We have started using I.V. lidocaine to help manage pain in some patients presenting to our ED. Can I.V. lidocaine be used as an adjunct to opioid therapy?-DN, MA.

Jenny Kim; Georges Eid; Janet Dumonchelle, PHARMD; and Bridget Parsh, EdD, RN, CNS Reply-With increasing misuse, overdose, dependency, and severe adverse effects (AEs) of opioids, the World Health Organization recommends healthcare providers find alternative methods to mitigate patients' pain.1 In 2017, the Colorado Hospital Association launched the alternative to opioid (ALTO) project to minimize opioid use and opt for alternatives such as lidocaine. Based on the success, numerous hospitals have adopted this program. Studies suggest that opioid-free anesthesia is associated with lower postoperative morphine consumption, decreased intubation time and noninvasive respiratory support, and shorter ICU stays.2 Although lidocaine has traditionally been used for local anesthesia, its nonopioid analgesic properties and minimal AE make it potentially useful as adjunctive therapy for pain management in the ED and postoperative setting.

Beneficial adjunctive therapy

The use of lidocaine as adjunctive analgesia is relatively new, but it may be beneficial for patients in perioperative gastrointestinal procedures, postoperative ileus, undifferentiated pain, and extremity trauma.2-4 One study looking at patients undergoing bariatric surgery found that the group receiving I.V. lidocaine with fentanyl experienced greater pain relief, less need for opioid, and better patient satisfaction scores than the group receiving an ultrasound-guided transversus abdominis plane block with fentanyl.4 Additionally, perioperative I.V. lidocaine infusions may be more beneficial for patients undergoing bariatric surgery as these patients are at greater risk for the respiratory depressant effects of opioids.5 In another study including patients undergoing major abdominal surgery, perioperative administration of small-dose I.V. lidocaine was found to reduce postoperative morphine consumption compared with placebo. Additionally, the results correlated with improved quality of recovery scores.5 After gastrointestinal surgery, patients who received I.V. lidocaine generally exhibited earlier return of bowel function, better pain relief, and lower opioid consumption than placebo.6-8

Alternatively, a study on women with breast cancer who underwent mastectomy found no difference in postoperative pain between the group that used I.V. lidocaine with opioids and placebo with opioids.6 A study on the use of I.V. lidocaine for treating patients with renal colic found mixed results.7 One study showed that using I.V. lidocaine with morphine reduced time to achieve relief of pain and nausea compared with using morphine alone, yet another study suggested that a combination of I.V. lidocaine and ketorolac provided no analgesic advantages over ketorolac alone.7,8 In a study on adults with acute limb trauma in the ED, pain reduction with I.V. lidocaine was not superior to I.V. morphine, but it was comparable with lidocaine producing fewer adverse reactions.9 While more research about I.V. lidocaine is warranted, recent studies have indicated its benefits for certain groups depending on the type of pain and procedure.2,6

It is uncertain whether perioperative I.V. lidocaine has a beneficial impact on pain intensity scores in the early postoperative phase, gastrointestinal recovery, postoperative nausea, and opioid consumption.2

Nursing considerations

While I.V. lidocaine is an alternative that can provide adjunctive analgesia, an ideal, effective infusion regimen has yet to be established and patients must be carefully monitored for AEs.6,10 High doses of I.V. lidocaine can cause dysrhythmias, seizures, and respiratory depression.10,11 I.V. lidocaine should be infused slowly on a pump to minimize AE. Since lidocaine has a relatively short half-life, AEs are usually transient and rapidly reversible. Use cautiously in older adults and patients with a severe cardiac history.11 Eliminating opioid use in hospital settings is impractical as patients experience varying types and degrees of pain. However, with careful patient selection, appropriate monitoring, and nursing protocols, I.V. lidocaine infusions may be safely administered for perioperative acute pain.

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