lidocaine hydrochloride

(lye' doe kane)

lidocaine HCl in 5% dextrose lidocaine HCl without preservatives
Antiarrhythmic preparations:

Xylocaine HCl IV for Cardiac Arrhythmias
Local anesthetic preparations:

Octocaine, Xylocaine HCl (injectable)
Topical for mucous membranes:

Anestacon, Burn-O-Jel, Dentipatch, DermaFlex, ELA-Max, Xylocaine, Zilactin-L
Topical dermatologic:

Lidoderm, Numby Stuff, Xylocaine Pregnancy Category B
Drug classes

Antiarrhythmic Local anesthetic
Therapeutic actions

Type 1 antiarrhythmic: Decreases diastolic depolarization, decreasing automaticity of ventricular cells; increases ventricular fibrillation threshold. Local anesthetic: Blocks the generation and conduction of action potentials in sensory nerves by reducing sodium permeability, reducing height and rate of rise of the action potential, increasing excitation threshold, and slowing conduction velocity.
Indications

As antiarrhythmic: Management of acute ventricular arrhythmias during cardiac surgery and MI (IV use). Use IM when IV administration is not possible or when ECG monitoring is not available and the danger of ventricular arrhythmias is great (single-dose IM use, for example, by paramedics in a mobile coronary care unit) As anesthetic: Infiltration anesthesia, peripheral and sympathetic nerve blocks, central nerve blocks, spinal and caudal anesthesia, retrobulbar and transtracheal injection; topical anesthetic for skin disorders and accessible mucous membranes Contraindicated with allergy to lidocaine or amide-type local anesthetics, CHF, cardiogenic shock, second- or third-degree heart block (if no artificial pacemaker), Wolff-Parkinson-White syndrome, Stokes-Adams syndrome. Use cautiously with hepatic or renal disease, inflammation or sepsis in the region of injection (local anesthetic), labor and delivery (epidural anesthesia may

Contraindications and cautions

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prolong the second stage of labor; monitor for fetal and neonatal CV and CNS toxicity), and lactation.
Available forms

Direct injection—10, 20 mg/mL; IV injection (admixture) 40, 100, 200 mg/mL; IV infusion—2, 4, 8 mg/mL; topical liquid—2.5%, 5%; topical ointment—2.5%, 5%; topical cream—0.5%; topical gel—0.5%, 2.5%; topical spray—0.5%, 10%; topical solution— 2%, 4%; topical jelly—2%; injection—0.5%, 1%, 1.5%, 2%, 4%, 5%; patch—varies
Dosages ADULTS IM

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Arrhythmia: Use only the 10% solution for IM injection. 300 mg in deltoid or thigh muscle. Switch to IV lidocaine or oral antiarrhythmic as soon as possible. Arrhythmia: Use only lidocaine injection labeled for IV use and without preservatives or catecholamines. Monitor ECG constantly. Give 50–100 mg at rate of 20–50 mg/min. One-third to one-half the initial dose may be given after 5 min if needed. Do not exceed 200–300 mg in 1 hr. Arrhythmia: Give 1–4 mg/min (or 20–50 mcg/kg/min). Titrate the dose down as soon as the cardiac rhythm stabilizes. Use lower doses in patients with CHF, liver disease, and in patients > 70 yr. Local anesthesia: Preparations containing preservatives should not be used for spinal or epidural anesthesia. Drug concentration and diluent should be appropriate to particular local anesthetic use: 5% solution with glucose is used for spinal anesthesia, 1.5% solution with dextrose for low spinal or "saddle block"; anesthesia. Dosage varies with the area to be anesthetized and the reason for the anesthesia; use the lowest dose possible to achieve results. Arrhythmia: Safety and efficacy have not been established. American Heart Association recommends bolus of 0.5–1 mg/kg IV, followed by 30 mcg/kg/min with caution. The IM auto-injector device is not recommended. Local anesthesia: See adult dosage discussion. Use lower concentrations.

IV bolus

IV, continuous infusion

Topical, intratissue, epidural

PEDIATRIC PATIENTS IV

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GERIATRIC OR DEBILITATED PATIENTS, PATIENTS WITH LIVER DISEASE OR CHF

Use lower concentrations in these patients.
Pharmacokinetics
Route IM IV Topical Onset 5–10 min Immediate Minimally absorbed systemically Peak 5–15 min Immediate Duration 2 hr 10–20 min

Metabolism: Hepatic; T1/2: 10 min, then 1.5–3 hr Distribution: Crosses placenta; enters breast milk

Excretion: Urine
IV facts

Preparation: Prepare solution for IV infusion as follows: 1–2 g lidocaine to 1 L 5% dextrose in water = 0.1%–0.2% solution; 1–2 mg lidocaine/mL. Stable for 24 hr after dilution. Infusion: IV bolus: give 50–100 mg at rate of 20–50 mg/min. An infusion rate of 1–4 mL/min will provide 1–4 mg lidocaine/min. Use only preparations of lidocaine specifically labeled for IV infusion.
Adverse effects Antiarrhythmic with systemic administration

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CNS: Dizziness or light-headedness, fatigue, drowsiness, unconsciousness, tremors, twitching, vision changes; may progress to seizures CV: Cardiac arrhythmias, cardiac arrest, vasodilation, hypotension GI: Nausea, vomiting Hypersensitivity: Rash, anaphylactoid reactions Respiratory: Respiratory depression and arrest Other: Malignant hyperthermia, fever, local injection site reaction CNS: Headache, backache, septic meningitis, persistent sensory, motor, or autonomic deficit of lower spinal segments, sometimes with incomplete recovery CV: Hypotension due to sympathetic block Dermatologic: Urticaria, pruritus, erythema, edema GU: Urinary retention, urinary or fecal incontinence Dermatologic: Contact dermatitis, urticaria, cutaneous lesions Hypersensitivity: Anaphylactoid reactions Local: Burning, stinging, tenderness, swelling, tissue irritation, tissue sloughing and necrosis Other: Methemoglobinemia, seizures (children)

Injectable local anesthetic for epidural or caudal anesthesia

Topical local anesthetic

Interactions

Drug-drug • Increased lidocaine levels with beta blockers (propranolol, metoprolol, nadolol, pindolol, atenolol), cimetidine, ranitidine • Prolonged apnea with succinylcholine Drug-lab test • Increased CPK if given IM
Nursing considerations Assessment

History: Allergy to lidocaine or amide-type local anesthetics, CHF, cardiogenic shock, second- or third-degree heart block, Wolff-Parkinson-White syndrome,

Stokes-Adams syndrome, hepatic or renal disease, inflammation or sepsis in region of injection, lactation, pregnancy Physical: T; skin color, rashes, lesions; orientation, speech, reflexes, sensation and movement (local anesthetic); P, BP, auscultation, continuous ECG monitoring during use as antiarrhythmic; edema; R, adventitious sounds; bowel sounds, liver evaluation; urine output; serum electrolytes, liver and renal function tests Check drug concentration carefully; many concentrations are available. Reduce dosage with hepatic or renal failure. Continuously monitor response when used as antiarrhythmic or injected as local anesthetic. Keep life-support equipment and vasopressors readily available in case severe adverse reaction (CNS, CV, or respiratory) occurs when lidocaine is injected. Establish safety precautions if CNS changes occur; have IV diazepam or shortacting barbiturate (thiopental, thiamylal) readily available in case of seizures. Monitor for malignant hyperthermia (jaw muscle spasm, rigidity); have lifesupport equipment and IV dantrolene on standby. Titrate dose to minimum needed for cardiac stability, when using lidocaine as antiarrhythmic. Reduce dosage when treating arrhythmias in CHF, digitalis toxicity with AV block, and geriatric patients. Monitor fluid load carefully; more concentrated solutions can be used to treat arrhythmias in patients on fluid restrictions. Have patients who have received lidocaine as a spinal anesthetic remain lying flat for 6–12 hr afterward, and ensure that they are adequately hydrated to minimize risk of headache. Check lidocaine preparation carefully; epinephrine is added to solutions of lidocaine to retard the absorption of the local anesthetic from the injection site. Be sure that such solutions are used only to produce local anesthesia. These solutions should be injected cautiously in body areas supplied by end arteries and used cautiously in patients with peripheral vascular disease, hypertension, thyrotoxicosis, or diabetes. Use caution to prevent choking. Patient may have difficulty swallowing following use of oral topical anesthetic. Do not give food or drink for 1 hr after use of oral anesthetic. Treat methemoglobinemia with 1% methylene blue, 0.1 mg/kg, IV over 10 min. Apply lidocaine ointments or creams to a gauze or bandage before applying to the skin. Monitor for safe and effective serum drug concentrations (antiarrhythmic use: 1–5 mcg/mL). Doses > 6–10 mcg/mL are usually toxic. Dosage is changed frequently in response to cardiac rhythm on monitor.

Interventions

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Teaching points

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Oral lidocaine can cause numbness of the tongue, cheeks, and throat. Do not eat or drink for 1 hr after using oral lidocaine to prevent biting cheeks or tongue and choking. These side effects may occur: Drowsiness, dizziness, numbness, double vision; nausea, vomiting; stinging, burning, local irritation (local anesthetic). Report difficulty speaking, thick tongue, numbness, tingling, difficulty breathing, pain or numbness at IV site, swelling, or pain at site of local anesthetic use.

Adverse effects in Italic are most common; those in Bold are life-threatening.