Postoperative Pain Management: Importance And Benefits Of Effective Healthcare Interventions

Patient Concerns and Care Following Surgery

Discuss about the Effectiveness of Intravenous Lignocaine to Enhance.

Patients undergoing surgery in healthcare settings due to confounding health conditions are subjected to multiple postoperative conditions that have a negative impact on health and wellbeing. Pain, discomfort, nausea and weakness are some of the common concerns that are frequently addressed by healthcare professionals for patients undergoing surgery. Pain in a poorly controlled form is considered as one of the most drastic aftermaths of medical surgery. Though there is an increased awareness among the care professionals regarding the impact of such pain on patient’s health outcomes, and widespread efforts have been made to address to concern, a considerable proportion of patients who undergo surgery are subjected to severe or moderate pain. Among this section of the patient population, the majority is found to report dissatisfaction related to the provided pain management interventions (Fritsch et al. 2017).  Chou et al. (2016) in this regard state that management of patient discomfort and pain are of prime importance to healthcare professionals post-surgery. Pain relief and relief from discomfort have been indicated to have physiological benefits, and thus monitoring of patient status is a crucial quality measure. It is imperative that acquaintance with the usefulness of agents and their respective administration routes are required for care professionals who can deliver individualized care to patients.

After the patient undergoes surgery, he is shifted to the recovery room in which the patient is to come out of the impact of anesthesia. While in the recovery room a patient is subjected to monitoring of vital signs and his condition is thoroughly assessed. Effective post-operative patient management is always a crucial element of the care process delivered to the patient. Pain control, if not done adequately, leads to increased morbidity.in certain cases, patient mortality has also been reported across settings. Since surgery is responsible for suppressing the immune system of the patient’s body, and as the suppression has a direct link with the invasive nature of the surgery, care provided needs to be comprehensive. An effective form of analgesia is helpful in combatting the deleterious effect (Dreyer et al. 2015).

Tobias (2013) pinpointed that a number of key benefits have come into limelight when a comparison is done between minimally invasive abdominal surgical processes (laparoscopy) and open surgical processes, encompassing early patient discharge after decreased pain and proper bowel function. Though the extent of pain suffered by patients is less as compared to open procedures, pain is still a crucial factor at the time of postoperative recovery following surgeries such as appendectomy and cholecystectomy. If effective treatment is not provided with the pain leads to recovery delay and unnecessary inpatient admission. The ultimate result is an increased healthcare cost and loss of valuable resources. The burden on care providers is also noteworthy in this context.

Rothrock and Alexander (2014) described the utility of laparoscopic appendectomy and cholecystectomy in the contemporary era in relation to better patient outcomes. Appendectomy is a minimally invasive procedure in which certain surgical instruments, including an endoscope, are inserted into the body of the patients through multiple incisions small in size. The aim of the procedure is to remove the appendix with less degree of pain. The objective is to enable a shorter recovery time frame for the patient in comparison to open surgery. The procedure can be completed in a day and patients are not needed to be admitted to the care setting. Laparoscopic cholecystectomy is the removal of gallbladder from the patient’s body through noninvasive surgery. The benefit of non-invasive surgery is that patients can faster return to normal lifestyle.  Post-operative care after these two procedures are directed towards rapid patient mobilization, less chances of cardiac complications, less likelihood of pulmonary complications, faster recovery process and less healthcare costs.

Pain Control: A Key Element of Post-Operative Patient Management

Shady et al. (2017) commented that surgical procedures across healthcare domain have witnessed tremendous advances in the past few years. Breakthroughs in instrumentation, computer-enhanced technology, adhesion prevention and video technology have enabled healthcare professionals to carry out a number of surgeries that are laparoscopic. The innovations might have enabled faster time for recovery, negligible adhesion formation, smaller scars, fewer costs and fewer complications. Nevertheless, patients who are to undergo laparoscopic procedures suffer considerable pain in the post-operative phase. The regions where such pain is more prominent are a shoulder, lower and upper abdomen, and back. For most of the patients, pain intensity is maximal during the initial post-operative hours though the same declines in the successive two or three days. Pain is suffered due to intra-abdominal cavity’s stretched condition, irritation of the phrenic nerve and peritoneal inflammation.

Rapid advancements are medical field has contributed hugely to the domain of pain management and postoperative care. Professionals now are witnessing myriad choices of techniques and pharmacotherapy for addressing postoperative needs of patients, and reducing pain and discomfort. Adequate post-operative pain control is now possible in the 21st century when continual research is going on to discover better quality drugs. Nevertheless, one must remembers that a number of significant factors drive the success of these pain management drugs. The most important ones amongst these are co-morbid conditions of the patient, type of surgical procedure and psychological status. The most common forms of pain relief medications are analgesia, patient controlled intravenous analgesic (PCIA) and opioids (Hadzic 2017). 

Analgesics are the class of drugs that are administered in post operation conditions to relief patient pain and discomfort. The pain suffered by the patient after undergoing a surgery is the biological indication that the body has suffered an injury in any certain tissue or organ. The initiation of pain is at the cellular level, and chemical messengers are released as a response to the inflammation or injury suffered. These messengers act by alerting other cells which are the pain receptors. Signals are sent to the brain where the interpretation of the signals leads to the feeling of pain. Analgesics act in the body through blockage of these chemical signals received by the brain. The second mechanism is through the interference of the signal interpretation carried out by the brain. Some of the common forms of analgesics are aspirin, magnesium, choline salicylate, ibuprofen and sodium salicylate (Kolettas et al. 2015). Though analgesics have been found to be efficient for controlling pain post operatively, there is no consensus that the idea is applicable for all forms of surgery. It has been proposed that procedure-specific acute pain management analgesics would be helpful for addressing patient needs. The risk-benefit ratio of the existing analgesics tends to vary depending on the surgery. Therefore, the true value of analgesics also is dependent on the intensity of surgical injury. The organ dysfunction and stress response greatly influences the extent to which the analgesics are effective (Souzdalnitski, Lerman, and Narouze 2016).

The novice concept of multimodal analgesia first came into limelight about one and a half decades back, and at present is well into practice. Non-steroidal anti-inflammatory medications when given in combination with intravenous patient-controlled morphine administration have the potential to lead to a decrease of nausea and sedation in patients as compared with the use of patient-controlled morphine alone. Different analgesics can be given through different routes such as epidural and intravenous, and the side effects of the same are less. However, patients might be suffering from mild forms of sedation, nausea and vomiting (Weingarten et al. 2015). According to Gatchel et al. (2014), there is an urgent need of developing analgesics that are particular for specific surgical processes and are thus comprehensive and reliable.

Benefits of Minimally Invasive Surgery Approaches

Patient-controlled intravenous analgesia (PCIA) is the form of analgesic administration wherein the patient has the ability to administer and control his own pain relief through the medication. The infusion is fundamentally programmable as deemed fit by the care professional and the machine has fewer chances of delivering an inappropriate dose of the pain relief medication (Hubner et al. 2015).  In such a case the professional has the responsibility of observing the initial administration of a drug that has not been given to the patient earlier for checking allergic responses. Narcotics are the analgesics commonly administered through this process and monitoring is crucial for the initial few hours. Advantages and disadvantages of PCIA had been pointed out by (Wang et al. 2016). The most important benefit is self-delivery of medication, followed by a faster easing of pain. Nevertheless, the disadvantage of using PCIA lies in the fact that a patient might end up using the medications for nonmedical purposes. In case the programming of the device is not done appropriate, overdose or under-dose of medication can occur. Further, the system might not be fruitful for certain group of patients, for instance, those with the confused state of mind due to surgery.

Opioid analgesics are drugs that have their functioning with opioid receptors found on nerve cells in the brain and body of human beings. These drugs have been linked with the treatment of severe pain and common postoperative pain. The action of the substances on the opioid receptors is responsible for producing effects similar to that of morphine. Opioids have been the choice of drug for pain relief in post-operative environment owing to its reduced dependence risk, high efficacy and fast onset (Manworren et al. 2016).

Pain has been indicated to be one of the three common causes of delayed discharge from care settings. The role of analgesics in pain management for surgery patients have been explored continually. In addition, analgesic adjuvants, such as gabapentinoids and lidocaine, also have received increased attention since analgesics have certain side effects. Shady et al. (2017) pointed out that though opioids have been used as a powerful analgesic for treating post-operative pain, the adverse effects related to the use of the same include vomiting, sedation, nausea, and gastrointestinal ileus. Although continual research is being conducted worldwide to understand and highlight alternatives to pain relieving medications, opioids are still the backbone of pain therapy post-surgery. The main side effects of opioids include respiratory, depression, sedation, nausea and vomiting, pruritus, hypotension, bradycardia and improper bowel function. These complications can be treated with additional drugs which again bring in additional side effects. Though conventionally the backbone of analgesia administered postoperatively is based primarily on an opioid, evidence recommend that multimodal approach is to be adhered to that reduced side effects of opioids and bring improvement in pain scores (Karamessinis et al. 2015).

Dunn and Durieux (2017) pointed out that risks of using opioids in the postoperative period have been noted to spur a noteworthy interest in the use of other alternatives such as non-opioid analgesic adjuncts. One particular drug of interest among clinical researchers is lidocaine which is also known as lignocaine in different countries. This drug holds the potential to be administered intra- and/or postoperatively for decreasing postoperative pain and improving other patient outcomes. As per the researchers, there exists a large pool of studies that carried out rigorous review and meta-analysis to highlight whether lidocaine or lignocaine, is effective. However, evidence supporting the effectiveness of the drug tends to vary greatly by different surgical processes. This is the reason why clinicians are faced in a dilemma when deciding which compound is to be used for better patient outcomes. The researchers highlighted that the benefits of lidocaine infusion are related to a reduction in nausea, pain, ileus duration, length of hospital stay and opioid requirement. Intravenous lidocaine is known to mimic plasma lidocaine concentrations at the time of epidural administration. There are no explanations for these effects though a considerable reduction in the requirements for opioid is a common factor. In most of the clinical trials, the effect of the drug has been found to be exceeding the duration of the infusion by more than 8.5 h. This is almost 5.5 times the half-life of the compound.

Understanding the Biological Basis of Pain

Lignocaine is a medication that has been used for resulting inn numbness of tissues in a particular area of the human body. Its extensive use has been in the treatment of ventricular tachycardia and in causing nerve blocks. As a pain relief medicine, lignocaine has drawn special attention in the recent past as extensive research is being carried out to understand its wider application in the clinical field. The efficacy profile has been linked with a fast onset of pain reliving the action and transitional duration of action. Thus, the agent has been known to act as a surface, block and infiltration anaesthesia (Madeira, et al. 2016).  Heitz (2016) stated that surgery has a profound impact on the anti-inflammatory and pro-inflammatory body systems of the patient. Among these two, the former one has the tendency to lead to infections, while the latter one has a contribution to postoperative complications such as ileus and pain. Research finds that perioperative lidocaine has a role in attenuation of the pro-inflammatory effects. A vast range of preclinical studies indicates numerous interactions are taking place between the body’s inflammatory system and the local anaesthetics.

Rothrock (2014) described the pharmacology of lignocaine in a detailed manner. According to the authors, there lies a challenge in explaining how the benefits of lignocaine administration are achieved when there are low blood concentrations at the time of infusion. Moreover, there exists no clear explanation for the persistence of the drug for a long duration after the infusion is terminated. It has been suggested that the mechanisms work in cascade after the drug has undergone metabolism to become concentrations that are non-biologically active. Scientists point out that the mechanism of drug action does not adequately link to sodium channel blockade. The rationale behind such comment is backed by two pieces of evidence. Firstly, one of the targets that hold much importance, polymorphonuclear granulocyte (PMN), has no role in the expression of sodium channels. Secondly, perioperative blood levels are only capable of blocking a negligible amount of neuronal sodium channels. What seems likely is that other distinct molecular targets are interfered with this drug, mostly those that take part in inflammatory signaling. Nevertheless, neuronal effects might be playing a minor role as well. One example is that of systemic lidocaine blocking the excitatory responses in neurons with wide dynamic range.

The dose if intravenous lignocaine that can lead to appropriate analgesic action in the perioperative period has been indicated to be 1-2 mg kg-1 as the initial bolus that is succeeded by a continuous infusion of 0.5–3 mg kg−1 h−1. Clinical research indicates that the most reported dose, which is clinically effective, falls between 1 to 2 mg kg−1 h−1. The drug under discussion has been found to be having a high hepatic extraction ratio. What is striking is that the metabolism of lignocaine is dependent on the hepatic blood flow apart from the hepatic metabolic capacity. If the drug is administered continuously without a bolus, it takes approximately four to eight hours for achieving a steady-state plasma concentration. When it is discontinued after a considerable time, there is a rapid decrease in the plasma levels. The context-sensitive half-time is 20–40 min when lidocaine is given for three days. In individuals who are in healthy condition, no accumulation has been found to occur over time.

Analgesia Approaches for Post-Operative Pain Control

The two most prominent metabolites of lignocaine are glycinexylidide (GX) and Monoethylglycinexylidide (MEGX). In case of MEGX, there is a similarity of anti-arrhythmic potency and convulsant between lignocaine and the metabolite. Nevertheless, the metabolism of MEGX to GX takes place in a rapid manner. Further, MEGX decreases lignocaine clearance in the body. Toxicity in the patient’s body can be due to MEGX that lead to cardiac failure, while GX accumulates in patient’s body for those who suffer renal failure (Ng and Sim 2016). Pardo and Miller (2017) in this regard stated that plasma concentration of free lignocaine is influenced by a number of factors including rate and dose of infection, hypoxia, hypercapnia, renal failure, plasma protein level and acid-base status. Patients usually do not suffer from, idiosyncrasy, hypersensitivity or reduced tolerance to systemic lidocaine self-regulating of the mentioned factors.

Chang et al. (2017) from their study concluded that current studies focusing on the effectiveness of perioperative lignocaine administration had indicated diverse outcomes depending on the patient condition and the surgical process. Nevertheless, there lays no particular mechanistic explanation regarding why there might be differences between similar procedures, such as hysterectomy and prostatectomy, and the differences might arise due to the differences in study designs. Perioperative lignocaine holds the potential to reduce pain in patients and promote bowel function in patients undergoing laparoscopic and open abdominal surgeries. Perioperative lignocaine can be used as an analgesic adjunct for the better recovery process. Lignocaine has been used in recovery protocols for those undergoing laparoscopic colorectal surgeries, showing benefits in opioid consumption and pain scores among other outcomes. The same agent has been addressed as a unique drug since it improves significantly enhanced recovery after surgery (ERAS) outcomes. These outcomes are early ambulation and feeding, early fitness for discharge, and increased patient satisfaction.

It is to be remembered that lignocaine might also be beneficial for other types of surgery where evidence indicates that benefits can be achieved with nominal cardiac and neurologic side effects. Care professionals must be monitoring the level of plasma lignocaine for patients who are at increased risk of toxicity like those having poor kidney function or abnormal functioning of the liver (Shady et al. 2017). Utilization of port sites and intraperitoneal lignocaine decreases pain scores in women after undergoing laparoscopic surgery. Therefore, the use of lignocaine can be advocated for regular use in laparoscopic surgeries. These can be surgeries of short duration such as cystectomy or minor laparoscopic surgeries such as laparoscopic surgery for gynaecological purposes.

In nursing research, a well-focused question is of prime importance without which searching appropriate resources is challenging. The best known specialized framework that evidence based practitioners refers to is PICO. PICO stands for

• Patient Problemor Population
• Intervention
• Comparison or Control
• Outcome

The PICO format was used to outline the research question to be addressed in the study. The PICO question for the research was “Can intravenous lignocaine effectively enhance post anesthesia care for patients undergoing Laparoscopic Appendectomy and Cholecystectomy?”

The present paper is an extensive literature review that aims to establish or disprove the effectiveness of intravenous lignocaine for enhancing post anesthesia care for patients undergoing laparoscopic appendectomy and cholecystectomy. Both laparoscopic cholecystectomy and appendectomy are performed as day cases; hence these were appropriate for assessment in the present study for desirable results. The review puts forward a comparison of IV lignocaine with traditional opioid-based regimens to understand the effectiveness of the former over the latter. The outcomes measures studied focus on use of opioid, length of stay at PACU (Post anesthesia care unit) and PONV (Postoperative nausea and vomiting)

The research methodology for the present paper is systematic literature review of selected literature resources. According to Moher et al. (2015) systematic reviews are the special forms of literature reviews where the aim of the researchers is to collect multiple research papers and critically analyze the same to draw key insights from the papers. Such literature reviews are important as they allow an exhaustive and complete summary of present existing literature having relevance to the selected research question. These studies are essential in evidence based clinical practice. Scientific literature reviews are known to be the powerhouse publications since they are based on multiple studies addressing a common research area (Shamseer et al. 2015). Critical analysis ensures that combining information is done in an appropriate manner and re-analyses of previous work is reliable. The present study had the aim of analysing the results of more than one study for arriving at a particular conclusion regarding the research question of effectiveness of lignocaine, and thus research approach of literature review was taken.

Relevant research articles were searched for in reputed online databases. As opined by Nieswiadomy and Bailey (2017) electronic databases are the rich pool of resources that are immensely useful for conducting secondary research on any domain. Relevant research papers can be extracted from the databases that have full-text paper, much to the convenience of the researchers. Having mostly peer-reviewed papers, these databases have been the common choice of researchers. Cochrane Central Register of Controlled Trials (CENTRAL) database was considered as the primary source for extracting relevant articles. In addition, the other databases that are used included SCOPUS and PubMed. In addition, a useful technique used was that manual search was undertaken using the reference lists of papers that were found to be relevant. The keywords for search process were extracted from the research objective. These included lignocaine, laparoscopy, laparoscopic, cholecystectomy, appendectomy, intravenous, intervenous, IV, placebo, compare, comparison, patient, patients.

At this juncture, it would be appropriate to highlight the inclusion/exclusion criteria used for the present paper. The criteria were limited to Randomised Controlled Trials (RTCs) and case study reviews that studied the effectiveness of lignocaine in perioperative environment. The focus was mostly on RCTs, as they are known to provide the empirical conditions required for generating new knowledge on the concerned research topic (Stamp et al. 2017). Studies that compared effectiveness of lignocaine infusion with placebo control, as well as studies that compared effectiveness of different administration routes of lignocaine were compared. Further, all studies included in the paper were published in English language. In addition, paper published in the last ten years that is after 2008 were considered. It is to be noted that knowledge in the clinical field is evolving at a fast rate, and older concepts are getting replaced by novice ideas due to extensive research (LoBiondo-Wood and Haber 2017). Keeping this is mind studies that were published in the past 10 years were selected for this study.

When the primary database was searched, the results displayed 45 research papers out of which 24 were RCTs. Based on the criteria developed earlier, and analysing the titles of the paper as well as the abstracts, five articles were found to be relevant. At this stage, PubMed mentioned earlier were explored thoroughly. From the 217 hits that were retrieved, only two articles were relevant. Further search showed 16 hits and only one study was relevant. On exploring SCOPUS database, 26 hits were retrieved of which one article was relevant. Finally, upon conducting a manual search of the reference lists of the already retrieved research works, one article was considered for the present study. A total number of ten studies were considered for the present review.

The literature review is a kind of study that enables a critical appraisal of the selected papers through understanding of the research strengths and limitations. Validity of research studies is to be analysed for understanding the quality of the selected papers. Validity can be defined as the approximate truth of an inference. Internal validity focuses on the extent to which the independent variables lead to the study outcome. On the other hand, external validity focuses on whether the observed relationships disappear or persist of measures of outcomes are changed LoBiondo-Wood et al. (2017). For the present critique, the framework selected considers the internal and external validity of the selected studies. According to Parahoo (2014), the need of referring to a suitable framework is felt as it acts as the backbone of analysing the key strengths and limitations of the research papers under scrutiny. An analysis of the research papers included in the present study was done based on the standard approach of NICE that helps in exploring the strengths and limitations of the studies. This particular framework is a reputed one in research domain and takes into consideration factors contributing to selection bias, performance bias, attrition bias and detection bias (Moule, Aveyard and Goodman 2015).

Randomisation is the process of assigning participants to different groups in a manner that each individual has equal chances of being assigned to one group as a part of the study (Nieswiadomy and Bailey 2017). Selection bias is the differences in comparison groups due to errors made in randomisation (Parahoo 2014). The RCT research papers selected for the present review is noteworthy as they clearly indicate the methods for allocation and those for ensuring allocation concealment. The exact process of randomisation can be explained in a brief manner through the following table-

Study	Details of randomisation
Dergizi et al. (2014)	48 patients were randomised into three groups using computer-generated random table
Ram et al. (2014)	Randomisation was done by block randomization (block size of 10) using Microsoft Excel 2007 (Microsoft Corp, Redmond, WA, USA). Allocation concealment was done using serially numbered opaque sealed envelope that was opened on the day of the surgery
Yang et al. (2013)	Randomization of patients into one of the three study groups was done using Excel_software (Microsoft, Redmond, WA, USA) random-number generation function
Lauwick et al. (2008)	50 participants were randomised into two groups of 25 patients each using a computer-generated randomization schedule
Ahn et al. (2015)	Participants were randomised into two groups with the help of a random table generated with the help of PASS11. Allocation concealment was done with the help of envelopes
Tikuisis et al. (2014)	Randomisation was done into one of the two groups with the help of using computer-generated randomisation lists that had random numbers
Saadawy et al. (2010)	Participants were assigned to one of the three groups using a computer-generated table
Kim et al. (2011)	Participants were assigned to one of the three groups with the help of Excel (Microsoft Corp., Redmond, WA) software. Envelopes were used for allocation concealment that was opened after patient admission.
Wuethrich et al. (2012)	Randomisation was done using computer-generated randomisation method

Hoffmeister et al. (2015) gave the definition of confounders as the variables that are not of primary interest but might have an effect on the interaction between independent and dependent variables. Proper randomisation is the elementary method of having control over the confounding variables. The research papers that were selected for the present paper mentioned the confounding factors considered. These include gender, age, BMI, weight, duration of surgery, duration of anaesthesia, and type of surgery.

RCT methodology must consider avoiding bias for which different techniques can be applied. It is significant that the arms each study are given similar care apart from the differences arising in addition to requirements for intervention (Parahoo 2014). All RCT studies included in the review had a clear mention of how participants belonging to different arms of the study were provided with similar treatment interventions as the guidelines. It can thus be concluded that differences in care did not lead to bias in the studies selected.

Blinding is an important factor in randomised controlled trials and according to Moule, Aveyard and Goodman (2015) a comparable control group would not be formed at any cost if the assessors of study outcome have the knowledge of the group to which a particular participant belongs to. In all of the RCT research papers selected for the present review, blinding of the researchers was achieved. Measures for maintaining blindness included labelling of vessels in a manner that promoted blindness. In most of the studies, the patients, the nursing staff, the surgeon or the anaesthesiologist were blind to the group assignment.

Attrition bias might come up in studies when there is any deviation from the research protocol, or when the patients are not included in the study after the allocation to treatment groups has been done (Mansournia et al. 2017). The RCT research papers that were selected for this review give detailed information about the number of participations that were considered for the study. In addition, those who dropped out of the process were mentioned with reason. In most of the cases, the outcome data were available. It can be stated that attrition bias was not an issue for the studies.

Detection bias can arise in studies when assessment of outcomes is carried out regarding the different study groups taking part in the study (Widom, Czaja and DuMont 2015). The RCT studies that were included in the present review ensured that assessors were blinded throughout the study. Further, statisticians who helped in randomisation had not further involvement in the study. Both the researcher and participant group were blinded to the use of medications. The study outcomes were defined in a clear manner, and statistical analysis was done using standard methods.

Internal validity is a quality of studies that depend on trial conduct, design, analysis and presentation. Such validity is reliant on three factors- attrition handling, randomisation and blinding (LoBiondo-Wood and Haber 2017). In the present case, all the RCT studies had mentioned that strict rules were implemented for ensuring participant blinding and blinding of researchers. All RCT studies included in the review considered power calculations for determining the number of participants required for having the desired detection of noteworthy clinical difference.

LoBiondo-Wood and Haber (2017) highlight that RCTs need to have a sample population that is a part of a larger population. External validity is linked to the generalisation of results as the method of sampling determines the population considered. In the present case, the studies were conducted in different countries of the world, such as Canada, Turkey, India and Lithuania. There lie significant differences among populations of these countries, thus highlighting the fact that the results of the study might not be applicable to all countries. Further, external validity can have an impact if the respective study’s selection criteria are violated. In the present case, the RCTS claimed that there was no violation of selection criteria. In addition, external validity can be affected if different studies use different scales for determining the outcomes. In most of the RCTs, visual analogue scale (VAS) system was used for measuring pain in patients. Thus it can be stated that external validity was not affected considerably. 

	Kim et al. (2011)	Dergisi et al. (2014)	Yang et al. (2013)	Ram et al. (2014)	Ahn et al.  (2015)	Tikuisis et al. (2014)	Saddawy et al. (2012)	Lauwik et al. (2008)	Weuthrich et al. (2012)
Selection Bias
A1	yes	yes	yes	yes	yes	yes	yes	yes	yes
A2	yes	yes	yes	yes	yes	yes	yes	yes	yes
A3	yes	yes	yes	yes	yes	yes	yes	yes	yes
Was selection bias present?	No	No	No	No	No	No	No	No	No
Performance Bias
B1	yes	yes	yes	yes	yes	yes	yes	yes	yes
B2	yes	yes	yes	yes	yes	yes	yes	yes	yes
B3	yes	yes	yes	yes	yes	yes	yes	yes	yes
Was performance bias present?	No	No	No	No	No	No	No	No	No
Attrition Bias
C1	yes	yes	yes	yes	yes	yes	yes	yes	yes
C2 (a)	0	0	0	0	3 patients in group C and 1 patient in group L	4 patients were excluded from final analysis	2 patients were excluded from final analysis in lignocaine group	1 patient were excluded from control group	0
(b)	yes	yes	yes	yes	yes	yes	yes	yes	yes
C3 (a)	None	None	None	None	None	4	2	1	None
(b)	yes	yes	yes	yes	yes	yes	yes	yes	yes
Was attrition bias present?	No	No	No	No	No	No	No	No	No
Detection Bias
D1	yes	yes	yes	yes	yes	yes	yes	yes	yes
D2	yes	yes	yes	yes	yes	yes	yes	yes	yes
D3	yes	yes	yes	yes	yes	yes	yes	yes	yes
D4	yes	yes	yes	yes	yes	yes	yes	yes	yes
D5	yes	yes	yes	yes	yes	yes	yes	yes	yes
Was detection bias present	No	No	No	No	No	No	No	No	No
Internal Validity	+	+	+	+	+	+	+	+	+
External Validity	+	+	+	+	+	+	+	+	+

Table: summary of analysis using NICE guideline

The PRISMA diagram for depicting the flow of information through the different phases of the present systematic review is presented below. It maps out the number of records identified, included and excluded, and the reasons for exclusion.

Ergil et al. (2014) in their prospective randomised study aimed to carry out a comparison of effects of intra-operative esmolol, lidocaine and saline infusions, and opioid for reducing pain in patients undergoing laparoscopic cholecystectomy. 48 patients with ASA physical status I-II took part in the study. Patients were given an intravenous (IV) injection of 1 mg kg-1 esmolol (Group E), 1.5 mg kg-1 lidocaine (Group L) or 10 mcg remifentanyl (Group C) before anesthesia. During the process, surgery patients were infused with 50 mcg kg-1 min-1 esmolol (IV, Group E) or 2 mg kg-1 min-1 lidocaine (IV, Group L) or 10mL h-1 saline (Group C). Visual analog scale (VAS) in the postoperative 24 hours was recorded. The study concluded that esmolol infusion led to decrease of opioid consumption during the 24-hour postoperative period in a more effective manner as compared to saline and lidocaine.

Ram et al. (2013) conducted a double-blind, randomised, clinical trial to compare the intraperitoneal (IP) and intravenous (IV) lignocaine for pain relief in patients after laparoscopic cholecystectomy (LC). 50 patients were randomised into two groups, and the intervention group was given IV 2 % lignocaine from induction until 1 h after surgery or IP instillation of 0.2 % lignocaine. Measurement of total morphine requirement, median VAS, first analgesic requirement time and total PCA demands was done. The study concluded that IV lignocaine is more effective for pain relief after laparoscopic cholecystectomy as compared to IP lignocaine, in addition to ensuring early return of bowel activity for patients.

Yang et al. (2013) in their randomized, double-blind, placebo-controlled trial considered the evaluation of intraperitoneal (IP) lidocaine administration and intravenous (IV) lidocaine infusion to control postoperative pain in patients undergoing laparoscopic cholecystectomy (LC). Patients were randomised to either group IP (intraperitoneal lidocaine administration), group IV (intravenous lidocaine infusion), or group C (control, IP and IV saline). The outcome measures were total fentanyl consumption (TFC), total postoperative pain severity (TPPS), frequency of administering patient-controlled analgesia (FPB), and a pain control satisfaction score (PCSS). It was indicated that both IP and IV lidocaine infusion was effective in reducing opioid consumption and postoperative pain in LC patients as compared to control infusion.

Lauwick et al. (2008) determined the effectiveness of intraoperative lidocaine infusion in the reduction of opioid consumption for patients undergoing laparoscopic cholecystectomy in post-anaesthesia care unit (PACU). 50 patients underwent randomisation wherein the control group (n = 25) received fentanyl 3 μg•kg–1, and the lidocaine group received fentanyl 1.5 μg•kg–1 and a bolus of lidocaine 1.5 mg•kg–1 together with a continuous infusion of lidocaine 2 mg•kg–1•hr–1. It was demonstrated that intraoperative lidocaine was helpful in the reduction of opioid consumption in PACU.

Ahn et al. (2015) in their prospective, randomised, double-blinded, placebo-controlled study evaluated the usefulness of IV lidocaine for reduction of postoperative pain in patients undergoing laparoscopic colectomy. 55 patients were randomised to two groups. While intervention group received an intravenous bolus injection of lidocaine 1.5 mg/kg prior to intubation, and 2 mg/kg/h continuous infusion during the operation, the control group received a similar dose of saline at the same time. VAS scores were less, opioid consumption was lower, and satisfaction score was higher in case of the intervention group. The main inference drawn from the study was that IV lidocaine infusion when given to patients in postoperative care after laparoscopic colectomy is highly beneficial.

The study of Tikuiss et al. (2013) was a randomised, placebo-controlled clinical trial that carried out an assessment of IV lidocaine when administered to hand-assisted laparoscopic colon surgery patients in terms of quality of post-operative analgesia and other outcomes. 64 patients were randomised and given 0.9 % saline infusion or lidocaine infusion for 24 hours. The study considered postoperative pain control as the primary outcome while the secondary outcome was the length of hospital stay and time to resumption of bowel function. The research was helpful in understanding that IV lidocaine has a beneficial impact in case of postoperative pain, length of hospital stay and restoration of bowel function for those undergoing hand-assisted laparoscopic colon surgeries.

A double-blinded study carried out by Saadawy et al. (2010) compared the impact of lidocaine and magnesium on quality of sleep, bowel function, analgesic requirements and pain in patients who undergo laparoscopic cholecystectomy (LC). Three groups were allocated for the 120 participants. One group received magnesium sulphate IV, one group received lidocaine IV, and one group received saline IV before anaesthesia. Researchers recorded intraoperative opioid consumption. It was found that magnesium or lidocaine was effective in reducing anaesthetic requirements, morphine consumption and pain scores. 

Kim et al. (2011) made a suitable comparison of IV lidocaine and IP lidocaine, in bringing about the analgesic effect in patients undergoing laparoscopic appendectomy (LA). The research was a prospective, randomised, double-blinded, placebo-controlled study. 68 patients undergoing LA were randomised into three groups wherein they were given either IP lidocaine, or IV lidocaine or normal saline. From the results, it was found that IV lidocaine was more useful as an IP instillation that can reduce pain in patients.

When Wuethrich et al. (2012) wanted to study the effect of lidocaine for patient care after laparoscopic renal surgery a randomised, placebo-controlled study was undertaken. 64 patients were randomised into two groups, and the intervention group received lidocaine during anaesthesia. The primary outcomes were the length of hospital stay, while the secondary outcomes were opioid consumption, sedation, the return of bowel function, readiness for discharge and postoperative nausea and vomiting. In this study, a systematic administration of lidocaine did not have any impact on most of the primary and secondary outcomes.

Lee et al. (2017) determined the extent to which peri-operative IV lignocaine can reduce pain and length of stay at the hospital, and shorten postoperative ileus for patients undergoing colorectal surgery. 16 patients were studied who had been given lignocaine infusion for 24 hours postoperatively. Categorical pain scores were measured, and patient’s rehabilitation was studied. The study highlighted that IV lignocaine is an effective and safe analgesic that is also useful in enhancing the rehabilitation process in case of patients who undergo surgery for colorectal cancer.

Study	Intervention group	Control group	Details of intervention	Effects on intervention on pain score	Effects of intervention on opioid consumption
Ergil et al. (2014)	32 participants divided in two groups (E and L)	16 participants	intravenous (IV) injection of 1 mg kg-1 esmolol (Group E), 1.5 mg kg-1 lidocaine (Group L) or 10 mcg remifentanyl (Group C) were given before induction of anesthesia	The postoperative VAS scores were lower in Group E as compared to group C (p<0.05)	Esmolol decreased the consumption of opioid more effectively as compared to lidocaine (p=0.000)
Ram et al. (2014)	25 participants	25 participants	IV 2% lignocaine was administered from the time of induction until 1 hour post surgery for the intervention group, or IP instillation of 0.2% lignocaine was given after gallbladder removal. Control group received 0.9% normal saline.	VAS scores were less in the IP group as compared to IV group	Total PCA requirement was less in the IV group 24 hour after surgery (p<0.001)
Lauwick et al. (2008)	25 participants	25 participants	Control group received fentanyl 3 microgram/kg, whereas the Lignocaine group given 1.5 microgram/kg of the same drug along with a bolus of Lignocaine 1.5 mg/kg. Subsequently, a continuous infusion of Lignocaine at 2 mg/kg/hr was maintained.	–	Opioid consumption was found to be reduced during postoperative period. On average, cumulative amount 98 micrograms in the Lignocaine group, compared to 153.54 micrograms in the control group (P value = 0.018)
Saadawy (2010)	40 participants (Group L)	40 participants (Group P)	Group L given intravenous Lignocaine 2 mg/kg (bolus), followed by 2 mg/kg/h continuous infusion. Group P given intravenous normal saline.	VAS abdominal pain scores and VAS shoulder pain scores were lower in Group L, compared to Group P. (P < 0.01)	Total fentanyl requirement in Group L = 242 micrograms; Group P = 323 micrograms. (P < 0.001)
Kim et al. (2011)	22 participants (Group IV)	21 participants (Group C)	Group IV received intravenous bolus injection 1.5 mg/kg Lignocaine followed by IV infusion @ 2 mg/kg/h & normal saline intraperitoneal instillation. Group C received IV and intraperitoneal normal saline.	Diminishing trend of VAS score observed in all groups. VAS pain score in Group IV remained lower than Group C, throughout the initial 48- hour postoperative period (P < 0.05).	Fentanyl consumption lower in Group IV, compared to Group C, and this trend persisted throughout the initial 48 hours postoperatively (P < 0.05).
Yang et al. (2014)	26 participants (Group IV)	24 participants (Group C)	Individuals in Group IV given IV bolus injection of 1.5 mg/kg Lignocaine, followed by 2 mg/kg/h Lignocaine IV infusion + intraperitoneal normal saline. Group C received IV and IP normal saline.	VAS score diminished with passage of time in all groups. VAS score in Group C remain >3 until end of 12 hours postoperatively. VAS as lower in Group IV (between 2 and 12 hours), compared to Group C. (P < 0.05).	Total fentanyl consumption in Group C remained persistently high postoperatively (compared to Group IV) until 24 hours after surgery (P < 0.001).
Ahn et al. (2015)	25 participants (Group L)	25 participants (Group C)	Group L administered intravenous bolus injection Lignocaine 1.5 mg/kg, followed by 2 mg/kg/h continuous infusion of same. Group C received normal saline at similar timings.	VAS scores of Group L remained lower than Group C, throughout the 48 hours period following surgery.	Fentanyl consumption remained lower in Group L, compared to Group C (48 hours postoperatively) (P = 0.039).
Tikuišis et al. (2014)	32 participants	32 participants	Intervention group received intravenous Lignocaine 1.5 mg/kg bolus, after which continuous infusion @ 2 mg/kg/h maintained during surgery. Control group given normal saline as placebo. 0.1 microgram/kg/h fentanyl continuous infusion was given for 24 hours postoperatively. .	Intensity of pain at rest and during movement lower in the intervention group, compared to the control group (P < 0.01).	Consumption of ketorolac in the control group was significantly higher than in the intervention group. 90% patients in control group required ketorolac as opposed to 73.3% patients in intervention group (P = 0.181).
Wuethrich et al. (2012)	32 participant	32 participant	Lidocaine was given as a 1.5mgkg_1 bolus during induction of anaesthesia, followed by a continuous intraoperative infusion of 2mgkg_1 h_1. Control group received 0.9% saline.	–	Lidocaine had no statistically significant effect on opioid consumption [lidocaine group: 7mg (±9) vs. control group: 11mg (±12), P¼0.23)]

Evidence-based healthcare is known to be the integration of the best available research evidence with the wide range of clinical expertise. Using the pool of evidence from authentic and reliable research for informing healthcare decisions is perceived to have the strength to make sure healthcare delivery variation is reduced, and best practice is delivered (Holloway and Galvin 2016). A systematic literature review has become growing important in clinical settings as healthcare professionals engage in research to update their knowledge level as per the needs of the practice guidelines in their respective field (DePoy and Gitlin 2015). The present systematic literature review acted as a summary of significant research existing about the importance and effectiveness of administration of lignocaine in improving and enhancing post anaesthesia care for patients undergoing laparoscopic appendectomy and cholecystectomy. Successful critical appraisal of articles was done for studies that provide key insight into the research topic. Nine out of ten research papers were randomised controlled trials. Randomised control trials are the most trustworthy scientific evidence in the outlined hierarchy of evidence influencing the healthcare practice as well as policy since there is a reduction of bias and causality (Taylor, Bogdan and DeVault 2015). Moreover, such studies have a distinct advantage for evaluation of clear and straightforward therapeutic procedures. High chances are there that randomisation would lead to different patient cohorts when the comparison is done with respect to prognostic factors. Put in a simplified manner, differ cohorts can indicate the similar rate of events throughout the study period if identical interventions are given.

The important study findings of the research papers considered for the present review indicate that intravenous lignocaine when administered to patients undergoing laparoscopic appendectomy and cholecystectomy leads to statistically significantly therapeutic benefits in terms of pain control at the time of perioperative care. The quality of the studies is reasonable and acceptable, and therefore the inferences drawn from the studies are considered when discussing the effects of the intervention for patients undergoing laparoscopic abdomen surgeries. Most of the studies had the primary outcomes as total morphine or opioid requirement postoperatively and pain. Measurement of pain was done with the help of Visual Analogue Scale (VAS). It is to be noted that a VAS is a notable measurement instrument that attempts to carry out the measurement of attitude or characteristic known to vary across a range of values that are difficult to be measured in a direct manner. It is widely used in clinical research for measuring the frequency or intensity of different symptoms such as pain (Del Cuvillo et al. 2017). There are a number of advantages of using this tool, and since these were understood by the researchers of the studies included in this review, the inclusion of these papers in justified. VAS is praised due to its adaptability and simplicity to different populations. Further, it is sensitive to minute changes as compared to other scales. However, it is to be remembered that assessment carried out with VAS is clearly subjective (Reed et al. 2017). Opioid consumption, as pointed out by Prabhu et al. (2018) acts as a representation of pain intensity and is influenced to a great extent by different psychological factors such as mood, recovery expectations and anxiety level.

Among the ten studies included in this review, most of them are in alignment with each other as they point out the similar results. Ram et al. (2014) have pointed out that IV lignocaine is much better when compared to IP lignocaine for controlling pain in patients undergoing laparoscopic cholecystectomy. The study suggested that IV lignocaine provide an added advantage of enhancing the early return of bowel function in patients undergoing abdomen surgery. It is noteworthy aspect since surgeons would be facilitated to perform laparoscopic surgery as a procedure to be completed within a day. Yang et al. (2013) from their study came to the conclusion that application of IV lidocaine after laparoscopic cholecystectomy is highly beneficial as opioid consumption in patients is reduced, and pain severity is decreased. IP administration would not be the choice of administration route as the same adds burden on the surgeon. Other rationale includes the fact that IP administration at times develops the risk of infections in patients presented with abdominal infections. Further, an intravenous method is convenient, and the safety profile is good and satisfactory. In this regard, Lauwick et al. (2008) in their paper stated that intraoperative lidocaine has the potential to reduce consumption of opioid in the post-anaesthesia care unit (PACU). The researchers added that lidocaine infusion can be administered in combination with low doses of opioids that are known to be short-acting for achieving reduction of consumption of fentanyl. Fentanyl is opioid acting as a pain medication when administered with other medications, which are anaesthesia medicines (Sun et al. 2017).

The study by Kim et al. (2010) also highlighted that lidocaine injection when given intravenously as intraperitoneal instillation is effective in reducing pain. The researchers had also pinpointed that the most striking advantage of intravenous injection is that the process is a universally applicable and valid process. As highlighted by Al-Shaikh and Stacey (2017) intravenous application is a safe procedure as the risks of adverse effects are less. The therapeutic impact of the drug, in this case, is achieved in the timely manner. Further, the patient is relieved from experience of severe pain and associated irritation when the medicine is administered. When applied intravenously, the desired effect has more bioavailability.

Ahn et al. (2015) demonstrated that patients receiving an intraoperative infusion of IV lidocaine suffer less severity of pain and the total fentanyl consumption is less. Significantly, the added information received from the paper was that as the study considered the impact of systematic lidocaine, the process of administration of the same contributes to a shorter hospital stay. There would also be an improvement in the quality of recovery for patients who undergo laparoscopic colectomy. Similar findings have been achieved by Tikuisis et al. (2013) who point out that perioperative infusion of IV lidocaine in a continuous manner has a beneficial impact on length of hospital stay apart from the reduction of post operative pain and restoration of bowel function. At this juncture, it would be advisable to point out the importance of reduced length of hospital stay. Reduced length of hospital stay has the potential to release capacity in the healthcare system including staff time and bed. The throughput of the system can thereby be enhanced, which in turn can enable the setting to serve a larger number of patients (Burrage et al. 2017). Van Daalen  et al. (2017) agreed to this and stated that reduced hospital length has an association with higher risk of readmission in diverse settings.

Sadaawy et al. (2010) contributed a significant study aligned with the research question as the research compared lidocaine and magnesium as analgesics for patient care after laparoscopic cholecystectomy. Both magnesium and lidocaine were found to be effective in improving post-operative analgesia while reducing opioid requirements for patients. It was inferred that the speedy recovery process has the possibility of enabling faster hospital discharge.  Based on the work of Kim et al. (2018) it is to be stated that magnesium and lidocaine can be applied in combination for gaining more benefits as compared to the sole application of magnesium or lidocaine. The reason is that while magnesium enhances sleep quality and facilitates the recovery process, lidocaine improves pain control. Lee et al. (2017) brought into limelight their research on facilitation of acute rehabilitation after laparoscopic colectomy in patients after infusion of intravenous lignocaine. The researchers opined that lignocaine is a cost-effective and feasible method for providing postoperative analgesia apart from being a safe one. Cost effectiveness of drug administration is a key aspect clinicians must consider when engaging in the decision-making process about which analgesic is to be delivered (Hatch et al. 2017).

Contradiction to such results has come from studies carried out by Ergil et al. (2014) and Wuehrich et al. (2012). The study of Ergil et al. (2014) concluded that esmolol infusion is more effective as compared to lidocaine in terms of decreased opioid consumption during the postoperative period. Further, esmolol has an added advantage of acting as an adjuvant for normal bowel functioning in patients undergoing laparoscopic cholecystectomy. Based on this study finding, researchers would be interested to study further the comparative effectiveness of esmolol and lignocaine in clinical application. Clinicians also need to consider the applicability of esmolol for a patient undergoing similar surgeries in place of lignocaine. Nevertheless, the comparative study of lignocaine and esmolol needs to consider a number of factors, including the patient condition and the risk factors for suffering side effects of lignocaine. According to Singh et al. (2017), lignocaine has a number of side effects such as diplopia, drowsiness, peri-oral numbness, agitation, euphoria and muscle twitching. Alternatives to lignocaine, such as esmolol are to be considered by clinicians when deciding on the appropriate analgesic. The side effects of lidocaine have also been mentioned in the study of Ahn et al. (2015) as tinnitus, vertigo, restlessness and drowsiness. When Wuethrich evaluated the effect of lidocaine on the length of hospital stay, readiness for discharge, opioid requirement, and bowel function after laparoscopic renal surgery, it was found that perioperative lidocaine did not have any positive impact on any of the outcome measures assessed.

A number of studies included in the review have detailed the mode of action of lignocaine, and the benefits of the same. Ram et al. (2014) stated free nerve endings are blocked by lignocaine in the peritoneum. The mode of action is suppression of neural excitability in neurons, inhibition of spinal visceromotor neurons and inhibition of nerve conduction. Postoperative ileus can be reduced by the decrease of consumption of opioid and inflammatory activity. According to Yang et al. (2013), lignocaine acts through blocking sodium channels. Other mode of action might relate to the interaction of lignocaine molecules with nonciceptive transmission pathways in addition to different receptors. Some of the noteworthy pathways include muscarinic antagonists, glycine inhibitors and neurokinin levels. Ahn et al. (2015) mentioned that lidocaine is an effective analgesic as it acts through different mechanisms such as blockage of sodium channels and inhibition of G protein-coupled receptors.

While conducting systematic reviews, it is essential to understand the limitations of the studies considered for the systematic research, since future research needs are dependent on the drawbacks. Holloway and Galvin (2016) pinpointed that researchers conducting literature reviews must acknowledge the limitations of the studies included in the review as the answered questions about the research topic come into focus. Acknowledgement of the limitations of the studies also ensures that an opportunity is taken to demonstrate the ability to critically analyse the respective research problem. In this section of the discussion, the limitations of the studies included in the present literature review are to be highlighted.

The study of Ergil et al. (2014) had the limitation that the inclusion of ASA I-II physical status patients restricted the scope of the study. In case patients with ASA III-IV patients were included, additional information might have been gathered that would have been important for practice. This would have been beneficial for assessing the side effects of lignocaine. The study by Ram et al. (2014) could not achieve the measurement of blood lignocaine in the patients. Further, a placebo group was not considered in the study. Yang et al. (2013) had stated that their study was limited by inability to characterise the nature of pain in alignment with VAS score. Since pain suffered by patient after laparoscopic surgery is multifactorial, there is a need to understand the differences in mechanisms in application of IP and IV lignocaine. Ahn et al. (2015) mentioned a number of limitations in their study. Firstly, the research did not collect data on pain score and this is crucial as pain score in preoperative condition can affect VAS for patients in the postoperative condition. Further, the research considered low-dose infusion of lignocaine in order to avoid toxic impact. Further, no toxic impact of lignocaine was recorded for the study.

Tikusis et al. (2014) also pointed out some limitations of their study. Data for pain score were recorded only for 24 hours after the completion of the surgery, and no data were recorded on consecutive days until discharge. Most importantly, though the research demonstrated the usefulness of IV lidocaine, the superiority of the same as compared to epidural anaesthesia was not demonstrated. Sadaawy et al. (2009) mentioned two limitations of their study research. On the first place, the only analgesic effect of lidocaine was assessed as the modality of pain control. Further, lower baseline pain scores were a limitation. The absence of comparison of the plasma lidocaine concentrations between groups IP and IV was the main limitation of the study of Kim et a. (2011). On critical examination of the study of Wuethrich et al. (2012), it can be noted that the study has a prime limitation. Since the study had a length of hospital stay as the primary end-point, the variability of the measure cannot be ruled out.

The implications of administration of lignocaine for care professional’s practice are noteworthy. Olaifa, Oguntoye and Brown (2017) argue that present pool of evidence is effective in indicating that infusion of lignocaine or lidocaine in perioperative condition is effective; however, clinical effectiveness might show variation depending on the form of surgery considered for the patient. The scholars also point out that no particular mechanistic justification is there behind this variation in effectiveness between procedures that can be noted as relatively similar. The differences might result from sample size considerations and study design. Ringvold et al. (2018) discussed the competency and required a level of skills needed by professionals who are to administered lignocaine for achieving better patient outcomes. The drug is to be administered by professionals who are armed with suitable equipment and have resuscitative skills. Hermanowski et al. (2017) threw light on the importance of professional collaboration for optimal administration of lignocaine in a safe manner. Communication is a key skill for professionals in a healthcare system and professionals are required to show this skill prior to administration of lignocaine. Communication within the inter-professional team is necessary to ensure patient safety. Effective communication has been recognised to be a crucial factor for delivery of high-quality healthcare. This is of more relevance in complex settings such as surgical units.

The present literature review had some limitations of its own due to the methodology considered at the core level. Firstly, the studies considered in the review were published between 2008 and 2017. More number of studies is in existence that covers the selected area of research. However, they were not included in the review since they did not meet the specific criteria defined for the study. Further, the studies that were used for the review were full text. This brings in a limitation of not selecting research that had the capability of adding key insights into the review. As pointed out by DePoy and Gitlin (2015) full text searching of relevant articles has some key weaknesses. The most striking aspect is that academic libraries are supposed to subscribe or purchase databases that include full-text databases. When particular databases are paid for, the search engines are to be evaluated accompanying the system. Full text articles of all papers might not be available at times. In addition, studies selected for the review were all in English language. Thus, it can be stated that input from research papers available in Non-English languages were not present in the review. There are high chances that research papers in other languages can contribute to the present study with valuable findings.

Coming to the last part of the discussion section, the implications for further research on the concerned topic is to be put forward. Based on the dialogue above, it is suggested that future research is immediately required that can provide more detailed information on the applicability of lignocaine as an analgesic for laparoscopic surgery care.  Before setting up reformed guidelines for administration of lignocaine is diverse care settings as a cost-effective and suitable drug for pain relief, research would be necessary to bring in clinical findings that are more accurate. From the results considered in this study, it can be demonstrated that only restricted doses of lignocaine were used for intervention assessment in the settings. Therefore, the results of the study findings in the future should be interpreted with much caution. In this regard, it is to be mentioned that lignocaine administration in different doses are to be studied in future (Weinberg et al. 2017). Studies to be conducted in future are to have the focus on identification of the complete range of doses of intravenous lignocaine. In addition, future studies assessing the effectiveness of lignocaine are to be directed at a broader multicentre trial which can determine the extent to which lignocaine is effective. To the best of knowledge, published studies are limited that address the association between administration of lignocaine and long-term clinical outcomes for the patient. This domain is also to be researchers further by professionals of this field.

In addition, future research is also needed that can throw light on the viewpoints and opinions of healthcare professionals who are accountable for administering lignocaine as pain relief drug in patients undergoing laparoscopic abdomen surgeries (Liu and Liu 2017). Their suggestions and valuable recommendations regarding the use of lignocaine in higher concentrations, patient satisfaction scores, and challenges in delivering the drug would be elementary. The involvement of care professionals in research would be noteworthy. Care professional’s involvement in research would serve as bridges between clinical practice and research, thereby facilitating relevant research as well as the application of evidence-based treatments into regular clinical services. Healthcare organisations must come forward to lay the provision for organisational infrastructure and adequate support given to the professionals. Support and encouragement would encourage clinicians in participating in clinical research.

Conclusion

The present research aimed at studying the effectiveness of intravenous lignocaine in enhancing post anesthesia care for patients undergoing laparoscopic appendectomy and cholecystectomy. The study was a valuable one that highlighted the different dimensions and implications of administering lignocaine in perioperative care for patients undergoing Laparoscopic Appendectomy and Cholecystectomy. A systematic literature review was the appropriate approach to scrutinize existing literature that can address the research question considered in clinical practice change. The research papers considered for the study acted as a rich pool of information contributing to the area of clinical practice and gave key insights into the research topic. Drawing evidences from the research papers, a conclusion is to be drawn that intravenous lignocaine when used for perioperative care in patients undergoing laparoscopic surgery brings in significant therapeutic benefits. The use of lignocaine as an analgesic drug can ensure optimum control of pain in patients, as indicated by a considerable number of studies discussed in this paper.

Health care professionals face considerable challenges in managing pain in patients who have undergone laparoscopic surgeries such as appendectomy and cholecystectomy. The pain suffered by patients after such surgeries have been noted to be multifactorial and complex in different settings. It is known that pain and other health complexities following surgeries are noteworthy causes of delay in patient discharge and longer hospital stay length. This eventually leads to delay in returning to normal daily activities of living. The treatment to be provided for such complications and pain lead to increased costs for healthcare, thereby undermining the fundamental basis for delivering laparoscopic surgical procedures. A number of pain control drugs have been researched about to understand their effectiveness as pain analgesics in such scenarios, contributing to a large pool of information. Research indicates that opioids have been the first choice of analgesics for ensuring pain relief in patients undergoing laparoscopic surgeries and other surgeries alike.

Nevertheless, the administration of opioids has drawn much criticism owing to the unfavourable side effects they bring in for the patients. A deep scrutiny of the previous research would point out that though opioids have the potential to ensure pain control at a superior level, the undesirable effects of the same are not to be left unnoticed by clinicians if optimal care is to be delivered in this regard. The continuous use of opioids for pain relief leads to physical dependence, rendering the patients highly vulnerable to misuse of the drug when considered over a long period. Under such conditions, an alternative drug is required which can act as an effective analgesic without bringing in the risk of adverse side effects for the patients.

The use of lignocaine has been highlighted as this much valuable alternative to conventional analgesic drugs that can bring in the same benefits without placing the patients at risk for developing complications. Lignocaine, when administered through the intravenous route, confers a number of benefits for the patient care process including reduced opioid consumption and better pain relief. It is safe to be used, as indicated by the research conducted across settings. Additional benefits of using intravenous lignocaine include early return to bowel function, lower risk of adverse effects, and most importantly early recovery. One must note that the patients can achieve better psychological and physical health status if lignocaine is used. The use of lignocaine also brings in benefits for the organisation considering the administration of lignocaine as a part of postoperative care for laparoscopic surgeries. As the length of hospital stay of patient decreases due to better pain relief, the healthcare resources are not used up in an unnecessary manner. This limits the expenses that otherwise would have been otherwise incurred as a result of allocating resources for side effect management and ensuring a better quality of life for patients.

While the strength of evidence pointing out the benefits of lignocaine is praiseworthy, the research studies that have contradicted such findings cannot be ruled out. Though the number of such research papers is considerably less as compared to those that support the use of lignocaine, the underlying factors that lead to such deviated results are to be assessed in future.

Based on the above discussion it can be stated that lignocaine has the potential to be administered for pain relief in surgical settings. The present study considered evidence primarily revolving around laparoscopic appendectomy and cholecystectomy. Therefore it can be highlighted that lignocaine is appropriate to be used for laparoscopic abdomen surgeries. In future practice, patients who would undergo such surgeries would serve as the desirable candidates for applying the research findings of the present paper. Nevertheless, IV lignocaine might be applicable for other forms of surgery as well. For ensuring, that such application is safe and as per the needs of the patient, clinicians must refer to evidence that pinpoints the utility of lignocaine for the respective surgery. Since lignocaine has a certain set of undesirable health impacts, such as hypotension, bradycardia, cardiac arrest, twitching, confusion, respiratory depression, blurred vision, vertigo, light-headedness, nausea, vomiting and hypersensitivity, such research is imperative.

The administration of lignocaine might prove to be a challenge for professionals in the context of diverse patient scenarios. A multi-professional team approach would be helpful in addressing such challenges since input from more than one professional would be present. Most importantly, the anaesthetist would have the important responsibility of delivering safe lignocaine administration since the drug is given before the surgery commences. The anaesthetist staff is to be held accountable for deciding upon the dosage of the drug and the continuity of the infusion.  After the surgery is completed, the role of the anaesthetist would be to collaborate with the surgical staff to ensure proper administration of the drug. Since the role of an anaesthetist in the complete process is pivotal, there is a need for such staffs to be highly skilled and competent. The role of the respective care settings in ensuring such skills is to be stressed, as they need to allocate resources for providing training to the staffs for professional development. Briefly, individual competency and organisational commitments together would ensure lignocaine administration for pain relief in patients undergoing laparoscopic appendectomy and cholecystectomy is effective.

References

Ahn, E., Kang, H., Choi, G.J., Park, Y.H., Yang, S.Y., Kim, B.G. and Choi, S.W., 2015. Intravenous lidocaine for effective pain relief after a laparoscopic colectomy: a prospective, randomized, double-blind, placebo-controlled study. International surgery, 100(3), pp.394-401.

Al-Shaikh, B. and Stacey, S.G., 2017. Essentials of Equipment in Anaesthesia, Critical Care, and Peri-Operative Medicine E-Book. Elsevier Health Sciences.

Burrage, M., Moore, P., Cole, C., Cox, S., Lo, W.C., Rafter, A., Garlick, B., Garrahy, P., Mundy, J. and Camuglia, A., 2017. Transcatheter aortic valve replacement is associated with comparable clinical outcomes to open aortic valve surgery but with a reduced length of in-patient hospital stay: A systematic review and meta-analysis of randomised trials. Heart, Lung and Circulation, 26(3), pp.285-295.

Chang, Y.C., Liu, C.L., Liu, T.P., Yang, P.S., Chen, M.J. and Cheng, S.P., 2017. Effect of Perioperative Intravenous Lidocaine Infusion on Acute and Chronic Pain after Breast Surgery: A Meta?Analysis of Randomized Controlled Trials. Pain Practice, 17(3), pp.336-343.

Chou, R., Gordon, D.B., de Leon-Casasola, O.A., Rosenberg, J.M., Bickler, S., Brennan, T., Carter, T., Cassidy, C.L., Chittenden, E.H., Degenhardt, E. and Griffith, S., 2016. Management of Postoperative Pain: a clinical practice guideline from the American pain society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists’ committee on regional anesthesia, executive committee, and administrative council. The Journal of Pain, 17(2), pp.131-157.

Del Cuvillo, A., Santos, V., Montoro, J., Bartra, J., Davilla, I. and Ferrer, M., 2017. Allergic rhinitis severity can be assessed using a visual analogue scale in mild, moderate and severe. Rhinology, 55(1), pp.34-38.

DePoy, E. and Gitlin, L.N., 2015. Introduction to Research-E-Book: Understanding and Applying Multiple Strategies. Elsevier Health Sciences.

Dreyer, N.E., Cutshall, S.M., Huebner, M., Foss, D.M., Lovely, J.K., Bauer, B.A. and Cima, R.R., 2015. Effect of massage therapy on pain, anxiety, relaxation, and tension after colorectal surgery: A randomized study. Complementary therapies in clinical practice, 21(3), pp.154-159.

Dunn, L.K. and Durieux, M.E., 2017.Perioperative use of intravenous lidocaine. Anesthesiology: The Journal of the American Society of Anesthesiologists, 126(4), pp.729-737.

Erg?l, J., Kavak Akelma, F., Özkan, D., Akinci, M., Özmen, M. and Gümü?, H., 2014. A comparison of the effects of intraoperative esmolol and lidocaine infusions on postoperative analgesia. Anestezi Dergisi, 22, pp.25-31.

Fritsch, C.G., Ferreira, M.L., Maher, C.G., Herbert, R.D., Pinto, R.Z., Koes, B. and Ferreira, P.H., 2017. The clinical course of pain and disability following surgery for spinal stenosis: a systematic review and meta-analysis of cohort studies. European Spine Journal, 26(2), pp.324-335.

Gatchel, R.J., McGeary, D.D., McGeary, C.A. and Lippe, B., 2014. Interdisciplinary chronic pain management: past, present, and future. American Psychologist, 69(2), p.119.

Hadzic, A., 2017. Textbook of regional anesthesia and acute pain management.McGraw-Hill Medical Publishing Division.

Hatch, M.D., Daniels, S.D., Glerum, K.M. and Higgins, L.D., 2017. The cost effectiveness of vancomycin for preventing infections after shoulder arthroplasty: a break-even analysis. Journal of shoulder and elbow surgery, 26(3), pp.472-477.

Heitz, J.W. ed., 2016. Post-Anesthesia Care: Symptoms, Diagnosis and Management. Cambridge University Press.

Hermanowski, J., Levy, N., Mills, P. and Penfold, N., 2017. Deprescribing: implications for the anaesthetist. Anaesthesia, 72(5), pp.565-569.

Hoffmeister, M., Jansen, L., Rudolph, A., Toth, C., Kloor, M., Roth, W., Bläker, H., Chang-Claude, J. and Brenner, H., 2015. Statin use and survival after colorectal cancer: the importance of comprehensive confounder adjustment. JNCI: Journal of the National Cancer Institute, 107(6).

Holloway, I. and Galvin, K., 2016. Qualitative research in nursing and healthcare. John Wiley & Sons.

Hübner, M., Blanc, C., Roulin, D., Winiker, M., Gander, S. and Demartines, N., 2015.Randomized clinical trial on epidural versus patient-controlled analgesia for laparoscopic colorectal surgery within an enhanced recovery pathway. Annals of surgery, 261(4), pp.648-653.

Karamessinis, L., Manworren, R., Pantaleao, A. and Cooper, J., 2015.  Adolescents’ home pain management after laparoscopic appendectomy. The Journal of Pain, 16(4), p.S79.

Kim, M.H., Kim, M.S., Lee, J.H., Kim, S.T. and Lee, J.R., 2018. Intravenously Administered Lidocaine and Magnesium During Thyroid Surgery in Female Patients for Better Quality of Recovery After Anesthesia. Anesthesia and analgesia.

Kim, T.H., Kang, H., Hong, J.H., Park, J.S., Baek, C.W., Kim, J.Y., Jung, Y.H. and Kim, H.K., 2011. Intraperitoneal and intravenous lidocaine for effective pain relief after laparoscopic appendectomy: a prospective, randomized, double-blind, placebo-controlled study. Surgical endoscopy, 25(10), pp.3183-3190.

Kolettas, A., Lazaridis, G., Baka, S., Mpoukovinas, I., Karavasilis, V., Kioumis, I., Pitsiou, G., Papaiwannou, A., Lampaki, S., Karavergou, A. and Pataka, A., 2015. Postoperative pain management. Journal of thoracic disease, 7(Suppl 1), p.S62.

Lauwick, S., Kim, D.J., Michelagnoli, G., Mistraletti, G., Feldman, L., Fried, G. and Carli, F., 2008. Intraoperative infusion of lidocaine reduces postoperative fentanyl requirements in patients undergoing laparoscopic cholecystectomy. Canadian Journal of Anesthesia, 55(11), p.754.

Lee, M.W., Or, D.Y., Tsang, A.C., Ng, D.C., Chen, P.P., Cheung, M.H., Li, R.S. and Leong, H.T., 2017. Intravenous lignocaine infusion facilitates acute rehabilitation after laparoscopic colectomy in the Chinese patients. Hong Kong Med J, 23(5), pp.441-5.

Liu, F. and Liu, L., 2017. Iontophoretic delivery of lignocaine in healthy volunteers: effect of concentration of epinephrine on local anesthesia. Biomedical Research, 28(1).

LoBiondo-Wood, G. and Haber, J., 2017. Nursing Research-E-Book: Methods and Critical Appraisal for Evidence-Based Practice. Elsevier Health Sciences.

LoBiondo-Wood, G., Haber, J., Cameron, C. and Singh, M., 2017. Nursing Research in Canada-E-Book: Methods, Critical Appraisal, and Utilization. Elsevier Health Sciences.

Madeira, G., Mocumbi, A.O. and Mayosi, B.M., 2016. Advice to health professionals: Use of lignocaine as a diluent to reduce the pain associated with the administration of benzathine penicillin G. South African Medical Journal, 106(8), pp.742-742.

Mansournia, M.A., Higgins, J.P., Sterne, J.A. and Hernán, M.A., 2017. Biases in Randomized Trials: A Conversation Between Trialists and Epidemiologists. Epidemiology (Cambridge, Mass.), 28(1), pp.54-59.

Manworren, R.C., McElligott, C.D., Deraska, P.V., Santanelli, J., Blair, S., Ruscher, K.A., Weiss, R., Rader, C., Finck, C., Bourque, M. and Campbell, B., 2016. Efficacy of analgesic treatments to manage children’s postoperative pain after laparoscopic appendectomy: retrospective medical record review. AORN journal, 103(3), pp.317-e1.

Moher, D., Shamseer, L., Clarke, M., Ghersi, D., Liberati, A., Petticrew, M., Shekelle, P. and Stewart, L.A., 2015. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Systematic reviews, 4(1), p.1.

Moule, P., Aveyard, H. and Goodman, M., 2016. Nursing research: An introduction. Sage.

Ng, K.P. and Sim, D.S.M. eds., 2016. Pharmacological Basis of Acute Care.Springer.

Nieswiadomy, R.M. and Bailey, C., 2017. Foundations of nursing research. Pearson.

Olaifa, A.K., Oguntoye, C.O. and Brown, A., 2017. Anaesthetic indices and vital parameters of PPR-infected West African Dwarf goats after epidural lignocaine anaesthesia. African Journal of Biomedical Research, 20(1), pp.59-63.

Parahoo, K., 2014. Nursing research: principles, process and issues. Palgrave Macmillan.

Pardo, M. and Miller, R.D., 2017. Basics of Anesthesia E-Book.Elsevier Health Sciences.

Prabhu, M., Dolisca, S., Wood, R., Gonzalez, J., James, K., Bateman, B.T., Wylie, B.J. and Barth, W.H., 2018. 558: Predictors of excess postoperative opioid consumption after cesarean delivery among opioid naive women. American Journal of Obstetrics and Gynecology, 218(1), pp.S333-S334.

Ram, D., Sistla, S.C., Karthikeyan, V.S., Ali, S.M., Badhe, A.S. and Mahalakshmy, T., 2014. Comparison of intravenous and intraperitoneal lignocaine for pain relief following laparoscopic cholecystectomy: a double-blind, randomized, clinical trial. Surgical endoscopy, 28(4), pp.1291-1297.

Reed, C.C., Wolf, W.A., Cotton, C.C. and Dellon, E.S., 2017. A visual analogue scale and a Likert scale are simple and responsive tools for assessing dysphagia in eosinophilic oesophagitis. Alimentary pharmacology & therapeutics, 45(11), pp.1443-1448.

Ringvold, E.M., Bekkevold, M., Bruun, A.M., Børke, W.B., Finjarn, T.J., Haugen, A.S., Isern, E., Skjeflo, G.W. and Ulvik, A., 2018. Norwegian standard for the safe practice of anaesthesia. Acta Anaesthesiologica Scandinavica, 62(3), pp.411-417.

Rothrock, J.C. and Alexander, S., 2014. Alexander’s Surgical Procedures-E-Book.Elsevier Health Sciences.

Rothrock, J.C., 2014. Alexander’s Care of the Patient in Surgery-E-Book.Elsevier Health Sciences.

Saadawy, I.M., Kaki, A.M., Abd El Latif, A.A., Abd?elmaksoud, A.M. and Tolba, O.M., 2010. Lidocaine vs. magnesium: effect on analgesia after a laparoscopic cholecystectomy. Acta Anaesthesiologica Scandinavica, 54(5), pp.549-556.

Shady, N.W., Sallam, H.F., Ali, S.S. and Abbas, A.M., 2017. Effect of intraperitoneal and incisional port site lidocaine on pain relief after gynecological laparoscopic surgery: A randomized controlled study. Middle East Fertility Society Journal.In press.

Shamseer, L., Moher, D., Clarke, M., Ghersi, D., Liberati, A., Petticrew, M., Shekelle, P. and Stewart, L.A., 2015. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015: elaboration and explanation. Bmj, 349, p.g7647.

Singh, G., Kaur, H., Aggarwal, S., Sharda, G., Singh, A., Jha, A. and Aggarwal, H., 2017. Intravenous dexmedetomidine vs. lignocaine in attenuating the hemodynamic responses during laryngoscopy and endotracheal intubation: a randomized double blind study. Anaesthesia, Pain & Intensive Care, 21(2).

Souzdalnitski, D., Lerman, I.R. and Narouze, S., 2016. Postoperative Pain Management. Chronic Pain Management for the Hospitalized Patient, p.347.

Stamp, L.K., Chapman, P.T., Barclay, M.L., Horne, A., Frampton, C., Tan, P., Drake, J. and Dalbeth, N., 2017. A randomised controlled trial of the efficacy and safety of allopurinol dose escalation to achieve target serum urate in people with gout. Annals of the rheumatic diseases, 76(9), pp.1522-1528.

Sun, S., Wang, J., Bao, N., Chen, Y. and Wang, J., 2017. Comparison of dexmedetomidine and fentanyl as local anesthetic adjuvants in spinal anesthesia: a systematic review and meta-analysis of randomized controlled trials. Drug design, development and therapy, 11, p.3413.

Taylor, S.J., Bogdan, R. and DeVault, M., 2015. Introduction to qualitative research methods: A guidebook and resource. John Wiley & Sons.

Tikuišis, R., Miliauskas, P., Samalavi?ius, N.E., Žurauskas, A., Samalavi?ius, R. and Zabulis, V., 2014. Intravenous lidocaine for post-operative pain relief after hand-assisted laparoscopic colon surgery: a randomized, placebo-controlled clinical trial. Techniques in coloproctology, 18(4), pp.373-380.

Tobias, J.D., 2013. Pain management following laparoscopy: Can we do better?. Saudi journal of anaesthesia, 7(1), p.3.

Van Daalen, F.V., Prins, J.M., Opmeer, B.C., Boermeester, M.A., Visser, C.E., van Hest, R.M., Branger, J., Mattsson, E., van de Broek, M.F.M., Roeleveld, T.C. and Karimbeg, A.A., 2017. Effect of an antibiotic checklist on length of hospital stay and appropriate antibiotic use in adult patients treated with intravenous antibiotics: a stepped wedge cluster randomized trial. Clinical Microbiology and Infection, 23(7), pp.485-e1.

Wang, N., Zhou, H., Song, X. and Wang, J., 2016. Comparison of oxycodone and sufentanil for patient-controlled intravenous analgesia after laparoscopic radical gastrectomy: A randomized double-blind clinical trial. Anesthesia, essays and researches, 10(3), p.557.

Weinberg, L., Jang, J., Rachbuch, C., Tan, C., Hu, R. and McNicol, L., 2017. The effects of intravenous lignocaine on depth of anaesthesia and intraoperative haemodynamics during open radical prostatectomy. BMC research notes, 10(1), p.248.

Weingarten, T.N., Jacob, A.K., Njathi, C.W., Wilson, G.A. and Sprung, J., 2015. Multimodal analgesic protocol and postanesthesia respiratory depression during phase I recovery after total joint arthroplasty. Regional anesthesia and pain medicine, 40(4), pp.330-336.

Widom, C.S., Czaja, S.J. and DuMont, K.A., 2015. Intergenerational transmission of child abuse and neglect: Real or detection bias?. Science, 347(6229), pp.1480-1485.

Wuethrich, P.Y., Romero, J., Burkhard, F.C. and Curatolo, M., 2012. No benefit from perioperative intravenous lidocaine in laparoscopic renal surgery: a randomised, placebo-controlled study. European Journal of Anaesthesiology (EJA), 29(11), pp.537-543.

Yang, S.Y., Kang, H., Choi, G.J., Shin, H.Y., Baek, C.W., Jung, Y.H. and Choi, Y.S., 2014. Efficacy of intraperitoneal and intravenous lidocaine on pain relief after laparoscopic cholecystectomy. Journal of International Medical Research, 42(2), pp.307-319.