Lidocaine and Epinephrine injection is used to produce local anesthesia when administered at the site of minor surgery. Lidocaine acts as a local anesthetic while epinephrine causes vasoconstriction resulting in concentrating lidocaine at the site and prolonging its duration of action by 3 - 4 times.

Lidocaine and epinephrine Uses:

• Local Anesthesia:

  • It acts as a local anesthetic when infiltrated during dental procedures or when administered around a nerve during nerve block procedures.

Lidocaine and Epinephrine Dose in Adults:

Lidocaine and Epinephrine injection Dosage in Adults:

• Dental: Oral infiltration/ mandibular block:

  • Initially it can be given as 1 to 5 mL (lidocaine 20 mg to 100 mg).
  • It should be noted that for most routine dental procedures, lidocaine 2% with epinephrine 1:100,000 is used.
  • When more pronounced hemostasis is required, use a 1:50,000 epinephrine concentration.
  • It should not be exceeded from 7 mg/kg body weight, up to a maximum range of 300 mg, in usual dental practice, to 500 mg of lidocaine and 3 mcg (0.003 mg) of epinephrine/kg of body weight or 0.2 mg epinephrine per dental appointment.

• Epidural:

  • It can be Administered as a test dose (eg, 2 to 3 mL of lidocaine 1.5%) at least 5 minutes before injecting the total volume required for a lumbar or caudal block.
  • The dose can vary with the number of dermatomes to be anesthetized which is generally 2 to 3 mL of lidocaine 1%, 1.5%, or 2% with epinephrine [1:200,000] per dermatome).
  • For continuous epidural or caudal anesthesia, the maximum dose should not be administered at intervals of less than 90 minutes.
  • The maximum total dose for the paracervical block is  200 mg/90 minutes. And 50% of the total dose should be injected on each side, with 5 minutes gap between sides.

• Local:

  • For local Infiltration the dose varies with the procedure, the degree of anesthesia needed, the vascularity of tissue, the duration of anesthesia required, and the physical condition of the patient.
  • The maximum dose of lidocaine is 7 mg/kg (up to 500 mg). The use of lidocaine 1%, 1.5%, or 2% with epinephrine (1:200,000) can be used as single-dose units.

Lidocaine and Epinephrine injection Dosage in Children:

The clinical condition should be assessed by proper anesthetist and the dose in ml/kg/hr should be calculated meticulously.

Note: Dosing should be based on lean body mass. Due to the shorter duration of action and potential toxicity with repeat dosing, lidocaine is not typically used for central (spinal) or regional (epidural/caudal) anesthesia.

Lidocaine and Epinephrine injection Dose in the Local anesthesia; dermal/cutaneous infiltration:

• Infants, Children, and Adolescents:

  • The usual concentration  is less than 2% (eg, 1% or 2%) solution:
  • It is then used to infiltrate area locally. The maximum dose is 7 mg/kg, not to exceed the adult maximum dose of 500 mg.
  • It is noteworthy Aspiration should be performed prior to each injection. However, the absence of blood in the syringe does not guarantee that intravascular injection has been avoided.

Lidocaine and Epinephrine injection Dose in the treatment of Peripheral nerve block; excluding digital or penile:

• Infants ≥6 months, Children, and Adolescents:

  • The usual concentration is less than 1%:
  • The dosage (i.econcentration [0.25, 0.5 or 1%]) and volume vary with the procedure, degree of anesthesia needed, the vascularity of tissue, the duration of anesthesia required, and the physical condition of the patient.
  • The maximum dose of lidocaine is  7 mg/kg, not to exceed the adult maximum of 500 mg. For infants <6 months, maximum doses should be deducted by 30%.

Lidocaine and Epinephrine injection Dose in the Dental anesthesia; oral infiltration/mandibular block:

It is important to note that for most routine dental procedures, lidocaine 2% with epinephrine 1:100,000 is preferred. When more pronounced hemostasis is required, a 1:50,000 epinephrine concentration can be used.

• Children <10 years:

  • Lidocaine 2% with epinephrine solution is used less than 0.9 to 1 mL (lidocaine 18 mg to 20 mg) per procedure.
  • The maximum dose is  4.4 mg/kg not to exceed 300 mg.
  • The doses for the procedures involving a single tooth, maxillary infiltration for 2 to 3 teeth, or mandibular block of an entire quadrant should be properly calculated.
  • It is rare that a patient would require a higher dose (ie, >1 mL)

• Children ≥10 years and Adolescents:

  • Lidocaine 2% with epinephrine solution:
    • Initially, it can be given as 1 to 5 mL (lidocaine 20 mg to 100 mg).
    • It should not exceed the usual dental guideline-recommended maximum dose of 4.4 mg/kg up to a maximum total dose of 300 mg.
    • Some trials suggest a higher maximum of 7 mg/kg up to a total maximum of 500 mg (approved by manufacturer) of lidocaine and 3 mcg (0.003 mg) of epinephrine/kg of body weight or 0.2 mg epinephrine per dental appointment.

Pregnancy Risk Factor B

• Animal studies have not shown any adverse effects on the pregnancy.
• Talk to individual agents.

Breastfeeding: Lidocaine and Epinephrine

• It is unknown if breast milk contains lidocaine.
• However, the manufacturer advises that nursing mothers be cautious when giving lidocaine or epinephrine.

Lidocaine and Epinephrine injection Dose in Kidney disease:

Its metabolites can be increased in renal impairment hence the dose adjustment can be considered. But the manufacturer hasn't given any recommendations.

• Dialysis: This drug is not dialyzable (0% to 5%) by hemo- or peritoneal dialysis. An additional supplemental dose is not necessary.

Dose in Liver disease:

No dose adjustments are required as per the manufacturer. However, because in severe hepatic disease its metabolites can prove to be more hepato-toxic.

Side effects of Lidocaine and Epinephrine injection:

See individual agents: Lidocaine (Lignocaine) and Epinephrine (Adrenaline)

Contraindications to Lidocaine and epinephrine Include:

• Hypersensitivity to lidocaine, or any of its components, is an absolute contraindication. 
• Additional contraindications to canadian labeling include hypersensitivity of para amino benzoic acids (PABA).

Warnings and precautions

• Cardiovascular effects

  • Patients with heart disease should not use it as it can cause cardiac depression.

• CNS toxicity:

  • Following each injection of local anesthetic, it is important to monitor the patient's consciousness carefully and continuously.
  • These symptoms may include restlessness, anxiety and dizziness.
  • The goal of treatment is to treat the symptoms and be supportive.

• Hypersensitivity

  • Some patients have experienced anaphylaxis.

• Infusion-related intra-articular chondrolysis

  • It is not recommended to continue intra-articular injections of local anesthetics following arthroscopic, or other surgical procedures.
  • Infusions can cause chondrolysis in the shoulder joint. Some cases may require arthroplasty, or replacement of the shoulder.

• Methemoglobinemia:

  • Local anesthetics have been shown to cause methemoglobinemia. 
  • Methemoglobinemia that is clinically significant must be treated immediately.
  • After administration, there can be immediate or delayed-onset.
  • Patients with G6PD deficiency or congenital or irreversible methemoglobinemia, cardiac and pulmonary compromise, or exposure to oxidizing agent or their metabolites or infants younger than 6 months old are more at risk. They should be closely monitored for signs such as fatigue, cyanosis and rapid pulse.

• Respiratory arrest

  • Local anesthesia can be used to treat respiratory arrest.

• Cardiovascular disease

  • Patients with bradycardia or severe shock, heart block, impaired cardiovascular function, bradycardia, or severe shock should be cautious. 
  • It is not recommended to be used in areas that are supplied by blood vessels or have a compromised blood supply.
  • Exaggerated vasoconstrictor responses may be seen in patients with hypertensive or peripheral vascular disease.
  • A ischemic injury such as exfoliating, ulcerating lesion or necrosis may be visible.

• Diabetes:

  • It should not be used in patients with diabetes.

• Hepatic impairment

  • Lidocaine has a liver metabolism so it should not be used without extreme caution to avoid toxic effects.

• Renal impairment

  • Patients with severe renal impairment should be cautious (lidocaine may accumulate).

• Thyroid disease:

  • It can lead to hyperthyroidism.

Lidocaine and epinephrine: Drug Interaction

Lidocaine and epinephrine: Drug Interaction

Monitoring parameters:

• Vital signs.
• ECG during the administration of a test dose.
• State of consciousness after each injection.
• Signs of CNS toxicity.

How to administer Lidocaine and epinephrine?

Avoid intravascular injections

• Aspirate the syringe after tissue penetration and before injection to minimize the chance of direct vascular injection.
• Use with caution or avoid use when there is inflammation and/or sepsis in the region of the proposed injection.
• Do not use injections containing preservatives (eg, methylparaben) for epidural or spinal anesthesia, or for any route of administration that would introduce the solution into the cerebrospinal fluid.
• For continuous epidural or caudal anesthesia, the maximum dose should not be administered at intervals of less than 90 minutes.

Mechanism of action of Lidocaine and epinephrine:

• Lidocaine inhibits both the conduction and initiation of nerve impulses.
• It decreases the neuronal membranes' permeability to sodiumions.
• This results in depolarization, with consequent blockage of conduction.

Epinephrine:

• Increases the length of action of lidocaine via vasoconstriction (via Alpha effects), which slows down the vascular absorption.

The onset of action:

• Dental: ≤2 to 4 minutes

Duration:

• Dental: About 2.5 hours (infiltration);
• Nerve Block: 3 to 3.5 hours; dose and anesthetic procedure dependent

International Brand Names of Lidocaine and epinephrine:

• D-Care 100X
• Lignospan Forte
• Lignospan Standard
• Xylocaine MPF With Epinephrine
• Xylocaine With Epinephrine
• Xylocaine With Epinephrine
• Anasica Adrenaline
• Chalocaine with Adrenaline
• Ecocain 25
• Ecocain w/Adrenaline
• Gobbicaina con Epinefrina
• Indican con Epinefrina
• Jasocaine A
• Jasocaine-A DC
• Lidocadren Teva
• Lignospan Special
• Lox
• Octacaine
• Octocaine
• Pisacaina
• Xilonest
• Xilonibsa
• Xylanaest Mit Epinephrin
• Xylocain Adrenalin
• Xylocain-Adrenalin
• Xylocain-Epinephrin
• Xylocaina con Epinefrina
• Xylocaine Adrenaline
• Xylocaine met Adrenaline
• Xylocaine w Adrenaline
• Xylocaine with Adrenaline
• Xylone-A
• Xylonor Dental

Lidocaine and epinephrine Brands Names in Pakistan:

No Brands Available in Pakistan.