Lidocaine Intravenous in the Emergency Department For Sickle Cell Crisis
Lidocaine Intravenous in the Emergency Department For Sickle Cell Crisis
Sickle cell crisis continues to be a frequent presentation to emergency departments. Patients
 presenting will often require immediate treatment for their pain and often times this will
 include opioids. The opioid epidemic has cost thousands of lives; and continues to be a
 significant problem posing several challenges when treating patients presenting with sickle
 cell disease. Primarily, opioids remain the mainstay of treatment for these patients and the
 push to address the opioid crisis may present challenges for adequate opioid administration
 in patients suffering from a sickle cell crisis while hospitals find ways to curb the opioid
 crisis overall. Opioid treatment for patients in acute vaso-occlusive crisis has
 significantly contributed to quality of life and life expectancy of patients with this
 diagnosis. Measures should continue to attempt to administer a multi-model approach to sickle
 cell patients to minimize the morphine milligram equivalents in these patients while also
 successfully addressing the patient's pain. IV lidocaine is a pain medication that has been
 evaluated in several painful experiences, such as in renal colic. A few case reports have
 shown IV lidocaine use in sickle cell can be a potential effective adjunct medication to
 opioids to treat pain and reduce further opioid requirements. Currently, no prospective
 controlled trial exists to evaluate the true benefit of IV lidocaine in this population. Our
 study aims to evaluate IV lidocaine as an adjunct to opioid treatment in the emergency
 department to determine if improved pain is achieved and if there is a reduction in overall
 morphine milligram equivalents throughout the emergency department visit.
Pain is the most frequent reason for emergency department visits in the United States,
 especially for those patients with sickle cell disease (SCD). Painful vaso-occlusive events
 frequently require admission to the hospital despite opioid therapy, which is the mainstay of
 treatment for moderate to severe pain in SCD. Achieving adequate pain control with escalating
 doses of opioid analgesics may be difficult due to tolerance, physical dependence, and side
 effects. Common side effects include pruritus, nausea and vomiting, constipation, urinary
 retention, sedation, and respiratory depression. With the recent focus on the opiate crisis
 there has been a push towards the use of alternative to opiates (ALTO) for a variety of pain
 syndromes.

 Lidocaine is a class 1b sodium channel blocking agent that is typically used as an
 anti-arrhythmic and local anesthetic. This medication also has potent anti-inflammatory,
 anti-hyperalgesic, and gastrointestinal pro-peristaltic properties. Lidocaine may be useful
 as an adjunct to opioids in response to a painful sickle cell crisis. Intravenous (IV)
 lidocaine infusion has previously shown benefit in neuropathic pain, renal colic, and
 peri-operative pain. No prospective studies have evaluated lidocaine for SCD pain thus far.

 A previous retrospective study evaluated lidocaine infusion as adjuvant therapy to patients
 with SCD. Eleven patients were given a total of 15 IV lidocaine trials. Investigators found
 clinical improvement in pain score from pre-lidocaine challenge to 24 hours post (defined as
 a >20% reduction in pain scores) in 53.3% (8 of 15) of patients. Of the 8 clinically
 successful trials, the mean reduction in morphine dose equivalents (MDE) from 24 hours pre to
 24 hours post lidocaine was 32.2%. Two patients experienced disorientation and dizziness. The
 authors concluded that lidocaine was able to provide pain relief and reduce the amount of
 morphine necessary during SCD vaso-occlusive crisis and that prospective studies are needed
 to determine its true efficacy, dosing, and tolerability.

 A prospective, single-arm, phase II trial evaluated lidocaine 5% patches for neuropathic pain
 and pain related to vaso-occlusive sickle cell crises in children ages 6 to 21 years old.
 Patches were applied to the painful area for 12 hours a day. The primary endpoint was the
 proportion of inpatients with significant pain relief defined as a decrease of at least 2
 points on the visual analog pain scale (VAS, from 0-10) measured at 12 hours after patch
 placement over two consecutive days. The use of additional treatments such as antiepileptics
 and opioids were allowed and their usage was documented. The primary outcome of VAS
 improvement of >2 over 2 consecutive days was observed in 48.6% of evaluated patients
 (19/39). Transdermal lidocaine was tolerated well with only 3 minor adverse events reported
 (two localized skin reactions and one generalized skin eruption) and no serious adverse
 events.

 The theoretical benefits along with the two previously discussed studies provide evidence to
 further investigate the use of lidocaine in SCD pain. Studies are needed to know whether
 lidocaine may be able to benefit alleviate pain quicker and minimize need for opiates
 similarly to its use in renal colic. This prospective trial aims to evaluate whether
 lidocaine can decrease the opiate needs during a SCD crisis while providing adequate pain
 relief and tolerability.
Inclusion Criteria:

 -  Patients > 18 years old with sickle cell disease experiencing persistent severe
 (7-10/10) pain despite receiving at least one dose of intravenous opiate analgesic.

 Exclusion Criteria:

 -  Patients < 18 years old and pregnant

 -  Patients presenting with or suspected to have acute chest syndrome

 -  Allergy or intolerance to lidocaine products or morphine/hydromorphone