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Lidocaine (Systemic)

Pronunciation

Pronunciation

(LYE doe kane)

Index Terms

  • Lidocaine HCl
  • Lidocaine Hydrochloride
  • Lignocaine Hydrochloride

Dosage Forms

Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product

Solution, Injection, as hydrochloride:

Xylocaine: 0.5% (50 mL); 1% (20 mL, 50 mL); 2% (10 mL, 20 mL, 50 mL) [contains methylparaben]

Xylocaine-MPF: 0.5% (50 mL); 1% (2 mL, 5 mL, 10 mL, 30 mL); 1.5% (10 mL, 20 mL); 2% (2 mL [DSC], 5 mL, 10 mL); 4% (5 mL) [methylparaben free]

Generic: 0.5% (50 mL); 1% (2 mL, 5 mL, 10 mL, 20 mL, 30 mL, 50 mL); 1.5% (20 mL [DSC]); 2% (2 mL, 5 mL, 20 mL, 50 mL)

Solution, Injection, as hydrochloride [preservative 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, Intravenous, as hydrochloride:

Xylocaine (Cardiac): 20 mg/mL (5 mL)

Generic: 20 mg/mL (5 mL [DSC]); 0.4% [4 mg/mL] (250 mL, 500 mL); 0.8% [8 mg/mL] (250 mL); 1% [10 mg/mL] (5 mL); 2% (5 mL); 5% [50 mg/mL] (2 mL)

Solution, Intravenous, as hydrochloride [preservative free]:

Generic: 20 mg/mL (5 mL); 1% [10 mg/mL] (5 mL)

Brand Names: U.S.

  • Xylocaine
  • Xylocaine (Cardiac)
  • Xylocaine-MPF

Pharmacologic Category

  • Antiarrhythmic Agent, Class Ib
  • Local Anesthetic

Pharmacology

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

Distribution

Vd: 1.5 ± 0.6 L/kg; range: 0.7 to 2.7 L/kg; alterable by many patient factors; decreased in CHF and liver disease; crosses blood-brain barrier

Metabolism

90% hepatic; active metabolites monoethylglycinexylidide (MEGX) and glycinexylidide (GX) can accumulate and may cause CNS toxicity

Excretion

Urine (<10% as unchanged drug, ~90% as metabolites)

Onset of Action

Single bolus dose: 45 to 90 seconds

Duration of Action

10 to 20 minutes

Half-Life Elimination

Biphasic: Prolonged with congestive heart failure, liver disease, shock, severe renal disease; Initial: 7 to 30 minutes; Terminal: Infants, premature: 3.2 hours, Adults: 1.5 to 2 hours

Protein Binding

60% to 80% to alpha1 acid glycoprotein

Use: Labeled Indications

Local and regional anesthesia by infiltration, nerve block, epidural, or spinal techniques; acute treatment of ventricular arrhythmias from myocardial infarction or cardiac manipulation (eg, cardiac surgery)

Note: The routine prophylactic use of lidocaine to prevent arrhythmia associated with fibrinolytic administration or to suppress isolated ventricular premature beats, couplets, runs of accelerated idioventricular rhythm, and nonsustained ventricular tachycardia (VT) is not recommended (ACCF/AHA [O'Gara, 2013]).

Use: Unlabeled

ACLS guidelines: Hemodynamically stable monomorphic ventricular tachycardia (VT) (preserved ventricular function); polymorphic VT (preserved ventricular function); drug-induced monomorphic VT; when amiodarone is not available, pulseless VT or ventricular fibrillation (VF) (unresponsive to defibrillation, CPR, and vasopressor administration)

PALS guidelines: When amiodarone is not available, pulseless VT or VF (unresponsive to defibrillation, CPR, and epinephrine administration); consider in patients with cocaine overdose to prevent arrhythmias secondary to MI

IV infusion for chronic pain syndrome

Contraindications

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

Dosing: Adult

Antiarrhythmic (ACLS 2010; ACLS 2015):

VF or pulseless VT (after defibrillation attempts, CPR, and vasopressor administration), alternative to amiodarone: IV, intraosseous (IO): Initial: 1 to 1.5 mg/kg. If refractory VF or pulseless VT, 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. Reappearance of arrhythmia during constant infusion: 0.5 mg/kg bolus and reassessment of infusion (Zipes, 2000)

Endotracheal (loading dose only): 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.

Hemodynamically stable monomorphic VT: 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 (or 14 to 57 mcg/kg/minute).

Note: Reduce maintenance infusion in patients with CHF, shock, or hepatic disease; initiate infusion at 10 mcg/kg/minute (maximum dose: 1.5 mg/minute or 20 mcg/kg/minute).

Anesthesia, local injectable: Varies with procedure, degree of anesthesia needed, vascularity of tissue, duration of anesthesia required, and physical condition of patient; maximum: 4.5 mg/kg/dose not to exceed 300 mg; do not repeat within 2 hours.

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).

Dosing: Geriatric

Refer to adult dosing.

Dosing: Pediatric

Ventricular arrhythmias, shock-refractory VF or pulseless VT (PALS [de Caen 2015]; PALS [Kleinman 2010]): Infants, Children, and Adolescents:

IV, intraosseous (I.O.):

Loading dose: 1 mg/kg; follow with continuous infusion; may administer second bolus if delay between initial bolus and start of infusion is >15 minutes

Continuous infusion: 20 to 50 mcg/kg/minute. Per the 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; flush with 5 mL of NS and follow with 5 assisted manual ventilations

Anesthesia, local injectable: Children and Adolescents: Dose varies with procedure, degree of anesthesia needed, vascularity of tissue, duration of anesthesia required, and physical condition of patient; for cutaneous infiltration, 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)

Dosing: Renal Impairment

No dosage adjustment provided in 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.

Dosing: Hepatic Impairment

Use with caution; reduce maintenance infusion. Initial: 0.75 mg/minute or 10 mcg/kg/minute; maximum dose: 1.5 mg/minute or 20 mcg/kg/minute. Monitor lidocaine concentrations closely and adjust infusion rate as necessary; consider alternative therapy.

Reconstitution

Local infiltration: Buffered lidocaine for injectable local anesthetic may be prepared: Add 2 mL of sodium bicarbonate 8.4% to 18 mL of lidocaine 1% (Christoph, 1988).

Administration

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 safe and effective alternative to venous access in children with cardiac arrest; the onset for most medications is similar to that of IV administration (PALS, 2010). In adults, IO 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).

Dietary Considerations

Premixed injection may contain corn-derived dextrose and its use is contraindicated in patients with allergy to corn-related products.

Compatibility

Stable in D5LR, D51/2NS, D5NS, D5W, LR, 1/4NS, NS.

Y-site administration: Incompatible with amphotericin B cholesteryl sulfate complex, metoprolol, pantoprazole.

Compatibility in syringe: Incompatible with cefazolin, pantoprazole.

Storage

Injection: Stable at room temperature. Stability of parenteral admixture at room temperature (25°C) is the expiration date on premixed bag; out of overwrap stability is 30 days.

Drug Interactions

Abiraterone Acetate: May increase the serum concentration of CYP1A2 Substrates. Monitor therapy

Amiodarone: May increase the serum concentration of Lidocaine (Systemic). Monitor therapy

Aprepitant: May increase the serum concentration of CYP3A4 Substrates. Monitor therapy

Beta-Blockers: May increase the serum concentration of Lidocaine (Systemic). Monitor therapy

Bosentan: May decrease the serum concentration of CYP3A4 Substrates. Monitor therapy

Bupivacaine (Liposomal): Lidocaine (Systemic) may enhance the adverse/toxic effect of Bupivacaine (Liposomal). Management: Liposomal bupivacaine should not be administered with topical lidocaine. Liposomal bupivacaine may be administered 20 minutes or more after the administration of lidocaine. Consider therapy modification

Cannabis: May decrease the serum concentration of CYP1A2 Substrates. Monitor therapy

Conivaptan: May increase the serum concentration of CYP3A4 Substrates. Avoid combination

CYP1A2 Inducers (Strong): May increase the metabolism of CYP1A2 Substrates. Management: Consider an alternative for one of the interacting drugs. Some combinations may be specifically contraindicated. Consult appropriate manufacturer labeling. Consider therapy modification

CYP1A2 Inhibitors (Moderate): May decrease the metabolism of CYP1A2 Substrates. Monitor therapy

CYP1A2 Inhibitors (Strong): May decrease the metabolism of CYP1A2 Substrates. Consider therapy modification

CYP3A4 Inducers (Moderate): May decrease the serum concentration of CYP3A4 Substrates. Monitor therapy

CYP3A4 Inducers (Strong): May increase the metabolism of CYP3A4 Substrates. Management: Consider an alternative for one of the interacting drugs. Some combinations may be specifically contraindicated. Consult appropriate manufacturer labeling. Consider therapy modification

CYP3A4 Inhibitors (Moderate): May decrease the metabolism of CYP3A4 Substrates. Monitor therapy

CYP3A4 Inhibitors (Strong): May decrease the metabolism of CYP3A4 Substrates. Consider therapy modification

Cyproterone: May decrease the serum concentration of CYP1A2 Substrates. Monitor therapy

Dabrafenib: May decrease the serum concentration of CYP3A4 Substrates. Management: Seek alternatives to the CYP3A4 substrate when possible. If concomitant therapy cannot be avoided, monitor clinical effects of the substrate closely (particularly therapeutic effects). Consider therapy modification

Dapsone (Topical): May enhance the adverse/toxic effect of Methemoglobinemia Associated Agents. Monitor therapy

Dasatinib: May increase the serum concentration of CYP3A4 Substrates. Monitor therapy

Deferasirox: May decrease the serum concentration of CYP3A4 Substrates. Monitor therapy

Deferasirox: May increase the serum concentration of CYP1A2 Substrates. 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. Monitor therapy

Enzalutamide: May decrease the serum concentration of CYP3A4 Substrates. Management: Concurrent use of enzalutamide with CYP3A4 substrates that have a narrow therapeutic index should be avoided. Use of enzalutamide and any other CYP3A4 substrate should be performed with caution and close monitoring. Consider therapy modification

Etravirine: May decrease the serum concentration of Lidocaine (Systemic). Monitor therapy

Fosaprepitant: May increase the serum concentration of CYP3A4 Substrates. Monitor therapy

Fusidic Acid (Systemic): May increase the serum concentration of CYP3A4 Substrates. Avoid combination

Hyaluronidase: May enhance the adverse/toxic effect of Local Anesthetics. Monitor therapy

Idelalisib: May increase the serum concentration of CYP3A4 Substrates. Avoid combination

Ivacaftor: May increase the serum concentration of CYP3A4 Substrates. Monitor therapy

Luliconazole: May increase the serum concentration of CYP3A4 Substrates. Monitor therapy

MiFEPRIStone: May increase the serum concentration of CYP3A4 Substrates. Management: Minimize doses of CYP3A4 substrates, and monitor for increased concentrations/toxicity, during and 2 weeks following treatment with mifepristone. Avoid cyclosporine, dihydroergotamine, ergotamine, fentanyl, pimozide, quinidine, sirolimus, and tacrolimus. Consider therapy modification

Mitotane: May decrease the serum concentration of CYP3A4 Substrates. Management: Doses of CYP3A4 substrates may need to be adjusted substantially when used in patients being treated with mitotane. Consider therapy modification

Netupitant: May increase the serum concentration of CYP3A4 Substrates. 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. Management: Monitor patients for signs of methemoglobinemia (e.g., hypoxia, cyanosis) when nitric oxide is used in combination with other agents associated with development of methemoglobinemia. Avoid lidocaine/prilocaine. Monitor therapy

Obeticholic Acid: May increase the serum concentration of CYP1A2 Substrates. Monitor therapy

Palbociclib: May increase the serum concentration of CYP3A4 Substrates. Monitor therapy

Peginterferon Alfa-2b: May increase the serum concentration of CYP1A2 Substrates. 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. Monitor therapy

Saquinavir: May enhance the arrhythmogenic effect of Lidocaine (Systemic). Saquinavir may increase the serum concentration of Lidocaine (Systemic). Avoid combination

Siltuximab: May decrease the serum concentration of CYP3A4 Substrates. Monitor therapy

Simeprevir: May increase the serum concentration of CYP3A4 Substrates. Monitor therapy

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. Monitor therapy

St John's Wort: May decrease the serum concentration of CYP3A4 Substrates. Management: Consider an alternative for one of the interacting drugs. Some combinations may be specifically contraindicated. Consult appropriate manufacturer labeling. Consider therapy modification

Stiripentol: May increase the serum concentration of CYP3A4 Substrates. Management: Use of stiripentol with CYP3A4 substrates that are considered to have a narrow therapeutic index should be avoided due to the increased risk for adverse effects and toxicity. Any CYP3A4 substrate used with stiripentol requires closer monitoring. Consider therapy modification

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. Monitor therapy

Telaprevir: May enhance the adverse/toxic effect of Lidocaine (Systemic). Telaprevir may increase the serum concentration of Lidocaine (Systemic). Monitor therapy

Teriflunomide: May decrease the serum concentration of CYP1A2 Substrates. Monitor therapy

Tetracaine (Topical): May enhance the adverse/toxic effect of Methemoglobinemia Associated Agents. Monitor therapy

TiZANidine: CYP1A2 Inhibitors (Weak) may increase the serum concentration of TiZANidine. Management: Avoid these combinations when possible. If combined use cannot be avoided, initiate tizanidine at an adult dose of 2 mg and increase in 2-4 mg increments based on patient response. Monitor for increased effects of tizanidine, including adverse reactions. Consider therapy modification

Tocilizumab: May decrease the serum concentration of CYP3A4 Substrates. Monitor therapy

Vemurafenib: May increase the serum concentration of CYP1A2 Substrates. Management: Consider alternatives to such combinations whenever possible, particularly if the CYP1A2 substrate has a relatively narrow therapeutic index. Consider therapy modification

Adverse Reactions

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, arterial spasm, cardiac arrhythmia, circulatory shock, edema, flushing, heart block, hypotension (including following spinal anesthesia), local thrombophlebitis, sinus node depression, 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% (Limited to important or life-threatening): Asystole, dermatological reaction, diplopia (following spinal anesthesia), methemoglobinemia

Warnings/Precautions

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.

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. Use products containing epinephrine cautiously in patients with significant vascular disease, compromised blood flow, or during or following general anesthesia (increased risk of arrhythmias). Adjust the dose for the 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.

Monitoring Parameters

Liver function tests, lidocaine concentrations, ECG; in patients requiring drug >24 hrs, blood level monitoring recommended; consult individual institutional policies and procedures

Pregnancy Risk Factor

B

Pregnancy Considerations

Adverse events were not observed in animal reproduction studies. Lidocaine and its metabolites cross the placenta and can be detected in the fetal circulation following injection (Cavalli, 2004; Mitani, 1987). Adverse reactions in the fetus/neonate may affect the CNS, heart, or peripheral vascular tone. Fetal heart monitoring is recommended. Lidocaine injection is approved for obstetric analgesia. Lidocaine administered by local infiltration is used to provide analgesia prior to episiotomy and during repair of obstetric lacerations (ACOG, 2002). 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. When used as an antiarrhythmic, ACLS guidelines recommend using the same dose that would be used in a nonpregnant woman (Vanden Hoek, 2010).

Patient Education

• Discuss specific use of drug and side effects with patient as it relates to treatment. (HCAHPS: During this hospital stay, were you given any medicine that you had not taken before? Before giving you any new medicine, how often did hospital staff tell you what the medicine was for? How often did hospital staff describe possible side effects in a way you could understand?)

• Patient may experience petechiae. Have patient report immediately to prescriber severe injection site bleeding or irritation, burning, bruising, difficulty breathing, slow breathing, shallow breathing, tachycardia, bradycardia, arrhythmia, confusion, severe anxiety, burning or numbness feeling, agitation, vision changes, tinnitus, severe dizziness, passing out, severe headache, twitching, fatigue, seizures, severe vomiting, or severe nausea (HCAHPS).

• Educate patient about signs of a significant reaction (eg, wheezing; chest tightness; fever; itching; bad cough; blue skin color; seizures; or swelling of face, lips, tongue, or throat). Note: This is not a comprehensive list of all side effects. Patient should consult prescriber for additional questions.

Intended Use and Disclaimer: Should not be printed and given to patients. This information is intended to serve as a concise initial reference for health care professionals to use when discussing medications with a patient. You must ultimately rely on your own discretion, experience, and judgment in diagnosing, treating, and advising patients.

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