Intravenous lidocaine for effective pain relief after a laparoscopic colectomy: a prospective, randomized, double-blind, placebo-controlled study

Pharmacologic prevention and therapy of postoperative paralytic ileus after gastrointestinal cancer surgery: systematic review and meta-analysis

BACKGROUND

Postoperative paralytic ileus (POI) is a significant concern following gastrointestinal tumor surgery. Effective preventive and therapeutic strategies are crucial but remain elusive. Current evidence from randomized-controlled trials on pharmacological interventions for prevention or treatment of POI are systematically reviewed to guide clinical practice and future research.

MATERIALS AND METHODS

Literature was systematically searched for prospective randomized-controlled trials testing pharmacological interventions for prevention or treatment of POI after gastrointestinal tumor surgery. Meta-analysis was performed using a random effects model to determine risk ratios and mean differences with 95% CI. Risk of bias and evidence quality were assessed.

RESULTS

Results from 55 studies, involving 5078 patients who received experimental interventions, indicate that approaches of opioid-sparing analgesia, peripheral opioid antagonism, reduction of sympathetic hyperreactivity, and early use of laxatives effectively prevent POI. Perioperative oral Alvimopan or intravenous administration of Lidocaine or Dexmedetomidine, while safe regarding cardio-pulmonary complications, demonstrated effectiveness concerning various aspects of postoperative bowel recovery [Lidocaine: -5.97 (-7.20 to -4.74)h, P <0.0001; Dexmedetomidine: -13.00 (-24.87 to -1.14)h, P =0.03 for time to first defecation; Alvimopan: -15.33 (-21.22 to -9.44)h, P <0.0001 for time to GI-2 ] and length of hospitalization [Lidocaine: -0.67 (-1.24 to -0.09)d, P =0.02; Dexmedetomidine: -1.28 (-1.96 to -0.60)d, P =0.0002; Alvimopan: -0.58 (-0.84 to -0.32)d, P <0.0001] across wide ranges of evidence quality. Perioperative nonopioid analgesic use showed efficacy concerning bowel recovery as well as length of hospitalization [-1.29 (-1.95 to -0.62)d, P =0.0001]. Laxatives showed efficacy regarding bowel movements, but not food tolerance and hospitalization. Evidence supporting pharmacological treatment for clinically evident POI is limited. Results from one single study suggest that Neostigmine reduces time to flatus and accelerates bowel movements [-37.06 (-40.26 to -33.87)h, P <0.0001 and -42.97 (-47.60 to -38.35)h, P <0.0001, respectively] with low evidence quality.

CONCLUSION

Current evidence concerning pharmacological prevention and treatment of POI following gastrointestinal tumor surgery is limited. Opioid-sparing concepts, reduction of sympathetic hyperreactivity, and laxatives should be implemented into multimodal perioperative approaches.

Effects of intravenous lidocaine on postoperative pain and gastrointestinal function recovery following gastrointestinal surgery: a meta-analysis

INTRODUCTION

The full extent of intravenous lidocaine's effectiveness in alleviating postoperative pain and enhancing gastrointestinal function recovery remains uncertain.

EVIDENCE ACQUISITION

We conducted an exhaustive search of databases to identify randomized controlled trials that compared intravenous lidocaine infusion's efficacy to that of a placebo or routine care in patients undergoing gastrointestinal surgery. The primary outcome measure was resting pain scores 24 h postoperatively. We utilized a random-effects model based on the intention-to-treat principle for the overall results.

EVIDENCE SYNTHESIS

This study included twenty-four trials with 1533 patients. Intravenous lidocaine significantly reduced resting pain scores 24 h after gastrointestinal surgery (twenty trials, SMD -0.67, 95% CI -1.09 to -0.24, P=0.002, I2 = 90%). This finding was consistent in subgroup analyses and sensitivity analyses. The benefit was also observed at other resting and moving time points (1, 2, 4, and 12 h) postoperatively. Intravenous lidocaine significantly decreased opioid consumption within 24 h after surgery (eleven trials, SMD: -1.19; 95% CI: -1.99 to -0.39; P=0.003). Intravenous lidocaine also shortened the time to bowel sound (MD: -8.51; 95% CI: -14.59 to -2.44; P=0.006), time to first flatus (MD: -6.00; 95% CI: -9.87 to -2.13; P=0.002), and time to first defecation (MD: -9.77; 95% CI: -17.19 to -2.36; P=0.01).

CONCLUSIONS

Perioperative intravenous lidocaine can alleviate acute pain and expedite gastrointestinal function recovery in patients undergoing gastrointestinal surgery. However, the results should be interpreted with caution due to substantial heterogeneity. Further large-scale studies are necessary to validate these findings.

PROcedure-SPECific postoperative pain management guideline for laparoscopic colorectal surgery: A systematic review with recommendations for postoperative pain management

Colorectal cancer is the second most common cancer diagnosed in women and third most common in men. Laparoscopic resection has become the standard surgical technique worldwide given its notable benefits, mainly the shorter length of stay and less postoperative pain. The aim of this systematic review was to evaluate the current literature on postoperative pain management following laparoscopic colorectal surgery and update previous procedure-specific pain management recommendations. The primary outcomes were postoperative pain scores and opioid requirements. We also considered study quality, clinical relevance of trial design, and a comprehensive risk-benefit assessment of the analgesic intervention. We performed a literature search to identify randomised controlled studies (RCTs) published before January 2022. Seventy-two studies were included in the present analysis. Through the established PROSPECT process, we recommend basic analgesia (paracetamol for rectal surgery, and paracetamol with either a nonsteroidal anti-inflammatory drug or cyclo-oxygenase-2-specific inhibitor for colonic surgery) and wound infiltration as first-line interventions. No consensus could be achieved either for the use of intrathecal morphine or intravenous lidocaine; no recommendation can be made for these interventions. However, intravenous lidocaine may be considered when basic analgesia cannot be provided.

Appropriate Duration of Perioperative Intravenous Administration of Lidocaine to Provide Satisfactory Analgesia for Adult Patients Undergoing Colorectal Surgery: A Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Perioperative lidocaine infusion has been reported to alleviate pain intensity after colorectal surgery. However, there is no consensus on whether prolonged lidocaine infusion is more effective than short lidocaine infusion. This meta-analysis aimed to determine an appropriate duration of lidocaine infusion in patients undergoing colorectal surgery.

METHODS

We searched the PubMed, EMBASE, Web of Science, and Cochrane Library databases to identify articles published before December 17, 2021. Randomized controlled trials comparing intravenous lidocaine with placebo for pain relief in patients undergoing colorectal surgery were included. The primary outcome was pain scores (visual analog scale [VAS], 0-10 cm) at 24 hours postoperatively at rest and on movement. Secondary outcomes included pain scores at 12, 48, and 72 hours postoperatively, analgesic consumption (mg), gastrointestinal function return (hour), length of hospital stay (days), and incidence of complications. According to the duration of lidocaine infusion, studies were grouped into infusion for at least 24 hours (prolonged lidocaine infusion) and less than 24 hours (short lidocaine infusion) to assess the impact of lidocaine infusion duration on the outcomes of interests. Quantitative analyses were performed using a random effects model.

RESULTS

Eleven studies with 548 patients were included. Five studies used prolonged lidocaine infusion, while 6 studies used short lidocaine infusion. Prolonged lidocaine infusion reduced postoperative pain scores versus placebo at 24 hours at rest (mean difference [MD], -0.91 cm; 95% confidence interval [CI], -1.54 to -0.28; P = .02) and on movement (MD, -1.69 cm; 95% CI, -2.15 to -1.22; P < .001), while short lidocaine infusion showed no benefit. Compared with placebo, prolonged lidocaine infusion reduced pain scores at 12 hours at rest and at 12 and 48 hours on movement, but short lidocaine infusion did not. However, there was no significant difference in pain scores between the prolonged and short lidocaine infusion groups at these time points. Compared with placebo, prolonged lidocaine infusion shortened the length of hospital stay (MD, -1.30 days; 95% CI, -1.72 to -0.88; P < .001) and time to first postoperative defecation (MD, -12.51 hours; 95% CI, -22.67 to -2.34; P = .02). There were no differences between groups regarding the other outcomes.

CONCLUSIONS

The analgesic effect of intravenous lidocaine may depend on the duration of infusion, and our results suggest that lidocaine infusion should be administered for at least 24 hours after colorectal surgery. Since overall evidence quality was low, further high-quality, large-sample trials are needed to explore an optimal lidocaine infusion strategy in patients undergoing colorectal surgery.

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.

Regional techniques for pain management following laparoscopic elective colonic resection: A systematic review

Introduction

Pain management is an integral part of Enhanced Recovery After Surgery (ERAS) following laparoscopic colonic resection. A variety of regional and neuraxial techniques were proposed, but their efficacy is still controversial. This systematic review evaluates published evidence on analgesic techniques and their impact on postoperative analgesia and recovery for laparoscopic colonic surgery patients.

Methods

We conducted bibliographic research on May 10, 2021, through PubMed, Cochrane database, and Google scholar. We retained meta-analysis and randomized clinical trials. We graded the strength of clinical data and subsequent recommendations according to the Oxford Centre for Evidence-Based Medicine.

Results

Twelve studies were included. Thoracic epidural analgesia improved postoperative analgesia and bowel function following laparoscopic colectomy. However, it lengthens the hospital stay. Transversus abdominis plane block was as effective as thoracic epidural analgesia concerning pain control but with better postoperative recovery and lower length of hospital stay. Moreover, Lidocaine intravenous infusion improved postoperative pain management and recovery; Quadratus lumborum block provided similar postoperative analgesia and recovery. Finally, wound infiltration reduced postoperative pain without improving recovery of bowel function, and it could be proposed as an alternative to thoracic epidural analgesia.

Conclusions

Several analgesic techniques have been investigated. We found that abdominal wall blocks were as effective as thoracic epidural analgesia for pain management but with lower hospital stay and better recovery. We registered this review on PROSPERO (ID: CRD42021279228).

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First systematic review assessing the efficacy of analgesic techniques following laparoscopic elective colonic resection.

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Only colonic resection was evaluated contrary to other studies, including rectal surgery.

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High-quality studies (randomized controlled trials and meta-analyses) were assessed.

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.

Effects of lidocaine, dexmedetomidine, and their combination infusion on postoperative nausea and vomiting following laparoscopic hysterectomy: a randomized controlled trial

Background

A few studies have reported that administration of lidocaine and dexmedetomidine relieves the incidence of postoperative nausea and vomiting (PONV). We explored whether combined infusion of lidocaine plus dexmedetomidine had lower occurrence of PONV undergoing laparoscopic hysterectomy with general anesthesia.

Methods

A total of 248 women undergoing elective laparoscopic hysterectomy were allocated into the following four groups: the control group (group C, n = 62) received an equal volume of saline, the lidocaine group (group L, n = 62) received intravenous lidocaine (bolus infusion of 1.5 mg/kg over 10 min, 1.5 mg/kg/h continuous infusion), the dexmedetomidine group (group D, n = 62) received dexmedetomidine administration (bolus infusion of 0.5 µg/kg over 10 min, 0.4 µg/kg/h continuous infusion), and the lidocaine plus dexmedetomidine group (group LD, n = 62) received combination of lidocaine (bolus infusion of 1.5 mg/kg over 10 min, 1.5 mg/kg/h continuous infusion) and dexmedetomidine administration (bolus infusion of 0.5 µg/kg over 10 min, 0.4 µg/kg/h continuous infusion). The primary outcome was the incidence of nausea, vomiting, and PONV during the first 48 h after surgery. The secondary outcomes included the incidence of total 24 h PONV after surgery, intraoperative remifentanil requirement, postoperative pain visual analogue scale (VAS) scores and fentanyl consumption, the incidence of bradycardia, agitation, shivering, and mouth dry during post-anesthesia care unit (PACU) stay period.

Results

The occurrence of nausea and PONV in group LD (5.0 and 8.3%) at 0–2 h after operation was lower than group C (21.7 and 28.3%) (P < 0.05). There was no statistically significant difference with respect to occurrence of nausea and PONV in groups L (13.3 and 20.0%) and D (8.3 and 13.3%) at 0–2 h after operation compared to group C (21.7 and 28.3%). The incidence of nausea, vomiting, and PONV at 2–24 and 24–48 h after surgery in all four groups was not statistically significant. The incidence of total 24 h PONV in group LD (33.3%) was significantly decreased compared to group C (60.0%) (P < 0.05). The cumulative consumption of fentanyl at 6 and 12 h after surgery was significantly reduced in group LD compared to other three groups (P < 0.05). The pain VAS scores were significantly decreased at 2, 6, and 12 h after operation in group LD compared to other three groups (P < 0.05). Remifentanil dose in the intraoperative period was significantly lower in groups LD and D compared with groups C and L (P < 0.05). The number of mouth dry, bradycardia, and over sedation during the PACU stay period was markedly increased in group LD (28.3, 30.0, and 35.0%, respectively) compared with groups C (1.7, 1.7, and 3.3%, respectively) and L (3.3, 5.0, and 6.7%, respectively) (P < 0.05).

Conclusions

Lidocaine combined with dexmedetomidine infusion markedly decreased the occurrence of nausea and PONV at 0–2 h as well as the total 24 h PONV. However, it significantly increased the incidence of mouth dry, bradycardia, and over sedation during the PACU stay period after laparoscopic hysterectomy with general anesthesia.

Trial registration

ClinicalTrials.gov (NCT03809923), registered on January 18, 2019.

Efficacy of systemic lidocaine on postoperative quality of recovery and analgesia after video-assisted thoracic surgery: A randomized controlled trial

STUDY OBJECTIVE

Intraoperative systemic lidocaine has become widely accepted as an adjunct to general anesthesia, associated with opioid-sparing and enhanced recovery. We hypothesized that perioperative systemic lidocaine improves postoperative pain and enhances the quality of recovery (QoR) in patients following video-assisted thoracic surgery (VATS).

DESIGN

Prospective, single-center, double-blind, randomized placebo-controlled clinical trial.

SETTING

Single institution, tertiary university hospital.

PATIENTS

Adult patients aged 18 to 65 undergoing VATS were eligible for participation.

INTERVENTIONS

Patients enrolled in this study were randomized to receive either system lidocaine (a bolus of 1.5 mg kg^-1, followed by an infusion of 2 mg kg^-1 h^-1 until the end of the surgical procedure) or identical volumes and rates of 0.9% saline.

MEASUREMENTS

The primary outcome was a global QoR-15 score 24 h after surgery. Secondary outcomes included postoperative pain score, cumulative opioid consumption, emergence time, length of PACU stay, adverse events, and patient satisfaction.

MAIN RESULTS

There was no difference in the global QoR-15 scores at 24 h postoperatively between the lidocaine and saline groups (median 117, IQR 113.5-124, vs. median 116, IQR 111-120, P = 0.067), with a median difference of 3 (95% CI 0 to 6, P = 0.507). Similarly, postoperative pain scores, postoperative cumulative opioid consumption, PACU length of stay, the occurrence of PONV, and patient satisfaction were comparable between the two groups (all P > 0.05).

CONCLUSIONS

Our current findings do not support using perioperative systemic lidocaine as a potential strategy to improve postoperative pain and enhance QoR in patients undergoing VATS.

TRIAL REGISTRATION

Chinese Clinical Trial Registry (identifier: ChiCTR1900027515).

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.

The use of intravenous lidocaine for postoperative pain and recovery: international consensus statement on efficacy and safety

Intravenous lidocaine is used widely for its effect on postoperative pain and recovery but it can be, and has been, fatal when used inappropriately and incorrectly. The risk-benefit ratio of i.v. lidocaine varies with type of surgery and with patient factors such as comorbidity (including pre-existing chronic pain). This consensus statement aims to address three questions. First, does i.v. lidocaine effectively reduce postoperative pain and facilitate recovery? Second, is i.v. lidocaine safe? Third, does the fact that i.v. lidocaine is not licensed for this indication affect its use? We suggest that i.v. lidocaine should be regarded as a 'high-risk' medicine. Individual anaesthetists may feel that, in selected patients, i.v. lidocaine may be beneficial as part of a multimodal peri-operative pain management strategy. This approach should be approved by hospital medication governance systems, and the individual clinical decision should be made with properly informed consent from the patient concerned. If i.v. lidocaine is used, we recommend an initial dose of no more than 1.5 mg.kg^-1 , calculated using the patient's ideal body weight and given as an infusion over 10 min. Thereafter, an infusion of no more than 1.5 mg.kg^-1 .h^-1 for no longer than 24 h is recommended, subject to review and re-assessment. Intravenous lidocaine should not be used at the same time as, or within the period of action of, other local anaesthetic interventions. This includes not starting i.v. lidocaine within 4 h after any nerve block, and not performing any nerve block until 4 h after discontinuing an i.v. lidocaine infusion.

Intravenous Lidocaine Infusion for the Management of Early Postoperative Pain: A Comprehensive Review of Controlled Trials

Previously used as anti-arrhythmic, intravenous lidocaine infusion is becoming popular for use in management of acute pain. There is still much to be understood about its pharmacokinetics and pharmacodynamics, especially with regard to optimal dosing to avoid side effects. In this article, we selected and reviewed randomized controlled trials to summarize the pharmacokinetics, antinociceptive effects, anti-hyperalgesic effects, anti-inflammatory effects, side effects, and role of intravenous lidocaine in the management of early postoperative pain. The mechanisms of action of lidocaine are still unclear but there are many theories postulated. Optimal dosing of lidocaine is not known but general consensus indicates that a loading dose of 1-2 mg/kg, followed by 1-2 mg/kg/hr continuous infusion during early postoperative pain control while recovering from anesthesia to achieve therapeutic levels of 0.5-5 mcg/kg clearly improves analgesia in the immediate postoperative period. Although lidocaine was initially studied and proven to have clear analgesic effects following laparoscopic and open abdominal surgeries, it has now been shown to be applicable in different clinical settings perioperatively including following spinal, breast, ENT and other surgeries. It is generally safe, with hypotension, headache and vomiting being the more common side effects. Serious adverse effects include cardiovascular block and arrhythmias, neuro-excitability and hypersensitivity, although the frequency of these are not known.

Management strategies for the treatment and prevention of postoperative/postdischarge nausea and vomiting: an updated review

Postoperative nausea and vomiting (PONV) and postdischarge nausea and vomiting (PDNV) remain common and distressing complications following surgery. The routine use of opioid analgesics for perioperative pain management is a major contributing factor to both PONV and PDNV after surgery. PONV and PDNV can delay discharge from the hospital or surgicenter, delay the return to normal activities of daily living after discharge home, and increase medical costs. The high incidence of PONV and PDNV has persisted despite the introduction of many new antiemetic drugs (and more aggressive use of antiemetic prophylaxis) over the last two decades as a result of growth in minimally invasive ambulatory surgery and the increased emphasis on earlier mobilization and discharge after both minor and major surgical procedures (e.g. enhanced recovery protocols). Pharmacologic management of PONV should be tailored to the patient’s risk level using the validated PONV and PDNV risk-scoring systems to encourage cost-effective practices and minimize the potential for adverse side effects due to drug interactions in the perioperative period. A combination of prophylactic antiemetic drugs with different mechanisms of action should be administered to patients with moderate to high risk of developing PONV. In addition to utilizing prophylactic antiemetic drugs, the management of perioperative pain using opioid-sparing multimodal analgesic techniques is critically important for achieving an enhanced recovery after surgery. In conclusion, the utilization of strategies to reduce the baseline risk of PONV (e.g. adequate hydration and the use of nonpharmacologic antiemetic and opioid-sparing analgesic techniques) and implementing multimodal antiemetic and analgesic regimens will reduce the likelihood of patients developing PONV and PDNV after surgery.

The impact of peri-operative intravenous lidocaine on postoperative outcome after elective colorectal surgery: A meta-analysis of randomised controlled trials

BACKGROUND

There has recently been increasing interest in the use of peri-operative intravenous lidocaine (IVL) due to its analgesic, anti-inflammatory and opioid-sparing effects. However, these potential benefits are not well established in elective colorectal surgery.

OBJECTIVES

To examine the effect of peri-operative IVL infusion on postoperative outcome in patients undergoing elective colorectal surgery.

DESIGN

A meta-analysis of randomised controlled trials (RCTs) comparing peri-operative IVL with placebo infusion in elective colorectal surgery. The primary outcome measure was postoperative pain scores up to 48 h. The secondary outcome measures included time to return of gastrointestinal function, postoperative morphine requirement, anastomotic leak, local anaesthetic toxicity and hospital length of stay.

DATA SOURCES

PubMed, Scopus and the Cochrane Library databases were searched on 5 November 2018.

ELIGIBILITY CRITERIA

Studies were included if they were RCTs evaluating the role of peri-operative IVL vs. placebo in adult patients undergoing elective colorectal surgery. Exclusion criteria were paediatric patients, noncolorectal or emergency procedures, non-RCT methodology or lack of relevant outcome measures.

RESULTS

A total of 10 studies were included (n = 508 patients; 265 who had undergone IVL infusion, 243 who had undergone placebo infusion). IVL infusion was associated with a significant reduction in time to defecation (mean difference -12.06 h, 95% CI -17.83 to -6.29, I = 93%, P = 0.0001), hospital length of stay (mean difference -0.76 days, 95% CI -1.32 to -0.19, I = 45%, P = 0.009) and postoperative pain scores at early time points, although this difference does not meet the threshold for a clinically relevant difference. There was no difference in time to pass flatus (mean difference -5.33 h, 95% CI -11.53 to 0.88, I = 90%, P = 0.09), nor in rates of surgical site infection or anastomotic leakage.

CONCLUSION

This meta-analysis provides some support for the administration of peri-operative IVL infusion in elective colorectal surgery. However, further evidence is necessary to fully elucidate its potential benefits in light of the high levels of study heterogeneity and mixed quality of methodology.

Effect of Intravenous Lidocaine Infusion on Postoperative Early Recovery Quality in Upper Airway Surgery

OBJECTIVES/HYPOTHESIS

Systemic infusions of lidocaine have been widely used as perioperative analgesic adjuvants. The aim of this randomized, double-blinded, controlled trial was to investigate the effect of perioperative lidocaine infusion on postoperative early recovery quality in upper airway surgery.

STUDY DESIGN

Prospective, randomized, double-blinded, placebo-controlled trial.

METHODS

A total of 99 patients were randomly assigned to the lidocaine group (group L) or the control group (group C). The patients received 2 mg/kg lidocaine completed within 10 minutes before the induction of anesthesia followed by continuous infusions of 2 mg/kg/hr lidocaine (group L) or the same volume of 0.9% normal saline (group C) intravenously during anesthesia. The Quality of Recovery-40 (QoR-40) survey was administered on the preoperative day (Pre) and postoperative days 1 (POD1) and 2 (POD2). The primary endpoint was QoR-40 score on POD1 and POD2.

RESULTS

Compared with Pre, global QoR-40 scores on POD1 and POD2 were significantly lower (P < .05). Compared with group C, global QoR-40 scores were significantly higher in group L on POD1 and POD2 (P < .05). Among the five dimensions of QoR-40, the scores for physical comfort, emotional state, and pain were superior in group L compared to group C (P < .05). Compared with group C, the consumption of remifentanil and diclofenac as well as the incidence of postoperative nausea and vomiting (PONV) and postoperative 48-hour numeric rating scale (NRS) scores in group L were significantly lower (P < .05).

CONCLUSIONS

Systemic lidocaine infusion can improve QoR-40 scores in patients with upper airway surgery, reduce the dosage of intraoperative opioids, decrease the incidence of PONV and NRS scores 2 days after surgery, thus improving postoperative early recovery quality.

LEVEL OF EVIDENCE

1b Laryngoscope, 131:E63-E69, 2021.

Impact of perioperative pain management on cancer recurrence: an ASRA/ESRA special article

Cancer causes considerable suffering and 80% of advanced cancer patients experience moderate to severe pain. Surgical tumor excision remains a cornerstone of primary cancer treatment, but is also recognized as one of the greatest risk factors for metastatic spread. The perioperative period, characterized by the surgical stress response, pharmacologic-induced angiogenesis, and immunomodulation results in a physiologic environment that supports tumor spread and distant reimplantation.In the perioperative period, anesthesiologists may have a brief and uniquewindow of opportunity to modulate the unwanted consequences of the stressresponse on the immune system and minimize residual disease. This reviewdiscusses the current research on analgesic therapies and their impact ondisease progression, followed by an evidence-based evaluation of perioperativepain interventions and medications.

Association of Body Mass Index and Serum Markers of Tissue Damage with Postoperative Pain. The Role of Lactate Dehydrogenase for Postoperative Pain Prediction

Objectives

i) To analyze the association of body mass index (BMI) and some serum tissue damage markers with postoperative pain. ii) To establish a biochemical marker cutoff point able to predict moderate to severe postoperative pain.

Design

Cross-sectional study.

Subjects

Ninety-six adult male patients from Southern Spain (55 ± 13 years old) who underwent an inguinal hernioplasty.

Methods

Postoperative pain (eight hours after surgery) was assessed through a visual analog scale (VAS). Moderate to severe pain was defined as a VAS &gt; 50 mm. BMI was calculated and medication, alcohol consumption, and smoking habit registered. Eight hours after surgery, some serum markers such as fibrinogen, lactate dehydrogenase (LDH), C-reactive protein, cortisol, creatine kinase, glutamic-pyruvic, glutamic oxaloacetic, and gamma-glutamyltransferase transaminases were determined by standard procedures.

Results

After adjusting for potential confounders, BMI was not associated with postoperative pain (P &gt; 0.05). Serum fibrinogen was associated with greater postoperative pain (β = 0.333, P &lt; 0.05). Serum LDH concentration was strongly associated with greater postoperative pain (β = 0.606, P &lt; 0.001). Alcohol consumption was associated with higher postoperative pain (β = 0.212, P &lt; 0.05). No associations were observed regarding age, tobacco consumption, and the rest of serum markers studied. Serum LDH concentration was able to discriminate between presence/absence of moderate to severe postoperative pain (receiver operating characteristic area under the curve = 0.655, P ≤ 0.01). An LDH concentration &gt;204 IU/L was associated with a three-times increased odds ratio of moderate to severe postoperative pain.

Conclusions

Contrary to expectations, greater BMI was not associated with higher postoperative pain. Notwithstanding, the assessment of serum LDH might provide useful information to predict moderate to severe postoperative pain.

The effects of intravenous lidocaine on wound pain and gastrointestinal function recovery after laparoscopic colorectal surgery

To evaluate the efficacy of intravenous lidocaine in relieving postoperative pain and promoting rehabilitation in laparoscopic colorectal surgery, we conducted this meta-analysis. The systematic search strategy was performed on PubMed, EMBASE, Chinese databases, and Cochrane Library before September 2019. As a result, 10 randomised clinical trials were included in this meta-analysis (n = 527 patients). Intravenous lidocaine significantly reduced pain scores at 2, 4, 12, 24, and 48 hours on movement and 2, 4, and 12 hours on resting-state and reduced opioid requirement in first 24 hours postoperatively (weighted mean difference [WMD] = -5.02 [-9.34, -0.70]; P = .02). It also decreased the first flatus time (WMD: -10.15 [-11.20, -9.10]; P < .00001), first defecation time (WMD: -10.27 [-17.62, -2.92]; P = .006), length of hospital stay (WMD: -1.05 [-1.89, -0.21]; P = .01), and reduced the incidence of postoperative nausea and vomiting (risk ratio: 0.53 [0.30, 0.93]; P = .03) when compared with control group. However, it had no effect on pain scores at 24 and 48 hours at rest, the normal dietary time, and the level of serum C-reactive protein. In summary, perioperative intravenous lidocaine could alleviate acute pain, reduce postoperative analgesic requirements, and accelerate recovery of gastrointestinal function in patients undergoing laparoscopic colorectal surgery.

Efficacy of intravenous lidocaine in improving post-operative nausea, vomiting and early recovery after laparoscopic gynaecological surgery

Post-operative nausea and vomiting (PONV) is a major peri-operative complication. It has numerous adverse consequences that seriously affect the post-operative recovery of patients. The aim of the present study was to investigate the efficacy of intravenous lidocaine in improving PONV and recovery after laparoscopic gynaecological surgery. A total of 40 patients were randomly assigned to 2 groups: Group L (lidocaine group) and Group C (control group). The patients in Group L received intravenous lidocaine throughout the operation, while patients in Group C were given a saline infusion. Vital signs, recovery time, extubation time, dosage of remifentanil, first flatus time and defecation time of each patient were recorded. The incidence of PONV after surgery was also recorded. The recovery of the patients was evaluated by using the quality of recovery score (QoR-40). The total dose of remifentanil was significantly lower in Group L (P<0.05). However, the recovery time and extubation time were shorter in Group C (P<0.05). The first flatus time and defecation time were longer in Group C (P<0.05). The mean arterial pressure and heart rate in Group L were lower and more stable (P<0.05). At 6 h after surgery, the incidence of PONV was significantly lower in Group L vs. that in Group C (P<0.05). The QoR-40 score in Group C was significantly lower at 1 and 3 days after the operation compared with that in Group C (P<0.05). In conclusion, intravenous lidocaine administered to patients undergoing laparoscopic gynaecological surgery may reduce PONV and supports their early recovery [trial registration number in Chinese Clinical Trial Registry: ChiCTR-IOR-17010782 (March 5, 2017)].

Intravenous Lidocaine Alleviates the Pain of Propofol Injection by Local Anesthetic and Central Analgesic Effects

Objective

Lidocaine alleviates propofol injection pain. However, whether lidocaine works through a local anesthetic effect at the site of intravenous injection or through a systemic effect on the central nervous system remains unknown. This study aimed to determine the pain-alleviating mechanism of lidocaine.

Design

A randomized controlled study.

Setting

A gastroscopy facility.

Methods

The study was divided into two parts. Part 1 involved 717 patients who were randomly assigned into five groups. Groups PR, RL20, and RL40 received normal saline or saline containing 20 or 40 mg of lidocaine, injected via the vein on the right hand. Groups LL20 and LL40 received 20 or 40 mg of lidocaine, injected via the vein on the left hand. Part 2 involved 378 patients who were randomly assigned into five groups. Groups RL40, RL1.2, and RL1.5 received 40 mg, 1.2 mg/kg, and 1.5 mg/kg of lidocaine, injected via the vein on the right hand. Groups LL1.2 and LL1.5 received 1.2 or 1.5 mg/kg of lidocaine, injected via the vein on the left hand. All received 2 mg/kg of propofol via the vein on the right hand two minutes later. Injection pain and patient satisfaction were recorded.

Results

The incidence of pain of group RL40 was lower than that of group PR. The incidence of pain of group LL1.2 was higher than that of other groups.

Conclusions

A dosage of 40 mg lidocaine is an appropriate dosage to alleviate propofol injection pain within the same vein. Lidocaine reduces propofol injection pain through both a local anesthetic effect and a central analgesic effect when the dosage reaches 1.5 mg/kg.

Influence of dexmedetomidine and lidocaine on perioperative opioid consumption in laparoscopic intestine resection: a randomized controlled clinical trial

Objective

The consumption of opioid analgesics could be reduced by the use of analgesics with different mechanisms of action. We investigated whether additional treatment with dexmedetomidine or lidocaine could reduce opioid consumption.

Methods

We randomized 59 study participants into three groups and examined: (i) fentanyl consumption, (ii) consumption of piritramide, and (iii) cognitive function and neuropathic pain. The control group received continuous propofol infusion and fentanyl boluses. Continuous intravenous infusion of dexmedetomidine (0.5 µg/kg/h) was administered to the dexmedetomidine group and lidocaine (1.5 mg/kg/h) was administered to the lidocaine group.

Results

No reduction in fentanyl consumption was observed among the groups. However, we noted a significantly lower consumption of piritramide on the first and second postoperative day in the lidocaine group. Total consumption of piritramide was significantly lower in the lidocaine group compared with the control group.

Conclusions

Lidocaine and dexmedetomidine reduced intraoperative propofol consumption, while lidocaine reduced postoperative piritramide consumption.

Clinical trial registration: NCT02616523

Continuous intravenous perioperative lidocaine infusion for postoperative pain and recovery in adults

BACKGROUND

The management of postoperative pain and recovery is still unsatisfactory in a number of cases in clinical practice. Opioids used for postoperative analgesia are frequently associated with adverse effects, including nausea and constipation, preventing smooth postoperative recovery. Not all patients are suitable for, and benefit from, epidural analgesia that is used to improve postoperative recovery. The non-opioid, lidocaine, was investigated in several studies for its use in multimodal management strategies to reduce postoperative pain and enhance recovery. This review was published in 2015 and updated in January 2017.

OBJECTIVES

To assess the effects (benefits and risks) of perioperative intravenous (IV) lidocaine infusion compared to placebo/no treatment or compared to epidural analgesia on postoperative pain and recovery in adults undergoing various surgical procedures.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL, and reference lists of articles in January 2017. We searched one trial registry contacted researchers in the field, and handsearched journals and congress proceedings. We updated this search in February 2018, but have not yet incorporated these results into the review.

SELECTION CRITERIA

We included randomized controlled trials comparing the effect of continuous perioperative IV lidocaine infusion either with placebo, or no treatment, or with thoracic epidural analgesia (TEA) in adults undergoing elective or urgent surgery under general anaesthesia. The IV lidocaine infusion must have been started intraoperatively, prior to incision, and continued at least until the end of surgery.

DATA COLLECTION AND ANALYSIS

We used Cochrane's standard methodological procedures. Our primary outcomes were: pain score at rest; gastrointestinal recovery and adverse events. Secondary outcomes included: postoperative nausea and postoperative opioid consumption. We used GRADE to assess the quality of evidence for each outcome.

MAIN RESULTS

We included 23 new trials in the update. In total, the review included 68 trials (4525 randomized participants). Two trials compared IV lidocaine with TEA. In all remaining trials, placebo or no treatment was used as a comparator. Trials involved participants undergoing open abdominal (22), laparoscopic abdominal (20), or various other surgical procedures (26). The application scheme of systemic lidocaine strongly varies between the studies related to both dose (1 mg/kg/h to 5 mg/kg/h) and termination of the infusion (from the end of surgery until several days after).The risk of bias was low with respect to selection bias (random sequence generation), performance bias, attrition bias, and detection bias in more than 50% of the included studies. For allocation concealment and selective reporting, the quality assessment yielded low risk of bias for only approximately 20% of the included studies.IV Lidocaine compared to placebo or no treatment We are uncertain whether IV lidocaine improves postoperative pain compared to placebo or no treatment at early time points (1 to 4 hours) (standardized mean difference (SMD) -0.50, 95% confidence interval (CI) -0.72 to -0.28; 29 studies, 1656 participants; very low-quality evidence) after surgery. Due to variation in the standard deviation (SD) in the studies, this would equate to an average pain reduction of between 0.37 cm and 2.48 cm on a 0 to 10 cm visual analogue scale . Assuming approximately 1 cm on a 0 to 10 cm pain scale is clinically meaningful, we ruled out a clinically relevant reduction in pain with lidocaine at intermediate (24 hours) (SMD -0.14, 95% CI -0.25 to -0.04; 33 studies, 1847 participants; moderate-quality evidence), and at late time points (48 hours) (SMD -0.11, 95% CI -0.25 to 0.04; 24 studies, 1404 participants; moderate-quality evidence). Due to variation in the SD in the studies, this would equate to an average pain reduction of between 0.10 cm to 0.48 cm at 24 hours and 0.08 cm to 0.42 cm at 48 hours. In contrast to the original review in 2015, we did not find any significant subgroup differences for different surgical procedures.We are uncertain whether lidocaine reduces the risk of ileus (risk ratio (RR) 0.37, 95% CI 0.15 to 0.87; 4 studies, 273 participants), time to first defaecation/bowel movement (mean difference (MD) -7.92 hours, 95% CI -12.71 to -3.13; 12 studies, 684 participants), risk of postoperative nausea (overall, i.e. 0 up to 72 hours) (RR 0.78, 95% CI 0.67 to 0.91; 35 studies, 1903 participants), and opioid consumption (overall) (MD -4.52 mg morphine equivalents , 95% CI -6.25 to -2.79; 40 studies, 2201 participants); quality of evidence was very low for all these outcomes.The effect of IV lidocaine on adverse effects compared to placebo treatment is uncertain, as only a small number of studies systematically analysed the occurrence of adverse effects (very low-quality evidence).IV Lidocaine compared to TEAThe effects of IV lidocaine compared with TEA are unclear (pain at 24 hours (MD 1.51, 95% CI -0.29 to 3.32; 2 studies, 102 participants), pain at 48 hours (MD 0.98, 95% CI -1.19 to 3.16; 2 studies, 102 participants), time to first bowel movement (MD -1.66, 95% CI -10.88 to 7.56; 2 studies, 102 participants); all very low-quality evidence). The risk for ileus and for postoperative nausea (overall) is also unclear, as only one small trial assessed these outcomes (very low-quality evidence). No trial assessed the outcomes, 'pain at early time points' and 'opioid consumption (overall)'. The effect of IV lidocaine on adverse effects compared to TEA is uncertain (very low-quality evidence).

AUTHORS' CONCLUSIONS

We are uncertain whether IV perioperative lidocaine, when compared to placebo or no treatment, has a beneficial impact on pain scores in the early postoperative phase, and on gastrointestinal recovery, postoperative nausea, and opioid consumption. The quality of evidence was limited due to inconsistency, imprecision, and study quality. Lidocaine probably has no clinically relevant effect on pain scores later than 24 hours. Few studies have systematically assessed the incidence of adverse effects. There is a lack of evidence about the effects of IV lidocaine compared with epidural anaesthesia in terms of the optimal dose and timing (including the duration) of the administration. We identified three ongoing studies, and 18 studies are awaiting classification; the results of the review may change when these studies are published and included in the review.

Effects of intravenous administration of fentanyl and lidocaine on hemodynamic responses following endotracheal intubation

OBJECTIVES

To compare the effects of intravenous fentanyl and lidocaine on hemodynamic changes following endotracheal intubation in patients requiring Rapid Sequence Intubation (RSI) in the emergency department (ED).

METHODS

A single-centered, prospective, simple non-randomized, double-blind clinical trial was conducted on 96 patients who needed RSI in Edalatian ED. They were randomly divided into three groups (fentanyl group (F), lidocaine group (L), and fentanyl plus lidocaine (M) as our control group). M was administered with 3 μgr/kg intravenous fentanyl and 1.5 μgr/kg intravenous lidocaine, F was injected with 3g/kg intravenous fentanyl and L received 1.5mg/kg intravenous lidocaine prior to endotracheal intubation. Heart rate (HR) and mean arterial pressure (MAP) were assessed four times with the chi-square test: before, immediately after, 5 and 10 min after intubation. Intervention was discontinued for five people due to unsuccessful CPR.

RESULTS

HR was notably different in F, L and M groups during four time courses (p<0.05). Comparison of MAP at measured points in all groups exhibited no significant difference (p>0.05). In fentanyl group both HR and MAP increased immediately after intubation, and significantly decreased 10 min after intubation (p<0.05).

CONCLUSIONS

Overall, the result of this study shows that lidocaine effectively prevents MAP and HR fluctuations following the endotracheal intubation. According to our findings, lidocaine or the combination of fentanyl and lidocaine are able to diminish hemodynamic changes and maintain the baseline conditions of the patient, thus could act more effectively than fentanyl alone.

Intravenous lignocaine in colorectal surgery: a systematic review

BACKGROUND

Colorectal surgery leads to morbidity during recovery including pain and fatigue. Intravenous (IV) lignocaine (IVL) has both analgesic and anti-inflammatory effects that may improve post-operative pain and recovery. The aim of this review is to compare the effectiveness of IVL to other perioperative analgesia regimens for reducing pain and opioid consumption following colorectal surgery.

METHODS

Using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement, a literature search was conducted to identify randomized clinical trials that compared IVL with IV placebo or epidural anaesthesia in open or laparoscopic colorectal surgery. The primary outcomes were opioid requirements and pain scores assessed by visual analogue score. Data were entered into pre-designed electronic spreadsheets.

RESULTS

The literature search identified 2707 studies. A total of nine randomized clinical trials met the inclusion criteria. Five studies investigated IVL compared with IV placebo and four studies investigated IVL compared with epidural anaesthesia. Two out of the five studies comparing IVL and placebo showed statistically significant reductions in opioid consumption with IVL. There was a variable degree of improvement in pain scores when IVL was compared with epidural. Two studies showed a significant difference, with lower opioid consumption and pain scores in the epidural group. Laparoscopic and open procedures could not be compared between the IVL and placebo group.

CONCLUSION

IVL has shown limited benefit towards reducing early pain and morphine consumption when compared with placebo in colorectal surgery. However, IVL did not show any significant reduction in pain or opioid consumption when compared with epidural. Further research investigating IVL combined with intraperitoneal local anaesthetic is warranted.

Evaluating the Effect of Lidocaine on the Interactions of C-reactive Protein with Its Aptamer and Antibody by Dynamic Force Spectroscopy

Effects of medicine on the biomolecular interaction have been given extensive attention in biochemistry and biomedicine because of the complexity of the environment in vivo and the increasing opportunity of exposure to medicine. Herein, the effect of lidocaine on the interactions of C-reactive protein (CRP) with its aptamer and antibody under different temperature was investigated through dynamic force spectroscopy (DFS). The results revealed that lidocaine could reduce the binding probabilities and binding affinities of the CRP-aptamer and the CRP-antibody. An interesting discovery was that lidocaine had differential influences on the dynamic force spectra of the CRP-aptamer and the CRP-antibody. The energy landscape of the CRP-aptamer turned from two activation barriers to one after the treatment of lidocaine, while the one activation barrier in energy landscape of the CRP-antibody almost remained unchanged. In addition, similar results were obtained for 25 and 37 °C. In accordance with the result of molecular docking, the reduction of binding probabilities might be due to the binding of lidocaine on CRP. Additionally, the alteration of the dissociation pathway of the CRP-aptamer and the change of binding affinities might be caused by the conformational change of CRP, which was verified through synchronous fluorescence spectroscopy. Furthermore, differential effects of lidocaine on the interactions of CRP-aptamer and CRP-antibody might be attributed to the different dissociation processes and binding sites of the CRP-aptamer and the CRP-antibody and different structures of the aptamer and the antibody. This work indicated that DFS provided information for further research and comprehensive applications of biomolecular interaction, especially in the design of biosensors in complex systems.