In Reply

We thank Dr. Roth for his response to our Clinical Concepts and Commentary article.¹  Although the risk of local anesthetic toxicity in patients receiving intravenous lidocaine in combination with local anesthetic for wound infiltration or peripheral nerve block is an appropriate concern, to our knowledge no published data exist on this topic. Therefore, it is not possible to formulate recommendations. Intravenous lidocaine is a component of many enhanced recovery protocols and is an alternative to epidural analgesia in patients for whom placement is difficult or contraindicated.^2,3  Patients undergoing major abdominal procedures at our institution receive an infusion of intravenous lidocaine intraoperatively and for the first 24 h after surgery as part of a multimodal analgesic regimen. Usual doses of local anesthetic are used for skin infiltration in these cases, and we have not observed toxicity. Similarly, we routinely use intravenous lidocaine as a component of total intravenous anesthesia, with additional local anesthetic used for skin infiltration prior to incision. We avoid use of intravenous lidocaine in procedures where liposomal bupivacaine is used due to concerns for toxicity.