The current article is an update in
the field of anesthesiology, adopted from the clinical findings published in
the renowned journal “Anesthesiology”. A number of studies and meta-analyses have
indicated that perioperative lidocaine infusion is effective in decreasing
postoperative pain and improve other outcomes. The authors of this article have
reported the findings relevant for the practicing anesthesiologist when using
lidocaine infusion in different clinical settings.
Surgery affects both pro- and
anti-inflammatory systems in the body. Anti-inflammatory components tend to
contribute to infections, whereas pro-inflammatory components are involved in
post-operative complication and sometimes leading to organ failure. However,
some of these complications can be alleviated by perioperative lidocaine
infusion. Many studies have reported the benefits of perioperative lidocaine
infusion with respect to reduction in pain, nausea, ileus duration, opioid
requirement, and length of hospital stay. The benefits have been observed with
infusion rates of IV lidocaine which mimics plasma lidocaine concentrations
obtained during epidural administration.
This article provides an overview of
the findings in the context relevant for practicing anesthesiologist in
different clinical settings as discussed below.
Abdominal Surgery
Following are some of the
observations made when perioperative lidocaine was administered in patients
undergoing open or laparoscopic abdominal surgery.
- Lidocaine infusion in doses ranging from 1.5 to 3 mg ∙
kg−1 ∙ h−1 (after a bolus of 0 to 1.5 mg/kg), has shown to improve
postoperative pain scores in patients undergoing open or laparoscopic
abdominal surgery.
- Opioid requirements in the post-anesthesia care unit
were reduced by an average of 4.2mg morphine equivalents. Total analgesic
consumption has been reduced by 35% when lidocaine continued for 0 to 1h
postoperatively.
- During colorectal surgery, lidocaine infusion was as effective as epidural
administration of local anesthetics with respect to pain scores, opioid
consumption, and other outcomes.
- In bariatric surgery patients,
lidocaine infusion reduced opioid consumption which improved recovery scores.
- Lidocaine Infusion shortened the duration of
postoperative ileus by an average of 8 hours and decreases the incidence
of postoperative nausea and vomiting by 10 to 20%
- Toxicity from perioperative lidocaine infusion (e.g.
neurologic changes—lightheadedness, dizziness and visual disturbances, and
cardiac dysrhythmias) is very rare.
Perioperative lidocaine infusion may
be an effective alternative for patients whom neuraxial analgesia is
contraindicated.
Breast Surgery
Studies noted no difference between
perioperative lidocaine infusion compared to placebo infusion, on total
morphine consumption, pain scores, duration of hospital stay, postoperative
nausea and vomiting (PONV), a return of bowel function, and patient
satisfaction in the immediate postoperative period. However, some studies have
shown that lidocaine infusion has reduced incidence of chronic postsurgical
pain at 3 and 6 months after mastectomy
Gynecologic And Obstetric Surgery
No difference was observed between
lidocaine and placebo in the primary outcomes (length of the hospital stay or
6-min walk) or secondary outcomes (pain scores, opioid consumption, PONV,
recovery, and fatigue scores in patients undergoing a total abdominal
hysterectomy. Hence these studies do not support the use of perioperative
lidocaine infusion for the patient undergoing total abdominal hysterectomy.
In obstetrics, the inclusion of
lidocaine did not affect the Apgar score or acid base status, suggesting that
the infusion may reduce the maternal stress due to surgery without ill effects
on neonates. However, additional studies are warranted in this regard.
Cardiothoracic Surgery
Studies have not shown any
difference in a postoperative pain or in opioid or benzodiazepines consumption
after coronary artery bypass grafting (CABG) in patients who received lidocaine
infusion (at 1.5 mg/kg bolus followed by an infusion rate of 30μg / kg∙ min
until 48 h postoperatively). As the lidocaine was not added to the
cardiopulmonary bypass pump volume, effective doses may not have been achieved
during bypass. The available evidence does not support the use of perioperative
lidocaine infusion for cardiac surgery patients.
Spine Surgery
Perioperative lidocaine infusion was
found to reduce pain scores and was non-inferior to postoperative opioid
consumption in major spine surgery patients. Also, postoperatively (at 1 and 3
months after surgery, patients reported improved quality of life in the survey.
Based on the short- and long- term benefits, perioperative lidocaine infusion
may provide value for patients undergoing major spine surgery.
Perioperative lidocaine infusion is
indeed beneficial but in some surgical procedures. So far, no mechanism can
provide the explanation for the differences in the outcomes between relatively
similar procedures. One of the reasons can be differences in the study design,
sample size, infusion rate etc.
In short, perioperative lidocaine
infusion may be useful adjunct analgesic in enhanced recovery protocols.
Reference
Dunn, Lauren K., and Marcel E.
Durieux. "Perioperative Use of Intravenous Lidocaine" The Journal of
the American Society of Anesthesiologists 126.4 (2017): 729-737'.
