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A smooth postoperative recovery can be
hindered by the adverse effects that often result from the use of opioids, such
as respiratory depression, nausea and constipation. Loco-regional anesthesia
and analgesia (LRA) is good technique to reduce opioid needs but not all
patients may be suited to or benefited by regional anesthesia techniques (e.g.
morbidly obese patients undergoing bariatric surgery) so additional options
such as intravenous non‐opioid analgesic medications that
enable a rapid recovery are required. Intravenous lidocaine can be used as an
alternative if LRA is not possible. Several studies have looked at the
potential for using the non‐opioid, lidocaine, as a feature of
multimodal management strategies designed to reduce postoperative pain and
speed recovery.
The
purpose of this review was to consider both the potential benefits and the
risks of treating perioperative pain in patients undergoing bariatric surgical
procedures with an intravenous infusion of lidocaine.
INTRODUCTION
The global prevalence of
obesity is increasing with the World Health Organization estimating that 11 %
of adults are obese worldwide [1]. Obesity is usually associated with
obstructive sleep apnea (OSA), which is now thought to affect at least 100
million adults [2]. Long-term weight reduction may also be achieved through
bariatric surgeries such as Laparoscopic sleeve gastrectomy and Roux en Y
gastric bypass surgery. These surgeries will both improve OSA outcomes and
glycemic control while reducing cardiovascular and cancer risk [3].
Concerns about opioid risks in
the postoperative period has spurred an increased interest in the use of nonopioid
analgesic adjuncts. It is well known that the patients with obstructive sleep
apnea (OSA) have increased sensitivity to opioid-induced respiratory depression
resulting in potential for developing postoperative pulmonary complications.
Morbidly obese patients have a high prevalence of both diagnosed and
undiagnosed OSA, and the perioperative respiratory disturbances related to OSA
may be exacerbated by opioids. The use of multimodal strategies that minimize
opioid-related side effects are highly desirable in morbidly obese patients
undergoing surgical procedures.
Almost 30 years ago, the well-known ‘WHO Step
Ladder’ was introduced and has since become a widely accepted concept for
rational pain management [4]. This introduced the concept of multimodal
analgesia which has proved very significant in the development of the current
rationale for managing acute pain.
Alvarez et al. recommend multi-modal
pharmacological approaches for providing optimal analgesia after abdominal
surgery [5]. Multimodal analgesia has been shown to
reduce opioids requirements, decrease opioid related side effects and
facilitate post-operative recovery after several surgical procedures. It
usually combines systematic administration of several non-opioid analgesics,
such as acetaminophen and non-steroidal anti-inflammatory drugs, and local
anesthetic-based analgesic techniques [6]. These local anesthetic based
techniques include epidural analgesia; truncal blocks such as the TAP block
continuous intravenous infusion of lignocaine and wound infiltration with local
anesthetics.
Intravenous lidocaine has been
used as a part of multimodal approach for postoperative analgesia and its use
is associated with reductions in post-operative pain, analgesic consumption,
nausea, vomiting and length of hospital stay in various surgeries including
laparoscopic bariatric procedure.
PHARMACOLOGY
Lidocaine has analgesic,
anti-inflammatory anti-nociceptive as well as immunomodulating properties. The
analgesic effects result, it is thought, from the inhibition of Na+
channels, NMDA and G-protein-coupled receptors which suppress spontaneous
impulses from damaged nerve fibers and the proximal dorsal root ganglion. It is
anti-inflammatory as it blocks neural transmission form the damaged tissue.
Neurogenic inflammation is vitiated by the blockade of neural transmission at
the site of tissue injury. The inhibition of the release of interleukin-1
(IL-1) coupled with the decreased release of lysosomal enzymes results in a
lessening of the release of pro- and anti-inflammatory cytokines. It is
proposed that consequently an anti-hyperalgesia effect [7] arises as peripheral
and central sensitization is suppressed. In addition, intravenous lignocaine
has been successfully used to treat visceral pain [8] and has been reported to
accelerate the return of bowel function after surgery [9].
The concerns for LA toxicity have been raised
with continuous intravenous lidocaine infusion. Lidocaine toxicity is more
likely to manifest when its plasma concentration reaches 5 μg/mL. It is considered
that administering a bolus of between 1 and 2 mg/kg, whether or not followed by
a continuous infusion of 1.5 mg/kg, (corresponding to plasma concentrations of
2 μg/ml) is small [10]. The intravenous lidocaine
dose less than 5 mg/kg, administered slowly over 30 min, under monitoring, are
considered safe [11].
Review
of literature for use of intravenous lidocaine for abdominal and bariatric
surgery
Rimbäck G et al. [12] published
one of the earliest clinical trials with i.e. lidocaine. Having noted that
intraperitoneal lidocaine reduced the incidence of postoperative ileus the
authors sought to establish whether this was a local or systemic effect of the
drug. They gave radio-opaque markers to 30 patients to swallow prior to them
undergoing open cholecystectomy. Patients randomized to, i.e., lidocaine
treatment (100 mg bolus followed by 3 mg/min for 24 h) demonstrated significant
recovery in bowel motility, and this was confirmed by serial radiographs. The
patients also experienced less pain, had fewer opioid requirements, and made a
speedier recovery. Intravenous lidocaine, it was proposed, was able to reduce
ileus and/or enhanced gut function recovery in any of five ways; by its
excitatory effect on gut smooth muscle (direct), with reduced pain and opioid
requirements (indirect), by blocking sympathetic reflexes, by reducing
catecholamine production and through its anti-inflammatory effect.
Lauretti GR [11] reviewed
intravenous lignocaine for mechanisms of action that diverge from the classical
Na+ channel blockade, the differential action of intravenous lidocaine in
central sensitization and the analgesic and cytoprotective actions. They
observed that intravenous lidocaine’s final analgesic action reflected its
multifactorial action. Central hyperexcitability or sensitization was blocked
through its peripheral anti-hyperalgic action on somatic pain and central
action on neuropathic pain.
Olivera GS et al. [13] compared
the effect of systemic intraoperative lidocaine versus placebo in a
prospective, randomized, double blind study on the quality of postoperative
recovery in patients undergoing laparoscopic bariatric surgery. 50 patients were
randomly given either intravenous lidocaine (1.5 mg/kg bolus followed by a 2
mg/kg/h infusion until the end of the surgical procedure) or an identical
volume of saline. The primary outcome was the quality of recovery 40
questionnaire at 24 h after surgery. He found that systemic lidocaine improves postoperative
quality of recovery. There was a lower opioid consumption among the patients
who had received lidocaine which consequently resulted in an improved quality
of recovery.
Alvey EN et al. [14] (2016)
evaluated the safety and effects of intravenous lidocaine in obese patients
undergoing laparoscopic Roux-en-Y gastric bypass (RYGB) surgery in a
prospective, double-blinded and placebo-controlled safety study among 20
patients who were separated at random into two groups of ten. The first group received a continuous
infusion of lidocaine 2 milligrams per kilogram per hour (mg/kg/hr)
intravenously from induction of general anesthesia until the end of the
operation. In parallel, the second group was administered a dextrose placebo
intravenously. Postoperatively both groups were observed for 24 h with the
primary end point being symptoms of lidocaine toxicity observed at 1 h
postoperatively. The exploratory outcomes studied were, visual analog scale
(VAS) pain scores, the volume of opioid consumed, the time to the first passage
of flatus and bowel movement, the duration of the stay in hospital and adverse
events. A trend towards less opioid consumption was observed in the group
receiving lidocaine but otherwise there was no significant difference between
the groups in respect to the adverse effects. Their study was underpowered to
detect statistical differences due to pilot study design; addressing safety as
the primary outcome measure as opposed to efficacy. The study did find that
intravenous lidocaine in RYGB surgery was safe without differences in
postoperative pain or adverse effects.
Budiansky AS et al. [15] completed a literature review for acute pain
management in morbid obesity and confirmed that multimodal pharmacological approach
in morbidly obese patients can improve post-operative pain scores, reduce
opioid analgesic consumption and side-effects notably sedation, respiratory depression,
nausea and vomiting and that the perioperative use of regional anesthesia and
non-opioid adjuvants (ketamine, lidocaine and dexmedetomidine etc.) are important to improve the safety and efficacy
of multimodal analgesia regimes.
Gupta C et al. [16] compared
intravenous lidocaine and ultrasound guided transversus abdominus plane block
for postoperative analgesia in a comparative randomized study in bariatric
surgical patients. 58
patients were studied, each with body mass index >35 kg/m2 and
were randomly allocated either to a to Lidocaine group (Group A) or a USG-TAP
group (Group B). Those in Group A received intravenous Lidocaine (1.5 mg/kg)
bolus followed by (1.5 mg/kg/h) infusion while those in Group B patients
received ultrasound-guided bilateral TAP block using 20 cc of 0.375%
ropivacaine each side. Their study concluded that obese patients undergoing
laparoscopic bariatric surgery who received intravenous Lidocaine as part of
multimodal analgesic technique had an improved pain score and reduced opioid
requirement when compared with a USG-TAP Block.
CONCLUSION
Perioperative lidocaine infusion results in
reduced postoperative pain and a more rapid recovery of bowel function in
several types of open abdominal and laparoscopic procedures [7]. It may also be
a useful analgesic adjunct in bariatric surgery. Lidocaine infusion resulted in
improved pain scores, reduced opioid consumption and a shorter hospital stay,
among other outcomes. Perioperative lidocaine infusion may also be considered
for other types of surgery where the available evidence suggests that there may
be a possible benefit and minimal risk of neurologic and cardiac side effects.
Although accumulation of lidocaine is a
concern with continuous infusion, at doses used in the studies cited here,
plasma concentrations remain well below the toxic level (5 μg/ml) and no
untoward events were attributed to the use of intravenous lidocaine in these
studies. It was extremely rare for the use of perioperative lidocaine infusion
to be toxic; it may present with tinnitus, perioral numbness and cardiovascular
instabilities. The local anesthetic systemic toxicity (LAST) requires immediate
management, as it is a life-threatening event. The LA injection must be stopped while help is summoned and
preparation made to resuscitate. Management of the airway, breathing and
circulation and the early administration of 20% Intralipid emulsion (initial
bolus of 1.5 mL⋅kg−1 over 2-3 min followed by
0.25 mL⋅kg−1⋅min−1 infusion
therapy; maximum of 12 mL⋅kg−1 of 20% lipid emulsion),
are key priorities, together with swift seizure management, and a considered
selection of cardiovascular supportive pharmacotherapy. Prevention should be
the priority for reducing the frequency and severity of LAST and consideration should be given to
monitoring plasma lidocaine levels in patients with a higher risk of lidocaine
toxicity e.g. those with preoperative deranged kidney or liver function tests.
1.
World Health Organization
(2014) WHO Factsheet N°311. Available online at:
http://www.who.int/mediacentre/factsheets/fs311/en/
2.
World Health Organization.
(2013) Chronic Respiratory Diseases. Available online at:
http://www.who.int/gard/publications/chronic_respiratory_diseases.pdf
3.
Ashrafian H, Darzi A,
Athanasiou T (2011) Bariatric surgery - Can we afford to do it or deny doing
it? Front Gastroenterol 2: 82–89.
4.
N Eipe , S Gupta, J Penning
(2013) Intravenous lidocaine for acute pain: An evidence-based clinical update.
BJA 16: 292-298.
5.
Felds HL, Martin JB (2005)
Harrison’s Principles of Internal Medicine. 16th ed. New York: McGraw-Hill, pp:
71-76.
6.
Elvir-Lazo OL, White PF (2010)
The role of multimodal analgesia in pain management after ambulatory surgery.
Curr Opin Anaesthesiol 23: 697-703.
7.
McCarthy GC, Megalla SA, Habib AS
(2010) Impact of intravenous lidocaine infusion on postoperative analgesia and
recovery from surgery a systematic review of randomized controlled trials.
Drugs 70: 1149–1163.
8.
Traystman RJ (2004) Anesthetic
mediated neuroprotection: Established fact or passing fancy? J Neurosurg
Anesthesiol 16: 308-312.
9.
Marret E, Rolin M, Beaussier M, Bonnet F
(2008) Meta-analysis of intravenous lidocaine and postoperative recovery after
abdominal surgery. Br J Surg 95: 1331-1338.
10.
Sucena M, Cachapuz I, Lombardia
E (2004) Plasma concentration of lidocaine during bronchoscopy. Rev Port
Pneumol 10: 287-296.
11.
Lauretti GR (2008) Mechanism of
analgesia of intravenous lidocaine. Rev Bras Anestesiol 58: 280-286.
12.
Rimbäck G, Cassuto J, Tollesson
PO (1990) Treatment of postoperative paralytic ileus by intravenous lidocaine
infusion. Anesth Analg 70: 414-419.
13.
De Oliveira GS, Duncan K, Fitzgerald P, Nader
A, Gould RW et al. (2014) Systemic lidocaine to improve quality of recovery
after laparoscopic bariatric surgery: A randomized double-blinded
placebo-controlled trial. Obes Surg 24: 212-218.
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Alvey EN, Ching Y, Karlnoski
RA, Dalvi PH (2016) Systemic intraoperative lidocaine infusion for
postoperative pain management in obese patients: A randomized, placebo-controlled pilot study.
Case Stud Surg 2: 4.
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Budiansky AS, Margarson MP,
Eipe N (2017) Acute pain management in morbid obesity – An evidence based
clinical update. Surgery Obes Relat Dis 13: 523-532.
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Gupta C, Valecha UK, Singh SP,
Varshney M (2020) Systemic lidocaine versus ultrasound-guided transversus
abdominus plane block for postoperative analgesia: A comparative randomized
study in bariatric surgical patients. Indian J Anaesth 64: 31-36.
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