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College of Nursing, University of Wisconsin, Oshkosh, WIAnesthesia Services of Fox Valley, Oshkosh, WINorth East Wisconsin Anesthesia Services, Neenah, WI
Pain is a universal event, and perianesthesia nurses provide a pivotal role in the assessment, treatment, and management of the physical and emotional responses to pain. Chronic neuropathic pain is particularly resistant to treatment, and patients often present after many failed therapies with multiple co-morbidities and complex medication histories. With more and more perianesthesia nurses involved with chronic pain management, it is imperative they understand the special nursing care needs of patients receiving intravenous lidocaine infusion therapy.
Objectives — (1) Describe signs and symptoms of lidocaine toxicity encountered during intravenous (IV) infusions. (2) Discuss pre-infusion assessments for patients with chronic neuropathic pain (CNP) undergoing IV lidocaine infusions. (3) Describe nursing interventions for patients with CNP experiencing untoward or toxic reactions during lidocaine infusions.
Pain is defined as an “unpleasant sensory and emotional experience associated with actual or potential tissue damage.”
Pain is a normal, physiologic response to tissue damage and is usually, but not always, self-limiting. Chronic pain is described as pain continuing after normal tissue healing is expected to occur. Chronic pain arises from changes to peripheral and central nervous system (CNS) structures and functions. These changes result in the continued transmission and processing of pain signals well beyond traditional healing times. Chronic pain is often clinically difficult to treat and manage long term.
Ideally, chronic pain treatment modalities should focus on addressing the underlying pathophysiology of damaged peripheral and central nerves. Current chronic pain management recommendations include medications to stabilize damaged nerve cell membranes, such as gabapentinoids as well as a variety of antidepressants and anticonvulsant medications. While opioid therapy may have a place in chronic pain management, due to side effects, addiction potential, and lack of multi-modal pain relief, it is not well-suited as the sole treatment modality for chronic pain management. Furthermore, a meta-analysis by Chou, Turner and Devine found no evidence of the effectiveness of long-term opioid therapy for the treatment of chronic pain.
The effectiveness and risks of long-term opioid therapy for chronic pain: a systematic review for a National Institutes of Health Pathways to Prevention Workshop.
Specifically, opioid therapy is also associated with mood changes, constipation, respiratory depression, tolerance, dependence, abuse, and even death. The unsuitability of opioid therapy for primary treatment of chronic pain, issues and costs associated management of opioid side effects, as well as the current opioid crisis in the United States, prompted the Centers for Disease Control and Prevention to call for development of nonopioid pain management strategies by experts in the field.
However, little has been published about the nursing care surrounding IV lidocaine infusion therapy. Perianesthesia nurses, due to their critical care background and diverse array of practice environments (preanesthesia and postanesthesia care, ambulatory surgery, and pain management) are well qualified to provide the ongoing assessment and management needed by patients receiving lidocaine infusions for chronic pain. The purpose of this article is to describe the nursing care required by patients with CNP receiving IV lidocaine infusions.
Pre-infusion Nursing Care
Initial nursing care for patients receiving lidocaine infusions includes confirming that informed consent has been obtained and a thorough assessment of patient allergies, medications, pain quantity and quality, concurrent health conditions, and functional status. Patients with chronic pain usually present with multiple allergies and/or intolerances due to the multiple medications and strategies attempted for pain management. Likewise, patients with chronic pain typically take multiple medications increasing the likelihood for additive side effects, drug interactions, dosing errors, sedation, and concomitant injury commonly manifest in patients taking medications.
During initial nursing assessment, patients’ daily opioid intake should be reviewed. In patients taking multiple opioids, daily intake can be assessed by calculating morphine equivalent dosages. This allows practitioners to determine a single equivalent dose of morphine by standardizing potencies and dosages of different opioid preparations. This is important because consuming greater than 50 mg morphine milligram equivalents (MME) per day usually fails to provide additional pain relief.
For patients consuming 50 to 99 MME per day, the risks of unintended overdose and death are increased by 1.9 to 4.6 times; taking ≥100 MME per day increases overdose risk 2 to 8.9 times.
A recent report involving 37 patients with CNP presenting for lidocaine infusion therapy found that 5 (13%) patients were taking ≥50 MME per day, and one patient was consuming >200 MME per day highlighting the need for MME assessments.
It is important to note that, while rare, some patients with CNP may receive IV or epidural opioids, which mandates conversion of these doses to an oral equivalent as well.
Chronic pain is commonly assessed and described using the PQRST model where the letters stand for Precipitating factors, Quality, Radiation, Subjective descriptions, and Time when the pain occurs. Subsequent assessments can focus on changes in pain quality or quantity over time using the Visual Annual or similar scale.
Functional status can be assessed with self-reported inventories such as the Brief Pain Inventory. The short Brief Pain Inventory is a valid and reliable tool measuring pain and the impact of pain on daily functions.
Pain assessment using the PQRST model and functional assessments should be conducted initially and intermittently throughout infusion therapy. Often, improvement in functional status is a more accurate measure of successful chronic pain management than improvements in the PQRST scale score alone.
Once baseline history and pain and functional status are addressed, the neurological and cardiac systems should be thoroughly assessed due to lidocaine's actions on sodium channels and cellular action potentials (central and peripheral nervous and cardiac systems). Thus, a baseline electrocardiography tracing should be obtained. Additionally, lidocaine undergoes hepatic metabolism via the cytochrome P450 system. Thus, liver dysfunction will prolong drug metabolism and clearance, increasing the risk for toxic reactions.
As previously described, patients with CNP typically present with significant co-morbidities, multiple drug allergies and extensive medication exposure. Like many other chronically ill patients, it is not unusual for patients with CNP to have difficult venous access availability.
Warming therapies, venous location devices (ultrasound, infrared), and local skin infiltration all help to achieve venous canulation and demonstrate a caring environment. For established therapy, long‐term venous access may be considered to avoid repeated difficult cannulations. Often, patients with CNP undergo lidocaine infusions as a last resort for intractable pain. In these situations, therapeutic, non-judgmental communication and ongoing emotional support from perianesthesia nurses is vitally important to treatment success and cannot be underestimated.
Nursing Care During Infusion
Following nursing assessments, patients should be positioned in comfortable, reclinable chairs or beds and instructed on the side effects of continuous IV lidocaine infusions, resulting from drug accumulation and lidocaine toxicity. Continuous electrocardiography and pulse oximetry monitoring and a baseline blood pressure measurement should be instituted before the infusion is started. For facilities with computer charting, blood pressure, heart rate, and pulse oximetry can be automatically recorded every 5 to 15 minutes and on demand for any changes in vital signs. The baseline cardiac rhythm should be charted as well as any changes throughout the infusion. Pre-infusion charting should also include duration of pain relief from last infusion and the pre-infusion PQRST or Visual Analogue pain score. Post-infusion charting should include rate of infusion, total lidocaine dose administered, patient tolerance of infusion, any changes in patient parameters or complications, along with the post-infusion pain score. Continuous monitoring by the perianesthesia nurse accompanied by appropriate chart notations is a vital part of the therapy.
Dosing regimens reported in the literature vary from a total dose of 3 mg/kg infused over 1 to 5 hours to a total dose of 21 mg/kg infused over 6 hours.
However, many report a dosing regimen of a total dose of 5 to 7 mg/kg to a maximum of 390 to 550 mg over 60 minutes for the initial lidocaine infusion,
Safety, tolerability, and short-term efficacy of intravenous lidocaine infusions for the treatment of chronic pain in adolescents and young adults: a preliminary report.
Researchers in one study found that most patients experienced side effects when lidocaine doses of 16.7 mg/min were administered, but infusion rates of 4 to 12 mg/min, equating to total dosages of ≤550 mg, were well tolerated.
Thus, during initial infusion therapy, doses are adjusted based upon patient parameters, and achievement and duration of pain relief. Despite these retrospective reviews, prospective studies are needed to determine effective lidocaine doses that promote prolonged pain relief while limiting toxic and side effects.
IV lidocaine infusions possess a long history of safe and effective use as an antiarrhythmic agent in critical care areas. More recently IV lidocaine is being used as part of a multimodal approach to pain management during anesthesia and surgery for enhanced recovery after surgery (ERAS) protocols to improve recovery times.
However, it is important to understand that side effects and toxicity reactions can, and do, occur with IV lidocaine. Early warning signs of lidocaine toxicity include tinnitus, blurred vision, circumoral numbness, paresthesia (especially of the tongue), and dizziness.
Safety, tolerability, and short-term efficacy of intravenous lidocaine infusions for the treatment of chronic pain in adolescents and young adults: a preliminary report.
As lidocaine blood levels increase, excitatory signs, restlessness, confusion, and agitation along with muscle twitching and seizures may appear. If left unattended, patients may attempt to get out of their chairs and/or remove their IVs, predisposing them to falls, injury, and loss of venous access. Thus, continuing assessment and monitoring by the perianesthesia nurse with immediate access to resuscitative equipment and rescue medication is mandatory.
If toxicity does start to manifest, the infusion should be stopped immediately. Rapid administration of an intralipid infusion should be given earlier rather than later in course of toxic lidocaine reactions (Figure 1), along with activations of the code or rapid response team.
It must be noted that intralipids may not abate CNS effects when toxicity from lidocaine occurs, and additional medication, such as midazolam or diazepam, may be required.
Helpful nonpharmacological interventions to suppress excitatory CNS effects for all patients throughout the infusion include lowering ambient lighting and limiting environmental noise with headphones. Pretreatment with IV midazolam to help ameliorate toxic effects and promote restfulness during the infusion is also very useful for patients without midazolam allergies or untoward reactions.
The most commonly encountered side effects of lidocaine infusions include dizziness, drowsiness, visual changes, tinnitus, numbness, tingling, perioral paresthesia, metallic taste in mouth, increases or decreases in blood pressure and/or pulse, arrhythmias, nausea and vomiting. These issues usually respond to slowing or stopping the infusion for a period 10 to 15 minutes. Once side effects abate, the infusion can typically be restarted at a slower rate as ordered by the prescribing provider. Patients who continue to exhibit side effects despite slowing of the infusion should have the infusion discontinued with notification sent to the referring healthcare provider. Thus, continuous patient assessment and monitoring of vital signs is required.
Safety, tolerability, and short-term efficacy of intravenous lidocaine infusions for the treatment of chronic pain in adolescents and young adults: a preliminary report.
Depending on patient co-morbidities and any previous reactions to lidocaine, nurse to patient ratios should be 1:1 or 1:2.
While undocumented in the literature and a rare occurrence, some patients may react paradoxically to IV lidocaine infusions with escalation of their chronic pain or experience a severe, unrelenting headache. Patients should be cautioned to immediately notify the nurse if their pain worsens and/or they start to develop a headache. In such events, the lidocaine infusion must be stopped immediately with intensive interventions implemented to prevent an episode of uncontrollable pain and/or headache. If the infusion continues during even mild increases in pain or sudden appearance of a mild headache, it quickly escalates and becomes uncontrollable. Following immediate discontinuation of the infusion, opioid and nonopioid analgesia should be administered until the pain is resolving or stabilized (not increasing).
Post-infusion Nursing Care
Lidocaine infusions are usually well tolerated in patients with CNP despite the presence of multiple co-morbidities. A recovery period of 30 to 60 minutes is recommended so patients can return to pre-infusion mentation, coordination, and mobility.
Patients can be discharged directly to their residence from the perianesthesia care area. For normal infusion encounters, discharge instructions should include restrictions on driving, making legal decisions, operating heavy equipment for 24 hours and avoidance of alcohol or other recreational drugs. Pre-infusion medications and dietary plans may be resumed on their regular schedule. Follow-up nursing assessments via telephone should be made within 3 to 5 days and include efficacy and duration of pain relief, appearance of side effects and requests for questions and feedback. A sample protocol for nursing care during IV lidocaine infusions for chronic pain patients is provided in Text Box 1.
Current medications and morphine milligram equivalents
•
Allergies and reactions
Obtain Intravenous Access
•
Venous location devices (ultrasound, infrared)
•
Skin localization using skin wheel or EMLA cream, if needed
•
Venous dilation strategies, such as extremity warming, if needed
Conduct Patient Education
•
Discuss importance of notifying the nurse immediately for:
○
Signs and symptoms of lidocaine side effects and toxicity, such as tinnitus, blurred vision, circumoral numbness, paresthesia (especially of the tongue), and dizziness
○
Increase in pain level, however slight
○
Appearance of headache, however slight
Transfusion Care
Prepare patient and environment:
•
Position patient comfortably, usually semi-recumbent position
•
Apply warm blankets and pillows, as preferred
•
Assess monitor functioning: continuous ECG and SaO2
•
Dim lighting, apply eye mask if preferred
•
Apply headphones to block ambient noises, or tune into favorite music if patient prefers
Administer IV midazolam, if ordered
Start lidocaine via syringe pump/infuser at prescribed dose and rate
Continuous patient monitoring: ECG and SaO2, with blood pressure if indicated
Avoid awakening/arousing patient
Stop infusion if side effects/toxic effects occur or until they disappear
Once side effects/toxic effects abate, restart infusion at slower rate
Immediately discontinue infusion if increased pain or headache occurs, and notify physician
Post Infusion Care
Continue patient monitoring for 30 to 60 minutes
Remove intravenous line
Schedule next infusion, if indicated(Continued on next page)
Discharge home when stable with the following instructions to:
•
Rest and relax and remainder of the day
•
Continue prescribed medications
•
Resume normal diet
•
Call clinic in case of issues
•
Call 9-1-1 in case of emergency
•
Avoid (for 24 hours):
○
driving, making legal decisions, and operating heavy equipment
○
alcohol and/or other recreational drugs
Telephone Follow-up
•
Three to 5 days post infusion
•
Assess:
○
efficacy and duration of pain relief,
○
appearance of side effects and
•
Also ask for:
○
any questions or concerns
○
feedback
Test ID W090221 – Expiration Date August 31, 2023
Nursing Care During Lidocaine Infusion Therapy for Chronic Pain
1.5 Contact Hours
Purpose of the Journal of PeriAnesthesia Nursing: To facilitate communication about and deliver education specific to the body of knowledge unique to the practice of perianesthesia nursing.
Outcome of this CNE Activity: To enable the nurse to increase knowledge on Lidocaine infusion therapy for chronic pain
Target Audience: All perianesthesia nurses
Article Objectives
1.
Describe signs and symptoms of lidocaine toxicity encountered during IV infusions
2.
Discuss pre-infusion assessments for patients with CNP undergoing IV lidocaine infusions
3.
Describe nursing interventions for patients with CNP experiencing untoward or toxic reactions during lidocaine infusions
Accreditation
American Society of Perianesthesia Nurses is accredited with distinction as a provider of nursing continuing professional development by the American Nurses Credentialing Center's Commission on Accreditation.
Provider approved by the California Board of Registered Nursing, Provider Number CEP5197, for 1.5 contact hours.
Additional provider numbers: Alabama #ABNP0074
Contact hours: Registered nurse participants can receive 1.5 contact hours for this activity.
Disclosure
All planners and authors of continuing nursing education activities are required to disclose any significant financial relationships with the manufacturer(s) of any commercial products, goods or services. Any conflicts of interest must be resolved prior to the development of the educational activity. Such disclosures are included below.
Planners and Author Disclosures
The members of the planning committee for this continuing nursing education activity do not have any financial arrangements, interests or affiliations related to the subject matter of this continuing education activity to disclose.
The authors for this continuing nursing education activity do not have any financial arrangements, interests or affiliations related to the subject matter of this continuing nursing education activity to disclose.
Requirements for Successful Completion: To receive contact hours for this continuing nursing education activity you must complete the registration form and payment, read the article, complete the online posttest and achieve a minimum grade of 100%, and complete the online evaluation.
Directions
A multiple-choice examination, designed to test your understanding of Nursing Care During Lidocaine Infusion Therapy for Chronic Pain according to the objectives listed, is available on the ASPAN website: https://learn.aspan.org/
To earn contact hours from the American Society of Perianesthesia Nurses (ASPAN) Continuing Nursing Education Accredited Provider Unit go to the ASPAN website: (1) select the article, complete the registration form and payment; (2) read the article; (3) complete the posttest on the ASPAN Website and achieve a minimum score of 100%; and (4) complete the online evaluation.
This all must be completed prior to the expiration date of August 31, 2023.
Your certificate will be available for you to print upon successful completion of the activity and completion of the online evaluation.
Online payment is required: ASPAN member: FREE per test; nonmember: $15.00 per test.
References
Raja SN
Carr DB
Cohen M
et al.
The revised international association for the study of pain definition of pain: concepts, challenges, and compromises.
The effectiveness and risks of long-term opioid therapy for chronic pain: a systematic review for a National Institutes of Health Pathways to Prevention Workshop.
Safety, tolerability, and short-term efficacy of intravenous lidocaine infusions for the treatment of chronic pain in adolescents and young adults: a preliminary report.
Conflict of interest: The author has declared no financial relationships with any commercial entity related to the content of this article. The author does not discuss off-label use within the article.
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