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Protocol for the selection and review of patients for administration of IV lidocaine infusion in Day Procedure Unit For Use in: By: For: Division responsible for document: Key words: Name of document author: Job title of document author: Name of document author’s Line Manager: Job title of author’s Line Manager: Supported by: Assessed and approved by the: Date of approval: Ratified by or reported as approved to (if applicable): To be reviewed before: This document remains current after this date but will be under review To be reviewed by: Reference and / or Trust Docs ID No: Version No: Description of changes: Compliance links: (is there any NICE related to guidance) If Yes - does the strategy/policy deviate from the recommendations of NICE? If so why? 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