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Anesticaine, Anesticon, Laryng-O-Jet (UK), Lidodan (CA), Lidoderm, Lidomax (CA), LidoPen Auto-Injector, LTA Pediatric, Lurocaine (CA), Xylocaine, Xylocaine-MPF, Xylocard (CA)
Pharmacologic class: Amide
Therapeutic class: Antiarrhythmic (class IB), local anesthetic
Pregnancy risk category B
Suppresses automaticity of ventricular cells, decreasing diastolic depolarization and increasing ventricular fibrillation threshold. Produces local anesthesia by reducing sodium permeability of sensory nerves, which blocks impulse generation and conduction.
Injection for I.M. use: 300 mg/3 ml (automatic injection device)
Injection for direct I.V. use: 1% and 2% in syringes and vials
Injection for I.V. infusion: 2 mg/ml, 4 mg/ml, 8 mg/ml
Injection for I.V injection admixtures: 40 mg/ml, 100 mg/ml, 200 mg/ml
Topical cream: 0.5%, 4%
Topical gel: 0.5%, 2.5%
Topical jelly: 2%
Topical liquid, ointment: 2.5%, 5%
Topical solution: 4%
Topical solution (viscous): 2%
Topical spray: 0.5%
⊘Indications and dosages
➣ Ventricular arrhythmias
Adults: Initially, 50 to 100 mg I.V. bolus given at rate of 25 to 50 mg/minute. If desired response doesn't occur after 5 minutes, give repeat dose at 25 to 50 mg/minute; maximum dosage is 300 mg given over 1 hour. Maintenance dosage is 1 to 4 mg/minute by continuous I.V. infusion for no more than 24 hours.
Children: Initially, 1 mg/kg I.V. bolus, then repeated based on patient response; don't exceed 5 mg/kg. Maintenance dosage is 30 mcg/kg/minute by continuous I.V. infusion.
➣ Caudal anesthesia (without epinephrine)
Adults: For obstetric analgesia, 200 to 300 mg caudally as 1% solution. For surgical anesthesia, 225 to 300 mg as 1.5% solution. For continuous caudal anesthesia, don't repeat maximum dosage at intervals of less than 90 minutes.
➣ Epidural anesthesia (without epinephrine)
Adults: For lumbar analgesia, 250 to 300 mg epidurally as 1% solution, 225 to 300 mg as 1.5% solution, or 200 to 300 mg as 2% solution. For thoracic anesthesia, 200 to 300 mg as 1% solution. For continuous epidural anesthesia, don't repeat maximum dosage at intervals of less than 90 minutes.
➣ I.V. regional infiltration (without epinephrine)
Adults: 50 to 300 mg I.V. as 0.5% solution. For I.V. regional anesthesia, maximum dosage is 4 mg/kg.
➣ I.V. local infiltration (without epinephrine)
Children: Up to 4.5 mg/kg I.V. as 0.25% to 1% solution
➣ Spinal anesthesia (without epinephrine)
Adults: For obstetric low-spinal or saddle-block anesthesia (normal vaginal delivery), 50 mg of 5% Xylocaine-MPF with glucose 7.5%, or 9 to 15 mg of 1.5% Xylocaine-MPF with dextrose 7.5%. For cesarean section, 75 mg of 5% Xylocaine-MPF with glucose 7.5%. For surgical anesthesia, 75 to 100 mg of 5% Xylocaine-MPF with glucose 7.5%.
➣ Paracervical anesthesia (without epinephrine)
Adults: For obstetric analgesia, 100 mg paracervically as 1% solution (each side). For paracervical block, maximum dosage is 200 mg over each 90-minute period (half administered on each side).
➣ Peripheral nerve block
Adults: For brachial nerve block, 225 to 300 mg as 1.5% solution. For dental nerve block, 20 to 100 mg as 2% solution with epinephrine 1:100,000 or 1:50,000. For intercostal nerve block, 30 mg as 1% solution. For pudendal nerve block, 100 mg as 1% solution. For paravertebral nerve block, 30 mg to 50 mg as 1% solution.
➣ Sympathetic nerve block (without epinephrine)
Adults: For cervical nerve block, 50 mg as 1% solution. For lumbar nerve block, 50 to 100 mg as 1% solution.
➣ Dental anesthesia
Adults: 1 to 5 ml of lidocaine 2% with epinephrine 1:50,000 or 1:100,000. Maximum dosage is less than 500 mg (7 mg/kg).
Children: 20 to 30 mg as 2% solution with epinephrine 1:100,000
➣ Topical anesthesia for skin or mucous membranes
Adults: Apply thin layer of gel, jelly, or ointment to skin or mucous membranes as needed before procedure; or apply 5% patch to most painful areas and intact skin (up to three patches at a time for up to 12 hours within a 24-hour period). For new denture fittings, use 5-g ointment (250 mg) per single dose or 20 g/day. For oropharyngeal use, apply to desired area or to instrument before insertion.
Children: Apply thin layer of ointment to skin or mucous membranes p.r.n. before procedure. Maximum dosage is 2.5 g ointment per 6 hours or 4.5 mg/kg.
➣ Prevention or treatment of pain during procedures involving male or female urethra
Adults: For female urethral examination, apply 3 to 5 ml of 2% jelly topically several minutes before exam. For male sounding or cystoscopy, apply 5 to 10 ml of 2% jelly topically before procedure, or apply 30 ml to fill or dilate urethra in divided doses using penile clamp for several minutes between doses. For male catheterization, apply 5 to 10 ml of 2% jelly to anterior urethra before procedure. Don't use more than 600 mg/12 hours.
➣ Oral cavity disorders; pharyngeal disorders
Adults: For oral cavity disorders, 300 mg (15 ml) of viscous oral topical solution swished and then expelled, or applied with cotton swab q 3 hours p.r.n. For pharyngeal disorders, use same dosage, but solution may be swallowed.
Children older than age 3: Dosage individualized based on age, weight, and physical condition. Maximum dosage is 4.5 mg/kg q 3 hours.
Children up to age 3: 1.25 ml applied with swab q 3 hours
➣ Local anesthesia (oral or nasal mucosa)
Adults: 0.6 to 3 mg/kg or 40 to 200 mg of 4% topical solution, not to exceed 4.5 mg/kg or 300 mg (7.5 ml)
Children: Dosage individualized
• Pediatric patients with cardiac arrest who develop frequent premature ventricular contractions
• Status epilepticus
• Hypersensitivity to drug, its components, or other amide local anesthetics
• Heart failure, cardiogenic shock, second- or third-degree heart block, intraventricular block in absence of a pacemaker
• Wolff-Parkinson-White or Adams-Stokes syndrome
• Severe hemorrhage, shock, or heart block (lidocaine with dextrose)
• Local infection at puncture site (lidocaine with dextrose)
• Septicemia (lidocaine with dextrose)
Use cautiously in:
• renal or hepatic disorders, inflammation or sepsis in injection area
• labor or delivery
• breastfeeding patients.
☞ Know that I.V. lidocaine is a high-alert drug.
☞ Make sure resuscitation equipment and oxygen are available before giving I.V. lidocaine.
• Dilute injection in additive syringe and single-use vial according to manufacturer's instructions before administering as I.V. infusion.
• Add 1 g lidocaine to 1 L dextrose 5% in water to yield a solution of 1 mg/ml.
• For I.V. bolus injection, give doses of 25 to 50 mg over at least 1 minute. Deliver continuous infusion by infusion pump no faster than 4 mg/minute.
☞ Know that too-rapid infusion may cause seizures.
• Be aware that drug can be given I.M. using 10% parenteral solution only.
CNS: anxiety; confusion; difficulty speaking; dizziness; hallucinations; lethargy; paresthesia; light-headedness; fatigue; drowsiness; headache; persistent sensory, motor, or autonomic deficit of lower spinal segment; septic meningitis; seizures
CV: bradycardia, hypotension, new or worsening arrhythmias, cardiac arrest
EENT: diplopia, abnormal vision
GI: nausea, vomiting, dry mouth
GU: urinary retention
Respiratory: suppressed cough reflex, respiratory depression, respiratory arrest
Skin: rash; urticaria; pruritus; erythema; contact dermatitis; cutaneous lesions; tissue irritation, sloughing, and necrosis
Other: fever; edema; infection, burning, stinging, tenderness, and swelling at injection site; anaphylaxis
Drug-drug.Beta-adrenergic blockers, cimetidine: increased lidocaine blood level
MAO inhibitors, tricyclic antidepressants: prolonged hypertension
Mexiletine, tocainide: additive cardiac effects
Phenytoin, procainamide: increased cardiac depression
Drug-diagnostic tests.Creatine kinase: increased level (with I.M. use)
☞ Monitor vital signs and ECG continuously. Watch for cardiac depression.
☞ Evaluate level of consciousness closely.
☞ Watch for adverse reactions, particularly anaphylaxis.
☞ Stay alert for seizures.
☞ Monitor neurologic status for lower spinal segment deficits.
• Give supportive oxygen therapy, as indicated and prescribed.
• Monitor electrolyte, blood urea nitrogen, and creatinine levels.
• Assess topical site for adverse reactions.
• Discuss reason for drug therapy with patient and family, when appropriate.
• Explain that patient will be monitored continuously during therapy.
☞ Instruct patient to promptly report discomfort at I.V. site as well as adverse effects, especially cardiovascular, respiratory, or neurologic problems or allergic reactions.
• As appropriate, review all other significant and life-threatening adverse reactions and interactions, especially those related to the drugs and tests mentioned above.
li·do·caine hy·dro·chlor·ide(lī'dō-kān hī'drō-klōr'īd),
lignocaine hydrochloride; lidocaine hydrochloride short-acting local anaesthetic with marked vasodilator and antiarrhythmic properties; to be used with care and at lowest effective dose in patients taking cimetidine (Tagamet), ranitidine (Zantac) or beta-blockers (especially propranolol); used with caution in cases with e.g. epilepsy, respiratory impairment, impaired cardiac conduction, bradycardia, porphyria, myasthenia gravis; dose should be reduced in the elderly, frail or debilitated, and those with hepatic or renal impairment; central nervous system effects (i.e. toxicity) include confusion, respiratory depression and convulsions; cardiac effects include hypotension and bradycardia or even cardiac arrest; hypersensitivity (anaphylaxis) has been reported (Table 1 and Table 2; see local anaesthetic (LA) administration; Table 3)
|Type of local anaesthetic||Onset time||Offset time|
|Lidocaine||5 minutes||30-90 minutes|
|Bupivacaine||20 minutes||6-8 hours|
|Prilocaine||5-10 minutes||2-4 hours|
|Mepivacaine||5-10 minutes||2-4 hours|
|Levo-bupivacaine||20-30 minutes||6-8 hours|
|Ropivacaine||5-10 minutes||2-4 hours|
|Local anaesthetic agent Proprietary name||Principal drug interactions||Effect of interaction|
|Increased myocardial depression|
Increased risk of ventricular arrhythmias if lidocaine is given with quinpristin/dalfopristin
Increased risk of ventricular arrhythmias if lidocaine is given with any drug that prolongs the QT interval of the cardiac cycle
Plasma concentration of lidocaine increased by amprenavir, atazanavir and lopinavir
Increased myocardial depression
Increased risk of lidocaine toxicity when given with propranolol
The action of lidocaine is antagonized by the hypokalaemia caused by acetazolamide, loop diuretics or thiazide and related diuretics (i.e. a greater dose of lidocaine would be required to achieve anaesthesia)
Increased risk of ventricular arrhythmia if lidocaine is given with dolasetron
Plasma concentration of lidocaine increased when given with cimetidine; risk of lidocaine toxicity increased with cimetidine
|Beta-blockers||Increased risk of bupivacaine toxicity when given with propranolol|
Increased risk of myocardial depression if given with other antiarrhythmic agents
|Increased risk of myocardial depression if given with antiarrhythmic agents|
Increased risk of methaemoglobinaemia if given with sulphonamide antibacterial agents
|Antidepressants||Metabolism of ropivacaine is inhibited by fluvoxamine, thereby enhancing the risk of ropivacaine toxicity|
|Drug not listed in the British National Formulary|
|Main presenting complaint||9-year-old girl presents with 3-week history consisting of pain in the medial (tibial) sulcus of the left hallux since 'picking' nail|
Otherwise fit (i.e. no other significant medical history; no regular medications)
Advised to contact you by GP
|Examination||Local tenderness, inflammation and swelling at medial area of left hallux; no signs of obvious infection; medial side of nail plate very ragged as a result of onychotillomania|
Vascular examination: normal
Neurological examination: normal
Dermatological examination: mild hyperhidrosis in both feet
Biomechanical assessment: fully compensated rearfoot varus; no joint pathologies
Social assessment: dance and gymnastics twice a week
Footwear assessment: trainers (one size too small); laces not tied
|Diagnostic tests||None indicated|
|Management plan|| Short-term plan |
Explanation of likely cause of current problem (picking nails, hyperhidrotic skin, short, unlaced shoes, excess pronation)
1. Immediate treatment: exploration of both sides of both first toenails, and reduction of ragged edges with Black's file + LA is necessary, with patient/parental consent. Advise regime of daily warm saline foot baths and demonstration to mother on how to pack affected sulcus with cotton wool. Review in 7 days (or SOS)
Exercise advice: no gym/sport/dance before next appointment
Shoe advice (give leaflet) - needs a larger trainer, and needs to tie laces so that rearfoot is retained in the heel cup of the shoe
Skin care advice (treatment/avoidance of hyperhidrosis) - give leaflet
3. Temporary insole with medial felt (cobra) pad to minimize hallux trauma due to excess compensatory pronation/foot lengthening on weight-bearing
4. Letter to GP informing of action to date (copy to notes)
Explanation of details of other treatments that may be necessary after next visit
1. Further clearance of medial side of first nail or removal of spike of nail under LA or removal of medial section of first nail under LA and phenolization of exposed pocket of nail matrix + dressings (94% cure rate) + details of aftercare regimes for this range of options
2. Biomechanical and gait evaluation, with provision of bespoke antipronatory orthoses
3. Review patient every 4 months to monitor biomechanical, skin and nail function
LA, local anaesthetic.