Effect of intravenous lidocaine on outcomes in patients receiving propofol for gastrointestinal endoscopic procedures: an updated systematic review and meta-analysis

BACKGROUND

Gastrointestinal endoscopic procedures (GEPs) are frequently employed for the diagnosis and treatment of various gastrointestinal ailments. While propofol sedation is widely used during these procedures, there is a concern regarding its potential negative effects. Intravenous (IV) lidocaine has been suggested as an add-on to propofol sedation for GEPs, but current evidence on its efficiency and safety is limited. This systematic review and meta-analysis aimed to assess the impact of IV lidocaine on outcomes in patients receiving propofol during GEPs.

METHODS

Electronic databases were screened for randomized controlled trials (RCTs), published up to 31 March 2023, investigating the effectiveness of intravenous lidocaine addition to propofol sedation during GEPs.

RESULTS

A total of 12 RCTs involving 712 patients that received IV lidocaine and propofol for GEF and 719 patients that received propofol were analyzed. Adding IV lidocaine to propofol sedation led to significant reduction in pain after the procedure (standardized mean difference (SMD) =  - 0.91, 95% confidence interval [CI]; - 1.51 to - 0.32), decreased propofol usage (SMD =  - 0.89; 95% CI, - 1.31 to - 0.48), lower recovery time (SMD =  - 0.95 min; 95% CI, - 1.48 to - 0.43), and decreased pain score (SMD =  - 0.91; 95% CI, - 1.51 to - 0.32). The overall rate of adverse events was markedly less in the lidocaine group than in the control group (RR = 0.74; 95% CI, 0.56 to 0.99).

CONCLUSION

Our results show that IV lidocaine improves patient outcomes by reducing post-procedural pain, decreasing propofol usage, shortening recovery time, and lowering pain scores. This study provides compelling evidence supporting the use of intravenous lidocaine as an adjunct to propofol sedation for gastrointestinal endoscopic procedures. However, further research is necessary to optimize the use of lidocaine and fully understand its long-term effects.

Postoperative use and early discontinuation of intravenous lidocaine in spine patients

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Effect of intravenous lidocaine on propofol consumption in elderly patients undergoing colonoscopy: a double-blinded, randomized, controlled trial

BACKGROUND

Elderly patients undergoing colonoscopy with propofol as sedation are prone to respiratory or cardiovascular complications. Intravenous lidocaine has analgesic efficacy and reduces propofol consumption during surgery. Here, the effect of intravenous lidocaine on propofol consumption was evaluated in elderly patients undergoing colonoscopy.

METHODS

Patients were randomly allocated to receive intravenous lidocaine (1.5 mg/kg bolus dose, followed by a 2 mg/kg/h continuous infusion during the procedure; Group L) or a placebo (saline; Group N). During the procedure, sedation was achieved by propofol. The following outcomes were recorded: total propofol consumption; time to loss of consciousness; number of airway modifications; time to the first airway intervention; incidence of sedation-related events; pain score after awakening; endoscopists' and patients' satisfaction scores; memory level of the procedure; and adverse events within 24 h postoperatively.

RESULTS

Compared with Group N, propofol consumption was reduced by 13.2% in Group L (100.30 ± 25.29 mg vs. 115.58 ± 27.52 mg, respectively, p = 0.008). Kaplan-Meier curves showed that the median time to the loss of consciousness episode was shorter in Group L than in Group N (40 s vs. 55 s, respectively, log rank p < 0.0001). The number of airway modifications, time to the first airway intervention, incidence of sedation-related events, time to awakening, pain score after awakening, endoscopists' and patients' satisfaction scores, memory level of the procedure and adverse events within 24 h postoperatively did not differ between the two groups (p > 0.05).

CONCLUSIONS

Intravenous lidocaine can reduce propofol consumption in elderly patients undergoing colonoscopy, with quicker time to loss of consciousness.

TRIAL REGISTRATION

The clinical trial was registered at (12/01/2021, ChiCTR2100042001 ).

The ALLEGRO trial: a placebo controlled randomised trial of intravenous lidocaine in accelerating gastrointestinal recovery after colorectal surgery

Background

Return of gastrointestinal (GI) function is fundamental to patient recovery after colorectal surgery and is required before patients can be discharged from hospital safely. Up to 40% of patients suffer delayed return of GI function after colorectal surgery, causing nausea, vomiting and abdominal discomfort, resulting in longer hospital stay. Small, randomised studies have suggested perioperative intravenous (IV) lidocaine, which has analgesic and anti-inflammatory effects, may accelerate return of GI function after colorectal surgery. The ALLEGRO trial is a pragmatic effectiveness study to assess the benefit of perioperative IV lidocaine in improving return of GI function after elective minimally invasive (laparoscopic or robotic) colorectal surgery.

Methods

United Kingdom (UK) multi-centre double blind placebo-controlled randomised controlled trial in 562 patients undergoing elective minimally invasive colorectal resection. IV lidocaine or placebo will be infused for 6–12 h commencing at the start of surgery as an adjunct to usual analgesic/anaesthetic technique. The primary outcome will be return of GI function.

Discussion

A 6–12-h perioperative intravenous infusion of 2% lidocaine is a cheap addition to usual anaesthetic/analgesic practice in elective colorectal surgery with a low incidence of adverse side-effects. If successful in achieving quicker return of gut function for more patients, it would reduce the rate of postoperative ileus and reduce the duration of inpatient recovery, resulting in reduced pain and discomfort with faster recovery and discharge from hospital. Since colorectal surgery is a common procedure undertaken in every acute hospital in the UK, a reduced length of stay and reduced rate of postoperative ileus would accrue significant cost savings for the National Health Service (NHS).

Trial registration

EudraCT Number 2017-003835-12; REC Number 17/WS/0210 the trial was prospectively registered (ISRCTN Number: ISRCTN52352431); date of registration 13 June 2018; date of enrolment of first participant 14 August 2018.

NSAIDs for migraine attack in the ED: a prospective, randomized, double-blind study

PURPOSE

Although different forms of lidocaine are used for migraine attack headaches, the effect of intravenous lidocaine is still limited. This study aimed to investigate the effects of intravenous lidocaine infusion for the treatment of migraine attack headaches.

METHODS

A hundred patients with migraine attacks, aged between 18 and 65, were randomly divided into two groups. The lidocaine group (n = 50) received a 1.5 mg/kg lidocaine bolus and a 1 mg/kg infusion (first 30 min), followed by a 0.5 mg/kg infusion for a further 30 min intravenously. The non-steroidal anti-inflammatory drug (NSAID) group (n = 50) received 50 mg dexketoprofen trometamol and saline at the same volume as the lidocaine at the same time intervals intravenously. The Visual Analog Scale (VAS) pain scores, additional analgesia requirement, side effects, and revisits to the emergency department were recorded.

RESULTS

The VAS score was significantly lower in the lidocaine group than in the NSAID group for the first 20th and 30th minutes (p = 0.014 and p = 0.024, respectively). There was no difference between the VAS scores for the remaining evaluation times (p > 0.05). In terms of secondary outcomes, rescue medication requirement was not different between the two groups at both the 60th and 90th minutes (p > 0.05). However, the number of patients revisiting ED within 48-72 h was statistically less in the lidocaine group than in the NSAID group (1/50 vs. 8/50; p = 0.031).

CONCLUSION

Intravenous lidocaine may be an alternative treatment method for patients with migraine attack headaches in the emergency department.

Pre-procedure intravenous lidocaine administration on propofol consumption for endoscopic retrograde cholangiopancreatography: A prospective, randomized, double-blind study

BACKGROUND AND AIM

The endoscopic retrograde cholangiopancreatography (ERCP) procedure is generally performed in patients with high comorbidity. We aimed to reduce the consumption of propofol by adding lidocaine before ERCP.

METHODS

Eighty ERCP patients with ASA I-III, aged between 45-75 years, were randomly divided into two groups. Lidocaine group (group L, n = 40), received 1-mg midazolam, 1.5 mg/kg lidocaine, and 1 mg/kg propofol intravenously. The control group (group C, n = 40) received 1-mg midazolam, saline in the same volume as the lidocaine group, and 1 mg/kg propofol intravenously. Propofol was administered with intermittent bolus doses. Propofol consumption, oropharyngeal reflex, recovery time, endoscopist satisfaction, ketamine need, and side-effects were recorded.

RESULTS

Propofol consumption during the procedure was statistically lower in group L than in the control group (157.25 ± 39.16 mg vs 228.75 ± 64.62 mg respectively, P < 0.001). Additionally, recovery time was statistically faster in group L compared with the control group (7.78 ± 3.95 min vs 11.92 ± 3.24 min respectively, P < 0.001). The oropharyngeal reflex was less in group L than control group (6/40 vs 15/40 respectively, P = 0.042). There was no significant difference between the two groups regarding visual analogue scale scores and endoscopist satisfaction (P > 0.05).

CONCLUSIONS

We recommend the use of intravenous lidocaine before the ERCP procedure as it reduces propofol consumption, recovery times, and oropharyngeal reflex.

Meta-analysis of the effect of perioperative intravenous lidocaine on return of gastrointestinal function after colorectal surgery

BACKGROUND

Return of normal gastrointestinal (GI) function is a critical determinant of recovery after colorectal surgery. The aim of this meta-analysis was to evaluate whether perioperative intravenous (IV) lidocaine benefits return of gastrointestinal function after colorectal resection.

METHODS

A comprehensive search of Ovid Medline, PubMed, Embase, Cochrane library, and clinicaltrials.org was performed on 1st July 2018. A manual search of reference lists was also performed. Inclusion criteria were as follows: randomized controlled trials (RCTs) of intravenous (IV) lidocaine administered perioperatively compared to placebo (0.9% saline infusion) as part of a multimodal perioperative analgesic regimen, human adults (> 16 years), and open or laparoscopic colorectal resectional surgery.

EXCLUSION CRITERIA

non-colorectal surgery, non-placebo comparator, children, non-general anaesthetic, and pharmacokinetic studies. The primary endpoint was time to first bowel movement. Secondary endpoints were time to first passage of flatus, time to toleration of diet, nausea and vomiting, ileus, pain scores, opioid analgesia consumption, and length of stay.

RESULTS

One hundred and ninety one studies were screened, with 9 RCTs meeting inclusion criteria (405 patients, four laparoscopic and five open surgery studies). IV lidocaine reduced time to first bowel movement compared to placebo [seven studies, 325 patients, mean weighted difference - 9.54 h, 95% CI 18.72-0.36, p = 0.04]. Ileus, pain scores, and length of stay were reduced with IV lidocaine compared with placebo.

CONCLUSIONS

Perioperative IV lidocaine may improve recovery of gastrointestinal function after colorectal surgery. Large-scale effectiveness studies to measure effect size and evaluate optimum dose/duration are warranted.

Intravenous lidocaine infusion

Systemic lidocaine used in continuous infusion during the peri-operative period has analgesic, anti-hyperalgesic, as well as anti-inflammatory properties. This makes it capable of reducing the use of opioids and inhalational anaesthetics, and the early return of bowel function, and patient hospital stay. The aim of this narrative review was to highlight the pharmacology and indications for clinical application, along with new and interesting research areas. The clinical applications of peri-operative lidocaine infusion have been reviewed in several recent systematic reviews and meta-analyses in patients undergoing open and laparoscopic abdominal procedures, ambulatory procedures, and other types of surgery. Peri-operative lidocaine infusion may be a useful analgesic adjunct in enhanced recovery protocols. Potential benefits of intravenous lidocaine in chronic post-surgical pain, post-operative cognitive dysfunction, and cancer recurrence are under investigation. Due to its immunomodulation properties over surgical stress, current evidence suggests that intravenous lidocaine could be used in the context of multimodal analgesia.

Effect of perioperative intravenous lidocaine infusion on postoperative recovery following laparoscopic Cholecystectomy-A randomized controlled trial

BACKGROUND AND OBJECTIVE

Intravenous lidocaine infusion has been shown to facilitate postoperative recovery after major abdominal surgery. The current randomized controlled study was performed to assess the effect of perioperative intravenous lidocaine infusion on pain intensity, bowel function and cytokine response after larparoscopic cholecystectomy.

METHODS

Eighty patients undergoing laparoscopic cholecystectomy were randomly allocated to receive intravenous lidocaine (bolus injection of 1.5 mg/kg lidocaine at induction of anesthesia, then a continuous infusion of 2 mg/kg/h until the end of surgery) or an equal volume of saline. Patients, anesthesiologists, and study personnel were blinded, and anesthesia and multimodal perioperative analgesia were standardized. Blood cytokines were measured at scheduled times within 48 h. Pain scores, opioid consumption, time to first flatus and time to first bowel movement were also measured after surgery.

RESULTS

Seventy-one of the 80 patients who were recruited completed the study protocol. Patient demographics were similar in the two groups. Lidocaine significantly reduced pain intensity [visual analogue scale (VAS), 0-10 cm] at 2 h (lidocaine 3.01 ± 0.65 cm vs. placebo 4.27 ± 0.58 cm, p = 0.01) and 6 h (lidocaine 3.38 ± 0.42 cm vs. placebo 4.22 ± 0.67 cm, p = 0.01) and total fentanyl consumption 24 h after surgery (lidocaine 98.27 ± 16.33 μg vs. placebo 187.49 ± 19.76 μg, p = 0.005). Time to first flatus passage (lidocaine 20 ± 11 h vs. placebo 29 ± 10 h, p = 0.01) and time to first bowel movement (lidocaine 41 ± 16 h vs. placebo 57 ± 14 h, p = 0.01) were also significantly shorter in patients who received lidocaine. Intravenous lidocaine infusion experienced less cytokine release than the control group.

CONCLUSIONS

This study indicates that perioperative systemic lidocaine improves postoperative recovery and attenuates the initiation of excessive inflammatory response following laparoscopic cholecystectomy.

Autonomic hyperreflexia after spinal cord injury managed successfully with intravenous lidocaine: a case report

Background

Some paraplegic patients may wish undergo some surgical procedures, like urological procedures, without anesthesia. However, these patients can develop autonomic hyperreflexia if cystoscopy is performed without anesthesia.

Case presentation

We present a case of severe autonomic hyperreflexia in a 44-year-old male with spinal cord injury at the level of T4 during urologic procedure under sedation and analgesia successfully treated with intravenous lidocaine.

Conclusions

This case illustrates that patients with spinal cord injuries are likely to develop autonomic hyperreflexia during urological procedures performed without anesthesia. Health professionals should educate spinal cord injury patients regarding risks of this serious condition and be aware to prevent and manage autonomic hyperreflexia. In an acute episode, nifedipine, nitrates and captopril are the most commonly used and recommended agents. To our knowledge, this is the first case report of severe autonomic hyperreflexia treated successfully with intravenous lidocaine.

Intravenous lidocaine for postmastectomy pain treatment: randomized, blind, placebo controlled clinical trial

BACKGROUND AND OBJECTIVE

Postoperative pain treatment in mastectomy remains a major challenge despite the multimodal approach. The aim of this study was to investigate the analgesic effect of intravenous lidocaine in patients undergoing mastectomy, as well as the postoperative consumption of opioids.

METHODS

After approval by the Human Research Ethics Committee of the Instituto de Medicina Integral Prof. Fernando Figueira in Recife, Pernambuco, a randomized, blind, controlled trial was conducted with intravenous lidocaine at a dose of 3mg/kg infused over 1h in 45 women undergoing mastectomy under general anesthesia. One patient from placebo group was.

RESULTS

Groups were similar in age, body mass index, type of surgery, and postoperative need for opioids. Two of 22 patients in lidocaine group and three of 22 patients in placebo group requested opioid (p=0.50). Pain on awakening was identified in 4/22 of lidocaine group and 5/22 of placebo group (p=0.50); in the post-anesthetic recovery room in 14/22 and 12/22 (p=0.37) of lidocaine and placebo groups, respectively. Pain evaluation 24h after surgery showed that 2/22 and 3/22 patients (p=0.50) of lidocaine and placebo groups, respectively, complained of pain.

CONCLUSION

Intravenous lidocaine at a dose of 3mg/kg administered over a period of an hour during mastectomy did not promote additional analgesia compared to placebo in the first 24h, and has not decreased opioid consumption. However, a beneficial effect of intravenous lidocaine in selected and/or other therapeutic regimens patients cannot be ruled out.

Effect of intraoperative lidocaine on anesthetic consumption, and bowel function, pain intensity, analgesic consumption and hospital stay after breast surgery

Background

Perioperative lidocaine infusion improves postoperative outcomes, mostly after abdominal and urologic surgeries. Knowledge of the effect of lidocaine on peripheral surgeries is limited. Presently, we investigated whether intraoperative lidocaine infusion reduced anesthetic consumption, duration of ileus, pain intensity, analgesic consumption and hospital stay after breast plastic surgeries.

Methods

Sixty female patients, aged 20-60 years, enrolled in this prospective study were randomly and equally divided to two groups. One group (n = 30) received a 1.5 mg/kg bolus of lidocaine approximately 30 min before incision followed by continuous infusion of lidocaine (1.5 mg/kg/h) until skin closure (lidocaine group). The other group (n = 30) was untreated (control group). Balanced inhalation (sevoflurane) anesthesia and multimodal postoperative analgesia were standardized. End tidal sevoflurane concentration during surgery, time to the first flatus and defecation, visual analog pain scale (0-10), analgesic consumption and associated side effects at 24, 48, and 72 h after surgery, hospital stay, and patient's general satisfaction were assessed.

Results

Compared to the control group, intraoperative lidocaine infusion reduced by 5% the amount of sevoflurane required at similar bispectral index (P = 0.014). However, there were no significant effects of lidocaine regarding the return of bowel function, postoperative pain intensity, analgesic sparing and side effects at all time points, hospital stay, and level of patient's satisfaction for pain control.

Conclusions

Low dose intraoperative lidocaine infusion offered no beneficial effects on return of bowel function, opioid sparing, pain intensity and hospital stay after various breast plastic surgeries.