American Society of Regional Anesthesia and Pain Medicine May 2017 - 25

Figure 2: Indications and contraindications of lidocaine infusion.

Used with permission from University of Virginia Department of
Anesthesiology and Acute Pain Medicine.

scores and cumulative opioid consumption in several clinical trials.
Infusion rates of 2 mg/kg/hr or higher are associated with lower
pain scores and opioid consumption when compared to lower
doses.2,3,8 In our institution, an infusion rate of 40 mcg/kg/min after
1-1.5 mg/kg bolus is used perioperatively as part of our ERAS
protocols. The infusion rate is decreased to 5-10 mcg/kg/min at
the end of the surgery and continues at the same rate until POD 2.
Our acute pain management lidocaine infusion protocol uses a 0.5
mg/min starting dose with a maximum of 1 mg/min for adults, and
doses between 15 to 25 mcg/kg/min for pediatric patients <40 kg.
APPROVAL AND DEVELOPMENT OF THE ACUTE PAIN MANAGEMENT
LIDOCAINE INFUSION PROTOCOL AT THE UNIVERSITY OF VIRGINIA
It is well known that factors such as postoperative pain, ileus,
nausea, and vomiting contribute to prolonged hospital stay and
increased cost.2,8 These realities have allowed our anesthesiology
and acute pain attendings to present IV lidocaine as a relatively
safe intervention aimed to improve such outcomes. IV lidocaine is
now routinely used for analgesia in acute pain management and
ERAS protocols at our institution. This protocol was established
through the interdisciplinary efforts of members of the anesthesia,
surgery, and nursing staff. Since the approval of the protocol,
several quality improvement projects and publications by our
department have strengthened the advocacy for the use of lidocaine
in the perioperative/acute pain settings.

chronic pain, etc.). Lidocaine infusion can be and is often used
in conjunction with lumbar and thoracic epidurals in both ERAS
and non-ERAS patients, as long as the epidural infusion does
not contain local anesthetic. Figure 2 presents the indications
and contraindications for IV lidocaine. APS rounds daily on these
patients, and patients are monitored for signs of lidocaine toxicity
(Figure 3). Recommendations regarding dosing of the lidocaine
infusion, as well as the multimodal pain regimen, are made during
rounds. There are specific instructions for nurses to monitor for
signs of toxicity while caring for patients receiving lidocaine
infusions. Other than mentioned, we do not require additional
physiologic monitoring other than unit protocol (ie, patients do not
require a monitored bed to be on lidocaine infusion). A member
of the APS team is available for nursing staff to contact with any
questions or concerns. We have had no adverse events related to
lidocaine infusion at the doses recommended in our protocol.
Our APS team takes an active role in nursing engagement (see
"Acknowledgement") by including nurses in the daily rounds
on patients receiving IV lidocaine. This allows communication
between APS and the nursing staff, which has been important to
the successful launch of the University of Virginia's acute pain
lidocaine infusion protocol as well as its implementation in our
ERAS protocols.
FINAL WORD
There are several limitations to the studies supporting the use
of perioperative lidocaine infusion. These include a lack of large
double-blinded placebo-controlled trials, as well as limited data
regarding the optimal dosing and duration of treatment. According
to ClinicalTrails.gov, at this time, there are 48 open clinical

Figure 3: Lidocaine toxicity: signs and symptoms.

In our institution, intraoperative lidocaine infusion is routinely
used in open and laparoscopic abdominal surgery, urology, GYN,
spine, orthopedic, and thoracic surgery in both ERAS and nonERAS patients. The decision regarding continuing lidocaine infusion
postoperatively for non-ERAS patients is made after discussions
with the surgical team and the Acute Pain Service (APS). APS is
routinely consulted for the start of and management of lidocaine
infusions for postoperative and nonsurgical patients (trauma,

American Society of Regional Anesthesia and Pain Medicine
2017

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http://www.ClinicalTrails.gov

Table of Contents for the Digital Edition of American Society of Regional Anesthesia and Pain Medicine May 2017