Beloeil et al.1  present a compelling pragmatic trial comparing dexmedetomidine with remifentanil in a balanced anesthetic. We congratulate them on executing such a challenging trial and reinforcing that “opioid-free” is not “complication-free.” Their work raises important questions about the future of balanced anesthetics, especially the use of non-opioid infusions. Although the authors primarily compared a dexmedetomidine infusion (to make it “opioid-free”) with a remifentanil infusion, their underlying anesthetic also included ketamine and lidocaine infusions. Of these infusions, we are concerned about the ubiquitous use of intravenous lidocaine for assumed benefit without regard to risk.

Intravenous lidocaine is fashionable for its analgesic properties in the opioid-sparing epoch.2  Given the high median lethal dose, short half-life, and rapid dissociation from voltage-gated sodium channels, most practitioners believe that lidocaine infusions are benign. However, clinicians have reported life-threatening events associated with lidocaine infusions for more than 40 yr and continue to do so.3  Further, lidocaine alone (16 cases) or in combination with other local anesthetics (8 cases) was implicated in a majority of 36 case reports of local anesthetic systemic toxicity between December 2017 and May 2020, including one lidocaine-precipitated fatality.4  Lidocaine infusions may have a large therapeutic index in healthy patients but less so in those who are elderly, are frail, and have systemic comorbidities. In particular, cardiac disease, liver disease, hypoalbuminemia, and other severe systemic diseases will compromise lidocaine clearance, necessitating dose reductions.5,6 

As a case in point, Beloeil et al. report a case of severe local anesthetic systemic toxicity in a 44-kg patient presenting for open pancreatic surgery that resulted in asystole and required intravenous lipid emulsion. Beloeil et al. justify their use of lidocaine by asserting that it “reflects some common practices based on international literature.”1  However, the referenced systematic review7  specifically stipulates the risk of bradycardia and arrythmia from intravenous lidocaine infusions. Further, the majority of the trials in that systematic review excluded patients with severe systemic disease that would put patients at risk for lidocaine accumulation and toxicity. We recognize the complexity of the trial design and do not wish to diminish the importance of the current work. However, the case of bradycardic arrest should not only give us pause about the safety of dexmedetomidine infusions; it also provides an opportunity to discuss appropriate use of lidocaine infusions in patients with severe systemic disease.

The authors declare no competing interests.

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