Lidocaine is an amide local anesthetic commonly used for local or topical anesthesia. As with other local anesthetics, lidocaine’s mechanism of action occurs at sodium ion channels on the internal surface of the plasma membranes of neurons. By ionizing via the hydrogen ions present in the axoplasm, the initially uncharged molecule becomes a cation that can bind reversibly to the sodium channels while they are in their “open” state, preventing depolarization and, consequently, signaling. Compared to other local anesthetic agents, lidocaine has a medium duration of action and lesser lipid solubility (which limits its overall potency).1 Nonetheless, the relative safety of this anesthetic as well as its ability to be administered via different routes has made it the most popularly used amide local anesthetic.2 In particular, intravenous lidocaine has several uses in the perioperative setting.
One of the uses of intravenous lidocaine is for the management of early postoperative pain. A 2020 review of controlled trials for intravenous lidocaine infusion conducted by Chu et al. found strong evidence that intravenous lidocaine reduces postoperative (defined in the review as 1–4 hours after surgery) pain when compared to placebo. The authors found that it was a relatively safe drug, with hypotension, headache, and emesis being the most common side effects. However, they note that clinicians should be cautious about the dosing of lidocaine. Intravenous lidocaine also appeared to have advantageous effects [RJ1] on gastro-intestinal motility, length of hospital stays, postoperative nausea, and opioid consumption. Because of these benefits, Chu et al. suggest that a postoperative pain management protocol that uses intravenous lidocaine could lead to improved recovery and reduce potential harmful effects of postoperative pain.3
A more recent 2022 review in the Journal of Clinical Medicine [RJ2] expands upon the potential uses of intravenous lidocaine perioperatively. For colorectal surgery, around 40% of patients experience a delay in the resumption of normal bowel function, leading to postoperative nausea, emesis, constipation, and abdominal distension, which can then necessitate further unpleasantness in the form of supportive intravenous fluids and nasogastric tube insertion. Various meta-analyses of lidocaine use in this context have shown that it consistently improved postoperative Visual Analogue Scale (VAS) scores in patients undergoing either open or laparoscopic colorectal surgery. Further, it has been demonstrated that intraoperative and postoperative opioid requirements were decreased with the use of lidocaine, indicating that lidocaine treatment may be especially beneficial for bariatric patients who are more susceptible to respiratory depression caused by opioid analgesics. Likely because of the reduction in opioid use, a reduction in postoperative nausea and emesis of up to 20% was also reported after perioperative intravenous lidocaine infusion. Finally, lidocaine was also shown to reduce the length of hospital stay by an average of eight hours.4
Lidocaine stands as a very promising potential non-opioid analgesic adjunct to reduce pain and improve results after surgery. However, as the 2022 review cautions, it is important to remember that there is much more research to be done to clarify the safety and efficacy of intravenous lidocaine for different surgical uses.4 Thus, it should be considered on a patient- and procedure-specific basis, and clinicians should exercise caution in particular when determining the dosage of lidocaine to be applied.
References
(1) Beecham, G. B.; Nessel, T. A.; Goyal, A. Lidocaine. In StatPearls; StatPearls Publishing: Treasure Island (FL), 2024.
(2) Golzari, S. E.; Soleimanpour, H.; Mahmoodpoor, A.; Safari, S.; Ala, A. Lidocaine and Pain Management in the Emergency Department: A Review Article. Anesth Pain Med 2014, 3 (3). https://doi.org/10.5812/aapm.15444.
(3) Chu, R.; Umukoro, N.; Greer, T.; Roberts, J.; Adekoya, P.; Odonkor, C. A.; Hagedorn, J. M.; Olatoye, D.; Urits, I.; Orhurhu, M. S.; Umukoro, P.; Viswanath, O.; Hasoon, J.; Kaye, A. D.; Orhurhu, V. Intravenous Lidocaine Infusion for the Management of Early Postoperative Pain: A Comprehensive Review of Controlled Trials. Psychopharmacol Bull 2020, 50 (4 Suppl 1), 216–259.
(4) Lee, I. W.-S.; Schraag, S. The Use of Intravenous Lidocaine in Perioperative Medicine: Anaesthetic, Analgesic and Immune-Modulatory Aspects. JCM 2022, 11 (12), 3543. https://doi.org/10.3390/jcm11123543.