Intravenous lidocaine is widely used for its effect on postoperative pain and recovery. In addition, concern about opioid risks in the postoperative period has galvanized the use of nonopioid analgesic adjuncts.1 However, if used inappropriately and incorrectly, intravenous lidocaine can have fatal consequences – therefore, it is extremely important to administer intravenous (IV) lidocaine for surgical pain according to a careful, well-informed protocol.
The decision to administer intravenous lidocaine or not depends on the type of surgery and individual patient factors, including but not limited to the presence of any existing condition that affects pain management and risk (such as pre-existing chronic pain). This decision mainly focuses on three priorities. First, is intravenous lidocaine safe? Second, does intravenous lidocaine effectively reduce postoperative pain and speed up recovery? Third, how is intravenous lidocaine licensed for use?2
In general, while perioperative IV lidocaine infusion is indeed effective at reducing pain, evidence supporting its use varies according to the surgical procedure. However, the benefits of intravenous lidocaine are clear in certain clinical contexts. For example, it prevents airway reactivity on emergence in smokers and quenches cerebral hemodynamic responses to airway manipulation.3 It may also reduce anesthetic requirements by approximately one-third in specific situations.4 It may further reduce neuropathic pain by inhibiting the activity of injured afferent nerves.5 Finally, following laparoscopic nephrectomy, it can reduce the need for postoperative morphine, ameliorating postoperative pain management and recovery.6
In general, notable guidelines have been developed to ensure the appropriateness, safety and efficacy of intravenous lidocaine for surgical pain.
First and foremost, the use of IV lidocaine for acute surgical pain should be approved by the local hospital and medication governance committee or equivalent. When possible, consent should also be obtained by patients.
As regards its administration, certain researchers recommend an initial dose not exceeding 1.5 mg/kg, calculated using the patient’s ideal body weight and provided as an infusion over 10 minutes. Thereafter, researchers recommend an infusion not exceeding 1.5 mg/kg/h for no more than 24 hours, subject to re-assessment.
Furthermore, intravenous lidocaine should not be used in conjunction with any other local anesthetic interventions. Therefore, intravenous lidocaine should not be administered within 4 hours of any nerve block. Conversely, no nerve block should be performed within 4 hours of discontinuing an intravenous lidocaine infusion.
Outside the operating theater and recovery room, patients receiving intravenous lidocaine should be monitored to quickly address complications, if any arise. Particular attention should be paid to patients who have an existing comorbidity.2
In the end, however, the approach selected for the use of intravenous lidocaine should be approved by hospital health governance systems, and the individual clinical decision should be carried out following properly informed consent on behalf of the patient.
In conclusion, IV lidocaine may be a key pillar of a pain management strategy for surgical pain. However, it needs to be very carefully delivered. In the meantime, additional research in the form of further randomized control trials with a large sample size7 is warranted in order to corroborate and specify current protocols.
References
1. Dunn, L. K. & Durieux, M. E. Perioperative Use of Intravenous Lidocaine. Anesthesiology (2017). doi:10.1097/ALN.0000000000001527
2. Foo, I. et al. The use of intravenous lidocaine for postoperative pain and recovery: international consensus statement on efficacy and safety. Anaesthesia (2021). doi:10.1111/anae.15270
3. Hamill, J. F., Bedford, R. F., Weaver, D. C. & Colohan, A. R. Lidocaine before endotracheal intubation: Intravenous or laryngotracheal? Anesthesiology (1981). doi:10.1097/00000542-198111000-00016
4. Kaba, A. et al. Intravenous lidocaine infusion facilitates acute rehabilitation after laparoscopic colectomy. Anesthesiology (2007). doi:10.1097/00000542-200701000-00007
5. Kirillova, I. et al. Effect of local and intravenous lidocaine on ongoing activity in injured afferent nerve fibers. Pain (2011). doi:10.1016/j.pain.2011.02.046
6. Tauzin-Fin, P. et al. Benefits of intravenous lidocaine on post-operative pain and acute rehabilitation after laparoscopic nephrectomy. J. Anaesthesiol. Clin. Pharmacol. (2014). doi:10.4103/0970-9185.137269
7. Yue, H., Zhou, M., Lu, Y., Chen, L. & Cui, W. Effect of intravenous lidocaine on postoperative pain in patients undergoing intraspinal tumor resection: Study protocol for a prospective randomized controlled trial. J. Pain Res. (2020). doi:10.2147/JPR.S249359