Lidocaine infiltration

Enlund M, Mentell O, Krekmanov L. Unintentional hypotension from lidocaine infiltration during orthognathic surgery and general anaesthesia. Acta Anaesthesiol Scand 2001 45(3) 294-7. 

An epidural abscess and paraplegia occurred after paravertebral lidocaine infiltration for back pain (SEDA-21,133). 

Lidocaine hydrochloride [73-78-9] (Xylocaine), is the most versatile local anesthetic agent because of its moderate potency and duration of action, rapid onset, topical activity, and low toxicity. Its main indications are for infiltration, peripheral nerve blocks, extradural anesthesia, and in spinal anesthesia where a duration of 30 to 60 min is desirable. Because of its vasodilator activity, addition of the vasoconstrictor, epinephrine, increases the duration of action of Hdocaine markedly. It is also available in ointment or aerosol preparations for a variety of topical appHcations. 

Lidocaine is the most widely used local anesthetic. Its excellent therapeutic activity is fast-acting and lasts sufficiently long to make it suitable for practically any clinical use. It stabilizes cell membranes, blocks sodium channels, facilitates the secretion of potassium ions out of the cell, and speeds up the repolarization process in the cell membrane. It is used for terminal infiltration, block, epidural, and spinal anesthesia during operational interventions in dentistry, otolaryngology, obstetrics, and gynecology. It is also used for premature ventricular extrasystole and tachycardia, especially in the acute phase of cardiac infarction. Synonyms for this drug are xylocaine, neflurane, and many others. 

Extravasation Extravasation of IV hypertonic solutions of sodium bicarbonate may cause chemical cellulitis (because of their alkalinity), with tissue necrosis, ulceration, or sloughing at the site of infiltration. Prompt elevation of the part, warmth, and local injection of lidocaine or hyaluronidase are recommended to prevent sloughing. 

Amide-type agents include articaine, lidocaine, bupivacaine, prilocaine, mepivacain and ropiva-caine. These are metabolized in the liver by microsomal enzymes with amidase activity. The amide group is preferred for parenteral and local use. If by accident rapidly administered intravascularly these agents, especially bupivacaine but also lidocaine, can produce serious and potentially lethal adverse effects including convulsions and cardiac arrest. They can more easily accumulate after multiple administrations. Intravenous lidocaine is sometimes used for regional anesthesia, for infiltration procedures, for the induction of nerve blockade and for epidural anesthesia. However, it is also used as an antiarrhythmic. Bupivacaine is a long-acting local anesthetic used for peripheral nerve blocks and epidural anesthesia. 

Infiltration anaesthesia is applied fan-shaped, with as few needle punctures as possible, in close proximity of the wound or the skin area to be treated. An aspiration should always take place to avoid intravascular injection. Suitable alternatives are lidocaine (lignocaine) or prilocaine for injection 5-10 mg/ml, with or without adrenaline. When making an incision of an abscess it is sometimes difficult to use a local anaesthetic if there is a pronounced inflammatory reaction, since the effect of the anaesthetic is reduced due to an increased acidity level. While adrenaline reduces bleeding and delays dispersion of the anaesthetic, local anaesthetic/adrenaline combinations are contraindicated for local anaesthesia of digits, on the face or where the skin survival is at risk. 

Lidocaine hydrochloride Xylocaine) is the most commonly used local anesthetic. It is well tolerated, and in addition to its use in infiltration and regional nerve blocks, it is commonly used for spinal and topical anesthesia and as an antiarrhythmic agent (see Chapter 16). Lidocaine has a more rapidly occurring, more intense, and more prolonged duration of action than does procaine. 

Lidocaine is used for all forms of infiltration anaesthesia, in addition to peripheral, regional, spinal and epidural block. Unlike bupivacaine, it is suitable for use in intravenous regional anaesthesia. Duration of anaesthesia is about 1 hour but this can be prolonged to 2 hours by the addition of adrenaline. The maximum doses are shown in Table 5.2. 

The choice of local anesthetic for infiltration, peripheral nerve blocks, and central neuraxis (spinal/epidural) blockade is usually based on the duration of action required. Procaine and chloroprocaine are short-acting lidocaine, mepivacaine, and prilocaine have an intermediate duration of action and tetracaine, bupivacaine, levobupivacaine, and ropivacaine are long-... 

Lidocaine (synonyme lignocaine) was introduced as the first amide in 1944 and is the most commonly used LA today. It has a rapid onset of action with intermediate duration and an intermediate toxicity. The maximum tolerated dose with infiltration or injection is 200 mg (500 mg when combined with adrenaline). Lidocaine is dealkylated in the liver to monoethylglycine xylidide and glycine xylidide which retain local anesthetic activity. It is available in a variety of preparations including creams, gels, patches and solutions, often in combination with adrenaline. 

Clinical use Mepivacaine has been employed for all types of infiltration and conduction nerve block anesthesia using solutions of 1.0 and 1.5 % lasting for 1.5 to 3 h. Epidural anesthesia with 2.0 % mepivacaine has a rapid onset with a dense motor block. Hyperbaric solutions of mepivacaine have also been used for spinal anesthesia (Tetzlaff, 2000). Mepivacaine has been used for topical applications, but other LA such as lidocaine are more effective. 

Clinical use Because of its poor penetration of intact mucous membranes, procaine is largely ineffective for topical applications and has been mainly used in injection in combination with adrenaline, although in general it has been replaced by other LAs such as lidocaine. For infiltration anesthesia, 0.25 to 0.5 % solutions of procaine have been used in doses up to 600 mg. For peripheral nerve block, a common dose of 500 mg of procaine has been given as a 0.5 to 2.0 % solution. 

Lidocaine Xylocaine Rapid Intermediate Infiltration Peripheral Nerve Block Epidural Spinal Transdermal Topical Sympathetic block Intravenous regional block... 

Lidocaine is effective in producing analgesia when administered by infiltration, or by nerve, epidural, caudal, and spinal block. In addition, it is effective when applied topically, with an onset of action of 5 min and a duration of action of 15 to 30 min. Lidocaine (1.5 pg/ml) is the agent of choice for the acute suppression of most ventricular arrhythmias. 

Mepivacaine, which is ineffective topically, is used for infiltration plus nerve, epidural, and caudal block. Its potency and speed of action are similar to those of lidocaine. 

Etidocaine is a long-acting derivative of lidocaine but is far more potent. It is effective for infiltration anesthesia, peripheral nerve block, and epidural and caudal blockade. 

PROCAINAMIDE LIDOCAINE Case report of neurotoxicity when intravenous lidocaine is administered with procainamide. No significant interaction is expected when lidocaine is used for focal anaesthetic infiltration Likely to be an additive effect both may cause neurotoxicity in overdose Care should be taken when administering lidocaine as an infusion for patients taking procainamide... 

Before infiltration anesthesia for chalazion resection, 4% lidocaine solution can be applied to the tarsal conjimctiva using a cotton-tipped applicator. This procedure... 

A death due to ventricular fibrillation after 50 mg and another due to sinus arrest after 100 mg have been reported (SED-12, 255) (17). Two cases of ventricular fibrillation and cardiopulmonary arrest occurred after local infiltration of lidocaine for cardiac catheterization (SEDA-21,136). 

In 23 patients there was a significant dose-dependent reduction in blood pressure following submucosal infiltration of lidocaine plus adrenaline compared with saline plus adrenaline for orthognathic surgery (20). The study was randomized but small larger studies are needed to confirm effects that could easily have been due to multifactorial causes in patients undergoing general anesthesia. 

The addition of dextran to a lidocaine + adrenaline solution used for infiltration reduced the absorption of both (62). 

A 50-year-old man had local infiltrations a few days after an injection of lidocaine and dexamethasone (43). Prick and intradermal tests were negative after 20 minutes. However, lidocaine produced a positive patch test after 2 days, with erythema and papules. 

A 76-year-old man had already received a deep and superficial cervical plexus block for an awake carotid endarterectomy. One hour later, during manipulation of the carotid artery discomfort was treated with infiltration of 1 ml of 0.5% lidocaine in that region. Immediately he became unresponsive, with generalized tonic-clonic seizure activity of the face and arms. He was given 100% oxygen and within 30 seconds the seizure terminated spontaneously with no sequelae. 

A 49-year-old man developed uvular deviation as a result of palatal muscle paralysis following intraoral mandibular block of the inferior alveolar nerve with 1.8 ml of 2% lidocaine with adrenaline 1 in 100 000 (96). A few minutes after injection he had swallowing difficulties and a foreign body sensation in his throat. There was paralysis of the velum palatinum, with deviation of the uvula towards the non-paralysed side opposite the point of anesthetic infiltration. This resolved after the anesthetic had worn off. 

The order of injection can affect the pain of local anesthetic infiltration with buffered lidocaine in a sequence of two injections the second injection was consistently reported to be more painful than the first. This finding has important consequences with regard to trial design in this area of research (167). Buffered hdocaine warmed to 37 C was less painful than warmed plain hdocaine, plain lidocaine, and buffered lidocaine in a randomized controUed trial in 26 volunteers (168). 

Local infiltration with prilocaine 2% was significantly more comfortable than lidocaine 2% in a prospective randomized study in 125 patients undergoing minor eyelid procedures (338). 

Skin infiltration with local anesthetics can cause pain. The pain experienced during skin infiltration of lidocaine, chloroprocaine, and buffered solutions of both has been studied in 22 volunteers in a double-blind, randomized study (361). The pH of the solutions was unrelated to the pain score, but both formulations of chloroprocaine were significantly less painful than lidocaine. 

Ventricular tachycardia, severe hypertension, and pulmonary edema developed in a 53-year-old woman soon after she had a skin flap infiltrated with 4 ml of 0.5% lidocaine and 0.0005% adrenaline (20 micrograms) (365). 

An iatrogenic tension pneumothorax was the result of breast infiltration with lidocaine and adrenaline before an augmentation procedure (SEDA-20, 127). 

Marica LS, O Day T, Janosky JE, Nystrom EU. Chloroprocaine is less painful than lidocaine for skin infiltration anesthesia. Anesth Analg 2002 94(2) 351. ... 

A 12-year-old black child developed a patch of hjrper-pigmentation on his forehead where Emla cream had been used for cutaneous anesthesia before local infiltration with lidocaine for removal of a nevus. This persisted, although fading, for at least 4 months. No other cause could be found. 

Complete atrioventricular block occurred in a 10-year-old child with a history of hypertension, severe renal dysfunction, incomplete right bundle branch block, and a ventricular septal defect that had been repaired at birth (10). After slow induction with sevoflurane and nitrous oxide 66%, complete atrioventricular block occurred when the inspired sevoflurane concentration was 3% and reverted to sinus rhythm after withdrawal of the sevoflurane. The dysrhjrthmia recurred at the end of the procedure, possibly caused by lidocaine, which had infiltrated into the abdominal wound, and again at 24 hours in association with congestive cardiac failure following absorption of peritoneal dialysis fluid. 

IM Use 10% (100 mg/ml) clearly identify lidocaine that is for IM use give in deltoid muscle (blood level is significantly higher than if injection is given in gluteus muscle or lateral thigh) Instruct patient that local infiltration may bum and sting briefly... 

Extension of Tropine Alkaloids. Here again, medicinal chemists have gone beyond nature by molecular modification. While cocaine possesses topical anesthetic activity but no local infiltration value as an anesthetic, a number of very useful, local anesthetic agents such as procaine and lidocaine have been derived from our knowledge of the structure of cocaine. Chemists have broadened the scope of usefulness of the cocaine structure. 

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