Lidocaine: Difference between revisions

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==General==
==General==
*Also known internationally as lignocaine
*Type: [[Local anesthetics]]; [[Antiarrhythmics]]
*Type: [[Local anesthetics]]; [[Antiarrhythmics]]
*Dosage Forms:
*Dosage Forms: Local injection, transdermal, intravenous, inhaled, viscous
*Common Trade Names:  
*Common Trade Names: Xylocaine, P-Care, ReadySharp Lidocaine, Xylocard <ref>Lidocaine. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Accessed March 15, 2019</ref>


==Adult Dosing==
==Adult Dosing==
===[[Local anesthetics|Local Anesthetic]]===
===[[Local anesthetics|Local Anesthetic]]===
*Without epinepherine: 5mg/kg (max 300mg)
*Maximum without epinephrine: 5mg/kg (max 300mg)
*With epinepherine: 7mg/kg (max 500mg)
*Maximum with epinepherine: 7mg/kg (max 500mg)


===[[Arrythmia|Antiarrhythmic]]===
===[[Arrythmia|Antiarrhythmic]]===
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==Special Populations==
==Special Populations==
*[[Drug Ratings in Pregnancy|Pregnancy Rating]]:
*[[Drug Ratings in Pregnancy|Pregnancy Rating]]: American B, Australia A
*Lactation:
*Lactation: Not expected to cause any adverse effect <ref>https://www.ncbi.nlm.nih.gov/books/NBK501230/</ref>
*Renal Dosing
*Renal Dosing
**Adult
**Adult: No adjustment provided in manufacturer's labelling but accumulation of metabolites may be increased in renal dysfunction<ref>Lidocaine. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Accessed March 15, 2019</ref>
**Pediatric
**Pediatric: No adjustment provided in manufacturer's labelling <ref>Lidocaine. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Accessed March 15, 2019</ref>
*Hepatic Dosing
*Hepatic Dosing
**Adult
**Adult: Reduce maintenance infusion when used IV (0.75 mg/minute). Monitor concentration.<ref>Lidocaine. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Accessed March 15, 2019</ref>
**Pediatric
**Pediatric: Use with caution. Reduce dose. <ref>Lidocaine. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Accessed March 15, 2019</ref>


==Contraindications==
==Contraindications==
*Allergy to class/drug
*Allergy to amide anesthetics
*High SA or AV block
**Note that these allergies are rare and are often caused by preservative, so a preservative-free formulation may be appropriate
**Note that allergy to amide anesthetics does not suggest allergy to ester anesthetics
*High SA or AV block (without pacemaker)
*Concurrent treatment with Class I anti-dysrhythmic agents
*[[Wolff-Parkinson-White syndrome]]


==Adverse Reactions==
==Adverse Reactions==
===Local===
*Dermatologic
**Itching or irritation
**Depigmentation
**Rash/urticaria
**Edema
**Venous inflammation
===Serious===
===Serious===
*[[Local Anesthetic Systemic Toxicity (LAST)]]
*[[Local Anesthetic Systemic Toxicity (LAST)]]
 
**Rare during infiltration of local anesthetic
===Common===
**CNS toxicity
***Metallic taste
***Tinnitus
***Tingling of lips
***Dizziness
***Anxiety
***Confusion
***Lethargy
***Loss of consciousness
***Seizures
***Nausea/vomiting
**Cardiovascular toxicity
***Bradycardia
***Decreased myocardial contractility
***Atrioventricular block
***Vasodilation
***Ventricular arrhythmias
***Cardiac arrest
*Bronchospasm
*Respiratory depression or arrest
*Methemoglobinemia


==Pharmacology==
==Pharmacology==
*Half-life:
*Pharmacokinetics
**Onset of action = 45-90s
**Onset of action = 45-90s
**Duration of action = 10-20min (antiarrythmic IV); 30-90 min (subcutaneous)
**Duration of action = 10-20min (antiarrythmic IV); 30-90 min (subcutaneous)
*Metabolism:
**Half-life 90 - 120 minutes
*Excretion:
***Prolonged in hepatic impairment or congestive heart failure
*Mechanism of Action:
*Metabolism
**Primarily hepatic
*Excretion
**Urine
*Mechanism of Action
**Class Ib antiarrythmic
**Class Ib antiarrythmic
***Binds to fast Na channels in inactive state thereby inhibiting recovery after repolarization
***Binds to fast Na channels in inactive state thereby raising the depolarization threshold
***Acts preferentially on ischemic tissue
***Acts preferentially on ischemic tissue
****Elevates V-fib threshold
****Elevates V-fib threshold
****Suppresses ventricular ectopy
****Suppresses ventricular ectopy
**Little effect on vascular tone, contractility or cardiac output
**Little effect on vascular tone, contractility, or cardiac output


==Comments==
==Comments==
*For wounds, may use HCO3 (1cc to 10cc Lido) to decrease pain  
*Mix lidocaine 1%/epinephrine with sodium bicarbonate 8.4% in 3:1 ratio results in significantly less painful injections. <ref>Vent A et. al Buffered lidocaine 1%/epinephrine 1:100,000 with sodium bicarbonate (sodium hydrogen carbonate) in a 3:1 ratio is less painful than a 9:1 ratio: A double-blind, randomized, placebo-controlled, crossover trial. J Am Acad Dermatol. 2020 Jul;83(1):159-165. doi: 10.1016/j.jaad.2019.09.088. https://pubmed.ncbi.nlm.nih.gov/31958526/ </ref> <ref>SGEM#307: Buff up the lido for the local anesthetic http://thesgem.com/2020/10/sgem307-buff-up-the-lido-for-the-local-anesthetic/</ref>
*Inject through wound edges NOT intact skin
**Shorter shelf-life due to decreased stability (use within 2 hours in the Vent A study)
*Warming local anesthetics also decreases pain of injection <ref>Hogan, M., vanderVaart, S., Perampaladas, K., Machado, M., Einarson, T. and Taddio, A., 2020. Systematic Review And Meta-Analysis Of The Effect Of Warming Local Anesthetics On Injection Pain.</ref>
*Inject through wound edges whenever possible
**Avoid injecting through intact skin when possible


==See Also==
==See Also==
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[[Category:Pharmacology]]
[[Category:Pharmacology]]
[[Category:Cardiology]]
[[Category:Cardiology]]
[[Category:Toxicology]]

Latest revision as of 09:22, 1 March 2024

See critical care quick reference for drug doses by weight.

General

  • Also known internationally as lignocaine
  • Type: Local anesthetics; Antiarrhythmics
  • Dosage Forms: Local injection, transdermal, intravenous, inhaled, viscous
  • Common Trade Names: Xylocaine, P-Care, ReadySharp Lidocaine, Xylocard [1]

Adult Dosing

Local Anesthetic

  • Maximum without epinephrine: 5mg/kg (max 300mg)
  • Maximum with epinepherine: 7mg/kg (max 500mg)

Antiarrhythmic

  • Loading dose = 1-1.5mg/kg
    • Additional boluses of 0.5-0.75mg/kg q5-10min up to max of 3mg/kg
    • If effective start infusion of 2mg/min
  • Indications

Pediatric Dosing

Local Anesthetic

  • Without epinepherine: 5mg/kg (max 300mg)
  • With epinepherine: 7mg/kg (max 500mg)

Antiarrhythmic

See critical care quick reference for drug doses by weight.

Special Populations

  • Pregnancy Rating: American B, Australia A
  • Lactation: Not expected to cause any adverse effect [2]
  • Renal Dosing
    • Adult: No adjustment provided in manufacturer's labelling but accumulation of metabolites may be increased in renal dysfunction[3]
    • Pediatric: No adjustment provided in manufacturer's labelling [4]
  • Hepatic Dosing
    • Adult: Reduce maintenance infusion when used IV (0.75 mg/minute). Monitor concentration.[5]
    • Pediatric: Use with caution. Reduce dose. [6]

Contraindications

  • Allergy to amide anesthetics
    • Note that these allergies are rare and are often caused by preservative, so a preservative-free formulation may be appropriate
    • Note that allergy to amide anesthetics does not suggest allergy to ester anesthetics
  • High SA or AV block (without pacemaker)
  • Concurrent treatment with Class I anti-dysrhythmic agents
  • Wolff-Parkinson-White syndrome

Adverse Reactions

Local

  • Dermatologic
    • Itching or irritation
    • Depigmentation
    • Rash/urticaria
    • Edema
    • Venous inflammation

Serious

  • Local Anesthetic Systemic Toxicity (LAST)
    • Rare during infiltration of local anesthetic
    • CNS toxicity
      • Metallic taste
      • Tinnitus
      • Tingling of lips
      • Dizziness
      • Anxiety
      • Confusion
      • Lethargy
      • Loss of consciousness
      • Seizures
      • Nausea/vomiting
    • Cardiovascular toxicity
      • Bradycardia
      • Decreased myocardial contractility
      • Atrioventricular block
      • Vasodilation
      • Ventricular arrhythmias
      • Cardiac arrest
  • Bronchospasm
  • Respiratory depression or arrest
  • Methemoglobinemia

Pharmacology

  • Pharmacokinetics
    • Onset of action = 45-90s
    • Duration of action = 10-20min (antiarrythmic IV); 30-90 min (subcutaneous)
    • Half-life 90 - 120 minutes
      • Prolonged in hepatic impairment or congestive heart failure
  • Metabolism
    • Primarily hepatic
  • Excretion
    • Urine
  • Mechanism of Action
    • Class Ib antiarrythmic
      • Binds to fast Na channels in inactive state thereby raising the depolarization threshold
      • Acts preferentially on ischemic tissue
        • Elevates V-fib threshold
        • Suppresses ventricular ectopy
    • Little effect on vascular tone, contractility, or cardiac output

Comments

  • Mix lidocaine 1%/epinephrine with sodium bicarbonate 8.4% in 3:1 ratio results in significantly less painful injections. [7] [8]
    • Shorter shelf-life due to decreased stability (use within 2 hours in the Vent A study)
  • Warming local anesthetics also decreases pain of injection [9]
  • Inject through wound edges whenever possible
    • Avoid injecting through intact skin when possible

See Also

References

  1. ↑ Lidocaine. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Accessed March 15, 2019
  2. ↑ https://www.ncbi.nlm.nih.gov/books/NBK501230/
  3. ↑ Lidocaine. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Accessed March 15, 2019
  4. ↑ Lidocaine. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Accessed March 15, 2019
  5. ↑ Lidocaine. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Accessed March 15, 2019
  6. ↑ Lidocaine. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Accessed March 15, 2019
  7. ↑ Vent A et. al Buffered lidocaine 1%/epinephrine 1:100,000 with sodium bicarbonate (sodium hydrogen carbonate) in a 3:1 ratio is less painful than a 9:1 ratio: A double-blind, randomized, placebo-controlled, crossover trial. J Am Acad Dermatol. 2020 Jul;83(1):159-165. doi: 10.1016/j.jaad.2019.09.088. https://pubmed.ncbi.nlm.nih.gov/31958526/
  8. ↑ SGEM#307: Buff up the lido for the local anesthetic http://thesgem.com/2020/10/sgem307-buff-up-the-lido-for-the-local-anesthetic/
  9. ↑ Hogan, M., vanderVaart, S., Perampaladas, K., Machado, M., Einarson, T. and Taddio, A., 2020. Systematic Review And Meta-Analysis Of The Effect Of Warming Local Anesthetics On Injection Pain.
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