Note: Continuous IV infusion dosing units may vary (mcg/kg/minute, mg/kg/hour); use extra caution.
Ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT), shock-refractory:
Neonates:
IV, Intraosseous (Ref): Initial:
Loading dose: 1 mg/kg/dose; follow with continuous IV infusion; may repeat bolus if delay between initial bolus and start of infusion is >15 minutes.
Continuous IV infusion: 20 to 50 mcg/kg/minute; per manufacturer, do not exceed 20 mcg/kg/minute in patients with shock, hepatic disease, cardiac arrest, or congestive heart failure.
Endotracheal: Loading dose: 2 to 3 mg/kg/dose; dilute with 1 to 5 mL of NS and flush with 5 mL of NS; follow with 5 assisted manual ventilations (Ref).
Neonatal seizures, refractory: Limited data available; multiple regimens have been reported: Note: Experts recommend using continuous EEG and cardiac monitoring during lidocaine administration; use is not recommended in patients with congenital heart disease or patients who have or are currently receiving proarrhythmic drugs (eg, fosphenytoin, phenytoin) (Ref).
Normothermic (Ref):
GA ≥25 weeks:
Loading dose: IV: 2 mg/kg over 10 minutes, followed by a continuous infusion.
Continuous IV infusion:
<1.6 kg: Continuous IV infusion: 5 mg/kg/hour for 4 hours, then 2.5 mg/kg/hour for 12 hours, then 1.25 mg/kg/hour for 12 hours.
1.6 to 2.6 kg: Continuous IV infusion: 6 mg/kg/hour for 4 hours, then 3 mg/kg/hour for 12 hours, then 1.5 mg/kg/hour for 12 hours.
>2.6 kg: Continuous IV infusion: 7 mg/kg/hour for 4 hours, then 3.5 mg/kg/hour for 12 hours, then 1.75 mg/kg/hour for 12 hours.
Therapeutic Hypothermia (Ref):
GA ≥36 weeks:
Loading dose: IV: 2 mg/kg over 10 minutes, followed by a continuous infusion.
Continuous IV infusion:
<2.5 kg: Continuous IV infusion: 6 mg/kg/hour for 3.5 hours, then 3 mg/kg/hour for 12 hours, then 1.5 mg/kg/hour for 12 hours.
≥2.5 kg: Continuous IV infusion: 7 mg/kg/hour for 3.5 hours, then 3.5 mg/kg/hour for 12 hours, then 1.75 mg/kg/hour for 12 hours.
Circumcision: Note: The combination of nerve blockade with other pharmacologic and nonpharmacologic interventions (eg, topical anesthetic cream, oral sucrose, and non-nutritive sucking) has been recommended to improve pain control (Ref).
GA ≥36 weeks:
Dorsal penile nerve block: 0.4 mL of 1% lidocaine (without epinephrine) injected subcutaneously on each side of the base of the penis (for a total of 0.8 mL administered) ~5 to 10 minutes before the procedure (Ref).
Ring block: 0.8 to 1 mL of 1% lidocaine (without epinephrine) injected subcutaneously in a band around the penis ~5 to 10 minutes prior to circumcision (Ref).
Ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT), shock-refractory: Infants, Children, and Adolescents:
IV, Intraosseous (Ref): Initial:
Loading dose: 1 mg/kg/dose; follow with continuous IV infusion; may administer second bolus if delay between initial bolus and start of infusion is >15 minutes.
Continuous IV infusion: 20 to 50 mcg/kg/minute. Per manufacturer, do not exceed 20 mcg/kg/minute in patients with shock, hepatic disease, cardiac arrest, or CHF.
Endotracheal: Loading dose: 2 to 3 mg/kg/dose; flush with 5 mL of NS and follow with 5 assisted manual ventilations (Ref).
Anesthesia, local injectable: Dose varies with procedure, degree of anesthesia needed, vascularity of tissue, duration of anesthesia required, and physical condition of patient.
Cutaneous infiltration: Children and Adolescents: Typically solutions with concentration <2% should be used (allow for larger volumes); maximum dose: 5 mg/kg/dose not to exceed the recommended adult maximum dose of 300 mg/dose; do not repeat within 2 hours (Ref).
Intraosseous line or infusion pain: Infants, Children, and Adolescents: Lidocaine 1% or 2 % preservative-free solution: Intraosseous: Initial dose: 0.5 mg/kg over 1 to 2 minutes; usual adult dose range and maximum: 20 to 50 mg/dose; follow with NS flush; immediately following the NS flush, some centers administer a second lower (50% dose reduction) lidocaine dose over 30 to 60 seconds (usual adult maximum repeat dose: 20 mg/dose); if discomfort reoccurs, may repeat doses at a maximum frequency of every 45 minutes during intraosseous access; maximum total dose not established, some centers suggest that dose should not exceed: 3 mg/kg/24 hours (Ref). Note: Intraosseous access devices have a minimum weight and age for a particular device in addition to specific instruction for insertion and validation; consult product specific information for more detail.
Infants, Children, and Adolescents: There are no dosage adjustments provided in the manufacturer's labeling; however, accumulation of metabolites may be increased in renal dysfunction. Not dialyzable (0% to 5%) by hemo- or peritoneal dialysis; supplemental dose is not necessary (Ref)
Infants, Children and Adolescents: Use with caution; reduce dose. Monitor lidocaine concentrations closely and adjust infusion rate as necessary; consider alternative therapy. Maximum rate of continuous IV infusion: 20 mcg/kg/minute
(For additional information see "Lidocaine (local and regional anesthetic) and (systemic): Drug information")
Interstitial cystitis (bladder pain syndrome) (off-label use):
Note: Various dosage regimens of alkalinized lidocaine alone or with heparin (20,000 to 50,000 units) have been used. When lidocaine and heparin are mixed, there is a risk of precipitation if proper alkalinization does not occur. Prior to administration, lidocaine stability and pH should be determined after the components have been mixed (Ref).
Intravesicular: Single instillation: Single bladder installation of lidocaine (200 mg)/heparin (50,000 units)/sodium bicarbonate (420 mg) in 15 mL of sterile water, instilled into the bladder via catheter and allowed to dwell for 30 minutes before drainage (Ref).
Intravesicular: Weekly instillation: Weekly bladder instillations for 12 consecutive weeks with lidocaine 4% (5 mL [200 mg])/heparin (20,000 units)/sodium bicarbonate 7% (25 mL [1,750 mg]), instilled into an empty bladder via catheter and allowed to dwell for 30 minutes before drainage (Ref).
Intravesicular: Daily instillation: Daily bladder instillations for 5 days with lidocaine (200 mg)/sodium bicarbonate 8.4% solution (final volume of 10 mL), instilled into an empty bladder and allowed to dwell for 1 hour before drainage (Ref).
Intraosseous, infusion pain (off-label use): Note: May consider in a conscious patient to decrease pain prior to the infusion of fluid, medications, or blood products through the intraosseous cannula (Ref).
Lidocaine 2% preservative-free: Intraosseous: Initial dose: 20 or 40 mg over 1 to 2 minutes; may administer 1 or 2 additional doses of 20 mg; follow each dose with an NS flush; maximum total dose not established (Ref).
Local or regional anesthesia: Note: Dosage varies with procedure, degree of anesthesia needed, vascularity of tissue, duration of anesthesia required, and physical condition of patient. General maximum single dose (unless noted otherwise below): 4.5 mg/kg/dose not to exceed 300 mg. Refer to institutional protocols; doses presented below are examples of recommended volumes and concentrations. Use the lowest concentration and smallest dose to achieve desired result; avoid rapid administration; inject slowly in fractional doses.
Caudal:
Note: The maximum recommended dose should not be administered at intervals of <90 minutes. A test dose such as 2 to 3 mL of lidocaine 1.5% should be administered at least 5 minutes prior to injecting the total volume of lidocaine required for a caudal epidural block. The test dose should be repeated if the patient is moved in a manner that may have displaced the catheter. Epinephrine, if contained in the test dose, may serve as a warning of unintentional intravascular injection.
Obstetrical analgesia (preservative free):
Lidocaine 1%: 20 to 30 mL; total dose: 200 to 300 mg.
Lidocaine 5%: Vaginal delivery: 1 mL; total dose: 50 mg.
Lidocaine 5%: Caesarean delivery: 1.5 mL; total dose: 75 mg.
Surgical anesthesia (preservative free):
Lidocaine 1.5%: 15 to 20 mL; total dose: 225 to 300 mg.
Lidocaine 5%: 1.5 to 2 mL; total dose: 75 to 100 mg.
Epidural:
Note: Dosage varies with the number of dermatomes to be anesthetized (generally 2 to 3 mL of the indicated concentration per dermatome). The maximum recommended dose should not be administered at intervals of <90 minutes. A test dose, such as 2 to 3 mL of lidocaine 1.5%, should be administered at least 5 minutes prior to injecting the total volume of lidocaine required for a lumbar epidural block. The test dose should be repeated if the patient is moved in a manner that may have displaced the catheter. Epinephrine, if contained in the test dose, may serve as a warning of unintentional intravascular injection.
Thoracic epidural anesthesia (preservative free): Lidocaine 1%: 20 to 30 mL; total dose: 200 to 300 mg.
Lumbar epidural anesthesia (preservative free):
Lidocaine 1.5%: 15 to 20 mL; total dose: 225 to 300 mg.
Lidocaine 2%: 10 to 15 mL; total dose: 200 to 300 mg.
Lumbar epidural analgesia (preservative free): Lidocaine 1%: 25 to 30 mL; total dose: 250 to 300 mg.
Infiltration:
Percutaneous: Lidocaine 0.5% or 1%: 1 to 60 mL; total dose: 5 to 300 mg.
IV regional: Lidocaine 0.5%: 10 to 60 mL; total dose: 50 to 300 mg; maximum dose: 4 mg/kg/dose. Note: Only the 50 mL, single-dose vial containing lidocaine hydrochloride 0.5% injection should be used for IV regional anesthesia.
Nerve block, peripheral:
Brachial: Lidocaine 1.5%: 15 to 20 mL; total dose: 225 to 300 mg.
Dental: Lidocaine 2%: 1 to 5 mL; total dose: 20 to 100 mg.
Intercostal: Lidocaine 1%: 3 mL; total dose: 30 mg.
Paravertebral: Lidocaine 1%: 3 to 5 mL; total dose: 30 to 50 mg.
Pudendal (each side): Lidocaine 1%: 10 mL; total dose: 100 mg.
Nerve block, sympathetic:
Cervical: Lidocaine 1%: 5 mL; total dose: 50 mg.
Lumbar: Lidocaine 1%: 5 to 10 mL; total dose: 50 to 100 mg.
Paracervical: Obstetrical analgesia (each side): Lidocaine 1%: 10 mL; total dose: 100 mg, wait 5 minutes before administering on other side; maximum dose: 200 mg (100 mg on each side) in a 90 minute period.
Retrobulbar: Lidocaine 4%: 3 to 5 mL; total dose: 120 to 200 mg; a portion of this dose is injected retrobulbarly and the remainder may be used to block the facial nerve.
Ventricular arrhythmias:
Sudden cardiac arrest due to ventricular fibrillation or pulseless ventricular tachycardia (unresponsive to CPR, defibrillation, epinephrine) (off-label use):
Bolus dose:
IV/intraosseous: 1 to 1.5 mg/kg; repeat with 0.5 to 0.75 mg/kg every 5 to 10 minutes as necessary; a typical dose is 50 to 100 mg; maximum cumulative dose: 3 mg/kg or up to 300 mg within 1 hour (Ref).
Endotracheal (off-label route; only use when IV or intraosseous access cannot be established): 2 to 3.75 mg/kg; before administration dilute in 5 to 10 mL NS or sterile water. Note: Absorption is greater with sterile water and results in less impairment of PaO2 (Ref).
Continuous infusion:
Note: Even if lidocaine was not administered during resuscitation but return of spontaneous circulation was achieved, may still consider a lidocaine infusion to prevent recurrent arrhythmia (Ref).
IV/intraosseous : 1 to 4 mg/minute; if used beyond 24 hours, the rate of elimination can be prolonged and dose reduction may be necessary; monitor serum concentrations and signs or symptoms of toxicity to guide dose adjustment; maximum cumulative dose: 300 mg within 1 hour (Ref).
Ventricular tachycardia, hemodynamically stable, sustained monomorphic:
Bolus dose:
IV: 1 to 1.5 mg/kg; repeat with 0.5 to 0.75 mg/kg every 5 to 10 minutes as necessary; a typical dose is 50 to 100 mg; maximum cumulative dose: 3 mg/kg or up to 300 mg within 1 hour (Ref).
Continuous infusion:
Note: Consider for use after bolus dose to prevent recurrent arrhythmia (Ref).
IV: 1 to 4 mg/minute; if used beyond 24 hours, the rate of elimination can be prolonged and dose reduction may be necessary; monitor serum concentrations and signs or symptoms of toxicity to guide dose adjustment; maximum cumulative dose: 300 mg within 1 hour (Ref).
eGFR <30 mL/minute/1.73 m2: Administer lower maintenance infusion rate with close monitoring for toxicity.
Administer lower maintenance infusion rate with close monitoring for toxicity.
The following adverse drug reactions and incidences are derived from product labeling unless otherwise specified. Effects vary with route of administration. Many effects are dose-related.
1% to 10%:
Central nervous system: Headache (positional headache following spinal anesthesia: 3%), shivering (following spinal anesthesia: 2%), radiculopathy (≤2%; transient pain; subarachnoid administration)
Frequency not defined:
Cardiovascular: Bradycardia, cardiac arrhythmia, circulatory shock, coronary artery vasospasm, edema, flushing, heart block, hypotension (including following spinal anesthesia), local thrombophlebitis, vascular insufficiency (periarticular injections)
Central nervous system: Agitation, anxiety, apprehension, cauda equina syndrome (following spinal anesthesia), coma, confusion, disorientation, dizziness, drowsiness, euphoria, hallucination, hyperesthesia, hypoesthesia, intolerance to temperature, lethargy, loss of consciousness, metallic taste, nervousness, paresthesia, peripheral neuropathy (following spinal anesthesia), psychosis, seizure, slurred speech, twitching
Gastrointestinal: Nausea (including following spinal anesthesia), vomiting
Hypersensitivity: Anaphylactoid reaction, anaphylaxis, hypersensitivity reaction
Neuromuscular & skeletal: Tremor, weakness
Otic: Tinnitus
Respiratory: Bronchospasm, dyspnea, respiratory depression, respiratory insufficiency (following spinal anesthesia)
<1%, postmarketing, and/or case reports: Asystole, dermatological reaction, diplopia (following spinal anesthesia), methemoglobinemia
Hypersensitivity to lidocaine or any component of the formulation; hypersensitivity to another local anesthetic of the amide type; Adam-Stokes syndrome; Wolff-Parkinson-White syndrome; severe degrees of SA, AV, or intraventricular heart block (except in patients with a functioning artificial pacemaker); premixed injection may contain corn-derived dextrose and its use is contraindicated in patients with allergy to corn or corn-related products.
Additional contraindications specific to spinal anesthesia include: Local infection at the site of proposed puncture, severe hemorrhage, shock, heart block, sepsis.
Canadian labeling: Additional contraindications (not in US labeling): Hypersensitivity to ester local anesthetics (paraben-containing solutions only); supraventricular arrhythmias; severe myocardial depression; antimicrobial preservative-containing solutions should not be used intra-or retro-ocularly or for epidural or spinal anesthesia or any route that would introduce solution into the cerebrospinal fluid or in doses ≥15 mL for other types of blockades.
Concerns related to adverse effects:
• Intra-articular infusion related chondrolysis: Continuous intra-articular infusion of local anesthetics after arthroscopic or other surgical procedures is not an approved use; chondrolysis (primarily in the shoulder joint) has occurred following infusion, with some cases requiring arthroplasty or shoulder replacement.
• Methemoglobinemia: Has been reported with local anesthetics; clinically significant methemoglobinemia requires immediate treatment along with discontinuation of the anesthetic and other oxidizing agents. Onset may be immediate or delayed (hours) after anesthetic exposure. Patients with glucose-6-phosphate dehydrogenase deficiency, congenital or idiopathic methemoglobinemia, cardiac or pulmonary compromise, exposure to oxidizing agents or their metabolites, or infants <6 months are more susceptible and should be closely monitored for signs and symptoms of methemoglobinemia (eg, cyanosis, headache, rapid pulse, shortness of breath, lightheadedness, fatigue).
Disease-related concerns:
• Hepatic dysfunction: Use extreme caution in patients with severe hepatic dysfunction; may have increased risk of lidocaine toxicity.
Dosage form specific issues:
• Benzyl alcohol and derivatives: Some dosage forms may contain benzyl alcohol; large amounts of benzyl alcohol (≥99 mg/kg/day) have been associated with a potentially fatal toxicity (“gasping syndrome”) in neonates; the “gasping syndrome” consists of metabolic acidosis, respiratory distress, gasping respirations, CNS dysfunction (including convulsions, intracranial hemorrhage), hypotension, and cardiovascular collapse (AAP ["Inactive" 1997]; CDC 1982); some data suggests that benzoate displaces bilirubin from protein binding sites (Ahlfors 2001); avoid or use dosage forms containing benzyl alcohol with caution in neonates. See manufacturer’s labeling.
• Injectable anesthetic: Follow appropriate administration techniques so as not to administer any intravascularly. Solutions containing antimicrobial preservatives should not be used for epidural or spinal anesthesia. Some solutions contain a bisulfite; avoid in patients who are allergic to bisulfite. Resuscitative equipment, medicine and oxygen should be available in case of emergency. Adjust the dose for elderly, pediatric, acutely ill, and debilitated patients.
• Intravenous: Constant ECG monitoring is necessary during IV administration. Use cautiously in hepatic impairment, HF, marked hypoxia, severe respiratory depression, hypovolemia, history of malignant hyperthermia, or shock. Increased ventricular rate may be seen when administered to a patient with atrial fibrillation. Use is contraindicated in patients with Wolff-Parkinson-White syndrome and severe degrees of SA, AV, or intraventricular heart block (except in patients with a functioning artificial pacemaker). Correct electrolyte disturbances, especially hypokalemia or hypomagnesemia, prior to use and throughout therapy. Correct any underlying causes of ventricular arrhythmias. Monitor closely for signs and symptoms of CNS toxicity. The elderly may be prone to increased CNS and cardiovascular side effects. Reduce dose in hepatic dysfunction and CHF.
Other warnings/precautions:
• CAST trial: In the Cardiac Arrhythmia Suppression Trial (CAST), recent (>6 days but <2 years ago) myocardial infarction patients with asymptomatic, non-life-threatening ventricular arrhythmias did not benefit and may have been harmed by attempts to suppress the arrhythmia with flecainide or encainide. An increased mortality or nonfatal cardiac arrest rate (7.7%) was seen in the active treatment group compared with patients in the placebo group (3%). The applicability of the CAST results to other populations is unknown. Antiarrhythmic agents should be reserved for patients with life-threatening ventricular arrhythmias.
Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product
Kit, Injection, as hydrochloride:
Lidomark 1/5: 1% [DSC]
Lidomark 2/5: 2% [DSC]
P-Care X: 1% [DSC]
ReadySharp Lidocaine: 1% [DSC]
Solution, Injection, as hydrochloride:
Xylocaine: 0.5% (50 mL); 1% (20 mL, 50 mL); 2% (10 mL, 20 mL, 50 mL) [contains methylparaben]
Generic: 0.5% (50 mL); 1% (2 mL, 5 mL, 10 mL, 20 mL, 50 mL); 2% (2 mL, 10 mL, 20 mL, 50 mL)
Solution, Injection, as hydrochloride [preservative free]:
Xylocaine-MPF: 0.5% (50 mL); 1% (2 mL, 5 mL, 10 mL, 30 mL); 1.5% (10 mL, 20 mL); 2% (2 mL, 5 mL, 10 mL) [methylparaben free]
Generic: 0.5% (50 mL); 1% (2 mL, 5 mL, 30 mL); 1.5% (20 mL); 2% (2 mL, 5 mL, 10 mL); 4% (5 mL)
Solution, Intraspinal, as hydrochloride [preservative free]:
Generic: Lidocaine 5% [50 mg/mL] and dextrose 7.5% (2 mL [DSC])
Solution, Intravenous, as hydrochloride:
Generic: 0.4% [4 mg/mL] (250 mL, 500 mL); 0.8% [8 mg/mL] (250 mL); 1% [10 mg/mL] (5 mL)
Solution, Intravenous, as hydrochloride [preservative free]:
Generic: 100 mg/5 mL (5 mL)
Solution Prefilled Syringe, Intravenous [preservative free]:
Generic: 100 mg/5 mL (5 mL)
Solution Prefilled Syringe, Intravenous, as hydrochloride [preservative free]:
Generic: 50 mg/5 mL (5 mL); 100 mg/5 mL (5 mL)
Yes
Solution (Lidocaine HCl (Cardiac) PF Intravenous)
100 mg/5 mL (per mL): $0.83
Solution (Lidocaine HCl (PF) Injection)
0.5% (per mL): $0.10
1% (per mL): $0.30 - $19.60
1.5% (per mL): $0.61
2% (per mL): $0.27 - $0.72
4% (per mL): $1.16
Solution (Lidocaine HCl Injection)
0.5% (per mL): $0.11
1% (per mL): $0.10 - $0.37
2% (per mL): $0.14 - $0.47
Solution (Lidocaine in D5W Intravenous)
4 mg/mL 5% (per mL): $0.02
8 mg/mL 5% (per mL): $0.04
Solution (Xylocaine Injection)
0.5% (per mL): $0.13
1% (per mL): $0.10
2% (per mL): $0.23
Solution (Xylocaine-MPF Injection)
0.5% (per mL): $0.35
1% (per mL): $0.38
1.5% (per mL): $0.92
2% (per mL): $0.34
Solution Prefilled Syringe (Lidocaine HCl (Cardiac) Intravenous)
50 mg/5 mL (per mL): $3.93
100 mg/5 mL (per mL): $1.37 - $1.78
Solution Prefilled Syringe (Lidocaine HCl (Cardiac) PF Intravenous)
50 mg/5 mL (per mL): $2.70
100 mg/5 mL (per mL): $1.31
Disclaimer: A representative AWP (Average Wholesale Price) price or price range is provided as reference price only. A range is provided when more than one manufacturer's AWP price is available and uses the low and high price reported by the manufacturers to determine the range. The pricing data should be used for benchmarking purposes only, and as such should not be used alone to set or adjudicate any prices for reimbursement or purchasing functions or considered to be an exact price for a single product and/or manufacturer. Medi-Span expressly disclaims all warranties of any kind or nature, whether express or implied, and assumes no liability with respect to accuracy of price or price range data published in its solutions. In no event shall Medi-Span be liable for special, indirect, incidental, or consequential damages arising from use of price or price range data. Pricing data is updated monthly.
Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Solution, Injection, as hydrochloride:
Xylocaine: 0.5% (20 mL)
Xylocaine: 1% (20 mL, 50 mL); 2% (20 mL, 50 mL) [contains methylparaben]
Xylocaine Plain: 1% (2 mL, 5 mL, 10 mL); 2% (2 mL, 5 mL, 10 mL)
Generic: 10 mg/mL (5 mL, 10 mL, 20 mL, 50 mL); 1% (2 mL, 5 mL, 20 mL, 50 mL); 2% (2 mL, 5 mL, 10 mL, 20 mL, 50 mL)
Solution, Intravenous, as hydrochloride:
Xylocard: 2% [20 mg/mL] (5 mL)
Generic: 100 mg/5 mL (5 mL); 0.4% [4 mg/mL] (250 mL, 500 mL); 2% [20 mg/mL] (5 mL)
Solution Prefilled Syringe, Intravenous, as hydrochloride:
Generic: 100 mg/5 mL (5 mL)
Endotracheal: Infants, Children, and Adolescents: May administer dose undiluted or may further dilute in 1 to 5 mL NS based on patient size, followed by flush with ≥5 mL of NS after endotracheal administration; follow with 5 assisted manual ventilations (Ref).
Parenteral:
IV push, Intraosseous: The manufacturer recommends that the rate of administration should not exceed 0.7 mg/kg/minute or 50 mg/minute, whichever is less; however, during acute situations (eg, pulseless ventricular tachycardia or ventricular fibrillation), administration by rapid IV push has been used by some clinicians in practice. Neonates: Loading doses for neonatal seizures are usually administered over 10 minutes (Ref).
Continuous IV infusion: Administer via an infusion pump.
SUBQ/local infiltration: May use plain or buffered lidocaine; for circumcisions, use a 23- to 27-gauge needle for administration (Ref).
IV:
Bolus: According to the manufacturer, may administer at 25 to 50 mg/minute. In the setting of cardiac arrest (eg, ventricular fibrillation or pulseless ventricular tachycardia), may be infused rapidly into a peripheral vein (Ref).
Continuous infusion: After initial bolus dosing, may administer as a continuous infusion; refer to indication-specific infusion rates in dosing for detailed recommendations. In the setting of cardiac arrest, infusion may be initiated once patient has return of spontaneous circulation resulting from lidocaine administration. Local thrombophlebitis may occur in patients receiving prolonged IV infusions.
Infiltration or peripheral block: Administer locally as single or multiple injections; may administer incremental injections or continuously through an indwelling catheter. Avoid rapid injection. Intravascular injections should be avoided; aspiration should be performed prior to administration; the needle must be repositioned until no return of blood can be elicited by aspiration; however, absence of blood in the syringe does not guarantee that intravascular injection has been avoided.
Intravesical (off-label use): Various regimens of alkalinized lidocaine (with or without heparin) have been instilled into the bladder (Ref).
The On-Q® infusion pump is used to slowly administer local anesthetics (eg, bupivacaine, lidocaine, ropivacaine) to or around surgical wound sites and/or in close proximity to nerves for pre- or postoperative regional anesthesia. When infused directly into the shoulder, destruction of articular cartilage (chondrolysis) has occurred. On-Q® pumps should never be placed directly into any joint (Ref).
Endotracheal (off-label administration route): Dilute in NS or sterile water. Absorption is greater with sterile water and results in less impairment of PaO2 (Ref). Stop compressions, spray drug quickly down tube. Flush with 5 mL of NS and follow immediately with several quick insufflations and continue chest compressions.
Epidural and spinal anesthesia: Do not use solutions containing preservatives. Do not puncture areas of the skin with signs of infection. Intravascular injections should be avoided; aspiration should be performed prior to administration; the needle must be repositioned until no return of blood can be elicited by aspiration; however, absence of blood in the syringe does not guarantee that intravascular injection has been avoided.
Intraosseous (IO; off-label administration route): Intraosseous administration is a reasonable alternative when quick IV access is not feasible (Ref).
Note: Premixed solutions available.
IV infusion: 4 mg/mL, 8 mg/mL.
Injection: Store at controlled room temperature. For products with an overwrap, do not remove overwrap until ready for use.
Treatment of ventricular arrhythmias (FDA approved in pediatric patients [age not specified] and adults); local or regional anesthetic (FDA approved in pediatric patients [age not specified] and adults); has also been used to treat refractory neonatal seizures.
The Institute for Safe Medication Practices (ISMP) includes this medication (epidural administration; IV formulation) among its list of drugs which have a heightened risk of causing significant patient harm when used in error.
Lidosen [Italy] may be confused with Lincocin brand name for lincomycin [US, Canada, and multiple international markets]; Lodosyn brand name for carbidopa [US].
Substrate of CYP1A2 (major), CYP2A6 (minor), CYP2B6 (minor), CYP2C9 (minor), CYP3A4 (major); Note: Assignment of Major/Minor substrate status based on clinically relevant drug interaction potential
Note: Interacting drugs may not be individually listed below if they are part of a group interaction (eg, individual drugs within “CYP3A4 Inducers [Strong]” are NOT listed). For a complete list of drug interactions by individual drug name and detailed management recommendations, use the Lexicomp drug interactions program by clicking on the “Launch drug interactions program” link above.
Amiodarone: May increase the serum concentration of Lidocaine (Systemic). Risk C: Monitor therapy
Broccoli: May decrease the serum concentration of CYP1A2 Substrates (High risk with Inducers). Risk C: Monitor therapy
BUPivacaine: Local Anesthetics may enhance the adverse/toxic effect of BUPivacaine. Management: Avoid using any additional local anesthetics within 96 hours after insertion of the bupivacaine implant (Xaracoll) or bupivacaine and meloxicam periarticular solution (Zynrelef) or within 168 hours after subacromial infiltration (Posimir brand). Risk C: Monitor therapy
BUPivacaine (Liposomal): Lidocaine (Systemic) may enhance the adverse/toxic effect of BUPivacaine (Liposomal). Management: Liposomal bupivacaine should not be administered with lidocaine. Liposomal bupivacaine may be administered 20 minutes or more after the administration of lidocaine. Lidocaine may be administered 96 hours or more after liposomal bupivacaine administration. Risk D: Consider therapy modification
Cannabis: May decrease the serum concentration of CYP1A2 Substrates (High risk with Inducers). Risk C: Monitor therapy
Cimetidine: May increase the serum concentration of Lidocaine (Systemic). Risk C: Monitor therapy
Clofazimine: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Risk C: Monitor therapy
CYP1A2 Inducers (Moderate): May decrease the serum concentration of Lidocaine (Systemic). Risk C: Monitor therapy
CYP1A2 Inhibitors (Strong): May increase the serum concentration of Lidocaine (Systemic). Risk C: Monitor therapy
CYP3A4 Inducers (Strong): May decrease the serum concentration of Lidocaine (Systemic). Risk C: Monitor therapy
CYP3A4 Inhibitors (Moderate): May increase serum concentrations of the active metabolite(s) of Lidocaine (Systemic). Specifically, concentrations of monoethylglycinexylidide (MEGX) may be increased. CYP3A4 Inhibitors (Moderate) may increase the serum concentration of Lidocaine (Systemic). Risk C: Monitor therapy
CYP3A4 Inhibitors (Strong): May increase the serum concentration of Lidocaine (Systemic). Risk C: Monitor therapy
Dapsone (Topical): May enhance the adverse/toxic effect of Methemoglobinemia Associated Agents. Risk C: Monitor therapy
Disopyramide: May enhance the arrhythmogenic effect of Lidocaine (Systemic). Disopyramide may increase the serum concentration of Lidocaine (Systemic). Specifically, the unbound/free fraction of lidocaine may be increased. Risk C: Monitor therapy
Etravirine: May decrease the serum concentration of Lidocaine (Systemic). Risk C: Monitor therapy
Fexinidazole: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Risk X: Avoid combination
Fusidic Acid (Systemic): May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Risk X: Avoid combination
Hyaluronidase: May enhance the adverse/toxic effect of Local Anesthetics. Risk C: Monitor therapy
Lacosamide: Lidocaine (Systemic) may enhance the adverse/toxic effect of Lacosamide. Specifically the risk for bradycardia, ventricular tachyarrhythmias, or a prolonged PR interval may be increased. Risk C: Monitor therapy
Lidocaine (Topical): May enhance the adverse/toxic effect of Antiarrhythmic Agents (Class IB). Risk C: Monitor therapy
Local Anesthetics: Methemoglobinemia Associated Agents may enhance the adverse/toxic effect of Local Anesthetics. Specifically, the risk for methemoglobinemia may be increased. Risk C: Monitor therapy
Methemoglobinemia Associated Agents: May enhance the adverse/toxic effect of Local Anesthetics. Specifically, the risk for methemoglobinemia may be increased. Risk C: Monitor therapy
Neuromuscular-Blocking Agents: Local Anesthetics may enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Risk C: Monitor therapy
Nitric Oxide: May enhance the adverse/toxic effect of Methemoglobinemia Associated Agents. Combinations of these agents may increase the likelihood of significant methemoglobinemia. Risk C: Monitor therapy
Prilocaine: Methemoglobinemia Associated Agents may enhance the adverse/toxic effect of Prilocaine. Combinations of these agents may increase the likelihood of significant methemoglobinemia. Management: Monitor patients for signs of methemoglobinemia (e.g., hypoxia, cyanosis) when prilocaine is used in combination with other agents associated with development of methemoglobinemia. Avoid lidocaine/prilocaine in infants receiving such agents. Risk C: Monitor therapy
Propranolol: May increase the serum concentration of Lidocaine (Systemic). Risk C: Monitor therapy
Saquinavir: May increase the serum concentration of Lidocaine (Systemic). Risk X: Avoid combination
Sodium Nitrite: Methemoglobinemia Associated Agents may enhance the adverse/toxic effect of Sodium Nitrite. Combinations of these agents may increase the likelihood of significant methemoglobinemia. Risk C: Monitor therapy
Technetium Tc 99m Tilmanocept: Local Anesthetics may diminish the diagnostic effect of Technetium Tc 99m Tilmanocept. Management: Avoid mixing and simultaneously co-injecting technetium Tc 99m tilmanocept with local anesthetics. This interaction does not appear to apply to other uses of these agents in combination. Risk C: Monitor therapy
Tobacco (Smoked): May decrease the serum concentration of Lidocaine (Systemic). Risk C: Monitor therapy
Premixed injection may contain corn-derived dextrose and its use is contraindicated in patients with allergy to corn-related products.
Lidocaine and its metabolites cross the placenta and can be detected in the fetal circulation following maternal injection for anesthesia prior to delivery (Cavalli 2004; Mitani 1987).
Adverse reactions in the fetus/neonate may affect the CNS, heart, or peripheral vascular tone. Fetal heart monitoring is recommended by the manufacturer.
Lidocaine injection is approved for obstetric analgesia (eg, prior to epidural or spinal anesthesia). Lidocaine administered by local infiltration is used to provide analgesia prior to episiotomy and during repair of obstetric lacerations (ACOG 209 2019). Administration by the perineal route may result in greater absorption than administration by the epidural route (Cavalli 2004). Cumulative exposure from all routes of administration should be considered. The ACOG recommends that pregnant women should not be denied medically necessary surgery regardless of trimester. If the procedure is elective, it should be delayed until after delivery (ACOG 775 2019).
Medications used for the treatment of cardiac arrest in pregnancy are the same as in the nonpregnant woman. Doses and indications should follow current Advanced Cardiovascular Life Support guidelines. Appropriate medications should not be withheld due to concerns of fetal teratogenicity (AHA [Jeejeebhoy 2015]).
Monitor ECG continuously; serum concentrations with continuous infusion; IV site (local thrombophlebitis may occur with prolonged infusions); for neonatal seizures, continuous EEG and ECG, serum concentration, signs and symptoms of methemoglobinemia (Bohnhorst 2017).
Arrhythmias:
Therapeutic: 1.5 to 5 mcg/mL (SI: 6 to 21 micromoles/L).
Potentially toxic: >6 mcg/mL (SI: >26 micromoles/L).
Toxic: >9 mcg/mL (SI: >38 micromoles/L).
Neonatal seizure: Some trials used a therapeutic target of 6 to 7 mcg/mL after the initial 4- to 6-hour infusion dose with concentrations not to exceed 9 mcg/mL (van den Broek 2011).
Class Ib antiarrhythmic; suppresses automaticity of conduction tissue, by increasing electrical stimulation threshold of ventricle, His-Purkinje system, and spontaneous depolarization of the ventricles during diastole by a direct action on the tissues; blocks both the initiation and conduction of nerve impulses by decreasing the neuronal membrane's permeability to sodium ions, which results in inhibition of depolarization with resultant blockade of conduction
Onset of action: Systemic administration: Single IV bolus dose: 45 to 90 seconds.
Duration: Systemic administration: Single IV bolus dose: 10 to 20 minutes.
Distribution: Systemic administration: Single IV bolus dose: 0.8 to 2.8 L/kg (Berkenstadt 1999); alterable by many patient factors; decreased in heart failure and liver disease; crosses blood-brain barrier.
Protein binding: Dependent on drug concentration; fraction bound decreases with increasing concentration. At 1 to 4 mcg/mL, 60% to 80% bound to alpha1 acid glycoprotein.
Metabolism: 90% hepatic via CYP1A2 and CYP3A4; active metabolites monoethylglycinexylidide (MEGX) and glycinexylidide (GX) can accumulate and may cause CNS toxicity.
Half-life elimination: Systemic administration: Biphasic: Initial: ~8 minutes following single IV bolus (Burm 1988); Terminal: Infants, premature: 3.2 hours; Adults: 1.5 to 2 hours following single IV bolus (Burm 1988; manufacturer's labeling). Prolonged with continuous infusions >24 hours, heart failure, liver disease, shock, severe renal impairment, neonatal therapeutic hypothermia (van den Broek 2013; manufacturer's labeling).
Excretion: Urine (<10% as unchanged drug, ~90% as metabolites).
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