Adult Intravenous 2% Lidocaine Infusion for Perioperative Analgesia

Publication: 31/10/2018  
Next review: 01/11/2024  
Clinical Guideline
CURRENT 
ID: 5766 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2021  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Adult Intravenous 2% Lidocaine Infusion for Perioperative Analgesia

Aims

This guideline sets out the evidence-based rationale and agreed standards for the safe delivery of intravenous lidocaine for the management of adult perioperative pain in Leeds Teaching Hospitals NHS Trust.

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Introduction

Lidocaine is an amide local anaesthetic that works by blocking voltage-gated fast sodium channels. Whilst historically a Class 1b anti-arrhythmic drug, its use as an intravenous analgesic, owing to both its analgesic and anti-inflammatory properties, is not new1-4.

The use of intravenous lidocaine in the management of peri-operative pain has been studied with encouraging results5-18. Meta-analyses of randomised controlled trials found intravenous lidocaine to have multidimensional effects on the quality of recovery6,7,17; reducing post-operative pain scores at 24 hours, reducing cumulative peri-operative opioid requirements, reducing post-operative nausea and vomiting and promoting earlier return of gut function and commencement of regular diet. The gastrointestinal pro-peristaltic effects of intravenous lidocaine and evidence for reducing post-operative pain scores and side-effects has made its use in laparoscopic and gastrointestinal surgery common6,7. A reduction in post-operative hospital length of stay has also been attributed to intravenous lidocaine use7,18.

Following an intravenous loading dose, lidocaine is distributed to the rapidly perfused organs such as heart, brain and kidneys followed by the slower perfused tissues such as skeletal muscle and fat. Its volume of distribution is thought to be 91L/kg. Infusion reaches steady state in approximately 4-8hours, however a loading dose will significantly reduce this time. Following a 3-day infusion in healthy subjects the context sensitive half time is 20-30mins8.

In plasma, lidocaine exists as both free unbound drug (responsible for its pharmacological effects) and drug bound to the plasma proteins α 1-acid glycoprotein (AAG) and to a lesser extent albumin. Approximately 90% of the drug undergoes hepatic metabolism by the P450 3A4 isoenzyme system19 and therefore relies heavily on hepatic metabolic function and hepatic blood flow.

The major lidocaine metabolites are Monoethylglycinexylidide (MEGX) and Glycinexylidide (GX). MEGX has comparable antiarrhythmic and convulsive properties to lidocaine, can cause toxicity, and is rapidly metabolised to GX by the liver. GX has less activity compared to its parent compound and is both metabolised and excreted by the kidney8.

Local anaesthetic systemic toxicity (LAST) describes the pattern of symptoms and signs related to increasing plasma concentrations of local anaesthetics above a toxic threshold, which for lidocaine is generally agreed to be 5µg/ml. In general, central nervous system excitatory phenomena predominate at concentrations less than 10µg/ml and cardiovascular signs become more apparent at plasma levels greater than 10µg/ml. However, up to 40% of LAST cases may present atypically, such as with cardiovascular signs alone20. A review of LAST cases reported in peer-reviewed journals and online registries, between 2014 and 2016, demonstrated no cases associated with the use of perioperative intravenous lidocaine therapy.

The lidocaine therapeutic plasma concentration is 2.5-3.5µg/ml8 and appears to be based on early studies measuring plasma concentrations of lidocaine when used as an anti-arrhythmic agent21. The studies quoted above reported safe study doses ranging from 1-3mg/kg loading dose followed by infusions of between 0.5-5mg/kg/hr. Reported adverse drug effects were limited to light headedness, dizziness or tinnitus and associated with prolonged infusions well into the postoperative period or infusions in the higher dose range.

An intravenous lidocaine loading dose of 1.5mg/kg at induction of anaesthesia followed by continuing infusion of 1-2mg/kg/hr can therefore be considered safe with a low side-effect and toxicity risk8. With careful patient selection, appropriate administration, monitoring and nursing education; intravenous lidocaine may be safely continued for 24 hours after surgery.

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Indications

Intravenous lidocaine should only be instituted under the guidance of the relevant anaesthetist or acute pain management team. Its role is in the management of acute pain following major surgery, including but not limited to trauma, spinal, neurosurgical, colorectal, gynaecological and urological procedures. It should be used as an opioid sparing analgesic adjunct in patients with ongoing analgesic requirements.

Intravenous lidocaine should only be commenced under the instruction of a consultant anaesthetist or intensivist with experience of using the drug.  Where it is used in a planned scenario, a conversation with the patient including risks, benefits and alternatives should be undertaken, and specific consent recorded, for example on the anaesthetic chart.

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Prescription, Dosage and Administration

  • Loading and maintenance infusion doses to be prescribed on the Trust Intravenous 2% Lidocaine Prescription Chart. A paper chart referral should also be completed on Emeds and can be found in the adult ‘Anaesthetics and Acute Pain’ protocol.
  • A referral should be made via PPM+ to the acute pain team
  • Dosage is based on the lower of ideal body weight or actual body weight, with an absolute minimum of 40kgs,
  • Loading dose to be given at time of induction of anaesthesia: 1.5mg/kg up to a maximum of 100mg given over 20 minutes
  • Intravenous Infusion to be continued up to a usual maximum of 24 hours.
  • To be administered using undiluted 2% w/v lidocaine solution for injection in a 50ml syringe
  • Infuse through a dedicated intravenous cannula and a Y-connector/anti-syphon/anti-reflux line.
  • Intravenous fluid to be infused at a minimum rate of 10mL/hour via the Y-connector.
  • The Drug Library of the B-Braun infusion pumps MUST be used.   It is found under the ‘Lidocaine 2% Pain Regimen’ monograph in the drug library of the B-braun smart pumps. This is located in the ‘Critical Care’ and ‘Anaesthetic’ care units in the drug library.

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Contraindications

  • Patients receiving local anaesthetics via other routes (eg. epidural, wound catheters, paravertebral), including local infiltration to wounds.
  • Lower of actual or ideal body weight less than 40kgs
  • Suspected or known amide local anaesthetic allergy
  • Hypovolaemia
  • Complete Heart Block

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Cautions

  • Liver failure or reduced liver metabolic function
  • eGFR<30ml/min/1.73m2
  • Congestive cardiac failure
  • Pregnancy and breast feeding
  • Sino-atrial disease and all grades of AV block
  • Hypokalaemia
  • Acid-base imbalance
  • Epilepsy
  • Myaesthesia Gravis
  • Porphyria

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Drug Interactions

  • Anti-retrovirals - increases plasma concentration of lidocaine
  • Macrolide and fluoroquinolone antibiotics - increases plasma concentration of lidocaine
  • Sodium Valproate - increases plasma concentration of lidocaine
  • Cimetidine - increases plasma concentration of lidocaine
  • Oral Contraceptive Pill - increases plasma concentration of lidocaine
  • Suxamethonium - prolongs neuromuscular blockade
  • Anti-arrhythmics - increased myocardial depression
  • Antipsychotics - increased risk of ventricular arrhythmias
  • Beta-blockers - increased myocardial depression
  • Diuretics and acetazolamide - hypokalaemia resulting from these agents may antagonise the effect of lidocaine.

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Side Effects and Toxicity

  • Bradycardia, arrhythmias
  • Nausea and vomiting, tinnitus, hyperacusis, tongue numbness
  • Nervousness, tremor, drowsiness, convulsions, coma
  • Hypotension (may lead to cardiac arrest), myocardial depression
  • Respiratory depression
  • Methaemoglobinaemia
  • If bolus injection given too rapidly: dizziness, light-headedness drowsiness and paraesthesia

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Minimum Monitoring Standards

  • HDU (level 2) or HOBS (level 1) bed with continuous cardiac monitoring is mandatory.
  • Nursing staff looking after patients receiving intravenous lidocaine should have been trained to recognise and manage associated complications.
  • Blood pressure, heart rate, oxygen saturations and signs of toxicity (above) must be checked and documented every 15 minutes for the first hour, then once every hour
  • Infusion must be stopped if there are ANY signs of local anaesthetic toxicity

The acute pain team/anaesthetist involved/acute anaesthetist on-call must be informed if there are ANY concerns.

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Treatment of Toxicity (LAST)

This is a rare event during a correctly prescribed and administered local anaesthetic infusion. Staff must observe for and recognise symptoms and signs of local anaesthetic toxicity and take appropriate action.

Mild and moderate toxicity: lightheadedness, restlessness, tingling in mouth or tongue, metallic taste sensation, tinnitus, blurred vision:

  • Stop local anaesthetic infusion immediately
  • Maintain oxygenation and support BP with IV fluid as needed
  • Contact acute anaesthetist on-call or original prescribing anaesthetist:
    • SJUH: #5011
    • LGI: #2507

Severe Toxicity: Sudden alteration in mental state, severe agitation or loss of consciousness with or without convulsions, sinus bradycardia, asystole, ventricular tachyarrhythmias:

  • Stop local anaesthetic infusion immediately and initiate adult cardiac arrest call (dial 2222)
  • Follow AAGBI Safety Guideline –‘Management of severe local anaesthetic toxicity’ printed on paper prescription chart
  • Laminated copy of AAGBI safety guideline available in all areas using intravenous lidocaine.

IntraLipid Storage Sites:
SJUH: All PACU (theatre recovery) areas/J81/J53/J54.
LGI: All PACU areas/L2/L3/L5/L6.

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Duration of Infusion and Discontinuation

  • Infusion usually runs for a maximum of 24 hours
  • Infusion may be discontinued before 24 hours if patient displays any signs or symptoms of toxicity (above)
  • At discontinuation of infusion, lidocaine giving set must be disconnected from the dedicated i.v. cannula and the cannula flushed with 0.9% Sodium Chloride. Remaining infusion solutions should be discarded, as per LTHT protocol, into blue medicines bins.
  • In exceptional circumstances, it may be appropriate to continue the infusion for longer than 24 hours.  This decision can only be made by a Consultant from the Acute Pain Team or Intensive Care Team and the decision must be carefully documented.  The infusion must be reduced to 50% of normal dose. No loading dose should be given and monitoring must be maintained at the same level until the end of the duration.  A new IV lidocaine prescription chart must be written, and correctly modified, and all staff involved in the patients care should be aware to ensure no dose deviations occur.

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Provenance

Record: 5766
Objective:
Clinical condition:
Target patient group:
Target professional group(s): Secondary Care Doctors
Pharmacists
Adapted from:

Evidence base

References/Evidence Base

  1. Hanson I R, Hingson R A. The Use of Xylocaine: A New Anesthetic in Surgery, Obstetrics and Therapeutics. Anesth Analg. 1950 29(136)
  2. Gilbert C, Hanson I R, Brown A B, Hingson RA. Intravenous Use of Xylocaine Anesth Analg 1951 30(6):301-313
  3. Clive-Lowe S G, Desmond J, North J. Intravenous lignocaine anaesthesia. Anaesthesia 1958 13(2):138-146
  4. Bartlett E E, Hutaserani 0. Xylocaine for the relief of postoperative pain. Anesth Analg 1961. (40):296-304
  5. Weibel S, Jokinen J et al. Efficacy and safety of intravenous lidocaine for postoperative analgesia and recovery after surgery: a systematic review with trial sequential analysis. BJA (2016) 116(6): 770-83
  6. Ventham NT, Kennedy ED et al. Efficacy of Intravenous Lidocaine for Postoperative Analgesia Following Laparoscopic Surgery: A Meta-Analysis. World Journal of Surgery (2015) 39: 2220-2234
  7. Vigneault L, Turgeon AF, Côté D. Perioperative intravenous lidocaine infusion for postoperative pain control: a meta-analysis of randomized controlled trials. Canadian Journal of Anesthesia (2011) 58: 22-37
  8. Eipe, N., Gupta, S., & Penning, J. (2016). Intravenous lidocaine for acute pain: an evidence-based clinical update. BJA Education, 16(9), 292-298
  9. Hollmann M W, Durieux M E. Local anesthetics and the inflammatory response: A new therapeutic indication? Anaesthesiology 2000. (93):858–75
  10. Rimback G, Cassuto J, Tollesson PO. Treatment of postoperative paralytic ileus by intravenous lidocaine infusion. Anesth Analg 1990 Apr; 70(4): 414–9
  11. Cassuto J, Wallin G, Hogstrom S et al. Inhibition of postoperative pain by continuous low-dose intravenous infusion of lidocaine. Anesth Analg 1985. 64(10):971–4
  12. Striebel H, Klettke U. Is intravenous lidocaine infusion suitable for postoperative pain management? Schmerz 1992. 6(4):245–50
  13. Yardeni I Z, Beilin B, Mayburd E et al. The effect of perioperative intravenous lidocaine on postoperative pain and immune function. Anesth Analg 2009 109(5):1464–9
  14. Koppert W, Weigand M, Neumann F et al. Perioperative intravenous lidocaine has preventive effects on postoperative pain and morphine consumption after major abdominal surgery. Anesth Analg 2004. 98(4):1050–5
  15. Kaba A, Laurent S R, Detroz B J et al. Intravenous lidocaine infusion facilitates acute rehabilitation after laparoscopic colectomy. Anesthesiology 106(1):11–8
  16. Song X, Sun Y, Zhang X, Li T, Yang B. Effect of perioperative intravenous lidocaine infusion on postoperative recovery following laparoscopic Cholecystectomy - A randomized controlled trial. International Journal of Surgery 2017. (45)8-13
  17. Zhao J B, Li Y L, Wang Y M, Teng J L et al. Intravenous lidocaine infusion for pain control after laparoscopic cholecystectomy: A meta-analysis of randomized controlled trials. Medicine 2018 97(5)
  18. Herroeder S, Pecher S, Schönherr M E, Kaulitz G et al. Systemic lidocaine shortens length of hospital stay after colorectal surgery: a double-blinded, randomized, placebo-controlled trial. Annals of surgery 2007. 246(2):192
  19. Guengerich F P. Cytochrome P-450 3A4: regulation and role in drug metabolism. Annual review of pharmacology and toxicology 1999. 39(1):1-17
  20. Neal J M, Barrington M J, Fettiplace M R, Gitman et al. The third American Society of Regional Anesthesia and Pain Medicine practice advisory on local anesthetic systemic toxicity: executive summary 2017. Regional anesthesia and pain medicine 2018. 43(2):113-123.
  21. Collinsworth K A, Kalman S M, Harrison D C. The clinical pharmacology of lidocaine as an antiarrhythymic drug. Circulation 1974. 50(6): 1217-1230

Approved By

Trust Clinical Guidelines Group

Document history

LHP version 1.0

Related information

July 2021 Guideline review

The death of a patient give postoperative lidocaine in an NHS hospital was widely reported in the National Media and reviewed by the Safe Anaesthesia Liaison Group- SALG.  They produced guidelines and an associated editorial.  For full detail please see:

The use of intravenous lidocaine for postoperative pain and recovery: international consensus statement on efficacy and safety.  Foo et al.  Anaesthesia 2021; 76: 238-250.

Associated editorial:  Unlicensed intravenous lidocaine for postoperative pain: always a safer ‘licence to stop’ than to start. Pandit.  Anaesthesia 2021; 76: 238-50.

They reviewed the published evidence in order to answer 3 questions:

Is it effective?
Data were inconclusive and probably insufficient.  There is a signal towards a reduction in post-operative pain, but it is unclear if it reaches clinical significance.  The incidence of post-operative ileus and time to first bowel movement was reduced.  This is being specifically studied in the Allegro trial, to which LTHT are a recruiting centre.

Is it safe?
Generally adverse effects noted in published clinical studies are minor, and the death of patient was noted to be due to errors in systems and communication, rather than inherent safety problem with intravenous lidocaine, with the proviso that suitable precautions are used, as outlined in this guideline.

Does the fact it is unlicenced for this use affect its use?
It is noted in both articles that many drugs are used ‘off-licence’, especially in anaesthesia, and the prescriber must be satisfied that there is suitable safety and efficacy evidence to support the drug’s use.  There should be discussion with the patient outlining the benefits, risks, and alternatives, and specific documentation to record this discussion of ‘consent’.

They made a series of specific recommendations, which this guideline now fulfils.  Changes made to this guideline in order to comply with the recommendations include:

Specifying the minimum weight of 40kgs.

Recommending specific consent is obtained and documented.  We now recommend the use of a written consent form, see next section.

Change the maximum infusion time period to 24 hours total, not 24 hours from admission to PACU, with added detail to ensure strict conditions are met in the rare circumstances that a longer infusion is deemed appropriate.

An increase in monitoring frequency.

Emphasis on the use of the B-Braun pump drug library

Alteration into the detail of how the prescriber should refer the patient to the Acute Pain Team.

Clarification into the types of the fluid to be co-infused with intravenous lidocaine.

The Prescription chart has been reviewed and modified to accurately reflect these changes.

Consent
There is now a recommendation for consent to be obtained before using IV lidocaine.  The process should be clearly documented.  We recommend the use of a pre-printed consent form, which contains the following information which must be discussed with the patient:

Name of proposed procedure or course of treatment:

Intravenous (IV) lidocaine infusion during and/or after surgery. You will be monitored and cared for in an area where staff are trained in the use of lidocaine for this purpose. This treatment will be given for a maximum of 24 hours.

The intended benefits:

To reduce post operative pain, to reduce the need for post operative opioids, to reduce nausea and vomiting following surgery,  to promote return of bowel function. 

Significant, unavoidable or frequently occurring risks:

Unlicensed use of lidocaine.

Minor or commonly occurring (between 1 in 10 and 1 in 100): thrombophlebitis, metallic taste, euphoria, facial flushing, drowsiness, dizziness or light-headedness, peri-oral numbness or tingling, agitation, nausea.

Serious (uncommon): hypotension, arrhythmias, respiratory depression, seizures, coma.

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