THE DOSE OF LIDOCAINE HYDROCHLORIDE USED FOR LOCAL ANAESTHESIA DEPENDS ON THE SITE OF INJECTION AND THE PROCEDURE USED. SPECIFIC LICENSED DOSES FOR INDIVIDUAL PROCEDURES ARE NOT ALWAYS AVAILABLE IN THE UK, ALTHOUGH US PRODUCT INFORMATION OFTEN INCLUDES THEM. WHEN GIVEN WITH ADRENALINE, THE SUGGESTED GENERAL MAXIMUM SINGLE DOSE OF LIDOCAINE HYDROCHLORIDE IS 500 MG; WITHOUT ADRENALINE, THE RECOMMENDED MAXIMUM SINGLE DOSE IN THE UK IS 200 MG AND IN THE USA, 300 MG, EXCEPT FOR SPINAL ANAESTHESIA. LIDOCAINE HYDROCHLORIDE SOLUTIONS CONTAINING ADRENALINE 1 IN 200 000 ARE USED FOR INFILTRATION ANAESTHESIA AND NERVE BLOCKS INCLUDING EPIDURAL BLOCK; HIGHER CONCENTRATIONS OF ADRENALINE ARE SELDOM NECESSARY, EXCEPT IN DENTISTRY, WHERE SOLUTIONS OF LIDOCAINE HYDROCHLORIDE WITH ADRENALINE 1 IN 80 000 ARE WIDELY USED. DOSES SHOULD BE REDUCED IN CHILDREN, THE ELDERLY, AND IN DEBILITATED PATIENTS. A TEST DOSE, PREFERABLY WITH ADRENALINE, SHOULD BE GIVEN BEFORE STARTING EPIDURAL BLOCK TO DETECT INADVERTENT INTRAVASCULAR OR SUBARACHNOID DOSAGE.
THE FOLLOWING DOSES HAVE BEEN RECOMMENDED FOR INDIVIDUAL LOCAL ANAESTHETIC PROCEDURES IN THE USA:
FOR PERCUTANEOUS INFILTRATION ANAESTHESIA, 5 TO 300 MG (1 TO 60 ML OF A 0.5% SOLUTION, OR 0.5 TO 30 ML OF A 1% SOLUTION).
THE DOSAGE IN PERIPHERAL NERVE BLOCK DEPENDS ON THE ROUTE. FOR BRACHIAL PLEXUS BLOCK 225 TO 300 MG (15 TO 20 ML) AS A 1.5% SOLUTION IS USED; FOR INTERCOSTAL NERVE BLOCK 30 MG (3 ML) IS GIVEN AS A 1% SOLUTION; FOR PARACERVICAL BLOCK A 1% SOLUTION IS USED IN A DOSE OF 100 MG (10 ML) ON EACH SIDE, REPEATED NOT MORE FREQUENTLY THAN EVERY 90 MINUTES; FOR PARAVERTEBRAL BLOCK A 1% SOLUTION MAY BE USED IN DOSES OF 30 TO 50 MG (3 TO 5 ML); A 1% SOLUTION IS RECOMMENDED FOR PUDENDAL BLOCK IN DOSES OF 100 MG (10 ML) ON EACH SIDE; FOR RETROBULBAR BLOCK A 4% SOLUTION MAY BE USED IN DOSES OF 120 TO 200 MG (3 TO 5 ML).
FOR SYMPATHETIC NERVE BLOCK A 1% SOLUTION IS RECOMMENDED; DOSES ARE 50 MG (5 ML) FOR CERVICAL BLOCK AND 50 TO 100 MG (5 TO 10 ML) FOR LUMBAR BLOCK.
FOR EPIDURAL ANAESTHESIA 2 TO 3 ML OF SOLUTION IS NEEDED FOR EACH DERMATOME TO BE ANAESTHETISED BUT USUAL TOTAL DOSES AND RECOMMENDED CONCENTRATIONS ARE: LUMBAR EPIDURAL 250 TO 300 MG (25 TO 30 ML) AS A 1% SOLUTION FOR ANALGESIA AND 225 TO 300 MG (15 TO 20 ML) AS A 1.5% SOLUTION OR 200 TO 300 MG (10 TO 15 ML) AS A 2% SOLUTION FOR ANAESTHESIA, AND FOR THORACIC EPIDURAL A 1% SOLUTION MAY BE USED AT DOSES OF 200 TO 300 MG (20 TO 30 ML). IN OBSTETRIC CAUDAL ANALGESIA UP TO 300 MG (30 ML) IS USED AS A 0.5% OR 1% SOLUTION AND IN SURGICAL CAUDAL ANALGESIA A 1.5% SOLUTION MAY BE USED IN DOSES OF 225 TO 300 MG (15 TO 20 ML). FOR CONTINUOUS EPIDURAL ANAESTHESIA, THE MAXIMUM DOSES SHOULD NOT BE REPEATED MORE FREQUENTLY THAN EVERY 90 MINUTES.
A HYPERBARIC SOLUTION OF 1.5% OR 5% LIDOCAINE HYDROCHLORIDE IN GLUCOSE 7.5% SOLUTION IS AVAILABLE FOR SPINAL ANAESTHESIA; ADRENALINE SHOULD NOT BE USED. DOSES OF UP TO 50 MG (1 ML) AS A 5% SOLUTION AND 9 TO 15 MG (0.6 TO 1 ML) AS A 1.5% SOLUTION HAVE BEEN USED DURING LABOUR FOR A NORMAL VAGINAL DELIVERY. UP TO 75 MG (1.5 ML) AS THE 5% SOLUTION HAS BEEN USED FOR CAESAREAN SECTION AND 75 TO 100 MG (1.5 TO 2 ML) FOR OTHER SURGICAL PROCEDURES.
FOR INTRAVENOUS REGIONAL ANAESTHESIA A 0.5% SOLUTION WITHOUT ADRENALINE HAS BEEN USED IN DOSES OF 50 TO 300 MG (10 TO 60 ML); A MAXIMUM DOSE OF 4 MG/KG HAS BEEN RECOMMENDED FOR ADULTS.
LIDOCAINE MAY BE USED IN A VARIETY OF FORMULATIONS FOR SURFACE ANAESTHESIA.
LIDOCAINE OINTMENT IS USED FOR ANAESTHESIA OF SKIN AND MUCOUS MEMBRANES WITH A MAXIMUM RECOMMENDED TOTAL DOSE OF 20 G OF 5% OINTMENT (EQUIVALENT TO 1 G OF LIDOCAINE BASE) IN 24 HOURS.
GELS ARE USED FOR ANAESTHESIA OF THE URINARY TRACT AND THE DOSE USED VARIES IN DIFFERENT COUNTRIES. THE MANUFACTURERS IN THE UK HAVE SUGGESTED THE FOLLOWING DOSES GIVEN AS A 2% GEL: IN FEMALES 60 TO 100 MG OF LIDOCAINE HYDROCHLORIDE INSERTED INTO THE URETHRA SEVERAL MINUTES BEFORE EXAMINATION; IN MALES 200 MG INSTILLED INITIALLY FOLLOWED BY 60 TO 100 MG. A 1% GEL MAY ALSO BE USED. THE DOSES USED IN THE USA ARE SIMILAR: IN FEMALES 60 TO 100 MG OF LIDOCAINE HYDROCHLORIDE AS A 2% GEL IS INSERTED INTO THE URETHRA SEVERAL MINUTES BEFORE EXAMINATION; IN MALES 100 TO 200 MG IS USED BEFORE CATHETERISATION AND 600 MG BEFORE SOUNDING OR CYSTOSCOPY.
A GEL MAY ALSO BE APPLIED FOR THE TREATMENT OF MAJOR APHTHAE IN IMMUNOCOMPROMISED PATIENTS; A DOSE OF 20 TO 30 MG (2 TO 3 ML) AS A 1% GEL OR 40 TO 60 MG (2 TO 3 ML) AS A 2% GEL IS USED. A MAXIMUM VOLUME OF UP TO 15 ML IS RECOMMENDED WITHIN 24 HOURS.
TOPICAL SOLUTIONS ARE USED FOR SURFACE ANAESTHESIA OF MUCOUS MEMBRANES OF THE MOUTH, THROAT, AND UPPER GASTROINTESTINAL TRACT. FOR PAINFUL CONDITIONS OF THE MOUTH AND THROAT A 2% SOLUTION MAY BE USED: 300 MG (15 ML) MAY BE RINSED AND EJECTED OR, FOR PHARYNGEAL PAIN, THE SOLUTION IS GARGLED AND SWALLOWED IF NECESSARY; IT SHOULD NOT BE USED MORE FREQUENTLY THAN EVERY 3 HOURS. THE RECOMMENDED MAXIMUM DAILY DOSE IN THE USA FOR TOPICAL ORAL SOLUTIONS IS 2.4 G. DOSES OF 40 TO 300 MG AS A 4% SOLUTION (1 TO 7.5 ML) ARE USED BEFORE BRONCHOSCOPY, BRONCHOGRAPHY, LARYNGOSCOPY, OESOPHAGOSCOPY, ENDOTRACHEAL INTUBATION, AND BIOPSY IN THE MOUTH AND THROAT. LIDOCAINE IN A STRENGTH OF 10% HAS ALSO BEEN USED AS A SPRAY FOR APPLICATION TO MUCOUS MEMBRANES FOR THE PREVENTION OF PAIN DURING VARIOUS PROCEDURES INCLUDING USE IN OTORHINOLARYNGOLOGY, DENTISTRY, INTRODUCTION OF INSTRUMENTS INTO THE RESPIRATORY AND GASTROINTESTINAL TRACTS, AND IN OBSTETRICS. THE DOSE DEPENDS ON THE EXTENT OF THE SITE TO BE ANAESTHETISED; 10 TO 50 MG IS GENERALLY SUFFICIENT FOR DENTISTRY AND OTORHINOLARYNGOLOGY; FOR OTHER PROCEDURES, THE MAXIMUM DOSE IN A 24-HOUR PERIOD IS 200 MG. FOR LARYNGOTRACHEAL ANAESTHESIA 160 MG OF LIDOCAINE HYDROCHLORIDE AS A 4% SOLUTION IS SPRAYED OR INSTILLED AS A SINGLE DOSE INTO THE LUMEN OF THE LARYNX AND TRACHEA.
LIDOCAINE IS USED RECTALLY AS SUPPOSITORIES, SPRAYS, OINTMENTS, AND CREAMS IN THE TREATMENT OF HAEMORRHOIDS AND OTHER PAINFUL PERIANAL CONDITIONS.
EYE DROPS CONTAINING LIDOCAINE HYDROCHLORIDE 4% WITH FLUORESCEIN ARE USED IN TONOMETRY.
A EUTECTIC MIXTURE CONTAINING LIDOCAINE BASE 2.5% AND PRILOCAINE BASE 2.5% IS APPLIED AS A CREAM UNDER AN OCCLUSIVE DRESSING TO PRODUCE SURFACE ANAESTHESIA OF THE SKIN BEFORE PROCEDURES REQUIRING NEEDLE PUNCTURE, SURGICAL TREATMENT OF LOCALISED LESIONS, AND SPLIT SKIN GRAFTING; IT HAS BEEN USED SIMILARLY, BUT WITHOUT AN OCCLUSIVE DRESSING, BEFORE REMOVAL OF GENITAL WARTS .
OTHER METHODS OF DERMAL DELIVERY INCLUDE A TRANSDERMAL PATCH OF LIDOCAINE 5% FOR THE TREATMENT OF PAIN ASSOCIATED WITH POSTHERPETIC NEURALGIA, AND AN IONTOPHORETIC DRUG DELIVERY SYSTEM INCORPORATING LIDOCAINE AND ADRENALINE.
FOR THE TREATMENT OF VENTRICULAR ARRHYTHMIAS LIDOCAINE IS GIVEN INTRAVENOUSLY AS THE HYDROCHLORIDE. IT MAY BE USED IN ADVANCED CARDIAC LIFE SUPPORT FOR CARDIAC ARREST DUE TO VENTRICULAR FIBRILLATION AND PULSELESS VENTRICULAR TACHYCARDIA WHEN DIRECT CURRENT SHOCKS (TOGETHER WITH ADRENALINE) HAVE FAILED TO RESTORE A NORMAL RHYTHM. FOR ADULTS, A USUAL DOSE OF 1 TO 1.5 MG/KG CAN BE GIVEN AND REPEATED AS NECESSARY TO A MAXIMUM TOTAL DOSE OF 3 MG/KG. THE ENDOTRACHEAL ROUTE HAS BEEN EMPLOYED WHEN INTRAVENOUS ACCESS CANNOT BE OBTAINED, ALTHOUGH DOSES SHOULD PROBABLY BE LARGER THAN THOSE EMPLOYED INTRAVENOUSLY; THE PRECISE ENDOTRACHEAL DOSE HAS NOT YET BEEN ESTABLISHED, HOWEVER.
LIDOCAINE IS ALSO USED IN OTHER VENTRICULAR ARRHYTHMIAS IN WHICH THE PATIENT IS IN A MORE STABLE CONDITION. IN THESE CIRCUMSTANCES LIDOCAINE HYDROCHLORIDE IS USUALLY GIVEN AS A LOADING DOSE FOLLOWED BY AN INFUSION. USUAL DOSES ARE 50 TO 100 MG OR 1 TO 1.5 MG/KG AS A DIRECT INTRAVENOUS INJECTION AT A RATE OF 25 TO 50 MG/MINUTE. IF NO EFFECT IS SEEN WITHIN 5 TO 10 MINUTES OF THIS LOADING DOSE, IT MAY BE REPEATED ONCE OR TWICE TO A MAXIMUM DOSE OF 200 TO 300 MG IN 1 HOUR. A CONTINUOUS INTRAVENOUS INFUSION IS USUALLY COMMENCED AFTER LOADING, AT A DOSE OF 1 TO 4 MG/MINUTE. IT IS RARELY NECESSARY TO CONTINUE THIS INFUSION FOR LONGER THAN 24 HOURS, BUT IN THE EVENT THAT A LONGER INFUSION IS REQUIRED, THE DOSE MAY NEED TO BE REDUCED TO AVOID POTENTIAL TOXICITY RESULTING FROM AN INCREASE IN THE HALF-LIFE. DOSAGE MAY NEED TO BE REDUCED IN THE ELDERLY AND IN PATIENTS WITH HEART FAILURE OR LIVER DISORDERS.
IN EMERGENCY SITUATIONS, LIDOCAINE HYDROCHLORIDE HAS ALSO BEEN GIVEN FOR ARRHYTHMIAS BY INTRAMUSCULAR INJECTION INTO THE DELTOID MUSCLE IN A DOSE OF 300 MG, REPEATED IF NECESSARY AFTER 60 TO 90 MINUTES.
HICCUP.
FOR THE MANAGEMENT OF INTRACTABLE HICCUPS SEE UNDER CHLORPROMAZINE. LIDOCAINE IS ONE OF A LARGE NUMBER OF DRUGS THAT HAS BEEN TRIED IN THE TREATMENT OF HICCUPS WITHOUT STRONG EVIDENCE OF THEIR EFFICACY. IT HAS BEEN GIVEN INTRAVENOUSLY, OR IN THE FORM OF A 2% VISCOUS SOLUTION TAKEN BY MOUTH. NEBULISED LIDOCAINE HAS ALSO BEEN TRIED.
NEUROPATHIC PAIN SYNDROMES.
LIDOCAINE MAY BE USEFUL IN THE MANAGEMENT OF SOME TYPES OF NEUROPATHIC PAIN SYNDROMES . THE PAIN OF POSTHERPETIC NEURALGIA HAS BEEN SIGNIFICANTLY REDUCED BY THE APPLICATION OF LIDOCAINE 5% TRANSDERMAL PATCHES; INTRAVENOUS LIDOCAINE AND A EUTECTIC MIXTURE OF LIDOCAINE AND PRILOCAINE HAVE ALSO BEEN OF BENEFIT. OTHER SYNDROMES WHERE INTRAVENOUS LIDOCAINE THERAPY HAS BEEN TRIED INCLUDE DIABETIC NEUROPATHY AND CENTRAL NEUROPATHIC PAIN ASSOCIATED WITH STROKE OR SPINAL CORD INJURY.
LIDOCAINE HAS BEEN INSTILLED INTRAPLEURALLY AS A 1% SOLUTION IN DOSES OF UP TO 300 MG TO RELIEVE THE SEVERE CHEST PAIN ASSOCIATED WITH THE USE OF TETRACYCLINE FOR PLEURODESIS. WHILE THE LARGER DOSES WERE SIGNIFICANTLY MORE EFFECTIVE TOXIC PLASMA CONCENTRATIONS WERE LESS LIKELY TO OCCUR IF A DOSE OF 3 MG/KG OR LESS WAS USED.
LIDOCAINE WAS USED INSTEAD OF DIAZEPAM FOR 42 EPISODES OF STATUS EPILEPTICUS IN 36 PATIENTS WHO EITHER HAD LIMITED PULMONARY RESERVE OR WHO HAD NOT RESPONDED TO INTRAVENOUS DIAZEPAM. LIDOCAINE 1.5 TO 2 MG/KG (USUALLY A DOSE OF 100 MG) WAS GIVEN AS A SINGLE INTRAVENOUS DOSE OVER 2 MINUTES. THIS DOSE WAS REPEATED ONCE IF THERE WAS NO POSITIVE RESPONSE TO THE FIRST DOSE (11 EPISODES) OR IF THE SEIZURES RECURRED (19 EPISODES). SUBSEQUENTLY A CONTINUOUS INFUSION OF LIDOCAINE AT A RATE OF 3 TO 4 MG/KG PER HOUR WAS GIVEN IN THE 7 EPISODES THAT RECURRED AFTER THE SECOND DOSE; 5 OF THESE SHOWED A POSITIVE RESPONSE. THE 11 EPISODES NOT RESPONDING TO THE FIRST DOSE DID NOT RESPOND TO THE SECOND DOSE OR TO A CONTINUOUS INFUSION. IN A RETROSPECTIVE ANALYSIS4 OF 37 CHILDREN WITH STATUS EPILEPTICUS, LIDOCAINE WAS EFFECTIVE IN ONLY 19 OF 53 EPISODES; HOWEVER, IN A FEW CASES IT WAS EFFECTIVE WHERE OTHER DRUGS HAD FAILED, AND THOSE PATIENTS WHO RESPONDED DID SO RAPIDLY (WITHIN 5 MINUTES OF BEING GIVEN THE DRUG).