General

High Alert Medication: This medication bears a heightened risk of causing significant patient harm when it is used in error.

lidocaine (parenteral)
(LYE-doe-kane)

• LidoPen

• Xylocaine

• Xylocard [Canada]

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

Pregnancy Category
Category B

Ther. class.
anesthetics topical local
antiarrhythmics
(class IB)

Indications

• IV: Ventricular arrhythmias

• IM: Self-injected or when IV unavailable (during transport to hospital facilities)

• Local: Infiltration/mucosal/topical anesthetic

• Patch: Pain due to post-herpetic neuralgia

Action

• 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 Effect(s):

• Control of ventricular arrhythmias

• Local anesthesia

Pharmacokinetics

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

Contraindication/Precautions

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)

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.

*CAPITALS indicates life-threatening.
*italic indicates most frequent.

Interactions

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 antidepressnts, and venlafaxine

• Effects of lidocaine may be by carbamazepine, phenobarbital, phenytoin, and rifampin

Route/Dosage

Ventricular Tachycardia (with a Pulse) or Pulseless Ventricular Tachycardia/Ventricular Fibrillation

• 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.

Local

• 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

• 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)

Assessment

Antiarrhythmic

• Monitor ECG continuously and blood pressure and respiratory status frequently during administration

Anesthetic

• Assess degree of numbness of affected part

Lab Test Considerations

• Serum electrolyte levels should be monitored periodically during prolonged therapy

» IM administration may cause CPK levels

Toxicity and Overdose

• Serum lidocaine levels should be monitored periodically during prolonged or high-dose IV therapy. Therapeutic serum lidocaine levels range from 1.5 to 5 mcg/ml

» Signs and symptoms of toxicity include confusion, excitation, blurred or double vision, nausea, vomiting, ringing in ears, tremors, twitching, seizures, difficulty breathing, severe dizziness or fainting, and unusually slow heart rate

» If symptoms of overdose occur, stop infusion and monitor patient closely

Potential Nursing Diagnoses

• Decreased cardiac output (Indications)

• Acute pain (Indications)

Implementation

• High Alert: Lidocaine is readily absorbed through mucous membranes. Inadvertent overdosage of lidocaine jelly and spray has resulted in patient harm or death from neurologic and/or cardiac toxicity. Do not exceed recommended dosages

• Throat Spray: Ensure that gag reflex is intact before allowing patient to drink or eat

• IM: IM injections are recommended only when ECG monitoring is not available and benefits outweigh risks. Administer IM injections only into deltoid muscle while frequently aspirating to prevent IV injection

IV Adminstration:

• Direct IV:
Only 1% and 2% solutions are used for direct IV injection.
Diluent: Administer undiluted.

• Rate:
Administer loading dose over 2–3 min. Follow by IV continuous infusion

• Continuous Infusion:
Diluent: Lidocaine vials need to be further diluted. Dilute 2 g of lidocaine in 250 ml or 500 ml of D5W or 0.9% NaCl. Admixed infusion stable for 24 hr at room temperature. Premixed infusions are already diluted and ready to use.
Concentration: 4–8 mg/ml

• Rate:
See Route/Dosage section. Administer via infusion pump for accurate dose

• Y-Site Compatibility:

» alteplase

» amikacin

» aminophylline

» amiodarone

» argatroban

» atropine

» aztreonam

» bivalirudin

» bumetanide

» calcium chloride

» calcium gluconate

» cefazolin

» cefotaxime

» cefoxitin

» ceftazidime

» ceftizoxime

» ceftriaxone

» cefuroxime

» chloramphenicol

» cimetidine

» ciprofloxacin

» cisatracurium

» clindamycin

» cyclosporine

» daptomycin

» dexamethasone sodium phosphate

» dexmedetomidine

» digoxin

» diltiazem

» diphenhydramine

» dobutamine

» dopamine

» doxycycline

» enalaprilat

» epinephrine

» eptifibatide

» ertapenem

» erythromycin

» esmolol

» etomidate

» famotidine

» fenoldopam

» fentanyl

» fluconazole

» furosemide

» gentamicin

» granisetron

» haloperidol

» heparin

» hydrocortisone sodium succinate

» imipenem/cilastatin

» inamrinone

» insulin

» isoproterenol

» ketorolac

» labetalol

» levofloxacin

» linezolid

» lorazepam

» magnesium sulfate

» meperidine

» methylprednisolone sodium succinate

» metoclopramide

» metoprolol

» metronidazole

» micafungin

» midazolam

» morphine

» nafcillin

» nicardipine

» nitroglycerin

» nitroprusside

» norepinephrine

» ondansetron

» palonosetron

» penicillin G potassium

» phenylephrine

» phytonadione

» piperacillin/tazobactam

» potassium chloride

» procainamide

» prochlorperazine

» promethazine

» propofol

» propranolol

» protamine

» quinupristin/dalfopristin

» ranitidine

» remifentanil

» sodium bicarbonate

» streptokinase

» tacrolimus

» theophylline

» ticarcillin/clavulanate

» tigecycline

» tirofiban

» tobramycin

» vancomycin

» vasopressin

» verapamil

» vitamin B complex with C

» voriconazole

» warfarin

• Y-Site Incompatibility:

» acyclovir

» amphotericin B cholesteryl sulfate complex

» caspofungin

» diazepam

» ganciclovir

» lansoprazole

» pantoprazole

» phenytoin

» thiopental

» trimethoprim/sulfamethoxazole

• Infiltration: Lidocaine with epinephrine may be used to minimize systemic absorption and prolong local anesthesia

Patient/Family Teaching

• May cause drowsiness and dizziness. Advise patient to call for assistance during ambulation and transfer

• IM: Available in LidoPen Auto-Injector for use outside the hospital setting. Advise patient to telephone health care professional immediately if symptoms of a heart attack occur. Do not administer unless instructed by health care professional. To administer, remove safety cap and place back end on thickest part of thigh or deltoid muscle. Press hard until needle prick is felt. Hold in place for 10 sec, then massage area for 10 sec. Do not drive after administration unless absolutely necessary

• Topical: Apply Lidoderm Patch to intact skin to cover the most painful area. Patch may be cut to smaller sizes with scissors before removing release liner. Clothing may be worn over patch. If irritation or burning sensation occurs during application, remove patch until irritation subsides. Wash hands after application; avoid contact with eyes. Dispose of used patch to avoid access by children or pets

Evaluation/Desired Outcomes

• Decrease in ventricular arrhythmias

• Local anesthesia

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