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I.v lidocaine as routine component of multimodal analgesia - not quite ready yet
ESRA Academy. Joshi G. Mar 7, 2017; 170350
Girish Joshi
Girish Joshi
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Lidocaine has been known to have analgesic, anti-hyperalgesic and anti-inflammatory effects (1). Several previous systematic reviews and meta-analyses have reported that the use of intravenous lidocaine infusion reduced postoperative pain scores and opioid requirements, as well as reduced postoperative ileus, gastrointestinal recovery time, nausea/vomiting, and hospital length of stay (2-5). In fact, lidocaine infusion has been suggested as an alternative to epidural analgesia.
In the present paper, Wiebel et al performed an updated systematic review and meta–analyses, and confirmed the findings of the previous studies. In contrast to previous studies, the reduction in pain scores was found only in the immediate postoperative period (first 4 hours after surgery). In addition, this study found no analgesic benefits of lidocaine infusion in surgical procedures other than abdominal surgeries. Interestingly, the analgesic benefits were superior in the laparoscopic surgery population as compared with the open abdominal surgery population. Given that open abdominal surgery is associated with significantly more pain than with laparoscopic procedures, one could have assumed that lidocaine infusion would provide superior pain relief after open abdominal surgery. This review found no complications associated with lidocaine infusion. However, the authors conceded that the total number of patients included in the analyses was not high enough to confirm the safety of this technique. Based on the findings of this study, should we use lidocaine infusion routinely as a part of our multimodal analgesia technique for patients undergoing abdominal surgery (laparoscopic or open approach)? Unfortunately, the answer to this question is NO!
There are several limitations to this systematic review that must be considered (6). The included randomised controlled trials had significant heterogeneity with respect to the type of surgical procedure, the outcome measures assessed, the definitions of outcomes, and the duration and dose of lidocaine infusion. One of the most important concerns is that the placebo-controlled randomised trials do not represent common clinical practice. In other words, the patients in the study received a single analgesic (i.e. lidocaine infusion) and opioid as rescue. In contrast most prudent anaesthesiologists would use a combination of analgesics such as paracetamol, a non-steroidal analgesic (NSAIDs – traditional or cyclooxygenase-2 specific inhibitors), and dexamethasone, which one could call ‘basic analgesic therapy’. Therefore, any study that does not administer such a ‘basic analgesic’ technique to all patients (i.e. to both the study and the placebo groups) does not represent routine clinical practice. Thus, placebocontrolled studies that use only opioids in the placebo group do not allow us to determine if the study drug or technique would add any benefit to the current analgesic technique.
Also, it is necessary to consider the effects of an analgesic medication or technique on relevant outcomes that would enhance recovery, not just the pain scores. A systematic review of randomised controlled trials assessing pain after laparoscopic colorectal surgery (7), demonstrated that patients who received epidural analgesia had significantly lower pain scores than those who received a balanced analgesic techniques, although the pain scores in this group were within an acceptable range (i.e. < 4⁄10). However, epidural analgesia did not improve the return of bowel function and length of stay. This suggests that when determining the role of an analgesic technique as a part of multimodal analgesic technique, pain scores should not be considered in isolation from clinically relevant outcome measures. Any study that does not evaluate recovery outcome measures other than pain should not be considered when formulating recommendations. Finally, it is necessary to take into account the risk/benefit of an analgesic intervention during decision-making.
Therefore, the PROSPECT Group (www.postoppain.org) has decided that the recommendations for procedure-specific pain management will be formulated based upon critical expert interpretation of the study design in the context of analgesic technique used, especially considering ‘pure’ placebo-controlled studies versus studies with well-defined ‘basic’ analgesic technique.
In conclusion, the clinical applicability of the systematic review by Wiebel et al is negligible. It is not surprising that practising anaesthesiologists are confused with regard to determination of the best practice for pain management for specific surgical procedures. Overall, based on the above-mentioned considerations/limitations, the role of lidocaine infusion may be limited to patients undergoing abdominal surgery with contraindications to commonly used analgesics (e.g. paracetamol and NSAIDs).

1. Joshi GP, Schug S, Kehlet H. Procedure specific pain management and outcome strategies. Best Pract Res Clin Anaesthesiol 2014; 28: 191–201.
2. Marret E, Rolin M, Beaussier M, et al. Meta-analysis of intravenous lidocaine and postoperative recovery after abdominal surgery. Br J Surg 2008; 95: 1331–8.
3. McCarthy GC, Megalla SA, Habib AS. Impact of intravenous lidocaine infusion on postoperative analgesia and recovery from Surgery: A systematic review of randomized controlled trials. Drugs 2010; 70: 1149–63.
4. Vigneault L, Turgeon AF, Cote D, et al. Perioperative intravenous lidocaine infusion for postoperative pain control: a meta-analysis of randomized controlled trials. Can J Anesth 2011; 58: 22–37.
5. De Oliveira GS, Fitzgerald P, Streicher LF, et al. Systemic lidocaine to improve postoperative quality of recovery after ambulatory laparoscopic surgery. Anesth Analg 2012; 115: 262–7.
6. Kehlet H, Joshi GP. Systematic reviews and meta-analyses of randomized controlled trials on perioperative outcomes: an urgent need for critical reappraisal. Anesth Analg 2015; 121: 1104–7.
7. Joshi GP, Bonnet F, Kehlet H, on behalf of the Prospect Group. Evidence-based postoperative pain management after laparoscopic colorectal surgery. Colorectal Dis 2012; 15: 146–55.

BACKGROUND:

Improvement of postoperative pain and other perioperative outcomes remain a significant challenge and a matter of debate among perioperative clinicians. This systematic review aims to evaluate the effects of perioperative i.v. lidocaine infusion on postoperative pain and recovery in patients undergoing various surgical procedures.

METHODS:

CENTRAL, MEDLINE, EMBASE, and CINAHL databases and ClinicalTrials.gov, and congress proceedings were searched for randomized controlled trials until May 2014, that compared patients who did or did not receive continuous perioperative i.v. lidocaine infusion.

RESULTS:

Forty-five trials (2802 participants) were included. Meta-analysis suggested that lidocaine reduced postoperative pain (visual analogue scale, 0 to 10 cm) at 1-4 h (MD -0.84, 95% CI -1.10 to -0.59) and at 24 h (MD -0.34, 95% CI -0.57 to -0.11) after surgery, but not at 48 h (MD -0.22, 95% CI -0.47 to 0.03). Subgroup analysis and trial sequential analysis suggested pain reduction for patients undergoing laparoscopic abdominal surgery or open abdominal surgery, but not for patients undergoing other surgeries. There was limited evidence of positive effects of lidocaine on postoperative gastrointestinal recovery, opioid requirements, postoperative nausea and vomiting, and length of hospital stay. There were limited data available on the effect of systemic lidocaine on adverse effects or surgical complications. Quality of evidence was limited as a result of inconsistency (heterogeneity) and indirectness (small studies).

CONCLUSIONS:

There is limited evidence suggesting that i.v. lidocaine may be a useful adjuvant during general anaesthesia because of its beneficial impact on several outcomes after surgery.

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