IMPACT OF THE USE OF LIDOCAINE AND MAGNESIUM SULFATE AS ANESTHETIC ADJUVANTS ON POSTOPERATIVE PAIN

Ciências da Saúde, Saúde Coletiva, Volume 29 – Edição 141/DEZ 2024 / 09/01/2025

REGISTRO DOI: 10.69849/revistaft/fa10202412301234

Danillo Xavier Santos1,
Fabrício Tavares Mendonça2

ABSTRACT

Local anesthetics such as lidocaine and NMDA receptor antagonists, like magnesium sulfate, have shown promise in the management of acute pain, offering antinociceptive, antihyperalgesic, and anti-inflammatory properties. However, despite being accessible and economically viable solutions, there are still gaps in knowledge. In this context, this study aims to review the scientific literature on the impact of using lidocaine and magnesium sulfate as adjuvants during anesthesia on postoperative pain intensity. The methodology of this study consisted of a narrative literature review, aimed at evaluating the effectiveness of analgesia using lidocaine and magnesium sulfate in reducing postoperative pain. To ensure the quality of the review, the SANRA (Scale for the Quality Assessment of Narrative Review Articles) was applied. The selection of articles was carried out through searches in the Pubmed (Medline), Embase, and Web of Science databases. Only full-text articles published in the last ten years were included, ensuring the relevance and timeliness of the evidence analyzed. Based on the analysis of the available studies, it can be concluded that, although lidocaine and magnesium sulfate show potential as effective adjuvants in perioperative analgesia, further research is needed to confirm their efficacy and safety.

Keywords: Anesthesia. Lidocaine. Magnesium Sulfate. Pain, Postoperative.

RESUMO

Anestésicos locais como a lidocaína e antagonistas de receptores NMDA, como o sulfato de magnésio, têm se mostrado promissores no controle da dor aguda, oferecendo propriedades antinociceptivas, antihiperalgésicas e anti-inflamatórias. No entanto, apesar de serem soluções acessíveis e economicamente viáveis, ainda existem lacunas no conhecimento. Nesse contexto, este estudo tem como objetivo revisar a literatura científica sobre o impacto do uso de lidocaína e sulfato de magnésio como adjuvantes durante o ato anestésico na intensidade da dor pós-operatória. A metodologia deste estudo consistiu em uma revisão narrativa da literatura, com o intuito de avaliar a eficácia da analgesia utilizando lidocaína e sulfato de magnésio na redução da dor pós-operatória. Para assegurar a qualidade da revisão, foi adotada a escala SANRA (Scale for the Quality Assessment of Narrative Review Articles). A seleção dos artigos foi realizada por meio da busca nas bases de dados Pubmed (Medline), Embase e Web of Science. Foram incluídos apenas artigos disponíveis em formato completo e publicados nos últimos dez anos, garantindo a relevância e atualidade das evidências analisadas. A partir da análise dos estudos disponíveis, é possível concluir que, embora a lidocaína e o sulfato de magnésio mostrem potencial como adjuvantes eficazes na analgesia perioperatória, há necessidade de mais pesquisas de para confirmar sua eficácia e segurança.

Palavras-Chave: Anestesia. Lidocaína. Sulfato de Magnésio. Dor Pós-Operatória.

INTRODUCTION

Postoperative pain is common, but often overlooked, and its management is crucial to prevent complications. Acute pain is related to nociceptive stimuli caused by tissue damage, affecting sensory, emotional, and cognitive perception. The goal of treatment, therefore, is to block these stimuli at various levels of the nervous system, reducing perioperative morbidity and the risk of pain chronicity (Mendonça et al., 2015).

Opioids, such as remifentanil, are widely used in intraoperative pain management, but they are associated with several side effects, including respiratory depression, chest wall rigidity, nausea, vomiting, drowsiness, pruritus, urinary retention, immunomodulation and postoperative hyperalgesia. Due to these issues, alternatives such as local anesthetics and NMDA receptor antagonists are being studied (Mendonça et al., 2020).

Systemic lidocaine has antinociceptive, antihyperalgesic, and anti-inflammatory properties, reducing postoperative pain and the use of analgesics (Mendonça et al., 2015). Magnesium sulfate, an NMDA receptor antagonist, can prevent central sensitization after peripheral injuries, as well as decrease airway reactivity and stress responses (Mendonça et al., 2020; Akhondzade et al., 2017; Manouchehrian et al., 2022).

Therefore, the use of lidocaine and magnesium sulfate has been investigated by different researchers for being effective, low-cost and widely available, although there are still uncertainties about the correct dosage (Mendonça et al., 2020; Akhondzade et al., 2017). Although it has been shown that magnesium reduces the need for rescue anesthetics and analgesics, more studies are needed to confirm its effectiveness (Akhondzade et al., 2017).

The conduct of this study is justified by the need to improve postoperative pain management, a common but often undertreated condition that can lead to serious complications and compromise the patient’s recovery. Although opioids, such as remifentanil, are widely used for intraoperative pain control, their use is associated with significant adverse effects, such as postoperative hyperalgesia and the risk of dependency, which underscores the need for safer and more effective alternatives.

Local anesthetics such as lidocaine and NMDA receptor antagonists, like magnesium sulfate, have shown promise in the management of acute pain, offering antinociceptive, antihyperalgesic, and anti-inflammatory properties. However, despite being accessible and economically viable solutions, there are still gaps in knowledge, particularly regarding the optimal dosage and the exact mechanism of action for different types of surgeries. Thus, this study aims to contribute to the existing literature by investigating the effectiveness of these alternatives, with the goal of improving postoperative pain control, reducing opioid use, and minimizing the risks of pain chronicity and perioperative complications.

In this context, the objective of this study is to review the scientific literature on the impact of using lidocaine and magnesium sulfate as adjuvants during the anesthetic procedure on the intensity of postoperative pain.

METHODOLOGY

The methodology of this study consisted of a narrative literature review, aimed at evaluating the effectiveness of analgesia using lidocaine and magnesium sulfate in reducing postoperative pain. To ensure the quality of the review, the SANRA scale (Scale for the Quality Assessment of Narrative Review Articles), developed by Baethge, Goldbeck-Wood, and Mertens (2019), was adopted. The selection of articles was carried out through searches in the databases PubMed (Medline), Embase and Web of Science, using the descriptors “Anesthesia”, “Lidocaine”, “Magnesium Sulfate” and “Pain, Postoperative”. Only full-text articles published in the last ten years were included, ensuring the relevance and currency of the evidence analyzed.

POSTOPERATIVE PAIN MANAGEMENT

Effective postoperative analgesia improves patient outcomes by facilitating early ambulation, reducing complications, and decreasing the incidence of chronic pain (Akhondzade et al., 2017). Rawal (2016) emphasizes that postoperative pain management has been poorly implemented for decades, with little significant improvement. Persistent postoperative pain is common, affecting about 50% of patients after surgeries such as thoracotomy and mastectomy. Despite their well-known side effects, opioids remain the primary treatment.

Ho, Kerr, and Stevens (2018) highlight that postoperative pain is a significant concern in abdominal surgery, as it can affect patient recovery and quality of life. They acknowledge that postoperative pain not only causes discomfort, but can also lead to complications, such as decreased mobility, delayed intestinal recovery, and increased reliance on opioid analgesics, which are associated with side effects. The study emphasizes the need for effective pain management strategies, given the prevalence of acute pain after surgeries and the impact it can have on recovery. The use of intravenous lidocaine is mentioned as an approach that can be employed to improve pain control, reducing the need for opioids and, consequently, the adverse effects associated with them.

Complementing this perspective, Weibel et al. (2018) observe that opioids, often used for analgesia, are associated with adverse effects such as nausea and constipation, which can hinder patient recovery. Intravenous (IV) lidocaine has been investigated as an alternative in multimodal management strategies, with the review including 68 clinical trials. The results suggest uncertainties about the effectiveness of lidocaine in reducing pain compared to placebo, showing no clinically relevant reduction in pain after 24 hours. Additionally, although lidocaine may help speed up the time to the first bowel movement, the evidence in this regard is uncertain.

Mendonça et al. (2015) reviewed the scientific literature on the use of intravenous lidocaine as a treatment for perioperative analgesia. The study analyzed 32 articles and found that lidocaine works by decreasing the conduction of excitatory nerve impulses, visceral pain, central sensitization to pain and the immune response. Lidocaine was effective at doses of 1,5 to 2 mg/kg administered in bolus, followed by continuous infusions of 1,5 to 3 mg/kg/h. The best results were observed in abdominal surgeries, with benefits such as reduced use of opioids and volatile anesthetics, as well as faster recovery of intestinal function. The research concluded that systemic lidocaine is an effective and low-cost alternative for treating perioperative pain, although more clinical studies are needed for different surgical interventions.

In contrast, Dewinter et al. (2017) conducted a randomized controlled clinical trial to evaluate whether perioperative systemic lidocaine infusion could reduce the need for opioids and improve recovery in adolescent and adult patients undergoing posterior spinal fusion. The study included 70 patients who received total intravenous anesthesia and were randomized to receive either lidocaine or a placebo. The results showed that lidocaine did not significantly reduce morphine consumption in the first 24 hours postoperatively, nor did it impact postoperative pain, morphine consumption in the subsequent 48 and 72 hours, or other outcomes such as nausea, inflammation, intestinal recovery time, length of hospital stay and quality of life. The authors concluded that systemic lidocaine did not provide significant analgesic benefits in this surgical context.

Similar results were found in the research by Couceiro et al. (2015), who investigated the analgesic effect of intravenous lidocaine in women undergoing mastectomy, focusing on postoperative pain management and opioid consumption. The study was a randomized controlled clinical trial in which 45 women received an intravenous infusion of lidocaine at 3 mg/kg for one hour under general anesthesia. The results showed no significant difference between the group that received lidocaine and the placebo group in terms of postoperative opioid needs or the presence of pain upon awakening and in the anesthetic recovery room. Pain assessments 24 hours after surgery also revealed no significant differences between the groups.

These results contrast with the findings of the study by Xia et al. (2022), which demonstrated that the intravenous lidocaine infusion significantly reduced the incidence of chronic postoperative pain (CPSP) in breast cancer patients, both at 3 and 6 months of follow-up. In their study, lidocaine decreased acute pain in the immediate postoperative period and had a positive impact on reducing chronic pain over time, as evidenced by a lower need for analgesics and better pain scores on pain scales.

The discrepancies between the two studies may be attributed to several variables, such as the doses of lidocaine used, the infusion time, the demographic characteristics of the patients and the type of surgery performed. While Xia et al. (2022) used an initial dose of 1,5 mg/kg followed by a continuous infusion of 2 mg/kg/h, Couceiro et al. administered a single dose of 3 mg/kg over a shorter period. This difference in approaches may have influenced the results, suggesting that the effectiveness of lidocaine could be dependent on a combination of factors, including the administration protocol and the patient profile.

Magnesium sulfate (SMG) may also have beneficial effects in postoperative pain management by reducing the side effects observed after local anesthesia and prolonging the duration of sensory blockade. Its action occurs through the inhibition of catecholamine release and sympathetic blockade, resulting in vasodilation and a reduction in blood pressure (Kiaee et al., 2014).

Taheri et al. (2015) found that magnesium sulfate may be an effective and safe option for reducing pain and opioid consumption after total abdominal hysterectomy (TAH) under balanced general anesthesia. In their study, 40 women were randomly divided into two groups: the magnesium group, which received a single dose of magnesium sulfate (50 mg/kg) diluted in 100 mL of saline solution 15 minutes before anesthesia induction, and the control group, which received only saline solution. Pain was assessed using the Numerical Rating Scale (NRS) in the first 24 hours post-surgery at 0, 6, 12, and 24 hours, while pethidine consumption was recorded as a measure of rescue analgesia. The results showed that the group receiving magnesium sulfate had significantly lower pain scores at the 6, 12, and 24-hour postoperative assessments, as well as a lower need for pethidine over the 24 hours (P = 0,0001).

In summary, the literature highlights the complexity of postoperative pain management and the need for alternatives that minimize opioid use due to the side effects associated with these drugs. Intravenous lidocaine and magnesium sulfate emerge as potential adjuncts in perioperative pain control, although studies reveal mixed results regarding their effectiveness, possibly influenced by variables such as the type of surgery, dosage, and administration protocol. The variability in results suggests that these agents may benefit specific patient subgroups or particular surgical contexts.

USE OF LIDOCAINE AND MAGNESIUM SULFATE AS ANESTHETIC ADJUVANTS IN POSTOPERATIVE PAIN

This section discusses the use of lidocaine and magnesium sulfate as anesthetic adjuvants in postoperative pain, emphasizing the variability in analgesic effects depending on the type of surgery performed. Several studies have shown that the combination of these drugs can provide significant benefits in pain management, but their effectiveness may vary depending on the specific characteristics of the surgical intervention. In this context, the findings of research exploring the use of lidocaine and magnesium sulfate in different surgical procedures are analyzed.

NEUROSURGERY

Pain management in neurosurgical procedures is a challenge due to the complexity of the interventions and the potential impact of analgesic control in the postoperative period. As a result, studies have considered the use of intravenous adjuvants.
Rady et al. (2024) investigated the effectiveness of intravenous adjuvants in reducing opioid use and pain scores following spinal fusion surgery, involving 120 patients aged 18 to 60 years, divided into four groups: intravenous lidocaine, intravenous magnesium sulfate, a combination of lidocaine and magnesium, and a control group with saline solution. The group receiving the combination of lidocaine and magnesium showed a longer interval before the first request for analgesia and required fewer rescue doses, as well as reporting lower pain levels, both at rest and in motion, compared to the other groups. This combination also reduced anxiety and depression and improved the overall health of patients for up to three months after the infusion, providing greater satisfaction. The study concluded that the combination of lidocaine and magnesium sulfate has a synergistic effect in reducing perioperative pain, analgesic consumption, and symptoms of anxiety and depression, leading to long-term health improvement.

Mestdagh et al. (2023) studied pain management after craniotomy, identifying effective interventions to optimize pain relief. Although the use of magnesium sulfate and lidocaine was considered, the evidence found was limited. Magnesium sulfate, administered during surgery, did not show conclusive results regarding postoperative pain reduction, nor did lidocaine infusion. The research highlighted that, while these substances may have potential as analgesic adjuvants, they were not sufficient to be recommended as standard practices in pain management after craniotomy.

A different result was observed by Mahajan et al. (2019), who assessed the effects of lidocaine and magnesium on postoperative pain and opioid consumption in 45 patients undergoing supratentorial craniotomies for tumor removal. The patients were divided into three groups: Group I received an initial dose of lidocaine at 1,5 mg/kg over 15 minutes, followed by infusion at 2 mg/kg/h; Group II (control) received a dose of 10 ml of 0,9% saline solution over 15 minutes, with continuous infusion at 6 ml/h; and Group III received magnesium sulfate (50%) at 50 mg/kg in a 15-minute bolus, followed by infusion at 25 mg/kg/h. The results showed that the groups receiving lidocaine and magnesium had lower pain scores (VAS) and lower fentanyl consumption in the first 24 hours compared to the control group. The authors also observed a significant reduction in S100 B levels only in the group that received magnesium, suggesting a potential neuroprotective effect. No significant hemodynamic adverse effects were observed between the groups during the procedure.

In summary, the use of adjuvants such as lidocaine and magnesium sulfate in neurosurgery represents a promising advancement in postoperative pain control, providing significant benefits in some procedures, such as spinal fusion surgeries. Although results vary depending on the type of intervention, as observed in craniotomies, the combination of these agents shows potential to reduce opioid consumption, minimize pain, and even improve patients’ emotional well-being in the postoperative period.

MASTECTOMY

The use of anesthetic adjuvants has also been considered in mastectomies. Mendonça et al. (2020) evaluated the effectiveness of the combination of lidocaine and magnesium sulfate in reducing opioid consumption and pain scores after mastectomy through a randomized, double-blind, parallel clinical trial. Patients who received both medications consumed significantly less alfentanil during surgery and less dipyrone and morphine in the postoperative period compared to those who received remifentanil or magnesium sulfate alone. Only 6,7% of patients in the combined group required morphine, and they reported lower pain levels in the first 24 hours postoperatively. The results suggest that the combination of lidocaine and magnesium sulfate may have a synergistic effect in perioperative analgesia, representing a promising strategy in multimodal analgesia regimens.

Kim et al. (2017) compared the effects of lidocaine and magnesium on postoperative functional recovery and chronic pain in women undergoing mastectomy due to breast cancer. In a prospective, double-blind clinical trial with 126 patients, participants were randomly divided into three groups: lidocaine, magnesium, and control. Lidocaine was administered at 2 mg/kg, and magnesium at 20 mg/kg over 15 minutes after induction, followed by continuous infusions. The control group received saline solution. The results showed that the global Quality of Recovery 40 (QoR-40) scores on the first postoperative day were significantly higher in the lidocaine group compared to the control group (P = 0,003). Furthermore, in the emotional dimensions and pain scores of QoR-40, the lidocaine group had superior results compared to the magnesium and control groups (P = 0,027 and P = 0,023, respectively). After three months, the short-form McGill pain questionnaire (SF-MPQ) scores and the sensory scores of SF-MPQ were significantly lower in the lidocaine group than in the control group (P = 0,046 and P = 0,036, respectively).

CARDIAC SUGERY

In the field of cardiac surgery, Kiaee et al. (2014) investigated the effects of magnesium sulfate and lidocaine on hemodynamic responses after endotracheal intubation in patients undergoing elective coronary artery bypass graft surgery. In a randomized clinical trial with 150 patients, divided into three groups, one group received lidocaine (1,5 mg/kg), another received magnesium sulfate (50 mg/kg over five minutes), and the third received saline solution, all administered 90 seconds before intubation. Hemodynamic parameters were measured before and after intubation. The results showed that both groups receiving lidocaine or magnesium sulfate had a reduction in heart rate compared to the control group; however, lidocaine caused a reduction of more than 20% in heart rate and mean arterial pressure immediately after intubation, leading to hemodynamic instability. The authors concluded that in patients undergoing cardiac surgery, magnesium sulfate is more effective than lidocaine in maintaining hemodynamic stability after endotracheal intubation.

OTORHINOLARYNGOLOGY SURGERIES

Manouchehrian et al. (2022) compared the effects of intravenous magnesium sulfate and lidocaine in preventing laryngospasm and the need for analgesics in tonsillectomy surgeries. Sixty-two children were divided into two groups: one received magnesium sulfate, and the other received lidocaine. The group that received magnesium sulfate had a lower incidence of stridor (9,7% versus 32,3% in the lidocaine group), as well as a lower frequency of nausea, vomiting, agitation, and need for analgesics. However, the recovery time and sedation level were higher in the magnesium sulfate group. The authors concluded that magnesium sulfate reduced postoperative complications compared to lidocaine.

HEAD AND NECK SURGERIES

In the study by Kim et al. (2018), the effects of intravenously administered lidocaine and magnesium were evaluated on the postoperative recovery quality of patients undergoing thyroidectomy. In a prospective, double-blind trial, 135 women were randomly divided into three groups: Group L (lidocaine – 2 mg/kg for 15 minutes, followed by 2 mg/kg/h), Group M (magnesium – 20 mg/kg for 15 minutes, followed by 20 mg/kg/h), and Group C (control – equivalent volume of saline). The results on the first postoperative day showed a significant improvement in the QoR-40 index for Group L (186,3) compared to Group C (179,4), particularly in the emotional state, physical comfort, and pain dimensions. However, there was no significant improvement in Group M compared to the control. The authors concluded that intravenous lidocaine improves postoperative recovery quality, while magnesium, at the dosage used, did not show a relevant effect.

GENERAL SURGERY

In the study by Toleska et al. (2022), 120 patients undergoing laparoscopic cholecystectomy were divided into three groups: Group 1 (lidocaine), receiving 1 mg/kg followed by continuous infusion of 2 mg/kg/h; Group 2 (ketamine), receiving 0.5 mg/kg; and Group 3 (magnesium sulfate), with continuous infusion of 1.5 g/kg. The results indicated that the lidocaine group had the highest pain scores in the postoperative period, both at rest and when coughing, and required more rescue analgesics. In contrast, the ketamine group had the lowest pain scores, and the magnesium group required the least amount of rescue analgesia. During the intraoperative period, the magnesium group received the highest dose of fentanyl, while the lidocaine group required the least. It was concluded that multimodal analgesia with these drugs can reduce the need for opioids in the intra- and postoperative periods.

In a prospective, randomized, double-blind study, Kumar et al. (2022) randomly divided 100 patients undergoing laparoscopic cholecystectomy into two groups. Group A received intravenous lidocaine (2 mg/kg bolus and maintenance at 3 mg/kg/h), while Group B received a combination of lidocaine and magnesium sulfate (50 mg/kg magnesium bolus and maintenance of 15 mg/kg/h magnesium and 3 mg/kg/h lidocaine). The results showed that the group receiving the combination of lidocaine and magnesium had significantly lower postoperative analgesic consumption. Although the lidocaine group had lower pain scores, the difference was not statistically significant. The authors concluded that the use of intravenous magnesium sulfate, followed by continuous infusion, can reduce postoperative pain and the need for analgesics.

CONCLUSION

The analysis of the effects of lidocaine and magnesium sulfate as adjuvants in perioperative pain control suggests that these medications offer significant benefits in some surgeries, contributing to a more comfortable recovery with reduced need for analgesics. In neurosurgical procedures, the combination of both adjuvants proved to be particularly effective in reducing opioid consumption and improving overall well-being, indicating a synergistic effect between them. In mastectomies, this combination also showed promising results, reducing analgesic use and postoperative discomfort.

In cardiac surgeries and thyroidectomy, lidocaine proved to be particularly beneficial in improving recovery and hemodynamic stability, while magnesium played a significant role in preventing respiratory complications in otorhinolaryngology procedures. In general surgery, both drugs demonstrated effectiveness in multimodal analgesia, helping to reduce the need for opioids.

These findings reinforce the potential of lidocaine and magnesium sulfate as useful strategies in pain management and postoperative recovery, especially when used in combination in certain types of surgeries, such as neurosurgeries and mastectomies. Based on the analysis of the available studies, it is possible to conclude that, although lidocaine and magnesium sulfate show potential as effective adjuvants in perioperative analgesia, further research is needed to confirm their efficacy and safety.

Despite the promising results, there is still a scarcity of studies exploring these drugs in different types of surgeries and populations. The available studies have limited sample sizes, significant methodological variations, or focus on specific procedures, making it difficult to generalize the findings. This lack of research contributes to the variability in the observed results, as the effects of lidocaine and magnesium may be influenced by various factors, such as the type of surgery, the dose administered, the patient profile, and local clinical practices.

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1Fundação de Ensino e Pesquisa em Ciências da Saúde / Hospital de Base do Distrito Federal  19 Norte Street, Lorys Building, Apt. 905, Águas Claras, Brasília – DF, Brazil 71915-000 danilloxs150@gmail.com

2Fundação de Ensino e Pesquisa em Ciências da Saúde / Hospital de Base do Distrito Federal