The effects of intravenous lidocaine infusion on hospital stay after major abdominal pediatric surgery. A randomized double-blinded study

Intravenous lidocaine for postoperative analgesia management in paediatrics: A systematic review with meta-analysis of published studies

BACKGROUND

The administration of intravenous lidocaine during the peri-operative period may improve pain management after paediatric surgery.

OBJECTIVE

To explore the decrease in postoperative pain intensity and opioid consumption associated with peri-operative lidocaine administration in the paediatric population.

DESIGN

A systematic review with meta-analysis of randomised controlled trials and a Grading of Recommendations Assessment, Development and Evaluation (GRADE) analysis.

DATA SOURCES

Extensive literature review.

ELIGIBILITY CRITERIA

This study includes clinical trials conducted during surgery that examined the effect of intravenous lidocaine compared with placebo on postoperative pain management.

RESULTS

Lidocaine administration decreased pain intensity in PACU (standardised mean difference (SMD) = -1.89 [-3.75, -0.03], I2  = 97%, P of I2  < 0.001) and on postoperative day 1 (SMD = -2.02 [-3.37, -0.66], I2  = 96%, P of I2  < 0.001, number of studies = 5). Lidocaine was associated with a decrease in opioid consumption on postoperative day 1 (SMD = -1.2 [-2.19, -0.2], I2  = 93%, P of I2  < 0.001) but not on postoperative day 2 (SMD = -1.73 [-3.9, 0.44], I2  = 96%, P of I2  < 0.001). GRADE analyses resulted in low-quality results. Subgroup analyses revealed that pain intensity in PACU and opioid consumption on postoperative day 1 decreased when lidocaine was administered during both the intra-operative and postoperative periods.

CONCLUSIONS

The use of lidocaine is associated with improved pain management. However, further studies are needed to increase the level of evidence and determine the optimal administration regimen for pain management.

Intravenous lidocaine infusion therapy and intraoperative neurophysiological monitoring in adolescents undergoing idiopathic scoliosis correction: A retrospective study

BACKGROUND

Posterior spinal instrumentation and fusion is an established surgical procedure for the correction of adolescent idiopathic scoliosis. Intraoperative neurophysiological monitoring is standard practice for this procedure. Anesthetic agents can have different, but significant, effects on neurophysiological monitoring outcomes.

AIM

To determine if intravenous lidocaine infusion therapy has an impact on the intraoperative neurophysiological monitoring during posterior spinal instrumentation and fusion for adolescent idiopathic scoliosis.

METHODS

Following ethical approval, we conducted a retrospective review of charts and the archived intraoperative neurophysiological data of adolescents undergoing posterior spinal instrumentation and fusion for adolescent idiopathic scoliosis. Intraoperative neurophysiological monitoring data included the amplitude of motor evoked potentials and the amplitude and latency of somatosensory evoked potentials. A cohort who received intraoperative lidocaine infusion were compared to those who did not.

RESULTS

Eighty-one patients were included in this analysis, who had surgery between February 4, 2016 and April 22, 2021: 39 had intraoperative intravenous lidocaine infusion and 42 did not. Based on hourly snapshot data, there was no evidence that lidocaine infusion had a detrimental effect on the measured change from baseline for MEP amplitudes in either lower (mean difference 41.9; 95% confidence interval -304.5 to 388.3; p = .182) or upper limbs (MD -279.0; 95% CI -562.5 to 4.4; p = .054). There was also no evidence of any effect on the measured change from baseline for SSEP amplitudes in either lower (MD 16.4; 95% CI -17.7 to 50.5; p = .345) or upper limbs (MD -2.4; 95% CI -14.5 to 9.8; p = .701). Finally, there was no evidence of a difference in time to first reportable neurophysiological event (hazard ratio 1.13; 95% CI 0.61 to 2.09; p = .680).

CONCLUSIONS

Data from these two cohorts provide preliminary evidence that intravenous lidocaine infusion has no negative impact on intraoperative neurophysiological monitoring during PSIF for adolescent idiopathic scoliosis.

Perioperative intravenous lignocaine for pediatric postoperative pain-A systematic review and meta-analysis

BACKGROUND

Intravenous lignocaine has been used as an analgesic adjunct in pediatric surgical patients, although its efficacy is still unclear.

OBJECTIVE

We aimed to clarify the efficacy of perioperative intravenous lignocaine (bolus followed by an infusion) on pediatric postoperative pain outcomes.

DESIGN

A systematic review and meta-analysis.

DATA SOURCES

PubMed, EMBASE, Web of Science, Google Scholar (inception to June 2024).

ELIGIBILITY CRITERIA

Studies involving pediatric patients (≤18 years) undergoing surgery under general anesthesia with one group receiving perioperative intravenous lignocaine (bolus followed by infusion) and the other group receiving placebo. The primary outcome was 24-h postoperative opioid consumption. Postoperative pain scores and the need for rescue analgesia were the secondary outcomes.

RESULTS

Seven studies (n = 415) were included in the final meta-analysis. The use of intravenous lignocaine significantly reduced the morphine consumption in the first 24 h after surgery, compared to placebo (SMD -1.31, 95% CI -2.18 to -0.43, p = 0.003). A meta-analysis could not be performed for the secondary outcomes.

CONCLUSION

There is low quality evidence to suggest that perioperative intravenous lignocaine bolus followed by an infusion significantly reduced the opioid consumption on the first postoperative day in pediatric surgical patients. The effects of perioperative lignocaine on postoperative pain scores and the need for rescue analgesia are uncertain.

Multimodal Analgesia for Paediatric Patients Undergoing Lower Limb Reconstruction with External Fixators: A Prospective Case Series of Post-operative Pain and Functional Goals

Aim

Limb reconstruction with external fixators requires appropriate pain management to promote effective analgesia and healing while minimising adverse events of the analgesic technique used. The objective of this prospective case series was to evaluate a multimodal analgesia regimen designed to reduce opioid requirements and hence reduce the opioid-related side effect profile.

Materials and methods

A prospective cohort of patients undergoing lower limb reconstruction surgery (LRS) were managed through an evidence-informed multimodal analgesia guideline (MMAG), including acetaminophen, pregabalin, dexmedetomidine, IV lidocaine, and opioids. Outcome measures included intraoperative and post-operative opioid administration, post-operative pain scores, time to achieve mobilisation milestones, and post-operative complications. Surveys were conducted to obtain patient reported experiences.

Results

26 patients were included in this prospective case series. 110.59 (84.29, 162.13) (median, interquartile range) µg/kg/hr intraoperative IV morphine equivalent opioids were administered. In the first 48 hours post-operatively, patients received 11.49 (6.41, 19.35) µg/kg/hr of IV morphine equivalent dose. Median level of pain (0-10) in the first 48 post-operative hours was 2 (1, 2). Patients achieved mobilisation. And 19/20 patients surveyed reported 'yes' to having effective pain management; 17/20 patients had no unwanted side effects associated with analgesia medications. There were no cases of compartment syndrome.

Conclusion

This multimodal analgesia regime applied to patients undergoing lower LRS with external fixators demonstrates the feasibility of this analgesic regimen which revealed effective pain control, early mobilisation, with minimal side effects, but warrants further study.

Clinical significance

This study provides valuable evidence that this standardised multimodal anaesthesia and analgesia regimen is feasible, offers adequate post-operative comfort and encourages early mobilization while minimising opioid use and adverse events in a paediatric LRS population at our institution.

How to cite this article

Wang AWT, Chhina H, Cooper A. Multimodal Analgesia for Paediatric Patients Undergoing Lower Limb Reconstruction with External Fixators: A Prospective Case Series of Post-operative Pain and Functional Goals. Strategies Trauma Limb Reconstr 2023;18(3):140-147.

The Effect of Preoperative Combined with Intravenous Lidocaine and Ketamine vs. Intravenous Ketamine on Pediatric Patients Undergoing Upper Gastrointestinal Endoscopy

Background

Ketamine is widely used in pediatric sedation. New studies have recommended combination therapy to reduce the side effects of ketamine.

Objectives

This study investigated the effect of adding intravenous (IV) lidocaine to ketamine on hemodynamic parameters, endoscopist satisfaction, and recovery time of children undergoing gastrointestinal endoscopy.

Methods

This triple-blind, randomized, controlled clinical trial was conducted in Isfahan, Iran (2021). One hundred twenty children between the ages of 1 and 6 were enrolled. Patients were divided into 2 groups. The intervention group received 1.0 mg/kg of IV lidocaine and 1.0 mg/kg of IV ketamine, and the placebo group received 1.0 mg/kg of IV ketamine and placebo 2 minutes before entering the endoscopic room. Patients in both groups were sedated with 1.0 mg/kg of propofol, 0.1 mg/kg of midazolam, and 2.0 ug/kg of fentanyl for the procedure. The pulse rate, mean arterial pressure (MAP), respiratory rate, and oxygen saturation were recorded 1 minute before injection and every 5 minutes afterward.

Results

The mean (SD) ages of the intervention and control groups were 3.4 (1.5) and 3.4 (1.7), respectively. The mean difference in hemodynamic parameters between the 2 groups was insignificant during the investigation (P > 0.05). Furthermore, no significant differences were found regarding endoscopist satisfaction scores and length of recovery room stay (P > 0.05).

Conclusions

Adding low-dose IV lidocaine to ketamine for pediatric sedation does not significantly affect the hemodynamic status, endoscopist satisfaction, and recovery time.

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.

Systematic Review of Definitions and Outcome Measures for Postoperative Ileus and Return of Bowel Function after Abdominal Surgery in Children

This review aims to objectify which definitions and outcome measures are used for the return of bowel function and postoperative ileus in children. PubMed and Embase were systematically searched from inception to December 17, 2020. Prospective studies conducted in children (aged 0-18 years) undergoing gastrointestinal surgery which reported on definitions and/or outcome measures for post-operative ileus or return of bowel function were evaluated. Definitions and outcome measures were extracted. From 4,027 references, 71 articles were included. From the 17 articles mentioning postoperative ileus, 8 (47%) provided a definition. In total, 34 outcome measures were used and 12 were unique. "Abdominal distension" was the most reported (41%) measure. In 41%, the outcome measures only described the return of gastric motility, while 18% described the return of intestinal motility. The return of bowel function was mentioned in 67 articles, none provided a definition. In total, 133 outcome measures were used and 37 were unique. Time to oral intake was the most reported (14%) measure. In 49%, the outcome measures only described the return of gastric motility, while 10% described the return of intestinal motility. High variation in definitions and outcome measures has limited the generalizability of research into postoperative bowel function in children. Without standardization, it will be impossible to compare research results and evaluate treatments. In children, the return of gastric motility seemingly should get more focus compared to adults. Therefore, we believe that a definition of postoperative ileus with an accompanying core outcome set, developed by a multidisciplinary team, specifically for children is required.

Impact of lidocaine on hemodynamic and respiratory parameters during laparoscopic appendectomy in children

We assessed the influence of systemic lidocaine administration on ventilatory and circulatory parameters, and the pneumoperitoneum impact on the cardiopulmonary system during a laparoscopic appendectomy in children. A single-center parallel single-masked randomized controlled study was carried out with 58 patients (3-17 years). Intravenous lidocaine bolus of 1.5 mg/kg over 5 min before induction of anesthesia followed by lidocaine infusion at 1.5 mg/kg/h intraoperatively. Respiratory system compliance (C, C/kg), P_peak-PEEP and Pulse rate (Pulse), systolic, diastolic and mean blood pressure (NBP_s, NBP_d, NBP_m), assessed in the Lidocaine and Control group, at the: beginning (P₁), minimum lung compliance (P₂) and at the end of surgery (P₃) were compared. The respiratory/hemodynamic parameters did not differ between the groups at any stage of operation. Blood Pressure and P_peak-PEEP were significantly higher at the P₂ compared to P₁ and P₃ stages (P < 0.001, 1 - β ≥ 0.895) that correlated with lung compliance changes: C/kg vs. NBP_s and P_peak-PEEP (- 0.42, - 0.84; P < 0.001); C vs. Pulse and P_peak-PEEP (- 0.48, - 0.46; P < 0.001). Although an increase in intraabdominal pressure up to 12(15) mmHg causes significant changes in hemodynamic/respiratory parameters, there appears to be no risk of fatal reactions in 1E, 2E ASA patients. Systemic lidocaine administration doesn't alleviate circulatory/respiratory alterations during pneumoperitoneum. No lidocaine related episode of anaphylaxis, systemic toxicity, circulatory disturbances or neurological impairment occurred.ClinicalTrials.gov: 22/03/2019.Trial registration number: NCT03886896.

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.

Intravenous lidocaine infusion for the treatment of acute pain in the pediatric intensive care unit: case series

Introduction: The use of intravenous lidocaine infusion has increased over the past decade as part of a multimodal approach to analgesia in adults; however, information about its safety and tolerability in the pediatric population is limited. Methods: Acute pain management using lidocaine infusion in eleven patients treated in the pediatric intensive care unit. Results: Five cases of postoperative abdominal pain and six cases of non-operative abdominal pain. Two cases were cancer patients affected by neutropenic colitis. Analgesic control achieved was good. Conclusion: Lidocaine infusions are apparently a safe option for the management of acute pain, either post-operative or not, in the pediatric population.

Efficacy of intravenous lidocaine infusions for pain relief in children undergoing laparoscopic appendectomy: a randomized controlled trial

Abstract

Intravenous lidocaine, a potent local anesthetic with analgesic and anti-inflammatory properties, has been shown to be an effective adjunct that reduces intra- and postoperative opioid consumption and facilitates pain management in adults. While it shows promise for use in the pediatric population, limited evidence is available.

Objectives

To determine if general anesthesia with intraoperative intravenous lidocaine infusion versus general anesthesia without intravenous lidocaine infusion in children undergoing laparoscopic appendectomy decreased opioid requirements intra- and postoperatively.

Design

A single-center parallel single-masked randomized controlled study. A computer-generated blocked randomization list was used to allocate participants. The study was conducted between March 2019 and January 2020. Setting: Pediatric teaching hospital in Poland.

Participants

Seventy-four patients aged between 18 months and 18 years undergoing laparoscopic appendectomy. Seventy-one patients fulfilled the study requirements.

Intervention

Intravenous lidocaine bolus of 1.5 mg/kg over 5 min before induction of anesthesia followed by lidocaine infusion at 1.5 mg/kg/h intraoperatively. The infusion was discontinued before the patients’ transfer to the postanesthesia care unit (PACU).

Primary outcome measure

The primary outcome measure was total nalbuphine requirement in milligrams during the first 24 h after surgery.

Secondary outcome measures

The secondary outcome measures were intraoperative fentanyl consumption, intraoperative sevoflurane consumption, time to the first rescue analgesic request, incidence of postoperative nausea and vomiting during the first 24 h after surgery, frequency of side effects of lidocaine.

Results

Children (n = 74) aged 5–17 randomly allocated to receive intraoperative lidocaine infusion (n = 37) or no intervention (n = 37). Seventy-one were included in the analysis (35 in the study group and 36 in the control group). There was no difference in the cumulative dose of nalbuphine in the first 24 h after removal of the endotracheal tube between groups [median of 0.1061 (IQR: 0.0962–0.2222) mg/kg in the lidocaine group, compared to the control group median of 0.1325 (IQR: 0.0899–0.22020) mg/kg, p = 0.63].

Intraoperative fentanyl consumption was lower in the lidocaine group [median of 5.091 (IQR: 4.848–5.714) μg/kg] than in the control group [median of 5.969 (IQR: 5.000–6.748), p = 0.03].

Taking into account the additional doses administered based on clinical indications, the reduction in the requirement for fentanyl in the lidocaine group was even greater [median of 0.0 (IQR: 0.0–0.952) vs 0.99 (IQR: 0.0–1.809) μg/kg, p = 0.01].

No difference was observed in the sevoflurane consumption between the two groups [median of 32.5 ml (IQR 25.0–43.0) in the lidocaine group vs median of 35.0 ml (IQR: 23.5–46.0) in the control group, p = 0.56].

The time to first analgesic request in the lidocaine group was prolonged [median of 55 (IQR: 40–110) min in the lidocaine group vs median of 40.5 (IQR: 28–65) min in the control group, p = 0.05].

There was no difference in the frequency of PONV between the two groups (48.57% in the lidocaine group vs 61.11% in the control group, p = 0.29).

No lidocaine related incidence of anaphylaxis, systemic toxicity, circulatory disturbances or neurological impairment was reported, during anesthesia or postoperative period.

Conclusions

Intraoperative systemic lidocaine administration reduced the intraoperative requirement for opioids in children undergoing laparoscopic appendectomy. This effect was time limited, and hence did not affect opioid consumption in the first 24 h following discontinuation of lidocaine infusion.

Trial registration

NCT03886896.

Systemic Lidocaine Infusion for Post-Operative Analgesia in Children Undergoing Laparoscopic Inguinal Hernia Repair: A Randomized Double-Blind Controlled Trial

Systemic lidocaine can provide satisfactory post-operative analgesia in adults. In this study, we assessed whether intravenous lidocaine is effective for post-operative analgesia and recovery in children undergoing laparoscopic inguinal hernia repair. A total of 66 children aged from six months to less than six years were classified in either the lidocaine (L) or control (C) groups. Children in Group L received a lidocaine infusion (a bolus dose of 1 mL kg⁻¹, followed by a 1.5 mg kg⁻¹ h⁻¹ infusion), whereas Group C received the same volume of 0.9% saline. The primary outcome was the number of patients who presented face, legs, activity, crying and consolability (FLACC) scores of four or more, and therefore received rescue analgesia in the post-anesthesia recovery care unit (PACU). Secondary outcomes included the highest FLACC score in the PACU, FLACC, and the parents’ postoperative pain measure (PPPM) score at 48 h post-operation, as well as side effects. The number of children who received rescue analgesia in the PACU was 15 (50%) in Group L and 22 (73%) in Group C (p = 0.063). However, the highest FLACC score in PACU was lower in Group L (3.8 ± 2.4) than in Group C (5.3 ± 2.7) (p = 0.029). In conclusion, systemic lidocaine did not reduce the number of children who received rescue analgesia in PACU.