Local anaesthetic agents, such as Lidocaine, are useful in some chronic pain indications, in acute pain it is mostly used intravenously in major surgeries with the objective of sparing opioid use which may decrease post operative ileus and promote earlier gastrointestinal motility.

Despite fears of toxicity with this technique, little is seen at the doses recommended in this guideline. It is inexpensive, safe with low toxicity relative to opioids and other analgesics.

Lidocaine has analgesic, anti-hyperalgesia and anti-inflammatory effects.

This results in:

• opioid sparing effects which may decrease post operative ileus in abdominal surgery, particularly colorectal and prostate surgery.

• analgesia in refractory neuropathic and cancer pain

• reduction of opioid tolerance 

Lidocaine was previously known as lignocaine

• This document covers the use of intravenous Lidocaine for acute pain in the perioperative period in Operating Theatre and Recovery.

• For cardiac indications see DRG0024 Lignocaine (Lidocaine) - Intravenous and Endotracheal (Cardiac)

• Second or third degree heart block (without pacemaker).

• Severe sinoatrial block or intraventricular block (without pacemaker).

• Stokes-Adams syndrome (without pacemaker)

• Lignocaine products containing adrenaline: not suitable for IV use.

• Known history of allergy or hypersensitivity to Lidocaine or other amide type local anaesthetics such as prilocaine, mepivacaine or bupivacaine.

• Uncontrolled seizures

PRECAUTIONS

• Heart failure lignocaine may worsen condition, also the clearance of lignocaine is reduced and toxicity may be increased

• Impaired renal function. Impairment of renal function is unlikely to affect Lidocaine clearance in the short term (24 hours). However toxicity due to accumulation of Lidocaine and its metabolites may develop with prolonged or repeated administration.

• Impaired hepatic function. Patients with reduced hepatic blood flow or function, and those on prolonged infusions of Lidocaine, have a longer Lidocaine half-life and lower clearance and may, therefore, require a reduction in dosage.

• Hypovolaemia, bradycardia, hypoxia, acid-base disturbances, cardiogenic shock or electrolyte disturbances (particularly hypokalaemia or hyperkalaemia) increased risk of arrhythmia with lignocaine use, correct before use where possible.

USE IN THE ELDERLY.

A reduction in dosage may be necessary for elderly patients with compromised cardiovascular and/or hepatic function and/or on prolonged infusions.

USE IN PREGNANCY. (Category A)

Seek specialist advice before prescribing, information may update regularly. Refer to the Royal Women's Pregnancy & Breastfeeding Guide for more information.

USE IN LACTATION.

Lidocaine passes into breast milk. The amount of Lidocaine appearing in breast milk from a lactating mother receiving parenteral Lidocaine is unlikely to lead to a significant accumulation of the parent drug in the breastfed infant. The remote possibility of an idiosyncratic or allergic reaction in the breastfed infant from Lidocaine remains to be determined.

USE IN CHILDREN.

The safety of Lidocaine in the treatment of pain in children has not been established.

PRESENTATION

Xylocard 500 ampoule contains Lidocaine 10% (500 mg in 5 mL)

Infusion solution is clear, colourless, sterile and isotonic

STORAGE

Store ampoules below 25C. Prepared infusion solution is stable for 24 hours below 25C.

DILUTION

Dilute 1000 mg Lidocaine with sodium chloride 0.9% to a final volume of 50 mL

Final concentration: 20 mg/mL

PHARMACOLOGY & PHARMACOKINETICS

Lidocaine is an amide local anaesthetic that acts by non-selectively blocking sodium channels, resulting in analgesia. At low systemic doses, lidocaine blocks nociceptive neurons without interfering with normal sensory, motor or cardiac functions. The onset of action is one to five minutes. A continuous infusion without bolus takes 4 to 8 hours to reach steady state. Metabolism is 90% hepatic, depending on the patient's hepatic metabolic capacity and hepatic blood flow. Less than 10% of Lidocaine is excreted unchanged via the kidneys. The initial half life is approximately 7 to 10 minutes during the first half hour after IV bolus injection. After the initial phase, the half life is 90-120 minutes however this is prolonged in heart failure, liver disease, shock and severe renal impairment.

DRUG INTERACTIONS

Beta blockers may increase serum Lidocaine concentrations; Phenytoin may stimulate hepatic metabolism of Lidocaine, thereby decrease serum Lidocaine concentration. Medications with a cardiac depressive effect or antiarrhythmic effect may cause an increased risk of cardiac abnormalities in combination with Lidocaine.

• Alaris PK Syringe Pump (in Operating Theatres/ Recovery)

DOSAGE AND ADMINISTRATION

For example,

In addition to the Lidocaine infusion, IV maintenance fluids at minimum rate of 42 mL/hr or 1000 mL 24 hourly should be prescribed.

DOSE MODIFICATION

Renal/hepatic dysfunction: titrate to effect and monitor for toxicity

TOXICITY

See CPG0199 Local Anaesthetic Toxicity - Management Using Lipid Rescue and contact Victorian Poisons Information Centre on 131 126 .