Lidocaine infusion for pain

  1. My ED is looking into a whole "narc free" model of pain treatment including Lidocaine infusion for pain. Does anyone have experience with this? Does it work? I've given it plenty prior to Amiodarone but never had a patient say it helped with pain.
    •  
  2. Visit nurse2033 profile page

    About nurse2033

    Joined: Jun '07; Posts: 2,119; Likes: 3,078
    RN, paramedic; from US
    Specialty: ER, ICU

    16 Comments

  3. by   offlabel
    It's an adjunct to a multi-modal approach to pain management. For acute pain, IV lidocaine is about as useful as giving the patient soothing music thru head phones. Now, if you add IV Tylenol, pregabalin (or something like it) and a little ketamine and maybe some MgSO4, then you might make the patient a little more comfortable.

    If I bring my kid to the ER for a broken bone, he ought to get a narcotic and not IV lidocaine.

    The whole notion of a "narcotic free ER" is pretty flawed, imho. Certainly, the notion of no iv narcotics is truly absurd, but I doubt that would catch on for long.

    If ER physicians really want to make good use of local anesthetics, they'll learn to do some useful peripheral nerve blocks.
  4. by   nurse2033
    Well that was my impression too, thanks. I think the goal will be for narcs as a second line intervention. Nitrous will be in the mix too.
  5. by   offlabel
    Quote from nurse2033
    Well that was my impression too, thanks. I think the goal will be for narcs as a second line intervention. Nitrous will be in the mix too.
    I think the nitrous makes less sense than the lidocaine. The goal is to move the patient along asap, but the nitrous is gone as soon as the mask is removed. You'd just have to start all over.

    What is the reason your department wants to do this?
  6. by   heron
    Quote from offlabel
    I think the nitrous makes less sense than the lidocaine. The goal is to move the patient along asap, but the nitrous is gone as soon as the mask is removed. You'd just have to start all over.

    What is the reason your department wants to do this?
    My guess is Pendulum Syndrome: from narcs for everything to no narcs at all, instead of a rational middle course of narcs only when they're known to be effective.
  7. by   nurse2033
    It's coming from our CEO and some interest at the state level.
  8. by   CraigB-RN
    It's been used perioperativly for awhile now, and used correctly in proper patients, it works OK but not as a stand alone.

    https://www.mc.vanderbilt.edu/docume...%20HR-PACU.pdf
    Effectiveness of intravenous lidocaine versus intravenous morphine for patients with renal colic in the emergency department
    IV Lidocaine for Renal Colic: Not Ready for Prime Time - NEJM Journal Watch

    I don't see it fixing out opiate problem any time soon.

    The issue with narcs isn't the treatment of accute pain right in front of you, it's the over use as a take home medication. You don't need to send the renal colic patient home with 40 Oxy 10/325. Just enough for a few days.
  9. by   offlabel
    Quote from CraigB-RN
    The issue with narcs isn't the treatment of accute pain right in front of you, it's the over use as a take home medication. You don't need to send the renal colic patient home with 40 Oxy 10/325. Just enough for a few days.
    Yes, the issue is prescription narcotic use, but the vast, and I mean vast, majority of the "problem" prescriptions are not written from the ER. It's PCP's from this or that clinic or office. To target the ER to fix that problem is like yelling at your kids because you had a lousy day at work.

    Yes, seekers come through the ER, but it doesn't mean that ER providers aren't grownups that are unable to direct the patient appropriately and who need bureaucratic assistance in doing so.
  10. by   Oh'Ello
    We use intravenous lidocaine perioperatively pretty often and the results are mixed but typically successful. We have specific programming surrounding its use and we're all quite familiar with the protocols. With that said, I've probably seen close to fifty patients with IV lidocaine infusions, and every single one of them was a GI / abdominal surgery patient. We implemented the use of IV lidocaine (in conjunction with ketamine) to reduce opiate requirements in this population because of the heightened risk of complications from decreased bowel motility that come with post op immobility and opiate use. This care bundle is apparently having a measurable positive effect on early recovery after gi surgery in our facilities.

    BUT

    Lidocaine has a very VERY narrow therapeutic index. Serial lidocaine levels MUST be drawn to assess for toxicity. And as we all know, tox labs take forevahhhh to result. Its also specified in our protocol that if the patient's pain is not adequately controlled with the ketamine/lidocaine infusion, and they are requiring more opiates (the opiate requirements are patient specific), the lidocaine must be discontinued and the plan of care can be reverted to a more common pain control regimen. The reason for this is that concurrent opiate use can obscure the early symptoms of lidocaine toxicity which are often very patient subjective (blurred vision, metallic taste, peripheral neuropathy, etc). These patients are also receiving the benefit of sedation for some time post-operatively, which is ultimately aiding pain control by lack of awareness. Long story short, we're giving this to bridge the gi-surg patients from the OR until their bowels start showing signs of movement and then converting them to lower dose opiates if necessary.

    with all that said

    none of that **** makes any sense for use in an ER.


    More (interesting and totally readable) info on ERAS here
  11. by   maporcrn1
    In the past, (25 yrs ago) I worked with a Pain Management specialist who ordered lidocaine infusions for pain management for patients with chronic pain. I am not sure if this worked for the patients or not. A patient recieving a lidocaine infusion should have continuous cardiac monitoring and be observed for signs of local anesthesia sytemic toxicity. Lidocaine or similar drugs given in a specified area or close to the nerve roots is definitely helpful. Lidocaine is a shorter acting medicine and may only be benificial for a short time period.
  12. by   Pixie.RN
    Quote from Oh'Ello
    with all that said

    none of that **** makes any sense for use in an ER
    YES. This right here.
  13. by   wyosamRN
    I worked with one doc that used IV lido & toradol for some kidney stone patients for a while instead of morphine/toradol. The first time he ordered it, I had to look it up to make sure it was a real thing. There were some studies supporting that use, and the few patients I administered it to seemed to have similar results- the lido gave some short term relief while the toradol had time to take effect. I dont know if he still does this, as I moved shortly after he started using this regimen. Just reporting on this use, I am in no way supporting anti-opiate EDs. There are benefits to finding workable alternatives though- those patients were able to be discharged without having to find someone to drive them home, we do occasionally see people who are recovering from opiate addiction who want to avoid opiates for fear of relapse, etc..
  14. by   pockunit
    NYT published a story about an ER going mostly narc-free. It was pretty interesting. I'd like it if we gave it a try, but I don't think management would go for it.

close