Lidocaine Infusion Research Articles

The effect of lidocaine when used as an area anesthetic or by injection

A fast onset of action and an average period of effectiveness describe the efficacy of lidocaine as a local anaesthetic. Lidocaine is also effective in penetrating the skin and providing an anesthetic on the surface. Long-acting anesthetics, such as bupivacaine, are sometimes recommended for spinal and subterranean anesthesia. Quick start, on the other hand, includes lidocaine. Adrenaline supplements cause absorption to be delayed. Thus a doubling of the length of strong surface anesthesia can be envisaged. For example, for endoscopy, pre-intubation, etc., there are few types that can be used. Lidocaine infusion is used to treat ventricular arrhythmias and is also the best antiarrhythmic medication in Class 1B. (for severe heart muscle atrophy, digitalis injury, cardioversion, or cardiac accumulation). Routine preventive treatment of severe dead heart tissue, however, is not suggested at this stage; Do not be satisfied with the general appreciation for this treatment. Lidocaine was also powerful in treating epilepsy.

Nursing Care During Lidocaine Infusion Therapy for Chronic Pain

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.

Can Acute Postoperative Pain Management After Tumour Resection Surgery Modulate Risk of Later Recurrence or Metastasis?

BackgroundCancer is a leading cause of mortality worldwide, but death is rarely from the primary tumour: Rather it is multi-organ dysfunction from metastatic disease that is responsible for up to 90% of cancer-related deaths. Surgical resection of the primary tumour is indicated in 70% of cases. The perioperative stress response, tissue hypoxia at the site of surgery, and acute pain contribute to immunosuppression and neo-angiogenesis, potentially promoting tumour survival, proliferation, and metastasis. Poorly controlled acute postoperative pain decreases Natural Killer (NK) immune cell activity, which could potentially facilitate circulating tumour cells from evading immune detection. This consequently promotes tumour growth and distal metastasis.MethodsWe conducted a comprehensive literature search for links between acute pain and cancer outcomes using multiple online databases. Relevant articles from January 1st, 2010 to September 1st, 2021 were analysed and appraised on whether postoperative pain control can modulate the risk of recurrence, metastasis, and overall cancer survival.ResultsAlthough experimental and retrospective clinical data suggest a plausible role for regional anaesthesia in cancer outcome modulation, this has not been supported by the single, largest prospective trial to date concerning breast cancer. While there are mixed results on anaesthesiology drug-related interventions, the most plausible data relates to total intravenous anaesthesia with propofol, and to systemic administration of lidocaine.ConclusionThe hypothesis that anaesthetic and analgesic technique during cancer surgery could influence risk of subsequent recurrence or metastasis has been prevalent for >15 years. The first, large-scale definitive trial among women with breast cancer found robust equivalent findings between volatile anaesthesia with opioid analgesia and regional anaesthesia. Therefore, while regional anaesthesia during tumour resection does not seem to have any effect on cancer outcomes, it remains plausible that other anaesthetic techniques (e.g. total intravenous anaesthesia and systemic lidocaine infusion) might influence oncologic outcome in other major tumour resection surgery (e.g. colorectal and lung). Therefore, another large trial is needed to definitively answer these specific research questions. Until such evidence is available, perioperative analgesia for cancer surgery of curative intent should be based on patient co-morbidity and non-cancer endpoints, such as optimising analgesia and minimising postoperative complications.

Efficacy of Perioperative Continuous Intravenous Lidocaine Infusion for 72 Hours on Postoperative Pain and Recovery in Patients Undergoing Hepatectomy: Study Protocol for a Prospective Randomized Controlled Trial.

PurposeMany patients develop severe and persistent pain after hepatectomy delaying postoperative rehabilitation. Studies have suggested that intravenous lidocaine infusion relieved postoperative pain and improved overall postoperative outcomes. However, its efficacy on hepatectomy is still masked, due to the postoperative metabolic change of lidocaine by the liver. We hypothesized that intravenous lidocaine infusion in the perioperative period would lead to postoperative pain reduction and improve the overall patient experience.Study Design and MethodsIn this prospective double-blind, randomized controlled design trial, 260 adults scheduled for hepatectomy will be allocated to the lidocaine and the placebo groups. The lidocaine group will be administered lidocaine intravenously during intraoperative period and 72 postoperative hours; the placebo group will be administered normal saline at the same volume, infusion rate, and timing. The primary outcome is the incidence of moderate-severe pain (numeric rating scale ≥4) during movement at 24 hours after surgery. The secondary outcomes include the incidence of moderate-severe pain at 24 hours after surgery at rest, the incidence of moderate-severe pain at 48 and 72 hours after surgery at rest and during movement, the cumulative morphine consumption at 24, 48 and 72 hours postoperatively, bowel function recovery, the incidence of postoperative nausea and vomiting, the incidence of postoperative pulmonary complications, the length of hospital stay, levels of inflammatory factors and patient satisfaction scores.DiscussionThis is the first prospective trial to shed light on the efficacy of intraoperative period and 72 postoperative hours intravenous lidocaine on postoperative pain and recovery after hepatectomy. The findings will provide a new strategy of perioperative pain management for hepatectomy.

Antinociceptive and analgesic effect of continuous intravenous infusion of maropitant, lidocaine and ketamine alone or in combination in cats undergoing ovariohysterectomy

BackgroundMultimodal analgesia consists of the combination of analgesic drugs at low doses to act in different places along the path of pain. Studies with continuous infusion of analgesic drugs in cats are not common. This study aimed to evaluate the analgesic effect of maropitant, lidocaine and ketamine alone or in combination (intravenous bolus + subsequent continuous intravenous infusion) in the management of acute postoperative pain in cats undergoing ovariohysterectomy. Seventy healthy cats undergoing an ovariohysterectomy received a standard anesthetic protocol consisting of acepromazine and morphine, propofol (anesthesia induction), and isoflurane (anesthesia maintenance). The animals were stratified into seven groups (n = 10 in each group): control (CG), maropitant (MG), lidocaine (LG), ketamine (KG), maropitant + lidocaine (LMG), maropitant + ketamine (KMG), and maropitant + lidocaine + ketamine (LKMG). All drugs were injected first as an intravenous bolus and then by continuous intravenous infusion. During surgery, esophageal temperature, respiratory rate, heart rate, oxygen saturation, expired isoflurane concentration, and partial pressure of carbon dioxide at the end of expiration were evaluated at 7 time points. Postoperative pain was evaluated for 6 h after extubation using the visual analogue scale and the UNESP-Botucatu multidimensional composite pain scale for assessing postoperative pain in cats.ResultsAdverse effects related to maropitant, lidocaine and ketamine infusion were not observed. Pain scores were lower in the MG, KG and LG groups when compared to the CG group using both scales. Although pain scores were also lower in all combination groups than CG, more animals in these groups required rescue analgesia compared to MG. This indicates that the postoperative analgesic effect of all drugs, either alone or in combination, confers analgesia, although the combinations did not promote greater analgesia.ConclusionsContinuous intravenous infusion of maropitant, lidocaine, and ketamine alone induces postoperative analgesic effect in cats undergoing ovariohysterectomy, but combinations of these drugs did not increase the analgesic effect. No adverse effect was observed with any drug or their combination.

Lidocaine infusions in chronic pain management: A prospective case series analysis

Chronic pain conditions are prevalent and cause a significant burden of disease. Intravenous lidocaine infusions have been reported to have an analgesic effect in patients with chronic neuropathic pain, but there is limited data supporting the efficacy of lidocaine across other chronic pain phenotypes. Our study aimed to evaluate the efficacy of a single infusion of intravenous lidocaine for pain relief and the impact on quality of life. We evaluated data from 74 patients with chronic pain who were treated with intravenous lidocaine at a specialist pain centre. Participants completed a questionnaire consisting of the Brief Pain Inventory (BPI) Short Form and additional EQ-5D quality of life metrics, before treatment and at follow-up.Data comparing pain severity did not demonstrate a statistically significant change after treatment when averaged across the entire patient cohort (6.15–5.88, p = .106), irrespective of gender or pain phenotype. Scores for pain interference showed statistically significant reductions following treatment (7.05–6.41, p = .023), which may have been driven through improvements in sleep (7.41–6.35, p = .001); however, these reductions are not clinically significant.The patient cohort was stratified into responders and non-responders based on >30% improvement in response to an overall impression of pain reduction question following treatment. In the ‘responder’ cohort, pain intensity scores showed a statistically significant reduction post-infusion (6.18–5.49, p = .0135), but no change was apparent for non-responders (6.07–6.09, p = .920). There were no differences between responders and non-responders for pain sub-types in our study.This study found no difference in pain outcomes in a cohort of patients with chronic pain, a mean of 63 days following a single lidocaine infusion. However, a specific subgroup of responders may show slight improvements in some pain outcomes that may warrant further exploration.

Influence of Fentanyl, Ketamine, and Lidocaine on Tear Production in Healthy Conscious Dogs

Tear production is an important factor in maintaining proper function of the cornea and conjunctiva. The purpose of this study was to determine the effects of bolus followed by infusion of fentanyl, lidocaine, and ketamine on tear production as measured by the Schirmer I Tear Test (STT-I) in dogs. A prospective, randomized, “double-blind” study was performed. A total of 55 healthy conscious client-owned dogs were included in the study. Dogs were randomly allocated to one of four groups and given intravenous fentanyl 0.005 mg kg-1 followed by 0.005 mg kg-1 hour−1 (FEN-group), ketamine 0.6 mg kg−1 followed by 0.6 mg kg−1 hour−1 (KET-group), lidocaine 1 mg kg-1 followed by 1 mg kg−1 hour−1 (LID-group), or saline 0.3 mL kg−1 followed by 2 mL kg−1 hour−1 (SAL-group). The STT-I was performed prior to (baseline) and again 30 minutes (T30) after initiation of drug administration. Data were expressed as the median (minimum – maximum) and analyzed by Wilcoxon and Steel-Dwass tests (P < .05). The STT-I values increased little but were statistically significant in the KET-group from 18 (14-23) to 19 (14-25) (P = .039) and in the LID-group from 21 (14-25) to 20 (17-29) (P = .027). At 30 minutes, STT-I values were significantly higher in LID-group 20 (17-29) than in FEN-group 18 (12-22) (P = .006). Fentanyl, ketamine, and lidocaine administered at the studied doses as a bolus and then followed by an infusion within 30 minutes in healthy conscious dogs demonstrated a clinically insignificant effect on tear production as measured by STT-I.

Continuous infusion of lidocaine in pediatric colonoscopy: A randomized double-blind placebo-controlled study.

Background:Propofol is commonly used for providing procedural sedation during pediatric colonoscopy. Intravenous (i.v.) lidocaine can mitigate visceral pain and reduce propofol requirements during surgery. The aim of this study is to investigate the effect of i.v. lidocaine on perioperative propofol and sufentanil dose, pulse oxygen saturation, postoperative pain score, and recovery time during pediatric colonoscopy.Methods:We designed a randomized, double-blind, placebo-controlled study and enrolled 40 children aged from 3 to 10 years who underwent colonoscopy. After titration of propofol to achieve unconsciousness, the patients were given i.v. lidocaine (1.5 mg/kg later 2 mg/kg/ hour) or the same volume of saline. Sedation was standardized and combined propofol with sufentanil. The primary outcome variables were intraoperative propofol and sufentanil requirements, and the number of oxygen desaturation episodes. Secondary outcome variables were recovery time after colonoscopy and post-colonoscopy pain.Results:Lidocaine infusion resulted in a significant reduction in propofol requirements: (median (quartile) 1.8 (1.5-2.0) vs. 3.0 (2.8-3.3) mg/kg respectively; P < 0.001) and sufentanil requirements: (median (quartile) 0.06 (0.05-0.08) vs. 0.1 (0.1-0.1) μg/kg respectively; P < 0.001). The number of subjects who experienced oxygen desaturation below 95% in the lidocaine group was also significantly less than that in the control group: 1 vs. 6 (P = 0.04). The mean (SD) recovery time was significantly shorter in the lidocaine group: (19.2 (2.6) vs. 13.3 (2.6) min respectively; P < 0.001). There was no significant difference in post-colonoscopy pain.Conclusion:Continuous infusion of lidocaine resulted in reduction of propofol and sufentanil requirements, recovery time, and risk of hypoxemia during pediatric colonoscopy.

Abstract 10819: Eosinophilic Myocarditis Due to Idiopathic Hypereosinophilic Syndrome

Background: Idiopathic Hypereosinophilic Syndrome (iHES) is a rare disease with varied clinical presentations including acute heart failure. Case: A 44-year-old man who had been treated for asthma 9 months ago was admitted with worsening exertional dyspnea. EKG demonstrated sinus tachycardia with anterolateral ST depressions. Labs revealed troponin-I 44.95 ng/ml, BNP 405 pg/mL, and white blood cell count 21.2k with 50% eosinophils. Transthoracic echocardiogram showed normal left ventricular size with globally reduced ejection fraction (30-35%). Coronary angiography found normal coronary arteries. An extensive infectious and auto-immune workup was unrevealing, and bone marrow biopsy was negative for monoclonal proliferation (Fig 1A). He received 1 gram of IV methylprednisolone for 2 days lowering eosinophil count to zero and was discharged on heart failure GDMT. Two weeks later, he was readmitted from clinic for ventricular tachycardia (VT) near 120bpm (Fig 1B). Cardiac MRI and endomyocardial biopsy confirmed active eosinophilic myocarditis (Fig 1C/D). Patient was diagnosed with iHES and treated with IV methylprednisolone (500mg BID x 3 days) with an oral prednisone taper. Amiodarone and lidocaine infusions were temporarily needed to suppress his VT and an ICD was placed. After clinical stabilization and immunology consultation, an interleukin-5 inhibitor was used for further treatment of iHES. Discussion: Only 6% of patients with iHES present with cardiac symptoms, however one in five eventually develop cardiac manifestations that are often rapidly progressive. Prompt treatment with glucocorticoids is indicated for severe presentations, and subsequent use of targeted therapies can dramatically reduce morbidity and mortality. Recognition of severe peripheral eosinophilia should prompt a broad hematologic, infectious, and auto-immune workup to guide treatment and prevent end-organ damage.

Dexmedetomidine vs. lidocaine for postoperative analgesia in pediatric patients undergoing craniotomy: a protocol for a prospective, randomized, double-blinded, placebo-controlled trial

BackgroundPostoperative pain is a common problem that occurs in pediatric patients following neurosurgery which may lead to severe complications. Dexmedetomidine is a commonly used adjuvant medicine in craniotomy owing to its sedative, amnestic, analgesic, and neuroprotective properties. Besides, studies suggest that lidocaine has similar effects on sedation, analgesia, and neuroprotection. Both two adjuvants can reduce postoperative pain after neurosurgery in adults. However, it is still unknown whether dexmedetomidine or lidocaine can reduce postoperative pain in children undergoing craniotomy, and if yes, which is a better medicine choice. Therefore, we aimed to compare the effect of dexmedetomidine vs. lidocaine on postoperative pain in pediatric patients after craniotomy.Methods/designWe will perform a randomized (1:1:1), double-blind, placebo-controlled, single-center trial. Children aged 1–12 years scheduled for craniotomy will be eligible for inclusion. The 255 recruited participants will be stratified by age in two strata (1–6 years and 7–12 years), and then each stratum will be equally randomized to three groups: group D (infusion of dexmedetomidine [intervention group]), group L (infusion of lidocaine [intervention group]), and group C (infusion of normal saline [control group]). Patients will be followed up at 1 h, 2 h, 4 h, 24 h, and 48 h after surgery. The primary outcome will be total sufentanil consumption within 24 h after surgery.DiscussionIn this clinical trial, we expect to clarify and compare the postoperative analgesic effect of dexmedetomidine vs. lidocaine infusion on pediatric patients undergoing craniotomy. We believe that the results of this trial will provide more choices for postoperative analgesia for the pediatric population.Trial registrationChinese ClinicalTrials.gov ChiCTR1800019411. Registered on 10 November 2018

Implementation of an Intravenous Lidocaine Guideline for Children and Adolescents with Sickle Cell Vaso-Occlusive Pain

IntroductionSickle cell disease (SCD) affects approximately 100,000 Americans.[1] Vaso-occlusive episodes (VOEs) are the leading cause of hospitalization in SCD; in 2016, out of 134,000 SCD hospitalizations, 81% included VOE. [2] Opioids are the mainstay of VOE treatment, but side effects include sedation, hyperalgesia, and dependency risk. Lidocaine, which inhibits voltage-gated sodium channels in peripheral sensory nerves, is given intravenously (IV) for postoperative pain management and holds promise for VOE treatment.[3]At St. Louis Children's Hospital (SLCH), children admitted with VOEs receive an opioid by continuous infusion plus patient-controlled analgesia (PCA) and non-opioid adjuvants. In 2019, the Sickle Cell Disease Program and Pain Management Service jointly developed a guideline for VOE management that includes:1. Standardized dosing of IV opioids and IV or oral NSAIDs2. Pain management service consultation for all children age ≥10 y admitted with VOE3. Initiation of IV lidocaine infusion (1-1.5 mg/kg/h x 48 h) within 24 h of admission for severe pain4. Addition of non opioid adjuvants, such as muscle relaxants, topical agents, and agents for neuropathic pain5. IV lidocaine is prescribed by the Pain Management Service. Patients are monitored for lidocaine side effects including tinnitus, perioral tingling, vital sign changes, and seizures. A 24 h serum lidocaine level is drawn to ensure levels are not supra-therapeutic.We aimed to evaluate the implementation of this care guideline, focused on IV lidocaine as a safe, tolerable and effective adjunct to opioids for VOE treatment in children.MethodsThis retrospective cohort study reviewed records of children with SCD age ≥10 years admitted for VOE at SLCH during 2018-2020. Data collected included patient demographics, impact on pain, lidocaine levels, and reported side effects. This study was approved by the institutional review board.ResultsWe identified 61 patients (31 males), median age 15.7 y (range 9-21), with 174 IV lidocaine administrations during 164 hospitalizations. Hemoglobin (Hb) SS comprised 60.7% of the cohort; 32.8% had Hb SC disease, 4.9% had Hb Sβ0 thalassemia and 1.6% had Hb Sβ+ thalassemia. IV lidocaine was started within 24 h for 78.7% (129/164) of included admissions. The mean blood lidocaine level was 2.14 mcg/ml (SD 1.23). Of the 164 admissions, 9 individuals had lidocaine levels above the limit of 4.5 mcg/ml, none had symptoms of toxicity. Few side effects were noted: lip paresthesia in 1 child (lidocaine stopped, but received in future admissions); nausea in 1 child (declined lidocaine in future admissions); pain increase in 1 teen (lidocaine was stopped). One child stopped lidocaine infusions prematurely during 2 admissions due to refusal of phlebotomy for the lidocaine level. Overall, 59 children perceived benefit of IV lidocaine and chose to receive it again during later admissions. During 10 prolonged hospitalizations, a second 48-hour lidocaine infusion was given due to patient reported benefit.We identified falsely elevated lidocaine levels when subcutaneous lidocaine was used before phlebotomy, but no patients with high lidocaine levels experienced toxicity. We altered our response to supratherapeutic levels by pausing the lidocaine infusion, redrawing lab at a peripheral site without subcutaneous lidocaine contamination, and resuming lidocaine infusion if level was normal. Every repeated lidocaine level was within normal limits.DiscussionIn our cohort, IV lidocaine was safe, tolerable, and improved pain control. The care guideline was initiated within 24 hours for 78.7% of admissions. Mild side effects occurred in only 3 patients, highlighting safety. Future considerations include a prospective study focused on length of stay, patient-reported outcomes, opioid exposure, and factors influencing the care guideline's utilization.

Short-Term Lidocaine Infusion as a Nonsedative Option to Maintain Ventilator Synchrony During Opioid Tapering in a COVID-19 Patient.

Short-Term Lidocaine Infusion as a Nonsedative Option to Maintain Ventilator Synchrony During Opioid Tapering in a COVID-19 Patient.

Comparison of continuous intravenous lidocaine versus transversus abdominis plane block for kidney transplant surgery: a randomized, non-inferiority trial

Background and objectivesTransversus abdominis plane (TAP) blocks are associated with an improvement in postoperative analgesia following kidney transplant surgery. However, these blocks carry inherent risk and require a degree of...

Perioperative Intravenous Lidocaine Infusion on Postoperative Recovery in Patients Undergoing Arthroscopic Rotator Cuff Repair Under General Anesthesia: A Randomized Controlled Trial.

Arthroscopic rotator cuff repair (ARCR) is known to cause severe postoperative pain that may interfere with recovery. Intravenous (IV) lidocaine has analgesic, anti-inflammatory, and antihyperalgesic effects, and is being used in various types of surgeries. However, the effect of IV lidocaine in ARCR is not well-known. Ninety patients undergoing ARCR were randomly allocated to receive IV lidocaine (1.5 mg/kg bolus of 1% lidocaine after anesthesia induction followed by a continuous infusion of 2 mg/kg/h up to 1 h after surgery) or an equal volume of saline. In both groups, an IV patient-controlled analgesia (PCA) device was used that contained fentanyl 10 µg/mL, infused at 1 mL/h with a 1 mL bolus dose. The primary outcome was fentanyl requirements given via IV PCA during the first 24 hours after surgery. Perioperative pain scores and functional recovery were assessed as secondary outcomes. The amount of fentanyl administered via IV PCA up to 24 hours after surgery was significantly lower in the lidocaine group compared with the control group (329 [256.2 to 428.3] vs. 394.5 [287.0 to 473.0], P=0.037). The number of PCA bolus attempts were lower in the lidocaine group without statistical significance. There were no differences in postoperative pain scores or functional shoulder scores between the 2 groups. IV lidocaine appears to be helpful in reducing opioid requirements during the acute postoperative period in patients undergoing ARCR. IV lidocaine may be a viable option as a component of multimodal analgesia in ARCR when regional analgesia is not possible.

Treatment of Neonatal Seizures: Comparison of Treatment Pathways From 11 Neonatal Intensive Care Units

ObjectiveSeizures are a common neonatal neurologic emergency. Many centers have developed pathways to optimize management. We evaluated neonatal seizure management pathways at level IV neonatal intensive care units (NICUs) in the United States to highlight areas of consensus and describe aspects of variability. MethodsWe conducted a descriptive analysis of 11 neonatal seizure management pathways from level IV NICUs that specialize in neonatal neurocritical care including guidelines for electroencephalography (EEG) monitoring, antiseizure medication (ASM) choice, timing, and dose. ResultsStudy center NICUs had a median of 70 beds (interquartile range: 52-96). All sites had 24/7 conventional EEG initiation, monitoring, and review capability. Management pathways uniformly included prompt EEG confirmation of seizures. Most pathways included a provision for intravenous benzodiazepine administration if either EEG or loading of ASM was delayed. Phenobarbital 20 mg/kg IV was the first-line ASM in all pathways. Pathways included either fosphenytoin or levetiracetam as the second-line ASM with variable dosing. Third-line ASMs were most commonly fosphenytoin or levetiracetam, with alternatives including topiramate or lacosamide. All pathways provided escalation to continuous midazolam infusion with variable dosing for seizures refractory to initial medication trials. Three pathways also included lidocaine infusion. Nine pathways discussed ASM discontinuation after resolution of acute symptomatic seizures with variable timing. ConclusionsDespite a paucity of data from controlled trials regarding optimal neonatal seizure management, there are areas of broad agreement among institutional pathways. Areas of substantial heterogeneity that require further research include optimal second-line ASM, dosage, and timing of ASM discontinuation.

VENTRICULAR TACHYCARDIA ELECTRICAL STORM AS A MANIFESTATION OF REVERSE VARIANT TAKOTSUBO CARDIOMYOPATHY

TOPIC: Cardiovascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Takotsubo cardiomyopathy (TTC) is a syndrome with transient systolic dysfunction in the absence of obstructive coronary arteries with the reverse variant being a rare entity (1,2). Here, we report a case of reverse TTC presenting with monomorphic ventricular tachycardia (VT) electrical storm. CASE PRESENTATION: A 76 year-old female with a history of recently diagnosed Stage IIIB lung adenocarcinoma presented to the emergency room with shortness of breath. On presentation, her vitals were: BP 134/82, pulse 120 beats/min, SPO2 93% in room air. Initial EKG showed no significant ST-T wave changes and normal QTc. Labs were significant for uptrending troponin from 0.8 to 4 ng/mL. Aspirin and heparin infusion were started for possible NSTEMI with a plan for catheterization. That night, she developed unstable, monomorphic VT (Figure 1). Consecutive synchronized cardioversions and amiodarone boluses were unsuccessful. Patient's VT terminated with repeated boluses of lidocaine followed by lidocaine infusion. Stat echocardiogram showed an ejection fraction of 25-30% with anterior and anteroseptal hypokinesis. Emergency cardiac catheterization revealed non-obstructive coronary arteries with akinesis of the basal wall and sparing of the apex suggesting reverse TTC (Figure 2). She was transferred to the critical care unit where she was transitioned to amiodarone infusion with no further VT episodes and was initiated on guideline-directed medical therapy. DISCUSSION: TTC usually occurs due to a surge of catecholamines leading to myocardial damage. The typical variant demonstrates apical ballooning with basal hypokinesis. Rarely, there may be basal hypokinesis with apical sparing, the reverse variant (2). Arrhythmias are uncommon in typical TTC and prior studies have indicated a low incidence of VT (3.2%) (3). There is sparse literature describing the incidence of VT or VT storm in the reverse variant. One of the postulated mechanisms for VT in TTC is transient QTc prolongation, however this remains controversial. (3). The incidence of arrhythmias is thought to be more prevalent during the acute phase leading to increased in-hospital mortality (3). Additionally, it remains uncertain whether prophylactic antiarrhythmics are beneficial in this population subset. Further studies are warranted to understand which variants of TTC develop critical arrhythmias. CONCLUSIONS: Reverse variant is a rare subset of TTC which can present with critical arrhythmias including VT storm. Awareness of this manifestation can help clinicians with early recognition and management of these critical arrhythmias. REFERENCE #1: Bybee KA., Prasad A. Stress-related cardiomyopathy syndromes. Circulation 2008;118(4):397–409. Doi: 10.1161/CIRCULATIONAHA.106.677625. REFERENCE #2: Templin C., Ghadri JR., Diekmann J., et al. Clinical Features and Outcomes of Takotsubo (Stress) Cardiomyopathy. New England Journal of Medicine 2015;373(10):929–38. Doi: 10.1056/NEJMoa1406761. REFERENCE #3: Pant S, Deshmukh A, Mehta K, et al. Burden of arrhythmias in patients with Takotsubo Cardiomyopathy (Apical Ballooning Syndrome). International Journal of Cardiology [Internet] 2013;170(1):64–68. Available from: https://doi.org/10.1016/j.ijcard.2013.10.041 DISCLOSURES: No relevant relationships by Anneka Hutton, source=Web Response No relevant relationships by Gagan Neupane, source=Web Response No relevant relationships by Enoemem Okpokpo, source=Web Response No relevant relationships by Bharadwaj Satyavolu, source=Web Response No relevant relationships by Raksha Sharma, source=Web Response No relevant relationships by Tracey Topacio, source=Web Response

CARDIAC CONVULSIONS-POLYMORPHIC VENTRICULAR TACHYCARDIA MASQUERADING AS SEIZURES

TOPIC: Cardiovascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Cardiac arrhythmias can occasionally precipitate convulsions through decreased cardiac output resulting in cerebral hypoxia and epileptiform-like activity. Differentiating a seizure from ventricular arrhythmia is crucial for accurate and timely management. CASE PRESENTATION: A 46-year-old female with a history of breast adenocarcinoma with metastasis to the brain presented with staring and unresponsive episodes. These episodes lasted for a few minutes and were accompanied by jerking of all extremities. Physical examination and laboratory investigations were unremarkable, except for mild hypokalemia of 3.2 mmol/L. She underwent a computerized tomography scan and magnetic resonance imaging of the head that redemonstrated multiple hypodense lesions within the internal capsule and caudate nucleus. The patient subsequently underwent an electroencephalogram (EEG) that did not reveal any epileptiform discharges. She was initiated on anti-epileptic drugs (AEDS). Her hospital course was complicated by recurrent unresponsive episodes similar to presentation despite the use of AEDS. She was lethargic during the episodes, without any post-ictal confusion. She was also tachycardic with a heart rate of 150 beats/min. Review of telemetry showed premature ventricular conduction dependent polymorphic ventricular tachycardia (PMVT), concerning for torsade de pointes. Her baseline EKG revealed a prolonged QTc of 550 msec. Further, it was noted that her recurrent episodes of unresponsiveness coincided with the PMVT events on telemetry. Her PMVT were managed with aggressive electrolyte repletion as well as a lidocaine infusion. DISCUSSION: While the brain metastasis and hypodense lesions on the MRI were a confounder to the patient's true diagnosis, the misdiagnosis of cardiac arrhythmias as convulsions is not uncommon. Since cardiac arrhythmia and convulsive seizures share many common characteristics, identifying the true cause of the patient's presentation is of paramount importance. CONCLUSIONS: All patients who present with neurological symptoms should have a baseline EKG and echo to evaluate for underlying cardiac pathology and ideally should be monitored on telemetry until a clear neurological diagnosis is established. Although torsades de pointe episodes can be short lasting and transient, they have the potential to cause cardiac arrest and death. REFERENCE #1: Sabu J, Regeti K, Mallappallil M, et al. Convulsive Syncope Induced by Ventricular Arrhythmia Masquerading as Epileptic Seizures: Case Report and Literature Review. J Clin Med Res. 2016;8(8):610-615. doi:10.14740/jocmr2583w DISCLOSURES: No relevant relationships by Naga Vaishnavi Gadela, source=Web Response No relevant relationships by Nino Nozadze, source=Web Response No relevant relationships by Mahati Paravathaneni, source=Web Response No relevant relationships by Naveen Sablani, source=Web Response No relevant relationships by Evan Wasserman, source=Web Response

Post-Thoracotomy Pain: Review Article

Background: Thoracotomy is a very painful surgical procedure that is used to get access into the pleural space, to the lungs, to the heart, to the esophagus or to get access to the thoracic aorta or anterior mediastinum. Objective: To study different modalities of treatment used for post thoracotomy pain control. Recent Findings: Inadequate post-thoracotomy analgesia enhances the postoperative stress response with deleterious effects on respiratory, cardiovascular, gastrointestinal, urinary, immune and coagulation systems. In addition to anxiety and increased risk of Post Thoracotomy Pain Syndrome (PTPS), which can interfere with normal life and may persist for years or even for life? Conclusion: Providing adequate post-thoracotomy analgesia can be challenging, as patients are often elderly or having multiple comorbidities. A multimodal approach is considered in managing post-thoracotomy pain starting with preemptive analgesia and cognitive behavioral modalities in addition to conventional multimodal systemic regimens as opioids, acetaminophen, NSAID, cyclooxygenase (COX)-2-specific inhibitors, gabapentin and pregabalin, steroids, IV lidocaine infusion, ketamine, and many regional analgesic modalities to avoid or decrease adverse effects of systemic regimens. These regional analgesic modalities include thoracic epidural blocks, thoracic paravertebral blocks, intrathecal opioid analgesia, serratus anterior plane blocks, intercostal nerve blocks, interscalene block, erector spinae block and interpleural block.

Влияние методов послеоперационного обезболивания на моторную функцию желудочно-кишечного тракта у детей с перитонитом, осложненным интраабдоминальной гипертензией

Актуальность. Метод послеоперационного обез­боливания может влиять на скорость восстановления моторной функции желудочно-кишечного тракта, уровень интраабдоминального давления (ИАД) и способствовать развитию интраабдоминальной гипертензии (ИАГ). Цель: исследовать влияние методов послеоперационного обезболивания на моторную функцию кишечника у детей с перитонитом, осложненным ИАГ. Материалы и методы. 115 детей, которым были проведены оперативные вмешательства по поводу аппендикулярного перитонита, рандомизированы на группы в зависимости от метода послеоперационного обезболивания: «Опиоиды» (n = 36, инфузия морфина), «Лидокаин» (n = 40, инфузия лидокаина), «ЭДА» (n = 39, эпидуральная аналгезия). В зависимости от уровня ИАД и наличия органной дисфункции дети каждой группы были разделены на подгруппы: «без ИАГ» (ИАД &lt; 10 мм рт.ст.), «ИАГ» (ИАД &gt; 10 мм рт.ст.) и «АКС» (абдоминальный компартмент-синдром, ИАГ с органной дисфункцией). Всем детям в послеоперационном периоде проводилось измерение уровня ИАД и оценка скорости восстановления моторной функции желудочно-кишечного тракта. Результаты. Во всех подгруппах группы «ЕДА» время до восстановления перистальтики и первых испражнений и объем остатка по назогастральному зонду были статистически значимо меньшими по сравнению с аналогичными показателями в подгруппах группы «Опиоиды» (Р &lt; 0,05). В подгруппах «ИАГ» и «АКС» группы «ЭДА» также было статистически значимо меньшим время до первых испражнений по сравнению с аналогичными показателями в подгруппах группы «Лидокаин» (Р &lt; 0,05). Статистически значимо меньшими были время до восстановления перистальтики и объем остатка по НГЗ во всех подгруппах группы «Лидокаин» по сравнению с аналогичными показателями группы «Опиоиды» (Р &lt; 0,05). Эпизоды повышения ИАД &gt;10 мм рт.ст. значительно чаще встречались у детей в группе «Опиоиды», чем в группах «Лидокаин» и «ЭДА» (Р &lt; 0,05). Количество эпизодов ИАД &gt; 10 мм рт.ст. имело прямую корреляцию с длительностью времени восстановления перистальтики, но сила такой корреляции была выше в группах «Опиоиды» (rs = 0,78; p = 0,001 и rs = 0,76; p = 0,01) и «Лидокаин» (rs = 0,58; p = 0,008 и rs = 0,95; p = 0,01), чем в группе «ЭДА» (rs = 0,39; p = 0,16 и rs = 0,46, p = 0,43). Выводы. ЭДА является оптимальным методом послеоперационного обезболивания у детей с перитонитом, осложненным ИАГ, который приводит к раннему восстановлению моторной функции ЖКТ и предотвращает дальнейший рост ИАД. Инфузия лидокаина может быть использована как альтернативный метод обезболивания. Системная опиоидная аналгезия оказывает негативное влияние на моторику желудочно-кишечного тракта.

Efficacy of intra-cuff alkalinized lidocaine compared to low dose lidocaine infusion in reducing extubation induced emergence phenomena

Efficacy of intra-cuff alkalinized lidocaine compared to low dose lidocaine infusion in reducing extubation induced emergence phenomena