IV lidocaine is an anti-arrhythmic and also can be for pain too

byAbdelwahab Ward, BS Pharm, PharmD - last updated
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As a hospital pharmacist, you will see intravenous lidocaine used to treat pain. IV lidocaine can help stop heart arrhythmias. But it also has some analgesic and anti-inflammatory effects. 

     Expect to see lidocaine 1.5 mg/kg bolus doses for pain due to conditions such as headache, kidney stones, or trauma when other analgesics don't do the trick. Don't be surprised if a lidocaine infusion of about 2 mg/kg/hr is ordered to provide analgesia during some surgeries and continued for a few days post-op.

Keep in mind, you'll most likely dispense the same IV lidocaine products for pain that you dispense for arrhythmias since the doses are similar. Follow pharmacy policies on where IV lidocaine can be dispensed. It should usually be restricted to areas where patients are closely monitored such as emergency department (ED), ICU, and perioperative areas due to the risk of side effects such as dangerously low blood pressure.

Table (1). Hospital Policy for IV Lidocaine
Clinical Questions Comments
Which types of pain can be managed with IV lidocaine? IV lidocaine may be a treatment option for visceral and central pain management, both acute and chronic.
  • Multiple mechanisms are likely responsible for lidocaine’s analgesic effect including inhibition of peripheral/central sodium channels and blocking neuronal pain signals.
Perioperative pain related to laparoscopic or open abdominal procedures (appendectomy, cholecystectomy, colectomy).
  • IV lidocaine infusions may be used as a component of multimodal analgesia and/or early recovery after surgery (ERAS) protocols.
  • Reserve for patients who are unable or unwilling to receive anesthesia via a regional approach.
Acute pain syndromes that may respond to IV lidocaine treatment include:
  • Renal colic, traumatic injury pain, limb ischemia, and herpetic neuralgia.
  • Reserve for pain not responding to NSAIDs or opioids, or when treatment is limited by side effects.
Chronic pain syndromes that may respond to IV lidocaine infusion include:
  • Neuropathic pain, CNS lesion-related pain, chronic headaches.
  • Reserve for pain refractory to first-line treatments or when usual therapies are contraindicated.
How is IV lidocaine dosed for pain management? Dosing of IV lidocaine varies by indication and institution. The most commonly used regimens by indication include:
Perioperative use for laparoscopic or open abdominal surgery
  • Loading dose: administer 1.5 mg/kg IV push over 2 to 4 minutes.
    • Actual body weight can be used to calculate dose, but one published protocol suggests use of ideal body weight for obese patients (BMI >30).
    • Consider capping loading dose at 300 mg, which was the highest loading dose studied in renal colic.
  • Infusion: Start with 2 mg/kg/hour and adjust to a range of 0.5 to 3 mg/kg/hour for pain score.
    • Infusions of ≥ 2 mg/kg/hour during surgery seem to provide optimal control of early postoperative pain (≤ 4 hours after closure). Infusions are usually continued until end of surgery.
    • Infusions may also be continued for up to 72 hours postoperatively.
      • Infusion rate may be adjusted to 0.5 to 3 mg/kg/hour for pain score.
      • Infusion rates < 2 mg/kg/hour appear to be most beneficial for intermediate to late postoperative pain control (> 4 to 24 hours after surgery).
    • Analgesic effects often persist for up to 8.5 hours following infusion discontinuation.
Renal Colic
  • 1.5 mg/kg IV push over 2 to 4 minutes x 1.
Neuropathic pain
  • 1 to 5 mg/kg IV infused over 30 minutes to 6 hours x 1.
  • Analgesic effects may persist for hours to days following discontinuation of the infusion.
Headaches
  • 60 mg/hour IV infused over 4 hours, then increased to 120 mg/hour. Infusion can then be titrated up as needed to better control pain, to a maximum rate of 240 mg/hr.
  • IV lidocaine infusions may be continued for 2 to 15 days, with an average duration being 8 days.
When should IV lidocaine be avoided?
  • Avoid combining IV lidocaine with regional anesthesia due to increased risk for local anesthetic systemic toxicity.
  • IV lidocaine is contraindicated in patients with cardiac conduction abnormalities (including Adams-Stokes or Wolff-Parkinson-White syndromes) and severe sino-atrial, atrioventricular, or intraventricular block.
  • Avoid use in patients with seizure disorders, due to seizure risk with supratherapeutic blood levels of lidocaine.
  • Use with caution in patients receiving amiodarone, aprepitant, beta-blockers, calcium channel blockers, or fosaprepitant, due to drug interactions that result in lidocaine accumulation. Consider reduced IV lidocaine dosing in patients who are also receiving these medications.
  • Use with caution in patients with liver dysfunction or heart failure, due to lidocaine accumulation related to reduced hepatic blood flow. Consider decreasing infusion rates in these patients to reduce risk for lidocaine toxicity development.

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