A multidisciplinary panel convened by the Youth Group of the Chinese Society of Anesthesiology and the Perioperative Medicine Professional Committee of the Chinese Medical Education Association has published a formal consensus on how intravenous lidocaine should be given to adult patients around the time of surgery. The document, developed by 27 anesthesiology experts plus two methodology specialists and finalized in October 2025, distills the evidence available through 30 September 2025 into 12 recommendations, each graded with the GRADE system for certainty of evidence and strength of recommendation. The work was registered as a practice guideline under PREPARE-2025CN653 and appears in Anesthesiology and Perioperative Science as the authorized English edition of a consensus first published in the Chinese Journal of Anesthesiology.

The panel’s core prescription is deliberately simple. Unless a specific recommendation says otherwise, the standard regimen is an intravenous loading dose of 1.5 mg/kg, injected over at least 10 minutes during anesthesia induction, followed by a continuous infusion of 1.5 to 2.0 mg/kg/h until the end of surgery, with the duration adjusted afterward to postoperative needs. Dose calculations should use ideal body weight in obese patients, and reductions with close monitoring apply to patients with hepatic or renal dysfunction, hypovolemia, or shock, with dose reduction also considered in the elderly. The consensus stresses that lidocaine is primarily metabolized by the liver, follows a multi-compartment distribution with a distribution half-life of 5 to 8 minutes and an elimination half-life of 80 to 110 minutes, and remains off-label for perioperative analgesia.

The strongest recommendations concern four indications. First, slow intravenous injection of lidocaine during induction is endorsed to blunt the burning pain that propofol injection can cause, a problem the document notes affects up to 63.7 percent of patients receiving the induction agent. Second, slow injection of lidocaine 1.0 to 1.5 mg/kg two to three minutes before intubation is recommended to attenuate the sympathetic stress response to laryngoscopy and tube insertion, which otherwise drives catecholamine release, elevated blood pressure, and increased heart rate. Third, the standard infusion is recommended to reduce the risk of postoperative nausea and vomiting, and fourth, it is recommended to reduce pulmonary complications including atelectasis after major abdominal or thoracic surgery. All four carry high evidence quality and strong recommendation strength.

The mechanistic reasoning behind these effects is laid out in detail. For intubation, lidocaine blocks neuronal voltage-gated sodium channels and suppresses the generation and conduction of action potentials, damping the neuroreflex and sympathetic responses to airway instrumentation; it also acts directly on peripheral vascular smooth muscle and exerts local anesthetic effects on laryngopharyngeal and tracheal nociceptors that reduce cough and laryngospasm. For analgesia, the drug produces central and peripheral anti-hyperalgesic effects by blocking sodium channels, regulating potassium channel activity, and inhibiting N-methyl-D-aspartate receptor-mediated central sensitization. For nausea and vomiting, sodium channel blockade may inhibit the excitability of the vomiting center, possibly involving the 5-hydroxytryptamine 3 receptor, while reduced opioid consumption removes a major chemical trigger of emesis.

Postoperative pain relief receives a moderate-quality, weak recommendation. In abdominal, orthopedic, thyroid, and otorhinolaryngologic surgery, lidocaine 1.5 to 2.0 mg/kg given intravenously over at least 10 minutes before induction, followed by infusion at 1.5 to 2.0 mg/kg/h until the end of surgery or for 24 to 72 hours postoperatively, significantly reduces resting and movement-evoked pain scores on the visual analogue scale. A non-inferiority randomized controlled trial of 210 adults undergoing major laparotomy found that movement-evoked pain at 24 hours did not differ significantly between a lidocaine infusion and thoracic epidural analgesia, making the drug a useful option when epidural puncture is contraindicated. A single intravenous dose provides analgesia for no more than about 8.5 hours, so prolonged infusion extends the effect, and for major abdominal surgery with severe pain the panel permits low-dose postoperative infusion of 0.3 to 0.36 mg/kg/h for up to 72 hours under close monitoring.

Opioid sparing is supported by a meta-analysis of 68 studies and 4,525 patients showing that infusions of 1 to 5 mg/kg/h reduced morphine equivalent consumption within 72 hours by approximately 2.8 to 6.3 mg in open or laparoscopic abdominal surgery, and by a trial of 116 adults undergoing complex spinal surgery in which a 2 mg/kg/h infusion significantly reduced morphine use within 24 hours. Recovery quality also improves: a meta-analysis of 14 randomized controlled trials with 1,148 adults found significantly higher Quality of Recovery-40 total and dimension scores with lidocaine than placebo at 24 hours, 72 hours, and 5 days, with benefits consistent across surgery type, age, sex, anesthetic technique, and dose. During colonoscopy, an infusion of 1.5 mg/kg followed by 2 to 4 mg/kg/h can cut propofol dosage by 50 percent, and in obese patients with BMI above 30 kg/m2 it reduced apnea and hypoxemia in a trial of 90 adults.

Two recommendations come with explicit caution. Gastrointestinal recovery is labeled exploratory: while multiple trials in colorectal cancer surgery shortened time to first flatus and defecation, and a meta-analysis of 9 studies with 405 patients found intestinal peristalsis recovered an average of 9.5 hours sooner, the largest trial to date, involving 557 patients undergoing elective minimally invasive colon surgery, showed no significant difference in gastrointestinal recovery at 72 hours. Neuroprotection is similarly exploratory and confined to cardiac surgery populations, where one trial in coronary artery bypass grafting reduced postoperative cognitive dysfunction, but a multicenter trial of 478 patients found no difference in cognitive decline at 6 weeks or 1 year, and a meta-analysis with trial sequential analysis found no benefit at 6 to 10 weeks. The panel also flags contested evidence on chronic postsurgical pain: a meta-analysis of 13 placebo-controlled trials with 1,039 patients reported no significant reduction at 3 or 6 months, yet pooled point estimates favored lidocaine, sensitivity analyses and an independent re-analysis reached significance, and the required information size was not reached, leaving the question unresolved.

Safety receives the most detailed treatment. Under the conventional regimen, measured plasma concentrations of 0.58 to 5.0 micrograms per milliliter remained within the safe threshold of 5.0 micrograms per milliliter, and a meta-analysis of 68 studies found only mild toxicity-related reactions such as dizziness, drowsiness, perioral numbness, and arrhythmia, all resolving after the infusion stopped. Absolute contraindications include hypersensitivity to lidocaine, Adams-Stokes syndrome, Wolff-Parkinson-White syndrome, severe sinoatrial, atrioventricular, or intraventricular conduction block, porphyria, and uncontrolled epilepsy, and the drug should be avoided in pregnant and lactating women because it crosses the placental barrier. Relative cautions include hepatic dysfunction, where the loading dose should be cut by 30 to 50 percent; renal impairment, where active metabolites may accumulate; congestive heart failure, where maintenance infusion should not exceed 1 mg/kg/h; severe myocardial damage requiring mandatory electrocardiogram monitoring; hypovolemia and shock; and age of 75 years or older, where a 20 to 30 percent dose reduction is advised.

Drug interactions add further constraints. Cimetidine and beta-adrenergic blockers such as propranolol, metoprolol, and nadolol inhibit hepatic lidocaine metabolism and raise plasma concentrations, so the lidocaine dose should be reduced by 25 to 30 percent with electrocardiographic monitoring; barbiturates accelerate metabolism and the combination may cause bradycardia or sinus arrest; isoprenaline increases hepatic clearance; and lidocaine is physically incompatible with phenobarbital, thiopental sodium, sodium nitroprusside, mannitol, amphotericin B, ampicillin, and sulfadiazine sodium. Prolonged infusion beyond 24 hours, high-dose use, or administration in hepatic or renal impairment increases the risk of local anesthetic systemic toxicity, whose neurological features range from perioral numbness and muscle tremor to seizures and coma, and whose cardiovascular features include hypotension, bradycardia, atrioventricular block, and depressed myocardial contractility. The panel’s twelfth recommendation, graded high and strong, demands that anesthesiologists recognize toxicity, stop the infusion immediately, secure ventilation and circulation, and give lipid emulsion when indicated, with institutional approval, individualized treatment, and informed consent required for analgesic use.

The consensus acknowledges that its evidence base has limits: heterogeneous designs, small sample sizes in many trials, inconsistent primary outcomes, and sparse data in elderly patients and those with hepatic or renal dysfunction or multiple comorbidities. It calls for multicenter large-sample trials in the weakly supported areas, individualized dosing stratified by age, physical status, and organ function, studies of lidocaine combined with other analgesics, long-term safety work on repeated exposure in elderly patients, and pharmacokinetic studies in obesity, organ impairment, and critical illness. For now, the document positions intravenous lidocaine as a low-cost, easily implemented perioperative intervention whose benefits for acute pain, opioid consumption, nausea and vomiting, pulmonary complications, and recovery quality rest on graded evidence, while its effects on gastrointestinal recovery, cognition, and chronic pain remain open questions that clinicians must weigh case by case.

Subject of Research: Perioperative intravenous lidocaine infusion in Chinese adult surgical patients

Article Title: Expert consensus on perioperative intravenous lidocaine infusion in Chinese adult patients (2025 edition)

Article References: Bo, L., Zhou, L., Chen, W., Xiao, X., Cao, X., Chen, L., Lei, Q., Li, N., Li, P., Liu, S., Lu, Z., Peng, K., Peng, Y., Qiao, H., Shangguan, W., Song, X., Wang, D., Xie, K., Xu, G., … Task Force on expert consensus on perioperative intravenous lidocaine infusion in Chinese adult patients (2025 edition) (2026). Expert consensus on perioperative intravenous lidocaine infusion in Chinese adult patients (2025 edition). Anesthesiology and Perioperative Science, 4(1), Article 55. https://doi.org/10.1007/s44254-026-00201-1

Image Credits: AI Generated

DOI: 10.1007/s44254-026-00201-1

Keywords: intravenous lidocaine, perioperative medicine, anesthesiology, postoperative analgesia, opioid sparing, local anesthetic systemic toxicity, PONV, colonoscopy sedation, expert consensus, GRADE evidence, chronic postsurgical pain, recovery quality