Effects of Intravenous Infusion of Lidocaine on Short-Term Outcomes and Survival in Patients Undergoing Surgery for Ovarian Cancer: A Retrospective Propensity Score Matching Study

BackgroundIntravenous lidocaine has been shown to reduce opioid consumption and is associated with favourable outcomes after surgery. In this study, we explored whether intraoperative lidocaine reduces intraoperative opioid use and length of stay (LOS) and improves long-term survival after primary debulking surgery for ovarian cancer and explored the correlation between SCN9A expression and ovarian cancer prognosis.MethodsThis retrospective study included patients who underwent primary debulking surgery(PDS) for ovarian cancer from January 2015 to December 2018. The patients were divided into non-lidocaine and lidocaine [bolus injection of 1.5 mg/kg lidocaine at the induction of anaesthesia followed by a continuous infusion of 2 mg/(kg∙h) intraoperatively] groups. Intraoperative opioid consumption, the verbal numeric rating scale (VNRS) at rest and LOS were recorded. Propensity score matching was used to minimize bias, and disease-free survival (DFS) and overall survival (OS) were compared between the two groups.ResultsAfter propensity score matching(PSM), the demographics were not significantly different between the groups. The intraoperative sufentanil consumption in the lidocaine group was significantly lower than that in the non-lidocaine group (Mean: 35.6 μg vs. 43.2 μg, P=0.035). LOS was similar between the groups (12.0 days vs. 12.4 days, P=0.386). There was a significant difference in DFS between the groups (32.3% vs. 21.6%, P=0.015), and OS rates were significantly higher in the lidocaine group than in the non-lidocaine group (35.2% vs. 25.6%, P=0.042). Multivariate analysis indicated that intraoperative lidocaine infusion was associated with prolonged OS and DFS.ConclusionIntraoperative intravenous lidocaine infusion appears to be associated with improved OS and DFS in patients undergoing primary debulking surgery for ovarian cancer. Our study has the limitations of a retrospective review. Hence, our results should be confirmed by a prospective randomized controlled trial.

Use of intravenous lidocaine for dose reduction of propofol in paediatric colonoscopy patients: a randomised placebo-controlled study

Background Propofol, a widely used sedative in endoscopic procedures, sometimes causes cardiopulmonary complications. Intravenous lidocaine can diminish visceral pain and decrease the dose of propofol. The purpose of this study was to assess the efficacy and safety of intravenous lidocaine in reducing propofol dosage during paediatric colonoscopy. Methods Forty children who underwent colonoscopy were divided into two groups. Lidocaine hydrochloride (1.5 mg/kg induction and 2 mg/kg/h maintenance) was given intravenously to the lidocaine group, and the same amount of saline was given to the control group after they received lidocaine induction. Propofol initial plasma concentration of 5 μg/mL was targeted, and the procedure was performed after the bispectral index value reached 55. The primary outcome was propofol requirement. Results The propofol requirement in the lidocaine group was decreased by 35.5% (128.6 ± 30.4 mg vs. 199.4 ± 57.6 mg; p < 0.001; 95%CI: − 100.60, − 41.02). The incidence of involuntary body movements was significantly lower in the lidocaine group (p = 0.028; OR = 0.17; 95%CI: 0.03, 0.92). The awakening time (p < 0.001; 95%CI: − 7.67, − 5.13) and recovery times (p < 0.001; 95%CI: − 7.45, − 4.35) were significantly lower in the lidocaine group. Pain was significantly less at 30 min and 60 min after the procedure in the lidocaine group (0 [0–4] vs. 3 [0–5], p < 0. 001; 0 [0–2] vs. 1 [0–3], p = 0.001). There was no difference in the incidence of bradycardia, hypotension, or hypoxia between the two groups. Conclusions For colonoscopy procedures in paediatric patients, intravenous lidocaine reduces the amount of propofol needed, provides better sedation and postprocedural pain management, as well as a reduction in recovery time. Trial registration The trial was registered on November 6, 2020 at China Clinical Trials Registration Center (www.chictr.org.cn) ref.: ChiCTR 2,000,039,706.

Lidocaine infusions in chronic pain management: A prospective case series analysis

Chronic pain conditions are prevalent and cause a significant burden of disease. Intravenous lidocaine infusions have been reported to have an analgesic effect in patients with chronic neuropathic pain, but there is limited data supporting the efficacy of lidocaine across other chronic pain phenotypes. Our study aimed to evaluate the efficacy of a single infusion of intravenous lidocaine for pain relief and the impact on quality of life. We evaluated data from 74 patients with chronic pain who were treated with intravenous lidocaine at a specialist pain centre. Participants completed a questionnaire consisting of the Brief Pain Inventory (BPI) Short Form and additional EQ-5D quality of life metrics, before treatment and at follow-up. Data comparing pain severity did not demonstrate a statistically significant change after treatment when averaged across the entire patient cohort (6.15–5.88, p = .106), irrespective of gender or pain phenotype. Scores for pain interference showed statistically significant reductions following treatment (7.05–6.41, p = .023), which may have been driven through improvements in sleep (7.41–6.35, p = .001); however, these reductions are not clinically significant. The patient cohort was stratified into responders and non-responders based on >30% improvement in response to an overall impression of pain reduction question following treatment. In the ‘responder’ cohort, pain intensity scores showed a statistically significant reduction post-infusion (6.18–5.49, p = .0135), but no change was apparent for non-responders (6.07–6.09, p = .920). There were no differences between responders and non-responders for pain sub-types in our study. This study found no difference in pain outcomes in a cohort of patients with chronic pain, a mean of 63 days following a single lidocaine infusion. However, a specific subgroup of responders may show slight improvements in some pain outcomes that may warrant further exploration.

Implementation of an Intravenous Lidocaine Guideline for Children and Adolescents with Sickle Cell Vaso-Occlusive Pain

Introduction Sickle cell disease (SCD) affects approximately 100,000 Americans.[1] Vaso-occlusive episodes (VOEs) are the leading cause of hospitalization in SCD; in 2016, out of 134,000 SCD hospitalizations, 81% included VOE. [2] Opioids are the mainstay of VOE treatment, but side effects include sedation, hyperalgesia, and dependency risk. Lidocaine, which inhibits voltage-gated sodium channels in peripheral sensory nerves, is given intravenously (IV) for postoperative pain management and holds promise for VOE treatment.[3] At St. Louis Children's Hospital (SLCH), children admitted with VOEs receive an opioid by continuous infusion plus patient-controlled analgesia (PCA) and non-opioid adjuvants. In 2019, the Sickle Cell Disease Program and Pain Management Service jointly developed a guideline for VOE management that includes: 1. Standardized dosing of IV opioids and IV or oral NSAIDs 2. Pain management service consultation for all children age ≥10 y admitted with VOE 3. Initiation of IV lidocaine infusion (1-1.5 mg/kg/h x 48 h) within 24 h of admission for severe pain 4. Addition of non opioid adjuvants, such as muscle relaxants, topical agents, and agents for neuropathic pain 5. IV lidocaine is prescribed by the Pain Management Service. Patients are monitored for lidocaine side effects including tinnitus, perioral tingling, vital sign changes, and seizures. A 24 h serum lidocaine level is drawn to ensure levels are not supra-therapeutic. We aimed to evaluate the implementation of this care guideline, focused on IV lidocaine as a safe, tolerable and effective adjunct to opioids for VOE treatment in children. Methods This retrospective cohort study reviewed records of children with SCD age ≥10 years admitted for VOE at SLCH during 2018-2020. Data collected included patient demographics, impact on pain, lidocaine levels, and reported side effects. This study was approved by the institutional review board. Results We identified 61 patients (31 males), median age 15.7 y (range 9-21), with 174 IV lidocaine administrations during 164 hospitalizations. Hemoglobin (Hb) SS comprised 60.7% of the cohort; 32.8% had Hb SC disease, 4.9% had Hb Sβ0 thalassemia and 1.6% had Hb Sβ+ thalassemia. IV lidocaine was started within 24 h for 78.7% (129/164) of included admissions. The mean blood lidocaine level was 2.14 mcg/ml (SD 1.23). Of the 164 admissions, 9 individuals had lidocaine levels above the limit of 4.5 mcg/ml, none had symptoms of toxicity. Few side effects were noted: lip paresthesia in 1 child (lidocaine stopped, but received in future admissions); nausea in 1 child (declined lidocaine in future admissions); pain increase in 1 teen (lidocaine was stopped). One child stopped lidocaine infusions prematurely during 2 admissions due to refusal of phlebotomy for the lidocaine level. Overall, 59 children perceived benefit of IV lidocaine and chose to receive it again during later admissions. During 10 prolonged hospitalizations, a second 48-hour lidocaine infusion was given due to patient reported benefit. We identified falsely elevated lidocaine levels when subcutaneous lidocaine was used before phlebotomy, but no patients with high lidocaine levels experienced toxicity. We altered our response to supratherapeutic levels by pausing the lidocaine infusion, redrawing lab at a peripheral site without subcutaneous lidocaine contamination, and resuming lidocaine infusion if level was normal. Every repeated lidocaine level was within normal limits. Discussion In our cohort, IV lidocaine was safe, tolerable, and improved pain control. The care guideline was initiated within 24 hours for 78.7% of admissions. Mild side effects occurred in only 3 patients, highlighting safety. Future considerations include a prospective study focused on length of stay, patient-reported outcomes, opioid exposure, and factors influencing the care guideline's utilization. References: 1. American Society of Hematology. Sickle Cell Disease. www.hematology.org/Patients/Anemia/Sickle-Cell.aspx 2.Fingar K, Owens P, et al (2019). Characteristics of Inpatient Hospital Stays Involving Sickle Cell Disease, 2000-2016. Agency for Healthcare Research and Quality. https://hcup-us.ahrq.gov/reports/statbriefs/sb251-Sickle-Cell-Disease-Stays-2016.jsp 3.Dunn L, Durieux ME, (2017). Perioperative use of intravenous lidocaine. Anesthesiology, 126(4), 729-737. https://doi.org/10.1097/aln.0000000000001527 Disclosures Di Paola: CSL Behring: Consultancy, Honoraria. Hulbert: Pfizer: Current Employment, Current holder of individual stocks in a privately-held company; bluebird bio: Consultancy; Global Blood Therapeutics: Research Funding; Forma Therapeutics: Consultancy, Research Funding.

Intravenous Lidocaine for Rib Fractures: Effect on Pain Control and Outcome

Background Multimodal analgesia in rib fractures (RFs) is designed to maximize pain control while minimizing narcotics. Prior research with intravenous lidocaine (IVL) efficacy produced conflicting results. We hypothesized IVL infusion reduces opioid utilization and pain scores. Methods A retrospective review of RF patients at an ACS-verified Level I trauma center from April 2018 to 2/2020 was conducted. Patients (pts) stratified as receiving IVL vs no IVL. Initial lidocaine dose: 1 mg/kg/hr with a maximum of 3 mg/kg/hr. Duration of infusion: 48 h. Pain quantified by the Stanford Pain Score system (PS). Bivariate and multivariate analyses of variables were performed on SPSS, version 21 (IBM Corp). Results 414 pts met inclusion criteria: 254 males and 160 females. The average age for the non-IVL = 67.4 ± 15.2 years vs IVL = 58.3 ± 17.1 years ( P < .001). There were no statistically significant differences between groups for ISS, PS for initial 48 h, and ICU length of stay (LOS). There was a difference in morphine equivalents per hour: non-IVL = 1.25 vs IVL = 1.72 ( P = .004) and LOS non-IVL = 10.2+/−7.6 vs IVL = 7.82+/−4.94. By analyzing IVL pts in a crossover comparison before and after IVL, there was reduction in opiates: 3.01 vs 1.72 ( P < .001) and PS: 7.0 vs 4.9 ( P < .001). Stanford Pain Score system reduction in the IVL = 48.3 ± 23.9%, but less effective in narcotic dependency (27 ± 22.9%, P = .035); IVL pts had hospital cost reduction: $82,927 vs $118,202 ( P < .01). Discussion In a crossover analysis, IVL is effective for reduction of PS and opiate use and reduces hospital LOS and costs. Patient age may confound interpretation of results. Our data support IVL use in multimodal pain regimens. Future prospective study is warranted.