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Intravenous Magnesium – Lidocaine - Ketorolac Cocktail for Postoperative Opioid Resistant Pain: A Case Series of Novel Rescue Therapy

[ Vol. 16 , Issue. 3 ]

Author(s):

Christian Zanza*, Yaroslava Longhitano, Edwin Lin, Jerry Luo, Marco Artico, Benedetta Savarese, Valeria Bonato, Andrea Piccioni, Francesco Franceschi, Samanta Taurone, Ludovico Abenavoli and Jack Marshall Berger   Pages 288 - 293 ( 6 )

Abstract:


Background: Severe postoperative pain is principally managed by opioids. While effective, opioids do not provide adequate relief in many patients and cause many side effects, including antinociceptive tolerance and opioid-induced hyperalgesia. To evaluate if a combination of intravenous Magnesium, Lidocaine, Ketorolac (MLK cocktail) is a useful rescue therapy through synergistic pharmacological mechanisms for acute pain relief. We present the intravenous combination of magnesium, lidocaine, and ketorolac (MLK cocktail) as a possible rescue for opioid insensitive severe post-operative pain.

Materials and Methods: The principal settings were the post-operative care unit (PACU) and the surgical ward. We retrospectively analyzed the electronic medical record and anesthesia documents of 14 patients experiencing severe postoperative pain, >7/10 visual-analogue pain score (VAS), despite receiving at least 8 mg of intravenous morphine milligram equivalents (MME) after arrival in the LAC+USC Medical Center PACU between September 2012 and January 2013. The data reviewed included patients’ demographics, disease etiology, surgical procedure, opioids received perioperatively, and visual-analogue pain scores before and after each analgesic received, and after the MLK cocktail. The a priori primary outcome and a posteriori secondary outcome of this study are mean visual-analogue pain score and morphine milligram equivalent dose administered per hour, respectively. The main tool evaluated has been VAS score.

Results: In patients who failed to respond to opioid analgesics, administration of the MLK cocktail improved the VAS pain scores immediately from 9.4 ± 1.0 to 3.6 ± 3.5. The MLK cocktail also decreased the MME doses/hour in the immediate 12 hours postoperative period from 12.4 ± 5.6 to 1.1 ± 0.9.

Conclusion: In patients experiencing opioid-resistant severe postoperative pain, the magnesium, lidocaine, and ketorolac combination may be an effective nonopioid rescue therapy. Additionally, magnesium, lidocaine, and ketorolac may be utilized in cases complicated by either antinociceptive tolerance or opioid-induced hyperalgesia and can restore opioid responsiveness.

Keywords:

Ketorolac, lidocaine, magnesium, multimodal analgesia, opioid antinociceptive tolerance, opioid-induced hyperalgesia, opioid sensitivity, opioid-sparing, severe postoperative pain.

Affiliation:

Department of Emergency Medicine, Policlinico Agostino Gemelli, Catholic University of Sacred Heart, Rome, Department of Anesthesiology, Keck Medical School of University of Southern California, Los Angeles, Department of Anesthesiology, Keck Medical School of University of Southern California, Los Angeles, Department of Anesthesiology, Keck Medical School of University of Southern California, Los Angeles, Department of Sensory Organs, Sapienza University of Rome/Policlinico Umberto I, Rome, Department of Anesthesiology and Critical Care, St. Antonio e Biagio e Cesare Arrigo Hospital, Alessandria, Department of Anesthesiology and Critical Care, St. Antonio e Biagio e Cesare Arrigo Hospital, Alessandria, Department of Emergency Medicine, Policlinico Agostino Gemelli, Catholic University of Sacred Heart, Rome, Department of Emergency Medicine, Policlinico Agostino Gemelli, Catholic University of Sacred Heart, Rome, Department of Sensory Organs, Sapienza University of Rome/Policlinico Umberto I, Rome, Department of Health Sciences, University Magna Graecia of Catanzaro, Catanzaro, Department of Anesthesiology, Keck Medical School of University of Southern California, Los Angeles

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