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ContinuousLidocaineInfusionasAdjunctiveAnalgesiainIntensiveCareUnitPatients
ComfortprotocolICUHugoTouw14juli2017
Metdankvoordeeldia’s:KimSmeijsters,AIOSAnesthesiologieVUMC
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• https://www.youtube.com/watch?v=simnth2DWuA
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CasusVrouw• VG:psychose• RvO:multitrauma• Wervelfracturen• Stabilisatie wervelkolom
• Ribfracturen
Pijnbeleid• PCM• Sufenta• S-Ketamine?• Epiduraal?
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Adjuvante/RegionalePijnstillingopIC
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TheErectorSpinaePlaneBlock
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IVLIContinuous IntravenousLidocaineInfusionasAdjunctive
AnalgesiainIntensiveCareUnitPatients
Antwoordopvolgendevragen:1. Watisdewerkingvanlidocaine?2. Watisaangetoond?3. Hoetegebruiken?4. Risico’s/bijwerkingen?
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Eigenschappenlidocaïne
Analgetischenanti-hyperalgesie
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Overigeeigenschappenlidocaïne
Herroeder2007
Anti-inflammatoirIleusreductieMarret2008Anti-thrombotischCooke1977
Neuro-protectiefMitchell1999enWang2002
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Evidence
45RCT2802patients5“ICU” postoperative
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ZoekactiePUBMED2016P:patiëntenopIntensivecareunitI:intraveneuslidocaïneC:-O:postoperatievepijn
=0
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• Allesoortenchirurgie• Abdominalechirurgie
• 29studies,1754patiënten• 90%placebo-gecontroleerdengeblindeerd• 19studiespostoperatievepijnalsuitkomstmaat
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Resultaten
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‘Ossale’ chirurgie• Martin2008- Heupvervanging• Lidocaïneperoperatieftot1upostOK• GeenverschilVAS
• Farag2013- Complexewervelchirurgie• Lidocaïnetotmax8upostoperatief• PCIA• GeenverschilVAS
• Cui2010- Thoraxchirurgie• Lidocaïneperoperatief• VerlagingVAStijdenshoesten(tot6upostOK)• VerlagingmorfinebehoefteopPACU(tot120minpostOK)
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Langdurigetoediening?• Toediening≥24u• 9studies(1985-2010)
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Effectief?• Pijnscoreverlaagdin2/6studies• Verminderingpijnmedicatie5/9studies
• Bolus:1,5mg/kgof100mg• Infusie:1,5mg/kg/uof2mg/min
• Veilig?
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Farmacokinetiek• 50-70%eiwitgebonden• 90%inlevergemetaboliseerdtotactievemetabolieten• Uitscheidingviaurine(10%onveranderd)• Eliminatiehalfwaardetijd90min(afhmetabolisatie)• Leverfalen343min,hartfalen136min
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Risicoverhoogdetoxiciteit• Lever- ennierfalen• MedicatieCYPactiviteitverminderen
• Hypoalbuminemie
• Verminderdecardiacoutput/hepatischflow↓• Intravasculairondervulling,medicatiecardiacoutput↓(betablokkers),
myocardinfarct• Ritmestoornissen(bradycardie,2-3e graadsblok)• Hypo/hyperkaliemie
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Bijwerkingen
Toxicologie.org
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RecentartikelContinuousLidocaineInfusionasAdjunctiveAnalgesiainIntensiveCareUnitPatients
YoonsunMo,MS,PharmD,BCPS,BCCCP1,MichaelC.Thomas,PharmD,BCPS,FCCP2,AbigailD.Antigua,PharmD3,AlexM.Ebied,PharmD4,andGeorgeE.KarrasJr,MD,FCCM5
TheJournalofClinicalPharmacology2017,57(7)830–836TheAmericanCollegeofClinicalPharmacologyDOI:10.1002/jcph.874
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IVLI• Treatmentofpainin21ICUpatientswithvaryingdegreesoforgan
dysfunctionfromMarch2014toMarch2016.• Theprimaryoutcomes
• timetoa20%reductioninpainscoresaftertheinitiationofIVLIandthedifferenceinopioidrequirementsaswellaspainscores
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Results• Themeantimetoa20%reductioninpainscoresfromthe
startofIVLIwas3.3hours(SD=2.2).• Themedianmorphinedoseequivalentsrequiredduring6,12,
and24hourspre-IVLIweresignificantlyhighercomparedtothesametimeperiodsafterIVLI(18.3vs10mg,P=.002;41.8vs18.3mg,P=.002;93.5vs30.5mg,P=.037).
• Neurologicaladverseeffectsoflidocainewerenotedin3patients
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AdverseDrugEvents• diastolicheartfailureandatrialfibrillation
• IVLIat1mg/min• lessresponsive• lidocaineserumlevel(8.4μg/mL)[therapeuticlevel1.5μg/mL]
• Kidneyinjury• AorticvalvereplacementwasadmittedtotheICUaftermotorvehicle
collision–relatedinjuries.• 2.1mg/minfor19hours.• elevatedserumcreatinine• disorientation
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ConclusieIVLIopICEffectiefvoorpijnreductieopIC
Evidence effectiviteitenveiligheidbeperkt
– Toepassing• PopulatiepostoperatiefopICzonderco-morbiditeiten• Peroperatiefgestart• Gezondepopulatie(VAS,vragenlijsten)
– Bijwerkingenmonitoren
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ProtocolUniversitätsklinikumKnappschaftskrankenhausBochum-Langendreer
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Vragen?