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Toner AJ, Bailey MA, Schug SA, Phillips M, Ungerer JP, Somogyi AA, Corcoran TB. Serum lidocaine (lignocaine) concentrations during prolonged perioperative infusion in patients undergoing breast cancer surgery: A secondary analysis of a randomised controlled trial. Anaesth Intensive Care 2023; 51:422-431. [PMID: 37802488 DOI: 10.1177/0310057x231194833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/10/2023]
Abstract
Perioperative lidocaine (lignocaine) infusions are being employed with increasing frequency. The determinants of systemic lidocaine concentrations during prolonged administration are unclear. In the Long-term Outcomes after Lidocaine Infusions for PostOperative Pain (LOLIPOP) pilot trial, the impact of infusion duration and body size metrics on serum lidocaine concentrations was examined with regression models in 48 women undergoing breast cancer surgery. Lidocaine was delivered as an intravenous bolus (1.5 mg/kg) and infusion (2 mg/kg per h) intraoperatively, followed by a 12-h subcutaneous infusion (1.33 mg/kg per h) postoperatively. Dosing was based on total body weight. Wound infiltration with other long-acting local anaesthetics was permitted. Protein binding and pharmacogenomic data were also collected. Lidocaine concentrations (median (interquartile range) (range)) during prolonged administration were in the safe and potentially therapeutic range: post-anaesthesia care unit 2.16 (1.73-2.82) (1.12-6.06) µg/ml; ward 1.41 (1.22-1.75) (0.64-2.81) µg/ml. Concentrations increased non-linearly during the early intravenous phase of administration (mean rise 1.21 µg/ml per hour of infusion, P = 0.007) but reached a pseudo steady-state during the later subcutaneous phase. Higher dose rates received per kilogram of lean (P = 0.004), adjusted (P = 0.006) and ideal body weight (P = 0.009) were associated with higher steady-state concentrations. The lidocaine free fraction was unaffected by the presence of ropivacaine, and phenotypes linked to slow metabolism were infrequent. Serum lidocaine concentrations reached a pseudo steady-state during a 12-h postoperative infusion. Greater precision in steady-state concentrations can be achieved by dosing on lean body weight versus adjusted or ideal body weight (equivalent lean body weight doses: intravenous bolus 2.5 mg/kg; intravenous infusion 3.33 mg/kg per h; subcutaneous infusion 2.22 mg/kg per h.
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Affiliation(s)
- Andrew J Toner
- Department of Anaesthesia and Pain Medicine, Royal Perth Hospital, Perth, Australia
- Medical School, University of Western Australia, Perth, Australia
| | - Martin A Bailey
- Department of Anaesthesia and Intensive Care Medicine, Taranaki Base Hospital, New Plymouth, New Zealand
| | - Stephan A Schug
- Medical School, University of Western Australia, Perth, Australia
| | - Michael Phillips
- Harry Perkins Institute of Medical Research, Nedlands, Australia
- Centre for Medical Research, University of Western Australia, Perth, Australia
| | - Jacobus Pj Ungerer
- Pathology Queensland, Royal Brisbane & Women's Hospital, Brisbane, Australia
- School of Biomedical Sciences, University of Queensland, Brisbane, Australia
| | - Andrew A Somogyi
- Discipline of Pharmacology, School of Biomedicine, University of Adelaide, Adelaide, Australia
| | - Tomas B Corcoran
- Department of Anaesthesia and Pain Medicine, Royal Perth Hospital, Perth, Australia
- Medical School, University of Western Australia, Perth, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
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Nelson M, Pal N, Tran B. Perioperative Lidocaine Infusions and Pain Measurements: Effect Size Matters. Anesth Analg 2023; 137:e24. [PMID: 37590807 DOI: 10.1213/ane.0000000000006580] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/19/2023]
Affiliation(s)
- Mark Nelson
- Department of Anesthesiology, Virginia Commonwealth University School of Medicine, Richmond, Virginia,
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Muacevic A, Adler JR, Kumari P, Kumar A. Evaluation of Propofol-Sparing Effect of Intravenous Lignocaine in Patients Undergoing Daycare Upper Gastrointestinal Endoscopic Procedures. Cureus 2022; 14:e32090. [PMID: 36601143 PMCID: PMC9803997 DOI: 10.7759/cureus.32090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/30/2022] [Indexed: 12/04/2022] Open
Abstract
Background Propofol is the most common sedative for endoscopies. Propofol alone may require larger doses for adequate level of sedation. Lignocaine is known for its anesthetic-sparing effect. We tested whether the addition of intravenous lignocaine to propofol-based sedation reduces its dose. Methods This prospective, randomized study was performed on 90 patients of 18 to 60 years of age, of either sex of the American Society of Anesthesiologists (ASA) Grade-I & II, and was divided into two groups. Group L + P received IV bolus of 1.5 mg/kg 2% lignocaine over 10 minutes followed by 1.5 mg/ kg/ h infusion and group NS + P- received the equivalent volumes of normal saline in bolus and infusion. Patients were induced with fentanyl (2 µg/kg) and propofol (1 mg/kg). To maintain an adequate sedation level, a supplemental bolus of 0.5 mg /kg propofol was administered. The outcomes recorded were the total and supplemental amount of propofol administered, as well as recovery time. Results The mean supplemental propofol for group L + P and group NS + P- 37.00 ± 29.93 and 58.67 ± 19.49 mg, respectively and mean total propofol consumption was 98.22 ± 34.00 mg and 131.11 ± 23.18 mg, respectively, (p < 0.001). Mean recovery time in group L + P was also shorter (5.22 ± 2.14 versus 9.96 ± 2.14). The incidence of adverse events like gag reflux, upper airway obstruction, pain on injection, and hypotension was significantly lower in group L + P (p < 0.05). Conclusion The addition of lignocaine to propofol-based sedation reduced the overall propofol requirement at the same time maintaining hemodynamic stability, spontaneous respiration, and early recovery.
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Bruneau A, Carrié S, Moscaritolo L, Ingelmo P. Mechanism-Based Pharmacological Treatment for Chronic Non-cancer Pain in Adolescents: Current Approaches and Future Directions. Paediatr Drugs 2022; 24:573-583. [PMID: 36053398 DOI: 10.1007/s40272-022-00534-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/22/2022] [Indexed: 11/26/2022]
Abstract
Chronic non-cancer pain in pediatrics is a widespread phenomenon that affects about 20% of adolescents (10-19 years old). Although interdisciplinary pain treatment programs, which often include pharmacological treatment, have emerged as the standard of care in management of this patient population, evidence regarding an optimal treatment is lacking. The efficacy and safety profiles of pharmacological treatments used to help adolescents suffering from chronic non-cancer pain remain understudied. This lack of evidence may increase polypharmacy and the risk of drug interactions and adverse events. This review examines evidence for the use of pharmacological treatments prescribed to treat chronic pain in adolescents (10-19 years old), with a focus on mechanism-based pharmacology. The objectives of this review are to: (a) review the evidence for mechanism-based pharmacological treatments for chronic non-cancer pain in adolescents and (b) describe the pharmacological agents that are commonly prescribed to manage chronic pain in adolescents, including dosage information, mechanism, and potential adverse effects. Pharmacological treatments should be used carefully with adolescents, ideally within an interdisciplinary treatment program that will incorporate physical rehabilitation, integrative medicine/active mind-body techniques, psychology, and global efforts to normalize daily activities.
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Affiliation(s)
- Alice Bruneau
- Faculty of Medicine, McGill University, Montreal, QC, H3A 0C7, Canada.
| | - Sabrina Carrié
- Edwards Family Interdisciplinary Center for Complex Pain, Montreal Children's Hospital, Montreal, QC, Canada
- Department of Anaesthesia, McGill University, Montreal, QC, Canada
| | - Lorenzo Moscaritolo
- Edwards Family Interdisciplinary Center for Complex Pain, Montreal Children's Hospital, Montreal, QC, Canada
- Department of Anaesthesia, McGill University, Montreal, QC, Canada
| | - Pablo Ingelmo
- Edwards Family Interdisciplinary Center for Complex Pain, Montreal Children's Hospital, Montreal, QC, Canada
- Department of Anaesthesia, McGill University, Montreal, QC, Canada
- Alan Edward Centre for Research on Pain, Montreal, QC, Canada
- Research Institute, McGill University Health Center, Montreal, QC, Canada
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Buren MA, Theologis A, Zuraek A, Behrends M, Clark AJ, Leung JM. Lidocaine Infusion for the Management of Postoperative Pain and Delirium (LIMPP): protocol for a randomised control trial. BMJ Open 2022; 12:e059416. [PMID: 35667730 PMCID: PMC9171272 DOI: 10.1136/bmjopen-2021-059416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 04/06/2022] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Postoperative delirium is a frequent adverse event following elective non-cardiac surgery. The occurrence of delirium increases the risk of functional impairment, placement to facilities other than home after discharge, cognitive impairment at discharge, as well as in-hospital and possibly long-term mortality. Unfortunately, there is a dearth of effective strategies to minimise the risk from modifiable risk factors, including postoperative pain control and the analgesic regimen. Use of potent opioids, currently the backbone of postoperative pain control, alters cognition and has been associated with an increased risk of postoperative delirium. Literature supports the intraoperative use of lidocaine infusions to decrease postoperative opioid requirements, however, whether the use of postoperative lidocaine infusions is associated with lower opioid requirements and subsequently a reduction in postoperative delirium has not been investigated. METHODS AND ANALYSIS The Lidocaine Infusion for the Management of Postoperative Pain and Delirium trial is a randomised, double-blinded study of a postoperative 48-hour infusion of lidocaine at 1.33 mg/kg/hour versus placebo in older patients undergoing major reconstructive spinal surgery at the University of California, San Francisco. Our primary outcome is incident delirium measured daily by the Confusion Assessment Method in the first three postoperative days. Secondary outcomes include delirium severity, changes in cognition, pain scores, opioid use, incidence of opioid related side effects and functional benefits including time to discharge and improved recovery from surgery. Lidocaine safety will be assessed with daily screening questionnaires and lidocaine plasma levels. ETHICS AND DISSEMINATION This study protocol has been approved by the ethics board at the University of California, San Francisco. The results of this study will be published in a peer-review journal and presented at national conferences as poster or oral presentations. Participants wishing to know the results of this study will be contacted directly on data publication. TRIAL REGISTRATION NUMBER NCT05010148.
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Affiliation(s)
- Marc Alan Buren
- Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, USA
| | - Alekos Theologis
- Orthopedic Surgery, University of California San Francisco, San Francisco, California, USA
| | - Ariadne Zuraek
- Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, USA
| | - Matthias Behrends
- Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, USA
| | - Aaron J Clark
- Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Jacqueline M Leung
- Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, USA
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Moon T, Oh M, Chen J. Patients with sleep-disordered breathing for bariatric surgery. Saudi J Anaesth 2022; 16:299-305. [PMID: 35898522 PMCID: PMC9311179 DOI: 10.4103/sja.sja_300_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Accepted: 04/10/2022] [Indexed: 11/04/2022] Open
Abstract
The prevalence of patients with obesity continues to rise worldwide and has reached epidemic proportions. There is a strong correlation between obesity and sleep-disordered breathing (SDB), and, in particular, obstructive sleep apnea (OSA). OSA is often undiagnosed in the surgical population. Bariatric surgery has been recognized as an effective treatment option for both obesity and OSA. Laparoscopic bariatric procedures, particularly laparoscopic sleeve gastrectomy (LSG), have become the most frequently performed procedures. OSA has been identified as an independent risk factor for perioperative complications and failure to recognize and prepare for patients with OSA is a major cause of postoperative adverse events, suggesting that all patients undergoing bariatric surgery should be screened preoperatively for OSA. These patients should be treated with an opioid-sparing analgesic plan and continuous positive airway pressure (CPAP) perioperatively to minimize respiratory complications. With the number of bariatric surgical patients with SDB likely to continue rising, it is critical to understand the best practices to manage this patient population.
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Affiliation(s)
- Naveen Eipe
- Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, Ontario, Canada,
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Weinberg GL. Perioperative Lidocaine Infusion: Does the Risk Outweigh the Benefit? Anesth Analg 2021; 132:906-909. [PMID: 33438966 DOI: 10.1213/ane.0000000000005322] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Guy L Weinberg
- From the Department of Anesthesiology, University of Illinois at Chicago, Chicago, Illinois
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Toner AJ, Bailey MA, Schug SA, Corcoran TB. A pilot multicentre randomised controlled trial of lidocaine infusion in women undergoing breast cancer surgery. Anaesthesia 2021; 76:1326-1341. [PMID: 33651896 DOI: 10.1111/anae.15440] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/21/2021] [Indexed: 12/01/2022]
Abstract
Chronic postoperative pain is common after breast cancer surgery. Peri-operative lidocaine infusion may prevent the development of chronic postoperative pain, but a large-scale trial is required to test this hypothesis. It is unclear whether a pragmatic, multicentre trial design that is consistent with expert guidance, addresses the limitations of previous studies, and overcomes existing translational barriers is safe, effective and feasible. We conducted a double-blind, randomised controlled pilot study in 150 patients undergoing breast cancer surgery across three hospitals in Western Australia. Patients received lidocaine, or equivalent volumes of saline, as an intravenous bolus (1.5 mg.kg-1 ) and infusion (2 mg.kg-1 .h-1 ) intra-operatively, and a subcutaneous infusion (1.33 mg.kg-1 .h-1 ) postoperatively for up to 12 h on a standard surgical ward, with novel safety monitoring tools in place. The co-primary outcomes were: in-hospital safety events; serum levels of lidocaine during intravenous and subcutaneous infusion; and annualised enrolment rates per site with long-term data capture. In-hospital safety events were rare, and similar in the placebo and lidocaine arms (3% vs. 1%). Median (IQR [range]) serum lidocaine levels during intravenous (2.16 (1.74-2.83 [1.12-6.06]) µg.ml-1 , n = 41) and subcutaneous (1.52 (1.28-1.83 [0.64-2.85]) µg.ml-1 , n = 48) infusion were comparable with previous trials reporting improved pain outcomes. Annualised enrolment approximated 50 patients per site per year, with high levels of protocol adherence and ≥ 99% capture of outcomes at 3 and 6 months. The adjusted odds ratio (95%CI) for postoperative pain at 6 months in the lidocaine arm was 0.790 (0.370-1.684). We conclude that this trial, as designed, is safe, effective and feasible in patients undergoing breast cancer surgery, and a larger-scale trial is planned.
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Affiliation(s)
- A J Toner
- Department of Anaesthesia and Pain Medicine, Royal Perth Hospital, Perth, Australia
| | - M A Bailey
- Department of Anaesthesia and Intensive Care Medicine, Taranaki Base Hospital, New Plymouth, New Zealand
| | - S A Schug
- Department of Anaesthesia and Pain Medicine, Royal Perth Hospital, Perth, Australia
| | - T B Corcoran
- Department of Anaesthesia and Pain Medicine, Royal Perth Hospital, Perth, Australia
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Foo I, Macfarlane AJR, Srivastava D, Bhaskar A, Barker H, Knaggs R, Eipe N, Smith AF. The use of intravenous lidocaine for postoperative pain and recovery: international consensus statement on efficacy and safety. Anaesthesia 2020; 76:238-250. [PMID: 33141959 DOI: 10.1111/anae.15270] [Citation(s) in RCA: 91] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/14/2020] [Indexed: 12/15/2022]
Abstract
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.
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Affiliation(s)
- I Foo
- Western General Infirmary, Edinburgh, UK
| | | | | | - A Bhaskar
- Imperial College Healthcare NHS Trust, London, UK
| | - H Barker
- Ashford and St Peter's Hospitals NHS Foundation Trust, Chertsey, UK
| | - R Knaggs
- University of Nottingham, Nottingham, UK
| | - N Eipe
- Ottowa Hospital, Ottowa, Canada
| | - A F Smith
- Royal Lancaster Infirmary, Lancaster, UK
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