In this section
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.
Usual procedure length - 60-120 minutes Recovery time - As needed (Avg. 30 min.)
is required for the administration of lignocaine.
For infusion: 50 mL syringe/ Normal saline ampoules x 5/ minimum volume tubing /
& 2% (20 mg/mL) Lignocaine (up to 13 ampoules)
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).
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.
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.
Lightheaded, dizziness, slurred speech, nystagmus, allergy to local anesthetic (rare)
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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
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Kosharskyy, B., W. Almonte, N. Shaparin, M. Pappagallo and H. Smith (2013). "Intravenous infusions in chronic pain management." Pain Physician16(3): 231-249.
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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.
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