Anesthesia, local injectable: Varies with procedure, degree of anesthesia needed, vascularity of tissue, duration of anesthesia required, and physical condition of patient.
Cutaneous infiltration: Maximum: 4.5 mg/kg/dose not to exceed 300 mg; do not repeat within 2 hours.
Intraosseous line or infusion pain: Lidocaine 1% or 2% preservative-free solution: Intraosseous: Initial dose: 40 mg over 1 to 2 minutes; usual adult dose range and maximum: 20 to 50 mg/dose; after allowing lidocaine to dwell for up to 1 minute, 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 (Philbeck 2010; Schalk 2011). 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.
Interstitial cystitis (bladder pain syndrome) (off-label use): Intravesical:
Various dosage regimens of alkalinized lidocaine alone or with heparin (20,000 to 50,000 units) have been used. There is a risk of precipitation if proper alkalinization does not occur. Lidocaine stability and pH should be determined after the components have been mixed, prior to administration (Parsons 2012).
Single instillation: Single intravesical administration 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 (Parsons 2012).
Weekly instillation: Weekly bladder instillations for 12 consecutive weeks with lidocaine 4% (5 mL)/heparin (20,000 units)/sodium bicarbonate 7% (25 mL), instilled into an empty bladder via catheter and allowed to dwell for 30 minutes before drainage (Nomiya 2013).
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 (Nickel 2009).
Ventricular arrhythmias:
Sudden cardiac arrest due to ventricular fibrillation or pulseless ventricular tachycardia, unresponsive to cardiopulmonary resuscitation, defibrillation, and epinephrine (off-label use):
IV, intraosseous: Initial: 1 to 1.5 mg/kg bolus. If refractory ventricular fibrillation or pulseless ventricular tachycardia, repeat 0.5 to 0.75 mg/kg bolus every 5 to 10 minutes (maximum cumulative dose: 3 mg/kg). Follow with continuous infusion (1 to 4 mg/minute) after return of perfusion (ACLS [Link 2015]; ACLS [Neumar 2010]; ACLS [Panchal 2018]; AHA/ACC/HRS [Al-Khatib 2018]).
Reappearance of arrhythmia during continuous infusion: Give an additional 0.5 mg/kg bolus then increase infusion (Zipes 2000).
Endotracheal (loading dose only) (off-label route): 2 to 3.75 mg/kg (2 to 2.5 times the recommended IV dose); dilute in 5 to 10 mL NS or sterile water. Note: Absorption is greater with sterile water and results in less impairment of PaO2 (ACLS [Neumar 2010]).
Ventricular tachycardia, hemodynamically stable:
IV: 1 to 1.5 mg/kg; repeat with 0.5 to 0.75 mg/kg every 5 to 10 minutes as necessary (maximum cumulative dose: 3 mg/kg). Follow with continuous infusion of 1 to 4 mg/minute (AHA/ACC/HRS [Al-Khatib 2018]) or 20 to 50 mcg/kg/minute.
Note: For prolonged infusion (after 24 hours), reduce the rate of infusion by approximately one-half to compensate for the reduced elimination rate. Administer under constant ECG monitoring.
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.
(For additional information see "Lidocaine (local and regional anesthetic) and (systemic): Pediatric drug information")
Ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT), shock-refractory: Infants, Children, and Adolescents:
IV, Intraosseous (PALS [de Caen 2015]; PALS [Duff 2018]; PALS [Kleinman 2010]; PALS [Topjian 2020]): 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 (PALS [Kleinman 2010]).
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 (Kliegman 2016).
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 (Hartholt 2010; Nagler 2011; Philbeck 2010; Schalk 2011). 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 (Aronoff 2007)
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
Refer to adult dosing.
Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product
Kit, Injection, as hydrochloride:
Lidomark 1/5: 1%
Lidomark 2/5: 2%
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: 1% [10 mg/mL] (5 mL); 2% [20 mg/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: 100 mg/5 mL (5 mL)
Yes
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: 0.4% [4 mg/mL] (250 mL, 500 mL); 2% [20 mg/mL] (5 mL)
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 (Dorian, 2002).
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; however, there is no evidence to support subsequent continuous infusion to prevent recurrence (ACLS [Peberdy 2010]). Local thrombophlebitis may occur in patients receiving prolonged IV infusions.
Endotracheal (off-label administration route): Dilute in NS or sterile water. Absorption is greater with sterile water and results in less impairment of PaO2 (Hahnel 1990). Stop compressions, spray drug quickly down tube. Flush with 5 mL of NS and follow immediately with several quick insufflations and continue chest compressions.
Intraosseous (IO; off-label administration route): Intraosseous administration is a reasonable alternative when quick IV access is not feasible (ACLS, 2010).
Intravesical (off-label use): Various regimens of alkalinized lidocaine (with or without heparin) have been instilled into the bladder
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 (see https://www.ismp.org/Newsletters/acutecare/archives/May09.asp).
Endotracheal: Infants, Children, and Adolescents: May administer dose undiluted, followed by flush with 5 mL of NS after endotracheal administration or may further dilute prior to administration; follow with 5 assisted manual ventilations (Hegenbarth 2008; PALS [Kleinman 2010]).
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 VT or VF), administration by rapid IV push has been used by some clinicians in practice.
Continuous IV infusion: Administer via an infusion pump.
Note: Premixed solutions available
IV infusion: 1000 mg in 250 mL (concentration: 4 mg/mL) or 2000 mg in 250 mL (concentration: 8 mg/mL) of D5W
Note: Premixed solutions available
IV infusion: 8000 mcg/mL
Local and regional anesthesia by infiltration, nerve block, epidural, or spinal techniques; acute treatment of ventricular arrhythmias (eg, due to acute myocardial infarction [MI] or during cardiac manipulation [eg, cardiac surgery]).
Note: The routine prophylactic use of lidocaine to prevent arrhythmia associated during ST-elevation MI or to suppress isolated ventricular premature beats, couplets, runs of accelerated idioventricular rhythm, and nonsustained ventricular tachycardia is not recommended (ACCF/AHA [O'Gara, 2013]).
Interstitial cystitis/bladder pain syndrome (alkalinized lidocaine); Sudden cardiac arrest due to ventricular fibrillation or pulseless ventricular tachycardia
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].
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.
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.
• Pseudocholinesterase deficiency: Use caution in patients with pseudocholinesterase deficiency; 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.
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
Beta-Blockers: 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. 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
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
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]).
Lidocaine is present in breast milk.
The relative infant dose (RID) of lidocaine is 4.9% when calculated using the highest breast milk concentration located and compared to a weight-adjusted maternal dose of 183 mg for epidural anesthesia.
In general, breastfeeding is considered acceptable when the RID of a medication is <10% (Anderson 2016; Ito 2000).
The RID of lidocaine was calculated using a mean milk concentration of 0.86 mcg/mL, providing an estimated daily infant dose via breast milk of 129 mcg/kg/day. This milk concentration was obtained following maternal administration lidocaine via local regional anesthesia to 22 women undergoing cesarean delivery. Milk was sampled 2 hours after the injection. Breast milk concentrations of lidocaine decreased over 12 hours (Ortega 1999). Lidocaine metabolites have also been detected in breast milk (Giuliani 2001; Lebedevs 1993; Puente 2001). Lower concentrations of lidocaine have been reported in breast milk following dental procedures, infusion for arrhythmias, and liposuction (Dryden 2000; Giuliani 2001; Lebedevs 1993; Zeisler 1986). Oral bioavailability to the breastfeeding infant is expected to be low (Lebedevs 1993; Ortega 1999).
Available guidelines consider lidocaine to be compatible with breastfeeding when used as an antiarrhythmic or local anesthetic (ABM [Reece-Stremtan 2017]; WHO 2002). Cumulative exposure from all routes of administration should be considered.
Premixed injection may contain corn-derived dextrose and its use is contraindicated in patients with allergy to corn-related products.
Liver function tests, lidocaine concentrations, ECG; in patients requiring drug >24 hrs, blood level monitoring recommended; consult individual institutional policies and procedures
Therapeutic: 1.5 to 5.0 mcg/mL (SI: 6 to 21 micromole/L)
Potentially toxic: >6 mcg/mL (SI: >26 micromole/L)
Toxic: >9 mcg/mL (SI: >38 micromole/L)
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 heart failure, liver disease, shock, severe renal impairment.
Excretion: Urine (<10% as unchanged drug, ~90% as metabolites).
Solution (Lidocaine HCl (Cardiac) PF Intravenous)
100 mg/5 mL (per mL): $0.72
Solution (Lidocaine HCl (PF) Injection)
0.5% (per mL): $0.09
1% (per mL): $0.30 - $19.60
1.5% (per mL): $0.55
2% (per mL): $0.27 - $0.72
4% (per mL): $1.05 - $1.06
Solution (Lidocaine HCl Injection)
0.5% (per mL): $0.10
1% (per mL): $0.09 - $0.22
2% (per mL): $0.09 - $0.19
Solution (Lidocaine in D5W Intravenous)
4 mg/mL 5% (per mL): $0.02
8 mg/mL 5% (per mL): $0.03 - $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): $0.30
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): $2.95
100 mg/5 mL (per mL): $1.03 - $1.62
Solution Prefilled Syringe (Lidocaine HCl (Cardiac) PF Intravenous)
50 mg/5 mL (per mL): $2.03
100 mg/5 mL (per mL): $0.98 - $0.99
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