|Year : 2018 | Volume
| Issue : 1 | Page : 16-20
Intraoperative lignocaine infusion achieving earlier discharge criteria among laparoscopic cholecystectomy patients
Shreya Lahiri1, Sabyasachi Das2, Sekhar Ranjan Basu3
1 Department of Anaesthesiology, Malda Medical College, Malda, West Bengal, India
2 Department of Anaesthesiology, Medical College, Kolkata, West Bengal, India
3 Department of Anaesthesiology, North Bengal Medical College, Siliguri, West Bengal, India
|Date of Web Publication||17-Aug-2018|
18/5, Majlish Ara Road, Kolkata - 700 041, West Bengal
Source of Support: None, Conflict of Interest: None
Background: Laparoscopic cholecystectomy (LC), gaining worldwide popularity for being less invasive, enhances earlier recovery. It can be performed on a short stay basis, reducing health care burden, if postoperative pain is adequately addressed. The aim of the present study is to determine the effect of intraoperative infusion of intravenous (IV) lignocaine primarily in terms of time to achieve fast-track eligibility (White Song score 12 out of 14) and postoperative analgesia in patients undergoing LC.
Materials and Methods: A total of 120 ASAPS 1 and 2 patients undergoing elective LC were included in this randomized, prospective, placebo-controlled clinical study. Patients were allocated into two groups to receive intraoperative IV lignocaine (Group L) or normal saline (Group C). Lignocaine bolus dose 1.5 mg/kg was administered over a period of 5 min before induction followed by continuous IV infusion 3 mg/kg/h until extubation. Postoperative fentanyl requirement (during the first 6 postoperative hours) and fast-track eligibility (time to reach White Song score 12 out of 14) were recorded.
Results: Time to achieve White Song score 12 out of 14 was found to be earlier in Group L (19.9 ± 3.6 min vs. 22.9 ± 2.9 min, P < 0.001). Postoperative requirement of fentanyl was significantly lower (99.3 ± 29.8 μg in Group L compared to 133 ± 35.9 μg in Group C, P < 0.001) in patients of lignocaine group.
Conclusion: IV lignocaine effectively improves recovery and reduces postoperative fentanyl requirement, thereby is an inexpensive and safe method of postoperative analgesia.
Keywords: Infusion, intravenous, laparoscopic cholecystectomy, lignocaine, postoperative analgesia
|How to cite this article:|
Lahiri S, Das S, Basu SR. Intraoperative lignocaine infusion achieving earlier discharge criteria among laparoscopic cholecystectomy patients. Saudi J Laparosc 2018;3:16-20
|How to cite this URL:|
Lahiri S, Das S, Basu SR. Intraoperative lignocaine infusion achieving earlier discharge criteria among laparoscopic cholecystectomy patients. Saudi J Laparosc [serial online] 2018 [cited 2019 Jun 24];3:16-20. Available from: http://www.saudijl.org/text.asp?2018/3/1/16/239217
| Introduction|| |
Laparoscopic cholecystectomy (LC) has gained much popularity as a short-stay basis procedure. Surgical trauma although less in LC compared to open one, provokes neuroendocrine stress response and inflammation leading to significant postoperative pain, nausea, and vomiting. Acute postoperative pain after LC can lead to a significant morbidity and slow patient recovery. This pain is considered unique as its characteristics are not limited to incisional and visceral deep pain, but also encompasses referred shoulder pain. In 17%–41% of the patients, pain is the dominating complaint and primary reason for staying overnight in the hospital on the day of surgery. The management of postoperative pain after LC can be particularly challenging because of lack of potent analgesics without dose-limiting adverse effects. Postoperative analgesia has never consistently satisfactory with conventional analgesics.
Lignocaine, being an amide local anesthetic has neural conduction inhibition property which makes it a potential adjuvant drug for postoperative pain relief. Intravenous (IV) lignocaine has analgesic, antihyperalgesic, and anti-inflammatory  properties. They act at the periphery, decreasing the release of inflammatory mediators, and centrally, modifying neuronal responses in the spinal dorsal horn. These effects are thought to be mediated by a variety of mechanisms, including sodium channel blockade, as well as inhibition of G-protein coupled receptors , and N-methyl-D-aspartate receptors.
Because postoperative pain is to a large extent an inflammatory phenomenon, administration of systemic local anesthetics, which have inflammation modulatory properties, could significantly reduce pain. A more important question remains unanswered-whether analgesic properties of systemic lignocaine translate into an improvement in postoperative recovery in patients undergoing ambulatory surgery.
This study is being carried out to assess the effect of intraoperative lignocaine infusion in LC patients in terms of fast-tracking eligibility  and analgesia in our population.
| Materials and Methods|| |
After obtaining the institutional ethics committee approval, this randomized, double-blinded, placebo-controlled trial was carried out between January and December 2010 in the Department of General Surgery and Anaesthesiology of our institution. Patients aged between 25 and 45 years of either sex, ASAPS I and II posted for LC were included in this study. Exclusion criteria were: patient's refusal, chronic systemic illness (hypertension, diabetes mellitus, liver and kidney failure), obesity, history of smoking, chronic use of opioids and other analgesics, inability to comprehend pain assessment.
A total of 120 patients (sample size = 100), scheduled for elective LC were enrolled in this prospective, randomized study. Five patients did not meet our study criteria and seven patients refused to participate. Thus, a total of 108 patients were randomized and assigned equally to receive either lignocaine (Group L, n = 54) or normal saline (Group C, n = 54) according to a computer-generated randomization schedule. After excluding dropouts (two patients in lignocaine group and one patient in control group were converted to open), data of 52 patients of Group L and 53 patients of Group C were finally analyzed. The detail of the conduct of the study (CONSORT diagram) is shown in [Figure 1].
|Figure 1: Study design according to the CONSORT diagram showing the flow of participants through each stage of randomized trial|
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During the preanesthetic checkup, written informed consents (after proper explanation of the study procedure in their own languages) were obtained from all the 108 participants. Patients were explained before surgery in the use of visual analog scale (VAS) score (0–10) to assess postoperative pain.
Randomization of the study medication (lignocaine versus normal saline) was performed with computer-generated random numbers maintained in sequentially numbered, opaque envelopes.
On arrival of the patient in the operation theatre, baseline values of heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), peripheral arterial oxygen saturation (SpO2), and temperature were recorded. Patients were preloaded with Ringer's lactate solution (10 ml/kg).
The study drug was prepared before induction by a junior resident who did not take part in further data retrieval or analysis. Twenty-five milliliter of 2% lignocaine (xylocard) was diluted with 25 ml of normal saline to make a 10 mg/ml lignocaine solution. The placebo and the lignocaine solutions looked identical. The anesthesiologist in charge of the case was unaware of the patient's group assignment undertook the anesthetic procedure and was instructed to avoid using local anesthetics. Another anesthesiologist performed the assessments and intraoperative data retrieval.
Before induction of anesthesia, all the patients of either Group L or Group C received IV injection fentanyl (2 μg/kg) 5 min before induction. Patients in the lignocaine group received the bolus dose 1.5 mg/kg over 5 min via infusion pump at the rate of 1.8 ml/kg/h started 5 min before induction. Bolus was followed by continuous infusion of 3 mg/kg/h of lignocaine. The infusion rate was 0.3 ml/kg/h and was to be stopped after extubation. This infusion dose was selected after conducting a few pilot studies. Normal saline bolus and continuous infusion were administered at the same rate.
General anesthesia was induced with propofol (2–2.5 mg/kg) until the loss of verbal contact. Optimum intubating condition was achieved using muscle relaxant vecuronium (0.1 mg/kg), and intubation was done under direct laryngoscopy. Adequate plane of anesthesia was maintained with N2O in O2, isoflurane (0.2%–0.8%) to maintain the HR and SBP within ± 20% of respective baseline values. The supplemental neuromuscular blockade was achieved with vecuronium at 15–20 min interval.
Intraoperative minute ventilation was continued so as to maintain normocarbia (EtCO2 between 30 and 35 mmHg). Intraabdominal pressure was maintained below 12 mm Hg. No local anesthetic infiltration was done.
Episodes of intraoperative hypotension (MAP <60 mm Hg) was treated with IV boluses of phenylephrine and bradycardia (HR <50/min) with atropine. There was a definitive back up plan provided to the attending anesthesiologist to address intraoperative hemodynamic instability and awareness.
Isoflurane was discontinued after the last skin suture, and on return of flickering movement on the reservoir bag, N2O inhalation was stopped. Reversal of residual neuromuscular blockade was achieved with incremental dosing of IV injection neostigmine (up to a maximum of 0.07 mg/kg) and glycopyrrolate (0.01–0.02 mg/kg). Tracheal extubation was done when standard criteria of extubation were fulfilled.
Injection diclofenac (1 mg/kg) was administered as infusion over 15 min, 10–15 min before reversal.
All the operative procedures were performed by two surgeons who were already performing LC for more than 5 years, thus limiting surgical variation.
After adequate reversal, all the patients were transferred to the postanesthesia care unit (PACU) for assessment during the next 6 h. During this period, VAS score (pain assessment), HR, SBP, DBP, electrocardiogram, and SpO2 were monitored by a junior resident unaware of the intraoperative anesthesia record. No intraoperative data were available in the PACU.
At the PACU, during first 6 postoperative hours, injection fentanyl was prescribed for postoperative pain relief as 10 μg aliquots on demand so as to maintain VAS score ≤3 at rest or ≤4 with movement. Maximum allowable dose was 100 μg of injection fentanyl over 1 h. VAS scores were noted at 10 min interval during first 30 min, thereafter hourly for next 6 h.
Fast-tracking eligibility was assessed by a junior resident using the White Song scoring system  every 3 min during postoperative period and time to achieve a score of 12 out of 14 was noted. The variables evaluated in White Song Scoring system included the level of consciousness, physical activity, hemodynamic stability, respiratory stability, SpO2 status, postoperative pain assessment, and postoperative emetic symptoms (each of 7 parameters having score 0–2).
Total IV fentanyl requirement in the PACU (during first 6 postoperative hours) was noted. The incidence of any adverse event such as postoperative nausea and vomiting (PONV), light-headedness, sedation, headache, perioral numbness, or seizures was reported.
Demographic and clinical variables between two groups were compared using independent sample t-test for normally distributed variables and Pearson Chi-square test for categorical variables. The level of statistical significance was set at P < 0.05 for all analyses. Statistical analyses were performed using SPSS statistical package, Version 14. (SPSS Inc., Chicago, IL).
| Results|| |
Patients' demographic parameters and surgical factor were not different between two groups [Table 1]. Patients reached White Song score 12 (out of 14) significantly earlier in the Group L. While patients of lignocaine group took 19.9 ± 3.6 min to recover, control group patients required 22.9 ± 2.9 min (P < 0.001) shown in [Figure 2].
Total fentanyl consumption during the postoperative period was significantly higher (133 ± 35.9 μg in Group C compared to 99.3 ± 29.8 μg in Group L, P < 0.001) in patients of control group. Time to first request of fentanyl (time between skin closure and first request of injection fentanyl) was also significantly earlier (30 ± 6.8 min in Group L and 20.3 ± 5.9 min in Group C) in the control group shown in [Table 2].
|Table 2: Total fentanyl requirement (mcg) and time to first request of fentanyl (min)|
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Regarding hemodynamic parameters monitored during anesthesia, HR, and MAP were better maintained in the Lignocaine Group. Regarding side effects, mild to moderate nausea was more in Group C (12 out of 53, i.e. 22.6%) than Group L (5 out of 52, i.e. 9.6%) (P < 0.05). Severe nausea and vomiting was significantly more in Group C (4 out of 53, i.e. 7.5%) compared to Group L (1 out of 52, i.e. 1.9%) (P < 0.05). Sedation was noted more in Group C (5 out of 53, i.e. 9.4%) and Group L (2 out of 52, i.e. 3.8%) although it was not significant (P > 0.05). No differences in lightheadedness, perioral numbness were noted among the groups.
| Discussion|| |
In the present study, patients receiving IV lignocaine achieved better fast-tracking criteria scoring (White Song Score 12 out of 14) earlier. In addition, we found 25% reduction of postoperative fentanyl consumption in the patients receiving lignocaine.
Postoperative pain associated with LC is not only incisional pain but also visceral pain arising from damage to internal organs. Pain was reported as the dominant complaint and the primary reason for postoperative admission after LC, however, implementation of multimodal analgesia during the last decade has made this operation an ambulatory procedure in the majority of patients.
Bartlett et al. have reported a significant analgesic effect of IV lignocaine extending into the third postoperative day with 1000 mg of lignocaine given intraoperatively. In the study, patients of Group L received 264.5 ± 27.2 mg of lignocaine infusion intraoperatively.
Opioid sparing effect of lignocaine was noted by Lauwick et al. who found 36% reduction in postoperative Fentanyl requirement in LC patients. Groudine et al. showed 53% reduction in postoperative morphine consumption in radical prostatectomy (lignocaine infused during the intraoperative period and continued 1 h postoperatively). Their study was optimized to reach an early hospital discharge in patients undergoing radical retropubic prostatectomy. In the study of Kaba, et al., lignocaine infusion was maintained for 24 h after laparoscopic colectomy surgery and resulted in >50% reduction in piritramide consumption from 0 to 24 h. Koppert, et al. demonstrated 35% reduction in postoperative Morphine requirement in major abdominal surgeries, where lignocaine was infused intraoperatively and was stopped 1 h after the end of surgery.
Two mechanisms are found to explain analgesic efficacy: a selective depression of pain transmission in spinal cord and a reduction in tonic neural discharge of active peripheral nerve fibers. The peripheral nerve fibers mediating pain are A-δ and C fibers, which appear to be uniquely sensitive to the effects of lignocaine without threat of toxicity or disturbance in hemodynamics. Although the analgesic effects of systemic lignocaine have been proven for chronic pain, especially for neuropathic pain states, conflicting results have been achieved in acute pain, such as postoperative pain. Cepeda et al. found no evident effect on opioid use or pain levels comparing lignocaine plus morphine versus morphine alone. In their study, lignocaine was used for intraoperative as well as postoperative period.
We carried out our study for the first six postoperative hours whereas most other studies lasted for more than 24 h postoperatively.,,
Recently, IV lignocaine was used for total hip arthroplasty, and no impact on postoperative analgesia was reported. This finding lends further support to the predominant role of lignocaine in the treatment of visceral pain.
No statistically significant difference was noted in the incidence of PONV, however, incidence was found to be more in control group. This finding corroborated with the results of other studies., The sedative property of systemic lignocaine is a concern for clinical practitioners because of a potential effect in delaying hospital discharge. In this study, incidence of sedation in the postoperative period was noted more in control group although it was not significant, similar to other studies. IV lignocaine in doses of 1–2 mg/kg has been shown to transiently suppress coughing and other airway reflexes. This increases the risk of aspiration, though no such event happened in our study. We did not observe any potential cardiovascular or neurological side effects associated with the infusion of systemic lignocaine. We were unable to detect early signs of neurological toxicity, as the subjects were paralyzed under general anesthesia. Nonetheless, the safety of small dose lignocaine infusion has been demonstrated by others in clinical investigations., No report of toxic concentration of plasma lignocaine was found in other studies measuring plasma concentration of lignocaine after bolus and at different time interval during and after bolus. Mean plasma lignocaine concentration ranged from 0.6 to 5 μg/ml. Not measuring plasma concentration of lignocaine was a limiting factor of our study. In addition, anesthetic or analgesic-sparing effect of lignocaine could not be commented from our study. Injection diclofenac was used in both groups before extubation, this could have affected to some extent on postoperative analgesic requirement in our study. Further studies can be carried out in this field to assess beneficial effects of lignocaine infusion in other types of surgeries; to establish optimum dosage, timing and duration of lignocaine infusion.
| Conclusion|| |
From this study, it can be concluded that IV lignocaine infusion promotes faster recovery in patients undergoing LC. It also reduces postoperative opioid consumption and opioid-induced nausea vomiting. Therefore, intraoperative lignocaine infusion is a reliable option as an adjuvant analgesic.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2]