**2.5. Role of IVLT in acute perioperative pain**

Lidocaine infusions were described to be effective in the relief of acute post-surgical pain as early as 1961 [179]. Since then many other studies have confirmed the analgesic effects of lidocaine in patients with acute pain, such as Stayer's report on the safe and successful use of continuous pleural lidocaine after thoracotomy in children [180]. In 2012, Sun et al. published a meta-analysis of randomized controlled trials examining systemic lidocaine for post-operative analgesia and recovery after abdominal surgery [181]. It showed a decrease in post-operative pain intensity, opioid consumption, time to first bowel movement, and hospital length of stay. The most widely used lidocaine infusion regimen was a bolus of 1.5 mg/kg lidocaine followed by an infusion of 1.5–2 mg/kg/h.

The current evidence for using IV lidocaine for perioperative pain is based on four systematic reviews and one Cochrane review [128, 182–185]. In the most recent Cochrane review Kranke et al., reviewed only perioperative studies where the IVLT had been started intraoperatively prior to incision and continued at least until the end of surgery. Forty studies met the inclusion criteria. Primary outcomes measures required were pain score (0–10 cm, 0–100 mm visual analogue scale, (VAS), numeric rating scale (NRS), post-operative ileus, and functional gastrointestinal recovery (either time to defaecation, time to first flatus, or time to first bowel movement/sounds). Secondary outcomes sought included length of hospital stay, functional post-operative neuropsychological status scales, surgical complications (such as post-operative infections, thromboembolism, wound breakdown), patient satisfaction (satisfaction survey), cessation of the intervention, intra-operative opioid requirements, opioid requirements during the postoperative period and any adverse events (e.g. post-operative nausea and vomiting (PONV), death, dysrhythmias or signs of lidocaine toxicity).

Intravenous lidocaine administration was initiated with a bolus dose in 64% of the included trials. The subsequent infusion ranged from 1 to 3 mg/kg/h but most commonly was 1.5 mg/ kg/h. In five studies, no bolus dose was given prior to the start on the intravenous infusion of lidocaine [186–190].

The lidocaine infusion was terminated either at skin closure or the end of the surgical procedure [45, 186, 188, 190–206]; 1 h after surgery/skin closure [207–212]; 1 h after arrival in the post anaesthesia care unit (PACU) [213]; 4 h post-operatively [214]; up to 8 h post-operatively (or at PACU discharge whichever occurred earlier) [187]; after a total of 12 h [215]; 24 h post-operatively [216–223]; 48 h post-operatively [215, 224–226]; or on the day of return of bowel function or, at the latest, on the fifth post-operative day [189]. One study did not report the cessation time for the lidocaine infusion [227].

In this review, intravenous lidocaine was used in a variety of surgical procedures such as abdominal surgeries, tonsillectomy, orthopaedic, cardiac, and ambulatory surgeries. It was found to be useful only in abdominal surgery, where anaesthetic and opioid requirements were significantly reduced in the perioperative period. Several studies reported a decrease in pain intensity (pain at rest, cough, and movement), opioid requirements, and opioidrelated side-effects, such as PONV. A decrease in the duration of post-operative ileus was also seen and is attributed to a combination of opioid-sparing effect, anti-inflammatory actions, decreased sympathetic tone and the direct effect of lidocaine on intestinal smooth muscle. These benefits did not translate to expedited discharge from PACU nor have a positive effect on ambulatory surgeries.

## **2.6. Role of lidocaine in paediatric acute perioperative pain**

None of the studies included in the most recent Cochrane review for IVLT in acute pain management were paediatric. There is currently only one randomized controlled trial of IVLT in a paediatric acute pain population [228]. This study demonstrated decreased hospital stay, decreased rescue analgesia requirements, decreased cortisol levels and earlier return of bowel function with IVLT (1.5mg/kg bolus followed by 1.5mg/kg/h infusion) compared to placebo followed abdominal surgery. Until further evidence of paediatric analgesic efficacy and safety are available doses have to be translated from adult practice. It is not clear what dose regime and plasma concentration provide the best analgesic efficacy for particular surgical models of pain. Pain management remains an off-label indication for the use of IVLT, and the paediatric continuous infusion dosing quoted in the drug information documentation (0.5–3 mg/kg/h) refers to its use as an anti-arrhythmic agent.

The author uses IVLT as an adjunct in preventative multimodal analgesia for major paediatric (non-infant) surgical procedures where a regional or neuraxial analgesia technique has to be avoided or is contra-indicated. Typical procedures include scoliosis surgery, laparoscopic abdominal surgery and external frame fixator procedures. Lidocaine infusion regimes are typically 1 mg/kg bolus dose followed by an infusion with 2 mg/kg/h started prior to incision and continued until just after surgical closure. With extensive surgical times, the IVLT is decreased to 1.5 mg/kg/h after 8 h. It is essential to understand that there is little data to confirm the appropriate dosing and safe lidocaine levels in the paediatric population. However, clinical evaluation would suggest that the use of intravenous lidocaine therapy, in this manner, has beneficial effects on paediatric post-operative pain, opioid requirements and child/youth sense of wellbeing, especially in the first 24 h. In an attempt to determine appropriate research questions and outcome measures we have retrospectively reviewed 24 paediatric scoliosis cases. Twelve children undergoing idiopathic scoliosis correction (posterior instrumentation and fusion only) between January 2012 and March 2014, where intra-operative IV lidocaine infusion was administered were compared against twelve matched controls. The lidocaine group received a total dose of 14.17 ± 2.39 mg/kg, given over 6.45 ± 0.74 h. Both groups were comparable with respect to age, gender, body mass index (BMI), number of levels instrumented and surgical duration. Morphine consumption within the first 48 h post-operatively was significantly lower in the IVLT group [229]. Despite the small sample size and the retrospective nature of this case matched chart review the significant opioid-sparing effect in the post-operative period with the use of intra-operative IV lidocaine infusion merits further study. Prospective, randomized controlled trials are recommended.

#### **2.7. Role of lidocaine in preventative analgesia**

requirements during the postoperative period and any adverse events (e.g. post-operative

Intravenous lidocaine administration was initiated with a bolus dose in 64% of the included trials. The subsequent infusion ranged from 1 to 3 mg/kg/h but most commonly was 1.5 mg/ kg/h. In five studies, no bolus dose was given prior to the start on the intravenous infusion of

The lidocaine infusion was terminated either at skin closure or the end of the surgical procedure [45, 186, 188, 190–206]; 1 h after surgery/skin closure [207–212]; 1 h after arrival in the post anaesthesia care unit (PACU) [213]; 4 h post-operatively [214]; up to 8 h post-operatively (or at PACU discharge whichever occurred earlier) [187]; after a total of 12 h [215]; 24 h post-operatively [216–223]; 48 h post-operatively [215, 224–226]; or on the day of return of bowel function or, at the latest, on the fifth post-operative day [189]. One study did not report

In this review, intravenous lidocaine was used in a variety of surgical procedures such as abdominal surgeries, tonsillectomy, orthopaedic, cardiac, and ambulatory surgeries. It was found to be useful only in abdominal surgery, where anaesthetic and opioid requirements were significantly reduced in the perioperative period. Several studies reported a decrease in pain intensity (pain at rest, cough, and movement), opioid requirements, and opioidrelated side-effects, such as PONV. A decrease in the duration of post-operative ileus was also seen and is attributed to a combination of opioid-sparing effect, anti-inflammatory actions, decreased sympathetic tone and the direct effect of lidocaine on intestinal smooth muscle. These benefits did not translate to expedited discharge from PACU nor have a positive effect

None of the studies included in the most recent Cochrane review for IVLT in acute pain management were paediatric. There is currently only one randomized controlled trial of IVLT in a paediatric acute pain population [228]. This study demonstrated decreased hospital stay, decreased rescue analgesia requirements, decreased cortisol levels and earlier return of bowel function with IVLT (1.5mg/kg bolus followed by 1.5mg/kg/h infusion) compared to placebo followed abdominal surgery. Until further evidence of paediatric analgesic efficacy and safety are available doses have to be translated from adult practice. It is not clear what dose regime and plasma concentration provide the best analgesic efficacy for particular surgical models of pain. Pain management remains an off-label indication for the use of IVLT, and the paediatric continuous infusion dosing quoted in the drug information

The author uses IVLT as an adjunct in preventative multimodal analgesia for major paediatric (non-infant) surgical procedures where a regional or neuraxial analgesia technique has to be avoided or is contra-indicated. Typical procedures include scoliosis surgery, laparoscopic abdominal surgery and external frame fixator procedures. Lidocaine infusion

documentation (0.5–3 mg/kg/h) refers to its use as an anti-arrhythmic agent.

nausea and vomiting (PONV), death, dysrhythmias or signs of lidocaine toxicity).

lidocaine [186–190].

76 Pain Relief - From Analgesics to Alternative Therapies

on ambulatory surgeries.

the cessation time for the lidocaine infusion [227].

**2.6. Role of lidocaine in paediatric acute perioperative pain**

In many studies, the analgesic effect has persisted after the lidocaine infusion was discontinued, which suggests prevention of peripheral and/or central hypersensitivity [209, 211]. Perioperative lidocaine has been found to have a preventive effect on post-operative pain for up to 72 h after abdominal surgery [211]. A randomized, double-blind, placebo-controlled study of 36 adult patients undergoing breast cancer surgery showed that perioperative intravenous lidocaine (bolus of IV lidocaine 1.5 mg/kg followed by a continuous infusion of lidocaine 1.5 mg/kg/h) was associated with decreased incidence and severity of chronic pain after breast surgery. Two (11.8%) patients in the lidocaine group and 9 (47.4%) patients in the control group reported CPSP at 3 months follow-up (*P* = 0.031) [209]. Secondary hyperalgesia (area of hyperalgesia over length of surgical incision) was significantly less in the lidocaine group compared with control group (0.2 ± 0.8 vs. 3.2 ± 4.5 cm; *P* = 0.002). The authors concluded that IV perioperative lidocaine decreases the incidence and severity of CPSP after breast cancer surgery siting prevention of the induction of central hyperalgesia is a potential mechanism [209].

#### **2.8. Multi-disciplinary team management of children with chronic pain**

Chronic pain is pain that persists for more than 3 months and often years beyond the expected time to heal from injury, surgery or onset of a painful condition. It occurs in one in five adults and is a significant cause of suffering and disability worldwide. Although mainly a disease of adults, it does occur in children and youths with slightly more than one child/youth in every twenty reporting a chronic pain issue. A Canadian study of 495 schoolchildren aged 9–13, reported that more than half reported having experienced at least one recurrent pain (headache, stomach pain or 'growing pains'). 46% of this population reported a 'long-lasting' pain, however, the authors classified 6% as having chronic pain [230]. A Statistics Canada health report identifies chronic pain among 2.4% of males and 5.9% of females aged 12–17 years [231].

Typical types of chronic pain seen in children and youths include headaches, complex regional pain syndrome (CRPS), recurrent abdominal pain, limb and other musculoskeletal pains. Girls are three times more likely to report chronic pain than boys [232, 233]. Abdominal pain is significantly more likely to be reported by girls and limb pain (or growing pains/muscle aches) is significantly more likely to be reported by boys [230, 233, 234]. Although prevalence of chronic pain in school children varies from 9 to 32% [235, 236] and is on an increase [234], the reported prevalence exceeds the prevalence of school aged children seeking medical care for pain [237]. Cross-sectional and/or retrospective studies may not reflect the true picture and call for more longitudinal research to establish the actual prevalence and impacts of ongoing pain in children and youths has been advocated [238].

Some children with severe chronic pain embark on a downhill spiral of decreased physical, psychological and social functioning [239]. This includes loss of mobility with inability to participate in physical or sporting activities, poor sleep, difficulty concentrating on school work, school absenteeism, social isolation and family stress [240]. As chronic pain persists, the child can experience increased pain intensity, distress, sadness, anxiety, depression resulting in very poor quality of life [241]. The impact of chronic pain on the family matches the adverse impact experienced by families caring for children at home with severe cerebral palsy or birth defects [242–244]. Direct and indirect costs such as loss of earnings, adaptations to housing, over-thecounter medications and care assistance managing a child with chronic pain are considerable [245–248].

When entangled in the disordered lifestyle associated with chronic pain the child/youth and their family require coordinated integrated care to affect a recovery. The multi-disciplinary team management approach, based on pharmacology, physiotherapy and psychology (the 3P approach), is now well established to be the standard of care for children with chronic pain. This method involves looking beyond a child's pathology in isolation and engages multiple specialists to optimize the child/youth's psychological and emotional wellbeing, physical function and pharmacological therapy [247, 249–251]. This process requires adoption of a self-management approach and reduced reliance on medical investigation and intervention. Children and youth with significant pain-related disability have been shown to derive significant improvements in functional ability after participating in an intensive pain rehabilitation program employing daily physical, occupational and psychological therapies [247, 248, 252, 253].

Multi-disciplinary treatment goals are targeted to each individual child/youth after careful consideration of the medical history, pain history, examination and relevant investigations. How each therapeutic modality of care is balanced is dependent on the individual child and takes into consideration the type and duration of pain, as well as the impact of pain on particular biopsychosocial aspects of the child's life. Early recognition and appropriate '3P' management is the key to success. Within the context of the coordinated multi-disciplinary approach, IVLT can serve as a useful adjunct to concurrent physical, and psychological interventions to manage chronic pain in children and youths [133, 254, 255]. IVLT needs to be explained and utilized in a way that does not negate the multi-disciplinary teams attempts to promote self-management and de-medicalization.

schoolchildren aged 9–13, reported that more than half reported having experienced at least one recurrent pain (headache, stomach pain or 'growing pains'). 46% of this population reported a 'long-lasting' pain, however, the authors classified 6% as having chronic pain [230]. A Statistics Canada health report identifies chronic pain among 2.4% of males and

Typical types of chronic pain seen in children and youths include headaches, complex regional pain syndrome (CRPS), recurrent abdominal pain, limb and other musculoskeletal pains. Girls are three times more likely to report chronic pain than boys [232, 233]. Abdominal pain is significantly more likely to be reported by girls and limb pain (or growing pains/muscle aches) is significantly more likely to be reported by boys [230, 233, 234]. Although prevalence of chronic pain in school children varies from 9 to 32% [235, 236] and is on an increase [234], the reported prevalence exceeds the prevalence of school aged children seeking medical care for pain [237]. Cross-sectional and/or retrospective studies may not reflect the true picture and call for more longitudinal research to establish the actual prevalence and impacts of ongoing pain in children and youths has been

Some children with severe chronic pain embark on a downhill spiral of decreased physical, psychological and social functioning [239]. This includes loss of mobility with inability to participate in physical or sporting activities, poor sleep, difficulty concentrating on school work, school absenteeism, social isolation and family stress [240]. As chronic pain persists, the child can experience increased pain intensity, distress, sadness, anxiety, depression resulting in very poor quality of life [241]. The impact of chronic pain on the family matches the adverse impact experienced by families caring for children at home with severe cerebral palsy or birth defects [242–244]. Direct and indirect costs such as loss of earnings, adaptations to housing, over-thecounter medications and care assistance managing a child with chronic pain are considerable

When entangled in the disordered lifestyle associated with chronic pain the child/youth and their family require coordinated integrated care to affect a recovery. The multi-disciplinary team management approach, based on pharmacology, physiotherapy and psychology (the 3P approach), is now well established to be the standard of care for children with chronic pain. This method involves looking beyond a child's pathology in isolation and engages multiple specialists to optimize the child/youth's psychological and emotional wellbeing, physical function and pharmacological therapy [247, 249–251]. This process requires adoption of a self-management approach and reduced reliance on medical investigation and intervention. Children and youth with significant pain-related disability have been shown to derive significant improvements in functional ability after participating in an intensive pain rehabilitation program employing daily physical, occupational and psychological therapies

Multi-disciplinary treatment goals are targeted to each individual child/youth after careful consideration of the medical history, pain history, examination and relevant investigations. How each therapeutic modality of care is balanced is dependent on the individual child and takes into consideration the type and duration of pain, as well as the impact of pain on particular biopsychosocial aspects of the child's life. Early recognition and appropriate '3P'

5.9% of females aged 12–17 years [231].

78 Pain Relief - From Analgesics to Alternative Therapies

advocated [238].

[245–248].

[247, 248, 252, 253].

Determining or predicting suitability for successful pharmacological treatment requires attention to a number of factors. It is essential to consider any available evidence (often lacking especially in the paediatric population), drug responsiveness (matching the predicted mechanism of action of the drug with the pathophysiology of the pain condition), side effect profile, goals of therapy and the possible impact of the pharmacological intervention to the holistic plan of self-management and return to function for the individual child/youth. One of the goals of therapy is a shift away from a change in the pain rating and pain responsiveness to restoration of physical and social functioning. For some children pharmacological therapy is not required to achieve this goal. Timing of pharmacological intervention is also important. For some children ensuring that self-management strategies and attempts at return to function are initiated prior to pharmacological intervention may decrease a reliance on medications to initiate or promote change. Not all children and youths will have a predictable or positive response to the types of medications used in chronic pain. Some will require a trial of more than one type of pharmacological agent. To minimize side-effect profiles only the lowest effective dose should be used. Different pharmacological agents may have to be used in a tiered proportional manner, balancing risk versus benefits but with the over-riding aim to improve quality of life. As the simplest most appropriate pharmacological strategy should be trialled first it is important to briefly discuss topical lidocaine.

## **2.9. The use of topical lidocaine therapy in paediatric chronic pain**

For the purpose of this review topical lidocaine refers to q12h 5% lidocaine patch or compounded 5% lidocaine applied under an occlusive dressing (12 h on, 12 h off) administered daily. Topical lidocaine should only be applied to intact skin over a localised painful area. It is assumed that topical lidocaine works by blocking sodium channels on C, A-delta [256] and A-beta nerve fibres [257]. Allodynia is a prominent component of neuropathic pain, which is A-beta mediated and driven by central sensitization [80]. Topical lidocaine reduces nociceptor discharge at the level of the skin, to enable a light mechanical stimulus to induce a sense of touch, not pain. The analgesic effects of topical lidocaine probably do not require anaesthesia to the skin [258]. When lidocaine patches are used according to the recommended dosing instructions, only 3 ± 2% of the dose applied is expected to be absorbed. Repeated application of three lidocaine patches, used for 3 days simultaneously (12 h on, 12 h off), indicates that the lidocaine concentration does not incrementally increase with ongoing daily use. Pain relief from topical lidocaine occurs despite the extremely low systemic lidocaine plasma levels achieved. These plasma levels range from 0.13 to 0.23 μg/ml [259, 260], which is approximately one-tenth of the effective level obtained with IVLT. Despite this, neuropathic pain patients achieve pain relief from topical lidocaine [259, 261–267]. Lidocaine patches also produce analgesia in patients with painful diabetic neuropathy [268], Complex regional pain syndrome (CRPS) [269] and non-neuropathic conditions such as osteoarthritis and low-back pain [261, 270–273]. Systemic side effects are extremely rare and topical lidocaine is therefore recommended as a first-line therapy for all children and youths with localized peripheral neuropathic pain or CRPS and definitely before consideration of IVLT.

#### **2.10. Selection criteria for the use of IVLT in paediatric chronic pain**

Lidocaine's short serum half-life of 120 min dictates that the analgesic effect disappears a few hours after treatment so this should completely preclude its use for chronic pain issues. However, prolonged relief has been reported in animal models [274] and in some non-randomized [255, 275] and randomized trials [175, 276, 277]. The Canadian Pain Society states that "intravenous lidocaine infusions are generally safe and can provide significant pain relief for 2–3 weeks at a time" [278]. The 2012 neuropathic pain interventional guidelines by Mailis and Taenzer issue a Grade B recommendation for IV lidocaine at 5–7.5 mg/kg, with relief expected to last in the range of hours to 4 weeks [279]. Clinical studies show analgesic effects of intravenously administered sodium channel blockers especially in pain conditions where hyperalgesia is prominent [114, 139, 143, 144, 276, 277, 280–282]. Chronic pain conditions, in which reports of IVLT have been beneficial include peripheral nerve injury [283], neuropathic pain [7, 16, 274, 276, 279, 284–286], CRPS [255, 287], headaches [133, 288, 289], cancer therapy, spinal cord injury [176] and fibromyalgia [290].

There is a distinct lack of evidence to support the use of IVLT for paediatric chronic pain management. Criteria and dosing guidelines are institutionally formulated based on clinical experience, but equate with dose regimes previously reported to manage chronic pain in adolescents and young adults [133], see **Table 3**.


**Table 3.** BCCH institutional selection criteria for initial IVLT in children/youth.

#### **2.11. IV lidocaine infusion protocol at BC children's hospital**

Initial infusion:


• Loading dose: 1 mg/kg bolus

recommended as a first-line therapy for all children and youths with localized peripheral

Lidocaine's short serum half-life of 120 min dictates that the analgesic effect disappears a few hours after treatment so this should completely preclude its use for chronic pain issues. However, prolonged relief has been reported in animal models [274] and in some non-randomized [255, 275] and randomized trials [175, 276, 277]. The Canadian Pain Society states that "intravenous lidocaine infusions are generally safe and can provide significant pain relief for 2–3 weeks at a time" [278]. The 2012 neuropathic pain interventional guidelines by Mailis and Taenzer issue a Grade B recommendation for IV lidocaine at 5–7.5 mg/kg, with relief expected to last in the range of hours to 4 weeks [279]. Clinical studies show analgesic effects of intravenously administered sodium channel blockers especially in pain conditions where hyperalgesia is prominent [114, 139, 143, 144, 276, 277, 280–282]. Chronic pain conditions, in which reports of IVLT have been beneficial include peripheral nerve injury [283], neuropathic pain [7, 16, 274, 276, 279, 284–286], CRPS [255, 287], headaches [133, 288, 289],

There is a distinct lack of evidence to support the use of IVLT for paediatric chronic pain management. Criteria and dosing guidelines are institutionally formulated based on clinical experience, but equate with dose regimes previously reported to manage chronic pain in

4. Patients have no contra-indication to the use of systemic lidocaine such as major cardiac dysfunction, liver

5. Child/youth capable of verbally communicating analgesic response and symptoms of potential local anaesthetic

6. A high-acuity environment capable of providing continuous ECG monitoring, oxygen saturation, and frequent blood pressure measurements, plus access to healthcare personnel skilled in resuscitation and airway management.

dysfunction, renal impairment, seizure activity, or allergy to amide local anaesthetics

neuropathic pain or CRPS and definitely before consideration of IVLT.

80 Pain Relief - From Analgesics to Alternative Therapies

**2.10. Selection criteria for the use of IVLT in paediatric chronic pain**

cancer therapy, spinal cord injury [176] and fibromyalgia [290].

**2.11. IV lidocaine infusion protocol at BC children's hospital**

**Table 3.** BCCH institutional selection criteria for initial IVLT in children/youth.

Initial infusion:

toxicity.

• Location: post-anaesthetic care unit

• Monitors: as dictated by CPSBC guideline

adolescents and young adults [133], see **Table 3**.

1. Child/youth is fully integrated into multi-disciplinary care 2. Their pain syndrome is considered to be lidocaine-responsive 3. The pain is not amenable to the use of topical lidocaine


IVLT should only be administered within a high-acuity environment such as a paediatric intensive care unit, high-acuity unit, step-down unit, or post-anaesthetic care unit.

The College of Physicians and Surgeons of British Columbia published out of hospital Pain Infusion Clinic guidelines in 2014. The guidelines are intended only for the treatment of adults, and to the best of our knowledge, no such guidelines exist for the paediatric population. Of note, they require two appropriately trained nurses or one anaesthesiologist plus one nurse to be present in the room at all times during a lidocaine infusion, as well as one-to-one nursing for the first hour of the infusion. If the patient remains stable and not overly sedated, then the nursing ratio can be dropped to one nurse per two patients. An anaesthesiologist must be present on site until the patient is suitable for discharge. Required equipment includes an ECG monitor, suction, oxygen source and delivery systems, intravenous supplies, emergency medications, a light source, and emergency power and lighting. Lidocaine infusions are to be administered by a programmable device with a locked control panel and delivered via a dedicated intravenous line. Loading doses are to be given only by an anaesthesiologist. Patient and vital sign monitoring should be performed every 5 min for the first 15 min, every 15 min for the next 45 min, and then every hour until the infusion is complete, then 30 min after discontinuation of the infusion [291].

## **2.12. Selection criteria for repeat IVLT in paediatric chronic pain**

There is also a distinct lack of evidence to support the use of repeated IVLT for chronic pain management. The following criteria and dosing guidelines are also institutionally formulated based on clinical experience, see **Table 4**.


**Table 4.** BCCH selection criteria for repeat systemic lidocaine therapy in child/youth.

Second infusion:


### Third infusion:


## **2.13. Continuous subcutaneous lidocaine therapy**

If IVLT is effective or partially effective, the patient can be started on a 5-day continuous subcutaneous (SC) infusion if pain is hampering for restoration of function/physical activity (**Table 5**). SC infusions use an elastomer pump which delivers a set volume of lidocaine per hour (depending on the pump used), usually 5 ml/h, which approximately equates with 2 mg/kg/h using 2% lidocaine for a patient who is 50 kg. The infusion only runs whilst the patient is awake so that they can self-report any symptoms, which may suggest lidocaine toxicity.


**Table 5.** BCCH selection criteria for subcutaneous lidocaine therapy in child/youth.
