lidocaine hydrochloride A

lye-doe-kane

(Anestacaine, Anestacon, Ela-Max, Ela-Max Plus, Laryng-O-Jet Spray, L-Caine, Lida Mantle, Lidoderm, Lidoject 1, Lidoject 2, LidoSite, LMX 4, LMX 4 with Tegaderm, LMX 5, Truxacaine, UAD Caine, Xylocaine, Xylocaine 10% Oral, Xylocaine Dental Cartridges, Xylocaine HCl For Spinal, Xylocaine Jelly, Xylocaine-MPF, Xylocaine Topical, Xylocaine Viscous, Xylocaine Viscous Topical Solution  J, Xylocard  J, Zilactin-L  J)

FIXED-COMBINATION(S)

EMLA: lidocaine/prilocaine (an anesthetic): 2.5%/2.5%. Lidocaine with epinephrine: lidocaine/epinephrine (a sympathomimetic): 2%/1:50,000; 1%/1:100,000; 1%/1:200,000; 0.5%/1:200,000. Lidosite: lidocaine/epinephrine, (a sympathomimetic): 10%/0.1%.

 CLASSIFICATION

PHARMACOTHERAPEUTIC: Amide anesthetic. CLINICAL: Antiarrhythmic, anesthetic.

ACTION

An amide anesthetic that inhibits conduction of nerve impulses. Therapeutic Effect: Causes temporary loss of feeling and sensation. Also an antiarrhythmic that decreases depolarization, automaticity, excitability of the ventricle during diastole by direct action. Therapeutic Effect: Inhibits ventricular arrhythmias.

PHARMACOKINETICS

Completely absorbed after IM administration. Protein binding: 60% to 80%. Widely distributed. Metabolized in the liver. Primarily excreted in urine. Minimally removed by hemodialysis. Half-life: 1U2 hr.

USES

Antiarrhythmic: Rapid control of acute ventricular arrhythmias following MI, cardiac catheterization, cardiac surgery, digitalis-induced ventricular arrhythmias. Local anesthetic: Infiltration/nerve block for dental or surgical procedures, childbirth. Topical Anesthetic: Local skin disorders (minor burns, insect bites, prickly heat, skin manifestations of chickenpox, abrasions). Mucous membranes (local anesthesia of oral, nasal, laryngeal mucous membranes; local anesthesia of respiratory, urinary tracts; relief of discomfort of pruritus ani, hemorrhoids, pruritus vulvae). Dermal Patch: Treatment of shingles-related skin pain.

PRECAUTIONS

CONTRAINDICATIONS: Adams-Stokes syndrome, hypersensitivity to amide-type local anesthetics, septicemia (spinal anesthesia), supraventricular arrhythmias, Wolff-Parkinson-White syndrome. CAUTIONS: Hepatic disease, marked hypoxia, severe respiratory depression, hypovolemia, heart block, bradycardia, atrial fibrillation.

B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Crosses placenta. Distributed in breast milk. Pregnancy Category B. Children: No age-related precautions noted. Elderly: More sensitive to adverse effects. Dose, rate of infusion should be reduced. Age-related renal impairment may require dosage adjustment.

INTERACTIONS

DRUG: Anticonvulsants: May increase cardiac depressant effects. Beta-adrenergic blockers: May increase risk of toxicity. Local anesthetics: Amount absorbed from all formulations may be increased. Other antiarrhythmics: May increase cardiac effects. HERBAL: None known. FOOD: None known. LAB VALUES: IM lidocaine may increase creatine kinase (CK) level (used to diagnose acute MI). Therapeutic serum level is 1.5 to 6 mcg/ml; toxic serum level is greater than 6 mcg/ml.

AVAILABILITY (Rx)

INJECTION (FOR CONTINUOUS INFUSION [XYLOCAINE]): 4% w/v (40 mg/ml), 10% w/v (100 mg/ml), 20% w/v (200 mg/ml). INJECTION (WITH DEXTROSE FOR CONTINUOUS INFUSION): 0.1% w/v (1 mg/ml), 0.2% w/v (2 mg/ml), 0.4% w/v (4 mg/ml), 0.8% w/v (8 mg/ml). INJECTION (FOR DIRECT INJECTION [XYLOCAINE]): 1% w/v (10 mg/ml), 2% w/v (20 mg/ml). INJECTABLE SOLUTION: 0.5% (Xylocaine HCl), 1% (Anestacaine, L-Caine, Lidoject 1, Truxacaine, UAD Caine, Xylocaine HCl, Xylocaine-MPF), 1.5% (Xylocaine HCl, Xylocaine-MPF), 2% (Anestacaine, Lidoject 2, Truxacaine, Xylocaine Dental Cartridges, Xylocaine HCl, Xylocaine-MPF), 4% (Xylocaine HCl, Xylocaine-MPF), 10% (Xylocaine), 20% (Xylocaine). OINTMENT (XYLOCAINE TOPICAL): 5%. CREAM: 3% (Lida Mantle), 4% (Ela-Max, Ela-Max Plus, LMX 4, LMX 4 with Tegaderm), 5% (LMX 5). GEL (ANESTACON, XYLOCAINE JELLY, XYLOCAINE TOPICAL): 2%. TOPICAL SPRAY (XYLOCAINE 10% ORAL): 10%. TOPICAL SOLUTION: 2% (Xylocaine Viscous), 4% (Xylocaine Topical). TOPICAL FILM (LIDODERM): 5%. TOPICAL LOTION (LIDA MANTLE): 3%. DERMAL PATCH (LIDODERM): 5%. KIT (LARYNG-O-JET SPRAY): 4%.

ADMINISTRATION/HANDLING

O ALERT P Resuscitative equipment, drugs (including O2) must always be readily available when administering lidocaine by any route.

L IV

O ALERT P Use only lidocaine without preservative, clearly marked for IV use.

Reconstitution N For IV infusion, prepare solution by adding 1 g to 1 L D5W to provide concentration of 1 mg/ml (0.1%). N Commercially available preparations of 0.2%, 0.4%, and 0.8% may be used for IV infusion. Maximum concentration: 4 g/250 ml.

Rate of administration N For IV push, use 1% (10 mg/ml) or 2% (20 mg/ml). N Administer IV push at rate of 25U50 mg/min. N Administer for IV infusion at rate of 1U4 mg/min (1U4 ml); use volume control IV set.

Storage N Store at room temperature.

IM

N Use 10% (100 mg/ml); clearly identify lidocaine that is for IM use. N Give in deltoid muscle (serum level is significantly higher than if injection is given in gluteus muscle or lateral thigh).

TOPICAL

N Not for ophthalmic use. N For skin disorders, apply directly to affected area or put on gauze or bandage, which is then applied to the skin. N For mucous membrane use, apply to desired area as per manufacturer's insert. N Administer the lowest dosage possible that still provides anesthesia.

 IV INCOMPATIBILITIES

Amphotericin B complex (Abelcet, AmBisome, Amphotec), thiopental.

IV COMPATIBILITIES

Aminophylline, amiodarone (Cordarone), calcium gluconate, digoxin (Lanoxin), diltiazem (Cardizem), dobutamine (Dobutrex), dopamine (Intropin), enalapril (Vasotec), furosemide (Lasix), heparin, insulin, nitroglycerin, potassium chloride.

INDICATIONS/ROUTES/DOSAGE

RAPID CONTROL OF ACUTE VENTRICULAR ARRHYTHMIAS AFTER AN MI, CARDIAC CATHETERIZATION, CARDIAC SURGERY, OR DIGITALIS-INDUCED VENTRICULAR ARRHYTHMIAS

IM: ADULTS, ELDERLY: 300 mg (or 4.3 mg/kg). May repeat in 60U90 min.

IV: ADULTS, ELDERLY: Initially, 50U100 mg (1 mg/kg) IV bolus at rate of 25U50 mg/min. May repeat in 5 min. Give no more than 200U300 mg in 1 hr. Maintenance: 20U50 mcg/kg/min (1U4 mg/min) as IV infusion. CHILDREN, INFANTS: Initially, 0.5U1 mg/kg IV bolus; may repeat but total dose not to exceed 3U5 mg/kg. Maintenance: 10U50 mcg/kg/min as IV infusion.

DENTAL OR SURGICAL PROCEDURES, CHILDBIRTH

INFILTRATION, NERVE BLOCK: ADULTS: Local anesthetic dosage varies with procedure, degree of anesthesia, vascularity, duration. Maximum dose: 4.5 mg/kg. Do not repeat within 2 hr.

LOCAL SKIN DISORDERS (MINOR BURNS, INSECT BITES, PRICKLY HEAT, SKIN MANIFESTATIONS OF CHICKENPOX, ABRASIONS), AND MUCOUS MEMBRANE DISORDERS (LOCAL ANESTHESIA OF ORAL, NASAL, AND LARYNGEAL MUCOUS MEMBRANES; LOCAL ANESTHESIA OF RESPIRATORY, URINARY TRACT; RELIEF OF DISCOMFORT OF PRURITUS ANI, HEMORRHOIDS, PRURITUS VULVAE)

TOPICAL: ADULTS, ELDERLY: Apply to affected areas as needed.

TREATMENT OF SHINGLES-RELATED SKIN PAIN

TOPICAL (DERMAL PATCH): ADULTS, ELDERLY: Apply to intact skin over most painful area (up to 3 applications once for up to 12 hr in a 24-hr period).

SIDE EFFECTS

CNS effects are generally dose-related and of short duration. OCCASIONAL: IM: Pain at injection site. Topical: Burning, stinging, tenderness at application site. RARE: Generally with high dose: Drowsiness; dizziness; disorientation; light-headedness; tremors; apprehension; euphoria; sensation of heat, cold, or numbness; blurred or double vision; ringing or roaring in ears (tinnitus); nausea.

ADVERSE REACTIONS/TOXIC EFFECTS

Although serious adverse reactions to lidocaine are uncommon, high dosage by any route may produce cardiovascular depression, bradycardia, hypotension, arrhythmias, heart block, cardiovascular collapse, and cardiac arrest. There is a potential for malignant hyperthermia. CNS toxicity may occur, especially with regional anesthesia use, progressing rapidly from mild side effects to tremors, somnolence, seizures, vomiting, and respiratory depression. Methemoglobinemia (evidenced by cyanosis) has occurred following topical application of lidocaine for teething discomfort and laryngeal anesthetic spray.

NURSING CONSIDERATIONS

BASELINE ASSESSMENT

Question for hypersensitivity to lidocaine, amide anesthetics. Obtain baseline BP, pulse, respirations, EKG, serum electrolytes.

INTERVENTION/EVALUATION

Monitor EKG, vital signs closely during and following drug administration for cardiac performance. If EKG shows arrhythmias, prolongation of PR interval or QRS complex, inform physician immediately. Assess pulse for irregularity, quality, bradycardia. Assess BP for evidence of hypotension. Monitor for therapeutic serum level (1.5U6 mcg/ml). For lidocaine given by all routes, monitor vital signs, patient's level of consciousness (LOC). Drowsiness should be considered a warning sign of high serum levels of lidocaine. Therapeutic serum level: 1.5U6 mcg/ml; toxic serum level: greater than 6 mcg/ml.

PATIENT/FAMILY TEACHING

N Local anesthesia: Ensure that patient understands loss of feeling or sensation, need for protection until anesthetic wears off (e.g., no ambulation, including special positions for some regional anesthesia). N Oral mucous membrane anesthesia: Do not eat, drink, chew gum for 1 hr after application (swallowing reflex may be impaired, increasing risk of aspiration; numbness of tongue or buccal mucosa may lead to bite trauma).