Lidocaine

Aka: Lidocaine

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II. Indications

  1. Amiodarone has replaced Lidocaine as first line agent in ACLS and PALS protocols
    1. However Lidocaine may have higher rate of ROSC and lower morbidity and mortality than Amiodarone
    2. Wagner (2023) Chest 163(5):1109-1119 +PMID: 36332663 [PubMed]
  2. Ventricular Fibrillation
  3. Ventricular Tachycardia (Wide Complex Tachycardia)
    1. Use Lidocaine only if unknown etiology
    2. Not indicated for drug induced Arrhythmia
    3. Not indicated for metabolic induced Arrhythmia
  4. Post-Resuscitation for ventricular Arrhythmia
    1. Myocarditis
    2. Structural heart disease

III. Contraindications

  1. Wide-complex Ventricular Escape Rhythm
  2. Associated with Bradycardia

IV. Mechanism

  1. See Lidocaine Local Skin Anesthesia
  2. Class Ib Antiarrhythmic Drug
  3. Increases conduction velocity in the AV Node, His Bundle and Purkinje Fibers
    1. Shortens QT Interval
  4. Suppresses ventricular Arrhythmias
    1. Terminates reentrant ventricular Arrhythmia
    2. Increases Ventricular Fibrillation threshold
      1. Requires high plasma Lidocaine levels (e.g. 6 mcg/ml)
  5. Suppresses ventricular ectopy (decreases automaticity)
    1. Post Myocardial Infarction, routine prophylactic Lidocaine use not recommended

V. Dosing: Pediatric

  1. Dose: 1 mg/kg IV/IO every 10 to 15 min up to 3 to 5 mg/kg in 1 hour
  2. ET Dose: Use 2 to 2.5 times the IV dose
  3. May continue with infusion dosing as below

VI. Dosing: Adult

  1. Ventricular Fibrillation
    1. Dose: 1.0-1.5 mg/kg IV/IO push
    2. ET Dose: Use 2 to 2.5 times the IV dose in 10 ml Normal Saline
    3. May repeat in 3-5 min to max dose 3 mg/kg
    4. May continue with infusion dosing as below
  2. Ventricular Tachycardia (with a pulse)
    1. First: 1.0-1.5 mg/kg IV/IO push
    2. Next: 0.5-0.75 mg/kg IV/IO push every 5 to 10 minutes
    3. Maximum total, cumulative dose: 3 mg/kg
    4. May continue with infusion dosing as below

VII. Dosing: Infusion (Pediatric and Adult)

  1. Preparation
    1. Lidocaine 4 g in 500 ml D5W (8 mg/ml)
    2. Precede infusion with 1 mg/kg bolus loading dose
    3. Then 20-50 mcg/kg/min up to 1 to 4 mg/min infusion
  2. If hepatic Blood Flow is compromised (e.g. CHF, liver disease, elderly)
    1. Decrease dose to under 20 mcg/kg/min

VIII. Adverse Effects

  1. Myocardial depression of conduction and contractility
    1. Concurrent Antiarrhythmic therapy
    2. Sick Sinus Syndrome
    3. Left Ventricular Dysfunction
  2. Circulatory depression
    1. May occur with rapid bolus dosing
  3. Neurologic changes (esp. with prolonged infusion)
    1. Drowsiness or Disorientation
    2. Decreased Hearing acuity
    3. Paresthesias
    4. Muscle Twitching (Fasciculations)
    5. Seizures (high dose)
  4. Overdosage
    1. Third degree AV Heart Block
    2. Altered AV conduction
    3. Sinus node automaticity depressed

IX. Safety

  1. Unknown safety in Lactation
  2. Pregnancy Category B

X. Metabolism

  1. Rapid hepatic metabolism (to 2 active metabolites)
  2. Renal excretion

XI. Drug Interactions

  1. Lidocaine serum levels increased by other medications
    1. Cimetidine
    2. Medications that reduce hepatic perfusion (e.g. Beta Blockers)

XII. Resources

  1. Lidocaine Injection Solution (DailyMed)
    1. https://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=f1b26274-a55e-4321-b96c-ce0df830f205

XIII. References

  1. Olson (2020) Clinical Pharmacology, Medmaster Miami, p. 74-5
  2. Hamilton (2020) Tarascon Pocket Pharmacopoeia
  3. Panchal (2018) Circulation 138(23):e740-e749 +PMID: 30571262 [PubMed]

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Cost: Medications

lidocaine (on 12/21/2022 at Medicaid.Gov Survey of pharmacy drug pricing)
LIDOCAINE 2% VISCOUS SOLN Generic $0.07 per ml
LIDOCAINE 2%-EPI 1:100,000 Generic $0.13 per ml
LIDOCAINE 3% CREAM Generic $0.78 per gram
LIDOCAINE 4% CREAM Generic OTC $0.76 per gram
LIDOCAINE 4% PATCH Generic OTC $0.91 each
LIDOCAINE 5% OINTMENT Generic $0.17 per gram
LIDOCAINE 5% PATCH Generic $1.78 each
LIDOCAINE ANORECTAL 5% CREAM Generic OTC $0.43 per gram
LIDOCAINE HCL 1% 20 MG/2 ML VL Generic $0.75 per ml
LIDOCAINE HCL 1% 50 MG/5 ML VIAL Generic $0.41 per ml
LIDOCAINE HCL 1% 50 MG/5 ML VL Generic $0.55 per ml
LIDOCAINE HCL 1% VIAL Generic $0.07 per ml
LIDOCAINE HCL 2% 100 MG/5 ML Generic $0.34 per ml
LIDOCAINE HCL 2% JELLY Generic $2.99 per ml
LIDOCAINE HCL 2% VIAL Generic $0.06 per ml
LIDOCAINE HCL 4% CREAM Generic OTC $0.05 per gram
LIDOCAINE HCL 4% SOLUTION Generic $0.46 per ml
LIDOCAINE PAIN RELIEF 4% PATCH Generic OTC $0.91 each
LIDOCAINE-HC 3-0.5% CREAM Generic $1.16 per gram
LIDOCAINE-PRILOCAINE CREAM Generic $0.51 per gram
FPNotebook does not benefit financially from showing this medication data or their pharmacy links. This information is provided only to help medical providers and their patients see relative costs. Insurance plans negotiate lower medication prices with suppliers. Prices shown here are out of pocket, non-negotiated rates. See Needy Meds for financial assistance information. GoodRx is another tool for finding lower drug prices.

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