Pain following hepatectomy may delay recovery and increase opioid use. We tested the primary hypothesis that combining lidocaine and low-dose esketamine would reduce movement-evoked pain 24 h after hepatic resection. We also evaluated whether this approach reduced opioid consumption and improved quality of recovery. Patients having elective hepatic resections were allocated randomly to receive lidocaine-esketamine or placebo from induction of anaesthesia until the end of surgery. After surgery, patients allocated to lidocaine-esketamine were given a continuous infusion of lidocaine with esketamine for 72 h. All patients received transversus abdominis plane blocks with ropivacaine 2 mg.kg after induction of anaesthesia. Postoperative analgesia was provided by patient-controlled intravenous analgesia with sufentanil. In total, 304 patients were included, of whom 145 (48%) had open surgery. Lidocaine-esketamine infusion reduced median (IQR [range]) pain scores with movement at 24 h (3 (2-4 [1-6]) vs. 4 (3-5 [1-9]), p < 0.001); 48 h (3 (2-4 [0-7]) vs. 4 (3-5 [0-8]), p < 0.001); and 72 h (2 (1-3 [0-6]) vs. 3 (2-4 [0-7]), p < 0.001), respectively. Moderate-to-severe movement-evoked pain at 24 h was evident in 52/152 (34%) patients who received lidocaine-esketamine vs. 85/152 (56%) who received placebo (p < 0.001). Cumulative sufentanil equivalents were significantly reduced at each measurement time and quality of recovery scores were significantly higher through the first 72 h for lidocaine-esketamine compared with placebo, but these changes were clinically modest. The combination of lidocaine with esketamine reduced movement-evoked pain and opioid consumption whilst improving quality of recovery during the initial 72 h after hepatic resection. However, treatment effects were modest and of limited clinical importance.
The concurrent use of a ropivacaine transversus abdominis plane (TAP) block with intravenous lidocaine infusion, though effective for pain relief, raises safety concerns regarding local anesthetic systemic toxicity (LAST). This study aimed to assess the dose-risk relationship of LAST in this combination by escalating the ropivacaine dose while fixing the lidocaine dose. In this dose-escalation study, adult patients undergoing colorectal cancer surgery received a 0.2% ropivacaine TAP block (1.5, 2.0 or 2.5 mg kg) and intravenous lidocaine infusion (2 mg kg bolus, followed by 2 mg kg h), both dosed according to ideal body weight (IBW). The primary outcome was the occurrence of LAST, identified by clinical symptoms, new-onset ECG irregularities, etc. Secondary outcomes included plasma concentrations of ropivacaine and lidocaine. Nine patients were included in the per-protocol analysis, and 26 were included in the intention-to-treat analysis. No signs of LAST were observed. Plasma ropivacaine concentrations remained consistently below 2.2 µg mL, however, eight patients in the intention-to-treat population and three patients in the per-protocol population had plasma lidocaine concentrations exceeding 5.0 µg mL at 10 min post-bolus. In the per-protocol population, peak plasma ropivacaine concentrations occurred at 30 min (range, 20-60) post-TAP block, with median values of 1.14 (range, 0.85-1.18), 1.42 (range, 1.29-1.80), and 1.96 (range, 1.47-2.06) µg mL across dose groups. The peak plasma lidocaine concentrations in patients occurred at 10 min post-bolus infusion, with median values of 4.59 µg mL (range, 3.24-6.67) and gradually decreased after 2 h. The intention-to-treat analysis found similar results. Although no signs of LAST were observed with the combination of a 1.5 to 2.5 mg kg ropivacaine TAP block and intravenous lidocaine infusion under general anaesthesia, extreme caution is still warranted regarding the potential risk of LAST. This trial was registered at ClinicalTrials.gov (NCT06006026) on 23 August 2023.
Postoperative cognitive dysfunction (POCD) has been reported as a significant complication in elderly patients. Various methods have been proposed for reducing the incidence and severity of POCD. Intravenous lidocaine administration has been reported in the literature to reduce POCD, but the effect of lidocaine remains controversial. We screened Medline, Embase, Cochrane Library, and China National Knowledge Infrastructure (up to April 2022) databases following a search strategy for intravenous lidocaine on POCD. We also screened related bibliographies on lidocaine for POCD. Ten articles comprising 1517 patients were selected and analyzed. We divided the postoperative follow-up period as follows: short term (<30 days), medium term (30-90 days), and long term (>90 days). We found that lidocaine could attenuate the overall incidence of POCD, especially in the short term. There were no differences between lidocaine and placebo on the overall severity of POCD. Lidocaine administered intravenously could attenuate the overall incidence of POCD and its severity in the short term.
Surgery is one of the most frequent and effective intervention strategies for lumbar spinal stenosis, however, one-third of patients are not satisfied with postoperative outcomes. It is not clear whether perioperative systemic lidocaine could accelerate the early postoperative quality of recovery in patients undergoing lumbar spinal stenosis surgery. 66 patients were enrolled in this trial. Lidocaine or placebo was administered at a loading dose of 1.5 mg/kg for 10 min and then infused at 2.0 mg/kg/hour till the end of surgery. Continued infusion by postoperative patient-controlled intravenous analgesia with a dose of 40 mg/hour. The primary outcome was the quality of recovery. Secondary outcomes included the time of the patient's first flatus, catheter removal time, underground time from the end of the surgery, pain score, levels of inflammatory factors (IL-6, IL-10, TNF-α), postoperative nausea and vomiting (PONV), sufentanil rescues, patients' satisfaction scores, and complications of lidocaine. Eventually, 56 patients were in the final analysis with similar age, Body Mass Index (BMI), duration of surgery and anesthesia, and median QoR-15 score (a development and Psychometric Evaluation of a Postoperative Quality of Recovery Score). The difference in median QoR-15 score in placebo versus lidocaine patients was statistically significant (IQR, 106 (104-108) versus 114 (108.25-119.25), P < 0.001). The Numeric Rating Scale (NRS) score at the 12th hour, median sufentanil rescue consumption, IL-6, tumor necrosis factor-alpha (TNF-α) of patients treatment with lidocaine were lower. Nevertheless, patients given lidocaine had high satisfaction scores. Suggesting that lidocaine enhanced the postoperative quality of recovery, met early postoperative gastrointestinal function recovery, provided superior pain relief, lessened inflammatory cytokines, etc., indicating it may be a useful intervention to aid recovery following lumbar spinal stenosis surgery.