American Society of Regional Anesthesia and Pain Medicine May 2017 - 24
Figure 1: Colorectal ERAS protocol.
in genitourinary, breast surgery, thoracic surgery, and spine
surgery.4,8-10 We do not recommend perioperative lidocaine infusion
for cardiac surgery, obstetrics, or hip surgery. This conclusion is
based on the inability of the corresponding studies to demonstrate
significantly different outcome measures when compared to nonlidocaine groups.11-13
There are few studies published regarding postoperative
lidocaine infusion. At our institution, we retrospectively compared
postoperative lidocaine infusion to epidural analgesia with
bupivacaine and hydromorphone up to postoperative day (POD) 6
in 216 patients (108 in each group) undergoing major abdominal
surgery. Lidocaine was associated with fewer episodes of
postoperative hypotension, nausea, vomiting, pruritus, and urinary
retention and earlier removal of the urinary catheter after surgery.14
Interestingly, the lidocaine group had higher IV and PO opioid
consumption (determined by equianalgesic doses of IV morphine).
We did not observe a significant difference in pain scores after
POD 2. Another retrospective study in our institution compared 52
patients receiving IV lidocaine as part of the colorectal ERAS protocol
(Figure 1) to 52 patients who received standard intraoperative and
postoperative lidocaine infusion (see below for dosing) undergoing
colorectal surgery (B. Naik, personal communication, October 19,
2016). The ERAS group had lower opioid consumption on POD 1;
however, the analysis of POD 1 pain scores was inconclusive. On
24
2
POD 2 and beyond, lidocaine alone was non-inferior to lidocaine
given as part of the ERAS protocol in terms of postoperative pain.
The ERAS group demonstrated decreased time to ambulation and
discharge, as well as urinary catheter removal.
SAFETY/SIDE EFFECTS
The safety profile of IV lidocaine has been previously described.2-4,7,15
Mild side effects, including dizziness and visual disturbances, have
been described in some meta-analyses.5,10 Serious side effects,
such as neurologic changes and cardiac toxicity, are exceedingly
rare.2,5,15 Anecdotally, some practitioners report delayed emergence
among patients receiving lidocaine infusion. However, to date, no
association has been demonstrated between perioperative lidocaine
infusion and delayed postoperative care unit (PACU) discharges.16
Blunting of airway reactivity to the endotracheal tube might be an
explanation for the perceived delayed emergence.
DOSING
Evidence regarding the optimal dose for IV lidocaine is lacking.
Doses that produce serum lidocaine concentrations equivalent
to epidural lidocaine infusion (approximately 1 micromolar) have
been associated with decreased pain, nausea, opioid requirement,
and shorter duration of ileus and length of stay after abdominal
surgery.5,17 Bolus doses of 0.5 to 1.5 mg/kg followed by 1.5 to 3
mg/kg/hr infusion resulted in decreased postoperative VAS pain
American Society of Regional Anesthesia and Pain Medicine
2017
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