Lidocaine (Local)

Drug class: Antineoplastic Agents

Usage of Lidocaine (Local)

Local or Regional Anesthesia

Local or regional anesthesia in surgical procedures (including oral surgery), diagnostic and therapeutic procedures, and obstetrical procedures.

Relate drugs

How to use Lidocaine (Local)

General

  • Determine dosage based on type and extent of surgical procedure, area to be anesthetized, vascularity of tissues, depth and duration of anesthesia, degree of muscular relaxation, and condition of the patient. Use lowest concentration and smallest dose required to produce the desired effect.

    • Administration

    Injection

    For solution and drug compatibility information, see Compatibility under Stability.

    Administer by local infiltration, peripheral nerve block, paracervical block, sympathetic nerve block, central neural block (e.g., epidural block), caudal block, or subarachnoid (spinal) block. Has been administered by continuous intra-articular infusion† [off-label] (e.g., for control of postoperative pain); however, such use associated with chondrolysis. (See Risk of Chondrolysis Associated with Intra-articular Infusions of Local Anesthetics under Cautions.)

    Consult specialized references for specific techniques and procedures for administering local anesthetics.

    For IV regional anesthesia, use 50-mL single-dose vials containing lidocaine hydrochloride 0.5% only.

    For paracervical block, inject slowly; allow a 5-minute interval between sides.

    For caudal or lumbar epidural block, avoid rapid injection of large volumes; when feasible, administer in fractional (incremental) doses.

    For epidural or spinal block, avoid using preparations containing antimicrobial preservatives (e.g., methylparaben), since safety of intrathecal administration using these preparations not established.

    For spinal block, inject slowly.

    Aspirate prior to injections to avoid inadvertent intravascular administration.

    For dental anesthesia, lidocaine hydrochloride 2% solution with epinephrine 1:100,000 preferred for most routine procedures; when greater depth and a more pronounced hemostasis are required, use preparation containing epinephrine 1:50,000.

    For chemical disinfection of container surface, moisten cotton or gauze with isopropyl (rubbing) alcohol (91%) or ethyl alcohol (70%) and wipe surface thoroughly just prior to use. Do not use alcohol brands that are not of USP grade, since these preparations may contain denaturants that may be injurious to rubber.

    Dilution

    Dilute with 0.9% sodium chloride injection to obtain desired concentration.

    Dosage

    Available as lidocaine hydrochloride, as fixed combination containing lidocaine hydrochloride and epinephrine bitartrate or epinephrine hydrochloride, and as lidocaine hydrochloride in Dextrose injection. Dosage expressed in terms of lidocaine hydrochloride.

    When larger dosages (volumes) are required, use preparations containing epinephrine (unless contraindicated).

    Pediatric Patients

    Local or Regional Anesthesia Local Infiltration, Peripheral/Sympathetic Nerve Block, Epidural/Caudal Block

    Use lower dosages than those suggested for healthy adults (see Adults under Dosage and Administration).

    Anesthesia in Maxillary and Mandibular Area (for oral surgery)

    Children <10 years of age: 18–20 mg (0.9–1 mL) of lidocaine hydrochloride 2% solution is adequate for a procedure involving 1 tooth (local infiltration), 2–3 teeth (maxillary infiltration), or teeth in an entire quadrant (mandibular block).

    Adults

    Local or Regional Anesthesia Local Infiltration

    Percutaneous: 5–300 mg (1–60 mL) of lidocaine hydrochloride 0.5 or 1% solution (without epinephrine).

    IV regional: 50–300 mg (10–60 mL) of lidocaine hydrochloride 0.5% solution (without epinephrine).

    Peripheral Nerve Block

    BraChial: 225–300 mg (15–20 mL) of lidocaine hydrochloride 1.5% solution (without epinephrine).

    Dental: 20–100 mg (1–5 mL) of lidocaine hydrochloride 2% solution (without epinephrine).

    Intercostal: 30 mg (3 mL) of lidocaine hydrochloride 1% solution (without epinephrine).

    Paravertebral: 30–50 mg (3–5 mL) of lidocaine hydrochloride 1% solution (without epinephrine).

    Pudendal: 100 mg (10 mL) of lidocaine hydrochloride 1% solution (without epinephrine) on each side (for a total dose of 200 mg).

    Paracervical Block

    Obstetrical analgesia: 100 mg (10 mL) of lidocaine hydrochloride 1% solution (without epinephrine) on each side (for a total dose of 200 mg).

    Sympathetic Nerve Block

    Cervical (stellate ganglion): 50 mg (5 mL) of lidocaine hydrochloride 1% solution (without epinephrine).

    Lumbar: 50–100 mg (5–10 mL) of lidocaine hydrochloride 1% solution (without epinephrine).

    Retrobulbar Block

    120–200 mg (3–5 mL) or 1.7–3 mg/kg of lidocaine hydrochloride 4% solution is suggested; a portion of the dose is injected retrobulbarly and the remainder may be used to block the facial nerve.

    Transtracheal Injection

    80–120 mg (2–3 mL) of lidocaine hydrochloride 4% solution is administered rapidly.

    If both transtracheal injection and topical application (oropharyngeal spray) are needed to achieve complete analgesia, combined total dose from transtracheal injection and oropharyngeal spray should be ≤200 mg (5 mL) of 4% solution or ≤3 mg/kg.

    Central Neural Block

    Prior to lumbar epidural block, administer test dose to detect accidental intravascular injection. Test doses containing 10–15 mcg epinephrine and 30–45 mg (2–3 mL) of 1.5% lidocaine hydrochloride have been suggested. Repeat test dose if patient is moved in a manner that could displace catheter.

    Thoracic epidural: 200–300 mg (20–30 mL) of lidocaine hydrochloride 1% solution (without epinephrine). Dosage is determined by number of dermatomes to be anesthetized (generally 2–3 mL per dermatome).

    Lumbar epidural (for analgesia): 250–300 mg (25–30 mL) of lidocaine hydrochloride 1% solution (without epinephrine).

    Lumbar epidural (for anesthesia): 225–300 mg (15–20 mL) of lidocaine hydrochloride 1.5% solution (without epinephrine) or 200–300 mg (10–15 mL) of lidocaine hydrochloride 2% solution (without epinephrine). Dosage is determined by number of dermatomes to be anesthetized (generally 2–3 mL per dermatome).

    Caudal Block

    Prior to caudal block, administer test dose to detect accidental intravascular injection. Test doses containing 10–15 mcg epinephrine and 30–45 mg (2–3 mL) of 1.5% lidocaine hydrochloride have been suggested. Repeat test dose if patient is moved in a manner that could displace catheter.

    Obstetrical analgesia: 200–300 mg (20–30 mL) of lidocaine hydrochloride 1% solution (without epinephrine).

    Surgical anesthesia: 225–300 mg (15–20 mL) of lidocaine hydrochloride 1.5% solution (without epinephrine).

    Subarachnoid (Spinal) Block

    Vaginal delivery: Approximately 50 mg (1 mL) of lidocaine hydrochloride 5% in dextrose 7.5% injection.

    Cesarean section or delivery requiring intrauterine manipulations: 75 mg (1.5 mL) of lidocaine hydrochloride 5% in dextrose 7.5%.

    Surgical anesthesia (abdominal): 75–100 mg (1.5–2 mL) of lidocaine hydrochloride 5% in dextrose 7.5%.

    Anesthesia in Maxillary and Mandibular Area (for oral surgery)

    20–100 mg (1–5 mL) of lidocaine hydrochloride 2% solution with epinephrine 1:50,000 or 1:100,000.

    Prescribing Limits

    Pediatric Patients

    Local or Regional Anesthesia Local Infiltration, Peripheral/Sympathetic Nerve Block, Epidural/Caudal Block

    For children >3 years of age with normal lean body mass and normal development, maximum dose is determined by child’s age and weight. For example, dosage for a 5-year old child weighing 50 lbs should not exceed 75–100 mg (3.3–4.4 mg/kg or 1.5–2 mg/lb). For IV regional anesthesia, maximum 3 mg/kg (1.4 mg/lb), using more dilute solutions (e.g., lidocaine hydrochloride 0.25 or 0.5% solution). (See Dilution under Dosage and Administration: Administration.)

    Anesthesia in Maxillary and Mandibular Area (for oral surgery)

    For children <10 years of age with normal lean body mass and normal development, maximum dose is determined by using standard pediatric drug formulas (e.g., Clark’s rule). For example, dosage for a 5-year old child weighing 50 lbs should not exceed 75–100 mg (3.3–4.4 mg/kg or 1.5–2 mg/lb).

    Maximum 4.5 mg/kg (2 mg/lb) of body weight (without epinephrine) or 7 mg/kg (3.2 mg/lb) of body weight (with epinephrine).

    Adults

    Local or Regional Anesthesia Local Infiltration, Peripheral/Sympathetic Nerve Block

    Maximum 4.5 mg/kg (2 mg/lb) of body weight (up to 300 mg) (without epinephrine) or 7 mg/kg (3.2 mg/lb) of body weight (up to 500 mg) (with epinephrine).

    IV regional: Maximum 4 mg/kg.

    Paracervical Block

    Obstetric or nonobstetric use: Maximum 200 mg (100 mg each side) per 90-minute period.

    Continuous Epidural/Caudal Block

    Maximum recommended dosage should not be administered at intervals of <90 minutes.

    Subarachnoid (Spinal) Block

    Dosages >100 mg not required if technique and needle placement are correct.

    Anesthesia in Maxillary and Mandibular Area (for oral surgery)

    Maximum 4.5 mg/kg (2 mg/lb) of body weight (up to 500 mg) (without epinephrine) or 7 mg/kg (3.2 mg/lb) of body weight (up to 300 mg) (with epinephrine).

    Special Populations

    Hepatic Impairment

    Reduce dosage in patients with hepatic impairment.

    Geriatric Patients

    Reduce dosage in geriatric patients.

    Other Populations

    Reduce dosage in patients with cardiac disease, debilitated patients, and acutely ill patients.

    Warnings

    Contraindications

  • Contraindications to spinal anesthesia: severe hemorrhage, shock, heart block, local infection at site of proposed puncture, and septicemia.
  • Known hypersensitivity to local anesthetics of the amide type or to any ingredient in the formulation.

    • Warnings/Precautions

    Warnings

    Experience of Supervising Clinician

    Should be used only by clinicians who are sufficiently knowledgeable in the diagnosis and management of dose-related toxicity and other acute emergencies that might arise. Oxygen, resuscitative equipment, drugs, and personnel required for treatment of adverse reactions must be immediately available. Delay in proper management of dose-related toxicity, underventilation, and/or altered sensitivity may result in acidosis, cardiac arrest, and, possibly, death.

    Risk of Chondrolysis Associated with Intra-articular Infusions of Local Anesthetics

    Chondrolysis (necrosis and destruction of articular cartilage) reported in patients receiving continuous intra-articular infusions of local anesthetics, administered for 48–72 hours via elastomeric infusion devices, for treatment of postoperative pain. Primarily observed in the shoulder joint following arthroscopic or other shoulder surgery. May result in long-term disability; often requires intervention (e.g., debridement, arthroplasty). Not known whether the drug, infusion device, and/or other factors contributed to the development of chondrolysis. Neither local anesthetics nor elastomeric infusion devices are approved for use for continuous intra-articular infusion therapy.

    Accidental Intravascular Injection

    Accidental intravascular injection may result in confusion, seizures, CNS excitement and/or depression, myocardial depression, coma, and/or respiratory arrest. (See Nervous System Effects and also see Cardiovascular Effects, under Cautions.)

    Aspirate prior to administration to guard against intravascular injection.

    Injection During Uterine Contractions

    Do not inject spinal anesthetics during uterine contractions, since spinal fluid current may carry drug further cephalad than desired.

    Epinephrine Administration

    Some lidocaine hydrochloride preparations contain epinephrine, which may cause ischemic injury or necrosis. Consider usual precautions associated with epinephrine administration. (See Cardiovascular Effects under Cautions.)

    Sensitivity Reactions

    Hypersensitivity Reactions and Cross Hypersensitivity

    Possible cutaneous lesions, urticaria, edema, or anaphylactoid reactions.

    No cross hypersensitivity reported in patients allergic to para-aminobenzoic derivatives (e.g., benzocaine, procaine [no longer commercially available in the US], tetracaine).

    Use with caution in patients with known drug sensitivities.

    Sulfite Sensitivity

    Some epinephrine-containing lidocaine preparations contain sodium metabisulfite, which may cause allergic-type reactions (including anaphylaxis and life-threatening or less severe asthmatic episodes) in certain susceptible individuals.

    General Precautions

    Nervous System Effects

    Toxic plasma concentrations of local anesthetics (resulting from systemic absorption) associated with adverse CNS effects (e.g., lightheadedness, nervousness, apprehension, euphoria, confusion, dizziness, drowsiness, tinnitus, blurred or double vision, vomiting, sensations of heat, cold or numbness, twitching, tremors, seizures, unconsciousness, respiratory arrest). Carefully monitor level of consciousness after each local anesthetic injection.

    Spinal anesthesia may be associated with adverse neurologic effects (e.g., loss of perineal sensation and sexual function, persistent anesthesia, paresthesia, weakness and paralysis of the lower extremities, headache).

    Risk of nerve injury with use of small-bore needles and microcatheters for spinal anesthesia; possibly a result of drug pooling and inconsistent distribution of concentrated anesthetic within the subarachnoid space. If an incomplete or patchy block occurs and is not responsive to patient repositioning, the drug may be missplaced or inadequately distributed. Use of a spinal needle of sufficient gauge may facilitate intrathecal distribution; in clinical trials, 22- and 25-gauge spinal needles were used safely for single-injection lidocaine spinal anesthesia. Animal studies suggest that dilution of 5% lidocaine hydrochloride with an equal volume of CSF or preservative-free 0.9% sodium chloride may decrease risk of nerve injury from pooling of concentrated drug.

    Cardiovascular Effects

    Toxic plasma concentrations of local anesthetics (resulting from systemic absorption) associated with adverse cardiovascular effects (e.g., bradycardia, hypotension, and cardiovascular collapse, cardiac arrest). Carefully monitor cardiovascular and respiratory vital signs after each local anesthetic injection.

    Use with caution in patients with impaired cardiovascular function, severe shock, or heart block.

    Some lidocaine hydrochloride preparations contain epinephrine; risk of exaggerated vasoconstrictor response in patients with peripheral or hypertensive vascular disease. Use with caution and in carefully restricted quantities in areas of the body supplied by end arteries or having otherwise compromised blood supply (e.g., digits, nose, external ear, penis).

    Familial Malignant Hyperthermia

    Many drugs used during the conduct of anesthesia may trigger familial malignant hyperthermia; not known whether amide-type local anesthetics trigger this reaction. However, standard protocol for management should be available. Early unexplained signs of tachycardia, tachypnea, labile BP, and metabolic acidosis may precede temperature elevation. If familial malignant hyperthermia is confirmed, discontinue triggering agent and initiate appropriate therapy (e.g., oxygen, dantrolene) and other supportive measures.

    Preexisting Conditions

    Employ lumbar epidural and caudal block with extreme caution in patients with preexisting neurological disease, spinal deformities, septicemia, and severe hypertension.

    Conditions that may preclude the use of spinal anesthesia (depending upon the clinician’s evaluation of the situation and ability to manage potential complications) include preexisting CNS disease (e.g., disease associated with pernicious anemia, poliomyelitis, paralysis from nerve injuries and syphilis); hematological disorders predisposing to coagulopathies; current anticoagulant therapy; chronic backache; preoperative headache; hypotension or hypertension; technical problems (persistent paresthesias, persistent bloody spinal tap); arthritis or spinal deformity; extremes of age; and psychosis or other causes of poor patient cooperation.

    Risks Associated with Various Administration Techniques

    Paracervical block: Possible rapid systemic absorption. Maternal seizures and cardiovascular collapse reported following paracervical block with certain local anesthetics (used to induce anesthesia for elective abortion). Administer dose slowly; do not exceed recommended maximum dose. (See Administration and see Prescribing Limits, under Dosage and Administration and also see Labor and Delivery under Cautions.)

    Retrobulbar block: Possible permanent injury to extraocular muscles requiring surgical repair.

    Serious Adverse Effects Associated with Local Anesthetics

    Risk of serious adverse effects (e.g., seizures, coma, irregular heart beat, respiratory depression) with use of topical local anesthetics; generally reported following application of extemporaneously prepared topical preparations containing high concentrations of anesthetics.

    Potential for life-threatening adverse effects (e.g., irregular heart beat, seizures, breathing difficulties, coma, death) when topical local anesthetics are applied to a large area of skin, when the area of application is covered with an occlusive dressing, if a large amount of topical anesthetic is applied, if the anesthetic is applied to irritated or broken skin, or if the skin temperature increases (from exercise or use of a heating pad).

    Lidocaine 4% gel has been investigated to reduce discomfort during mammography. Whether such use could result in serious reactions has not been determined. Patients should speak with their clinician if they are considering using a topical anesthetic before obtaining a mammogram.

    When a topical anesthetic is needed for a procedure, use of an FDA-approved preparation has been recommended. Use a preparation containing the lowest concentration of anesthetic likely to be effective; apply a small amount of the preparation to the affected area for the shortest period necessary for the desired effect, and do not apply to broken or irritated skin.

    Use of Fixed Combination

    When used in fixed combination with other agents, consider the cautions, precautions, and contraindications associated with the concomitant agents.

    Specific Populations

    Pregnancy

    Category B.

    Labor and Delivery

    Maternal hypotension reported. To prevent decreases in BP, elevate patient’s legs and position patient on her left side. Monitor fetal heart rate continuously; electronic fetal monitoring highly advisable.

    Accidental intravascular or fetal intracranial injection following paracervical and/or may result in unexplained neonatal depression at birth or seizures within 6 hours after birth.

    Paracervical block may decrease duration of first stage labor and facilitate cervical dilation. Possible fetal bradycardia and acidosis; always monitor fetal heart rate. For paracervical block in prematurity, toxemia of pregnancy, or presence of fetal distress, weigh benefit of therapy versus risk.

    Epidural and spinal anesthesia may prolong second stage of labor (by removing parturient’s reflex urge to bear down or by interfering with motor function); may increase need for forceps assistance.

    Possible diminished muscle strength and tone on neonate’s first or second day of life.

    Lactation

    Not known whether lidocaine is distributed into milk. Caution if used in nursing women.

    Pediatric Use

    Safety and efficacy of lidocaine hydrochloride in dextrose injection not established in pediatric patients <16 years of age.

    Geriatric Use

    Dosage reduction recommended.

    Hepatic Impairment

    Possible increased risk of toxicity, particularly in patients with severe hepatic impairment. Use with caution. Dosage adjustments recommended.

    Common Adverse Effects

    Adverse nervous system and cardiovascular effects. (See Nervous System Effects and Cardiovascular Effects, under Cautions.)

    Spinal block: Positional headache, hypotension, backache, shivering.

    What other drugs will affect Lidocaine (Local)

    Consider usual drug interactions associated with epinephrine administration.

    Specific Drugs and Laboratory Tests

    Drug

    Interaction

    Comments

    Anesthetics, general

    Possible cardiac arrhythmias due to epinephrine component.

    Use with caution.

    Antidepressants, tricyclics

    Possible severe, prolonged hypertension due to epinephrine component.

    Avoid concomitant use; if must be used concomitantly, careful monitoring is required.

    Butyrophenones

    Possible reduction or reversal of pressor effect of epinephrine.

    Avoid concomitant use; if must be used concomitantly, careful monitoring is required.

    Ergot alkaloid oxytocics (ergonovine, methylergonovine)

    Possible severe, persistent hypertension or cerebrovascular accidents due to epinephrine component.

    MAO inhibitors

    Possible severe, prolonged hypertension due to epinephrine component.

    Avoid concomitant use; if must be used concomitantly, careful monitoring is required.

    Phenothiazines

    Possible reduction or reversal of pressor effect of epinephrine.

    Avoid concomitant use; if must be used concomitantly, careful monitoring is required.

    Vasopressors

    Possible severe, persistent hypertension or cerebrovascular accidents due to epinephrine component.

    Test for CPK

    Possible increased CPK concentrations following IM injection of lidocaine.

    Accuracy as diagnostic test for AMI compromised if used without isoenzyme separation.

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