lignocaine hydrochloride


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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)
Table 1: Onset and offset times of local anaesthetics
Type of local anaestheticOnset timeOffset time
Lidocaine5 minutes30-90 minutes
Bupivacaine20 minutes6-8 hours
Prilocaine5-10 minutes2-4 hours
Mepivacaine5-10 minutes2-4 hours
Levo-bupivacaine20-30 minutes6-8 hours
Ropivacaine5-10 minutes2-4 hours
Table 2: Principal drug interactions of local anaesthetic agents and other medications
Local anaesthetic agent Proprietary name Principal drug interactionsEffect of interaction
Lidocaine
Xylocaine
Antiarrhythmic agents
Antibacterial agents
Antipsychotics
Antivirals
Beta-blockers
Diuretics
Dolasetron
Ulcer-healing drugs
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
Bupivacaine
Marcain
Levo-bupivacaine
Chirocaine
Beta-blockersIncreased risk of bupivacaine toxicity when given with propranolol
Increased risk of myocardial depression if given with other antiarrhythmic agents
Prilocaine
Citanest
Antiarrhythmic agents
Antibacterial agents
Increased risk of myocardial depression if given with antiarrhythmic agents
Increased risk of methaemoglobinaemia if given with sulphonamide antibacterial agents
Ropivacaine
Naropin
AntidepressantsMetabolism of ropivacaine is inhibited by fluvoxamine, thereby enhancing the risk of ropivacaine toxicity
Mepivacaine
Scandonest
Drug not listed in the British National Formulary
Table 3: Example of a management plan for a child with nail pain
FeatureDetail/explanation
Main presenting complaint9-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
ExaminationLocal 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 testsNone 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)
2. Advice
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)
Long-term plan
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.

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