For more information see Nursing Patient Care Policy 10.18 Parenteral (IV/SQ) Lidocaine for Neuropathic Pain.
Objective: To provide orientation and "on-time" information necessary for competent, safe, and effective delivery of systemic parenteral lidocaine for neuropathic pain.
The cardinal behaviors for safe and effective administration of parenteral lidocaine include the ability to:
- Screen patients for indications and contraindications of lidocaine administration
- Assess and document patient response to lidocaine
- Respond appropriately to lidocaine side effects
- Adhere to guidelines for the administration of a trial intravenous bolus dose of IV lidocaine prior to initiation of a continuous parenteral (IV or SQ) lidocaine infusion
- Titrate continuous infusions to achieve maximum efficacy without side effects
- Teach patients and families how to monitor for side effects and manage continuous infusions
Estimated Time to Complete: 30 minutes
Neuropathic pain is pain that arises from injury, disease, or dysfunction of the nervous system. Neuropathic pain syndromes represent heterogeneous conditions that can not be explained by one single etiology or specific pathophysiology. Pain is typically described as burning, paroxsymal, lancinating, shooting and dysesthetic (tingling, electrical, pins and needles). It can be associated with abnormal neurologic (sensory, autonomic, or motor) examination but often occurs in the absence on any demonstrable physical findings. Examples include post-herpetic neuralgia, diabetic painful polyneuropathy, complex regional pain syndrome (formerly called reflex sympathetic dystrophy), phantom limb pain, and pain from spinal cord injury or thalamic pain syndrome. Neuropathic pain is often severe, disabling and difficult to treat requiring adjuvant analgesics and often higher than usual doses of opioids.
Lidocaine is a local anesthetic commonly administered (locally or regionally) to block nerve conduction for surgical anesthesia. It is also used systemically as an antiarrhythmic agent. When administered systemically, lidocaine has been show to produce analgesia in neuropathic pain, including pain from peripheral and central nervous system dysfunction. Theoretically, lidocaine diminishes pain by inhibiting hyperactive nerves through the blockade of sodium channels.
First and second degree heart conduction blocks could be aggravated and progress into a higher degree of heart block with lidocaine administration. Cardiovascular instability and concomitant use of alpha agonists or beta blockers are also contraindications. Allergies to other amide local anesthetics (bupivacaine). Allergy to Novacaine is not a contraindication as novacaine is an ester local anesthetic.
Clinically Important Drug-Drug Interactions
Beta blockers (nadolol, propranolol, metoprolol, etc) (lidocaine toxicity); Cimetidine (lidocaine toxicity); Dihyrdoergotamine (extreme elevation in blood pressure); Dofetilide (cardiac arrhythmias); Fosphenytoin (cardiac depression); Phenytoin (cardiac depression); Tocainide (CNS toxicity); Quinupristin/Dalfopristin (lidocaine toxicity).
The side effects of lidocaine are directly related to the serum lidocaine level. There is no specific target range for pain relief as each individual’s response and requirements are different, however, side effects are rare at serum levels within the 2-6 mcg/ml range. Side effects are more pronounced in patients with liver dysfunction, pulmonary diseases when the predominant problem is carbon dioxide retention, and congestive heart failure.
Health Fact for You #5314 should be used to instruct the patient and family regarding possible side effects and their management.
Mild side effects always occur first as an early warning of lidocaine toxicity. If left unchecked side effects can progress to cardiovascular collapse and death. If any side effects occur during continuous infusion; stop infusion, obtain BP, pain rating, associated symptoms assessment, and obtain blood sample for serum lidocaine level. The treating physician should be informed immediately.
Mild (at serum levels 3-8 mcg/ml)
- numbness and tingling in the fingers and toes
- numbness and unusual sensations around your mouth
- a metallic taste in your mouth
- ringing in the ears, or
- lightheadedness and dizziness
Moderate side effects (at serum levels 8-12 mcg/ml)
- nausea and vomiting
- severe dizziness
- decreased hearing
- changes in blood pressure and pulse
Severe side effects (at serum levels greater than 12 mcg/ml)
- muscle twitching
- loss of consciousness
- serious heart problems
Half-life of lidocaine is 30-60 minutes, which means the side effects typically dissipate within this time frame after stopping a bolus or infusion.
Surprisingly (considering the short half-life), the analgesic effect of lidocaine may last hours, days, and even weeks.
Treatment of Overdose
- Maintain airway - administer 02 at 100% - ask patient to hyperventilate (this raises the seizure threshold)
- Get help
- Diazepam 2.5 mg-30 mg IV for convulsions
- Trendelenberg position (this adds volume to the circulation)
- IV fluids (fluid challenge for hypotension)
- Artificial ventilation if necessary
- Treatment of CV depression:
- Atropine 0.25-1 mg IV
- Ephedrine 5-25 mg IV
- Epinephrine .05-.1 mg IV
- Sodium bicarb
- CPR and intubation
First Dose/IV Bolus Trial
Only patients who have responded to a test intravenous lidocaine infusion or bolus should be considered for continuous parenteral lidocaine infusion. All patients must have a stable 12 lead electrocardiogram (ECG) on file in the medical record within the past 6 months. The dose and rate of the IV lidocaine trial is ordered by the physician and the appropriate solution prepared by the pharmacist. The initial test dose is typically ordered and infused as 500milligrams/100ml over 30 minutes. The first trial is administered in the presence of a physician by the RN.
If you are assisting with the first dose, your job is to:
- Insert and maintain a patient IV line in the patient with normal saline.
- Telemetry is NOT required
- Obtain appropriate solution from pharmacy of preservative free lidocaine (4% which is 40milligrams/mL) in a 100mL bag.
- Assist with constant patient monitoring (pain, heart rate, pulse, respiratory rate, pulse oximetry, and side effects) before, and every 10 minutes throughout infusion, and again at 30 minutes following infusion.
Following a positive response to an initial IV trial, a patient may receive intermittent therapeutic infusions as an outpatient in the Infusion Center. The dose will be individualized and ordered by the physician and infused over 30 minutes. The physician need not be present and pulse oximetry and telemetry are not required.
If the patient obtains significant relief of limited duration from a first test IV bolus dose, a continuous infusion may be indicated. The dosage and monitoring requirements are the same whether the continuous infusion is delivered intravenously or subcutaneously. The only difference is that SQ infusions are more convenient to patients without venous access devices for long term therapy, and the volume that can be administered subcutaneously is limited to no more than 2ml/hr per site.
The standard solution prepared by pharmacy for continuous infusion is 4% (40mg/ml) preservative free lidocaine.
If you are assisting with the continuous infusion (IV or SQ), your job is to:
- Continuous telemetry is not required for patients following the initial IV bolus trial of lidocaine.
- If any side effects occur: stop infusion, obtain BP, pain rating, associated symptoms assessment, and obtain blood sample for serum lidocaine level. The treating physicians, including the house staff should be informed immediately.
- Under physician order, the infusion may be restarted once side effects have resolved 30-60 minutes later at the rate that was previously well tolerated without side effect, or at the 25% smaller dose.
- Assess patient and document every four (4) hours during infusion or more frequently as warranted by patient condition.
- Obtain serum lidocaine levels if side effects occur.
Review of Key Points
- Systemic parenteral lidocaine is effective in relieving neuropathic pain.
- Cardiovascular instability, conduction heart block and concomitant use of alpha agonists or beta blockers are contraindications for IV lidocaine therapy for neuropathic pain.
- Only patients who have responded to a test intravenous lidocaine bolus (prior to hospital admission or as outlined) should be considered for continuous parenteral lidocaine infusion.
- Lidocaine must be preservative free. Note the concentration: infusion solution of 4% (40mg/ml).
- Obtain serum lidocaine levels if patient develops side effects in 7ml royal blue tube during titration period and the day of discharge.
- Titrate up by 20% every 8 hours if pain > or = 3 (on a 0-10 scale). If pain is < 3, do not change drip rate.
- Record patient's pain rating, BP, HR and side effects Q 4 hours on lidocaine flowsheet.
- If side effects occur, stop infusion, obtain HR, BP, pain rating, symptoms and obtain serum lidocaine level. Inform MD. Restart infusion when side effects have resolved (usually within 30-60 minutes) at a previously well tolerated rate as directed by the physician.
- Backonja M, Gombar KA. Response of Central Pain Syndromes to Intravenous Lidocaine (pdf). Journal of Pain and Symptom Management 1992;7(3):172-178.
- Backonja MM. Local Anesthetics as Adjuvant Analgesics (pdf). Journal of Pain and Symptom Management 1994;9(8):491-499.
- Mao J, Chen LL. Systemic lidocaine for neuropathic pain relief (pdf). PAIN 2000;87:7-17.
- V Challapalli, IW Tremont-Lukats, ED McNicol, J Lau, DB Carr. Systemic administration of local anesthetic agents to relieve neuropathic pain. Cochrane Database of Systematic Reviews 2005, Issue 4. Art. No.: CD003345. DOI: 10.1002/14651858.CD003345.pub2.
- Carroll I, Gaeta R, Mackey S. Multivariate analysis of chronic pain patients undergoing lidocaine infusions: increasing pain severity and advancing age predict likelihood of clinically meaningful analgesia. Clin J Pain. 2007 Oct;23(8):702-6.
- Tremont-Lukats IW, Challapalli V, McNicol ED, Lau J, Carr DB. Systemic Administration of Local Anesthetics to Relieve Neuropathic Pain: A Systematic Review and Meta-Analysis. Anesth Analg 2005;101:1738-1749 © 2005 International Anesthesia Research Society. doi: 10.1213/01.ANE.0000186348.86792.38
For more information, contact the Inpatient Pain Consult Service Monday through Friday during business hours (pager 1010) or the UW Center for Pain Treatment and Research at 263-9550.
HFFY: Continuous SQ Lidocaine for Pain Mgmt #5314
Contact: Peggy Riley, Pain CNS pager 7645