Perioperative intravenous lidocaine infusion for postoperative pain control: a meta-analysis of randomized controlled trials

Prevention of persistent pain with lidocaine infusions in breast cancer surgery (PLAN): study protocol for a multicenter randomized controlled trial

BACKGROUND

Persistent pain is a common yet debilitating complication after breast cancer surgery. Given the pervasive effects of this pain disorder on the patient and healthcare system, post-mastectomy pain syndrome (PMPS) is becoming a larger population health problem, especially as the prognosis and survivorship of breast cancer increases. Interventions that prevent persistent pain after breast surgery are needed to improve the quality of life of breast cancer survivors. An intraoperative intravenous lidocaine infusion has emerged as a potential intervention to decrease the incidence of PMPS. We aim to determine the definitive effects of this intervention in patients undergoing breast cancer surgery.

METHODS

PLAN will be a multicenter, parallel-group, blinded, 1:1 randomized, placebo-controlled trial of 1,602 patients undergoing breast cancer surgery. Adult patients scheduled for a lumpectomy or mastectomy will be randomized to receive an intravenous 2% lidocaine bolus of 1.5 mg/kg with induction of anesthesia, followed by a 2.0 mg/kg/h infusion until the end of surgery, or placebo solution (normal saline) at the same volume. The primary outcome will be the incidence of persistent pain at 3 months. Secondary outcomes include the incidence of pain and opioid consumption at 1 h, 1-3 days, and 12 months after surgery, as well as emotional, physical, and functional parameters, and cost-effectiveness.

DISCUSSION

This trial aims to provide definitive evidence on an intervention that could potentially prevent persistent pain after breast cancer surgery. If this trial is successful, lidocaine infusion would be integrated as standard of care in breast cancer management. This inexpensive, widely available, and easily administered intervention has the potential to reduce pain and suffering in an already afflicted patient population, decrease the substantial costs of chronic pain management, potentially decrease opioid use, and improve the quality of life in patients.

TRIAL REGISTRATION

This trial has been registered on clinicaltrials.gov (NCT04874038, Dr. James Khan. Date of registration: May 5, 2021).

Postoperative use and early discontinuation of intravenous lidocaine in spine patients

PURPOSE

Our institution employs a multimodal approach to manage postoperative pain after spine surgery. It involves continuous intravenous (IV) lidocaine until the morning of postoperative day two. This study aimed to determine the rate and reasons for early discontinuation of IV lidocaine in our spine patients.

METHODS

We conducted a retrospective chart review and included pediatric patients who underwent ≥ 3-level spine surgery and received postoperative IV lidocaine from November 2019 to September 2022. For each case, we recorded the side effects of IV lidocaine, adverse events, time to discontinuation, and discontinuation rate. Subsequently, we used the same methodology to generate an adult cohort for comparison.

RESULTS

We included 52 pediatric (18M:34F) and 50 (21M:29F) adult patients. The pediatric cohort's mean age was 14 years (8-18), and BMI 23.9 kg/m2 (13.0-42.8). The adult cohort's mean age was 61 years (29-82), and BMI 28.8 kg/m2 (17.2-44.1). IV lidocaine was discontinued prematurely in 21/52 (40.4%) of the pediatric cases and 26/50 (52.0%) of the adult cases (RR = 0.78, p = 0.2428). The side effects noted in the pediatric cases vary, including numbness, visual disturbance, and obtundation, but no seizures. The most common adverse events were fever and motor dysfunction.

CONCLUSION

The early discontinuation rate of IV lidocaine use after spine surgery for children in our institution does not differ significantly from that of adults. The nature of the side effects and the reasons for discontinuation between the groups were similar. Thus, the safety profile of IV lidocaine for pediatric spine patients is comparable to adults.

Regional anesthesia and POCUS in the intensive care unit

This chapter focuses on resident recruitment and recent US National Resident Matching Program changes and the impact in the evaluation and ranking of applicants within the specialty of anesthesiology. Recruitment challenges are examined as well as program strategies and potential future directions. Also discussed are DEI initiatives within the recruitment process.

Perioperative Lidocaine Infusion Reduces Opioid Use in Enhanced Recovery After Surgery Patients Undergoing Laparoscopic Colectomy

BACKGROUND

Enhanced Recovery After Surgery (ERAS) programs have become a mainstay of modern surgical care, and efforts to decrease postoperative opioid consumption have been increasingly employed. A previous study from our institution demonstrated that ERAS protocols decreased opioid use in the first 48 hours after surgery by 61%. In the present study, a lidocaine infusion was added for postoperative pain control. The aim was to analyze the differences in opioid requirements with and without this infusion in the first 48 hours after laparoscopic colectomy in ERAS patients.

METHODS

Retrospective review of patients was conducted at an academically affiliated tertiary care hospital. The population included patients undergoing elective laparoscopic colon surgery enrolled in the ERAS program with the implementation of a lidocaine drip from June 2019 to October 2019, and compared to a previous patient cohort of ERAS patients evaluated without the lidocaine drip from September 2015 to May 2018.

RESULTS

The primary endpoint was postoperative opioid use in the first 48 hours based on IV morphine milligram equivalents (MME). Secondary measures included type of surgery, age, BMI, prior abdominal surgery, and prior opioid use. Median MMEs were 6.0 in the lidocaine infusion group and 12.5 in the group without lidocaine, representing a 52% reduction (p < 0.001).

DISCUSSION

This study demonstrates a significant reduction in post-op opioid use in ERAS patients who receive a lidocaine infusion after laparoscopic colectomy. Further studies should focus on measures to limit the treatment side effects in order to maximize the opioid-sparing benefits of this intervention.

Frailty: the perioperative and anesthesia challenges of an emerging pandemic

Frailty is a complex and multisystem biological process characterized by reductions in physiological reserve. It is an increasingly common phenomena in the surgical population, and significantly impacts postoperative recovery. In this review, we will discuss the pathophysiology of frailty, as well as preoperative, intraoperative, and postoperative considerations for frailty care. We will also discuss the different models of postoperative care, including enhanced recovery pathways, as well as elective critical care admission. With discoveries of new effective interventions, and advances in healthcare information technology, optimized pathways could be developed to provide the best care possible that meets the challenges of perioperative frailty.

Systemic Anti-Inflammatory Effects of Intravenous Lidocaine in Surgical Patients: A Systematic Review and Meta-Analysis

There has recently been increasing evidence that the use of perioperative intravenous lidocaine infusion possesses analgesic, opioid-sparing and anti-inflammatory effects in surgical patients. Although opioid-sparing and analgesic properties have been strongly supported, the anti-inflammatory features are not well established in elective surgery. Therefore, the aim of this systematic review is to examine the effect of perioperative intravenous lidocaine infusion on postoperative anti-inflammatory status in patients undergoing elective surgery. A search strategy was created to identify suitable randomised clinical trials (RCTs) in PubMed, Scopus, Web of Science and Clinicaltrials.gov databases until January 2023. RCTs that evaluated the effect of intravenous lidocaine infusion, compared with placebo, on adult patients who underwent elective surgery, in inflammatory markers response were included. Exclusion criteria consisted of paediatric patients, animal studies, non-RCT methodology, intervention without intravenous lidocaine, inadequate control group, duplicated samples, ongoing studies and lack of any relevant clinical outcome measures. The following inflammatory markers-interleukin (IL)-6, tumour necrosis factor (TNF)-α, IL-1RA, IL-8, IL-10, C-reactive protein (CRP), IL-1, IL-1β, interferon (IFN)-γ, cortisol, IL-4, IL-17, high-mobility group protein B1 (HMGB1) and transforming growth factor (TGF)-β-were evaluated as outcomes in this review. A total of 21 studies, including 1254 patients, were identified. Intravenous lidocaine infusion significantly reduced the change from IL-6 baseline levels at the end of surgery compared to a placebo (standardised mean difference [SMD]: -0.647, 95% confidence interval [CI]: -1.034 to -0.260). Usage of lidocaine was associated with a significant reduction in other postoperative pro-inflammatory markers, such as TNF-α, IL-1RA, IL-8, IL-17, HMGB-1 and CRP. There was no significant difference in other markers, such as IL-10, IL-1β, IL-1, IFN-γ, IL-4, TGF-β and cortisol. This systematic review and meta-analysis provide support for the administration of perioperative intravenous lidocaine infusion as an anti-inflammatory strategy in elective surgery.

Analgesic efficacy of systemic lidocaine using lean body mass based dosing regime versus placebo in bariatric surgery: a prospective, randomised, double-blinded, placebo-controlled, single centre study

BACKGROUND

Intravenous lidocaine is used as an adjuvant analgesic agent in perioperative settings. It has been investigated in various patient populations and surgical interventions, but there are limited data on its efficacy, particularly for patients undergoing bariatric surgery. Obese patients are at high risk of postoperative respiratory complications and can be expected to benefit from anaesthetic techniques that minimise opioid administration.

METHODS

We studied administration of lidocaine hydrochloride 1% i.v. to general anaesthesia at a dose of 1.5 mg kg^-1 (lean body mass×1.28) or placebo in patients undergoing bariatric surgery. Subjects randomly assigned to each group were surveyed for 48 h after surgery for experienced pain (primary outcome), and administered opioids, postoperative nausea and vomiting (PONV), resumption of bowel function, and length of hospital stay (secondary outcomes).

RESULTS

We recruited and randomised 140 subjects to either the lidocaine or placebo group; 137 completed the study. Subjects with pain numeric rating scale (NRS) >3 within the first 4 h postoperatively were similar in both groups (proportion of any NRS >3 within first 4 h lidocaine group: 47/68 (69%) vs placebo group: 44/69 (63%), P=0.507; within first h P=0.177, within second h P=0.513, within third h P=0.145, within fourth h P=0.510). There was no difference in maximal pain score, opioid consumption, recovery of bowel function, incidence of PONV, or length of hospital stay.

CONCLUSIONS

Lidocaine does not improve postoperative pain scores, analgesia, or any secondary outcomes in patients undergoing bariatric surgery.

CLINICAL TRIAL REGISTRATION

NCT03667001.

Intravenous lidocaine infusion compared to thoracic epidural analgesia in cytoreductive surgery with or without heated intraperitoneal chemotherapy. A retrospective case-cohort study

BACKGROUND

Intravenous (IV) lidocaine is a proven analgesic therapy but has not been evaluated in extensive procedures such as cytoreductive surgery (CRS). Our aim was to assess the effectiveness and safety of IV lidocaine in this setting.

METHODS

This is a retrospective hybrid case-cohort study investigating analgesic effectiveness and complications of perioperative IV lidocaine at 1.5 mg/kg/h for 48 h compared to thoracic epidural anaesthesia (TEA) among patients undergoing CRS in a high-volume centre.

RESULTS

Sixty patients were included, 20 received IV lidocaine and 40 underwent TEA. Pain scores were low (median ≤2) and similar in both groups (p = 0.88). At 72 h, the lidocaine group had a lower median pain score (p = 0.03). Overall opioid consumption in the first 48 h was lower in the lidocaine compared to the TEA group (median 0 (IQR 0-9.5) mg vs. 45.4 (0-62.4) MME respectively, p = 0.001). Opioid consumption was also lower in the lidocaine compared to the TEA group during the whole 5-day period (median 1 (IQR 1-13.5) mg vs. 112 (36.6-137.85) MME respectively, p = 0.000). The incidence of PONV was significantly lower in the lidocaine group (27.5% vs 5%, p = 0.047) with no difference in other complications or length of in-hospital stay.

CONCLUSION

Intravenous lidocaine infusion may be a safe and effective analgesic approach in CRS and is associated with a significant reduction of opioid use and PONV compared to opioid-containing TEA.

Application of topical pharyngeal anesthesia to reduce adverse reactions during painless gastroscopy: A prospective randomized study

BACKGROUND

Studies have reported that certain adverse reactions can occur during painless gastroscopy examination. Knowing how to decrease the risks and incidence of adverse reactions is of great importance.

OBJECTIVE

To investigate whether topical pharyngeal anesthesia combined with intravenous anesthesia is superior to intravenous anesthesia alone in patients undergoing painless gastroscopy and to determine whether this combined approach had any additional benefits.

METHODS

Three hundred patients undergoing painless gastroscopy were randomly assigned to either the control group or the experimental group. In the control group, patients were anesthetized with propofol, while patients in the experimental group received propofol combined with 2% lidocaine spray for topical pharyngeal anesthesia. Hemodynamic parameters before and after the procedure, including the heart rate (HR), mean arterial pressure (MAP), and pulse oxygen saturation (SPO2) were recorded. Any adverse reactions experienced by the patient, including choking and respiratory depression, and the total dosage of propofol required during each procedure were also documented.

RESULTS

Compared with pre-anesthetic data, the HR, MAP, and SPO2 were reduced after the completion of the painless gastroscopy procedure in both groups. However, the HR, MAP, and SPO2 measurements taken after the gastroscopy were significantly lower in the control group than those of the experimental group (P< 0.05); thus, the hemodynamic parameters of the experimental group were more stable. Compared with the control group, there was significant reduction in the total amount of propofol administered in the experimental group (P< 0.05). The incidence of adverse reactions, including choking and respiratory depression, was significantly lower in the experimental group (P< 0.05).

CONCLUSION

The results demonstrated that the application of topical pharyngeal anesthesia in painless gastroscopy can significantly reduce the incidence of adverse reactions. Thus, the combination of topical pharyngeal and intravenous anesthesia is worthy of clinical application and promotion.

Long-term effect of anesthesia choice on patients with hepatocellular carcinoma undergoing open liver resection

Clinical and experimental evidence suggested that anesthesia choice can influence cancer progression and patients' outcomes by modulating tumor microenvironment and tumorigenic pathways. Curative resection is the mainstay of therapy for hepatocellular carcinoma (HCC), which is an intractable disease due to high recurrence and poor prognosis. However, different anesthetics may play different roles in alleviating surgery-induced stress response and inflammatory cytokines release that are considered to be closely associated with proliferation, invasion and metastasis of tumor cells. Propofol, sevoflurane, non-steroidal anti-inflammatory drugs and local anesthetics have shown to exert anti-tumor effect on HCC mainly through regulating microRNAs or signaling pathways, while other inhalational agents, dexmedetomidine and opioids have the potential to promote tumor growth. In terms of anesthetic methods and analgesia strategies, propofol based total intravenous anesthesia and thoracic epidural analgesia could be preferred for HCC patients undergoing open liver resection rather than inhalational anesthesia. Local anesthesia techniques have great potential to attenuate perioperative stress response, hence they may contribute to more favorable outcomes. This review summarized the relations between different anesthesia choices and HCC patients' long-term outcomes as well as their underlying mechanisms. Due to the complexity of molecules interactions and signaling pathways, further studies are warranted to confirm these results so as to optimize anesthesia strategy for HCC patients.

Perioperative intravenous lidocaine use in children

Perioperative pain management impacts patient morbidity, quality of life, and hospitalization cost. In children, it impacts not only the child, but the whole family. Adjuncts for improved perioperative analgesia continue to be sought to minimize adverse side effects associated with opioids and for those in whom regional or neuraxial anesthesia is not suitable. The use of ketamine and alpha agonists may be useful in these settings but have noted adverse effects including hallucinations, hemodynamic instability, and excessive sedation. One alternative is intravenous lidocaine. Despite its off-label use, intravenous lidocaine has demonstrated anti-neuropathic, anti-hyperalgesic, and anti-inflammatory actions and is an emerging technique. Multiple studies in adults have demonstrated beneficial effects of perioperative intravenous lidocaine including improved perioperative analgesia with reduced postoperative opioid use, improved gastrointestinal function, earlier mobilization, and reduction in hospital length of stay. Despite the limited pediatric literature, some of these findings have been replicated. Large-scale trials providing evidence for the pediatric pharmacokinetics and high-quality safety data with respect to intravenous lidocaine are still however lacking. To date, dose ranges studied in the pediatric population have not been associated with serious side effects and current data suggests perioperative intravenous lidocaine in a subgroup of pediatric surgical patients seems well-tolerated and beneficial.

Intraoperative lidocaine infusion as a sole analgesic agent versus morphine in laparoscopic gastric bypass surgery

Background

The aim of this study was to assess the effect of intra-operative intra-venous (IV) lidocaine infusion compared to IV morphine, on the post-operative pain at rest, the intra-operative and post-operative morphine requirements, the sedation and the Modified Aldrete scores in the post-anesthesia care unit (PACU), the hemodynamic parameters; mean values of the mean blood pressure (MBP) and the heart rate (HR), the peri-operative changes in the SpO2, and the respiratory rate (RR) in laparoscopic Roux-en-y gastric bypass. Sixty patients ˃ 18 years old, with body mass index (BMI) ˃ 35 kg/m2, American Society of Anesthesiologists (ASA) physical status II or III, were randomly divided into 2 groups: the lidocaine (L) group patients received intra-operative IV lidocaine infusion, and the morphine (M) group patients received intra-operative IV morphine.

Results

The post-operative numeric pain rating scale (NPRS) at rest was statistically significant less in group L than in group M patients, in the post-operative 90 min in the PACU. This was reflected on the post-operative morphine requirements in the PACU, as 26.6% of patients in group M required morphine with a mean total dose of 10.8 mg. The mean values of the MBP and HR recorded after intubation were comparable between patients of both groups, indicating attenuation of the stress response to endotracheal intubation by both lidocaine and morphine. However, the mean values of the MBP and HR recorded after extubation were statistically significant lower in patients of group L, indicating the attenuation of the stress response to extubation by lidocaine. Patients in group M showed statistically significant lower mean values of the MBP; before pneumoperitoneum and after 15 min from the pneumoperitoneum, this was reflected on statistically significant higher mean values of the HR. Patients in group L showed statistically significant lower mean values of the MBP and the HR; at 30 and 45 min from the pneumoperitoneum. Patients in group L showed statistically significant lower mean values of the MBP; 60 min from the pneumoperitoneum, after release of pneumoperitoneum and in the PACU. Patients of both groups showed comparable mean values of the HR after 60 min from the pneumoperitoneum, after release of the pneumoperitoneum and in the PACU. No patient in either groups developed post-operative respiratory depression in the PACU. Patients in group L showed statistically significant higher median sedation score, which was reflected on statistically but not clinically significant less Modified Aldrete score in patients of group L.

Conclusions

In morbid obese patients, the intra-operative IV lidocaine infusion offered post-operative analgesia in the PACU, on the expense of a higher sedation score, which didn’t affect the Modified Aldrete score clinically, with attenuation of the stress response to endotracheal intubation and extubation.

Trial registrations

FMASU R16/2021. Registered 1st February 2021, with Clinical Trials Registry (NCT05150756) on 10/08/2021.

The efficacy and safety of an adapted opioid-free anesthesia regimen versus conventional general anesthesia in gynecological surgery for low-resource settings: a randomized pilot study

Introduction

There is scarce data on the safety and efficacy of opioid-free anesthesia (OFA), in resource-limited settings due to the non-availability of dexmedetomidine, the reference OFA agent. We aimed to demonstrate the feasibility, efficacy and safety of a practical OFA protocol not containing dexmedetomidine, adapted for low-resource environments in very painful surgeries like gynecological surgery.

Methods

We conducted a randomized pilot study on ASA I and II women undergoing elective gynecological surgery at a tertiary care hospital in Cameroon. Patients were matched in a ratio of 1:1 into an OFA and a conventional general anesthesia (CGA) group. The OFA protocol entailed the intravenous (IV) magnesium sulfate, lidocaine, ketamine, dexamethasone, propofol, and rocuronium, followed by isoflurane and a continuous infusion of a calibrated mixture of magnesium sulfate, ketamine and clonidine. The CGA protocol was IV dexamethasone, diazepam, fentanyl, propofol, and rocuronium, followed by isoflurane and reinjections of fentanyl propofol and a continuous infusion of normal saline as placebo. The primary endpoints were the success rate of OFA, isoflurane consumption and intraoperative anesthetic complications. The secondary endpoints were postoperative pain intensity, postoperative complications, patient satisfaction assessed using the QoR-40 questionnaire and the financial cost of anesthesia.

Results

We enrolled a total of 36 women undergoing gynecological surgery; 18 in the OFA group and 18 in the CGA group. The success rate of OFA was 100% with significant lesser consumption of isoflurane in the OFA group, no significant intraoperative complication and better intraoperative hemodynamic stability in the OFA group. Postoperatively, compared to the CGA group, the OFA group had statistically significantly less pain during the first 24 h, no morphine consumption for pain relief, had less hypoxemia during the first six hours, less paralytic ileus, less nausea and vomiting, no pruritus and better satisfaction. The mean financial cost of this adapted OFA protocol was statistically significant lesser than that of CGA.

Conclusion

This OFA regimen without dexmedetomidine for a low-resource setting has a promising success rate with few perioperative complications including mild intraoperative hemodynamic changes, decrease postoperative complications, pain, and opioid consumption in patients undergoing elective gynecology surgery.

Trial registration

This study was registered at clinicaltrials.gov on 03/02/2021 under the registration number NCT04737473.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12871-022-01856-6.

Effect of intravenous lidocaine on pain after head and neck cancer surgery (ELICO trial): A randomised controlled trial

BACKGROUND

Treatment of postoperative pain after ear, nose and throat (ENT) cancer surgery is mainly morphine administration. Additional systemic lidocaine has shown promising results in some surgical procedures.

OBJECTIVE

The main objective was to evaluate morphine consumption in the first 48 postoperative hours after intra-operative lidocaine infusion during major ENT cancer surgery.

DESIGN

A randomised, double-blind, placebo-controlled trial.

SETTING

Bicentric study including a university hospital and a major cancer centre, conducted from December 2016 to December 2019.

PATIENTS

A total of 144 patients undergoing major ENT cancer surgery were included.

INTERVENTION

The patients were randomly assigned to receive intravenous lidocaine or placebo during surgery and in the recovery room.

MAIN OUTCOME MEASURES

Endpoints were postoperative morphine consumption in the first 24 and 48 h postoperatively, intra-operative remifentanil consumption, adverse events occurrence and assessment 3 to 6 months after surgery with the McGill pain questionnaire.

RESULTS

A total of 118 patients were included (lidocaine n  = 57; placebo n  = 61, 26 patients were excluded). There was no significant difference in morphine consumption during the first 48 postoperative hours in the lidocaine group compared with the placebo group with a median [IQR] of 0.60 [0.30 to 1.03] mg kg -1 vs. 0.57 [0.37 to 0.96] mg kg -1 , total dose 44 [21 to 73.3] mg vs. 38 [23.3 to 56.5] mg, P  = 0.92.There was no significant difference between the two groups in any of the other endpoints, including at follow up 3 to 6 months after surgery.

CONCLUSION

Intravenous lidocaine in ENT cancer surgery did not show any additional analgesic or morphine-sparing effect 48 h after surgery. Three to six months after surgery, there was no significant difference in pain scores or consumption of analgesics. Patients treated pre-operatively with opioids were not evaluated in the study.

TRIAL REGISTRATION

Clinicaltrials.gov identifier: NCT02894710 and EUDRACT number 2015-005799-90.

Opioid-free total intravenous anesthesia for thyroid and parathyroid surgery: Protocol for a randomized, double-blind, controlled trial

Background

Opioid-free anesthesia (OFA) may improve postoperative outcomes by reducing opioid-related adverse effects. This study aims to evaluate the effects of OFA on postoperative nausea and vomiting (PONV), postoperative pain, and 30-day outcomes after thyroid and parathyroid surgery.

Methods

This two-center, randomized, double-blind, controlled trial will include 400 adult patients scheduled for thyroid and parathyroid surgery. Patients will be randomly assigned, 1:1 and stratified by sex and site, to an OFA group (esketamine, lidocaine, and dexmedetomidine) or a control group (opioid-based anesthesia with sufentanil). All patients will receive propofol-based total intravenous anesthesia and PONV prophylaxis with dexamethasone and ondansetron. The primary outcome is the incidence of PONV (defined as experiencing any event of nausea, retching, or vomiting) during the first 48 h postoperatively. The secondary outcomes include the severity of PONV, antiemetic rescue therapy, pain scores at rest and while coughing, need for rescue analgesia, perioperative adverse effects related to anesthetics or analgesics (hypotension, bradycardia, hypertension, tachycardia, desaturation, dizziness, headache, hallucination, and nightmare), time to extubation, length of post-anesthesia care unit stay, length of postoperative hospital stay, patient satisfaction, and a composite of 30-day major adverse events (myocardial infarction, cardiac arrest, cerebrovascular accident, coma, acute renal failure, pulmonary embolism, sepsis, septic shock, deep neck space infection, reintubation, reoperation, blood transfusion, failure to wean off ventilator, and death). Analyses will be performed in the modified intention-to-treat population.

Discussion

We hypothesize that our OFA regimen reduces PONV after thyroid and parathyroid surgery. We will also investigate whether OFA leads to improvements in postoperative pain and major adverse events. Our results will offer evidence for optimizing anesthesia regimens in patients who undergo thyroid and parathyroid surgical procedures.

Clinical trial registration

http://www.chictr.org.cn, identifier: ChiCTR2200059656.

The Use of Intravenous Lidocaine in Perioperative Medicine: Anaesthetic, Analgesic and Immune-Modulatory Aspects

This narrative review provides an update on the applied pharmacology of lidocaine, its clinical scope in anaesthesia, novel concepts of analgesic and immune-modulatory effects as well as the current controversy around its use in perioperative opioid-sparing multi-modal strategies. Potential benefits of intravenous lidocaine in the context of cancer, inflammation and chronic pain are discussed against concerns of safety, toxicity and medico-legal constraints.

Opioid-Sparing Analgesia Impacts the Perioperative Anesthetic Management in Major Abdominal Surgery

Background and Objectives: The management of acute postoperative pain (APP) following major abdominal surgery implies various analgetic strategies. Opioids lie at the core of every analgesia protocol, despite their side effect profile. To limit patients’ exposure to opioids, considerable effort has been made to define new opioid-sparing anesthesia techniques relying on multimodal analgesia. Our study aims to investigate the role of adjuvant multimodal analgesic agents, such as ketamine, lidocaine, and epidural analgesia in perioperative pain control, the incidence of postoperative cognitive dysfunction (POCD), and the incidence of postoperative nausea and vomiting (PONV) after major abdominal surgery. Materials and Methods: This is a clinical, observational, randomized, monocentric study, in which 80 patients were enrolled and divided into three groups: Standard group, C (n = 32), where patients received perioperative opioids combined with a fixed regimen of metamizole/acetaminophen for pain control; co-analgetic group, Co-A (n = 26), where, in addition to standard therapy, patients received perioperative systemic ketamine and lidocaine; and the epidural group, EA (n = 22), which included patients that received standard perioperative analgetic therapy combined with epidural analgesia. We considered the primary outcome, the postoperative pain intensity, assessed by the visual analogue scale (VAS) at 1 h, 6 h, and 12 h postoperatively. The secondary outcomes were the total intraoperative fentanyl dose, total postoperative morphine dose, maximal intraoperative sevoflurane concentration, confusion assessment method for intensive care units score (CAM-ICU) at 1 h, 6 h, and 12 h postoperatively, and the postoperative dose of ondansetron as a marker for postoperative nausea and vomiting (PONV) severity. Results: We observed a significant decrease in VAS score, as the primary outcome, for both multimodal analgesic regimens, as compared to the control. Moreover, the intraoperative fentanyl and postoperative morphine doses were, consequently, reduced. The maximal sevoflurane concentration and POCD were reduced by EA. No differences were observed between groups concerning PONV severity. Conclusions: Multimodal analgesia concepts should be individualized based on the patient’s needs and consent. Efforts should be made to develop strategies that can aid in the reduction of opioid use in a perioperative setting and improve the standard of care.

Intravenous Lidocaine Infusion Reduce Post-operative Pain and Length of Hospital in Elderly Patients Undergoing Surgery: Meta-analysis of Randomized Controlled Trials

Objective. It is debated wheter intravenous (IV) lidocaine improves post-operative pain and has other potential benefits in elderly patients. This systematic review and meta-analysis aimed to estimate the effect of perioperative continuous IV lidocaine in elderly patients undergoing surgery. Method. PubMed/Medline, Web of Science, Embase, and CENTRAL databases (through OVID SP) were searched independently until October 10, 2020 by two authors. We included all randomized controlled trials that compared the effect of continuous IV lidocaine and any placebo or no treatment in elderly patients after surgery. Primary outcomes were length of hospital stay and post-operative pain score. Results. Eighteen studies (988 patients) were included. Meta-analysis suggested that IV lidocaine reduced the post-operative pain scores 2 hours (standardized mean difference [SMD]: −1.58, 95% confidence interval [CI]: −2.03 to −1.13), 4 hours (SMD:−1.20, 95% CI: −2.02 to −.39), 8 hours (SMD:−.82, 95% CI: −1.51 to −.13), 12 hours (SMD:−.66, 95% CI: −1.28 to −.04), and 24 hours (SMD:−.42, 95% CI: −.72 to −.12) post-operatively. Moreover, those patients given IV lidocaine had a shorter length of hospital stay (MD: −.24, 95% CI: −.71 to −.23) and required fewer opioid drugs (SMD: −.31, 95% CI: −.31 to −.01). Conclusion. The evidence suggested that IV lidocaine significantly reduced post-operative pain intensity and opioid consumption and shortened the length of hospital stay in elderly patients. IV lidocaine decreased the incidence of post-operative nausea while it could not reduce the incidence of post-operative vomiting and accelerate the recovery of gastrointestinal function.

Anesthesia and Oncology: Friend or Foe?

Cancer is a leading cause of death, and surgery is an important treatment modality. Laboratory research and retrospective studies have raised the suspicion that the choice of anesthetics for cancer surgery might affect the course of cancerous disease. The aim of this review is to provide a critical overview of the current state of knowledge. Inhalational anesthesia with volatiles or total intravenous anesthesia (TIVA) with propofol are the two most commonly used anesthetic techniques. Most data comparing volatile anesthetics with TIVA is from either in vitro or retrospective studies. Although conflicting, data shows a trend towards favoring propofol. Opioids are commonly used in anesthesia. Data on potential effects of opioids on growth and recurrence of cancer are scarce and conflicting. Preclinical studies have shown that opioids stimulate cancer growth through the µ-opioid receptor. Opioids also act as immunosuppressants and, therefore, have the potential to facilitate metastatic spread. However, the finding of an adverse effect of opioids on tumor growth and cancer recurrence by some retrospective studies has not been confirmed by prospective studies. Regional anesthesia has not been found to have a beneficial effect on the outcome of surgically treated cancer patients, but prospective studies are scarce. Local anesthetics might have a beneficial effect, as observed in animal and in vitro studies. However, prospective clinical studies strongly question such an effect. Blood products, which may be needed during extensive cancer surgery suppress the immune system, and data strongly suggest a negative impact on cancer recurrence. The potential effects of other commonly used anesthetic agents on the outcome of cancer patients have not been sufficiently studied for drawing valid conclusions. In conclusion, laboratory data and most retrospective studies suggest a potential advantage of TIVA over inhalational anesthesia on the outcome of surgical cancer patients, but prospective, randomized studies are missing. Given the state of weak scientific evidence, TIVA may be used as the preferred type of anesthesia unless there is an individual contraindication against it. Studies on the effects of other drugs frequently used in anesthesia are limited in number and quality, and have found conflicting results.

Opioid-Sparing Perioperative Analgesia Within Enhanced Recovery Programs

Opioid-based analgesia in the perioperative period can provide excellent pain control, but this approach exposes the patient to avoidable side effects and possible harm. Optimal analgesia, an approach that targets the fastest functional recovery with adequate pain control while minimizing side effects, can be achieved with opioid minimization. Many different options for nonopioid multimodal analgesia exist and have been shown to be efficacious, with certain modalities being more beneficial for specific surgeries. This review will present the evidence and practical tips for these management strategies.

Anaesthesia for Hepatic Resection Surgery

This article will focus on the perioperative management of hepatic resection for colorectal cancer (CRC) liver metastases (CLRMs) (the liver is the dominant metastatic site for CRC) within the context of the Enhanced Recovery After Surgery (ERAS) paradigm. It discusses the epidemiology and outcomes along with the history of hepatic resection surgery and pertinent anatomy. The discussion of the preoperative phase includes patient selection, assessment of liver functional status, and new developments in prehabilitation. The intraoperative phase details developments in surgical and anesthetic techniques to minimize liver hemorrhage and reduce the risk of postoperative hepatic failure. Newer analgesic options are included. Management of potential complications is outlined in the postoperative section followed by a description of current evidence for ERAS and future directions.

Perioperative Breast Analgesia: a Systematic Review of the Evidence for Perioperative Analgesic Medications

PURPOSE OF REVIEW

Breast surgery is common and may result in significant acute as well as chronic pain. A wide range of pharmacologic interventions is available including opioids, non-steroidal anti-inflammatory drugs (NSAIDs), N-methyl-D-aspartate (NMDA) receptor antagonists, anticonvulsants, and other non-opioids with analgesic properties. We present a review of the evidence for these pharmacologic interventions. A literature search of the MEDLINE database was performed via PubMed with combined terms related to breast surgery, anesthesia, and analgesia. Articles were limited to randomized controlled trial (RCT) design, adult patients undergoing elective surgery on the breast (not including biopsy), and pharmacologic interventions only. Article titles and abstracts were screened, and risk of bias assessments were performed.

RECENT FINDINGS

The search strategy initially captured 7254 articles of which 60 articles met the full inclusion criteria. Articles were organized according to intervention: 6 opioid agonists, 14 NSAIDs and acetaminophen, 4 alpha-2 agonists, 7 NMDA receptor antagonists, 6 local anesthetics, 7 steroids, 15 anticonvulsants (one of which also discussed an NMDA antagonist), 1 antiarrhythmic, and 2 serotonin reuptake inhibitors (one of which also studied an anticonvulsant). A wide variety of medications is effective for perioperative breast analgesia, but results vary by agent and dose. The most efficacious are likely NSAIDs and anticonvulsants. Some agents may also decrease the incidence of chronic postoperative pain, including flurbiprofen, gabapentin, venlafaxine, and memantine. While many individual agents are well studied, optimal combinations of analgesic medications remain unclear.

Intravenous Lidocaine for the Management of Traumatic Rib Fractures: A Double-Blind Randomized Controlled Trial (INITIATE Program of Research)

BACKGROUND

Traumatic rib fractures (TRFs) are common with a 10% incidence in all trauma patients and are associated with significant morbidity and mortality. Adequate analgesia is paramount for preventing pulmonary complications and death. Evidence exists for intravenous (IV) lidocaine's effectiveness and safety in post-operative thoracic and abdominal surgery and we hypothesized it would be effective in patients with TRFs.

METHODS

We conducted a single-centre, double-blind, randomized control trial comparing IV lidocaine plus usual analgesics to placebo infusion plus usual analgesics for 72-96 hours. Participants were adult trauma patients diagnosed with two or more TRFs requiring hospital admission. The primary outcome was mean pain score at rest and with movement, as measured on the Visual Analog Scale (VAS). Secondary outcomes included patient satisfaction and opioid requirements (standardized total morphine equivalents (TME)). The study was powered to detect a 20% reduction in pain scores, which has been deemed clinically meaningful.

RESULTS

36 patients were enrolled and randomized to IV lidocaine or placebo. Comparison of the mean VAS pain scores demonstrated significant pain reduction with movement in the lidocaine group compared to placebo (7.05 ± 1.72 vs 8.22 ± 1.28, p = 0.042). Although pain scores at rest were reduced in the lidocaine group, this difference was not statistically significant (3.37 ± 2.00 vs 3.82 ± 1.97, p = 0.519). Patient satisfaction was higher in the lidocaine group than the placebo group, though this did not reach statistical significance (8.3 (IQR 7.0, 9.6) vs 6.3 (IQR 5.2, 7.1), p = 0.105). TMEs were lower in the lidocaine group than the placebo group, but this difference did not reach statistical significance (167 (IQR 60, 340) vs 290 (IQR 148, 390), p = 0.194).

CONCLUSIONS

These results demonstrate that lidocaine has a beneficial analgesic effect in patients with TRFs. Future work is needed to evaluate lidocaine's ability to reduce patient important consequences of inadequate analgesia.

LEVEL OF EVIDENCE

Level 2: RCT with significance and only 1 negative criterion (Missing >20% data).

Clinical Efficacy of Perioperative Intravenous Dexmedetomidine and Lidocaine Combined Infusion for Thyroidectomy: A Prospective, Randomized, Double-Blind, Placebo-Controlled Trial

OBJECTIVES

The aim of this study was to evaluate the efficacy of perioperative dexmedetomidine (DEX) combined with lidocaine intravenous infusion on relieving postoperative pain and improving recovery for patients undergoing thyroidectomy.

MATERIALS AND METHODS

A total of 138 patients undergoing thyroidectomy with general anesthesia were randomly divided into 4 groups: lidocaine (1.5 mg/kg bolus followed by 2 mg/kg/h infusion) in the group L, DEX (0.5 µg/kg) in the group D, lidocaine (same as the group L) with DEX (0.5 µg/kg) in the group L+D, and placebo as normal saline in the group C. All drugs were infused until the end of the surgery. The visual analog scale (VAS) scores of patients at 1, 4, 8, 12, and 24 hours following surgery, opioid requirement, propofol consumption, incidence of postoperative nausea and vomiting, awaking time, hemodynamic variables, and any adverse effects were assessed.

RESULTS

Compared with the group C, the VAS scores in the group L+D were significantly lower until 8 hours after surgery (P<0.05), while the VAS scores were significantly decreased just until 4 hours in the group L and 1 hour in the group D after surgery (P<0.05). There was no significant difference in opioid consumption between 4 groups. Propofol consumption in the group L+D was significantly lower than other groups (P<0.05). Compared with the group C, the incidence of postoperative nausea and vomiting in the group L+D was lower (P<0.05), and awaking time in the group L+D and the group L was shorter (P<0.05).

CONCLUSION

DEX combined with lidocaine infusion can effectively attenuate the postoperative pain without any serious adverse events, which may improve postoperative recovery in patients undergoing thyroidectomy.

Opioid sparing strategies for perioperative pain management other than regional anaesthesia: A narrative review

Opioids play a crucial role in pain management in spite of causing increased hospital morbidity and related costs. It may also cause significant risks such as postoperative nausea and vomiting (PONV), sedation, sleep disturbances, urinary retention and respiratory depression (commonly referred to as opioid related adverse effects) in postoperative patients. In order to evade these opioid related side effects and also improve pain management, multimodal analgesia i.e., combination of different analgesics, was introduced more than a decade ago. Both pharmacological and non-pharmacological techniques are available as opioid sparing analgesia. Research from around the world have proved pharmacological techniques ranging from acetaminophen, NSAIDs (non-steroidal anti-inflammatory drugs), N-methyl-D-aspartate receptor antagonists (NDMA), alpha-2 agonists, anticonvulsants such as gamma aminobutyric acid analogues, beta-blockers, capsaicin, lignocaine infusion to glucocorticoids to be effective. On the other hand, non-pharmacological methods include techniques such as cognitive behavioral therapy, transcutaneous electrical nerve stimulation (TENS), electroanalgesia, acupuncture and hypnosis. However, research regarding the effect of these non-pharmacological techniques on pain management is still needed.

Postoperative Pain Management in Enhanced Recovery Pathways

Postoperative pain is a common but often inadequately treated condition. Enhanced recovery pathways (ERPs) are increasingly being utilized to standardize perioperative care and improve outcomes. ERPs employ multimodal postoperative pain management strategies that minimize opioid use and promote recovery. While traditional opioid medications continue to play an important role in the treatment of postoperative pain, ERPs also rely on a wide range of non-opioid pharmacologic therapies as well as regional anesthesia techniques to manage pain in the postoperative setting. The evidence for the use of these interventions continues to evolve rapidly given the increasing focus on enhanced postoperative recovery. This article reviews the current evidence and knowledge gaps pertaining to commonly utilized modalities for postoperative pain management in ERPs.

Opioid Sparing Anesthesia and Enhanced Recovery After Surgery Protocol for Pancreaticoduodenectomy

Background

Opioid sparing anesthesia and enhanced recovery after surgery protocols are not innovative ideas. However, the utilization of pancreaticoduodenectomy is limited. With the rise in awareness of the opioid epidemic in the United States, we have created a multimodal approach to anesthesia and postoperative care to limit adverse effects of opioids and curb the use of opioids postoperatively.

Methods

We conducted a retrospective cohort study performed by chart review of an opioid-sparing anesthetic and enhanced recovery after surgery (ERAS) protocol initiated jointly by the anesthesiology departments and transplant surgery for pancreaticoduodenectomy from January 2017 to October 2019.

Results

Demographic data was found to be comparable between the control and protocol groups. Hospital length of stay, ICU length of stay, and opioid requirements significantly decreased in the protocol group. Hospital length of stay decreased from 8.92 to 5.72 days, ICU days decreased from 1.52 to 0.42 days, and narcotics for the first five hospital days were significantly decreased from 130.13 to 71.2 morphine milligram equivalents.

Conclusion

Proper postoperative pain management can improve patient satisfaction and decrease complication rates. Pancreaticoduodenectomy is a complicated procedure with relatively limited data regarding enhanced recovery after surgery protocols. Likewise, there is limited data regarding opioid-sparing anesthesia techniques. Our protocol produced promising hospital length of stay and reduced opioid administration during the first five hospital days without increasing 30-day readmission rates.

Evaluation of lignocaine, dexmedetomidine, lignocaine-dexmedetomidine infusion on pain and quality of recovery for robotic abdominal hysterectomy: a prospective randomized controlled trial

Background: Acute postoperative pain is associated with poor quality of recovery after surgery. Perioperative use of intravenous lignocaine or dexmedetomidine have demonstrated better pain control, early return of bowel function, and effects on quality of recovery.

Methods: Ninety-six women planned for elective robotic abdominal hysterectomy were randomized into four groups. Groups received lignocaine infusion (1.5 mg.kg⁻¹ loading, 2 mg.kg⁻¹.h⁻¹ infusion) (Group I), dexmedetomidine infusion (1 µg.kg⁻¹ loading, 0.6 µg.kg⁻¹.h⁻¹ infusion) (Group 2), lidocaine (1.5 mg.kg⁻¹ loading, 2 mg.kg⁻¹.h⁻¹ infusion), and dexmedetomidine infusions (1 µg.kg⁻¹ loading, 0.5 µg.kg⁻¹.h⁻¹ infusion) (Group 3), and normal saline 10 mL loading, 1 mL.kg⁻¹.h⁻¹ infusion) (Group 4). Primary outcome was visual analogue pain scores at 1, 2, 4, 12, and 24 hours after surgery. Secondary outcomes included postoperative fentanyl requirement, time of return of bowel sounds and flatus, QoR15 score on day 1, 2, and discharge.

Results: The VAS was significantly lower in Groups 2 and 3 compared to Groups 1 and 4. Total postoperative fentanyl consumption in the first 24 hours was 256.25 ± 16.36 mcg (Group 1), 177.71 ± 16.81 mcg (Group 2), 114.17 ± 16.19 mcg (Group 3), and 304.42 ± 31.26 mcg (Group 4), respectively. Time to return of bowel sounds and passage of flatus was significantly shorter in Groups 2 and 3 (p < 0.01). QoR15 scores after surgery were higher in Group 3 compared to Groups 1, 2, and 4, (p < 0.01) respectively.

Conclusion: Combined infusion of lignocaine and dexmedetomidine significantly decreased postoperative pain, fentanyl consumption, and improved quality of recovery score after surgery in patients undergoing Robotic abdominal hysterectomy.

Continuous infusion of lidocaine in pediatric colonoscopy: A randomized double-blind placebo-controlled study

BACKGROUND

Propofol is commonly used for providing procedural sedation during pediatric colonoscopy. Intravenous (i.v.) lidocaine can mitigate visceral pain and reduce propofol requirements during surgery. The aim of this study is to investigate the effect of i.v. lidocaine on perioperative propofol and sufentanil dose, pulse oxygen saturation, postoperative pain score, and recovery time during pediatric colonoscopy.

METHODS

We designed a randomized, double-blind, placebo-controlled study and enrolled 40 children aged from 3 to 10 years who underwent colonoscopy. After titration of propofol to achieve unconsciousness, the patients were given i.v. lidocaine (1.5 mg/kg later 2 mg/kg^/hour) or the same volume of saline. Sedation was standardized and combined propofol with sufentanil. The primary outcome variables were intraoperative propofol and sufentanil requirements, and the number of oxygen desaturation episodes. Secondary outcome variables were recovery time after colonoscopy and post-colonoscopy pain.

RESULTS

Lidocaine infusion resulted in a significant reduction in propofol requirements: (median (quartile) 1.8 (1.5-2.0) vs. 3.0 (2.8-3.3) mg/kg respectively; P < 0.001) and sufentanil requirements: (median (quartile) 0.06 (0.05-0.08) vs. 0.1 (0.1-0.1) μg/kg respectively; P < 0.001). The number of subjects who experienced oxygen desaturation below 95% in the lidocaine group was also significantly less than that in the control group: 1 vs. 6 (P = 0.04). The mean (SD) recovery time was significantly shorter in the lidocaine group: (19.2 (2.6) vs. 13.3 (2.6) min respectively; P < 0.001). There was no significant difference in post-colonoscopy pain.

CONCLUSION

Continuous infusion of lidocaine resulted in reduction of propofol and sufentanil requirements, recovery time, and risk of hypoxemia during pediatric colonoscopy.

Intravenous Lidocaine for Rib Fractures: Effect on Pain Control and Outcome

BACKGROUND

Multimodal analgesia in rib fractures (RFs) is designed to maximize pain control while minimizing narcotics. Prior research with intravenous lidocaine (IVL) efficacy produced conflicting results. We hypothesized IVL infusion reduces opioid utilization and pain scores.

METHODS

A retrospective review of RF patients at an ACS-verified Level I trauma center from April 2018 to 2/2020 was conducted. Patients (pts) stratified as receiving IVL vs no IVL. Initial lidocaine dose: 1 mg/kg/hr with a maximum of 3 mg/kg/hr. Duration of infusion: 48 h. Pain quantified by the Stanford Pain Score system (PS). Bivariate and multivariate analyses of variables were performed on SPSS, version 21 (IBM Corp).

RESULTS

414 pts met inclusion criteria: 254 males and 160 females. The average age for the non-IVL = 67.4 ± 15.2 years vs IVL = 58.3 ± 17.1 years (P < .001). There were no statistically significant differences between groups for ISS, PS for initial 48 h, and ICU length of stay (LOS). There was a difference in morphine equivalents per hour: non-IVL = 1.25 vs IVL = 1.72 (P = .004) and LOS non-IVL = 10.2+/-7.6 vs IVL = 7.82+/-4.94. By analyzing IVL pts in a crossover comparison before and after IVL, there was reduction in opiates: 3.01 vs 1.72 (P < .001) and PS: 7.0 vs 4.9 (P < .001). Stanford Pain Score system reduction in the IVL = 48.3 ± 23.9%, but less effective in narcotic dependency (27 ± 22.9%, P = .035); IVL pts had hospital cost reduction: $82,927 vs $118,202 (P < .01).

DISCUSSION

In a crossover analysis, IVL is effective for reduction of PS and opiate use and reduces hospital LOS and costs. Patient age may confound interpretation of results. Our data support IVL use in multimodal pain regimens. Future prospective study is warranted.

Lidocaine infusions and reduced opioid consumption-Retrospective experience in pediatric hematology and oncology patients with refractory pain

BACKGROUND

Despite a more robust experience with lidocaine infusions for pain management in adults and general pediatric population, there is limited evidence of efficacy of lidocaine infusions for pain management in patients with pediatric hematology and oncology diagnoses.

METHODS

Data pertaining to continuous intravenous lidocaine infusions prescribed between January 2009 and June 2019 were reviewed, including patients' demographic characteristics, hematology/oncology and pain diagnoses, concurrent pain medications, and lidocaine infusion dose regimens and duration. Pain scores and opioid consumption calculations based on morphine equivalent doses (mg/kg/day) of patient-controlled analgesia were collected 1 day before infusion (D1), during infusion (D2), and 1 day after infusion (D3).

RESULTS

The mean opioid consumption on D3 was significantly lower than that on D2 (p = .01). The pain scores on D3 were significantly lower than those on D1 when measured as average pain scores per 24 hours (p < .001) or as single pain scores immediately before and after infusions (p < .001). No significant associations were found between cumulative doses of lidocaine (loading dose plus total infusion dose) and either a decrease in the opioid consumption or a decrease in pain scores.

CONCLUSIONS

In this retrospective series of pediatric hematology and oncology cases, we report positive outcomes in reducing opioid consumption and pain scores after lidocaine infusions. Prospective investigations designed in a collaborative, multi-institutional fashion, including a variety of pediatric populations are needed to further investigate the efficacy of lidocaine infusions.

Perioperative Intravenous Lidocaine Infusion on Postoperative Recovery in Patients Undergoing Arthroscopic Rotator Cuff Repair Under General Anesthesia - A Randomized Controlled Trial

OBJECTIVE

Arthroscopic rotator cuff repair (ARCR) is known to cause severe postoperative pain which may interfere with recovery. Intravenous (IV) lidocaine has analgesic, anti-inflammatory, and anti-hyperalgesic effects, and is being used in various types of surgeries. However, the effect of IV lidocaine in ARCR is not well known.

MATERIALS AND METHODS

Ninety patients undergoing ARCR were randomly allocated to receive IV lidocaine (1.5▒mg/kg bolus of 1% lidocaine after anesthesia induction followed by a continuous infusion of 2▒mg/kg/h up to 1▒h after surgery) or an equal volume of saline. In both groups, an IV patient-controlled analgesia (PCA) device was used which contained fentanyl 10▒µg/mL, infused at 1▒mL/h with a 1▒mL bolus dose. The primary outcome was fentanyl requirements given via IV PCA during the first 24 hours after surgery. Perioperative pain scores and functional recovery were assessed as secondary outcomes.

RESULTS

The amount of fentanyl administered via IV PCA up to 24 hours after surgery was significantly lower in the Lidocaine group compared to the Control group (329 [256.2-428.3] vs. 394.5 [287.0-473.0], P=0.037) The number of PCA bolus attempts were lower in the Lidocaine group without statistical significance. There were no differences in postoperative pain scores or functional shoulder scores between the two groups.

DISCUSSION

IV lidocaine appears to be helpful in reducing opioid requirements during the acute postoperative period in patients undergoing ARCR. IV lidocaine may be a viable option as a component of multimodal analgesia in ARCR when regional analgesia is not possible.

Association between perioperative intravenous lidocaine and subjective quality of recovery: A meta-analysis of randomized controlled trials

STUDY OBJECTIVE

To evaluate the impact of perioperative intravenous lidocaine on the quality of recovery (QoR) following surgery.

DESIGN

Meta-analysis of randomized controlled trials (RCTs).

SETTING

Postoperative care.

INTERVENTION

Intravenous lidocaine during perioperative period.

PATIENTS

Adults undergoing surgery under general anesthesia.

MEASUREMENTS

The primary outcome was postoperative QoR measured with QoR-40 questionnaire, while the secondary outcomes included five individual dimensions (i.e., emotional, state, physical comfort, psychological support, physical independence, and pain) of QoR-40, intraoperative opioid consumption, and risk of chronic postsurgical pain (CPSP).

MAIN RESULTS

Medline, Cochrane Library, Google scholar, and EMBASE databases were searched from inception to June 2021. Fourteen RCTs involving 1148 patients in total undergoing elective surgery published from 2012 to 2021 were included. QoR-40 scores were evaluated at postoperative 24 h (12 trials), 72 h (one trial), and Day 5 (one trial), respectively. Pooled results revealed significantly higher global [mean difference (MD) = 9.65, 95% confidence interval (CI): 6.33 to 12.97; I² = 97%; 13 RCTs; n = 1085] and individual dimension QoR-40 scores in the lidocaine group than those in placebo group. Subgroup analysis demonstrated no significant impact of the type of surgery, age, gender, surgical time, anesthetic technique, lidocaine dosage, and time of assessment on global QoR-40 scores. The use of intravenous lidocaine was associated with a significant reduction in intraoperative remifentanil consumption compared with that in the placebo group (standardized MD = -0.91, 95%CI: -1.32 to -0.51; I² = 86%; 10 RCTs; n = 799). There was no difference in risk of CPSP between the two groups [relative risk (RR) = 0.65, 95%CI: 0.33 to 1.25; I² = 58%; 4 RCTs; n = 309].

CONCLUSION

Our results verified the efficacy of intravenous lidocaine for enhancing postoperative quality of recovery by using a validated subjective tool and reducing intraoperative remifentanil consumption in patients receiving elective surgery under general anesthesia. Further studies are warranted to verify its efficacy in the acute care setting.

Efficacy of intraoperative intravenous lidocaine for postoperative analgesia following bariatric surgery: a meta-analysis of randomized controlled studies

BACKGROUND

The impact of intravenous lidocaine in adults undergoing laparoscopic bariatric surgeries (LBS) remains unclear.

OBJECTIVES

This study aimed at investigating the effect of intravenous lidocaine on postoperative opioid consumption and recovery following LBS.

SETTING

Meta-analysis.

METHODS

We searched databases including MEDLINE, Embase, Google Scholar, and the Cochrane Library for randomized controlled trials that evaluated the use of intravenous lidocaine compared to placebo only prior to May 2021. The primary outcome was 24-hour postoperative opioid consumption, while secondary outcomes included pain score, quality of recovery (QOR)-40 score, length of hospital stay (LOS), and postoperative nausea/vomiting (PONV).

RESULTS

Seven trials (496 participants) were included. Intraoperative intravenous lidocaine significantly reduced 24-hour equivalent morphine consumption (mean difference [MD]: -11.97 mg; 95% confidence interval [CI]: -23.12 to -.83), pain score at 1 to 3 hours (MD: -.77; 95% CI: -1.5 to -.04), and LOS (MD: -8.93 hr; 95% CI: -13.41 to -4.44) without positive impact on 24-hour pain score and PONV. There was also an increase in time to first opioid requirement (MD: 20.23 min; 95% CI: 11.76-28.7) and QOR-40 score (MD: 24.38; 95% CI: 5.57-43.18). However, sensitivity analysis demonstrated evidence supporting the beneficial effect of lidocaine only for time to first opioid requirement and QOR-40. The associations of intraoperative intravenous lidocaine with reductions in morphine consumption, pain score at 1 to 3 hours, and LOS after LBS were also weak.

CONCLUSION

Intraoperative intravenous lidocaine during LBS prolonged time to first opioid requirement and improved quality of recovery postoperatively without 24-hour pain or nausea/vomiting benefits. Due to the small number of trials, larger studies are warranted to verify our findings.

Molecular mechanisms of lidocaine

Lidocaine is an amide-class local anesthetic used clinically to inhibit pain sensations. Systemic administration of lidocaine has antinociceptive, antiarrhythmic, anti-inflammatory, and antithrombotic effects. Lidocaine exerts these effects under both acute and chronic pain conditions and acute respiratory distress syndrome through mechanisms that can be independent of its primary mechanism of action, sodium channel inhibition. Here we review the pathophysiological underpinnings of lidocaine's role as an anti-nociceptive, anti-inflammatory mediated by toll-like receptor (TLR) and nuclear factor kappa-β (NF-kβ) signalling pathways and downstream cytokine effectors high mobility group box 1 (HMGB1) and tumour necrosis factor-α (TNF-α).

Effect of Intravenous Lidocaine on Serum Interleukin-17 After Video-Assisted Thoracic Surgery for Non-Small-Cell Lung Cancer: A Randomized, Double-Blind, Placebo-Controlled Trial

Purpose

Surgical stress promotes tumor metastasis. Interleukin (IL)-17 plays a pivotal role in cancer progression, and high IL-17 expression predicts poor prognosis of non-small-cell lung cancer (NSCLC). Lidocaine may exert tumor-inhibiting effects. We hypothesize that intravenous lidocaine attenuates surgical stress and reduces serum IL-17 levels during video-assisted thoracic surgery (VATS) for NSCLC.

Methods

This randomized, double-blind, placebo-controlled trial included 60 early-stage NSCLC patients undergoing VATS, into a lidocaine group (n = 30; intravenous lidocaine bolus 1.0 mg/kg, and 1.0 mg/kg/h until the end of surgery) or a normal saline control group (n = 30). The primary outcome was serum IL-17 level at 24 hours postoperatively. The secondary outcomes included serum IL-17 level at the time of post-anesthesia care unit (PACU) discharge, serum cortisol level at PACU discharge and postoperative 24 hours, pain scores (0–10) from PACU discharge to 48 hours postoperatively, incidences of postoperative nausea and vomiting, dizziness, and arrhythmia during 0–48 hours postoperatively, and 30-day mortality. Long-term outcomes included chemotherapy, cancer recurrence, and mortality.

Results

The lidocaine group had lower serum IL-17 at 24 hours postoperatively compared with the control group (23.0 ± 5.8 pg/mL vs 27.3 ± 8.2 pg/mL, difference [95% CI] = −4.3 [−8.4 to −0.2] pg/mL; P = 0.038). The lidocaine group also had reduced serum IL-17 (difference [95% CI] = −4.6 [−8.7 to −0.5] pg/mL), serum cortisol (difference [95% CI] = −37 [−73 to −2] ng/mL), and pain scores (difference [95% CI] = −0.7 [−1.3 to −0.1] points) at PACU discharge. During a median follow-up of 10 (IQR, 9–13) months, 2 patients in the lidocaine group and 6 patients in the control group received chemotherapy, one patient in the control group had cancer recurrence, and no death event occurred.

Conclusion

Intravenous lidocaine was associated with reduced serum IL-17 and cortisol following VATS procedures in early-stage NSCLC patients.

Trial Registration

ChiCTR2000030629.

Perioperative Intravenous Lidocaine Infusion for Post-operative Analgesia in Patients undergoing Surgery of the Spine Systematic Review and Meta-analysis

OBJECTIVE

We conducted a systematic review and meta-analysis to examine the impact of perioperative intravenous lidocaine infusion on pain management scores, opioid consumption, adverse events and hospital length of stay in patients undergoing spinal surgery.

METHODS

We included randomized controlled trials (RCT's) evaluating the use of perioperative intravenous lidocaine in adult and paediatric patients undergoing spinal surgery. Primary outcomes were post-operative pain scores at rest, at two, four- six, twenty-four and forty-eight hours and adverse events attributable to lidocaine administration. We searched electronic databases from inception to present. We used Cochrane's standard methods. We used a random-effects model to synthetize data. We conducted three subgroup analysis: major versus minor surgery, patients with chronic pain conditions versus patients without, and adult versus paediatric.

RESULTS

A total of eight studies were included comparing patients having intravenous lidocaine (n = 349) to controls (n = 343). Intravenous lidocaine administration was associated with significantly reduced visual analogue pain scores at two MD= -1.13, four-six MD =-0.79 and twenty-four hours MD= -0.50 post-operatively. In the adults, efficacy of treatment was extended to forty-eight hours MD= -0.72. Perioperative intravenous lidocaine administration was associated with reduced peri-operative opioid consumption at twenty-four and forty-eight as well as decreased hospital length of stay.

CONCLUSION

Perioperative intravenous lidocaine infusion consistently improves analgesic measures in adult and paediatric population in the first twenty-four hours, with an effective decrease in opioid consumption noted to forty-eight hours. These results are most generalizable in the adult population in the first four-six to twenty four post-operative hours.

Lidocaine for postoperative pain after cardiac surgery: a systematic review

OBJECTIVE

Lidocaine is one of the most widely used local anesthetics with well-known pharmacological properties. The purpose of this systematic review is to investigate the effects of lidocaine on postoperative pain scores and recovery after cardiac surgery.

METHODS

A comprehensive database search was conducted by a reference librarian for randomized clinical trials (RCT) from January 1, 1980 to September 1, 2019. Eligible study designs included randomized controlled trials of lidocaine for postoperative pain management in adults undergoing cardiac surgery. After removal of duplicates, 947 records were screened for eligibility and 3 RCTs met inclusion criteria.

RESULTS

Sources of bias were identified in 2 of 3 RCTs. Lidocaine was administered intravenously, topically, and intrapleurally. Key findings included [1] 2% lidocaine placed topically on chest tube prior to intraoperative insertion was associated with significantly lower pain scores and lower cumulative doses of fentanyl; and [2] 2% lidocaine administered intrapleurally was associated with significantly lower pain scores and significant improvements in pulmonary mechanics. Lidocaine infusions were not associated with significant changes in pain scores or measures of recovery. No significant associations were observed between lidocaine and overall mortality, hospital length of stay or ICU length of stay. No data were reported for postoperative nausea and vomiting or arrhythmias.

CONCLUSIONS

Due to the favorable risk profile of topical lidocaine and the need for further advancements in the postoperative care of adults after cardiac surgery, topically administered lidocaine could be considered for incorporation into established postoperative recovery protocols.

Randomized, Double-Blind Study of the Effect of Intraoperative Intravenous Lidocaine on the Opioid Consumption and Criteria for Hospital Discharge After Bariatric Surgery

BACKGROUND AND OBJECTIVES

Surgical trauma, pain and opioids can cause nausea, vomiting, ileus and increased length of hospital stay. The primary objective of the study was to evaluate the time to recovery of gastrointestinal function and the time to meet hospital discharge criteria after laparoscopic bariatric surgery with intraoperative intravenous lidocaine administration. Secondary objectives were to evaluate morphine consumption during the first 24 h and the side effects of opioids.

METHODS

Fifty-eight patients aged 18 to 60 years who underwent bariatric surgery were allocated into two groups. Group 1 patients received intravenous lidocaine (1.5 mg/kg) 5 min before induction of anaesthesia, followed by infusion (2 mg/kg/h) until the end of surgery. Group 2 patients were given 0.9% saline solution (placebo) and infusion of 0.9% saline solution during surgery, in same volume as group 1. Anaesthesia was performed with fentanyl (5 μg/kg), propofol (2 mg/kg), rocuronium (0.6 mg/kg) and sevoflurane. Postoperative patient-controlled analgesia was with morphine. There were two groups that were evaluated: time to recovery of gastrointestinal function and time to meet discharge criteria.

RESULTS

There was no significant difference between groups regarding the time to first flatus, time to meet discharge criteria and occurrence of side effects. Consumption of intraoperative sevoflurane and morphine over 24 h was significantly lower in the lidocaine group. Side effects observed were nausea and vomiting, with no difference between groups.

CONCLUSIONS

Perioperative intravenous lidocaine is feasible and easily accessible when administered at appropriate doses. Lidocaine reduces morphine consumption.

The effect of systemic lidocaine on post-operative opioid consumption in ambulatory surgical patients: a meta-analysis of randomized controlled trials

Background

Ambulatory surgical procedures continue to grow in relevance to perioperative medicine. Clinical studies have examined the use of systemic lidocaine as a component of multimodal analgesia in various surgeries with mixed results. A quantitative review of the opioid-sparing effects of systemic lidocaine in ambulatory surgery has not been investigated. The primary objective of this study was to systematically review the effectiveness of systemic lidocaine on postoperative analgesic outcomes in patients undergoing ambulatory surgery.

Methods

We performed a quantitative systematic review of randomized controlled trials in electronic databases (Cochrane Library, Embase, PubMed, and Google Scholar) from their inception through February 2019. Included trials investigated the effects of intraoperative systemic lidocaine on postoperative analgesic outcomes, time to hospital discharge, and adverse events. Methodological quality was evaluated using Cochrane Collaboration’s tool and the level of evidence was assessed using GRADE criteria. Data was combined in a meta-analysis using random-effects models.

Results

Five trials evaluating 297 patients were included in the analysis. The pooled effect of systemic lidocaine on postoperative opioid consumption at post-anesthesia care unit revealed a significant effect, weighted mean difference (95% CI) of − 4.23 (− 7.3 to 1.2, P = 0.007), and, at 24 h, weighted mean difference (95% CI) of − 1.91 (− 3.80 to − 0.03, P = 0.04) mg intravenous morphine equivalents. Postoperative pain control during both time intervals, postoperative nausea and vomiting reported at post anesthesia care unit, and time to hospital discharge were not different between groups. The incidence rate of self-limiting adverse events of the included studies is 0.007 (2/297).

Conclusion

Our results suggest that intraoperative systemic lidocaine as treatment for postoperative pain has a moderate opioid-sparing effect in post anesthesia care unit with limited effect at 24 h after ambulatory surgery. Moreover, the opioid-sparing effect did not impact the analgesia or the presence of nausea and vomiting immediately or 24 h after surgery. Clinical trials with larger sample sizes are necessary to further confirm the short-term analgesic benefit of systemic lidocaine following ambulatory surgery.

Trial registration

PROSPERO (CRD42019142229)

Supplementary Information

The online version contains supplementary material available at 10.1186/s13741-021-00181-9.

Lidocaine infusion, basics and clinical issues

Optimum pain management, minimizing chronic complications and ensuring a good safety profile, is growing in importance day by day. Lidocaine infusion has an adequate safety profile and several desirable characteristics in the clinical setting. This review describes the characteristics of this drug, as well as its potential indications. Moreover, it describes the basic concepts around lidocaine use, mechanisms of action and clinical applications, as well as the use of infusions in acute pain and repercussions in chronic pain. A review of the literature in English and Spanish was conducted in several databases, with no publication date limit. Articles considered relevant, without including the grey literature, were selected independently. Lidocaine infusion is an option for acute postoperative pain control in major surgery and contributes to opioid sparing and reduced length of stay, with ample evidence in abdominal surgery, rendering it an option to recommend in various protocols. It has an acceptable safety profile in special populations and it is considered useful to diminish the incidence of persistent, chronic and neuropathic pain related to the surgical procedure.

Adoption of enhanced recovery after surgery and intraoperative transverse abdominis plane block decreases opioid use and length of stay in very large open ventral hernia repairs

BACKGROUND

The effect of an enhanced recovery after surgery (ERAS) pathway including liposomal bupivacaine transversus abdominus plane (TAP)-blocks for abdominal wall reconstruction (AWR) on opioids use is not clear.

METHODS

A prospective, tertiary hernia center database of patients undergoing AWR before and after ERAS and operative TAP-blocks was matched in large ventral hernias.

RESULTS

In 106 patients, non-TAP-block and TAP-block groups were comparable in mean BMI (p = 0.694), hernia defect size (p = 0.424), components separation (p = 0.610), complete fascial closure (p = 1.0), and panniculectomy (p = 1.0). The total morphine milligram equivalents (MME) used during hospitalization was reduced by 3-fold in the TAP-block group (p < 0.001), and opioid usage decreased by 35%-71% during days 1-5. Length of stay (LOS) was shorter in the TAP-block group by average of 1 day (p = 0.011).

CONCLUSION

ERAS and TAP-block in AWR leads to a decrease in mean opioid usage by 65% and decreased LOS by an average of 1 day.

Intravenous Infusion of Lidocaine Can Accelerate Postoperative Early Recovery in Patients Undergoing Surgery for Obstructive Sleep Apnea

Obstructive sleep apnea (OSA) is defined by intermittent and recurrent episodes of partial or complete obstruction of the upper airway during sleep. Intermittent and recurrent hypoxia/reoxygenation is the main pathophysiological mechanism of OSA. Its consequences include systemic inflammation, activation of the sympathetic nervous system, and release of oxygen free radicals. Infusion of intravenous (IV) lidocaine has anti-inflammatory, antihyperalgesic, and analgesic properties, supporting its use as an anesthetic adjuvant. Lidocaine can reduce nociception and/or cardiovascular responses to surgical stress, as well as postoperative pain and/or analgesic requirements. Because of the high prevalence of OSA in obese patients, the use of opioids to manage postoperative pain in that population is often accompanied by the development of adverse respiratory events, such as hypoventilation and hypoxemia. IV infusion of lidocaine has been shown to enhance the quality of early recovery after laparoscopic bariatric and upper airway surgery. However, limited evidence exists regarding its use in patients undergoing surgery for OSA. In addition, whether IV infusion of lidocaine can improve postoperative early recovery in patients undergoing surgery for OSA remains unknown. Therefore, we hypothesized that IV infusion of lidocaine can improve postoperative early recovery in patients undergoing surgery for OSA. Perioperative infusion also may be a promising analgesic adjunct to enhanced recovery after surgery (ERAS) protocols.

Intravenous Local Anesthetic Compared with Intraperitoneal Local Anesthetic in Laparoscopic Colectomy: A Double-Blind Randomized Controlled Trial

INTRODUCTION

Controlling perioperative pain is essential to improving patient experience and satisfaction following surgery. Traditionally opioids have been frequently utilised for postoperative analgesia. Although they are effective at controlling pain, they are associated with adverse effects, including postoperative nausea, vomiting, ileus and long-term opioid dependency.Following laparoscopic colectomy, the use of intravenous or intraperitoneal infusions of lidocaine (IVL, IPL) are promising emerging analgesic options. Although both techniques are promising, there have been no direct, prospective randomized comparisons in patients undergoing laparoscopic colon resection. The purpose of this study was to compare IPL with IVL.

METHODS

Double blinded, randomized controlled trial of patients undergoing laparoscopic colonic resection. The two groups received equal doses of either IPL or IVL which commenced intra-operatively with a bolus followed by a continuous infusion for 3 days postoperatively. Patients were cared for through a standardized ERAS program. The primary outcome was total post-operative opioid consumption over the first three post-operative days. Patients were followed for 60 days.

RESULTS

Fifty-six patients were randomized in a 1:1 fashion to the IVL or IPL groups. Total opioid consumption over the first three post-operative days was significantly lower in the IPL group (70.9 mg vs 157.8 mg p < 0.05) and overall opioid consumption during the total length of stay was also significantly lower (80.3 mg vs 187.36 mg p < 0.05. Pain scores were significantly lower at two hours post-operatively in the IPL group, however, all other time points were not significant. There were no differences in complications between the two groups.

CONCLUSION

Perioperative use of IPL results in a significant reduction in opioid consumption following laparoscopic colon surgery when compared to IVL. This suggests that the peritoneal cavity/compartment is a strategic target for local anesthetic administration. Future ERAS recommendations should consider IPL as an important component of a multimodal pain strategy following colectomy.

Pain management in the surgical ICU patient

PURPOSE OF REVIEW

Acute pain management in the surgical ICU is imperative. Effective acute pain management hastens a patient's return to normal function and avoid the negative sequelae of untreated acute pain. Traditionally, opioids have been the mainstay of acute pain management strategies in the surgical ICU, but alternative medications and management strategies are increasingly being utilized.

RECENT FINDINGS

Extrapolating from lessons learned from enhanced recovery after surgery protocols, surgical intensivists are increasingly utilizing multimodal pain regimens (MMPRs) in critically ill surgical patients recovering from major surgical procedures and injuries. MMPRs incorporate both oral medications from several drug classes and regional blocks when feasible. In addition, although MMPRs may include opioids as needed, they are able to achieve effective pain control while minimizing opioid exposure.

SUMMARY

Even after major elective surgery or significant injury, opioid-minimizing MMPRs can effectively treat acute pain.

Effect of perioperative intravenous lidocaine for patients undergoing spine surgery: A meta-analysis and systematic review

BACKGROUND

Perioperative intravenous lidocaine has been reported to have analgesic and opioid-sparing effects in many kinds of surgery. Several studies have evaluated its use in the settings of spine surgery. The aim of the study is to examine the effect of intravenous lidocaine in patients undergoing spine surgery.

METHODS

We performed a quantitative systematic review. Databases of PubMed, Medline, Embase database and Cochrane library were investigated for eligible literatures from their establishments to June, 2019. Articles of randomized controlled trials that compared intravenous lidocaine to a control group in patients undergoing spine surgery were included. The primary outcome was postoperative pain intensity. Secondary outcomes included postoperative opioid consumption and the length of hospital stay.

RESULT

Four randomized controlled trials with 275 patients were included in the study. postoperative pain compared with control was reduced at 6 hours after surgery (WMD -0.50, 95%CI, -0.76 to -0.25, P < .001), at 24 hours after surgery (WMD -0.50, 95%CI, -0.70 to -0.29, P < .001) and at 48 hours after surgery (WMD -0.57, 95%CI, -0.96 to -0.17, P = .005). The effect of intravenous lidocaine on postoperative opioid consumption compared with control revealed a significant effect (WMD -15.36, 95%CI, -21.40 to -9.33 mg intravenous morphine equivalents, P < .001).

CONCLUSION

This quantitative analysis of randomized controlled trials demonstrated that the perioperative intravenous lidocaine was effective for reducing postoperative opioid consumption and pain in patients undergoing spine surgery. The intravenous lidocaine should be considered as an effective adjunct to improve analgesic outcomes in patients undergoing spine surgery. However, the quantity of the studies was very low, more research is needed.