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 Table of Contents  
CASE REPORT
Year : 2014  |  Volume : 28  |  Issue : 1  |  Page : 42-43

Beneficial effect of intravenous nitroglycerin and lidocaine in severe pain due to acute arterial occlusion


1 Department of Anesthesiology and Pain Medicine, Boali Hospital, Tehran Azad University of Medical Science, Tehran, Iran
2 Department of Anesthesiology and Pain, Rasoul-Akram Hospital, Tehran University of Medical Science, Tehran, Iran

Date of Web Publication15-Mar-2014

Correspondence Address:
Helen Gharaei
Department of Anesthesiology and Pain Medicine, Boali Hospital, Damavand St, Tehran
Iran
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-5333.128893

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  Abstract 

This is a case report of a patient (man, 65 year, 70 kg) with severe abdominal and lower extremity pain. Diagnostic methods including color Doppler ultrasound, computed tomography (CT) with contrast, and CT angiography showed thrombosis in abdominal artery near bifurcation of superior mesenteric artery. His pain did not respond to abdominal thromboembolectomy and intravenous injection of heparin and then opioid and acetaminophen. After continuous infusion of lidocaine and nitroglycerin, pain decrease about 20% and after 48 h, it decreases to 80%. This method may be a good option for pain management of acute ischemic pain due to acute arterial occlusion.

Keywords: Acute arterial occlusion, lidocaine, nitroglycerin


How to cite this article:
Gharaei H, Imani F. Beneficial effect of intravenous nitroglycerin and lidocaine in severe pain due to acute arterial occlusion. Indian J Pain 2014;28:42-3

How to cite this URL:
Gharaei H, Imani F. Beneficial effect of intravenous nitroglycerin and lidocaine in severe pain due to acute arterial occlusion. Indian J Pain [serial online] 2014 [cited 2019 Dec 7];28:42-3. Available from: http://www.indianjpain.org/text.asp?2014/28/1/42/128893


  Introduction Top


Acute arterial occlusion is sudden cutoff of blood flow in a limb that can be a threat to limb viability and is often with severe pain. Abdominal acute arterial occlusion is an internal emergency because it can be a threat to limb's viability and it usually origins from the heart. [1]

Diagnostic methods for acute arterial occlusion including magnetic resonance imaging (MRI), computed tomography (CT) scan, and angiography. Ischemic pain is a nociceptive pain and nonsteroidal ant-inflammatory drugs (NSAIDs) and opioid are the most common medical therapy. Sometimes severe pain does not respond to these therapies. Acute ischemia of limb can result in highly dysfunction, amputation (30%) and death (20%). [2]


  Case Report Top


The patient was a 65-year-old man and weighted 70 kg. He was urgently hospitalized with symptoms of sudden abdominal pain, severe bilateral lower extremity pain (visual analog scale (VAS) for pain score = 10) [Figure 1] with paresthesia and delirium. In physical examination, the left ankle was pale, cold, and tender with no arterial pulse and was cyanotic, but with normal motor function. In the right lower limb, the distal part was cold and cyanotic, with no pulse and movement. He had a history of chronic obstructive pulmonary disease (COPD) and alcoholism. Diagnostic methods including color Doppler ultrasound, CT with contrast, and CT angiography showed thrombosis in abdominal artery near bifurcation of superior mesenteric artery [Figure 2]. Therefore, emergency ambolectomy was performed. After removal of a 15 cm clot, heparin therapy was started. Echocardiography, perfusion scanning, and electrocardiology were normal. He did not appropriately response to medical therapy including NSAIDs and intravenous (IV) meperidine. Then IV analgesic infusion including fentanyl (20 μg/h) and acetaminophen (100 μg/h) was started. On the 2 nd day, pain score remained high (VAS = 8), so the dose of fentanyl was doubled (40 μg/h). On the 3 rd day, he was still suffering from a lot of pain (VAS = 8). After getting oral informed patient consent, we decided to add lidocaine (45 mg/h) and nitroglycerin (45 μg/h) infusion to above treatment. After 24 h, the patient was satisfied with 20% decrease in the pain and after 48 h the pain decreased to 80%. After 5 days, pulse and the color of left distal lower limb were back to normal. Overall the patient was very satisfied.
Figure 1: Visual analog scale (VAS)

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Figure 2: Abdominal aortic aneurysm with clot and calcification

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  Discussion Top


Since lidocaine and nitroglycerin infusion had a positive effect of 80% decrease in pain, this method may be a good option for pain management of acute ischemic pain due to acute arterial occlusion. In therapeutic dosage, lidocaine beside analgesic effects is also a vasodilator that block sodium channel which are involved in neuropathic pain. [3] Lidocaine, by having effects on collagen secretion, lymphocyte traffic, cytokine production or release, and neutrophil and macrophage activation; decreases chronic inflammation. Part of vasodilatation effects of lidocaine and analgesic effects of nitroglycerin is through the release of nitric oxide which increases peripheral blood flow. [4],[5],[6] Nitric oxide increases intercellular cyclic guanosine monophosphate concentration and modulates pain in the central and peripheral nervous systems. [7] Adding nitroglycerin to lidocaine in IV regional analgesia shortens the start time of blockage and tourniquet postoperative pain. Nitroglycerin increases the vasodilator effects of lidocaine. [8],[9] Decreasing acute ischemic pain due to arterial occlusion has to be focused on increasing blood flow and decreasing the ischemic pain. So, regards to the mentioned mechanism and vasodilation and analgesia effects of lidocaine and nitroglycerin, choosing these drugs in order to decrease the pain due to acute arterial occlusion, can be a right choice.

 
  References Top

1.Norgren L, Hiatt WR, Dormancy JA. Inter-society consensus for the management of peripheral arterial disease (TASC II). J Vasc Surg 2007;45:1-70.  Back to cited text no. 1
    
2.Yeager RA, Moneta GL, Taylor LM Jr, Hamre DW, McConnell DB, Porter JM. Surgical management of severe acute lower extremity ischemia. J Vasc Surg 1992;15:385-91.  Back to cited text no. 2
    
3.Aps C, Reynolds F. The effect of concentration on vasoactivity of bupivacaine and lignocaine. Br J Anaesth 1976;48:1171-4.  Back to cited text no. 3
    
4.Newton DJ, McLeod GA, Khan F, Belch JJ. Mechanisms influencing the vasoactive effects of lidocaine in human skin. Anaesthesia 2007;62:146-50.  Back to cited text no. 4
    
5.Zollner RL, Dantas RO, Godoy RA. Treatment of progressive systemic sclerosis with lidocaine hydrochloride: A preliminary study. Braz J Med Biol Res 1985;18:620-7.  Back to cited text no. 5
    
6.Hashimoto S, Kobayashi A. Clinical pharmacokinetics and pharmacodynamics of glyceryl trinitrate and its metabolites. Clin Pharmacokinet 2003;42:205-21.  Back to cited text no. 6
    
7.Lauretti GR, Perez MV, Reis MP, Pereira NL. Double-blind evaluation of transdermal nitroglycerin as adjuvant to oral morphine for cancer pain management. J Clin Anesth 2002;14:83-6.  Back to cited text no. 7
    
8.Abbasivash R, Hassani E, Aghdashi MM, Shirvani M. The effect of nitroglycerin as an adjuvant to lidocaine in intravenous regional anesthesia. Middle East J Anesthesiol 2009;20:265-9.  Back to cited text no. 8
    
9.Sen S, Ugur B, Aydin ON, Ogurlu M, Gursoy F, Savk O. The analgesic effect of nitroglycerin added to lidocaine on intravenous regional anesthesia. Anesth Analg 2006;102:916-20.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2]



 

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