Peri-operative lidocaine and ketamine infusions
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Transcript of Peri-operative lidocaine and ketamine infusions
Perioperative low dose
analgesic infusions
Dr Mike Foss
FANZCA FFPMANZCA
Aims of Peri-operative
analgesia
• Part of Holistic compassionate care
• Improved acute outcomes
• Reduce the burden of Persistent Post
operative Pain
• Reduce complications of surgery with
minimal side effects
• Manage short to long term complications
of therapy.
Persistent Post Operative Pain
• pain that “develops after surgical
intervention and lasts at least 2 months;
other causes for the pain have to be
excluded, in particular pain from a
condition preceding the surgery”
• Overall, the estimated incidence of severe
disabling pain after surgery is in the range
of 2–10%
Surgery and the chronic pain
patient/avoiding PPP
• Surgery – nice quick slickly done,
minimally invasive, nerve sparing
operation, in a high volume unit. Minimise
complications
• Anaesthesia and analgesia – Local
anaesthesic iv or regional, Nitrous,
Ketamine, NSAIDs…
• Patient factors– essentially not modified in
our current system
Opioid Husbandry
• North America “Bigger is better” in terms
of opioid therapy
• CDC Guideline for Prescribing Opioids for
Chronic Pain — United States, 2016
• A sea change in North American practice
to come more into line with the rest of the
developed world.
• ASRA purposing an “adjunct before
opioid” policy at most recent meeting
Adjuncts available peri
operatively in Canada
• IV NSAIDs (limited use to risk with renal
impairment in major surgery)
• Nitrous oxide
• IV magnesium
• IV ketamine
• Local anaesthetic
• (oral tramadol, clonidine, tylenol,
gabapentinoid)
Reducing Persistent Post
Operative pain
• Level One evidence for preventive effect
with ketamine and local anaesthetic (IV or
regional)
• Tylenol may also have a preventive effect
• Not shown for gabapentanoids or opioid
Ketamine
• NMDA receptor non competitive antagonist. High
trapping rate with slow off rate – leads to prolonged
tonic blockade
Ketamine Continued
• Advantages – Dissociative anaesthetic,
preventive analgesic/anti nociception,
opioid sparing, reduced PONV, maintains
airway tone/respiration. Antidepressant
effect
• Disadvantages – psychotomimetic effects,
abuse potential, long term bladder irritation
Ketamine continued
• Works on a multitude of receptors
• Potentiates opioid analgesia as well as
being an analgesic in its own right
• Change in gene expression which may be
responsible for anti depressant and anti
chronic pain effects
• Metabolised in liver to Norketamine then to
glucuronide conjugates – excreted in urine
• Elimination half time 3 hours
Ketamine cont
• Doses of less than 0.1mg/kg/hr
• Loading dose of 0.1-0.2 mg/kg
• Side effects can usually be managed by
reducing the infusion rate
Lidocaine
• Na Channel Blocker
• are opioid-sparing and significantly reduce
pain scores, nausea, vomiting and
duration of ileus after abdominal surgery
• Metabolised to MEGX (NA block and
?Anti-inflam properties) in liver, excreted in
urine
• Elimination half time 90-120mins
Lido cont
• Loading dose 1.5mg/kg
• Infusion rates variable 1.5-3mg/kg/hr
• Discussing a rate of 2mg/min for over 65
and 1mg/min for over 80 (or with risk
factors)
Glial effects
Multi modal in Recovery:
• Paracetamol – Cox 3/Endocannbinoids
• NSAIDs – Cox1/2
• Na Channel – Local anaesthetic
The 3 Prongs of the pain system:
1. Opioid (possibility of ultra low dose
naloxone)
2. Glutamate –
N20/Ketamine/Gabapentanoids
3. Descending inhibition –
clonidine/Tramadol
references
• Sleigh, J etal. Ketamine – more mechanisms of action than just nmda blockade.. Trends in
anaesthesia and critical care 4(2014) 71-81
• Tong Yuan etal. Lidocaine attenuates lipopolysaccharide-induced inflammatory responses in
microglia.. Journal of Surgical Research 192- 1 (2014) 150-162
• Loftus etal. Intraoperative Ketamine reduces perioperative opioid consumption in HOT patients..
Anaesthesiology V113 (3) 639-646.
• ANZCA/FPM. (2015). Other patient groups - the opioid tolerant patient. In P. Macintyre, D. Scott,
S. Schug, E. Visser, & S. Walker (Eds.), Acute Pain Management: Scientific Evidence (pp. 569-
571). Melbourne, Australia: Australian and New Zealand College of Anaesthetists 2015.
• ANZCA/FPM. (2015). Analgesic medications. In P. Macintyre, D. Scott, S. Schug, E. Visser, & S.
Walker (Eds.), Acute Pain Management: Scientific Evidence (pp. 69-178). Melbourne, Australia:
Australian and New Zealand College of Anaesthetists 2015.
• Khan, J. etal. (2015, September). An estimation of the appropriate end time for intraoperative
intravenous lidocaine infuion in bowel surgery; a comparative meta analysis. Journal of Clinical
Anaesthesia , http://dx.doi.org/10.1016/j.jclinane.2015.07.007 .
• Laskowski, etal. (2011, Oct). A systematic review of intravenous ketamine for post operative
analgesia. Canadian Journal of Anaesthesia , 911-923.
• IASP. Chronic pain after surgery. Pain – clinical updates, Volume XIX – 1, 2011. http://www.iasp-
pain.org/files/Content/ContentFolders/Publications2/PainClinicalUpdates/Archives/PCU_19-
1_for_web_1390260524448_6.pdf