Intravenous lidocaine therapy (IVLT) is often used in perioperative multimodal analgesia due to its analgesic, anti-hyperalgesic, and anti-inflammatory effects. In adults, IVLT doses of 1-2 mg/kg/h produce plasma concentrations of 1-2 μg/mL, within the presumed therapeutic range of 1-5 μg/mL. The dose range, expected plasma concentrations, and presumed therapeutic range are not well defined in children. We aimed to review available pharmacokinetic data in pediatric patients receiving IVLT. We searched MEDLINE, EMBASE, and CINAHL databases for studies reporting pharmacokinetic data for IVLT in healthy 1-18-year-olds, with plasma lidocaine or metabolite levels collected post-infusion, excluding studies involving non-therapeutic infusions or children with comorbidities affecting lidocaine metabolism. Bias was assessed using validated tools. We conducted narrative data synthesis due to reporting variability and summarized plasma lidocaine and/or metabolite levels and the incidence of reported adverse events. Four studies comprising 174 children were included. A study (n = 22) using a 1.5 mg/kg bolus over 30 min followed by a 1 mg/kg/h infusion for 6 h post-surgery achieved highest mean drug concentrations of 2.82 ± 0.65 μg/mL immediately following surgery. Another study (n = 46) utilized a 1.5 mg/kg bolus over 5 min followed by a 2 mg/kg/h infusion and achieved peak concentrations of 4 to < 5 μg/mL. Two studies (n = 106) utilized a 1.5 mg/kg bolus and 1.5 mg/kg/h infusion until transfer to the post-operative anesthesia care unit or six hours post-operatively achieved concentrations that were detectable and < 5 μg/mL. The only adverse event reported was a single participant who experienced transient sensory disturbances. Existing pharmacokinetic data for pediatric IVLT is extremely limited. Reported plasma concentrations were detectable and lower than presumed toxic levels with one reported adverse event. Large-scale, multicenter research is needed to determine optimal pediatric dosing, elucidate dose response curves, and ensure safe and effective use of IVLT in the pediatric population. Prospective Register of Systematic Reviews (PROSPERO): CRD42025636554.
Posterior spinal instrumentation and fusion is a common surgical correction for adolescent idiopathic scoliosis. Preventative multimodal analgesia, including opioids, is required to minimize postoperative pain, but opioids are associated with dose-dependent side effects that may disrupt recovery. We hypothesized that the addition of 48-h perioperative intravenous lidocaine therapy to a multimodal analgesia regimen would reduce morphine utilization. We conducted a double-blinded randomized controlled trial in 10-19 years old, ASA I-III, undergoing single-stage scoliosis correction. Participants were randomly allocated to the Intervention group (intravenous lidocaine 1 mg kg bolus at anesthesia start, followed by 2 mg kg h infusion for 8 h, followed by 1 mg kg h for 40 h) or Control (normal saline). Participants received standardized perioperative multimodal analgesia, including a postoperative morphine infusion with titration rules protocolized to self-reported pain scores. The primary outcome was 48-h morphine utilization; secondary outcomes were median and worst pain scores, and times to first stand, first walk > 15 steps, urinary catheter removal, termination of morphine infusion, and hospital discharge. Data were available from 38 participants: 32 (84%) female; median (IQR) age 16.3 (14.9-17.2) years, with curve magnitude (Cobb angle) 62 (56-70) degrees. The 48-h morphine utilization did not differ between groups: Intervention median (IQR) 0.86 (0.73-1.05) mg kg versus Control 1.00 (0.77-1.18) mg kg; median difference -0.11 (95% CI -0.30 to 0.13) mg kg; p = 0.264. There were similarly no differences in morphine utilization at 12, 24, or 36 h or any secondary outcome, except the first postoperative pain score: Intervention 3/10 (1.75-5) versus Control 5/10 (3-7); median difference -2 (95% CI 0 to -3); p = 0.035. Three cases with mild symptoms of suspected local anesthetic systemic toxicity were observed in the Intervention group. We found no evidence to support the adjunctive use of 48-h perioperative intravenous lidocaine therapy in adolescents undergoing scoliosis correction in which effective multimodal analgesia was adopted. ClinicalTrials.gov identifier: NCT04069169.
Gregoire N, Kaseweter K, Klukas E, Sanan A, Louw WF
Journal of clinical medicine •
Chronic widespread pain (CWP) is characterized by persistent pain across multiple body regions, often accompanied by fatigue, cognitive difficulties, and psychological distress. Affecting approximately 10% of the general population, CWP disproportionately impacts women, individuals from lower socioeconomic backgrounds, immigrants, and those with a family history of chronic pain. Standard treatments, including cognitive-behavioral therapy, exercise, and pharmacotherapy, often provide insufficient relief. This study explores a novel approach to treating treatment-resistant CWP: high-dose subcutaneous lidocaine infusions administered over extended periods. The research included a retrospective chart review and patient survey to evaluate safety and tolerability. The protocol started with a dose of 10-12 mg/kg of adjusted body weight, increasing by 10-15% per month, with a maximum dose of 2000 mg. The chart review of 27 patients revealed mild to moderate adverse events (AEs) in seven patients, with no severe AEs. A survey of 15 patients indicated a higher incidence of AEs; however, all patients reported that the benefits outweighed the negatives. On average, patients experienced 61% pain relief, lasting 19 days per infusion. This study demonstrates that subcutaneous lidocaine infusions are a well-tolerated treatment for CWP, offering substantial pain relief and improving patients' quality of life.
