I.V. Lignocaine Lidocaine infusion for chronic pain for in and outpatients

  • Background

    Administration of intravenous lignocaine infusion is indicated in patients with chronic neuropathic (nerve memory) pain [such as occurs with acute spinal cord injury, polyneuropathy, complex regional pain syndrome, deafferentation or postamputation], central pain syndromes and cancer pain that have not responded to other interventions.

    Scheduling:

    Usual procedure length - 60-120 minutes  Recovery time - As needed  (Avg. 30 min.)

    Intravenous access

    is required for the administration of lignocaine.

    Equipment:

    For infusion: 50 mL syringe/ Normal saline ampoules x 5/ minimum volume tubing /

    & 2% (20 mg/mL) Lignocaine (up to 13 ampoules)

    Contraindications:

    • Unavailability of an area with appropriate patient monitoring. 
    • Allergy to lignocaine or other amide local anaesthetics (bupivacaine, ropivacaine, prilocaine). 
    • Local anaesthesia by another route eg epidural or regional infusion. 
    • Cardiac arrhythmias eg. atrial fibrillation, cardiac conduction block, Stokes-Adams attacks, implantable pacemaker, other anti-arrhythmics  (eg. amiodarone, phenytoin). 
    • Cardiovascular instability (shock) eg with major trauma, head injury, sepsis. 
    • Severe renal or liver function impairment. 
    • Reduced conscious state, seizure disorder. 
    • Pregnancy.

    Indications and dosing for Chronic pain

    Usual total dose is 5-7.5 mg/kg --maximum 500mg.

    Usual infusion rate at RCH to 40-75mcg/kg/min (~150-250mg/hr in adult sized patients).

    A bolus is not usually ordered at RCH (but 1mg/kg may be initiated at the discretion of the ordering pain specialist) and the infusion rate is titrated up or down  in the awake patient, depending on  side effects the patient reports. 

    [This dose is conservative and doses of 5mg/kg have been administered over 30 minutes to awake adult pain patients : Edwards, Habib et al. 1985, Kalso, Tramer et al. 1998, Tremont-Lukats, Challapalli et al. 2005, Kosharskyy, Almonte et al. 2013) ( Challapalli, Tremont-Lukats et al. 2005).

    Nursing observations/monitoring:

    • Non-invasive Blood pressure (NIBP)
    • Continuous or intermittent pulse oximetry monitoring.
    • Cardiac monitor with continuous ECG facility during the infusion.
    • Age appropriate pain score
    • Clinical observations (pulse, oxygen saturation and NIBP) and pain score to be taken at baseline.
    • Clinical observations to continue at 10 minutely intervals for the first 30 minutes, then 15 minutely thereafter until the infusion is ceased.
    • Vital signs are to be recorded  with an age appropriate pain score at 30minutes post cessation.

    Description of procedure in the awake/non-anaesthetised patient

    Prior to the start of the procedure, baseline clinical observations (HR, BP, O2 sat) and pain score (Visual Analogue Scale - VAS) is documented.

    After I.V. access is obtained, with the patient comfortably positioned on the trolley/bed and continuous monitoring in place, the lignocaine infusion is charted by the pain specialist.

    Infusion is initially commenced at 40mcg/kg/min and increased 5 minutely in 5mcg/kg/min increments to a maximum 75mcg/kg/min.

    The patient is monitored throughout the procedure - 10-minutely clinical observations are recorded and the patient is asked to report and is assessed at the time of observations for early signs of local anesthetic toxicity (sedation, dizziness, tingling around the mouth/periphery, nausea). 

    If patient develops signs of toxicity, the infusion is to be ceased immediately and pain medical practitioner paged to review the patient.

    Continuing assessment will determine whether the infusion is recommenced at a lower rate if symptoms resolve.

    The remainder of the infusion is run according to patient tolerance.

    The infusion will be ceased if the patient

    1. Is unable to tolerate the infusion, even at reduced rates,
    2. Has escalating blood pressure readings
    3. Is having escalating signs of toxicity.

    If nursing or medical staff are concerned at any time during the administration of IV lignocaine,  - they should contact CPMS (Ascom 52702 or Pain fellow pager 4886 or Pain consultant who has written the order).

    If the patients are in breach of VICTOR thresholds, a Rapid Review or MET call should be made. 

    The patient is observed post infusion until CNS status has returned to baseline (no dizziness and alert) for 30-60minutes and vital signs are stable. 

    A Post infusion VAS score is obtained and documented.

    Potential side effects

    Lightheaded, dizziness, slurred speech, nystagmus, allergy to local anesthetic (rare)

    References

    Barreveld, A., J. Witte, H. Chahal, M. E. Durieux and G. Strichartz (2013). "Preventive analgesia by local anesthetics: the reduction of postoperative pain by peripheral nerve blocks and intravenous drugs." Anesth Analg116(5): 1141-1161.

    Challapalli, V., I. W. Tremont-Lukats, E. D. McNicol, J. Lau and D. B. Carr (2005). "Systemic administration of local anesthetic agents to relieve neuropathic pain." Cochrane Database Syst Rev(4): CD003345.

    Edwards, T. W., F. Habib, R. G. Burney and G. Begin (1985). "Intravenous Lidocaine in the Management of Various Chronic Pain States: A Review of 211 Cases." Regional Anesthesia 10(1): 1-6.

    Kalso, E., M. R. Tramer, H. J. McQuay and R. A. Moore (1998). "Systemic local-anaesthetic-type drugs in chronic pain: a systematic review." Eur J Pain 2(1): 3-14.

    Kosharskyy, B., W. Almonte, N. Shaparin, M. Pappagallo and H. Smith (2013). "Intravenous infusions in chronic pain management." Pain Physician16(3): 231-249.

    Sun, Y., T. Li, N. Wang, Y. Yun and T. J. Gan (2012). "Perioperative systemic lidocaine for postoperative analgesia and recovery after abdominal surgery: a meta-analysis of randomized controlled trials." Dis Colon Rectum 55(11): 1183-1194.

    Tremont-Lukats, I. W., V. Challapalli, E. D. McNicol, J. Lau and D. B. Carr (2005). "Systemic administration of local anesthetics to relieve neuropathic pain: a systematic review and meta-analysis." Anesth Analg 101(6): 1738-1749.

    Vigneault, L., A. F. Turgeon, D. Cote, F. Lauzier, R. Zarychanski, L. Moore, L. A. McIntyre, P. C. Nicole and D. A. Fergusson (2011). "Perioperative intravenous lidocaine infusion for postoperative pain control: a meta-analysis of randomized controlled trials." Can J Anaesth 58(1): 22-37.