Lidocaine
Clinical Particulars
Pharmacokinetics
Lidocaine is an amide local anaesthetic and antiarrhythmic commonly used as a local anesthetic and occasionally used for acute treatment of ventricular arrhythmias (PubChem, 2024).
Mechanism of Action
Nerves: Local anaesthetics bind reversibly to a target receptor in the pore of voltage-gated sodium channels in nerves. Subsequently, ion movement is blocked, preventing the conduction of the action potential in any nerve fibre (Barletta and Reed, 2019; Booth, 2011; Catterall, 2000; PubChem, 2024; Wann, 1993).
Muscles: Lidocaine reduces muscle contractility. This may result in vasodilation, hypotension, and altered heart rate (Barletta and Reed, 2019; Booth, 2011; Catterall, 2000; PubChem, 2024; Wann, 1993)
Clinical Applications
Local Lidocaine
Indications include local or regional anaesthesia using infiltration techniques such as percutaneous injection and intravenous regional anaesthesia, peripheral nerve block techniques such as brachial plexus and intercostal, and central neural techniques such as lumbar and caudal epidural blocks. Lidocaine typically produces local anaesthesia within 3 to 5 minutes of administration, and in most veterinary species, this persists for about an hour. Compared to bupivacaine, lidocaine has a faster onset and shorter duration of action (Barletta and Reed, 2019; Booth, 2011; Maddison, 2008; PubChem, 2024).
Systemic Lidocaine
Systemic lidocaine can provide analgesia, anti-inflammatory effects, antiarrhythmic effects (e.g., ventricular fibrillation), and a reduction in inhalant anaesthetic requirements. Lidocaine is considered a class Ib anti-arrhythmic agent. Lidocaine also enhances gastrointestinal motility and free-radical scavenging (Barletta and Reed, 2019; Booth, 2011; Maddison, 2008; PubChem, 2024).
Pharmacodynamics
Absorption
Lidocaine is readily absorbed across mucous membranes and damaged skin but poorly through intact skin. It is quickly absorbed from the upper airway, tracheobronchial tree, and alveoli into the bloodstream (PubChem, 2024).
Oral Administration: Although lidocaine is well absorbed across the gastrointestinal tract, the oral bioavailability is only about 35% due to a high degree of first-pass metabolism.
Locally Administration: The absorption rate is affected by local vascularity and the presence of tissue and fat capable of binding lidocaine to particular tissues. Subsequently, the concentration of lidocaine in the blood is affected by various aspects, including its absorption rate from the injection site, tissue distribution rate, and metabolism and excretion.
Systemic Administration: Systemic absorption of lidocaine is determined by the injection site and the dosage given.
Distribution
Lidocaine is well distributed throughout all body tissues. The highest percentage of this drug will be found in skeletal muscle, mainly due to its mass rather than its affinity (PubChem, 2024).
Metabolism
Aminoamide local anaesthetics are metabolised primarily by cytochrome P450 enzymes in the liver (PubChem, 2024).
Excretion
The excretion of unchanged lidocaine and its metabolites occurs predominantly via the kidney (PubChem, 2024).
Precautions
Adverse Effects
Adverse reactions to lidocaine are rare and usually the result of intravascular injection, excessive dosage or rapid absorption from highly vascular areas. The following adverse effects were identified in our literature search.
Cardiovascular: Decreased cardiac output, cardiovascular depression, and decreased oxygen delivery to tissues have been reported. PR and QRS interval prolongation and QT interval shortening have also been reported. Lidocaine can produce cardiac arrhythmias but has a more significant effect on abnormal than normal cardiac tissue (Papich, 2011; SPC Data).
Epidural Administration: Use may result in hypotension, urinary retention, and/or ataxia (SPC Data).
Epinephrine Formulations: Systemic absorption or IV injection may cause tachycardia and hypertension (Papich, 2011; SPC Data).
Central Nervous System: Drowsiness, ataxia, muscle tremors, depression, and seizures have been reported progressing to grand-mal convulsions. An initial phase of excitation is followed by CNS depression, progressing to coma and, ultimately, respiratory arrest (Beecroft and Davies, 2013; Verlinde et al., 2016).
Haemolysis and Methemoglobinemia: Methemoglobinemia and hemolysis have been reported in humans and cats (Katsuki et al., 2004; Khajavirad et al., 2023; Papich, 2011)
Local Administration: Nerve damage due to needle injury, hematoma, or local anaesthetic toxicity has been reported (Beecroft and Davies, 2013; Verlinde et al., 2016).
Contraindications
The following contraindications relate to using preparations containing adrenaline (epinephrine).
Cardiovascular Disease: Avoid lidocaine/epinephrine formulations in patients with cardiovascular disease or hyperthyroidism (SPC Data).
Extremities: Lidocaine/epinephrine formulations should not be used in extremities (e.g. digits, ears, nose, or penis) as ischemic injury may result (SPC Data).
Intravenous Use: Lidocaine/epinephrine formulations should not be used intravenously (SPC Data).
Reproductive Safety
Pregnancy: Avoid Use; lidocaine should not be administered during early pregnancy unless the benefits are considered to outweigh the risks. Lidocaine crosses the placental barrier after epidural or intravenous administration but recommended dose levels are unlikely to have adverse effects (Demeulemeester et al., 2018; Hagai et al., 2015; Morishima et al., 1990; Ramanathan et al., 1986; Reynolds, 2011; Smith et al., 1986).
Lactation: Small amounts of Lidocaine are secreted into breast milk, but recommended dose levels are not expected to cause any adverse effects in breastfed infants. No special precautions are required (LactMed, 2006; Reynolds, 2011; Zeisler et al., 1986).
Male Fertility: No data available (SPC data).
Female Fertility: No data available (SPC data).
Neonates: No data available (SPC data).
Potentially Significant Interactions
Significant Interactions are unlikely when lidocaine is administered as recommended.
Acidic Solutions: Because lidocaine preparations are acidic, mixing with alkaline solutions may interfere with stability and should be avoided (Papich, 2011).
Anaesthetic Agents: Lidocaine infusions perioperatively reduce MAC requirements of volatile agents, e.g., isoflurane and sevoflurane; Local application may also help stabilise anaesthesia and reduce additional agent requirements during minor procedures (El-Hawari et al., 2022; Hamp et al., 2013; Marzok et al., 2022; Matsubara et al., 2009; Moran-Muñoz et al., 2014; Rezende et al., 2011; Thengchaisri and Mahidol, 2019; Wilson et al., 2008).
Antiarrhythmics If systemically absorbed, lidocaine may cause additive or antagonistic cardiac effects to some antiarrhythmic agents (e.g., procainamide, propranolol, quinidine), and toxicity may be enhanced (Wyse et al., 1988).
β-Adrenergic Antagonists: Lidocaine levels or effects may be increased if administered simultaneously with β-Adrenergic Antagonists, e.g., atenolol, esmolol, propranolol, and sotalol (Wyse et al., 1988).
Morphine: Coadministration of morphine and lidocaine has demonstrated a beneficial synergistic interaction regarding visceral pain (Penning and Yaksh, 1992).
Safe and Toxic Dose
Rabbits
Maximum Safe Dose: We recommend a maximum therapeutic dose of 2 mg/kg per administration regardless of route, with a maximum administration of 0.5 mg/kg at any site.
Toxic Dose: Doses above 4mg/kg are potentially toxic. However, several studies have safely administered 2mg/kg multiple times intravenously or through deep body injection without adverse effects, and therefore, dosing as high as 4mg/kg appears well tolerated, and rabbits are presumed to metabolise this agent faster than most major pet species (Di Bella et al., 2021; Schnellbacher et al., 2017, 2013)
Lethal Dose: Regard doses above 20 mg/kg as potentially lethal (Schnellbacher et al., 2013).
Convulsive Dose: The cumulative convulsive and lethal (cardiotoxic) doses are above 25 mg/kg (Schnellbacher et al., 2013).
Cardiotoxic Dose: The cumulative convulsive and lethal (cardiotoxic) doses are above 25 mg/kg (Schnellbacher et al., 2013).
Dogs
Maximum Safe Dose:
Toxic Dose:
Lethal Dose: the minmum cumulative lethal dose located in the literature was 80 mg/kg IV.
Convulsive Dose: The cumulative IV dose for CNS toxicity resulting in convulsive activity in conscious dogs is around 20-22 mg/kg (Feldman, Arthur, & Covino, 1989; Liu, Feldman, Giasi, Patterson, & Covino, 1983)
Cardiotoxic Dose: the IV dose resulting in death from cardiovascular toxicity in pentobarbital anaesthetized dogs was 80 mg/kg (Liu, Feldman, Covino, Giasi, & Covino, 1982) and 127 mg/kg in fentanyl/midazolam anaesthetized dogs (Groban, Deal, Vernon, James, & Butterworth, 2001)
Cats
Maximum Safe Dose:
Toxic Dose:
Lethal Dose:
Convulsive Dose: The mean convulsive dose is 11.7 mg/kg IV (Chadwick, 1985).
Cardiotoxic Dose: the mean cardiotoxic dose was 47.3 mg/kg IV (Chadwick, 1985).
Acute Toxicity
In veterinary species, significant local anaesthetic toxicity is associated with cardiotoxicity and neurotoxicity. A specific presentation will depend upon the species, the agent used, the dose administered, the administration route (s), and the time and number of administrations. Some agents, such as bupivacaine, are more cardiotoxic than others, such as Lidocaine. For this reason, we recommend that clinicians become familiar with the concept of a maximum safe dose, a toxic dose, and a lethal dose. Ideally, clinicians should calculate a maximum safe dose for their patient before administration and ensure that the dose administered is significantly lower than this. This information is not yet available for all species.
Management of Acute Toxicity
Oxygen: If signs of overdose are present, management must begin with the delivery of oxygen via a patent airway, as successful oxygen delivery may prevent convulsions caused by toxicity (Barletta and Reed, 2019).
Vascular Decontamination: Intravenous lipids may be helpful where available. Lipid emulsion 20% 1.5 mL/kg IV over 30 minutes can benefit veterinary lidocaine toxicity (Markert et al., 2023).
Availability
Some Common Formulations
SPC Data, 2024a. EMLA Cream 5% (5g pack) - Summary of Product Characteristics (SmPC) - (emc) [WWW Document]. URL https://www.medicines.org.uk/emc/product/871/smpc (accessed 2.11.24).
SPC Data, 2024b. Intubeaze 20 mg/ml Laryngopharyngeal Spray, Solution for Cats [WWW Document]. URL https://www.vmd.defra.gov.uk/productinformationdatabase/product/A010010 (accessed 9.30.24).
SPC Data, 2024c. Lidocaine Hydrochloride Injection B.P. 0.5% w/v - Summary of Product Characteristics (SmPC) - (emc) [WWW Document]. URL https://www.medicines.org.uk/emc/product/6593/smpc (accessed 2.12.24).
SPC Data, 2024d. Lidocaine Hydrochloride Injection B.P. 1.0% w/v - Summary of Product Characteristics (SmPC) - (emc) [WWW Document]. URL https://www.medicines.org.uk/emc/product/4781/smpc (accessed 2.12.24).
SPC Data, 2024e. Lidocaine Hydrochloride Injection BP 1% w/v - Summary of Product Characteristics (SmPC) - (emc) [WWW Document]. URL https://www.medicines.org.uk/emc/product/6277/smpc (accessed 2.12.24).
SPC Data, 2024f. Lignol 2.0% w/v Solution for Injection [WWW Document]. URL https://www.vmd.defra.gov.uk/productinformationdatabase/product/A001223 (accessed 2.12.24).
Identifiers
Description: Lidocaine is an anaesthetic of the amide group.
Systematic IUPAC Name: 2-(diethylamino)-N-(2,6-dimethyl-phenyl) acetamide
Formula: C14-H22-N2-O
Pharmacotherapeutic Group: Antiarrhythmic medicines; Local anaesthetics
ATC Code(s): S02DA01; R02AD02; C01BB01; C05AD01; N01BB02; S01HA07; D04AB01
Evidence Base
Aria, N., Kauffman, C.L., 2003. Important drug interactions and reactions in dermatology. Dermatol Clin 21, 207–215, ix. https://doi.org/10.1016/s0733-8635(02)00071-2
Barletta, M., Reed, R., 2019. Local Anesthetics. Veterinary Clinics of North America: Small Animal Practice 49, 1109–1125. https://doi.org/10.1016/j.cvsm.2019.07.004
Becker, D.E., Reed, K.L., 2012. Local Anesthetics: Review of Pharmacological Considerations. Anesth Prog 59, 90–102. https://doi.org/10.2344/0003-3006-59.2.90
Beecroft, C., Davies, G., 2013. Systemic toxic effects of local anaesthetics. Anaesthesia & Intensive Care Medicine, Regional Anaesthesia 14, 146–148. https://doi.org/10.1016/j.mpaic.2013.02.001
Booth, D., 2011. Small Animal Clinical Pharmacology and Therapeutics - 2nd Edition [WWW Document]. URL https://shop.elsevier.com/books/small-animal-clinical-pharmacology-and-therapeutics/boothe/978-0-7216-0555-5 (accessed 1.24.24).
Catterall, W.A., 2000. From Ionic Currents to Molecular Mechanisms: The Structure and Function of Voltage-Gated Sodium Channels. Neuron 26, 13–25. https://doi.org/10.1016/S0896-6273(00)81133-2
Cox, B., Durieux, M.E., Marcus, M.A.E., 2003. Toxicity of local anaesthetics. Best Practice & Research Clinical Anaesthesiology 17, 111–136. https://doi.org/10.1053/bean.2003.0275
Demeulemeester, V., Van Hautem, H., Cools, F., Lefevere, J., 2018. Transplacental lidocaine intoxication. J Neonatal Perinatal Med 11, 439–441. https://doi.org/10.3233/NPM-1791
Hagai, A., Diav-Citrin, O., Shechtman, S., Ornoy, A., 2015. Pregnancy outcome after in utero exposure to local anesthetics as part of dental treatment: A prospective comparative cohort study. The Journal of the American Dental Association 146, 572–580. https://doi.org/10.1016/j.adaj.2015.04.002
LactMed, 2006. Lidocaine, in: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development, Bethesda (MD).
Maddison, G., 2008. Small Animal Clinical Pharmacology E-Book: 2nd edition | Edited by Jill E. Maddison | ISBN: 9780702037252 [WWW Document]. Elsevier Asia Bookstore. URL https://www.asia.elsevierhealth.com/small-animal-clinical-pharmacology-e-book-9780702037252.html (accessed 1.23.24).
Morishima, H.O., Finster, M., Arthur, G.R., Covino, B.G., 1990. Pregnancy does not alter lidocaine toxicity. Am J Obstet Gynecol 162, 1320–1324. https://doi.org/10.1016/0002-9378(90)90045-9
Penning, J.P., Yaksh, T.L., 1992. Interaction of intrathecal morphine with bupivacaine and lidocaine in the rat. Anesthesiology 77, 1186–2000. https://doi.org/10.1097/00000542-199212000-00021
Plumb, 2024. Lidocaine [WWW Document]. URL https://app.plumbs.com/drug/aazQZ5yCEYPROD?source=search&searchQuery=lidocaine (accessed 9.18.24).
PubChem, 2024. Lidocaine [WWW Document]. URL https://pubchem.ncbi.nlm.nih.gov/compound/3676 (accessed 9.30.24).
Ramanathan, J., Bottorff, M., Jeter, J.N., Khalil, M., Sibai, B.M., 1986. The pharmacokinetics and maternal and neonatal effects of epidural lidocaine in preeclampsia. Anesth Analg 65, 120–126.
Reynolds, F., 2011. Labour analgesia and the baby: good news is no news. Int J Obstet Anesth 20, 38–50. https://doi.org/10.1016/j.ijoa.2010.08.004
Smith, R.F., Wharton, G.G., Kurtz, S.L., Mattran, K.M., Hollenbeck, A.R., 1986. Behavioral effects of mid-pregnancy administration of lidocaine and mepivacaine in the rat. Neurobehav Toxicol Teratol 8, 61–68.
Verlinde, M., Hollmann, M.W., Stevens, M.F., Hermanns, H., Werdehausen, R., Lirk, P., 2016. Local Anesthetic-Induced Neurotoxicity. International Journal of Molecular Sciences 17, 339. https://doi.org/10.3390/ijms17030339
Wann, K.T., 1993. NEURONAL SODIUM AND POTASSIUM CHANNELS: STRUCTURE AND FUNCTION. British Journal of Anaesthesia 71, 2–14. https://doi.org/10.1093/bja/71.1.2
Wyse, D.G., Kellen, J., Tam, Y., Rademaker, A.W., 1988. Increased efficacy and toxicity of lidocaine in patients on beta-blockers. Int J Cardiol 21, 59–70. https://doi.org/10.1016/0167-5273(88)90009-5
Zeisler, J.A., Gaarder, T.D., De Mesquita, S.A., 1986. Lidocaine excretion in breast milk. Drug Intell Clin Pharm 20, 691–693. https://doi.org/10.1177/106002808602000913