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  • Animated spinning picture(Intermediate)Tip: Some shape effects on this slide are created with the Combine Shapes commands. To access this command, you must add it to the Quick Access Toolbar, located above the File tab. To customize the Quick Access Toolbar, do the following:Click the arrow next to the Quick Access Toolbar, and then under CustomizeQuickAccessToolbar click MoreCommands.In the PowerPointOptions dialog box, in the Choose commands from list, select All Commands. In the list of commands, click CombineShapes, and then click Add.To reproduce the shape effect on this slide, do the following:On the Home tab, in the Slides group, click Layout, and then click Blank.Also on the Home tab, in the Drawing group, click Shapes, and then under Basic Shapes click Oval (first row).On the slide, drag to draw an oval.Select the oval. Under DrawingTools, on the Format tab, in the Size group, enter 6” in the Height box and 6” in the Width box.Also on the Format shape, in the ShapeStyles group, click ShapeOutline, and then click NoOutline.On the Home tab, in the Drawing group, click Shapes, and then under BasicShapes click Pie (second row).On the slide, drag to draw a pie.Select the pie. Drag the yellow diamond adjustment handle to create a wedge shape.Under DrawingTools, on the Format tab, in the Size group, enter 5.7” in the Height box and 5.7” in the Width box.Press and hold CTRL, select the oval, and then select the pie. On the Home tab, in the Drawing group, click Arrange, point to Align, and then do the following:Click Align to Slide.Click Align Center.Click Align Middle.Press and hold CTRL, and then select the oval and then the pie shape. On the Quick Access Toolbar, click Combine Shapes, and then click ShapeSubtract.Select the new shape. Under DrawingTools, on the Format tab, in the ShapeStyle group, click the FormatShape dialog box launcher. In the FormatShape dialog box, click Fill in the left pane, in the Fill pane, click Pictureor texture fill, and then click the button next to Texture and click RecycledPaper (third row). Also in the FormatShape dialog box, click PictureColor in the left pane, in the PictureColor pane, under Recolor, click the button next to Presets, and then click Grayscale (first row). Also in the FormatShape dialog box, click PictureCorrections in the left pane, in the PictureCorrections pane, under Brightness and Contrast, in the Contrast box, enter 20%. Also in the FormatShape dialog box, click Shadow in the left pane, in the Shadow pane, click the Presets button, and then under Outer, click Offset Diagonal Bottom Left.Also in the Shadow pane, in the Blur box, enter 10 pt. To reproduce the picture effects on this slide, do the following:On the Insert tab, in the Images group, click Picture. In the Insert Picture dialog box, select a picture and then click Insert.Select the picture. Under PictureTools, on the Format tab, in the Size group, click the Size and Position dialog box launcher. In the Format Picture dialog box, resize or crop the image so that the height is set to 5.8” and the widthis set to 5.8”. To crop the picture, click Crop in the left pane, and in the right pane, under Crop position, enter values into the Height, Width, Left, and Top boxes. To resize the picture, click Size in the left pane, and in the right pane, under Size and rotate, enter values into the Height and Width boxes.Under Picture Tools, on the Format tab, in the Size group, click the down arrow under Crop, and then click Crop to Shape. Under Basic Shapes, click Oval (first row, first option from the left).Also under PictureTools, on the Format tab, in the Arrange group, click SendBackward.To reproduce the other shapes on this slide, do the following:Also on the Home tab, in the Drawing group, click Shapes, and then under BasicShapes click Oval (first row). On the slide, drag to draw an oval.Select the oval. Under DrawingsTools, on the Format tab, in the Size group, enter 0.17” in the Height box and 0.17” in the Width box. Also on the Format tab, in the ShapeStyles group, click ShapeFill, and then under ThemeColors, click Black, Text 1, Lighter 25% (fourth row). Also on the Format tab, in the ShapeStyles group, click ShapeOutline, and then click No Line. On the Home tab, in the Drawing group, click Shapes, and then under BasicShapes click Donut.On the slide, drag to draw a donut.Select the donut. Under Drawing Tools, on the Format tab in the Size group, enter 0.25” in the Height box and 0.25” in the Width box.Also on the Format tab, in the ShapeStyles group, click the FormatShape dialog box launcher. In the FormatShape dialog box, click Fill in the left pane, in the Fill pane, click Gradientfill, and then click the button next to Preset colors and click Silver (fifth row). Also in the FormatShape dialog box, click LineColor in the left pane, in the LineColor pane, click No line.Also in the FormatShape dialog box, click 3-DFormat in the left pane, in the 3-DFormat pane, under Bevel, click the button next to Top, and then click Circle (first row).Press and hold CTRL, and then select the freeform shape, the picture, the small circle, and the donut. On the Home tab, in the Drawing group, click Arrange, point to Align, and the do the following:Click Align to Slide.Click Align Center.Click Align Middle.Also on the Home tab, in the Drawing group, click Shapes, and then under BasicShapes click Oval.On the slide, drag to draw an oval.Select the oval. Under DrawingTools, on the Format tab, in the Size group, enter 0.65” in the Height box and 0.65” in the Width box. Also on the Format tab, in the ShapeStyles group, click the FormatShape dialog box launcher. In the FormatShape dialog box, click Fill in the left pane, in the Fill pane, click Picture or texture fill, and then click the button next to Texture and then click Recycled Paper (fourth row). Select the freeform shape. On the Home tab, in the Clipboard group, click Format Painter, and then click the new oval. Position this circle over the top edge of the freeform shape. On the Home tab, in the Drawing group, click Arrange, and then do the following:Under OrderObjects, click Send to Back.Point to Align, and then click Align Center.To reproduce the animation effects on this slide, do the following:Select the picture. On the Animations tab, in the AdvancedAnimation group, click AddAnimation, and then under EmphasisEffects, click Spin.Also on the Animations tab, in the Animation group, click the Show Additional Effects Options dialog box launcher. In the Spin dialog box, on the Effect tab, do the following:In the Smoothstart box, enter 5 sec.In the Smooth end box, enter 5 sec.Also in the Spin dialog box, click the Timing tab, and then do the following:In the Start list, select WithPrevious.In the Duration box, enter 20 sec.Select the small oval at the top edge of the freeform shape. On the Animations tab, in the AdvancedAnimation group, click AddAnimation, under Motion Paths, click Shapes.On the slide, drag the bottom, left, and right sides of the motion path so that it matches the inside edge of the freeform shape.Also on the Animations tab, in the Animation group, click the Show Additional Effects Options dialog box launcher. In the Circle dialog box, on the Effect tab, do the following:In the Smoothstart box, enter 5 sec.In the Smooth end box, enter 5 sec.Also in the Spin dialog box, click the Timing tab, and then do the following:In the Start list, select WithPrevious.In the Duration box, enter 20 sec.To reproduce the background effects on this slide, do the following:On the Design tab, in the Background group, click BackgroundStyles, and then click Style9.
  • A bolus injection of lidocaine 1.5 mg/kg followed by a continuous infusion of 1.5 mg /kg/ h led to lidocaine plasma levels of approximately 2 mic mL
  • Performed between Dec. 2003 and Nov. 2004. Sixty patients, ASA I or II, aged 40–80 yr, and Undergoing elective surgery for colon cancer were recruited

Transcript

  • 1. Guidelines Lidocaine Systemic Lidocaine infusionNone Operative pain Operative pain
  • 2. LidocaineLidocaine, the first amino amide-type local anesthetic, was first synthesized under the name Xylocaine by Swedish chemist Nils Löfgren in 1943.
  • 3. Indications Rapid acting local anesthetic for procedures ranging from infiltration to regional nerve block Antiarrhythmic in the treatment of vent. arrhythmias Treatment of status epilepticus (INVESTIGATIONAL) Treatment of pain Operative Neuropathic pain
  • 4. Pharmacology Half life: 90-120 min. Time to steady state: 8-10 hours Distribution: Lipo-philic, widely distributed into body Protein binding: 60-80 % Metabolism: 90% metabolite in the liver, 10 % unchanged drug excreted by kidney. Mao & Chen, 2000
  • 5. PharmacologyActive metabolites: Active metabolites: 90% in the liver monoethylglycinexylidide(MEDX), half life 2 hrs, 60-80% as potent as lidocaine glycinexylidine(GX), half life 10 hrs Half-life of lidocaine is approximately 90–120 min. hepatic impairment (average 343 min.) or Congestive heart failure (average 136 min.)
  • 6. Mechanism of action:Intravenous lidocaine is analgesic, antihyperalgesic, and antiinflammatory.These properties are mediated by a variety of mechanisms, including sodium channel blockade,as well as inhibition of G protein–coupled receptors and N-methyl-D-aspartate receptors. * *In sub-anesthetic dose, it blocks spontaneous ectopic discharge of the injured nerve without blocking normal nerve conduction** * Acta Anaesthesiol Scand.2006 * * Int Anesthesiol Clin. 2003 * Mao & Chen, 2000
  • 7. Toxicity Ferrini,2000
  • 8. Contraindications for the use of lidocaine • Heart block, second or third degree (without pacemaker) • Severe sinoatrial block (without pacemaker) • Serious adverse drug reaction to amide local anaesthetics • Concurrent treatment with quinidine, flecainide, disopyramide, procainamide (Class I agents) • Prior use of Amiodarone hydrochloride • Hypotension not due to Arrhythmia • Bradycardia • Accelerated idioventricular rhythm • Pacemaker • Porphyria, especially acute porphyria (AIP);
  • 9. Sodium Channel• The sodium channel is a voltage gated channel (Nav) is grouped into 9 classifications dependant upon there location and action.• The therapeutic goal would be to develop one that could specifically block the four channels (1.3, 1.7, 1.8 and 1.9) that have been shown to be in use for the proliferation of neuropathic and other pain signals.
  • 10. Sodium Channels role in neuropathic pain A Theory suggests that the fast activation, inactivation and rapid re-priming kinetics and persistent current component of The sodium channel 1.3 contribute to the development of spontaneous ectopic discharges and sustained firing characteristics of injured sensory nerves, leading to neuropatheic pain. Rogers M, et al.2006
  • 11.  Its mode of action is the attenuation of peripheral nociceptors sensitisation and CNS hyperexcitability, it achieves this by stablaising the open state of the sodium channel, this will lead to the sodium channel effectively being deactivated. Rogers M, et al., Semin Cell Dev Biol (2006)
  • 12. Lidocaine Bartlett et al. 1961 First study suggesting there is a role for systemic lidocaine for relief of post-op pain Boas et al. 1982 Clinical role for lidocaine for treatment of peripheral and central pain
  • 13. Inhibition of Postoperative Pain by Continuous Low- Dose intravenous Infusion of Lidocaine Jean Cassuto, Anesthesia and Analgesia low-dose continuous infusion of lidocaine is devoid of side effects and can be used to decrease the severity of postoperative pain, thus reducing the need for potent morphinomimetic drugs in the postoperative period
  • 14. Treatment of Postoperative Paralytic ileus by Intravenous Lidocaine Infusion Gunnar Rimback, Md, Anesth Analg,1990 lidocaine or saline placebo. Thirty patients scheduled for elective cholecystectomy were studiedContinuous IV infusion of lidocaine during the first postoperative day after cholecystectomy can reduce the need for narcotics and shorten the period of postoperative colonic inhibition in patients undergoing major abdominal surgery.Secondary to the inhibition of peritoneal irritation followed by reduced activation of inhibitory gastrointestinal reflexes.
  • 15. Intravenous Lidocaine Infusion Facilitates Acute Rehabilitation after Laparoscopic Colectomy Abdourahamane Kaba, M.D.,*Anesthesiology 2007 45 patients enrolledConclusions: Intravenous lidocaine improves postoperative analgesia, fatigue, and bowel function after laparoscopic colectomy. These benefits are associated with a significant reduction in hospital stay.
  • 16. Perioperative Intravenous Lidocaine Has Preventive Effects on Postoperative Pain and Morphine Consumption After Major Abdominal Surgery Wolfgang Koppert, Germany ,Anesth Analg 2004 A prospective, randomized, and double-blinded study of 40 patients undergoing major abdominal surgeryThe perioperative administration of systemic lidocaine is most effective in surgery associated with the development of pronounced central hyperalgesia, i.e., intestinal and bowel surgery.The pain experience after these types of surgery can be attenuated by lidocaine in a clinically relevant manner.
  • 17. Intravenous Lidocaine for Ambulatory Anesthesia Christopher L. Wu, MD ,Inter Anes Research Society,Dec. 2009Using 1.5–3 mg kg h lidocaine significantly reduced the incidence of nausea and vomiting (32% vs 52%), Marginally reduced pain scores , Decreased duration of postoperative ileus (8.4 h) and hospital stay (0.84 days).
  • 18. Systemic Lidocaine Shortens Length of Hospital Stay After Colorectal Surgery A Double-blinded, Randomized, Placebo-controlled Trial Susanne Herroeder, MD Annals of Surgery, August 200760 patients of ASA physical status I to III, between 18 and 75 years of age, scheduled for elective colorectal surgery
  • 19. Study Drug AdministrationPatients in the lidocaine group received 1.5 mg/kglidocaine intravenously as a loading dose before induction of general anesthesia.Immediately after tracheal intubation, a continuous systemic lidocaine infusion (2 mg/min) was initiated and terminated 4 hours after skin closure.Patients in the control group were treated likewise using NaCl 0.9% in a double-blinded fashion.
  • 20. Outcome Measures The primary outcome measure • length of hospital stay. Secondary outcome measures • Length of PACU stay, • Time until return of bowel function, • Postoperative pain and opioid consumption, • Plasma levels of several pro- and anti- inflammatory interleukins .
  • 21. Length of hospital stay
  • 22. Visual analog scale (VAS)
  • 23. Gastrointestinal motility
  • 24. Conclusions:Systemic lidocaine may thus provide a convenient and inexpensive approach to improve outcome for patients not suitable for epidural anesthesia.
  • 25. Comparison of the effects of thoracic epiduralanalgesia and i.v. infusion with lidocaine on cytokine response, postoperative pain and bowel function in patients undergoing colonic surgery C. P. Kuo ,British Journal of Anaesthesia Sept, 2006Conclusions The TEA lidocaine had better pain relief, lower opioid consumption, earlier return of bowel function and lesser production of cytokines than IV lidocaine during 72 h after colonic surgery; IV group was better than the control group.
  • 26. Systemic administration of local anesthetics to relieve neuropathic pain : a systemic review and meta-analysis Tremont-Lukats, 2005
  • 27. conclude“Lidocaine and mexiletine produced no major adverse events in controlled clinical trials, were superior to placebo to relieve neuropathic pain, and were as effective as other analgesics used for this condition.” Tremont-Lukats, 2005
  • 28. The Analgesic Response to IntravenousLidocaine in the Treatment of Neuropathic Pain F. Michael Ferrante, Anesth A nalg 199613 patients were enrolled in the study,with neuropathic pain for at least 6 months .Lidocaine was administered IV at a rate of 8.35 mg/min over 60 min.In conclusion, the results of this study suggest that the analgesic response to IV lidocaine is best characterized by a precipitous ‘break in pain” over a narrow dosage and concentration range.
  • 29. Topical Lidocaine Patch Relieves a Variety of Neuropathic Pain Conditions Devers, Clinical Journal of Pain: Sept 2000Results:Moderate or better pain relief was reported by 13 of the 16 participants (81%).Patients had a mean duration of patch use of 6.2 weeks with continued relief.
  • 30. Chronic pain treatment with intravenous lidocaine Petersen P, Neurol Res., Sep,1986 18 patients with severe chronic pain states due neurological diseases. After the infusion of lidocaine 14 patients (78%) had significant pain relief ranging from 2 hours to 25 days.
  • 31. Efficacy of 5-Day Infusion Continuous Lidocaine for the Treatment of Refractory C R P S Robert . schwartzman, md,pain medicine, 2009The majority of patients demonstrated a significant decrease in pain parameters and other symptoms and signs of CRPS. The pain reduction lasted an average of 3 months.Lidocaine may be particularly effective for thermal and mechanical allodynia. Less clinically significant effects were documented on the motor aspects of the syndrome.
  • 32. Diabetic Polyneuropathy (DPN) Viola et al., Journal of Diabetes and Complications, 2006 15 pat. with intractable painful DPN Double-blind, placebo-controlled crossover trial Two doses: 5mg/kg and 7.5mg/kg vs. saline Infusion during 4h and every 4 weeks Both doses ↓↓ severity of pain  Dose-response effect ! Reduction present at 14 and 28 days after Decrease in qualitative nature of pain up to 28d
  • 33. Guidelines Pre infusion assessment and preperation Lidocaine test Lidocaine infusion Home infusion
  • 34. Pre infusion assessment Complete history and physical examination Quantitative pain assessment Any history of allergy from lidocaine Any history of Heart or liver diseases ECG Ferrini& Paice, 2004
  • 35. Patient preperation Patients are required to have nothing by mouth for 4 hours prior to the procedures Written consent Vital signs are monitored including heart rhythm, heart rate, blood pressure and oxygen saturation
  • 36.  Lidocaine test Dose: 1-3 mg/kg (average 100 mg) Concentration: 8 mg/ml IV over 20-30 min. OR 40 mg/ml SC over 30-60 min (2-3 ml/hr) Monitor pain relief, vital signs and side effects q15 min. 50% of the dose in elderly patients >70 year, patients with heart or liver disease Ferrini& Paice, 2004
  • 37. Lidocaine infusion If pain relief > 50% and no side effects Dose 0.5 -2 mg/kg/hr IV OR SC Monitor pain, V/S and side effect after 15 min then 60 min then q 8 hr then prn Titrate up based on pain relief If any side effects occurred, stop infusion, reassess after 30-60 min then resume with 20% Or last safe dose
  • 38. Home infusion Patient must have a stable caregiver situation, with 24-hour supervision by a competent adult Patient must consent to being visited by a registered nurse 2–7 times a week Patient/caregiver should be provided with a lidocaine patient information sheet
  • 39. Home Massages• Lidocaine infusion is safe and effective intervention for operative and chronic pain• Lidocaine infusion has narrow therapeutic index. So, it needs clear guidelines to demonstrate how we use it safely