COMPOSITION :
Lidocaine HCl Monohydrate Injection 2%, each ml contains Lidocaine HCl monohydrate equivalent to Lidocaine HCl 20 mg.
DESCRIPTIONS :
Lidocaine HCl Monohydrate containing Lidocaine HCl monohydrate (equivalent to Lidocaine HCl) is available in 20 mg/ml solution for injection.
INDICATIONS :
Lidocaine HCl Monohydrate are indicated for the production of local or regional anaesthesia by the following techniques :
- Infiltration
- Epidural block
DOSAGE AND ADMINISTRATIONS :
The lowest dosage and volume that results in effective anaesthesia should be used and should be based on the status of the patient and the type of regional anaesthesia intended. Lidocaine HCl Monohydrate solutions contain no antimicrobial agent and should be used only once and any residue discarded. Lidocaine should be administered with great caution to patients with impaired cardiovascular function as they may be less able to compensate for functional changes associated with the prolongation of AV conduction produced by these drugs.
Use in adult
Recommended dosages for Lidocaine HCl Monohydrate for various anaesthetic procedures in the average, healthy, 70 kg adult patient.
| Procedure | Concentration | Dose | |
| % | Plain | ||
| ml | mg | ||
| Infiltration | 2.0 | 10 | 200 |
| Epidural anaesthesia* | |||
| Lumbar | 2.0 | 5 – 10 | 100 – 200 |
*Dose determined by number of segments to be anaesthetized (2 – 3 ml per segment).
Note :
Recommended dose
The above suggested concentrations and volumes serve only as a guide. Toxic doses vary widely between patients and toxic effects may occur after any local anaesthetic procedure.
Careful observation of the patient must therefore be maintained. It is recommended that the dose of Lidocaine at any one time should not exceed 3 mg/kg. However, the dose administered must be tailored to the individual patient and procedure, and the maximum doses here quoted should be used as a guide only.
Hypotension
During thoracic, lumbar and caudal epidural anaesthesia, a marked fall in blood pressure and/or intercostals paralysis may be seen, possibly due to the use of excessive doses, improper positioning of the patient or accidental diposition of the anaesthetic within the subarachnoid space. Hypotension and bradycardia may occur as a result of sympathetic blockade.
Test dose
For epidural anaesthesia, a 3 – 5 ml test dose of a local anaesthetic solution preferably containing up to 15 micrograms of Adrenaline should be administered.
Verbal contact and repeated monitoring of heart rate and blood pressure should be maintained for 5 minutes after the test dose after which, in the absence of signs or subarachnoid or intravascular injections, the main dose may be administered.
Use of a test dose containing Adrenaline may have further advantages in that an intravascular injection of Adrenaline will be quickly recognized by an increase in heart rate, usually within about 40 seconds. To detect this, the heart rate and rhythm should be monitored with an electrocardiogram.
Prior to administration of the total dose, aspiration should be repeated. The main dose should be injected slowly, with continual assessment of the patient. If toxic symptoms or signs occur, the injection should be stopped immediately.
Use in children
For children, a reduced dosage based on body weight or surface area should be used. The dosage should be calculated for each patient individually and modified in accordance with the physician’s experience and knowledge of the patient.
In children, early signs of local anaesthetic toxicity may be difficult to detect in cases where the block is given during general anaesthetics.
Use in elderly
A reduction in dosage may be necessary for elderly patients especially those with compromised cardiovascular and/or hepatic function.
In epidural anaesthesia, a smaller dose may provide adequate anaesthesia.
With impaired hepatic function
Although Lidocaine is metabolised by the liver, dosage reduction for local anaesthesia is probably not warranted. However, caution should be exercised with repeated doses.
With impaired renal function
Impairment of renal function is unlikely to affect Lidocaine clearance in the short term (24 hours). However, toxicity due to accumulation may develop with prolonged or repeated administration.
OVERDOSAGE :
- Symptoms :
Acute emergencies associated with the use of local anaesthetics are generally related to high plasma levels or to unintended subarachnoid injection of the local anaesthetic solution (see ADVERSE REACTIONS and WARNINGS AND PRECAUTIONS).
With accidental intravascular injections, the toxic effect will be obvious within 1 – 3 minutes. With overdosage, peak plasma concentrations may not be reached for 20 – 30 minutes depending on the site of injection and toxic signs will be delayed. Toxic reactions mainly involve the central nervous and cardiovascular systems.
In children, early signs of local anaesthetic toxicity may be difficult to detect in cases where the block is given during general anaesthesia. - Symptoms of acute toxicity :
Central nervous system toxicity is a graded response with symptoms and signs of escalating severity. The first symptoms are circumoral paraesthesia, numbness of the tongue, light-headedness, hyperacusis and tinnitus. Visual disturbances and muscular tremors are more serious and precede the onset of generalized convulsions. These signs must not be mistaken for neurotic behavior.
Unconsciousness and grand mal convulsions may follow. These may last from a few seconds to several minutes. Hypoxia and hypercarbia occur rapidly following convulsions due to the increased muscular activity, together with the interference with normal respiration and loss of the airway. In severe cases, apnoea may occur. Acidosis increases the toxic effects of local anaesthetics.
Recovery is due to redistribution of the local anaesthetic drug from the central nervous system and metabolism. Recovery may be rapid unless large amounts of the drug have been injected. - Cardiovascular toxicity :
Indicates a more severe situation. Hypotension, bradycardia, decreased cardiac output, heart block, arrhythmia and even ventricular arrhythmias, ventricular fibrillation and cardiac arrest may occur as a result of huge systemic concentrations of local anaesthetics.
Cardiovascular toxic effects are generally preceded by signs of toxicity in the central nervous system, unless the patient is receiving a general anaesthetic or is heavily sedated with drugs such as a Benzodiazepine or a Barbiturate. In rare cases, cardiac arrest has occured without prodromal CNS effects. - Treatment of overdosage :
If signs of acute systemic toxicity appear injection of the local anaesthetic should be stopped immediately. If convulsions occur then immediate attention is required for the maintenance of a patent airway and assisted or controlled ventilation with oxygen, via a positive airway pressure delivery system mask. Adequacy of the circulation should then be evaluated, bearing in mind that drugs used to treat convulsions depress the circulation when administered intravenously.
Should convulsions persist despite adequate respiratory support, and if the status of the circulation permits, appropriate anticonvulsant medication such as an ultra-short acting Barbiturate (e.g., Thiopentone) or a Benzodiazepine (e.g., Diazepam) may be administered IV. The clinician should be familiar with these anticonvulsant drugs prior to use of local anaesthetics.
Suxamethonium will stop the muscle convulsions rapidly but will require tracheal intubation and controlled ventilation, and should only be used by those familiar with these procedures.
If ventricular fibrillation or cardiac arrest occurs, effective cardiovascular resuscitation treatment must be instituted and maintained for a prolonged period if necessary. Optimal oxygenation and ventilation, and circulatory support as well as treatment of acidosis are of vital importance.
If cardiovascular depression occurs (hypotention, bradycardia), appropriate treatment with intravenous fluids, vasopressor, chronotropic and or inotropic agents should be considered. Children should be given doses commensurate with age and weight.
Dialysis is of negligible value in the treatment of acute overdosage with Lidocaine.
To counteract the pressor effects of Adrenaline, use rapidly acting vasodilators, for instance nitrates or α-blocking agents.
For treatment of reactions caused by Adrenaline, consult standard textbooks.
CONTRAINDICATIONS :
- Allergy or hypersensitivity to Amide type local anaesthetics or to any excipients. Detection of suspected hypersensitivity by skin testing is of limited value.
- Local anaesthetics are contraindicated for epidural and spinal anaesthesia in patients with uncorrected hypotension or coagulation disorders or in patients receiving anticoagulation treatment.
- Local anaesthetics techniques must not be used when there is inflammation and/or sepsis in the region of the proposed injection and/or in the presence of septicaemia.
- General contraindications related to epidural anaesthesia, regardless of the local anaesthetic used, should be taken into account.
WARNINGS AND PRECAUTIONS :
- When any local anaesthetic agent is used, resuscitative equipment and drugs, including oxygen, should be immediately available in order to manage possible adverse reactions involving the cardiovascular, respiratory or central nervous system. Because of the possibility of hypotension and bradycardia following major blocks, an IV canulla should be inserted before the local anaesthetic is injected. Delay in proper management of dose-related toxicity, underventilation from any cause and/or altered sensitivity may lead to the development of acidosis, cardiac arrest and death.
- Injection should always be made slowly with frequent aspirations to avoid inadvertent intravascular injection, which can produce cerebral symptoms even at low doses.
- Careful and constant monitoring of cardiovascular and respiratory vital signs and the patient’s state of consciousness should be accomplished after each local anaesthetic injection. It should be kept in mind that at such times restlessness, anxiety, tinnitus, dizziness, blured vision, tremors, depression or drowsiness may be early warning signs of CNS toxicity.
- Low molecular weight heparins and heparinoids (spinal/epidural haematomas). When neuraxial anaesthesia (epidural/spinal anaesthesia) is employed, patients anticoagulated with low molecular weight heparins or heparinoids are at risk of developing an epidural or spinal haematoma which can result in long-term or permanent paralysis. The risk of these events is increased by the use of indwelling epidural catheters, traumatic or repeated epidural/spinal puncture, and the concomitant use of drugs affecting haemostasis such as NSAID, platelet inhibitors or other anti-coagulants. Patient should be frequently monitored for signs and symptoms of neurological impairment.
- The safety and effectiveness of Lidocaine HCl Monohydrate depends on proper dosage, correct techniques and precautions for various regional anaesthetic procedures.
- The lowest dosage that results in effective anaesthesia should be used (see DOSAGE AND ADMINISTRATIONS). Repeated injection of Lidocaine HCl Monohydrate may cause accumulation of Lidocaine or its metabolites and result in toxic effects.
Tolerance to elevated blood levels varies with the status of the patient. Elderly, young or debilitated patients, including those with advanced liver disease or severe renal dysfunction, should be given reduced doses commensurate with their age and physical condition. - Lidocaine should be given with great caution to patients with epilepsy, impaired cardiac conduction, bradycardia, severe shock or Digitalis intoxication. Lidocaine should also be administered with great caution to patients with impaired cardiovascular function as they may be less able to compensate for functional changes associated with the prolongation of AV conduction produced by these drugs. In patients with Stokes-Adams syndrome or Wolff-Parkinson-White syndrome extreme care should be taken to avoid accidental arteriovenous injection.
- Central nerve blocks may cause cardiovascular depression, especially in the presence of hypovolaemia. Epidural anaesthesia should be used with caution in patients with impaired cardiovascular function. Epidural anaesthesia may lead to hypotension and bradycardia.
Hypotension should be treated promptly with a sympathomimetic intravenously and repeated as necessary. - Local anaesthetics should be given with great caution (if it all) to patients with pre-existing abnormal neurological pathology e.g., myasthenia gravis. Use with extreme caution in epidural, caudal and spinal anaesthesia when there are serious diseases of CNS or of the spinal cord, e.g., meningitis, spinal fluid block, cranial or spinal haemorrhage, tumours, poliomyelitis, syphilis, tuberculosis or metastatic lesions of the spinal cord.
- Since Lidocaine is metabolised in the liver and excreted via the kidneys, the possibility of drug accumulation should be considered in patients with hepatic and/or renal impairment (see DOSAGE AND ADMINISTRATIONS).
- Inadvertent intravascular or subarachnoid injection of small doses of local anaesthetics injected into the head and neck area, including retrobulbar, dental and stellate ganglion blocks, may produce adverse reactions similar to systemic toxicity seen with unintentional intravascular injections of larger doses.
Clinicians who perform retrobulbar blocks should be aware that there have been reports of cardiovascular collapse and apnoea following the use of local anaesthetic injections for retrobulbar block. Prior to retrobulbar block, necessary equipment, drugs and personnel should be immediately available as with all other regional procedures. Retrobulbar injections may very occasionally reach the subarachnoid space, causing temporary blindness, cardiovascular collapse, apnoea, convulsions, etc. These must be diagnosed and treated promptly.
Retro and peribulbar injections of local anaesthetics should be use. Vasoconstrictors may aggravate tissue reactions and should be used only when indicated. - Fetal bradycardia/tachycardia frequently follows paracervical block and may be associated with fetal acidosis and hypoxia. Occasional cases of perinatal morbidity and mortality have been reported. When the recommended dose is exceeded, the risk of fetal bradycardia increases. Careful monitoring of the fetal heart rate is necessary.
- Lidocaine should be used with caution in patients with known drug sensitivities.
- Patients being treated with anti-arrhythmic drugs class III (e.g., Amiodarone) should be under close surveillance and ECG monitoring since cardiac effects may be additive.
- Lidocaine HCl Monohydrate solution for injection are probably porphyrinogenic and should only be prescribed to patients with acute porphyria on strong or urgent indications. Appropriate precautions should be taken for all porphyric patients.
- There have been post-marketing reports of chondrolysis in patients receiving post-operative intra-articular continuous infusion of local anaesthetics. The majority of reported cases of chondrolysis have involved the shoulder joint. Due to multiple contributing factors and inconsistency in the scientific literature regarding mechanism of action, casuality has not been established. Intra-articular continuous infusion is not an approved indication for Lidocaine HCl Monohydrate.
- Effects on ability to drive and operate machinery : Depending on dosage, local anaesthetics may have a very mild effect on mental function and may temporarily impair locomotion and coordination.
- Carcinogenicity/mutagenicity/impairment of fertility : 2,6-xylidine, a metabolite of Lidocaine, in daily doses of 900 mg/m2 (150 mg/kg) resulted in carcinomas and adenomas of the nasal cavity. No nasal tumours were observed in the low dose (15 mg/kg). In addition, the compound also caused subcutaneous fibromas and or fibrosarcomas (significant at 150 mg/kg).
The genotoxic potential of 2,6-xylidine has been studied with mixed results : Positive result were reported in assays for gene mutations (weekly positive in the Ames test with metabolic activation and in the mouse lymphoma assay) and chromosomal damage (chromosomal aberrations in Chinese hamster ovary cells at concentrations at which the drug precipitated from solution). No evidence of genotoxicity was found in in vivo assays for chromosomal damage (micronucleus assay) and DNA damage (unscheduled DNA synthesis). Covalent binding of DNA from liver and ethmoid turbinates indicated that 2,6-xylidine may be genotoxic under certain conditions in vivo. - Use in pregnancy category A : The safe use of Lidocaine during pregnancy has not been established. Although Lidocaine has been used extensively for surgical procedures during pregnancy with no report of ill effects to mother or fetus, there are no adequate or well-controlled studies in pregnant women of the effects of Lidocaine on the developing fetus.
Lidocaine has been effectively used for obstretrical analgesia and adverse effects on the course of labour or delivery are rare. After epidural administration of Lidocaine to women in labour, Lidocaine crosses the placental barrier. However, concentrations in umbilical veins are lower than those found in the maternal circulation. It has been suggested that blood glucose levels should be checked in newborns after obstetric regional anaesthesia.
Adrenaline free solutions should be used during labour for paraservical or pudendal blocks.
Note : Paracervical may be associated with fetal bradycardia. - Use during lactation : Lidocaine passes into breast milk. The amount of Lidocaine appearing in breast milk from a nursing 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.
DRUG INTERACTIONS :
-
- Antiarrhythmic drugs : Local anaesthetics of the amide type, such as Lidocaine, should be used with caution in patients receiving other local anaesthetics or agents structurally related to amide-type local anaesthetics e.g., certain antiarrhythmic drugs such as Disopyramide, Procainamide, Mexilitene since potentiation of cardiac effects may occur. Specific interaction studies with Lidocaine and antiarrhythmic drugs class III (e.g., Amiodarone) have not been performed, but caution should be advised (see WARNINGS AND PRECAUTIONS).
- Amiodarone : Amiodarone has been reported to reduce the clearance of Lidocaine in two case reports, although a small protective study of combined therapy on Lidocaine pharmacokinetics found no change in clearance or other pharmacokinetic factor. This combination has been reported to precipitate seizures and to lead to severe sinus bradycardia and a long sinoatrial arrest. Until more experience with concurrent use of Lidocaine and Amiodarone becomes available, patients receiving the combination should be monitored carefully.
- β-adrenoceptor antagonists : Propanolol and Metaprolol reduce the metabolism of IV administered Lidocaine and the possibility of this effect with other β-adrenergic blockers should be kept in mind. If these drugs are administered concurrently, the patient should be closely observed for signs of Lidocaine toxicity.
- Cimetidine : Cimetidine reduces the clearance of IV administered Lidocaine and toxic effects due to high serum Lidocaine levels have been reported when these two drugs have been administered concurrently.
- Anticonvulsive agents : Phenytoin and other antiepileptic drugs such as Phenobarbitone, Primidone and Carbamazepine appear to enhance the metabolism of Lidocaine but the significance on this effect is not known. Phenytoin and Lidocaine have additive cardiac depressant effects.
- Inhalational anaesthetics : Lidocaine decreases the minimum effective concentration of inhalational anaesthetics, e.g., Nitrous oxide.
- Skeletal muscle relaxants : Lidocaine and skeletal muscle relaxants, e.g., Suxamethonium, lead to excessive neuromuscular blockade; therefore this combination must be used with caution.
- Structurally related local anaesthetics : Lidocaine should be used with caution in patients receiving agents structurally related to local anaesthetics.
- Laboratory test effects :
- Creatinine : Creatinine measurements in patients with therapeutic plasma levels of Lidocaine are about 15 – 35% higher when measured by an enzymatic method versus the Jaffe method. This appears to be due to assays interference from N-ethylglycine, a metabolite of Lidocaine.
- Creatinine kinase : The intramuscular injection of Lidocaine may result in an increase in creatinine kinase levels for up to 48 hours. This may interfere with the diagnosis of myocardial infarction.
ADVERSE REACTIONS :
Adverse reaction following the administration of Lidocaine are similiar in nature to those observed with other amide local anaesthetics agents. These adverse experience are, in general, dose-related and may result from high plasma levels cause by excessive dosage or rapid absorption, or may result from a hypersensitivity, idiosyncrasy or diminished tolerance on the part of the patient.
Serious adverse experience are generally systemic in nature. The following types are those most commonly reported :
Central nervous system : CNS manifestations are excitatory and/or depressant and may be characterised by light-headedness, nervousness, apprehension, euphoria, confusion, dizziness, drowsiness, tinnitus, hyperacusis, blurred vision, vomitting, sensations of heat, cold or numbness, twitching, tremors, convulsions, unconsciousness, respiratory depression and/or arrest, agitation, difficulty swallowing, paraesthesia circumoral, numbness of the tongue and slurred speech.
The excitatory manifestations may be very brief or may not occur at all, in which case the first manifestation of toxicity may be drowsiness merging into unconsciousness and respiratory arrest. Drowsiness following administration of Lidocaine is usually an early sign of a high blood level of the drug and may occur as a result of rapid absorption. In unconscious patients, circulatory collapse should be watched for as CNS effects may not be apparent, as an early manifestation of toxicity may in some cases progress to frank convulsions and ultimately lead to respiratory depression and/or arrest. It is crucial to have resuscitative equipment and anticonvulsant drugs available to manage such patients (see OVERDOSAGE).
Cardiovascular : Cardiovascular manifestations are usually depressant and are characterised by bradycardia, hypotension and cardiovascular collapse, which may lead to cardiac arrest. Cardiac arrhythmias and hypertension have also been observed.
Methaemoglobinaemia can occur following IV administration.
Cardiovascular toxic effects are generally preceded by signs of toxicity in the central nervous system, unless the patient is receiving a general anaesthetic or is heavily sedated with drugs such as Benzodiazepine or a Barbiturate. In rare cases, caediac arrest has occured without prodromal CNS effect.
In children, early signs of local anaesthetic toxicity may be difficult to detect in cases where the block is given during general anaesthesia.
Haemodynamic : Regional anaesthesia may lead to maternal hypotension.
Allergic : Allergic reactions are characterised by cutaneous lessions, urticaria, oedema or anaphylactoid reaction/shock. Allergy to Amide type local anaesthetics is rare. The detection of sensitivity by skin testing is of doubtful value.
Neurologic : The incidences of adverse reactions associated with the use of local anaesthetics may be related to the total dose of local anaesthetic administered and are also dependent on the particular drug used, the route of administration and the physical status of the patient.
Neurological reactions following regional nerve blocks have included persistent numbness, paraesthesia and other sensory disturbances.
In patients who received Lidocaine for spinal anaesthesia, there are incidences were reported for positional headaches, hypotension, backache, shivering, peripheral nerve symptoms, nausea, respiratory inadequacy and double vision. Many of these observations may be related to local anaesthetic techniques, with or without a contribution from the local anaesthetic.
In the practice of caudal or lumbar epidural block, occasional unintentional penetration of the subarachnoid space by the catheter may occur. Subsequent adverse effects may depend partially on the amount of drug administered subdurally.
These may include spinal block of varying magnitude (including total spinal block), hypotension secondary to spinal block, loss of bladder and bowel control and loss of perineal sensation and sexual function. Persistent motor, sensory and/or autonomic (sphincter control) deficit of some lower spinal segments with slow recovery (several months) or incomplete recovery have been reported in rare instances when caudal or lumbar epidural block has been attempted. Backache and headache have also been noted following use of these anaesthetic procedures.
Peripheral nerve injury and arachnoiditis have been reported.
PRESENTATION :
Lidocaine HCl Monohydrate Injection 2% Box, 100 ampoules @ 2 ml
Reg. No. GKL8102300243A1
STORAGE :
STORE BELOW 30ºC, PROTECT FROM LIGHT
ON MEDICAL PRESCRIPTION ONLY
Manufactured by:
BERNOFARM
Sidoarjo – Indonesia
