Local Anaesthetic Toxicity question..

[CavGas]

Greetings to everyone in the forum!

I am still an unwise resident so I would like anyone with experience to comment..

After I read about lidocaine infusion benefits in open colorectal surgery I 've been convincing some of my more ''open minded'' attendings to run it intraop and in PACU in selected patients with no liver disease, at 2mg/kg/hr IBW. My issue is that surgeons regularly infiltrate the wound with 0.375% ropi, usually at a total dose of 75-150mg, during closure. Could this combination of local produce LAST? Should I tell them to omit the local or is it fine since SQ absorption is so slow and we d/c the IV infusion upon discharge from PACU?

Thanks in advance!

---

Members don't see this ad.

 

[Velefunt]

Wouldn't your open colorectal surgery patients be better served with an epidural or TAP blocks for post-op pain management?

Or better yet, robotic-assist procedure + TAP blocks post vs open?

 

[GassYous]

Epidurals are great. iv lido is such crap

 

[Morzh]

What you are describing is done very commonly at many places.

There's decent evidence for it. It's not as good as an epidural. May be better than TAP blocks, though. Helps with not only analgesia, but potent anti-inflammatory and anti-NMDA. Call it a "poor man's epidural". Where lidocaine infusions really shine are as part of a overall multi-modal approach. I've seen some pretty amazing wake-ups and POD#1 patients with high satisfaction when they had an intra-op combination of lidocaine, ketamine, precedex, NSAIDs, and acetaminophen - with very minimal opioids. And when they do get the opioid they are more naive to it so it seems to work better at lower dosages.

To answer your question, you should probably not have the surgeons inject local at the end. Or, if you're willing to abandon the lidocaine in PACU, then just stop it about 45 minutes before they inject.

If you've been reading then you've probably come across this excellent review article.

Also, a European task force just came out with this consensus on efficacy and safety of intravenous lidocaine for post-op pain control. It's an interesting read - very controversial actually. And may not be generalizable to the patients you are describing... but worth skimming through anyway because it's a buzzing topic amongst regional anesthesia folks right now.

 

[JiPo]

I haven't had much luck with lidocaine infusion for colorectal cases, tbh. They still wake up with similar amount of pain and required similar amount of narcotics compared to not using it based on my limited experience. TAP blocks have been quite variable - some great, some pain. I've had most luck with TAP blocks AND rectus sheath blocks.

Colorectal surgeons at my shop are against epidural for some reason, although that would be the best option for open colorectal procedures. Epidural works great on our gyn patients undergoing open procedure, so I assume it would be just as beneficial for patients undergoing open colorectal procedures.

 

[deleted171991]

Non-opiate analgesia is overrated, especially for big surgeries. And I'm saying it as an anesthesiologist who's good at drug-based analgesia. regardless of type.

I've had a number of stepdown admission requests, for patients who were on IV lidocaine intraop, and emerged sedated and hypotensive. I told them NO; just let them wake up in the PACU, and tell the anesthesia provider to stop the darn lidocaine infusion in time.

If a treatment has such bad therapeutic profile and is so unpredictable that half the patients either don't achieve analgesia or have significant side effects, maybe we shouldn't put it on a pedestal. And I'm refering not just to lidocaine, but also to precedex, and cacapentin. I will rather combine ketamine and Mag with a decreased dose of opiates (and other stuff I use in every case, such as decadron), than put the patient at risk of slow emergence, bradycardia and hypotension with lidocaine or cacadex.

My residents are always surprised when my cases are pretty tram-track, set it and forget it, while they keep struggling with hypotension etc. in some other rooms, running 2-3 infusions at a time. Those people wouldn't survive in PP a week. Nobody gives a crap about non-opiate analgesia in the real world, except some populist politicians and some curious anesthesiologists. All the patients and surgeons care about is the perfect periop experience.

Give somebody 100 mg of lidocaine IV and ask them how they feel. A lot of people will hate the feeling, describing it as dizzy. Few of us know, because we give propofol almost immediately. Same for awake remi, by the way.

 

[GassYous]

Non-opiate analgesia is overrated, especially for big surgeries. And I'm saying it as an anesthesiologist who's good at drug-based analgesia. regardless of type.

I've had a number of stepdown admission requests, for patients who were on IV lidocaine intraop, and emerged sedated and hypotensive. I told them NO; just let them wake up in the PACU, and tell the anesthesia provider to stop the darn lidocaine infusion in time.

If a treatment has such bad therapeutic profile and is so unpredictable that half the patients either don't achieve analgesia or have significant side effects, maybe we shouldn't put it on a pedestal. And I'm refering not just to lidocaine, but also to precedex, and cacapentin. I will rather combine ketamine and Mag with a decreased dose of opiates (and other stuff I use in every case, such as decadron), than put the patient at risk of slow emergence, bradycardia and hypotension with lidocaine or cacadex.

My residents are always surprised when my cases are pretty tram-track, set it and forget it, while they keep struggling with hypotension etc. in some other rooms, running 2-3 infusions at a time. Those people wouldn't survive in PP a week. Nobody gives a crap about non-opiate analgesia in the real world, except some populist politicians and some curious anesthesiologists. All the patients and surgeons care about is the perfect periop experience.

Give somebody 100 mg of lidocaine IV and ask them how they feel. A lot of people will hate the feeling, describing it as dizzy. Few of us know, because we give propofol almost immediately. Same for awake remi, by the way.

Agree 100% with everythiing you say here. I don't give 100 of lido anymore, just put 20 in the propofol syringe to decrease the burning. Love ketamine and use mag all the time in the spine room. I stopped using precedex in my blocks and the only reason why I use precedex instead of ketamine is that you have to waste the ketamine. But I think ketamine is a superior adjuvant for propofol.

 

[anbuitachi]

you should try esmolol infusion... works great.. according to some studies

 

[woopedazz]

I don't mind lignocaine for the chronic pain endometriosis patient getting laparoscopies. Doesn't slow the case down and helps with the PACU/ward calls post-op. They're normally very happy with analgesia on APS rounds, and objectively use less opioids postop on our audits. If I'm doing an open I'll do a block of some description and lignocaine IV gets in the way.

I also think the research is reasonable.

The esmolol papers that try to conclude "less opioids intra-op and in PACU," but neglect to tell you the patient receives 0 opioids intra-op until the last minute, where they are loaded with an enormous dose (but less overall) --> PACU in an opioid-induced stupor and graduate to the ward requiring 0 pain protocol (less in PACU) --> ward where they wake up and use the exact same amount of opioids once equilibrium is reached/more opioid to reach equilibrium...

 

[CavGas]

Thanks to everybody for taking the time to reply, it's really something to be able to have a conversation with attendings outside my own institution!

@Velefunt

I always try to push for an epidural but sometimes the pt is not suitable or the surgeon is against it, so I 'm trying to find an alternative to the 100% narc-based analgesia we usually do here.
I 've read about TAP blocks but we don't have anybody that does them at our hospital and I wouldn't be willing to try by myself..

@Morzh

Thanks for the answer and the articles, I will definitely look them up!

@FFP

Tbh I gave a type 2 resp failure pt 100 of lido as part of RSI once and he started seizing immediately, thankfully prop-rocuronium followed immediately after. Maybe it was coincidence but I learned to respect it since then..
On ketamine.. I wish they would let me try it. Everybody is afraid of emergence delirium - hallucinations so we use it on very select circumstances.
On narcs, shouldn't we try to minimize them intraop so the μ receptors can work with less post op? We regularly give 500ug fent and 6-10mg of morphine for a 3hr colectomy and it seems like a lot?

 

[MirrorTodd]

Thanks to everybody for taking the time to reply, it's really something to be able to have a conversation with attendings outside my own institution!

@Velefunt

I always try to push for an epidural but sometimes the pt is not suitable or the surgeon is against it, so I 'm trying to find an alternative to the 100% narc-based analgesia we usually do here.
I 've read about TAP blocks but we don't have anybody that does them at our hospital and I wouldn't be willing to try by myself..

@Morzh

Thanks for the answer and the articles, I will definitely look them up!

@FFP

Tbh I gave a type 2 resp failure pt 100 of lido as part of RSI once and he started seizing immediately, thankfully prop-rocuronium followed immediately after. Maybe it was coincidence but I learned to respect it since then..
On ketamine.. I wish they would let me try it. Everybody is afraid of emergence delirium - hallucinations so we use it on very select circumstances.
On narcs, shouldn't we try to minimize them intraop so the μ receptors can work with less post op? We regularly give 500ug fent and 6-10mg of morphine for a 3hr colectomy and it seems like a lot?

That does seem relatively like a lot. No blocks or epidurals for colostomy? Open or lap? We have pretty much transitioned to QL's instead TAP for almost all of our lap cases. They're fairly easy to learn and perform.

 

[GassYous]

The biggest problem with epidurals is the anticoagulation. Heparin sq is nbd. There is no good reason for surgeons to be against it unless they think it takes too much time. Then you can tell them that their 3 hour colectomy is about 2 hours too long. Epidurals give you perfect pain control and happy patients.

You don't need 100 of lido for every patient. I used to give 1/kg but then I realized if I mix 20 with the propofol I don't have any issues with the burning. I don't mix it until within 30 minutes of induction because the lido can degrade the prop.

You can teach yourself blocks. Read the page on nysora and watch a bunch of youtube videos. The angle is relatively shallow and there's a small risk of hitting organ if you just go blindly without seeing your needle but it's a pretty easy and straightforward block. The only problem is lack of visceral coverage so I like ql more. But sometimes taps can give you a very comfy patient with no pacu narcs but can be hit or miss. Still worth doing.

Minimizing narcs is overrated esp since pacu will be giving them what you didn't. I give around 250 of fent and 1 of dilaudid. Dilaudid is a better drug than mofine. Ketamine is great. Low doses, around 0.2-0.3 ucg/kg/h is great for analgesia and avoids delirium. I try not to give more than 200 in a case but if I give a lot then I give a lot. It is the doses in the middle that cause problems.

tldr your attendings suck

 

[deleted875186]

Thanks to everybody for taking the time to reply, it's really something to be able to have a conversation with attendings outside my own institution!

@Velefunt

I always try to push for an epidural but sometimes the pt is not suitable or the surgeon is against it, so I 'm trying to find an alternative to the 100% narc-based analgesia we usually do here.
I 've read about TAP blocks but we don't have anybody that does them at our hospital and I wouldn't be willing to try by myself..

@Morzh

Thanks for the answer and the articles, I will definitely look them up!

@FFP

Tbh I gave a type 2 resp failure pt 100 of lido as part of RSI once and he started seizing immediately, thankfully prop-rocuronium followed immediately after. Maybe it was coincidence but I learned to respect it since then..
On ketamine.. I wish they would let me try it. Everybody is afraid of emergence delirium - hallucinations so we use it on very select circumstances.
On narcs, shouldn't we try to minimize them intraop so the μ receptors can work with less post op? We regularly give 500ug fent and 6-10mg of morphine for a 3hr colectomy and it seems like a lot?

I never give more than 100 mcg of fentanyl, 200 mcg max if patient is begging for it intraoper. Try skipping fentanyl on induction, give some fentanyl before incision or most stimulating part of the surgery.

I also never use morphine, more side effects than hydromorphone.

Ketamine works great, if worried about emergence, just make sure you give it at the start of surgery, up to 0.5 mg/kg, maybe another smaller bolus if needed mid surgery, than nothing for the last hour or so before wake up, shouldn’t have any emergence priblems.

 

[abolt18]

That does seem relatively like a lot. No blocks or epidurals for colostomy? Open or lap? We have pretty much transitioned to QL's instead TAP for almost all of our lap cases. They're fairly easy to learn and perform.

QL 1, 2 or TM?

 

[MirrorTodd]

QL 1, 2 or TM?

QL2 primarily.

 

[deleted875186]

Thanks to everybody for taking the time to reply, it's really something to be able to have a conversation with attendings outside my own institution!

@Velefunt

I always try to push for an epidural but sometimes the pt is not suitable or the surgeon is against it, so I 'm trying to find an alternative to the 100% narc-based analgesia we usually do here.
I 've read about TAP blocks but we don't have anybody that does them at our hospital and I wouldn't be willing to try by myself..

@Morzh

Thanks for the answer and the articles, I will definitely look them up!

@FFP

Tbh I gave a type 2 resp failure pt 100 of lido as part of RSI once and he started seizing immediately, thankfully prop-rocuronium followed immediately after. Maybe it was coincidence but I learned to respect it since then..
On ketamine.. I wish they would let me try it. Everybody is afraid of emergence delirium - hallucinations so we use it on very select circumstances.
On narcs, shouldn't we try to minimize them intraop so the μ receptors can work with less post op? We regularly give 500ug fent and 6-10mg of morphine for a 3hr colectomy and it seems like a lot?

500 mcg fentanyl is a lot. A lot of people for routine CABGs have stopped giving that much for a whole pump case. If your going to give morphine or hydromorphone, try just giving the 10mg morphine at the start and skip the fentanyl completely. I think people seem to wake up better and have more tolerable pain when I skip the potent opioid and use long acting instead.

 

[CavGas]

@dipriMAN

Thanks for all the tips!

Unfortunately our pharmacy only stocks morphine and pethidine as long acting narcs so no choice about it..
I 'll try to convince my attending to use some ketamine next time. 100 fentanyl for a colectomy would be considered heresy and 'torturing' the pt here.. I think hearts get around 2mg of fentanyl, maybe more.
Out of curiosity, at what MAC do you need to run the volatile to have the sympathetic not responding with so little narc? We usually run 0.7-0.8..

@GassYous

I 'll read up on the QL. Seems to me we are doing so little for the patients here.. Thanks!

 

[deleted875186]

@dipriMAN

Thanks for all the tips!

Unfortunately our pharmacy only stocks morphine and pethidine as long acting narcs so no choice about it..
I 'll try to convince my attending to use some ketamine next time. 100 fentanyl for a colectomy would be considered heresy and 'torturing' the pt here.. I think hearts get around 2mg of fentanyl, maybe more.
Out of curiosity, at what MAC do you need to run the volatile to have the sympathetic not responding with so little narc? We usually run 0.7-0.8..

@GassYous

I 'll read up on the QL. Seems to me we are doing so little for the patients here.. Thanks!

I run the same, 0.7-0.8 MAC, go up if needed, the key is to time your fentanyl or ketamine for skin incision or other stimulating parts of the surgery, there are still many parts of the surgery without too much stimulation. Of course you also have to make sure your relaxed at the same time.

 

[deleted875186]

@dipriMAN

Thanks for all the tips!

Unfortunately our pharmacy only stocks morphine and pethidine as long acting narcs so no choice about it..
I 'll try to convince my attending to use some ketamine next time. 100 fentanyl for a colectomy would be considered heresy and 'torturing' the pt here.. I think hearts get around 2mg of fentanyl, maybe more.
Out of curiosity, at what MAC do you need to run the volatile to have the sympathetic not responding with so little narc? We usually run 0.7-0.8..

@GassYous

I 'll read up on the QL. Seems to me we are doing so little for the patients here.. Thanks!

I might also add, I don’t care if their BP goes up a bit. Obviously don’t want people tachy or very hypertensive, but sometimes the BP will bump up a little than just come right down. I also will bolus a few ccs of the prop left from induction for some parts of the case if needed. In my mind, if there is a stimulating part of surgery, you just need to deepen the anesthetic to match the stimulation, whether you do it with gas, prop, ketamine, opioids, is up to you, I just prefer to use less opioid most of the time.