La lidocaïne intraveineuse a des vertus analgésiques. Son utilisation comme anesthésique local ou pour une anesthésie loco-régionale est bien connue mais en IV ce médicament reste peu usité en France.
Après l’ECN, en bon polard, j’ai acheté mon premier livre d’anesthésie à l’étranger. Clinical Anesthesiology de Morgan. Evidemment je ne comprenais rien à ce bouquin. Spécialité mystérieuse. Je me souviens avoir été particulièrement surpris de l’utilisation de la lidocaïne en IV pour intuber. Une fois que j’ai commencé les stages d’interne, je n’ai jamais vu personne utilisé de la lidocaïne en IV pour faciliter une intubation. J’ai commencé à me demander si ça relevait de la science-fiction…
Les années passent et la lidocaïne revient à la mode avec la réhabilitation précoce en chirurgie viscérale, en IV elle permettrait un compromis entre analgésie et reprise précoce du transit. Je me souviens alors de mon grimoire anglo-saxon et j’entends aussi de vieilles légendes sur des docteurs qui utilisaient la lidocaïne comme analgésique dans la pancréatite aigüe.
Les années filent, et je deviens franchement responsable de ce que j’injecte au patient. Je creuse le sujet, je trouve ça intéressant. Je fais de plus en plus de lidocaïne et je me rends compte que ça se passe bien, je mets moins d’hypnotique et moins de morphinique. Malgré tout la lidocaïne continue de faire peur : sur les flacons à 1 et 2% c’est bien écrit « ne pas injecter en intraveineux » (une histoire d’AMM) et on nous rabache les oreilles dans les cours d’anesthésie loco-régionale sur les complications neurologiques et cardio-vasculaire d’une intoxication aux anesthésiques locaux. Tout ça ne pousse pas à la consommation et au développement de l’utilisation du produit…
C’est dommage parce que je pense que la lidocaïne pourrait rendre un paquet de service. En atteignant une masse critique de prescripteurs de lidocaïne en intra-veineux on créerait une culture intéressante de l’épargne morphinique et les soignants comprendrait mieux son utilisation et ses risques.
Bref. Moi j’aime bien la lidocaïne en intraveineux car elle joue sur plusieurs cibles :
– les canaux sodiques voltage-dépendants, notamment ceux qui se multiplient après une lésion nerveuse
– certains récepteurs médullaires muscariniques jouant sur l’inhibition descendante des voies de la douleurs,
– elle peut moduler l’action de canaux NMDA
– elle peut avoir des vertus anti-inflammatoires
En plus des papiers démontrent une activité antimicrobienne en destabilisant la membrane de certains germes, interesting…
Donc en pratique, je l’utilise souvent à 1,5 mg/kg à l’induction (après avoir fait des petites doses d’hypnotiques et de kétamine qui augmentent le seuil épileptogène, on n’est jamais à l’abri d’un gag) et une SAP per-op entre 1 et 2 mg/kg/heure (le XYLOCARD 5% est pratique, utilisé pur de 1 à 4 ml/h). J’aimerais qu’on la continue en post-opératoire mais la routine n’est pas acquise, on reste donc un peu frileux à l’heure actuelle sur le sujet.
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22 réponses sur « La lidocaïne comme analgésique intraveineux »
Merci pour ce sujet très instructif qui apporte une pierre dans ce but que les anesthésistes poursuivent : une analgésie per et post opératoire optimale avec le minimum d’inconvénient post opératoire
j’avais cru comprendre que les problèmes d’analgésie ne sont pas hyperfréquents en CCV, me trompe-je ? Quelles sont les chirurgies difficiles à gérer chez vous ? La sterno chez les jeunes ?
Je fais aussi de la chirurgie viscérale , bariatrique ,urologique ,gynecologique orthopédique et ORL
As tu des chirurgies de prédilection pour cette technique ou généralises tu ce protocole ?
Effectivement pas trop de difficultés en post op vasculaire .
ah OK, j’avais mal compris, je pensais que tu faisais surtout du vasculaire 🙂
La lecture de l’article d’anesthesio peut te guider pour le choix des chirurgies. En gros la littérature n’est pas « pour » en orthopédie (mais y’a l’ALR à gogo)
En viscérale je le fais dès qu’il n’y a pas de péri, je commence à le faire en carcino ORL avec un certains succès empirique, en gynéco je pense que ça a un intérêt mais je n’en fais pas du tout. En urologie je ne sais pas trop, j’en fais peu. J’aurais tendance à essayer comme en viscéral (pas de péri = lido IV)
En bariatrique, je pense peu d’intérêt car chirurgie rapide, coelio, patient motivés, peu sujets aux douleurs chroniques à vue de nez.
Tu peux retrouver des infos plus précises sur mes pratiques dans mon billet sur l’induction en viscérale. Bye
Que pensez vous de l’utilisation de la Lidocaine dans le syndrome fibromyalgique.
Cette molécule peut utilisé en France et jamais dans cette indication mériterait de s’y attarder un peu notamment grâce à ces propriétés surl’action de canaux NMDA et sur les récepteurs muscariniques.
Quels sont vraiment les risques en IV ?
Je ne connais pas du tout la fibromyalgie, je n’ai donc pas de réponses à cette question.
La lidocaïne en IV a été utilisé dans certains syndromes douloureux chroniques avec des améliorations. C’est une piste à essayer au cas par cas je pense.
Les risques de la lidocaïne en IV sont sérieux et justifient une administration à l’hôpital sous surveillance ECG :
1) risque de convulsions
2) risque de troubles du rythme cardiaque et arrêt cardiaque
Il faut toujours l’administrer lentement, en seringue autopulsée avec une surveillance rapprochée et du matériel de réanimation (avec des gens qui savent s’en servir) à portée de main.
J’ai personnellement participé et inclus quelques patients dans l’étude de Kaba et Joris (Anesthesiology).
J’utilise le même protocole en chirurgie gynécologique cœlioscopique ou non en alternative à l’APD (refus, échec ou CI).
En plus j’associe une perfusion de kétamine 0,2 mg/kg/h.
L’épargne morphinique est patente, je fais uniquement un bolus de sufentanil à l’induction (0,15-0,20 gammas/kg) et aucune réinjection en perop.
J’arrête la perfusion en sortie de SSPI car je suis le seul à en faire et je ne tiens pas à avoir des gags en salle avec les changements de seringues.
Analgésie post-op avec AINS si possible, néfopam. Quasiment jamais de recours à la morphine en post-op.
dans mes bras 🙂 \o/
depuis 2 ans je profite de la xylocaine pour ma fibromyalgie qui me fait revivre un peu pres pendant 4 mois, autrement c l’enfer …
je suis bien surveiller medicalement et apres les perfusions c comme un mort-vivant revie…..
merci a la xylocaine eternellement
maria
Ca fait déjà un petit moment que j’utilise ce protocole ketamine- lidocaine -catapressan avec très peu d’opioide ( 0.1mcg/kg à l’induction, car je n’ai pas encore le courage d’en renoncer complètement, sans ré-injection) en gyneco surtout, cœlioscopie ou pas et spécialement sur la cancéro quand il n’y a pas l’APD , mais aussi en uro pour les laparo. C’est un protocole que j’affectionne particulièrement, vue le degré de satisfaction de mes patientes en postopératoire ( pas de douleur, très peu de morphine- si jamais- en postop, pas des NVPO, pas des frissons, transit repris rapidement…)
J’arrête moi aussi les SAP de xylocard a la sorti de SSPI pour les mêmes raisons que Doc Propofol.
J’avais un petit peu peur au début de la réaction des IADE,car je suis la seule a le faire sur le site ou je travaille, mais une fois qu’ils ont tous eu la petit´formation’ et qu’ils ont compri le ´pourquoi’, ca se passe plutôt bien.
eh bien ça fait plaisir de voir que l’on est plusieurs à travailler de la même façon. Néanmoins je ne sais pas ce qui fait défaut pour convaincre nos collègues…
Vivement que la SFAR « modernise » son propos, ça aidera peut-être la diffusion de ces techniques analgésiques alternatives parce qu’actuellement le topo de la SFAR sur la douleur post-op ne laisse pas trop de place à ces stratégies http://www.sfar.org/article/56/attitude-pratique-pour-la-prise-en-charge-de-la-douleur-postoperatoire
On a souvent utilisé ces protocoles dans la région liégeoise (d’où sont issus Kaba et Joris), mais l’effet de mode est un peu passé, à tord sans doute…
A part la Lidocaïne que peut-on utiliser d’autre pour l’anesthésie sans morphinique???
ça reste un peu du domaine du fantasme pour moi, pour la chirurgie lourde sans locorégionale srt…
Merci pour ce blog super sympa!!( il se retrouve dans les favoris dans toutes nos salles d’op!)
merci pour votre commentaire !
j’ai beaucoup appris avec des anesthésistes de formation belge, notamment au CHU de Lille et à Valenciennes et je suis flatté de me retrouver lu par des collègues outre-quiévrain 🙂
à part la lidocaïne, à titre personnel j’aime beaucoup la ketamine, la clonidine et le magnesium surtout quand il n’y a pas de loco régionale
Et mon nouveau dada c’est de faire les antalgiques que l’on réserve en fin de bloc PENDANT le bloc (nefopam, AINS par exemple)
Avec toutes ses stratégies alternatives on arrive à vraiment diminuer drastiquement les doses de morphiniques
à bientôt !
Merci pour le billet ! Nous utilisons la lidocaine en postop, en analgésie complémentaire à 1 mg/kg.h pendant 24h postop. Perso, j’utilise ce dosage depuis une dizaine d’années en laparo sans avoir jamais vu ni troublés du rythme ni réaction neuro adverse ( j’évite de le donner aux épileptiques) . En ortho, l’équipe de Joris à bien montré son inutilité. En stomato ( ostéotomies), il y a un effet anti-œdème net qui mériterait une étude. Pour la petite histoire, il semble qu’une partie de l’effet anti inflammatoire soit lié à un effet de la lidocaine sur le système des micro tubules intracellulaires. Cela diminuerait notamment la margination leucocytaire.
Bonjour,
Nous utilisons la lido 2mg/kg/h en post op de chirurgie viscérale en plus de la PCA avec d’excellents résultats.
Cependant ce week-end j’ai récupéré un arrêt anoxique in extremis sur une jeune femme de 55 ans en BEG ASA 1, colectomie G pour sigmoidite, ATCd : HTA, qui a fait un état de mal convulsif apres 30 h de xylo 2 mg/h sans dose de charge.
A noter que j’avais prolongé le protocole PSE a 48 h car elle était un peu algique ( en fait par sous consommation de PCA).
Elle était en coma aréactif mydriase bilat aréactive GSC à 3 apres l’intubation/VC/MCE., mais a complètement récupéré. Je ne dépasserai plus jamais 24h!! Il existait une valve anti-retour et le PSE n’a pas été reprogrammé au changement de seringue. Avis aux amateurs!
wow ! frightening ! comme je l’écris on l’utilise peu en post-op (pourtant j’imagine qu’on pourrait sous certaines conditions) et que je l’ai proposé j’étais plutôt sur du 1,3 mg/kg/h
Je sais que des études proposent 2 mg/kg/h mais je pensais que c’était uniquement en per op.
Toujours est il qu’il semble que vous ayiez bien géré la situation, et que l’issue est bonne, ouf !
Vous avez fait combien d’intralipide ? (lorsque je vais dans l’hopital de rééducation pour un cathéter périnerveux, c’est ma petite poche contraphobique)
Il y a t il à votre avis des problèmes de préparation ? la patiente était-elle plus mince que d’autres ? des antécédents de convulsions ? des médicaments qui auraient pu faire une interaction ? un trouble ionique en plus ? un alcoolisme passé à l’as ? avez-vous pu faire un dosage sérique de la lidocaïne en période critique ? a-t-elle eu une irm ?
bonne journée
Salut nfkb,
Pour faire simple j’utilise également la lidocaine et le catapressan dans les memes proportions que toi. De plus j’ai eu la chance de tomber récemment sur un MAR en pédiatrie qui »dans son coin » l’utilise pour l’intubation et l’analgésie. Les résultats sont excellents. Pour connaitre ce magnifique domaine de la douleur trop souvent délaissé par les anesthésistes (perso douleur chronique) et avoir travailler sur les protocoles CHU en collaboration avec le CLUD c’est difficile de faire changer les mentalités. La RFE SFAR qui a été récemment réactualisée sur la DPO est, je l’avoue, pauvre sur les techniques annexes. La meilleure façon de faire est je pense de contacter soit Frederic Aubrun soit directement le comité douleur de la SFAR. La thématique Douleur est en vogue et malheureusement trop peu de données sont publiées en france. Les 2 thématiques à développer: lido +/- AINS. Je réfléchi pré-conditionnement nerveux comme piste.
Je ne suis qu’une vétérinaire, mais je parcours malgré tout avec intérêt ces articles, même si j’ai parfois un peu de mal avec les acronymes.
Je m’immisce dans votre si sérieuse discussion, pour une remarque : quand j’ai la chance d’avoir à disposition un pousse-seringue (denrée rare et précieuse), je l’utilise associée à la kétamine, ainsi qu’au fentanyl, sensiblement aux mêmes dosages que vous. Mes patients ne m’ont jamais fait de retour, mais je constate que les chats polytraumatisés sont en général plus aimables avec lido que sans.
Voilà, c’était ma minute inutile, en espérant vous avoir fait sourire !
Merci pour votre commentaire.
Le « je ne suis que » est de trop car je suis très admiratif de votre travail.
Je parle un peu de médecine vétérinaire dans l’article sur la clonidine.
Bonne journée
Bonjour!
Fervent adepte de la lido à l’induction, d’abord 20ml pour éviter la brulure propofol (98-2001) puis 1,5ml/kg pour l’ouverture de la glotte sous le pretexte que moins de curare: moins d’allergie (dès 2001). Puis les 2ml/kg/h pour l’antalgie pendant 24 et qqfois 48h (2006). Seule diffficulté convaincre les collègues. Pour le 2ml/kg/h je préfère la 2% car le débit est le dixième du poids patient en ml/h. C’est facile à retenir et les bolus, s’il y en a, sont moins concentrés.
Où tu me surprends, c’est l’affirmation de ton utilisation précoce des antalgiques, je pensais que tout le monde le faisait déja…
Je mets en prémèd : 2g de paracétamol per os, du biprofenid (sf CI), 600mg de gabapentine. Je n’ai plus qu’à faire l’Acupan après l’intubation. Moins de geste, moins cher, aussi efficace.
Mais pour convaincre les confrères….
Tant qu’à se raconter: j’ai arrêté les benzo (prémèd et perop) : trop de troubles mnésiques pour les patients.
Merci pour ton site!
Ken@vo!
Jeune interne d’AR, un remplaçant est venu dans mon périph et nous a fait découvrir l’Opioïd Free Anesthesia… (pas d’opiacés en per op, une seringue électrique de lidocaïne+clonidine+ketamine jusqu’à la sortie de salle)
Des résultats bluffants en terme de douleur per et post op, et surtout de stabilité hémodynamique…
A voir sur le long terme, mais nos chirs digestifs trouvent ça pas mal (reprise du transit etc)
Existe-t-il des données précises sur les douleurs chroniques post op ? et chez l’enfant ?
Sujet sur le forum i ALR, avec le protocole : http://www.i-alr.com/index.php/forum/11-bienvenue/1361-ofa
sur la lido et la ket Patricia Lavandhomme et Marc de Kock ont bien publié sur les avantages à la long terme, j’ai du mettre les articles dans une biblio d’un billet de ce blog (c’était pour les laparos)