LIDOCAINE lidocaine (parenteral)
LidoPen, Xylocaine, Xylocard lidocaine (local anesthetic)
Xylocaine lidocaine (mucosal)
Anestacon, Xylocaine Viscous lidocaine patch
Lidoderm lidocaine (topical)
L-M-X 4, L-M-X 5, Solarcaine Aloe Extra Burn Relief, Xylocaine, Zilactin-L
Therapeutic: anesthetics (topical/local); antiarrhythmics (class IB)
IV: Ventricular arrhythmias. IM: Self-injected or when IV unavailable (during transport to hospital facilities). Local: Infiltration/mucosal/topical anesthetic. Patch: Pain due to postherpetic neuralgia.
IV, IM: Suppresses automaticity and spontaneous depolarization of the ventricles during diastole by altering the flux of sodium ions across cell membranes with little or no effect on heart rate. Local: Produces local anesthesia by inhibiting transport of ions across neuronal membranes, thereby preventing initiation and conduction of normal nerve impulses. Therapeutic Effects: Control of ventricular arrhythmias. Local anesthesia.
Adverse Reactions/Side Effects
Applies mainly to systemic use
CNS: SEIZURES, confusion, drowsiness, blurred vision, dizziness, nervousness, slurred speech, tremor. EENT: mucosal use—decreased or absent gag reflex. CV: CARDIAC ARREST, arrhythmias, bradycardia, heart block, hypotension. GI: nausea, vomiting. Resp: bronchospasm. Local: stinging, burning, contact dermatitis, erythema. Misc: ALLERGIC REACTIONS, INCLUDING ANAPHYLAXIS.
PHYSICAL THERAPY IMPLICATIONS
Examination and Evaluation
Be alert for new seizures or increased seizure activity, especially during IV or IM administration. Document the number, duration, and severity of seizures, and report these findings immediately to the physician.
Monitor cardiac symptoms at rest and during exercise. Seek immediate medical assistance if symptoms of cardiac arrest develop, including sudden chest pain, pain radiating into the arm or jaw, shortness of breath, dizziness, sweating, anxiety, and nausea.
Monitor signs of allergic reactions and anaphylaxis, including pulmonary symptoms (laryngeal edema, bronchospasm, wheezing, cough, dyspnea) or skin reactions (rash, pruritus, urticaria). Notify physician or nursing staff immediately if these reactions occur.
Assess heart rate, ECG, and heart sounds, especially during exercise (See Appendices G, H). Although intended to treat certain arrhythmias, this drug can unmask or precipitate new arrhythmias (proarrhythmic effect). Report any rhythm disturbances or symptoms of increased arrhythmias, including palpitations, chest pain, shortness of breath, fainting, and fatigue/weakness.
Be alert for other signs of toxicity during continuous systemic administration or prolonged use of lidocaine patches. Signs of toxicity include confusion, nervousness, tremor, blurred or double vision, nausea, vomiting, slurred speech, ringing in ears, tremors, twitching, difficulty breathing, severe dizziness or fainting, and unusually slow heart rate. Report these signs to physician or nursing staff immediately.
When used for regional pain control or neuropathic pain, use appropriate pain scales and sensory testing to document level of local anesthesia and analgesic effects.
Assess dizziness and drowsiness that might affect gait, balance, and other functional activities (See Appendix C). Report balance problems and functional limitations to the physician and nursing staff, and caution the patient and family/caregivers to guard against falls and trauma.
Monitor skin reactions during local or topical use. Report severe or prolonged reactions such as stinging, burning, or irritation.
Because of the risk of arrhythmias and cardiac arrest, use extreme caution during aerobic exercise and other forms of therapeutic exercise. Assess exercise tolerance frequently (blood pressure, heart rate, fatigue levels), and terminate exercise immediately if any untoward responses occur (See Appendix L).
When administered via a patch, be aware of patch location and do not apply thermal agents or massage on or near the patch.
Advise patient and family or caregivers about the signs of cardiac arrest (see above under Examination and Evaluation) and to seek immediate medical assistance if these signs develop.
Instruct patient and family/caregivers to report other severe or prolonged side effects such as bronchospasm or GI reactions (nausea, vomiting).
Absorption: Well absorbed after administration into the deltoid muscle; some absorption follows local use.
Distribution: Widely distributed. Concentrates in adipose tissue. Crosses the blood-brain barrier and placenta; enters breast milk.
Metabolism and Excretion: Mostly metabolized by the liver; <10% excreted in urine as unchanged drug.
Half-life: Biphasic—initial phase, 7–30 min; terminal phase, 90–120 min; increased in CHF and liver impairment.
TIME/ACTION PROFILE (IV, IM = antiarrhythmic effects; local = anesthetic effects)
|ROUTE ||ONSET ||PEAK ||DURATION |
|IV ||immediate ||immediate ||10–20 min (up to several hours after continuous infusion) |
|IM ||5–15 min ||20–30 min ||60–90 min |
|local ||rapid ||unknown ||1–3 hr |
Applies mainly to systemic use
Contraindicated in: Hypersensitivity; cross-sensitivity may occur; Third-degree heart block.
Use Cautiously in: Liver disease, CHF, patients weighing <50 kg, and geriatric patients (reduce bolus and/or maintenance dose); Respiratory depression; Shock; Heart block; Pregnancy or lactation (safety not established); Children (safety not established for transdermal patch).
Applies mainly to systemic use
Drug-Drug: ↑ cardiac depression and toxicity with phenytoin, amiodarone, quinidine, procainamide, or propranolol. Cimetidine, azole antifungals, clarithromycin, erythromycin, fluoxetine, nefazodone, paroxetine, protease inhibitors, ritonavir, verapamil, and beta blockers may ↓ metabolism and ↑ risk of toxicity. Lidocaine may ↑ levels of calcium channel blockers, certain benzodiazepines, cyclosporine, fluoxetine, lovastatin, simvastatin, mirtazapine, paroxetine, ritonavir, tacrolimus, theophylline, tricyclic antidepressants, and venlafaxine. Effects of lidocaine may be ↓ by carbamazepine, phenobarbital, phenytoin, and rifampin.
Ventricular Tachycardia (with a Pulse) or Pulseless Ventricular
IV (Adults): 1–1.5 mg/kg bolus; may repeat doses of 0.5–0.75 mg/kg q 5–10 min up to a total dose of 3 mg/kg; may then start continuous infusion of 1–4 mg/min.
Endotracheal:(Adults): Give 2–2.5 times the IV loading dose down the endotracheal tube, followed by a 10 mL saline flush.
IV (Children): 1 mg/kg bolus (not to exceed 100 mg), followed by 20–50 mcg/kg/min continuous infusion (range 20–50 mcg/kg/min); may administer second bolus of 0.5–1 mg/kg if delay between bolus and continuous infusion.
Endotracheal (Children): Give 2–3 mg/kg down the endotracheal tube followed by a 5-mL saline flush.
IM (Adults and Children ≥50 kg): 300 mg (4.5 mg/kg); may be repeated in 60–90 min.
Infiltration (Adults and Children): Infiltrate affected area as needed (increased amount and frequency of use increases likelihood of systemic absorption and adverse reactions).
Topical (Adults): Apply to affected area 2–3 times daily.
Mucosal (Adults): For anesthetizing oral surfaces—20 mg as 2 sprays/quadrant (not to exceed 30 mg/quadrant) may be used. 15 mL of the viscous solution may be used q 3 hr for oral or pharyngeal pain. For anesthetizing the female urethra—3–5 mL of the jelly or 20 mg as 2% solution may be used. For anesthetizing the male urethra—5–10 mL of the jelly or 5–15 mL of 2% solution may be used before catheterization or 30 mL of jelly before cystoscopy or similar procedures. Topical solutions may be used to anesthetize mucous membranes of the larynx, trachea, or esophagus.
Patch: (Adults): Up to 3 patches may be applied once for up to 12 hr in any 24-hr period; consider smaller areas of application in geriatric or debilitated patients.
Availability (generic available)
Autoinjector for IM injection: 300 mg/3 mL. Direct IV injection: 10 mg/mL (1%), 20 mg/mL (2%). For IV admixture: 100 mg/mL (10%). Premixed solution for IV infusion: 4 mg/mL (0.4%), 8 mg/mL (0.8%). Injection for local infiltration/nerve block: 0.5%, 1%, 2%, 4%. In combination with: epinephrine for local infiltration. Cream: 4% OTC. Gel: 0.5% OTC, 2.5% OTC. Jelly: 2%. Liquid: 5%. Ointment: 5%. Transdermal system: 5% patch Cost: $189.98/box of 30 patches. Solution: 4%. Spray: 10%. Viscous solution: 2%. In combination with: prilocaine (as EMLA cream, Oraquix); with tetracaine (Synera); with bupivacaine (Duocaine); with epinephrine (LidoSite).