Introduction

Antiarrhythmic agent; an amide-type local anesthetic, class Ib agent.

Uses for Lidocaine (Systemic)

Ventricular Arrhythmias

Alternative to other antiarrhythmic drugs (e.g., amiodarone, procainamide, sotalol) for the acute treatment of life-threatening ventricular arrhythmias such as those that occur following MI or during cardiac manipulative procedures such as cardiac surgery.

Used during cardiac arrest for treatment of refractory (i.e., resistant to CPR, defibrillation, and a vasopressor [epinephrine]) VF or pulseless VT. Considered an alternative to amiodarone for this use in current ACLS guidelines in adults; in pediatric patients, current evidence supports use of either amiodarone or lidocaine.

Alternative to other antiarrhythmic agents or synchronized electrical cardioversion in the treatment of hemodynamically stable monomorphic VT; however, other agents (e.g., procainamide, sotalol, amiodarone) preferred.

Status Epilepticus

Treatment of status epilepticus^{† [off-label]}, as a last resort.

Lidocaine (Systemic) Dosage and Administration

General

Ventricular Arrhythmias

• Solutions containing epinephrine must not be used to treat arrhythmias.

• Adjust dosage carefully according to individual requirements and response; constant ECG monitoring is recommended.

• Terminate infusion as soon as the basic cardiac rhythm appears to be stable or at the earliest sign of toxicity. Immediately stop infusion if signs of excessive cardiac depression occur (e.g., prolongation of PR interval and QRS complex, appearance or aggravation of arrhythmias).

• Infusions continued for >24 hours should be rarely necessary.

Administration

Administer IV. Has been administered IM (IM formulation no longer commercially available in the US).

Also has been administered via endotracheal tube^{† [off-label]} or by intraosseous (IO) injection^{† [off-label]} during cardiac resuscitation when IV administration is not possible. Although endotracheal^{† [off-label]} administration also is possible, IV or IO^{† [off-label]} administration is preferred because of more predictable drug delivery and pharmacologic effect. (See Absorption under Pharmacokinetics.)

IV Administration

For solution and drug compatibility information, see Compatibility under Stability.

Administer as a bolus IV injection for initial treatment of ventricular arrhythmias. Maintenance IV infusions may be required to maintain normal sinus rhythm if oral antiarrhythmic therapy is not feasible.

Injections containing preservatives should not be given IV.

Do not introduce additives into solutions of lidocaine in 5% dextrose, since dosage is titrated to response.

Do not add to blood transfusion assemblies.

Do not use commercially available solutions of lidocaine in 5% dextrose in series connections with other plastic containers; such use could result in air embolism.

Rate of Administration

Administer IV bolus dose at a rate of 25–50 mg/minute.

Administer maintenance infusions at a rate of 1–4 mg/minute (14–57 mcg/kg per minute) in adults or 10–50 mcg/kg per minute in pediatric patients.

For other populations, see Special Populations under Dosage and Administration.

Endotracheal Administration

For endotracheal administration in adults, dilute dose in 5–10 mL of 0.9% sodium chloride injection or sterile water.

In pediatric patients, flush with 5 mL of 0.9% sodium chloride injection after dose is administered.

Dilution in sterile water may increase absorption of lidocaine.

Dosage

Available as lidocaine hydrochloride; dosage is expressed in terms of the salt.

Pediatric Patients

Ventricular Arrhythmias

IV

Controlled clinical studies to establish pediatric dosing have not been performed.

Some clinicians have suggested initial dose of 0.5–1 mg/kg as a rapid IV injection (i.e., bolus); dose may be repeated according to patient response, up to a maximum total dose of 3–5 mg/kg. Maintenance infusion of 10–50 mcg/kg per minute.

Pediatric Resuscitation

For shock-refractory VF or pulseless VT: 1 mg/kg initially, followed by maintenance infusion of 20–50 mcg/kg per minute. If time between initial bolus dose and onset of IV infusion >15 minutes, repeat bolus dose.

Optimal dose not established, but usually 2–2.5 times the recommended IV dosage.

Adults

Ventricular Arrhythmias

IV

Usual initial dose is 50–100 mg administered as a direct IV injection. If desired response is not achieved, a second dose may be administered 5 minutes after completion of the first injection.

For hemodynamically stable monomorphic VT: AHA recommends initial dose of 1–1.5 mg/kg, followed by 0.5–0.75 mg/kg repeated at 5- to 10-minute intervals as necessary, up to a maximum total dose of 3 mg/kg.

ACLS

For refractory VF or pulseless VT: 1–1.5 mg/kg as initial loading dose, then 0.5–0.75 mg/kg repeated at 5- to 10-minute intervals as necessary, up to a total of 3 doses (or up to 3 mg/kg).

Optimal dose not established, but usually 2–2.5 times the recommended IV dosage.

Status Epilepticus†

IV

Initially, 1 mg/kg. After 2 minutes, administer 0.5 mg/kg if seizure is not terminated. Maintenance infusion of 30 mcg/kg per minute for prevention of seizure recurrence.

Prescribing Limits

Adults

Ventricular Arrhythmias

IV

Maximum total dose of 200–300 mg over a 1-hour period.

Special Populations

Hepatic Impairment

Careful and individualized dosing recommended.

Renal Impairment

Dosage modification not required.

Decreased Cardiac Output

Smaller bolus doses may be required.

Some clinicians recommend infusion rates <30 mcg/kg per minute in patients with CHF.

Patients Requiring Prolonged Therapy

Possible increased half-life following infusions lasting>24 hours; reduce dosage accordingly (e.g., by 50%) to avoid accumulation of the drug and potential toxicity.

Contraindications

• Adams-Stokes syndrome; severe degrees of SA, AV, or intraventricular heart block (unless a functioning pacemaker is present). Some manufacturers state that lidocaine is contraindicated in patients with Wolff-Parkinson-White syndrome.

• Known hypersensitivity to amide-type local anesthetics.

Warnings/Precautions

Warnings

Cardiac Monitoring

Constant ECG monitoring is necessary during IV administration. Discontinue infusion if signs of excessive cardiac depression occur (e.g., prolongation of PR interval and QRS complex, appearance or aggravation of arrhythmias).

Severe Reactions

Resuscitative equipment and drugs should be immediately available for the management of severe adverse cardiovascular, respiratory, or CNS effects. Discontinue therapy if severe reactions occur; institute emergency resuscitative procedures and other supportive measures as required.

Severe reactions may be preceded by somnolence and paresthesia.

Sensitivity Reactions

Hypersensitivity

Possible hypersensitivity reactions (e.g., skin lesions, urticaria, edema, anaphylactoid reactions).

General Precautions

Prolonged Therapy

Possible increased half-life following infusions lasting >24 hours; reduce dosage accordingly (see Patients Requiring Prolonged Therapy under Dosage and Administration).

If maintenance therapy is necessary, an oral antiarrhythmic agent is recommended.

Nervous System Effects

Possible muscle twitching or tremors, seizures, unconsciousness, and coma; may be associated with high doses or overdosage.

Cardiovascular Effects

Possible hypotension, arrhythmias, heart block, cardiovascular collapse, and bradycardia, which may lead to cardiac arrest in patients with high plasma lidocaine concentrations or myocardial conduction defects.

Possible serious ventricular arrhythmias or heart block in patients with sinus bradycardia.

Possible increased sensitivity to cardiac depressant effects in patients with a diseased or abnormal sinus node.

Possible increased ventricular rate in patients with atrial fibrillation.

Possible increased coronary blood flow in patients with recent MI.

Possible myocardial and circulatory depression.

Cautious use recommended in patients with any form of heart block, CHF, marked hypoxia, severe respiratory depression, hypovolemia, or shock.

Respiratory Effects

Possible respiratory depression and arrest; may be associated with high doses or overdosage.

Local Effects

Possible local thrombophlebitis in patients receiving prolonged IV infusions.

Tissue infiltration may lead to local ischemia, tissue injury, and ulceration.

Laboratory Test Interference

Possible increased serum CK (CPK) concentrations associated with IM injections. Isoenzyme separation is necessary when CK determinations are used in the diagnosis of acute MI.

Specific Populations

Pregnancy

Category B.

Lactation

Distributed into milk. Use with caution.

Pediatric Use

Safety and efficacy not established in controlled clinical studies; however, lidocaine has been used for treatment of ventricular arrhythmias in infants and children.

Hepatic Impairment

Use with caution. (See Pharmacokinetics and also see Hepatic Impairment under Dosage and Administration.)

Renal Impairment

Use with caution in severe renal impairment. (See Elimination: Special Populations, under Pharmacokinetics.)

Common Adverse Effects

Adverse CNS effects (e.g., drowsiness, dizziness, disorientation, confusion, lightheadedness, tremulousness, psychosis, nervousness, apprehension, agitation, euphoria, tinnitus, visual disturbances, paresthesia, difficulty swallowing, dyspnea, slurred speech, sensations of heat, cold, or numbness), nausea, vomiting.

General

Ventricular Arrhythmias

• Solutions containing epinephrine must not be used to treat arrhythmias.

• Adjust dosage carefully according to individual requirements and response; constant ECG monitoring is recommended.

• Terminate infusion as soon as the basic cardiac rhythm appears to be stable or at the earliest sign of toxicity. Immediately stop infusion if signs of excessive cardiac depression occur (e.g., prolongation of PR interval and QRS complex, appearance or aggravation of arrhythmias).

• Infusions continued for >24 hours should be rarely necessary.

Administration

Administer IV. Has been administered IM (IM formulation no longer commercially available in the US).

Also has been administered via endotracheal tube^{† [off-label]} or by intraosseous (IO) injection^{† [off-label]} during cardiac resuscitation when IV administration is not possible. Although endotracheal^{† [off-label]} administration also is possible, IV or IO^{† [off-label]} administration is preferred because of more predictable drug delivery and pharmacologic effect. (See Absorption under Pharmacokinetics.)

IV Administration

For solution and drug compatibility information, see Compatibility under Stability.

Administer as a bolus IV injection for initial treatment of ventricular arrhythmias. Maintenance IV infusions may be required to maintain normal sinus rhythm if oral antiarrhythmic therapy is not feasible.

Injections containing preservatives should not be given IV.

Do not introduce additives into solutions of lidocaine in 5% dextrose, since dosage is titrated to response.

Do not add to blood transfusion assemblies.

Do not use commercially available solutions of lidocaine in 5% dextrose in series connections with other plastic containers; such use could result in air embolism.

Rate of Administration

Administer IV bolus dose at a rate of 25–50 mg/minute.

Administer maintenance infusions at a rate of 1–4 mg/minute (14–57 mcg/kg per minute) in adults or 10–50 mcg/kg per minute in pediatric patients.

For other populations, see Special Populations under Dosage and Administration.

Endotracheal Administration

For endotracheal administration in adults, dilute dose in 5–10 mL of 0.9% sodium chloride injection or sterile water.

In pediatric patients, flush with 5 mL of 0.9% sodium chloride injection after dose is administered.

Dilution in sterile water may increase absorption of lidocaine.

Dosage

Available as lidocaine hydrochloride; dosage is expressed in terms of the salt.

Pediatric Patients

Ventricular Arrhythmias

IV

Controlled clinical studies to establish pediatric dosing have not been performed.

Some clinicians have suggested initial dose of 0.5–1 mg/kg as a rapid IV injection (i.e., bolus); dose may be repeated according to patient response, up to a maximum total dose of 3–5 mg/kg. Maintenance infusion of 10–50 mcg/kg per minute.

Pediatric Resuscitation

For shock-refractory VF or pulseless VT: 1 mg/kg initially, followed by maintenance infusion of 20–50 mcg/kg per minute. If time between initial bolus dose and onset of IV infusion >15 minutes, repeat bolus dose.

Optimal dose not established, but usually 2–2.5 times the recommended IV dosage.

Adults

Ventricular Arrhythmias

IV

Usual initial dose is 50–100 mg administered as a direct IV injection. If desired response is not achieved, a second dose may be administered 5 minutes after completion of the first injection.

For hemodynamically stable monomorphic VT: AHA recommends initial dose of 1–1.5 mg/kg, followed by 0.5–0.75 mg/kg repeated at 5- to 10-minute intervals as necessary, up to a maximum total dose of 3 mg/kg.

ACLS

For refractory VF or pulseless VT: 1–1.5 mg/kg as initial loading dose, then 0.5–0.75 mg/kg repeated at 5- to 10-minute intervals as necessary, up to a total of 3 doses (or up to 3 mg/kg).

Optimal dose not established, but usually 2–2.5 times the recommended IV dosage.

Status Epilepticus†

IV

Initially, 1 mg/kg. After 2 minutes, administer 0.5 mg/kg if seizure is not terminated. Maintenance infusion of 30 mcg/kg per minute for prevention of seizure recurrence.

Prescribing Limits

Adults

Ventricular Arrhythmias

IV

Maximum total dose of 200–300 mg over a 1-hour period.

Special Populations

Hepatic Impairment

Careful and individualized dosing recommended.

Renal Impairment

Dosage modification not required.

Decreased Cardiac Output

Smaller bolus doses may be required.

Some clinicians recommend infusion rates <30 mcg/kg per minute in patients with CHF.

Patients Requiring Prolonged Therapy

Possible increased half-life following infusions lasting>24 hours; reduce dosage accordingly (e.g., by 50%) to avoid accumulation of the drug and potential toxicity.

Antiarrhythmic Agents

Potential pharmacologic interaction (additive or antagonistic cardiac effects and additive toxicity) with concomitant administration of antiarrhythmic agents (e.g., phenytoin, procainamide, propranolol, quinidine).

Specific Drugs