Lidocaine: Difference between revisions
 
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==Anesthetic==
''See [[critical care quick reference]] for drug doses by weight.''
===Precautions===
*For wounds, may use HCO3 (1cc to 10cc Lido) to decr pain
*inject through wound edges NOT intact skin


=== Theraputic Doses ===
==General==
{| class="wikitable"
*Also known internationally as lignocaine
| align="center" style="background:#f0f0f0;"|'''Agent'''
*Type: [[Local anesthetics]]; [[Antiarrhythmics]]
| align="center" style="background:#f0f0f0;"|'''Without [[Epi]]'''
*Dosage Forms: Local injection, transdermal, intravenous, inhaled, viscous
| align="center" style="background:#f0f0f0;"|'''With [[Epi]]'''
*Common Trade Names: Xylocaine, P-Care, ReadySharp Lidocaine, Xylocard <ref>Lidocaine. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Accessed March 15, 2019</ref>
| align="center" style="background:#f0f0f0;"|'''Notes'''
|-
| [[Lidocaine]]||5 mg/kg (max 300mg)||7 mg/kg||
*1% soln contains 10 mg/ml
*2% soln contains 20 mg/ml
|-
| [[Mevipicaine]]||7 mg/kg||8 mg/kg||
|-
| [[Bupivicaine]]||2.5 mg/kg (max 175mg)||3 mg/kg||0.5% soln contains 5 mg/ml
|-
| [[Ropivacaine]]||3 mg/kg||-||
|-
| [[Prilocaine]]||6 mg/kg||-||
|}


==Antiarrhythmic==
==Adult Dosing==
=== Adult Dosing ===
===[[Local anesthetics|Local Anesthetic]]===
*Loading dose = 1-1.5 mg/kg
*Maximum without epinephrine: 5mg/kg (max 300mg)
**Additional boluses of 0.5-0.75 mg/kg q5-10min up to max of 3mg/kg
*Maximum with epinepherine: 7mg/kg (max 500mg)
 
===[[Arrythmia|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
**If effective start infusion of 2mg/min
*Indications
**Treatment of ventricular arrhythmias and ectopy
***Considered 2nd-line to [[amiodarone]] for treatment of [[V-fib]] and [[pulseless v-tach]]
==Pediatric Dosing==
===[[Local anesthetics|Local Anesthetic]]===
*Without epinepherine: 5mg/kg (max 300mg)
*With epinepherine: 7mg/kg (max 500mg)


=== Contraindications ===
===[[Arrythmia|Antiarrhythmic]]===
*High SA or AV block
''See [[critical care quick reference]] for drug doses by weight.''


=== Indications ===
==Special Populations==
*Treatment of ventricular arrhythmias and ectopy
*[[Drug Ratings in Pregnancy|Pregnancy Rating]]: American B, Australia A
**Considered 2nd-line to amiodarone for tx of V-fib and pulseless v-tach
*Lactation: Not expected to cause any adverse effect <ref>https://www.ncbi.nlm.nih.gov/books/NBK501230/</ref>
*Renal Dosing
**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: No adjustment provided in manufacturer's labelling <ref>Lidocaine. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Accessed March 15, 2019</ref>
*Hepatic Dosing
**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: Use with caution. Reduce dose. <ref>Lidocaine. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Accessed March 15, 2019</ref>


=== Mechanism of Action ===
==Contraindications==
*Class Ib
*Allergy to amide anesthetics
**Binds to fast Na channels in inactive state thereby inhibiting recovery after repolarization
**Note that these allergies are rare and are often caused by preservative, so a preservative-free formulation may be appropriate
**Acts preferentially on ischemic tissue
**Note that allergy to amide anesthetics does not suggest allergy to ester anesthetics
***Elevates V-fib threshold
*High SA or AV block (without pacemaker)
***Suppresses ventricular ectopy
*Concurrent treatment with Class I anti-dysrhythmic agents
*Little effect on vascular tone, contractility or cardiac output
*[[Wolff-Parkinson-White syndrome]]


=== Kinetics ===
==Adverse Reactions==
*Onset of action = 45-90s
===Local===
*Duration of action = 10-20min
*Dermatologic
**Itching or irritation
**Depigmentation
**Rash/urticaria
**Edema
**Venous inflammation


===See Also===
===Serious===
*[[Critical care quick reference]]
*[[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


== Toxicity==
==Pharmacology==
===Diagnosis ===
*Pharmacokinetics
Symptoms:
**Onset of action = 45-90s
# CV
**Duration of action = 10-20min (antiarrythmic IV); 30-90 min (subcutaneous)
##(brady/arrest)
**Half-life 90 - 120 minutes
###Tx w/ epi per ACLS
***Prolonged in hepatic impairment or congestive heart failure
#CNS
*Metabolism
##lightheaded, ringing in ears
**Primarily hepatic
##Seizure
*Excretion
##Abrupt change in MS, drowsiness, confusion
**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


See Also: [[Local Anesthetic Systemic Toxicity (LAST)]]
==Comments==
*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>
**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==
*[[Antiarrhythmics]]
*[[Local anesthetic systemic toxicity]]
*[[Incision and Drainage]]
*[[Critical care quick reference]]
*[[Local Anesthetic Systemic Toxicity (LAST)]]
 
==References==
<references/>


[[Category:Drugs]]
[[Category:Pharmacology]]
[[Category:Cards]]
[[Category:Cardiology]]
[[Category:Tox]]

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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