Severe Pain

Vignette:

A 64 year-old female with metastatic lung cancer, history of low back pain with chronic opioid use, sickle cell disease and recent herpes zoster is experiencing a pain crisis from multiple etiologies. She is currently taking MS-ER 200 mg orally every 8 hours and Methadone 15 mg orally every 8 hours. She continues to suffer from severe pain despite these medications. She is in curled up in bed stating, "This is the worst pain in my life". What else can be done to treat this woman's pain?

Discussion:

The recommended treatment is a Lidocaine infusion. The loading dose of Lidocaine is 2 mg/kg infused intravenously or subcutaneously over 20 minutes. Infusion is continued at 1-3 mg/kg/hr and adjusted with drug level evaluation. The therapeutic blood level for Lidocaine analgesia is 2 – 6 mcg/ml. Blood level should be drawn 8 – 10 hours after start of infusion. During initiation of Lidocaine, recommend assessment and documentation of vital signs, pain level and side effects every 15 minutes for the first hour, every 60 minutes for 3 hours, and every 12 hours thereafter. Side effects of Lidocaine infusion include lightheadedness, peri-oral numbness, metallic taste, and tinnitus. If adverse drug reactions such as blurry vision, twitching, seizures, or bradycardia with heart rate < 50 occur, infusion should be stopped. Opioid requirements may decrease with the use of Lidocaine. If patient responds well to Lidocaine, consider rotation to mexilitine orally for discharge from hospital.

References:

Thomas, J., Kronenberg, R., Cox, M., Naco, G., Wallace, M., von Gunten, C. "Intravenous Lidicaine relieves severe pain: results of an inpatient hospice chart review." Journal of Palliative Medicine. 2004; 7: 660-667.

Carr, C. ed. Lidocaine Infusion Protocol. Nurse Practitioner Protocols Pocket guide for Palliative Care. 2011.

< Previous Case     Next Case >