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On-line version ISSN 1806-907X
Rev. Bras. Anestesiol. vol.54 no.2 Campinas Mar./Apr. 2004
Peripheral regional analgesia with lidocaine in burned patient. Case report*
Analgesia regional periférica con lidocaína en paciente quemado. Relato de caso
Karl Otto Geier, M.D.
Anestesiologista do Hospital Municipal de Pronto Socorro de Porto Alegre/RS; Anestesiologista Colaborador da Clindor do Hospital São Lucas da PUC/RS; Mestre em Cirurgia pela UFRGS
BACKGROUND AND OBJECTIVES: Regional anesthesia
is difficult in burned patients due to the randomized location of thermal injuries.
High plasma levels of alpha1-acid glycoprotein with major affinity
to basic drugs, especially lidocaine, have been observed in these patients.
This report shows how intermittent peripheral regional anesthesia and analgesia
with high lidocaine doses may be useful in inducing effective analgesia in patient
with almost 20% Total Burn Skin Area (TBSA) of partial thickness burn in his
CASE REPORT: Male patient, 23 years old, 86 kg, physical status ASA II, with superficial facial burn, partial thickness burn on four limbs and increased serum a1-acid glycoprotein levels (260 mg.dL-1), who was treated with 11.6 mg.kg-1 lidocaine with 1:400,000 epinephrine through catheters inserted and tunnelized, for several procedures - irrigations and dressing changes, débridements, physical therapy, skin grafting and daily analgesia during 28 days.
CONCLUSIONS: Burned patients with thermal injuries on the extremities are suitable for peripheral regional analgesia. High a1-acid glycoprotein serum levels and injection site may allow the use of high lidocaine doses.
Key Words: ANESTHETICS, Local: lidocaine; ANESTHETIC TECHNIQUES, Regional: peripheral nerve block
JUSTIFICATIVA Y OBJETIVOS: La realización
de anestesia regional en pacientes quemados es dificultosa por la localización
aleatoria de las lesiones térmicas. Elevadas tasas de a1
glicoproteína ácida con grande afinidad para drogas alcalinas,
especialmente la lidocaína ha sido observado en esos pacientes. Este
caso, relata como el uso intermitente de anestesia y analgesia regional periférica
con altas dosis de lidocaína puede ser útil en proveer efectiva
analgesia en un paciente con quemaduras de segundo grado en los cuatro miembros,
abarcando, aproximadamente, 20% de área superficial quemada.
RELATO DE CASO: Paciente masculino, 23 años, 86 kg, estado físico ASA II, con quemadura superficial del rostro, segundo grado en los cuatro miembros y elevada tasa sérica de a1 glicoproteína ácida (260 mg.dl-1), tuvo su dolor controlado con 11,6 mg.kg-1 de lidocaína con adrenalina 1:400.000 administrada por catéteres introducidos y tunelizados para diversos procedimientos - irrigaciones y cambio de curativos, desbridamientos, fisioterapia, injertos cutáneos y analgesia diaria durante 28 días.
CONCLUSIONES: En pacientes quemados con injurias térmicas localizadas en las extremidades, la analgesia regional periférica puede ser útil. Las elevadas tasas séricas de a1 glicoproteína ácida y el local de la inyección pueden permitir el uso de altas dosis de lidocaína.
Regional anesthesia is difficult to perform and its use is limited in burned patients, due to random location of injuries in different dermatomes. It addition, skin loss of continuity is an absolute counterindication for peripheral and central conductive analgesia. Other difficulty for anesthesiologists is the effective and prolonged analgesia required by such patients due to severe neuroendocrine metabolic responses following pain. Secondary hyperalgesia, hyperesthesia and drug tachyphylaxis are other challenges. All these ingredients may be markedly attenuated by the effective use of local anesthetics blocking repetitive nociceptive afference, responsible for medullary neuronal sensitization change and exacerbation. On the other hand, opioids and local anesthetics for pain control highly favor the latter 1-4, allowing better ventilatory parameters, especially in the elderly 5. It is known that prevention of nociceptive afferent pathways sensitization is possible with preemptive analgesia with local anesthetics 6 or, in the presence of pain, with long-acting conductive block.
This case report describes the evolution of electric burns on four limbs, where regional anesthesia with high local anesthetic doses was the anesthetic technique of choice both for surgical procedures and for daily dressings and analgesia.
Male patient, 23 years old, 166 cm height and 86 kg, physical status ASA II, admitted with superficial facial burns and predominantly partial thickness burns on four limbs (Figure 1) involving approximately 20% of body surface (Figure 2). Blood biochemical profile was: Hb = 12.9 g.dL-1; Ht = 38%; leucocytes = 10,000 mL-1; bands = 33%; segmented = 40%; eosinophils = 2%; monocytes = 7%; lymphocytes = 18%; platelets = 224000 mL-1; albumin = 1.8 g.dL-1; glycemia = 106 mg.dL-1; urea = 11 mg.dL-1; creatinine = 0.9 mg.dL-1; CPK = 326 U.L-1; DHL = 597; Na = 138 mEq.L-1; K = 3.8 mEq.L-1; magnesium = 2 mg.dL-1.
With permanent venous access, alternating peripheral and central, and lactated Ringer's and gluco-saline solution infusion, vital signs were maintained stable with HR of approximately 103 bpm; BP = 137/70 mmHg and diuresis of approximately 2000 mL every 12 hours. First dressing changes with injuries cleaning twice a day were started 24 hours later at bedside, under intravenous analgesia with ketamine (0.15 mg.kg-1) followed by fractioned fentanyl (up to 550 µg) and midazolam (up to 5 mg) doses. Mild nausea was reported by patient during recovery and was monitored by the intensivist. The next day patient was submitted in the operating center to surgical burns débridement with ECG monitoring at DII lead with continuous heart rate, noninvasive BP and peripheral oximetry. Transarterial brachial plexus axillary blockade was the technique of choice 7 followed by neurovascular sheath puncture with 18G venous catheter for epidural catheter insertion (Portex® 18G) tunnelized under skin and emerging close to coracoid apophysis (Figure 1). Antibacterial filter was adapted to catheter and replaced every 5 days. After catheterization and with anesthetized upper limbs, anesthesia was induced with minimum ketamine dose (total dose 15 mg), fentanyl (initially 3 µg.kg-1 perioperatively titrated between 5 and 6 µg.kg-1), propofol (2 mg.kg-1) and isoflurane (3%), aiming at lower limbs. With current plasma a1 acid glycoprotein rate equal to 260 mg.dL-1, insertion and tunnelization of long catheters (epidural - Portex® 18G) anteriorly in lumbar plexus by Winnie's technique at the left and Dalens' technique at the right (Figure 1) were scheduled for the next day in the operating center. From this point on, changes of subsequent dressings and burned areas cleaning were performed at bedside with 1.2% lidocaine with 1:240,000 epinephrine, 20 mL in each limb, in a total of 80 mL (total dose: 960 mg or 11.2 mg.kg-1). The same analgesic regimen was repeated for the next two days, adding 100 to 200 µg intravenous fentanyl, as needed, at the same time that passive and active physical therapy was started in large (knee, elbow, wrist) and small (fingers) burned joints. Due to total local anesthetic dose and potential anesthetic toxicity, continuous surveillance was instituted with available cardiopulmonary resuscitation support. Except for mild to moderate pain, there were no abnormalities for the next four hours. New surgical débridements were scheduled after three days. In the operating center and repeating the same hemodynamic monitoring, 1% lidocaine with 1:400,000 epinephrine was injected by the catheters in a total volume of 100 mL (1000 mg), distributed in 25 mL (250 mg) by catheter, in a total dose of 11.63 mg.kg-1. Next, external jugular vein was catheterized for blood sample collection 40, 50, 60, 70, 80 and 90 minutes after the last lidocaine dose, aiming at: 1) checking plasma levels; and 2) check the highest dose for further administrations. Then, anesthesia was induced with 15 mg ketamine, sub-doses of fentanyl, midazolam and 1.5% isoflurane under spontaneous ventilation mask. Blood samples were collected according to schedule, were sent to the lab and analyzed by the Fluorometric Polarization Immuno Assay method for lidocaine with Abbott's TDX device. At surgical procedures completion, patient was referred to the post anesthetic recovery unit awaken and painless. The next four hours were asymptomatic. Plasma lidocaine levels have indicated sub-toxic levels (Figure 3).
Dressings continued to be changed for seven days, with the same lidocaine doses boosted with 0.25% bupivacaine (20 to 25 mL distributed to four limbs), due to tachyphylaxis developed by the former. No other local anesthetic serum analyses were performed. Thirteen days after admission and with left arm recovered, axillary catheters were removed and their edges were sent for culture and antibiogram. With remaining thermal injuries decreased in size and ready for grafting, cutaneous grafts were performed the next day in the operating center, with the same hemodynamic monitoring under lumbar epidural block with 100 mg of 0.5% bupivacaine with epinephrine 1:200,000 and 50 µg fentanyl without preservatives aiming at lower limbs, and 1.5% lidocaine with epinephrine 1:300,000 blockade of medial, radial and musculocutaneous nerves at elbow, aiming at their respective right hand and forearm peripheral dermatomes. Donor areas were right leg lateral thigh and right arm medial face, which were anesthetized with 1.5% subcutaneous lidocaine with 1:300,000 epinephrine at axillary region apex where arm cutaneous brachial and forearm cutaneous brachial nerves are located. Lower limbs catheters were maintained for 24 hours more, being removed, catalogued and sent to culture and antibiogram. After 48 hours of incubation, only one lower limb catheter has identified Staphylococcus epidermitis growth without further repercussions.
At 28 days patient was discharged under physical therapy, especially for hands. No sequelae were observed in the next 6 months related to anesthetic procedures, except for minor finger movements limitations.
In general, burned patients have two types of prolonged pain: persistent pain, inherent to thermal injuries themselves and post-procedure pain (débridements, dressings change, hydrotherapy, skin grafting and physical therapy) 8. Ketamine sub-doses were administered for promoting preemptive and postoperative analgesia 9,10 without side-effects.
In our case, highest lidocaine dose was extrapolated (up to 8 mg.kg-1), due to high a1 acid glycoprotein levels peculiar to trauma, oncologic processes and especially thermal injuries. Although albuminemia is typical of burned patients, absorbed drugs are fixed by albumin and, particularly, by a1 acid glycoprotein (normal = 55 to 140 mg.dL-1), which has highly affinity to lidocaine. Although amide-type local anesthetics with their preservatives have bactericide action on several bacteria 11, including Staphylococcus aureus 12, the reason for using lidocaine with epinephrine and not bupivacaine were: 1) shorter onset; 2) possibility of using higher anesthetic volumes in plexus; 3) lower cardiotoxicity; and 4) higher safety due to patient's high a1 acid glycoprotein levels (260 mg.dL-1). Another reason for using 1% lidocaine were previous observations that the same local anesthetic in the same concentration and high volumes was responsible for analgesia's higher quality and longer duration 13. Anyway, verbal contact with patient is important during regional anesthesia because peribuccal dormancy and hum are early toxicity manifestations.
Highest local anesthetic dose results from free plasma rate of absorbed anesthetics, and is directly related to the administration site, to the anesthetic itself and to the use of vasoconstrictor. For example, if other anesthetic blocks are compared to multiple costal nerves block, it makes no sense to establish for the latter the highest bupivacaine dose of 3 mg.kg-1 or lidocaine of 8 to 10 mg.kg-1, due to the fast anesthetic absorption by the intercostal space, resulting in high serum levels. In this case, a lower dose would be more prudent. Conversely, in regions of slower absorption, such as our patient, highest local anesthetic dose may be higher than values established as the maximum.
Major nervous blockades, brachial and femoral 3:1, have very safe maximum plasma levels as compared to other blocks, especially of intercostal nerves 14. Based on those facts and on the build up of a1 acid glycoprotein we have increased lidocaine dose. It has been observed that doses up to 18 mg.kg-1 in brachial blocks have resulted in 5.6 mg.dL-1 lidocaine plasma concentration 15. Nevertheless, 1000 mg lidocaine (11.63 mg.kg-1) used in our patient and higher serum concentration in approximately 40 to 45 minutes15 have resulted in 5.7 mg.dL-1 at 60 minutes, slightly higher than therapeutic arrhythmia levels (2 to 5 mg.dL-1) and lower than toxic levels (6 to 10 mg.dL-1) which, according to Palve et al. 15 are above 10 mg.dL-1. Serum concentrations between 10 and 12 mg.dL-1 are convulsivant, well below than 20 to 25 mg.dL-1 plasma levels considered cardiotoxic 16.
Because lateral thigh is the preferred donor region, paravascular femoral block, or Winnie et al. 3:1 17, reaches the lateral-femoral nerve in less than 40% of children 18 and between 62% 19 to 67.5% 20 in adults, whereas Dalens et al.'s blockade reaches approximately 90% of adults 19 and slightly more than 90% of children 21. Since patient had free right lateral thigh, Dalens et al.'s blockade was used aiming at donor area innervated by the lateral femoral-cutaneous nerve anesthesia. Conversely, due to the presence of burns in left medial thigh, where the obturator nerve has sensory participation imbricated with the femoral nerve, Winnie et al.'s 17 blockade was induced for assuring 100% anesthesia of the latter nerve.
Catheters allow for continuous or intermitted administration of anesthetic solutions for passive and active physical therapy 4, preventing post-burn joint limitations and scar retractions. With analgesic purposes, they are often used in acute postoperative pain of upper limbs trauma 22 and in other chronic pain situations, such as oncologic pain 23 for 5 to 6 weeks, or for sympathetic maintained pain for 118 days 24. There are reports on peripheral catheters remaining for 15 days in lower limbs in posterior lumbar plexus of obese patient, with no mention to infection 25. Judging from its use, it seems that the incidence of infection is not a direct function of catheter permanence 22,23-25, and it may be maintained in situ for an undetermined period, provided benefits overcome risks, especially potential local infections. Aseptic techniques for catheters insertion and/or tunnelization, complemented with transparent sterile dressings allowing frequent inspections are major approaches for the maintenance of the catheter in place.
Clinical inflammation signals are the most frequent and deserve periodic surveillance. Pain followed by secretions around catheter emergence site makes us suspect of infection and determine its prompt removal and analysis to identify microorganisms and complementation with bacterial culture and antibiogram. Staphylococcus epidermitis is often found, with an incidence of 70% in the inguinal region 26. Peripheral regional analgesia may be useful for burned patients with thermal injuries on extremities. High serum a1 acid glycoprotein levels and puncture site may allow the use of high lidocaine doses.
We acknowledge academic Martin Geier for helping in preparing the figures.
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Dr. Karl Otto Geier
Rua Cel. Camisão, 172
90540-030 Porto Alegre, RS
Apresentado (Submitted) em 28 de
abril de 2003
Aceito (Accepted) para publicação em 21 de julho de 2003
* Recebido do (Received from) Hospital Mãe de Deus de Porto Alegre, RS