Download Selection and review of patients for administration of IV lidocaine

Protocol for the selection and review of patients for administration of IV lidocaine
infusion in Day Procedure Unit
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Day Procedure Unit
Consultants in Pain Medicine and Advanced Pain
Trainees
Patients with pain of neuropathic origin fulfilling the
inclusion criteria
Surgical; Pain Management
Lidocaine neuropathic pain
Mike Hudspith, Kate Wyatt
Consultant in Pain Medicine, Specialist Nurse Pain
Management
David Spackman
Clinical director Anaesthetics
Dr Mike Sidery, Dr Ravi Kare, Dr Mark Sanders, Dr
Ann-Katrin Fritz ( Consultants in Pain Medicine)
Drugs, Therapeutics and Medicines
Management Committee / Pain Management
Governance Meeting
Clinical Guidelines and Assessment Panel
(CGAP)
If approved by committee or Governance
Lead Chair’s Action; tick here 
26/04/2016
Clinical Standards Group and Effectiveness
Sub-Board
26/04/2019
Mike Hudspith
12613
1
None
N/A
This guideline has been approved by the Trust's Clinical Guidelines Assessment Panel as an aid to the diagnosis and
management of relevant patients and clinical circumstances. Not every patient or situation fits neatly into a standard
guideline scenario and the guideline must be interpreted and applied in practice in the light of prevailing clinical
circumstances, the diagnostic and treatment options available and the professional judgement, knowledge and
expertise of relevant clinicians. It is advised that the rationale for any departure from relevant guidance should be
documented in the patient's case notes.
The Trust's guidelines are made publicly available as part of the collective endeavour to continuously improve the
quality of healthcare through sharing medical experience and knowledge. The Trust accepts no responsibility for any
misunderstanding or misapplication of this document.
Protocol for: The se lection and review of patients for administration of IV lidocaine in Day Procedure Unit
Author/s and title: Mike Hudspith, Consultant in Pain Medicine , Kate Wyatt , Specialist Nurse Pain Management
Approved by: CGAP
Date approved: 26/04/2016
Review date: 26/04/ 2019
Trust Docs ID: 12613 v1
Page 1 of 4
Protocol for the selection and review of patients for administration of IV lidocaine
infusion in Day Procedure Unit
Objective

To select appropriate patients with neuropathic pain for administration of IV
lidocaine infusion in the Day Procedure Unit.

To assess the effect of IV lidocaine and repeat the infusion if indicated
Glossary
CRPS – Complex Regional Pain Syndrome
NeP – neuropathic pain
Rationale
Neuropathic pain patients typically have higher than average pain scores, require more
medication and report less pain relief after treatment (O’Connor & Dworkin 2009).
Medications used routinely in the management of neuropathic pain include
antidepressants (TCA and SNRI), anticonvulsants, opioids and topical agents. However,
a significant proportion of patients obtain minimal benefit and side effects may limit their
tolerability.
Extensive animal studies of neuropathic pain demonstrate that the pathophysiology of
neuropathic pain includes up-regulation and/or phenotypic change of expression of
sodium channel sub-types in both peripheral and central neurones (see Cummins &
Waxman 2010 for review). Sodium channel blockade with lidocaine is therefore an
appropriate mechanism-based treatment for management of neuropathic pain. Similar
evidence exists for subgroups of patients with widespread diffuse pain syndromes
(Vargas-Alarcon et al 2012, Uceyler et al 2013)
The clinical efficacy of intravenous lidocaine in neuropathic pain has been widely
reported. Systematic review and meta-analysis (Tremont-Lukats et al 2005)
supplemented by a recent Cochrane review (Challapali et al 2014) have demonstrated
that iv lidocaine 3-5mg/kg over 30-60 mins is safe and more effective than placebo in
the treatment of neuropathic pain.
Selection Criteria:
1. Inclusion – the patient has completed the following assessment

Consultant assessment and MDT involvement to encompass biopsychosocial
components of pain presentation

Pain diagnosis and NeP symptoms compatible with potential response to
lidocaine
o peripheral NeP
o Central NeP
o CRPS
o Fibromyalgia with neuropathic descriptors
Protocol for: The se lection and review of patients for administration of IV lidocaine in Day Procedure Unit
Author/s and title: Mike Hudspith, Consultant in Pain Medicine , Kate Wyatt , Specialist Nurse Pain Management
Approved by: CGAP
Date approved: 26/04/2016
Review date: 26/04/ 2019
Trust Docs ID: 12613 v1
Page 2 of 4
Protocol for the selection and review of patients for administration of IV lidocaine
infusion in Day Procedure Unit

pain uncontrolled despite trials (unless contraindicated) of
o
o
o
o
amitriptyline or other tricyclic
gabapentinoid
duloxetine
tramadol or other low dose opioid

pain not treatable by neuraxial or peripheral neural blockade

pain not treatable by neuromodulation
2. Exclusion – contra indications

Symptomatic cardiovascular disease
o tachyarrythmia
o cardiac failure
o angina

Epilepsy with seizure within 6 months

Hypersensitivity to amide local anaesthetic drug
Review post infusion
Outpatient review at ~90 days post-procedure:

>50% pain relief during infusion but no post-procedure analgesia
o oral sodium channel blocking drug at consultant discretion
o do not repeat infusion

>50% relief during infusion and global improvement >2/12 duration
o repeat infusion after minimum 3/12 interval

minimal pain relief during or after infusion
o do not repeat infusion
o do not use sodium channel blocking drugs
Monitoring compliance
To ensure that this document is compliant with the above standards, the following
monitoring processes will be undertaken:
Annual monitoring will take place using Electronic Template and /or ORSOS to identify
patients who have had administration of IV Lidocaine infusion (see appendix for
monitoring table)
Protocol for: The se lection and review of patients for administration of IV lidocaine in Day Procedure Unit
Author/s and title: Mike Hudspith, Consultant in Pain Medicine , Kate Wyatt , Specialist Nurse Pain Management
Approved by: CGAP
Date approved: 26/04/2016
Review date: 26/04/ 2019
Trust Docs ID: 12613 v1
Page 3 of 4
Protocol for the selection and review of patients for administration of IV lidocaine
infusion in Day Procedure Unit
The monitoring results will be sent to the Drugs, Therapeutics and Medicines
Management Committee who will ensure that these are discussed at relevant
governance meetings to review the results and make recommendations for further
action.
Summary of development and consultation process undertaken before
registration and dissemination
The authors listed above drafted this document on behalf of the Pain Management
Centre who has agreed the final content. During its development it has been circulated
for comment to:
Consultants in Pain Medicine
Pain nurses
Specialist physiotherapists in Pain Management
Specialist Psychologists in Pain Management
Inclusion and exclusion criteria were agreed in Pain governance and the protocol
approved in Pain governance 28/01/2016.
This version has been endorsed by the (relevant) Committee(s).
References
Challapalli et al 2014: The Cochrane Library
Cummins & Waxman 2010: in Beaulieu et al (Eds) Pharmacology of Pain IASP 2010 pp
139-61
O’Connor AB and Dworkin RH. Treatment of neuropathic pain: An overview of recent
guidelines. The American Journal of Medicine 2009; 122: S22–S32.
Tremont-Lukats et al 2005: Anesth. Analg. 101: 1738-49
Uceyler et al 2013: Brain 136: 1857-67
Vargas-Alarcon et al 2012: http://www.biomedcentral.com/1471-2474/13/23
Protocol for: The se lection and review of patients for administration of IV lidocaine in Day Procedure Unit
Author/s and title: Mike Hudspith, Consultant in Pain Medicine , Kate Wyatt , Specialist Nurse Pain Management
Approved by: CGAP
Date approved: 26/04/2016
Review date: 26/04/ 2019
Trust Docs ID: 12613 v1
Page 4 of 4