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Parenteral (Intravenous or Subcutaneous) Lidocaine for Neuropathic Pain (Adult & Pediatric) (10.18AP)

Parenteral (Intravenous or Subcutaneous) Lidocaine for Neuropathic Pain (Adult & Pediatric) (10.18AP) - Policies, Clinical, UWHC Clinical, Department Specific, Nursing Patient Care, Medications

10.18AP

NURSING PATIENT CARE POLICY & PROCEDURE





Effective Date:
April 2, 2015

Administrative Manual
Nursing Manual (Red)
Other _______________

Policy #: 10.18AP

Original
Revision

Page
1
of 7

Title: Parenteral (Intravenous or Subcutaneous)
Lidocaine for Neuropathic Pain (Adult &
Pediatric)

I. PURPOSE

A. To establish safe and effective administration of a trial intravenous bolus dose of
lidocaine (for inpatients) for pain management prior to initiation of continuous
parenteral (intravenous [IV] or subcutaneous [Subcu]) lidocaine.
B. To initiate and maintain a continuous parenteral (IV or Subcu) lidocaine infusion for
treatment of neuropathic pain.
C. To provide guidelines for administration of intravenous lidocaine in accordance with
UWHC Hospital Administrative Policy 8.31, Guidelines for Hospital Location Specific
Administration of IV Medications.

II. POLICY

A. All patients must have at minimum, a stable 12-lead electrocardiogram (ECG) on file in
the medical record within the past six (6) months.
B. Only patients who have responded to a test intravenous lidocaine trial (prior to hospital
admission or as outlined below) should be considered for continuous parenteral lidocaine
infusion. For more information, contact the Inpatient Pain Consult Service (pager 1010)
or the UW Pain Center at 263-9550.
C. More detailed information is available in the Pain Management Resources website on U-
Connect, including a self-learning module.
D. The dose and rate of a continuous subcutaneous lidocaine infusion is ordered by the
prescriber, verified by the pharmacist, who then prepares the appropriate solution. The
infusion is initiated and maintained by the registered nurse.

III. EQUIPMENT
A. For continuous infusions:
1. MiniMed® Sof-set subcutaneous needle model number MMT-390
(Central Service [CS] Item Number 1216552)
2. Alaris® infusion pump and administration set
3. Maintenance intravenous solution, as prescribed
4. Lidocaine infusion, as prescribed
5. Tape
a. Use transparent adhesive dressing; or, if the patient is sensitive to these,
adhesive or non-allergic tape
6. Choice of skin preparation
a. 2% chlorhexidine and alcohol prep swab, povidone iodine, or alcohol

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7. If two sites will be used due to subcutaneous infusion rate greater than 2-3 mL/hr,
extension set bifuse connector (CS Item Number 4014051), two male-male
adapters and one female-female adapter (stored in B66 Nurse Manager’s office)
are needed to connect the subcutaneous needles to the IV infusion.

IV. PROCEDURE

A. Perform hand hygiene according to UWHC Hospital Administrative Policy 13.08, Hand
Hygiene.
B. Follow standard and transmission based precautions according to UWHC Hospital
Administrative Policy 13.07, Standard Precautions & Transmission-based Precautions
(Isolation) in Inpatient Settings.
C. Indications and Contraindications
1. Indications: Parenteral (IV or Subcu) lidocaine infusions are indicated for
neuropathic pain syndromes with or without other sensory and motor phenomena
present. Some examples include:
a. Post-herpetic neuralgia
b. Painful diabetic polyneuropathy
c. Complex regional pain syndrome
d. Plexopathy
e. Pain from spinal cord injury
f. Thalamic syndrome
2. Contraindications:
a. Any allergies (sensitivities) to lidocaine or amide local anesthetics
b. Wolf-Parkinson-White syndrome
c. Severe SA, AV or intraventricular block without a pacemaker
d. Cardiovascular instability
e. First and second-degree heart conduction blocks could be aggravated and
progress into a higher degree of heart block with lidocaine administration.
Use cautiously with beta-blockers or amiodarone in patients without a
pacemaker. Multiple drug interactions exist, some medications are
contraindicated with lidocaine
3. Pediatric Cardiology approval for pediatric patients with known congenital heart
disease or inherited arrhythmias (such as long QT or CPVT). Those pediatric
patients that have 12-lead EKGs with rhythms that include bradycardia for age,
blocks, or those with newly noted prolonged QT should be excluded from
infusion or receive cardiology evaluation prior to therapy.
4. Side effects can be more pronounced in patients with liver dysfunction,
pulmonary diseases when the predominant problem is carbon dioxide retention,
and congestive heart failure.
D. Intravenous Lidocaine Bolus Trial
1. Identify the patient with two identifiers.
2. Determine if the patient has any allergies (sensitivities) to lidocaine, tape, etc.
3. Telemetry is NOT required. All patients must have a stable 12-lead ECG on file
in the medical record within the past six (6) months.
4. The trial may be administered on any general care unit.
5. The dose and rate of the IV lidocaine bolus is ordered by the prescriber and the
appropriate solution prepared by the pharmacist.
6. Only lidocaine (4% which is 40 mg/mL) can be used for trial.

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7. The prescriber explains the procedure to the patient, noting possible side effects
from the medication and possible benefits. The RN reinforces this information.
8. The RN will start an IV of normal saline according to prescriber order at a
minimum of 10 mL/hr to keep line open during the IV bolus administration to
assure drug delivery to the patient.
9. The RN obtains a baseline assessment including current blood pressure, pulse,
respiratory rate, patient's pain intensity rating, and presence of side effects.
Assessments are repeated at least every 10 minutes throughout the procedure and
documented in the clinical record.
10. The RN encourages the patient to immediately report any symptoms such as
metallic taste, ringing in the ears, dizziness, numbness around the mouth, or
lightheadedness during administration of the lidocaine. Numbness or tingling in
the extremities is an indication the medication is working and does not necessitate
stopping the trial.
11. Only patients who have responded to a test intravenous lidocaine infusion or
bolus should be considered for continuous parenteral lidocaine infusion. The
initial test dose is typically ordered and infused as 500 milligrams/100 mL over
30 minutes. If assisting with the first dose, responsibilities include:
a. Insert and maintain a patent IV line with maintenance fluid.
b. Telemetry is NOT required. See section IV, D, 3 above.
c. Obtain appropriate solution from pharmacy: 500 mg lidocaine (4% in a
100 mL bag).
d. Patient monitoring (pain, pulse, respiratory rate, pulse oximetry, and side
effects) before, and every 10 minutes throughout infusion, and again at 30
minutes following infusion.
12. Once the infusion is complete, including the 30 minute post infusion check, the
RN pages the MD to determine next steps. Thirty minutes post-infusion, re-check
patient's blood pressure, pulse, respiratory rate, pain intensity rating and presence
of side effects.
13. The prescriber will document the patient's response to the procedure and follow-
up plan. 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 prescriber and infused over 30 minutes.
The prescriber need not be present and pulse oximetry and telemetry are not
required.
14. If indicated, the prescriber completes the order set for initiation of continuous
parenteral lidocaine. The dosage and monitoring requirements are the same
whether the continuous infusion is delivered intravenously or subcutaneously. The
only difference is that subcutaneous infusions are more convenient to patients
without venous access devices for long-term therapy, and the volume that can be
administered subcutaneously is limited generally to no more than 2 to 3 mL/hr per
site.
15. If change in vital signs is within 20% of baseline, patient can be discharged.
E. Placement of Subcutaneous Needle and Initiation of Continuous Infusion
1. Determine if the patient has any allergies (sensitivities) to lidocaine, tape, etc.
2. Check the prescriber's order for prescribed solution, volume, additives, and rate of
flow.
a. Usual starting dose is one mg/kg/hr. Lidocaine should be 4% (40 mg/mL)
preservative-free solution in 100 mL minibag.

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3. A single subcutaneous infusion site can usually accept up to 2-3 mL per hour. If
the infusion must run at a rate of greater than 80 - 120 mg/hr (2-3 mL/hour) two
subcutaneous infusion sets should be branched to infuse into two sites. These sites
can be placed as close as two inches apart.
a. If two sites are needed, either two separate pumps must be used or an
extension set bifuse connector (CS Item Number 4014051), two male-
male adapters and one female-female adapter (stored in B66 Nurse
Manager’s office) are needed to connect the subcutaneous needles to the
IV infusion.
4. Order infusion pump and gather other supplies as needed from Central
Services. Because of the highly concentrated medication solutions used, it is
essential to use an infusion pump capable of delivering 0.1 mL increments. Select
the appropriate therapy from the Alaris® Guardrails drug library.
5. Obtain prescribed solution, check the solution and added medications in the
electronic record and/or prescriber order.
6. Identify the patient with two identifiers.
7. Perform hand hygiene with alcohol hand gel (preferred) or soap and water.
8. Connect administration set to the solution container. Place tubing in the pump and
prime with solution, following the pump instructions. Attach subcutaneous needle
to the end of the tubing, and flush with solution.
9. Select site for placement of SQ needle.
a. Any area with a layer of subcutaneous fat is potentially available as an
infusion site. However, consideration should be given to the patient's
preferred lying positions and fat distribution. If there are no
contraindications, choose one of the following four sites: left and right,
between the breast and the clavicle; or right or left on the abdomen (see
Figure 1 below).

b. Other sites, such as the upper arms, thighs or the upper buttocks, may also
be appropriate if they fit the individual patient's needs. If these exceptions
are to be utilized, document the reason why.
10. Remove excessive hair with clippers if indicated.
11. Follow instructions for placement of Medtronic Quick-set® for Subcutaneous
Infusions in the Related section on U-Connect.
12. Cover and anchor the infusion site with a transparent adhesive dressing.

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13. The infusion site should be left as visible as possible to allow for checks for
redness, swelling, or leakage.
14. Make a loose loop of infusion tubing and anchor with tape. If tension is applied to
the tubing, it is absorbed in the taped loop.
15. Write the time and date of placement of the infusion site on a small piece of
adhesive tape and place it over the tape used to cover the site.
a. The infusion site should be changed approximately every 48-72 hours,
sooner if inflammation or leakage occurs.
b. The tape or dressing covering the site may be left in place for the duration
of each infusion set placement.
c. Record in the clinical record:
i. Solution type and additives
ii. Resulting concentration of medication per mL
iii. Initial infusion rate and dose
iv. Placement site and site assessment
F. Subcutaneous Site and Infusion Maintenance
1. The RN is responsible for maintaining the rate of flow as ordered.
2. Change the subcutaneous infusion site every 48-72 hours, or if it develops any
redness, leakage, or swelling. Use appropriate skin prep prior to changing the
infusion site.
a. If there are no contraindications, rotate clockwise around these four sites:
left and right, between the breast and the clavicle; followed by right then
left on the abdomen (see Figure 1).
b. Other sites, such as the upper arms or thighs or the upper buttocks, may
also be appropriate if they fit the individual patient's needs. If these
exceptions are to be utilized, document the plan for their use and rotation
on the plan of care such as in the nursing communications orders. If
possible, include at least four distinct sites in any plan for rotation to
ensure that each site has adequate time to rest and heal between uses.
c. If tenderness and swelling occurs at the infusion site, change sites and
apply warm compresses to inflamed site.
3. Change the entire administration set and all connectors every 72 hours.
4. Check infusion site a minimum of one time each shift (8 hours) for redness,
swelling, or leakage and document as appropriate. Change the infusion site to the
next planned location should any of these occur.
5. Check the site more frequently (at least twice within an 8-hour shift) if an infusion
site is receiving more than 2 mL per hour. Poor absorption of fluid and
medication is more prone to appear when an infusion site approaches or surpasses
2-3 mL per hour, or in the presence of inflammation.
6. If the infusion site surpasses 3 mL/hour, the extension set bifuse connector (CS
Item Number 4014051), two male-male adapters and one female-female adapter
(stored in B66 Nurse Manager’s office) are needed to connect the subcutaneous
needles to the IV infusion.. These sites can be placed as close as two inches apart,
but place further apart if tubing length and patient anatomy allows.
G. Monitoring and Documentation
1. Monitor and document every four (4) hours:
a. Patient pain ratings
b. Blood pressure and pulse
c. Side effects

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d. Drug usage
2. Side effects to monitor and document include:
a. MILD (at serum levels 3-8 mcg/mL): numbness and tingling in fingers
and toes, perioral numbness and paresthesias, metallic taste in the mouth,
ringing in the ears, lightheadedness and dizziness
b. MODERATE (at serum levels 8-12 mcg/mL): nausea, vomiting, true
vertigo, decreased hearing, tremor, scotoma, blood pressure changes,
increased or decreased heart rate
c. SEVERE (at serum levels 12 mcg/mL): drowsiness, disorientation,
muscle twitching, convulsions, coma and cardiovascular collapse
3. Review patient side effects to report using Health Facts for You (HFFY) 5314,
Continuous Subcutaneous Lidocaine for Pain Management.
4. If any side effects occur, refer to the orders for appropriate interventions or page
provider for instructions.
H. Discontinuation of Site and Infusion
1. To discontinue infusion:
a. Turn off pump and discontinue site as below.
b. Discard any remaining drug and document date and time of
discontinuation of infusion in the clinical record.
2. To discontinue site:
a. Loosen tape, and pull the infusion set straight out with a swift motion.
Hold 2x2 gauze over the site with pressure for 30 seconds. Check site; if
there is leakage of fluid, repeat the pressure till the site is dry. There is no
need to dress the site if the skin is intact.
I. Discharge Planning
1. If the patient will be discharged on a continuous infusion, contact Chartwell at
831-8555 at least two (2) days prior to discharge.
2. Chartwell will arrange for a pump or another home infusion vendor and/or
continuing home health service as appropriate to the patient/family needs and
insurance requirements.

V. UWHC CROSS REFERENCES

A. Health Facts for You 5314, Parenteral (Intravenous or Subcutaneous) Lidocaine for
Neuropathic Pain
B. Hospital Administrative Policy 8.31, Guidelines for Hospital Location Specific
Administration of IV Medications
C. Hospital Administrative Policy 13.07, Standard Precautions & Transmission-based
Precautions (Isolation) in Inpatient Settings
D. Hospital Administrative Policy 13.08, Hand Hygiene
E. Medtronic Quick-set® for Subcutaneous Infusions (see Related section on U-Connect)
F. Pain Management Resources website (on U-Connect)

VI. REFERENCES

A. Backonja, M., & Gombar, K. A. (1992). Response of central pain syndromes to
intravenous lidocaine. Journal of Pain and Symptom Management, 7(3), 172-178.
B. Glazer, S., & Portenoy, R. K. (1991). Systemic local anesthetics in pain control. Journal
of Pain and Symptom Management, 6(1), 30-39.

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C. Knurr, H., Backonja, M., & Hutson, P. (2014). Parenteral intravenous lidocaine for
neuropathic pain – a retrospective analysis. Pain Medicine.
D. Nozaki-Taguchi, N., Chaplan. S. R., Higuera, E. S., Ajakwe, R. C., & Yaksch, T. L.
(2001). Vincristine-induced allodynia in the rat. Pain, 93(1), 69-76.
E. Tremont-Lukatz, I. W., Hutson, P. R., & Backonja, M. M. (2006). A randomized, double-
masked, placebo-controlled pilot trial of extended IV lidocaine infusion for reliefe of
ongoing neuropathic pain. Clinical Journal of Pain, 22(3), 266-71.

VII. REVIEWED BY

Clinical Nurse Specialist, Adult Pain
Clinical Nurse Specialist, Pediatric Pain
Clinical Pharmacist, Pharmacy
UWMF Medicine-Hematology/Oncology Physician
UWMF Pediatric Hematology/Oncology Physician
Nursing Patient Care Policy and Procedure Committee, July 2014

SIGNED BY

Beth Houlahan, MSN, RN, CENP
Senior Vice President Patient Care Services, Chief Nursing Officer