Drugs List

Therapeutic Indications

Uses

Local anaesthesia for use in infiltration anaesthesia, minor and major nerve blocks.

Administration

By perineural injection for infiltration anaesthesia.

Doses should be injected slowly at a rate of 100-200mg/minute or in increments.

Duration of block (with adrenaline) is about 90 minutes.

Contraindications

Children under 1 year.
Porphyria - if to be given intravenously

Must NOT be used for anaesthesia of the fingers, toes, tip of the nose, ears or penis because of the vasoconstrictor effect of adrenaline.

Precautions and Warnings

Lidocaine with adrenaline should only be used by those with the necessary training and experience.

Careful aspiration before and during injection is recommended to prevent intravascular administration and subsequent acute toxic reactions.

The patient's vital signs should be observed closely during the injection and verbal contact maintained. If toxic symptoms occur, the injection should be stopped immediately.

Resuscitation facilities must be available when the injection is administered.

Use with caution in patients with:
Epilepsy
Impaired cardiac conduction
Impaired respiratory function
Hepatic impairment
Severe renal impairment.
Elderly
Severe shock
Myasthenia gravis
Debilitation
Hypovolaemia

Pregnancy - see Pregnancy section

Breastfeeding - see Breastfeeding section

Solutions containing adrenaline must be used with caution in patients with:
Hypertension
Cardiac disease
Cerebrovascular impairment
Hyperthyroidism
Diabetes (advanced)

The condition of the patient should be optimised before major blocks are produced.

ECG monitoring should be considered in patients taking concurrent anti-arrhythmic drugs.

Administration into inflamed or infected tissues should be avoided as increased absorption into the blood can result in increased systemic side effects. The local anaesthetic effect may be reduced by the altered local pH of such tissues.

Administration into the head or neck area may lead to accidental arterial administration leading to cerebral symptoms.
Paracervical block can cause foetal bradycardia or tachycardia. The foetal heart rate should therefore be monitored closely.

The solution for injection contains sodium metabisulfite, which can cause allergic reactions including anaphylaxis and potentially life-threatening asthmatic reactions in susceptible people. Sulfite sensitivity is more common in patients with asthma.

Mental function and co-ordination may be affected by anaesthesia and the patient's ability to drive and operate machinery may therefore be reduced.

Not all available products are licensed for all age groups.

Use in Porphyria

Intravenous lidocaine is considered unsafe in acute porphyria.

Pregnancy and Lactation

Pregnancy

Must not be given during early pregnancy unless the potential benefits outweigh the possible risks.

The adrenaline component of the injection has the potential to decrease uterine blood flow and contractility, especially after accidental intravascular administration in the mother.

Foetal adverse effects, such as foetal bradycardia, seem to be more common in paracervical anaesthesia. High concentrations of the anaesthetic reaching the foetus may cause these effects. Large doses during delivery can also cause neonatal respiratory depression and hypotonia after paracervical block.

Briggs (2011) and Schaefer (2007) both indicate that lidocaine, when administered systemically to a pregnant woman, is able to cross the placenta without any adverse effect on pregnancy. Schaefer (2007) concludes that local anaesthetics with adrenaline may be used during pregnancy.

Animal studies have not demonstrated evidence of foetal harm.

The use of all medication in pregnancy should be avoided whenever possible; particularly in the first trimester. Non-drug treatments should also be considered. When essential, a medication with the best safety record over time should be chosen, employing the lowest effective dose for the shortest possible time. Polypharmacy should be avoided. Teratogens taken in the pre-embryonic period, often quoted as lasting until 14-17 days post-conception, are believed to have an all-or-nothing effect. Where drugs have a short half-life, and when the date of conception is certain, this may allow women to be reassured where drug exposure has occurred within this time frame. Further advice may be available from the UK National Teratology Information Service (NTIS) and through ToxBase, available via password on the internet ( www.toxbase.org ) or if this is unavailable at the backup site ( www.toxbasebackup.org ).

Known human teratogen? - No

Crosses placenta? - Yes, both lidocaine and adrenaline

Effects on foetus - Paracervical block can sometimes cause foetal bradycardia / tachycardia

Lactation

Use with caution during breastfeeding. There is limited information available on the combination of lidocaine with adrenaline. Lidocaine enters breast milk but the levels are generally low and lidocaine is poorly absorbed by the infant. Hale (2010) indicates that although likely to be secreted in milk, adrenaline is rapidly destroyed by the gastrointestinal tract, it is unlikely any would be absorbed.

Neonates, infants born prematurely, those with low birth weight, those with an unstable gastrointestinal function or who have serious illnesses may require special consideration. For any infant, if a drug is prescribed to the nursing mother, it should be at the lowest practical dose and for the shortest time. When drug administration is unavoidable and breastfeeding is to continue, minimisation of exposure of the infant to the drug may sometimes be achieved by timing the maternal doses to just after a feeding episode. Infants exposed to drugs via breast milk should be monitored for unusual signs or symptoms. Interactions between the drug received by the infant from the mother's milk and medication prescribed for the infant should also be considered, for example, when the drug given to the infant may prevent metabolism of the drug received via breast milk.
Specialist advice is available from the UK Drugs in Lactation Advisory Service at https://www.midlandsmedicines.nhs.uk/content.asp?section=6&subsection=17&pageIdx=1

Drug excreted in breast milk? - Lidocaine - Yes, Adrenaline - likely

Side Effects

Hypotension
Hypertension
Nausea
Vomiting
Paraesthesia
Dizziness
Bradycardia
CNS toxicity
Convulsions
Tongue numbness
Tinnitus
Tremor
Dysarthria
Hyperacusis
Visual disturbances
CNS depression
Cardiac arrest
Cardiac arrhythmias
Allergic reaction
Anaphylactic reaction
Respiratory depression
Neuropathy
Peripheral neuropathy
Arachnoiditis
Diplopia

Presentation

Solution for injection containing lidocaine hydrochloride monohydrate equivalent to 10mg per ml of lidocaine hydrochloride anhydrous (200mg per 20ml vial) and 5micrograms per ml of adrenaline as the acid tartrate (100micrograms per 20ml vial)

Solution for injection containing lidocaine hydrochloride monohydrate equivalent to 20mg per ml of lidocaine hydrochloride anhydrous (400mg per 20ml vial) and 5micrograms per ml of adrenaline as the acid tartrate (100micrograms per 20ml vial)

Drugs List

Therapeutic Indications

Uses

Local anaesthesia for use in infiltration anaesthesia, minor and major nerve blocks.

Dosage

Dosage should be adjusted according to the response of the patient and the area to be anaesthetised. The patient's age, weight, physique, clinical condition and the degree of vascularity in the application area should also be considered. The lowest concentration and smallest dose needed to provide effective anaesthesia should be administered.

Adults

Children

Administration

By perineural injection for infiltration anaesthesia.

Doses should be injected slowly at a rate of 100-200mg/minute or in increments.

Duration of block (with adrenaline) is about 90 minutes.

Contraindications

Children under 1 year.
Porphyria - if to be given intravenously

Must NOT be used for anaesthesia of the fingers, toes, tip of the nose, ears or penis because of the vasoconstrictor effect of adrenaline.

Precautions and Warnings

Lidocaine with adrenaline should only be used by those with the necessary training and experience.

Careful aspiration before and during injection is recommended to prevent intravascular administration and subsequent acute toxic reactions.

The patient's vital signs should be observed closely during the injection and verbal contact maintained. If toxic symptoms occur, the injection should be stopped immediately.

Resuscitation facilities must be available when the injection is administered.

Use with caution in patients with:
Epilepsy
Impaired cardiac conduction
Impaired respiratory function
Hepatic impairment
Severe renal impairment.
Elderly
Severe shock
Myasthenia gravis
Debilitation
Hypovolaemia

Pregnancy - see Pregnancy section

Breastfeeding - see Breastfeeding section

Solutions containing adrenaline must be used with caution in patients with:
Hypertension
Cardiac disease
Cerebrovascular impairment
Hyperthyroidism
Diabetes (advanced)

The condition of the patient should be optimised before major blocks are produced.

ECG monitoring should be considered in patients taking concurrent anti-arrhythmic drugs.

Administration into inflamed or infected tissues should be avoided as increased absorption into the blood can result in increased systemic side effects. The local anaesthetic effect may be reduced by the altered local pH of such tissues.

Administration into the head or neck area may lead to accidental arterial administration leading to cerebral symptoms.
Paracervical block can cause foetal bradycardia or tachycardia. The foetal heart rate should therefore be monitored closely.

The solution for injection contains sodium metabisulfite, which can cause allergic reactions including anaphylaxis and potentially life-threatening asthmatic reactions in susceptible people. Sulfite sensitivity is more common in patients with asthma.

Mental function and co-ordination may be affected by anaesthesia and the patient's ability to drive and operate machinery may therefore be reduced.

Not all available products are licensed for all age groups.

Use in Porphyria

Intravenous lidocaine is considered unsafe in acute porphyria.

Pregnancy and Lactation

Pregnancy

Must not be given during early pregnancy unless the potential benefits outweigh the possible risks.

The adrenaline component of the injection has the potential to decrease uterine blood flow and contractility, especially after accidental intravascular administration in the mother.

Foetal adverse effects, such as foetal bradycardia, seem to be more common in paracervical anaesthesia. High concentrations of the anaesthetic reaching the foetus may cause these effects. Large doses during delivery can also cause neonatal respiratory depression and hypotonia after paracervical block.

Briggs (2011) and Schaefer (2007) both indicate that lidocaine, when administered systemically to a pregnant woman, is able to cross the placenta without any adverse effect on pregnancy. Schaefer (2007) concludes that local anaesthetics with adrenaline may be used during pregnancy.

Animal studies have not demonstrated evidence of foetal harm.

The use of all medication in pregnancy should be avoided whenever possible; particularly in the first trimester. Non-drug treatments should also be considered. When essential, a medication with the best safety record over time should be chosen, employing the lowest effective dose for the shortest possible time. Polypharmacy should be avoided. Teratogens taken in the pre-embryonic period, often quoted as lasting until 14-17 days post-conception, are believed to have an all-or-nothing effect. Where drugs have a short half-life, and when the date of conception is certain, this may allow women to be reassured where drug exposure has occurred within this time frame. Further advice may be available from the UK National Teratology Information Service (NTIS) and through ToxBase, available via password on the internet ( www.toxbase.org ) or if this is unavailable at the backup site ( www.toxbasebackup.org ).

Known human teratogen? - No

Crosses placenta? - Yes, both lidocaine and adrenaline

Effects on foetus - Paracervical block can sometimes cause foetal bradycardia / tachycardia

Lactation

Use with caution during breastfeeding. There is limited information available on the combination of lidocaine with adrenaline. Lidocaine enters breast milk but the levels are generally low and lidocaine is poorly absorbed by the infant. Hale (2010) indicates that although likely to be secreted in milk, adrenaline is rapidly destroyed by the gastrointestinal tract, it is unlikely any would be absorbed.

Neonates, infants born prematurely, those with low birth weight, those with an unstable gastrointestinal function or who have serious illnesses may require special consideration. For any infant, if a drug is prescribed to the nursing mother, it should be at the lowest practical dose and for the shortest time. When drug administration is unavoidable and breastfeeding is to continue, minimisation of exposure of the infant to the drug may sometimes be achieved by timing the maternal doses to just after a feeding episode. Infants exposed to drugs via breast milk should be monitored for unusual signs or symptoms. Interactions between the drug received by the infant from the mother's milk and medication prescribed for the infant should also be considered, for example, when the drug given to the infant may prevent metabolism of the drug received via breast milk.
Specialist advice is available from the UK Drugs in Lactation Advisory Service at https://www.midlandsmedicines.nhs.uk/content.asp?section=6&subsection=17&pageIdx=1

Drug excreted in breast milk? - Lidocaine - Yes, Adrenaline - likely

Effects on Ability to Drive and Operate Machinery

Mental function and co-ordination may be affected by anaesthesia and the patient's ability to drive and operate machinery may therefore be reduced.

Counselling

Advise patients that they should not drive or operate machinery for a suitable period after an anaesthetic.

Side Effects

Hypotension
Hypertension
Nausea
Vomiting
Paraesthesia
Dizziness
Bradycardia
CNS toxicity
Convulsions
Tongue numbness
Tinnitus
Tremor
Dysarthria
Hyperacusis
Visual disturbances
CNS depression
Cardiac arrest
Cardiac arrhythmias
Allergic reaction
Anaphylactic reaction
Respiratory depression
Neuropathy
Peripheral neuropathy
Arachnoiditis
Diplopia

Overdosage

It is strongly recommended that the UK National Poisons Information Service be consulted on cases of suspected or actual overdose where there is doubt over the degree of risk or about appropriate management.

The following number will direct the caller to the relevant local centre (0844) 892 0111

Information may be obtained if you have access to ToxBase the primary clinical toxicology database of the National Poisons Information Service. This is available via password on the internet ( www.toxbase.org ) or if this is unavailable at the backup site ( www.toxbasebackup.org ).

Shelf Life and Storage

Store at 2-8 degrees C

Further Information

Last Full Review Date: September 2012

Reference Sources

Acute Porphyria Safe List, Welsh Medicines Information Centre, Cardiff and Vale NHS Trust, September 2013.

British National Formulary, 64th Edition (2012) Pharmaceutical Press, London.

BNF for Children (2012-2013) Pharmaceutical Press, London.

Drugs During Pregnancy and Lactation: Treatment Options and Risk Assessment, 2nd edition (2007) ed. Schaefer, C., Peters, P. and Miller, R. Elsevier, London.

Drugs in Pregnancy and Lactation: A Reference Guide to Fetal and Neonatal Risk, 9th edition (2011) ed. Briggs, G., Freeman, R. and Yaffe, S. Lippincott Williams & Wilkins, Philadelphia.

European Porphyria Initiative, Available at; https://www.porphyria-europe.com/index.asp Last Revised: November 21, 2008 Last Accessed: February 12, 2014

Medications and Mothers' Milk, 14th Edition (2010) Hale, T. Hale Publishing, Amarillo, Texas.

Summary of Product Characteristics: Xylocaine 1% and 2% with Adrenaline 1:200,000. AstraZeneca UK Ltd. Revised August 2015.

N.A.P.O.S The Drug Database for Acute Porphyria, available at; https://www.drugs-porphyria.com/languages/UnitedKingdom/s1.php?l=gbr Last Revised: September 9, 2011 Last Accessed: February 12, 2014

US National Library of Medicine. Toxicology Data Network. Drugs and Lactation Database (LactMed).
Available at: https://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT
Lidocaine Last revised: May 3, 2012.
Last accessed: October 17, 2012.
Epinephrine Last revised: May 3, 2012.
Last accessed: October 17, 2012.