Background

Administration of intravenous lignocaine infusion is indicated as an adjunctive intervention in patients with severe acute pain eg during and post laparotomy, following major trauma or burns and for acute cancer pain flares or neuropathic (nerve memory) pain [such as deafferentation/postamputation pain or from acute spinal cord injury, polyneuropathy] that has not responded to other interventions.

Scheduling

Usual procedure length - 2-72  hours

Intravenous access

Is required prior to the administration of lignocaine.

Equipment/preparation for infusion:

• 50 mL syringe/  minimum volume tubing and infusion pump
• 0.9% Normal saline 10 mL x 5 ampoules,
  
• 2% (20 mg/mL) Lignocaine x 5 ampoules
• Aspirate the above solutions into the 50mL syringe which makes final concentration Lignocaine 1% (10mg/mL) 50mLs
  [NB: this concentration is 20% greater than the Paediatric Injectable Guidelines {8mg/mL} as per CPMS/PICU/NICU infusion practices]

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 Acute pain

The usual bolus dose is 1-2mg/kg over 1-2 minutes with a subsequent lower intra-operative infusion rate of 17-25mcg/kg/min ( equating to 1 to 1.5mg/kg/h in an adult patient) that may be continued into the post-operative period for 6-72h ( Vigneault, Turgeon et al. 2011, Sun, Li et al. 2012, Barreveld, Witte et al. 2013).

Nursing observations/monitoring:

Non-invasive Blood pressure (NIBP) and pulse oximeter monitoring. Continuous (if available) or intermittent measurements acceptable

Vital signs and pain scores hourly (age appropriate) at baseline and then repeat hourly for first 6 hours.Thereafter 4 hourly or earlier if side effects reported.

Description of procedure in the awake/non-anaesthetised patient

Prior to the start of the procedure in the awake patient:

• Baseline observations (HR, BP, O2sat) and pain score (Visual Analogue Scale – VAS or other age appropriate score) is obtained. (This not required if commenced in the anaesthetised patient intraoperatively).
• With I.V. access obtained and the patient comfortably positioned on the trolley/bed with continuous monitoring in place
• The lignocaine infusion charted by the anaesthetist/ pain specialist.
• The patient is monitored through out
• Local anesthetic toxicity
  The patient is asked to report at any time and is specifically questioned by nursing staff when awake 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

• Cease the infusion  immediately and the pain medical practitioner paged to review the patient. CPMS (Ascom 52702 or Pain fellow pager 4886)
• 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

Complications

During the administration of IV lignocaine, if nursing or medical staff are concerned at anytime -

• contact CPMS (Ascom 52702 or Pain fellow pager 4886).
• If the patients are in breach of VICTOR thresholds, a Rapid Review or MET call should be made. 

Post Infusion of lignocaine

• 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 pain score is obtained and documented.

Potential side effects-lightheadedness, 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.

2023 update