|Year : 2018 | Volume
| Issue : 1 | Page : 83-86
The effect of intraoperative lidocaine infusion on perioperative opioid consumption for laparoscopic cholecystectomy
Ezzeldin Saleh1, Hatem Abo El-Wafa1, Mohamed I Abd El-Salam Ahmed2
1 Anaesthesia and Surgical Intensive Care Department, Faculty of Medicine, University of Menoufia, Egypt
2 Anaesthesia and Surgical Intensive Care Department, Alex Police Hospital, Alexandria, Egypt
|Date of Submission||14-Nov-2016|
|Date of Acceptance||19-Jan-2017|
|Date of Web Publication||14-Jun-2018|
Mohamed I Abd El-Salam Ahmed
18 Street, Sidi Bisher, Alexandria
Source of Support: None, Conflict of Interest: None
The aim of this study was to determine the role of intraoperative lidocaine infusion in reducing perioperative pain and analgesia requirement in patients undergoing laparoscopic cholecystectomy.
An alternative approach to pain relief in laparoscopic cholecystectomy is the use of intravenous (i.v.) lidocaine intraoperatively, which decreases perioperative analgesic requirement.
Patients and methods
This double-blinded randomized study was conducted on 60 patients of both sexes. Patients between 40 and 50 years of age, of American Society of Anesthesiologists I and II physical status, and scheduled for laparoscopic cholecystectomy were included in the study. Patients were randomly assigned using computerized software to one of the two groups, each containing 30 patients. Group L (the study group) was infused with lidocaine at a rate of 2 mg/kg/h, and group S (the control group) was infused with normal saline at a rate of 2 mg/kg/h. Anesthesia was induced with i.v. fentanyl 2 mg/kg and propofol 2–3 mg/kg. Patients received supplemental i.v. dose of morphine 0.1 mg/kg intraoperatively if needed. (Additional morphine intraoperatively was indicated when heart rate and mean arterial blood pressure increased more than 20% of preoperative heart rate and mean arterial blood pressure values.) The total amount of opioid used for patients intraoperatively and postoperatively was recorded. All patients were asked to quantify their pain on a visual analog scale immediately postoperatively and every 4 h until hospital discharge.
In the current study, there was a significant difference as regards postoperative pain; it was significantly lower in the lidocaine group. Total analgesic dose required was significantly lower in the lidocaine group.
Perioperative i.v. lidocaine provides analgesia and low pain scores after laparoscopic cholecystectomy. The use of lidocaine intraoperatively decreases perioperative opioid consumption.
Keywords: intravenous lidocaine infusion, laparoscopic cholecystectomy, perioperative opioid consumption
|How to cite this article:|
Saleh E, El-Wafa HA, Abd El-Salam Ahmed MI. The effect of intraoperative lidocaine infusion on perioperative opioid consumption for laparoscopic cholecystectomy. Menoufia Med J 2018;31:83-6
|How to cite this URL:|
Saleh E, El-Wafa HA, Abd El-Salam Ahmed MI. The effect of intraoperative lidocaine infusion on perioperative opioid consumption for laparoscopic cholecystectomy. Menoufia Med J [serial online] 2018 [cited 2018 Aug 17];31:83-6. Available from: http://www.mmj.eg.net/text.asp?2018/31/1/83/234239
| Introduction|| |
Intraoperative analgesia is traditionally provided by opioid analgesics. However, the use of opioids during ambulatory surgery can be associated with an increased incidence of postoperative complications, such as respiratory depression, sedation, postoperative nausea and vomiting, ileus, and urinary retention . Some of these side effects can delay recovery and discharge from the day-surgery unit, and can cause unanticipated hospital admission . It is therefore appropriate to minimize these side effects by using either multimodal analgesic techniques or adjuvant therapies to reduce the doses of opioids .
The fact that pain after laparoscopic cholecystectomy is complex in nature and has unique elements compared with other laparoscopic procedures suggests that effective analgesic treatment must be multimodal in nature .
A prophylactic multimodal analgesia regimen is suggested to reduce postoperative pain, consisting of intraoperative short-acting opioids, injection of local anesthetics into the surgical wound, and administering NSAIDs .
Despite this multipharmacological intervention, postoperative analgesia has not been consistently satisfactory . Intravenous (i.v.) lidocaine has been shown to provide good pain relief in patients who underwent retropubic prostatectomy and laparoscopic colon resection . This effect appears to be due to a reduction in neural responses to pain by inhibiting nerve conduction . In addition, lidocaine has significant anti-inflammatory properties [7–9]. Perioperative i.v. lidocaine decreases postoperative pain and morphine consumption following prostatic surgery and colon resection ,.
| Patients and Methods|| |
After approval from the ethics committee of El Menoufia University Hospitals and informed written consent, the present study was conducted on 60 patients of both sexes. Patients between 40 and 50 years of age, of American Society of Anesthesiologists I and II physical status, and scheduled for laparoscopic cholecystectomy were included in this double-blinded randomized study.
The following patients were excluded from the study: patients with allergy to lidocaine; patients with neuromuscular disease, patients with a history of chronic pain syndromes; patients with endocrine or metabolic disease; pregnant women; and patients who underwent emergency cholecystectomy.
Patients were randomly assigned using computerized software to two groups, comprising 30 patients in each group. Group L (the study group) was infused with lidocaine 2% at a rate of 2 mg/kg/h, and group S (the control group) was infused with normal saline at a rate of 2 mg/kg/h through infusion sets (Injectomat Agilia; Fresenius Kabi (Fresenius Kabi India Pvt. Ltd., Pune, India)).
On arrival to the operating room, each patient was attached to a multichannel monitor to display continuous ECG, mean arterial blood pressure, and arterial oxygen saturation. Anesthesia was induced with i.v. fentanyl 2 mg/kg, propofol 2–3 mg/kg, and atracurium 0.5 mg/kg. Patients received lidocaine or saline infusion through infusion sets prepared by the independent anesthetic trainee. Patients received supplemental i.v. dose of morphine 0.1 mg/kg intraoperatively if needed. (Additional morphine intraoperatively was indicated when heart rate and mean arterial blood pressure increased more than 20% of preoperative heart rate and mean arterial blood pressure values.) Pain assessment was carried out using visual analog scale (VAS). The total dose of analgesic consumption was recorded for each patient.
Data were fed to the computer and analyzed using IBM SPSS software package, version 20.0 (IBM Corp., Armonk, NY). Qualitative data were described using number and percent. Quantitative data were described using range (minimum and maximum), mean, SD, and median. Significance of the obtained results was judged at the 5% level . The following tests were used: the χ2-test (for categorical variables, to compare between different groups); Student's t-test (for normally quantitative variables, to compare between two studied groups); analysis of variance with repeated measures (for normally quantitative variables, to compare between more than two periods or stages); post-hoc test (for pair-wise comparisons); the Mann–Whitney U-test (for abnormally quantitative variables, to compare between two studied groups); and Wilcoxon signed-rank test (for abnormally quantitative variables, to compare between two periods).
| Results|| |
In the current study, both groups were matched as regards age, sex, body weight, BMI, and operative time. This indicates that the mentioned variables would have the least influence on the assessed parameters when comparing the effect of lidocaine with control operative pain and analgesia requirement in the current laparoscopic cholecystectomy study.
Comparison between the two groups revealed a significant difference as regards postoperative pain (VAS); it was significantly lower in the lidocaine group at 4, 8, 12, and 24 h postoperatively [Table 1]. Total analgesic dose required was significantly lower in the lidocaine group [Table 2] and [Table 3].
|Table 1: Comparison between the two studied groups according to visual analog scale|
Click here to view
|Table 2: Comparison between the two studied groups according to total dose of morphine intraoperative (mg)|
Click here to view
|Table 3: Comparison between the two studied groups according to total dose of morphine postoperatively (mg)|
Click here to view
| Discussion|| |
Little or no work, however, seems to have been carried out on the efficacy of i.v. lidocaine on pain relief after laparoscopic cholecystectomy, which is frequently associated with persistent postoperative discomfort and distress for patients and late discharge from hospital .
The study by Lauwick et al.  is in agreement with the results of the current study. They studied patients undergoing laparoscopic cholecystectomy. (The lidocaine group received a bolus of 1.5 mg/kg of lidocaine, followed by continuous infusion at a rate of 2 mg/kg/h.) They found that lidocaine-treated patients were more alert due to the improved postoperative analgesia and reduced opioid consumption, which accelerated the time of discharge from postanesthesia care unit (PACU) .
Moreover, in accordance with our study, Saadawy et al.  conducted the same study with the same operation (laparoscopic cholecystectomy) and the same dose of lidocaine 2 mg/kg/h. One hundred and twenty patients were divided into three equal groups to receive either magnesium, lidocaine, or saline. They found that the lidocaine group had lower VAS score and total morphine consumption in the first 24 h postoperatively. Moreover, they concluded that they had the least PACU stay .
Again, Wu et al.  found that both dextromethorphan and i.v. lidocaine improved postoperative pain relief after laparoscopic cholecystectomy. Patients had significantly better pain relief than those in the control group. The results showed an additional effect on pain relief and a synergistic effect on recovery of bowel function when dextromethorphan was combined with i.v. lidocaine after laparoscopic cholecystectomy .
Moreover, in accordance with our study, Dogan et al.  conducted a similar study with laparoscopic cholecystectomy with lidocaine infusion at a rate of 1.5 mg/kg/h. Sixty patients were divided into two equal groups to receive either lidocaine or esmolol. They found that the lidocaine group had a lower VAS score and total analgesia consumption postoperatively .
In contrast to the results of the current study, Martin et al.  demonstrated that an i.v. bolus of 1.5 mg/kg lidocaine 1% 30 min before surgical incision for total hip arthroplasty followed by continuous infusion of 1.5 mg/kg/h until 1 h after skin closure had no effect on pain score. Moreover, they found no significant difference between the two groups considering morphine requirement in the PACU and first 24 h. The first study on the effect of i.v. lidocaine on nociceptive processing after orthopedic surgery was conducted by Martin et al. . Most of the previously published studies have been performed during abdominal surgery using as primary criterion the accelerated postoperative recovery of bowel function. Despite adequate lidocaine plasma levels, they did not observe an opioid-sparing effect at any time postoperatively. The discrepancies between them and other lidocaine studies during abdominal surgeries might be attributed to the type of surgery used for the study .
Again Dewinter et al.  studied the effect of lidocaine infusion in laparoscopic sterilization against the placebo group. The study failed to prove that 1.5 mg/kg/h lidocaine infusion had significant differences in pain score, opioid consumption, incidence of postoperative nausea and vomiting, and time to readiness for discharge. This may be attributed to the different technique used, which was not mentioned, lower dose of the study drug, or type of patient .
Moreover, Insler et al.  reported that, in patients who underwent coronary artery bypass grafting, an i.v. bolus of 1.5 mg/kg lidocaine followed by continuous infusion of 30 mg/kg/min during and until 48 h after surgery had no effect on postoperative pain. They assume that discrepancies between studies are related to the different types of surgery and the different doses of infused lidocaine .
Other studies have been conducted to compare the analgesic efficacies of i.v. lidocaine versus intraperitoneal (i.p.) lidocaine in laparoscopic surgeries; there was no significant difference between analgesic modalities in any of the measured outcomes.
Ram et al.  studied lidocaine in 50 patients undergoing laparoscopic cholecystectomy. (They compared the effect of i.v. bolus of lidocaine 1.5 mg/kg followed by continuous i.v. infusion of lidocaine 2 mg/kg/h maintained until 1 h after surgery with that of i.p. instillation of 100 ml saline and i.p. instillation of 100 ml of 0.2% lidocaine with i.v. bolus and continuous i.v. infusion of saline based on volume of lidocaine that would be needed.) They found that i.v. lidocaine is superior to i.p. lidocaine in providing pain relief .
Kim et al.  studied lidocaine in 68 patients undergoing laparoscopic appendicectomy. (They compared the effect an i.v. bolus of lidocaine 1.5 mg/kg followed by continuous i.v. infusion of lidocaine 2 mg/kg/h maintained until end of procedure with that of i.p. instillation of saline and i.p. instillation of lidocaine 3.5 mg/kg at pneumoperitoneum and with that of an i.v. bolus of saline followed by continuous i.v. infusion of saline until end of procedure.) They found that i.v. lidocaine is as effective as i.p. instillation in reducing pain and fentanyl consumption .
| Conclusion|| |
Intraoperative i.v. lidocaine provides analgesia and low pain scores after laparoscopic cholecystectomy. The use of lidocaine intraoperatively decreases perioperative opioid consumption.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
White PF. The role of non-opioid analgesic techniques in the management of pain after ambulatory surgery. Anesth Analg 2002; 94
Watt-Watson J, Chung F, Chan VW, McGillion M. Pain management following discharge after ambulatory same-day surgery. J Nurs Manag 2004; 12
Bisgaard T, Klarskov B, Rosenberg J, Kehlet H. Characteristics and prediction of early pain after laparoscopic cholecystectomy. Pain 2001; 90
Bisgaard T. Analgesic treatment after laparoscopic cholecystectomy: a critical assessment of the evidence. Anesthesiology 2006; 104
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
Koppert W, Weigand M, Neumann F, Sittl R, Schuettler J, Schmelz M, Hering W. Perioperative intravenouslidocaine has preventive effects on postoperative pain and morphine consumption after major abdominal surgery. Anesth Analg 2004; 98
Wu CT, Borel CO, Lee MS, Yu JC, Liou HS, Yi HD, Yang CP. The interaction effect of perioperative cotreatment with dextromethorphan and intravenous lidocaine on pain relief and recovery of bowel function after laparoscopic cholecystectomy. Anesth Analg 2005; 100
Grady P, Clark N, Lenahan J, Oudekerk C, Hawkins R, Nezat G, et al.
Effect of intraoperative intravenous lidocaine on postoperative pain and return of bowel function after laparoscopic abdominal gynecologic procedures. AANA J 2012; 80
De Oliveira GSJ, Fitzgerald P, Streicher LF, Marcus RJ, McCarthy RJ. Systemic lidocaine to improve postoperative quality of recovery after ambulatory laparoscopic surgery. Anesth Analg 2012; 115
Vigneault L, Turgeon AF, Côté D, Lauzier F, Zarychanski R, Moore L, McIntyre LA, Nicole PC, et al.
Perioperative intravenous lidocaine infusion for postoperative pain control: a meta-analysis of randomized controlled trials. Can J Anaesth 2011; 58
Groudine SB, Fisher HA, Kaufman RP Jr, Patel MK, Wilkins LJ, Mehta SA, Lumb PD. Intravenous lidocaine speeds the return of bowel function, decreases postoperative pain, and shortens hospital stay in patients undergoing radical retropubic prostatectomy. Anesth Analg 1998; 86
Kotz S, Balakrishnan N, Read CB, Vidakovic B. Encyclopedia of statistical sciences
ed. Hoboken, NJ: Wiley InterScience; 2006.
Callesen T, Kehlet H. Postherniorrhaphy pain. Anesthesiology 1997; 87
Lauwick S, Kim DJ, Michelagnoli G, Mistraletti G, Feldman L, Fried G, Carli F. Intraoperative infusion of lidocaine reduces postoperative fentanyl requirements in patients undergoing laparoscopic cholecystectomy. Can J Anesth 2008; 55
Saadawy M, Kaki AM, Abd El Latif AA, Abd-Elmaksoud AM, Tolb OM. Lidocaine vs. magnesium: effect on analgesia after a laparoscopic cholecystectomy. Acta Anaesthesiol Scand 2010; 54: 549–556.
Dogan SD, Ustun FE, Sener EB, Koksal E, Ustun YB, Kaya C, Ozkan F. Effects of lidocaine and esmolol infusions on hemodynamic changes, analgesic requirement, and recovery in laparoscopic cholecystectomy operations. Braz J Anesthesiol. 2016; 66
Martin F, Cherif K, Gentili ME, Enel D, Abe E, et al.
Lack of impact of intravenous lidocaine on analgesia, functional recovery, and nociceptive pain threshold after total hip arthroplasty. Anesthesiology 2008; 109
Dewinter GB, Teunkens A, Vermeulen K, Al Tmimi L, Van de Velde M, Rex S. Systemic lidocaine fails to improve post-operative pain, but reduces time to discharge readiness in patients undergoing laparoscopic sterilization in day-case surgery. Reg Anesth Pain Med 2016; 41:362–367.
Insler SR, O'Connor M, Samonte AF, Bazaral IMG. Lidocaine and the inhibition of postoperative pain in coronary artery bypass patients. J Cardiothorac Vasc Anesth 1995; 9:
Ram D, Sistla SC, Karthikeyan VS. Comparison of intravenous and intra-peritoneal lignocaine for pain relief following laparoscopic cholecystectomy: a double-blind, randomized, clinical trial. Surg Endosc 2014; 28
Kim TH, Kang H, Hong JH. Intra-peritoneal and intravenous lidocaine for effective pain relief after laparoscopic appendectomy: a prospective, randomized, double-blind, placebo-controlled study. Surg Endosc 2011; 25
[Table 1], [Table 2], [Table 3]