the therapeutic and non-toxic range. Weight-based lidocaine regimens in studies have shown that 1.33–3 mg/kg/hour achieved adequate plasma concentrations of 2–5 µg/mL. One study Koppert et al. reported a 35% reduction in morphine consumption between 0 to 72 h after surgery in patients undergoing major abdominal surgery.

Also of note, in patient’s undergoing colorectal surgery:

• Perioperative lidocaine infusion was shown to be as effective as epidural administration of local anesthetics with regard to pain scores, opioid consumption, and other outcomes!
• In addition to improving analgesia, perioperative lidocaine infusion shortens the duration of postoperative ileus by an average of 8 h.
• Decreases the incidence of PONV by 10 to 20%.
• Reduces the length of hospital stay after colorectal surgery and may be useful for enhanced recovery.

 

[anbuitachi]

Question...If I run lido all day on a belly case do you all thing that would preclude me from doing a large volume truncal block? They are both amides and additive toxicity I am sure. The studies w lido infusion gives a blood level of 2-5 ucg so it is not insignificant. It would be a bummer to not do the blocks like a rectus sheath for midline etc? Anyone know of any work done with this?

Here is a summary if you haven't been following the lido lit

LIDOCAINE
The real benefit for lidocaine infusion seems to be in abdominal surgery and prostate surgery. The benefits HAVE NOT panned out in the literature for acute pain in GYN surgery, CT surgery, hip surgery, or breast surgery. There seems to be long term benefits if it is utilized in spine and breast surgery relating to quality of life and chronic pain.
First a word of caution, My biggest fear is that a innocent unassuming soul will program the pump wrong and give some poor patient 2 grams of lidocaine resulting in a death (keep the intralipid handy). Potentially we could limit the amount of lidocaine mixed in the bag? Also this drug also has extensively renal clearance so I opt out as the CrCl drops and sometimes in the elderly.

So back to abdominal surgery where the best evidence is. Perioperative lidocaine infusion, in doses ranging from 1.5 to 3mg/kg/hr ideal body weight (after a bolus of 1 mg/kg), consistently improved postoperative pain scores in patients undergoing open or laparoscopic abdominal surgery. The goal of an infusion is to achieve a steady state concentration within the therapeutic and non-toxic range. Weight-based lidocaine regimens in studies have shown that 1.33–3 mg/kg/hour achieved adequate plasma concentrations of 2–5 µg/mL. One study Koppert et al. reported a 35% reduction in morphine consumption between 0 to 72 h after surgery in patients undergoing major abdominal surgery.

Also of note, in patient’s undergoing colorectal surgery:

• Perioperative lidocaine infusion was shown to be as effective as epidural administration of local anesthetics with regard to pain scores, opioid consumption, and other outcomes!
• In addition to improving analgesia, perioperative lidocaine infusion shortens the duration of postoperative ileus by an average of 8 h.
• Decreases the incidence of PONV by 10 to 20%.
• Reduces the length of hospital stay after colorectal surgery and may be useful for enhanced recovery.

Prob not backed by data but personally if I plan on blocking in the beginning of the case w large volume bupi I don't even give lidocaine on induction

 

[deleted697535]

Did you split your research up by open vs lap? Cause I have them as 2 very different ops.
Almost Everything open gets an epidural, and everything lap gets lido or nothing with a tap block at the beginning or end depending on how slow the surgeon is

 

[anbuitachi]

Did you split your research up by open vs lap? Cause I have them as 2 very different ops.
Almost Everything open gets an epidural, and everything lap gets lido or nothing with a tap block at the beginning or end depending on how slow the surgeon is

Is it true that lap procedures dont hurt very much? I've never had one on myself. Obviously the skin incisions are smaller, but you have more incisions, and your viscerals got cut. Why wouldn't an epidural be helpful to help with the visceral pain?

 

[deleted697535]

Is it true that lap procedures dont hurt very much? I've never had one on myself. Obviously the skin incisions are smaller, but you have more incisions, and your viscerals got cut. Why wouldn't an epidural be helpful to help with the visceral pain?

I'm not sure if you're serious or not? Who knows is the answer. I'm no pain expert.

I do know colleagues who run opioid free lap cases. Just give some esmolol to control hemodynamics with pre-op Tylenol pregab and diclofenac

But I don't think I'd ever put in an epidural for any kind of a lap case

 

[dhb]

Imho lido infusions are good for (and probably invented by) people who can't do blocks.
Do one or the other but both is ******ed.
I did a single port lap colon the other day with a TAP block and the patient uses 8mg of morphine over 48h

 

[NightNight]

If its an all day case, why do the trunk blocks pre- and waste hours of analgesia?

Run the lido infusion (and ketamine infusion) intra-op, once closed keep the patient barely asleep and do TAP/RS just before wake-up. If you’ve managed the ketamine infusion correctly, they’ll be awake, breathing, and stoned in PACU til the trunk blocks set up.

To answer the original question, I have (and still do) done trunk blocks and run lido infusion intra-op (limit to 2mg/min). Assuming your pts liver works, they won’t have any problems.

 

[turnupthevapor]

If its an all day case, why do the trunk blocks pre- and waste hours of analgesia?

Run the lido infusion (and ketamine infusion) intra-op, once closed keep the patient barely asleep and do TAP/RS just before wake-up. If you’ve managed the ketamine infusion correctly, they’ll be awake, breathing, and stoned in PACU til the trunk blocks set up.

To answer the original question, I have (and still do) done trunk blocks and run lido infusion intra-op (limit to 2mg/min). Assuming your pts liver works, they won’t have any problems.

Thank you, seems like since blood levels are in the 2-5 ucg/kg with lido infusions could get into a toxic range, wonder if anyone has done the work in this (measuring blood levels with a combination of the two techniques)
thank you for your input

 

[turnupthevapor]

Imho lido infusions are good for (and probably invented by) people who can't do blocks.
Do one or the other but both is ******ed.
I did a single port lap colon the other day with a TAP block and the patient uses 8mg of morphine over 48h

are you using Exparel? I thought TAPS only lasted 12-18 hours?

 

[NightNight]

are you using Exparel? I thought TAPS only lasted 12-18 hours?

Put Dex in your TAP blocks, can stretch to 24hrs in my experience

 

[NightNight]

Thank you, seems like since blood levels are in the 2-5 ucg/kg with lido infusions could get into a toxic range, wonder if anyone has done the work in this (measuring blood levels with a combination of the two techniques)
thank you for your input

I don’t know if any specific literature, but from what I understand there is a rapid systemic absorption after TAP with a high peak, but by the time the lido infusion reaches a steady state this will have reduced to acceptable levels.

 

[Hoya11]

Question...If I run lido all day on a belly case do you all thing that would preclude me from doing a large volume truncal block? They are both amides and additive toxicity I am sure. The studies w lido infusion gives a blood level of 2-5 ucg so it is not insignificant. It would be a bummer to not do the blocks like a rectus sheath for midline etc? Anyone know of any work done with this?

Here is a summary if you haven't been following the lido lit

LIDOCAINE
The real benefit for lidocaine infusion seems to be in abdominal surgery and prostate surgery. The benefits HAVE NOT panned out in the literature for acute pain in GYN surgery, CT surgery, hip surgery, or breast surgery. There seems to be long term benefits if it is utilized in spine and breast surgery relating to quality of life and chronic pain.
First a word of caution, My biggest fear is that a innocent unassuming soul will program the pump wrong and give some poor patient 2 grams of lidocaine resulting in a death (keep the intralipid handy). Potentially we could limit the amount of lidocaine mixed in the bag? Also this drug also has extensively renal clearance so I opt out as the CrCl drops and sometimes in the elderly.

So back to abdominal surgery where the best evidence is. Perioperative lidocaine infusion, in doses ranging from 1.5 to 3mg/kg/hr ideal body weight (after a bolus of 1 mg/kg), consistently improved postoperative pain scores in patients undergoing open or laparoscopic abdominal surgery. The goal of an infusion is to achieve a steady state concentration within the therapeutic and non-toxic range. Weight-based lidocaine regimens in studies have shown that 1.33–3 mg/kg/hour achieved adequate plasma concentrations of 2–5 µg/mL. One study Koppert et al. reported a 35% reduction in morphine consumption between 0 to 72 h after surgery in patients undergoing major abdominal surgery.

Also of note, in patient’s undergoing colorectal surgery:

• Perioperative lidocaine infusion was shown to be as effective as epidural administration of local anesthetics with regard to pain scores, opioid consumption, and other outcomes!
• In addition to improving analgesia, perioperative lidocaine infusion shortens the duration of postoperative ileus by an average of 8 h.
• Decreases the incidence of PONV by 10 to 20%.
• Reduces the length of hospital stay after colorectal surgery and may be useful for enhanced recovery.

Ugh. I find this post very frustrating.

Lido infusions do nothing..
Ketamine infusions do nothing except for obtund the person (and probably leave them with subtle psychological trauma undetected forever)...

TAP blocks are (mostly) either not needed or are used when an epidural should be used...

Things that work for pain:
Toradol, Celebrex
Steroids
Tylenol (IV>PO)
Epidurals
Brachial Plexus Blocks
FNBs, Pop sciatic blocks
OPIATES!!

Multimodal analgesia doesn't mean you read the latest article about sparing opioids and then do whatever it says.. it means you use the benign stuff that you know works to the best you can, and the for the rest of the pain you give opioids...

You would rather risk LAST than give a little fent/dilaudid ?! I get you want to minimize opioids but minimize does not mean eliminate.
If I knew I was getting a lido infusion and a ketamine infusion, the the docs thought that was a good idea, I would immediately choose another hospital.

 

[Hoya11]

Is it true that lap procedures dont hurt very much? I've never had one on myself. Obviously the skin incisions are smaller, but you have more incisions, and your viscerals got cut. Why wouldn't an epidural be helpful to help with the visceral pain?

An epidural would help visceral pain but this would be like a mallet to kill an ant... Give 100 of fent and call it a day... If pain is severe that's a different story...

 

[NightNight]

Ugh. I find this post very frustrating.

Lido infusions do nothing..
Ketamine infusions do nothing except for obtund the person (and probably leave them with subtle psychological trauma undetected forever)...

TAP blocks are (mostly) either not needed or are used when an epidural should be used...

Things that work for pain:
Toradol, Celebrex
Steroids
Tylenol (IV>PO)
Epidurals
Brachial Plexus Blocks
FNBs, Pop sciatic blocks
OPIATES!!

Multimodal analgesia doesn't mean you read the latest article about sparing opioids and then do whatever it says.. it means you use the benign stuff that you know works to the best you can, and the for the rest of the pain you give opioids...

You would rather risk LAST than give a little fent/dilaudid ?! I get you want to minimize opioids but minimize does not mean eliminate.
If I knew I was getting a lido infusion and a ketamine infusion, the the docs thought that was a good idea, I would immediately choose another hospital.

Sorry, but you sound like somebody who is scared of change and/or too lazy to learn how to do anything new. Just because you don’t know how to utilize certain agents doesn’t mean they “do nothing”.

Sometimes epidurals are contraindicated, in which case TAP/RS are, demonstrably, effective for post-op analgesia. You just have to know how to do them correctly.

Same goes (contraindications) for a number of the non-opioid analgesics you have in your list, although I agree they can be effective as well.

Lidocaine infusions are fantastic for a wide variety of cases, if for nothing else limiting volatile, since you seem to be so worried about long term cognitive effects. The risk of LAST is wildly overstated by people looking for a reason not to use it.

Ketamine is a potent analgesic and, again demonstrably, a useful agent in prevention of wind-up/central sensitization. If you know how to use it (ie when to turn it off), you can have your patient breathing and stoned in PACU (desirable sometimes) or wide awake and comfortable.

Who is saying the patient can’t have any opioids? Change is scary...

 

[anbuitachi]

An epidural would help visceral pain but this would be like a mallet to kill an ant... Give 100 of fent and call it a day... If pain is severe that's a different story...

Is visceral pain less painful than incisional pain?

 

[Scotty_G]

Hoya is in the real world (pp) and wants to KISS which is perfectly fine. The OP is a resident and will change some of his/her techniques once they are in the real world too :0 I used to do lidocaine infusions.......when in residency :0

 

[deleted162650]

Hoya is in the real world (pp) and wants to KISS which is perfectly fine. The OP is a resident and will change some of his/her techniques once they are in the real world too :0 I used to do lidocaine infusions.......when in residency :0

Then you realized they didn’t actually do anything 😉

 

[dhb]

Ugh. I find this post very frustrating.

Lido infusions do nothing..
Ketamine infusions do nothing except for obtund the person (and probably leave them with subtle psychological trauma undetected forever)...

TAP blocks are (mostly) either not needed or are used when an epidural should be used...

Things that work for pain:
Toradol, Celebrex
Steroids
Tylenol (IV>PO)
Epidurals
Brachial Plexus Blocks
FNBs, Pop sciatic blocks
OPIATES!!

Multimodal analgesia doesn't mean you read the latest article about sparing opioids and then do whatever it says.. it means you use the benign stuff that you know works to the best you can, and the for the rest of the pain you give opioids...

You would rather risk LAST than give a little fent/dilaudid ?! I get you want to minimize opioids but minimize does not mean eliminate.
If I knew I was getting a lido infusion and a ketamine infusion, the the docs thought that was a good idea, I would immediately choose another hospital.

You've gotta be over 55


Subtle psychological trauma? That was laugh out loud funny

 

[dhb]

are you using Exparel? I thought TAPS only lasted 12-18 hours?

20cc 0.5% ropivacaine + 5mg dex on both sides.

 

[Hoya11]

Sorry, but you sound like somebody who is scared of change and/or too lazy to learn how to do anything new. Just because you don’t know how to utilize certain agents doesn’t mean they “do nothing”.

Sometimes epidurals are contraindicated, in which case TAP/RS are, demonstrably, effective for post-op analgesia. You just have to know how to do them correctly.

Same goes (contraindications) for a number of the non-opioid analgesics you have in your list, although I agree they can be effective as well.

Lidocaine infusions are fantastic for a wide variety of cases, if for nothing else limiting volatile, since you seem to be so worried about long term cognitive effects. The risk of LAST is wildly overstated by people looking for a reason not to use it.

Ketamine is a potent analgesic and, again demonstrably, a useful agent in prevention of wind-up/central sensitization. If you know how to use it (ie when to turn it off), you can have your patient breathing and stoned in PACU (desirable sometimes) or wide awake and comfortable.

Who is saying the patient can’t have any opioids? Change is scary...

And you sound like someone who lacks the criticial thinking ability to understand what modalities are effective and which are just effective in articles... I'm not afraid of change and I am very highly knowledgable on all of these medications/techniques.. they have been around for years and have been discarded by those of us with any common sense years ago.. so if I were you I would be a little less insulting to those with more experience than yourself and have an open mind beyond what your attendings tell you, but you don't seem like that kind of person, you seem like a book smart person clinically clueless.. but I digress..

 

[Hoya11]

Is visceral pain less painful than incisional pain?

There is a range of mild to severe visceral pain, and mild to sever somatic pain..

 

[dhb]

If its an all day case, why do the trunk blocks pre- and waste hours of analgesia?

Run the lido infusion (and ketamine infusion) intra-op, once closed keep the patient barely asleep and do TAP/RS just before wake-up. If you’ve managed the ketamine infusion correctly, they’ll be awake, breathing, and stoned in PACU til the trunk blocks set up.

To answer the original question, I have (and still do) done trunk blocks and run lido infusion intra-op (limit to 2mg/min). Assuming your pts liver works, they won’t have any problems.

If it's an all day case then it probably deserves an epidural. As i said for laparotomies patients usually use 10-15mg of morphine over 48h so i don't mind doing the block pre-op.

 

[Hoya11]

You've gotta be over 55


Subtle psychological trauma? That was laugh out loud funny

I'm glad you got a kick out of it.. anyone with any personal experience with hallucinogens and their downsides can understand they are not ideal anesthetics.. ill argue all day about the inefficacy of lido infusions and ketamine infusions.. both are completely ridiculous

 

[dhb]

so if I were you I would be a little less insulting to those with more experience than yourself

Definitely over 55 😀

 

[Hoya11]

Definately over 55 😀

definitely wrong

 

[NightNight]

If it's an all day case then it probably deserves an epidural. As i said for laparotomies patients usually use 10-15mg of morphine over 48h so i don't mind doing the block pre-op.

I agree, unless they have some contraindication to doing so. I guess I assumed this was the situation, or else why even ask about trunk blocks and lido infusions...

 

[NightNight]

And for the record, no I’m not getting social security checks yet (apparently a qualification for being a “real” anesthesiologist) but I am out in the real world (PP) and do exactly what I’ve described here on a routine basis.

In my experience, those who routinely write off people as “book smart clinically clueless” are the type who refuse to keep up with the literature and do the same exact anesthetic they were doing twenty years ago because “it’s always worked for me”, meanwhile having no clue what kind of outcomes their patients have outside of what they looked like when they dropped them off in PACU

 

[deleted697535]

How do you calculate the clearance?

Ugh. I find this post very frustrating.

Lido infusions do nothing..
Ketamine infusions do nothing except for obtund the person (and probably leave them with subtle psychological trauma undetected forever)...

TAP blocks are (mostly) either not needed or are used when an epidural should be used...

Things that work for pain:
Toradol, Celebrex
Steroids
Tylenol (IV>PO)
Epidurals
Brachial Plexus Blocks
FNBs, Pop sciatic blocks
OPIATES!!

UOTE]

I don't understand. How does lidocaine 'not work'?

How does it 'work' when given epiduraly or in a peripheral nerve block but doesn't work iv?

Can you explain that to me?

Also you're mixing in brachial plexus blocks etc in with epidurals laparotomies and laparoscopies.
These are all obviously vastly different procedures interventions and can't be lumped together into a pot and say a binary works/fails. Why are you muddying the waters like this?

 

[vector2]

I'm glad you got a kick out of it.. anyone with any personal experience with hallucinogens and their downsides can understand they are not ideal anesthetics.. ill argue all day about the inefficacy of lido infusions and ketamine infusions.. both are completely ridiculous

I doubt there's much of a difference between ketamine infusion and just periodically bolusing 10-20mg q1h throughout a case, but I took over a whipple the other day near the end of the case. Pt had a TAP and had only gotten opioids, tylenol, and ibuprofen. Dilaudid 2mg is worked in before extubation. Post-ext pt is writhing in pain and nurse has given another 1mg. I come back in cause the patient is in agony, splinting, and almost desatting. I tell the nurse to give 30mg ketamine- the pt comfortably drifts backs to sleep, starts ventilating normally, and we roll out.

All I can say is that you're nuts if you don't think sub-anesthetic, sub-hallucinatory doses of ketamine are the best thing since sliced bread.

 

[Psai]

I doubt there's much of a difference between ketamine infusion and just periodically bolusing 10-20mg q1h throughout a case, but I took over a whipple the other day near the end of the case. Pt had a TAP and had only gotten opioids, tylenol, and ibuprofen. Dilaudid 2mg is worked in before extubation. Post-ext pt is writhing in pain and nurse has given another 1mg. I come back in cause the patient is in agony, splinting, and almost desatting. I tell the nurse to give 30mg ketamine- the pt comfortably drifts backs to sleep, starts ventilating normally, and we roll out.

All I can say is that you're nuts if you don't think sub-anesthetic, sub-hallucinatory doses of ketamine are the best thing since sliced bread.

Well we are almost out of the stuff so...