Medications | Systemic Lidocaine for the Treatment of Pain - Adult/Pediatric - Inpatient/Ambulatory/Emergency Department
1
Systemic Lidocaine for the Treatment of Pain -
Adult/Pediatric -
Inpatient/Ambulatory/Emergency Department
Clinical Practice Guideline
Note: Active Table of Contents – Click each header below to jump to the section of interest
Table of Contents
INTRODUCTION ............................................................................................................. 3
SCOPE ............................................................................................................................ 5
DEFINITIONS ................................................................................................................. 5
RECOMMENDATIONS ................................................................................................... 6
METHODOLOGY .......................................................................................................... 15
COLLATERAL TOOLS & RESOURCES ..................................................................... 17
APPENDIX A ................................................................................................................ 18
REFERENCES .............................................................................................................. 19
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Content Expert(s):
Name: Kara Buck, PharmD, BCPS - Pharmacy
Phone Number: (608) 263-1290
Email Address: KBuck@uwhealth.org
Name: Hanna Christensen, PharmD, BCPPS - Pharmacy
Phone Number: (608) 263-1290
Email Address: HChristensen@uwhealth.org
Name: Marilyn Bazinski, BSN, RN-BC – Nursing Practice Innovation
Phone Number: (608) 890-5472
Email Address: mbazinski@uwhealth.org
Contact for Changes:
Name: Carin Bouchard, PharmD, BCPS - Drug Policy Program
Phone Number: (608) 263-8967
Email Address: cbouchard@uwhealth.org
Guideline Author(s):
Kara Buck, PharmD, BCPS – Pharmacy
Hanna Christensen, PharmD, BCPPS – Pharmacy
Marilyn Bazinski, BSN, RN-BC – Nursing Practice Innovation
Workgroup Members:
Carin Bouchard, PharmD, BCPS – Drug Policy Program
Noreen Hogan, RN, BSN – Infusion Center
Mary Mably, RPh, BCOP - Pharmacy
Peggy Riley, MSN, RN – Nursing Administration AFCH
Jennifer Sandra, PharmD, BCPS – Pharmacy
Michael Zywicki, MSN, RN, APNP, NP-C – Anesthesiology
Mike Nyffeler, PharmD – UnityPoint Meriter Pharmacy
Sandra Fahlstrom, BSN, RN – Pain Management Clinic 1102 S. Park St
Reviewer(s):
Dr. Alaa Abd-Elsayed - Anesthesiology
Dr. Sara Christensen Holz - Rehabilitation
Dr. Tim Casias - Anesthesiology
Dr. Nathan Rudin - Rehabilitation
Dr. Nalini Sehgal - Rehabilitation
Dr. Michelle Poliak-Tunis - Rehabilitation
Dr. Ben Walker - Anesthesiology
Dr. Bonnie Weigert - Rehabilitation
Dr. Peggy Kim - Anesthesiology
Dr. Aleksandra Zgierska – Family Medicine
Dr. Miguel Leal - Cardiology
Dr. Annie Kelly - Cardiology
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Committee Approval(s):
Pain Steering Committee (12/2018)
UW Health Lab Practice Committee (1/2019)
Nursing Practice Council (3/2019)
Pediatric Practice Council (4/2019)
Pharmacy & Therapeutics Committee (4/2019)
Introduction
Lidocaine is a sodium channel blocker classified as a type Ib antiarrhythmic and is an amide
local anesthetic1. It is FDA approved for local and regional anesthesia as well as for the
treatment of ventricular arrhythmia. Systemic lidocaine is used off label for the treatment of
various pain conditions. In adults, lidocaine has been used to treat both acute and chronic pain
conditions including, but not limited to, neuropathic pain2, headache3 and renal colic4-8 and
postoperative pain9.
A Cochrane review of neuropathic pain conditions summarized the evidence of 16 randomized,
double-blind, controlled trials, with doses ranging from 1-5 mg/kg. The authors concluded that
systemic lidocaine is superior to placebo for controlling neuropathic pain. The included trials
were small, and many were underpowered to detect significance. Studies enrolled patients with
various types of neuropathic pain syndromes making it unclear if lidocaine is more effective for
certain types of neuropathic pain compared to others. Evidence is not as strong when lidocaine
is compared to other medications (ketamine, morphine and amantadine) used to treat
neuropathic pain2.
Lidocaine has used for cancer related pain control with varying results. Eleven patients with
cancer related neuropathic pain received a 5mg/kg lidocaine infusion with no significant
improvement in pain intensity10. Conversely, a case series detailed the use of continuous
infusion lidocaine for the treatment of intractable pain in six hospice patients in the home setting
with an average dose 44mg/hr (range 10-80mg/hr)11. A randomized, double blind, placebo-
controlled crossover study was conducted in 50 patients with opioid refractory cancer pain and
showed pain control was significantly improved with lidocaine (4mg/kg total dose) 12.
Subcutaneous lidocaine infusions (median dose 0.67 mg/kg/hr) were studied in twenty patients
with cancer related pain and were deemed effective in 45% of patients13.
Parenteral lidocaine has been studied in various headache subtypes, including chronic daily
headache and acute migraine management, with variable results. Two retrospective reviews
describe the successful use of continuous infusion lidocaine (dose range 1-4 mg/min for 2-15
days) for treatment of chronic headache in adults14,15. One study specifically describes its
successful use in treating chronic daily headache associated with medication overuse
(decreased average headache days per month = 29 to 15 after lidocaine infusion)15. Case
studies describing IV lidocaine (dose range 1.3 mg/kg/hour to 3.3 mg/kg/hour) for short-lasting
unilateral neuralgiform headache with conjunctival injection and tearing (SUNCT syndrome)
have shown variable efficacy with some patients seeing minimal benefit, and most seeing
benefit only during the lidocaine infusion16,17. Lidocaine for treatment of acute migraine or
headache in the emergency room was shown to be no more efficacious than placebo when
dosed at 1 mg/kg and given over 2 minutes18. A small randomized, single blinded study showed
chlorpromazine to be significantly more effective than lidocaine (50mg boluses up to a max of
150mg) for the treatment of acute headache, and that lidocaine and dihydroergotamine have a
similar effect on pain scores in patients with acute headache19.
In patients with renal colic, lidocaine has been investigated as both monotherapy and adjuvant
therapy to opioids. A randomized, double-blind trial compared IV lidocaine (1.5 mg/kg) to IV
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morphine (0.1 mg/kg) for renal colic. Results indicate that lidocaine produced a greater
reduction in pain score than morphine at 30 minutes (P = 0.0001)5. Another study compared
lidocaine (1.5 mg/kg) and morphine (0.1 mg/kg) with morphine (0.1 mg/kg) alone for the
treatment of renal colic. Pain scores were reduced in both groups but the between group
reduction differences were not statistically significant. However, the combination of lidocaine
and morphine produced a more rapid pain resolution. Additionally, the authors noted that the
lidocaine/morphine group had a significant reduction in nausea-free time when compared to
morphine alone6.
Intravenous lidocaine infusions have shown to have an opioid sparing effect during the post-
operative period when administered during abdominal surgery20. Additionally, lidocaine
infusions have reduced the duration of postoperative ileus21 and decreased length of stay by 8-
24 hours22. Secondary to limited quality evidence, a 2018 Cochrane review, however, concluded
that it is uncertain if lidocaine has a beneficial impact, when compared to placebo, for pain
control, bowel recovery and on opioid consumption.23
In pediatric populations, lidocaine has been studied for use in neuropathic pain, refractory
cancer pain, postoperative pain and headache. However, the evidence to support lidocaine for
use in these pain conditions is mainly derived from case series and expert opinion.
A case series details the effectiveness of continuous IV lidocaine for dinutuximab-induced
neuropathic pain in neuroblastoma patients24. There are also a case series25-27and expert
opinion articles28 that describe the successful use of continuous IV lidocaine for refractory
cancer pain. Doses used for these indications range from 0.5-2 mg/kg/hour continuous infusion
with or without a 1-2 mg/kg loading dose over 30 minutes28. One case study reports dose
escalation up to 3.8 mg/kg/hour after more than 2 months of IV lidocaine therapy for severe
neuropathic pain due to terminal cancer27. However, doses this high should only be considered
in extreme circumstances where the benefit outweighs the risk of toxicity, and the patient still
receives pain relief with an increase in dose.28
Continuous lidocaine has been used to successfully treat postoperative pain in children in a
small randomized controlled trial.29 The trial included 12 pediatric patients (age 1-6) who
received lidocaine perioperatively at 1.5 mg/kg/hour. This infusion was initiated with a 1.5 mg/kg
bolus 20 minutes before incision and continued for up to 6 hours post-procedure. Lidocaine
levels were monitored, and no patient achieved a level >5 micrograms/ml. Patients receiving IV
lidocaine had significantly shorter length of stay and significantly lower opioid consumption
compared to the placebo group. Expert opinions support lidocaine for postoperative pain control
as well.30,31
Additionally, a retrospective review in of adolescents demonstrates the effectiveness of
intermittent IV lidocaine for the treatment of various kinds of chronic pain including headache,
neuropathy, sickle cell disease, and skeletal pain3. In this study 15 patients underwent a total of
58 infusions and a decrease in pain score was reported after 41/58 infusions.
A 2018 retrospective review described the use of continuous lidocaine for refractory status
migraine in 26 pediatric patients. After initiating a lidocaine 3 mg/kg loading dose over 90 min
and then starting a continuous infusion at 1 mg/kg/hour (range 1.125-2.25 mg/kg/hour with
titration), it took an average of 16 (+/- 12) hours to reduce patients’ pain scores by 50% & 19 (+/-
19) hours to achieve complete resolution for the 28/31 patients who did achieve complete
resolution. Unfortunately, 16/31 patients had relapse of pain at the time of discharge but were
reported at significantly lower intensities than on admission32.
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Scope
Intended User(s): Physicians, Advanced Practice Providers, Nurses, Pharmacists
Objective(s): To provide evidence-based recommendations for the dosing, administration and
monitoring of parenteral lidocaine for the treatment of pain at University Hospital inpatient units,
infusion center, and emergency departments and at UW Health pain clinics.
Target Population: Adult and pediatric patients with acute, chronic (cancer and non-cancer)
and postoperative pain conditions.
Clinical Questions Considered:
• What indications and contraindications should be considered when using intravenous or
subcutaneous lidocaine infusions for pain?
• Do patients need an ECG and baseline labs prior to initiation of lidocaine treatment?
• How is lidocaine dosed, how frequently should it be administered, and how should it be
administered for pain?
• What are the monitoring parameters for lidocaine infusions?
• Should lidocaine levels be routinely ordered for patients receiving lidocaine for pain?
• What interventions should be used to treat adverse reactions to lidocaine?
Definitions
• Adult – any patient > 18 years of age
• Pediatric – any patient > 1 month of age to 18 years of age
• Chronic pain – pain that persists beyond normal tissue healing time, which is assumed to be
three months33
• Central pain syndrome (CPS) - a neurological condition caused by damage to or dysfunction
of the central nervous system (CNS), which includes the brain, brainstem, and spinal cord.
This syndrome can be caused by stroke, multiple sclerosis, tumors, epilepsy, brain or spinal
cord trauma, or Parkinson's disease34
• Complex regional pain syndrome (CRPS) is an array of painful conditions that are
characterized by a continuing (spontaneous and/or evoked) regional pain that is seemingly
disproportionate in time or degree to the usual course of any known trauma or other lesion.
The pain is regional (not in a specific nerve territory or dermatome) and usually has a distal
predominance of abnormal sensory, motor, pseudo motor, vasomotor, and/or trophic
findings. The syndrome shows variable progression over time. See Appendix A for
Budapest Criteria for diagnosis of CRPS35,36.
• Peripheral neuropathy - damage to the peripheral nervous system, which transmits
information to and from the brain and spinal cord to every other part of the body. More than
100 types of peripheral neuropathy have been identified, each with its own characteristic set
of symptoms, pattern of development, and prognosis. Impaired function and symptoms
depend on the type of nerves -- motor, sensory, or autonomic -- that are damaged37.
• Status Migraine – prolonged migraine attack (≥ 72 hr) of unremitting headache38
• Chronic Daily Headache - headache occurs greater than 15 days per month for at least 3
months39
• Actual body weight (Actual BW) – actual total mass of the patient in kilograms
• Ideal body weight (IBW):
o Males IBW = 50 kg + 2.3 kg for each inch over 5 feet in height
o Females IBW = 45.5 kg + 2.3 kg for each inch over 5 feet in height
• Adjusted body weight (Adj BW)40
o Adj BW = IBW + 0.4 x (Actual BW – IBW)
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Recommendations
1. Indications for lidocaine infusions: Lidocaine has been studied a variety of pain
conditions. See Table 1.
Table 1: Lidocaine Indications
Patient Population Indications for Lidocaine
UW Health Evidence
rating
Adult acute and chronic
pain
• Neuropathic pain2
o Spinal cord injury/stroke41,42
o Diabetic neuropathy43
o Postherpetic neuralgia44,45
o Radiculopathy/radicular/nerve
injuries46-48
o Fibromyalgia49
o Central pain syndrome41
o Complex regional pain
syndrome50
o Multiple sclerosis51
(UW Health moderate
quality evidence, S
recommendation)
• Opioid refractory cancer pain10-12
(UW Health moderate
quality evidence, S
recommendation)
• Post-operative pain9,15,20,52-54
(UW Health high quality
evidence, C
recommendation)
• Headache14,15
o Chronic daily headache
o Chronic cluster headache
(UW Health low quality
evidence, C
recommendation)
• Renal colic4-8
(UW Health moderate
quality evidence, S
recommendation)
Pediatric acute and
chronic pain
• Post-operative pain29,31
• Chemotherapy induced
neuropathic pain24
• Opioid refractory cancer pain25-27
• Headache3
• Neuropathic pain3,31
o Erythromyalgia55
o CRPS56
o Avascular necrosis3
o Diabetic peripheral
nephropathy3
(UW Health low quality
evidence, C
recommendation)
2. Inappropriate indications53
2.1. Lidocaine has not been shown to be beneficial for the treatment of certain pain
conditions such as (but not limited to) mastectomy57,58, hysterectomy59,60, total hip
arthroplasty53, coronary artery bypass surgery53, tonsillectomy53. A list of evidence-
based indications is contained in Table 1 (UW Health moderate quality evidence, S
recommendation)
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2.2. Systemic lidocaine is not typically the first line agent for any pain condition (UW Health
moderate quality evidence, S recommendation).
2.3. For the treatment of neuropathic pain, systemic lidocaine is not recommended unless
patients have tried and failed or have contraindications to first or second line agents
such as tricyclic antidepressants (TCA), serotonin reuptake inhibitors (SNRI),
gabapentin/pregabalin, opioids/tramadol, topical agents and anticonvulsants61,62 (UW
Health high quality evidence, S recommendation)
3. Contraindications for lidocaine infusions: Lidocaine can affect cardiac conduction,
therefore care should be taken to evaluate patient’s cardiac history and concurrent
medications prior to infusion21,63. An ECG should be obtained prior to initiation of lidocaine.
The ECG should be reviewed by the ordering provider and if concerns over appropriateness
of lidocaine therapy arise, the ECG should be escalated to a qualified clinician for review.
Additionally, renal and hepatic dysfunction may lead to the accumulation of lidocaine
metabolites.1 Therefore, an assessment of serum creatinine and ALT should be completed
prior to initiation of all lidocaine infusions, periodically during prolonged therapy and/or if
clinical status changes (UW Health low quality of evidence, S recommendation).
Table 2: Contraindications for Lidocaine
Contraindications for Lidocaine Evidence rating
Absolute Contraindications
• Conduction block21,63 with the following findings:
• Adam-Stokes syndrome;
• Wolff-Parkinson-White syndrome;
• Severe degrees of SA, AV, or intraventricular heart
block (e.g. 2nd degree), except in patients with a
functioning artificial pacemaker
• Allergy to lidocaine or other amide local anesthetics
• Pregnancy
• Age less than 6 months31 (secondary to increased risk
of toxicity related to immature hepatic function and
increased free lidocaine levels)
Relative Contraindications
• Chronic alcoholism or substance abuse (due to risk for
additive CNS adverse events, evaluate on an individual
basis if the benefit is greater than the risk)
• ECG findings:
• PR interval > 200 milliseconds
• QRS complex > 120 milliseconds
• Bifascicular block regardless of QRS complex
duration
• Age 6 months – 1 year31,64 (secondary to increased risk
of toxicity related to immature hepatic function and
increased free lidocaine levels)
• Patients who are unable to self-report adverse events
• Seizure history or at risk for seizure65
UW Health low quality of
evidence, S recommendation
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• Advanced age/poor functional status66
• Renal dysfunction1,65,67
• Hepatic dysfunction1,67
• Drug-drug interactions1
• Medications that induce CYP1A2 (primary enzyme
responsible for metabolism) or CYP3A4 (minor
enzyme involved in metabolism) decrease
lidocaine concentrations, but therefore increase
active metabolites which are renally eliminated
• Medications that inhibit CYP1A2 and CYP3A4 (will
increase lidocaine concentrations)
• Antiarrhythmic agents (concern for additive cardiac
toxicity-concomitant use should be evaluated by a
cardiologist prior to initiating IV lidocaine for pain)
4. Baseline assessment
4.1. Prior to initiation of a lidocaine infusion, baseline patient assessments should be
completed. There is no consensus in the literature as to when baseline ECG and
laboratory evaluation should occur. It is recommended that for inpatients, these
assessments be completed within one week of initiation of the infusion. For outpatients,
it is recommended these assessments should be completed as close as possible to the
initiation of the infusion, ideally within one month, but no more than 6 months prior to
the infusion. (UW Health very low-quality evidence, C recommendation)
4.1.1. ECG
4.1.1.1. An ECG should be reviewed by the ordering provider. If concerns over
appropriateness of lidocaine therapy arise, the ECG review should be
escalated to a qualified clinician.
4.1.2. Laboratory:
4.1.2.1. Potassium
4.1.2.2. Magnesium
4.1.2.3. Serum creatinine
4.1.2.4. ALT
4.1.3. Vital signs:
4.1.3.1. Blood Pressure
4.1.3.2. Heart Rate
4.1.3.3. Respiratory Rate
4.1.4. Pain Assessment:
4.1.4.1. Location, quality, frequency and severity
4.1.5. Assessment of previous tolerability and side effects if patient has received IV
lidocaine before
Table 3: Timing of Baseline Assessments
Inpatient Outpatient
ECG Within 1 week of initiation Within 1 – 6 months of initiation
Labs Within 1 week of initiation Within 1 – 6 months of initiation
Vital signs Day of infusion Day of infusion
Pain assessment Day of infusion Day of infusion
Previous tolerability/side
effects
Day of infusion Day of infusion
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5. Patient education
5.1. Patient to have lidocaine teaching completed by RN including review of side effects and
need for a driver following lidocaine trials.
5.2. A Health Facts for You (HFFY #5314) should be given to all patients prior to initiation of
therapy.
6. Dosing of Lidocaine
6.1. Dosing regimens and routes of delivery are based on indication (See Table 4)
6.2. Actual body weight should be used for intermittent dosing, however for patients with
body mass index (BMI) > 30 may consider using ideal body weight59,68. Ideal body
weight should be used for continuous infusions (UW Health very low-quality evidence, C
recommendation).
6.3. A test dose of lidocaine is recommended prior to initiating intermittent and continuous
lidocaine infusions for neuropathic pain. If the test dose is effective, and without
significant adverse effects, may proceed with maintenance dose or continuous infusion
(UW Health very low-quality evidence, C recommendation).
6.3.1. A test dose of lidocaine is also recommended whenever an intermittent
maintenance dose is increased to allow for proper monitoring and to assess for
efficacy prior to scheduling further maintenance doses.
6.4. The optimal and maximum frequency of lidocaine intermittent intravenous infusions for
chronic pain have not been established. Consider an initial frequency of every other
week or weekly as needed based on patient response to the test dose (UW Health very
low-quality evidence, C recommendation).
6.5. In patients who had a minimal or partial response to 5 mg/kg test dose, consider
repeating the same dose for 2-3 additional appointments before opting for dose
escalation. It may take more than a single dose to realize the full effect of intravenous
lidocaine69 (UW Health very low quality evidence, C recommendation).
6.6. Renal adjustment1,20
6.6.1. No dosage adjustment provided in manufacturer’s labeling. However,
accumulation of metabolites may be increased in renal dysfunction1.
6.6.2. Intermittent infusions: no adjustment necessary70
6.6.3. Continuous infusion: use caution and start infusion at the low end of the dosing
range.
6.6.3.1. Consider monitoring lidocaine and monoethylglycinexylidide (MEGX)
concentrations
6.6.3.2. Limit duration to 24 hours if not monitoring lidocaine and MEGX levels70
6.6.3.3. Place patient on continuous ECG monitoring48
6.6.3.3.1. Unless otherwise directed by ordering provider secondary to
patient specific factors
6.7. Hepatic adjustment
6.7.1. Use with caution in patient with hepatic impairment; reduced maintenance
infusion recommended1
6.7.2. Intermittent infusions: no adjustment necessary70
6.7.3. Continuous infusion: use caution and start infusion at the low end of the dosing
range.
6.7.3.1. Consider monitoring lidocaine and MEGX concentrations
6.7.3.2. Limit duration to 24 hours if not monitoring lidocaine and MEGX levels70
6.7.3.3. Place patient on continuous ECG monitoring48
6.7.3.3.1. Unless otherwise directed by ordering provider secondary to
patient specific factors
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Table 4: Lidocaine Dosing Recommendations
Indication
Patient
population
Route Test Dose
Test Dose
Duration
Maintenance Dose
Maintenance Dose
Duration
Neuropathic
pain
Adult2
IV
intermittent
infusion
Initial test dose:
5 mg/kg
Actual BW*
[Suggested max
dose: 500mg]
Subsequent test
doses#:
Dose ranges:
5 - 7.5 mg/kg
Actual BW*
[Suggested max:
750 mg]
60 minutes
First maintenance dose:
5 mg/kg Actual BW*
[Suggested max: 500 mg]
Subsequent maintenance
doses based on patient
response#:
Dose ranges: 3 - 7.5 mg/kg
Actual BW*
[Suggested max: 750 mg]
60 minutes
Adult
13,56,71,72
SQ
continuous
infusion
5mg/kg *
Actual BW
[Suggested max:
dose 500 mg]
60 minutes 0.5-3 mg/kg/hour Ideal BW
Variable:
Range days to
months
Peds2,3,56
IV or SQ
intermittent
infusion
5 mg/kg
Actual BW
[Suggested max
dose: 500mg]
90-120
minutes
First maintenance dose:
5 mg/kg Actual BW
Subsequent maintenance
doses based on patient
response:
Dose ranges: 3 - 7.5 mg/kg
Actual BW
[Suggested max: 750 mg]
60 minutes
*Round dose to the nearest 50 mg increment
# Subsequent test doses are recommended whenever a maintenance dose is increased to allow for
proper monitoring and to assess for efficacy prior to scheduling further maintenance doses
Indication
Patient
population
Route Bolus Dose
Bolus Dose
Duration
Continuous Infusion Dose
Continuous Infusion
Duration
Post-
operative
pain
Adult59
IV
continuous
infusion
1-2 mg/kg
Actual BW
1-2
minutes
0.5-3 mg/kg/hour Ideal BW Up to 24 hours
Peds29,59
IV or SQ
continuous
infusion
1-2 mg/kg
Actual BW
1-2
minutes
0.5-2 mg/kg/hour Ideal BW Up to 24 hours
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Indication
Patient
population
Route Bolus Dose
Bolus Dose
Duration
Maintenance Dose
Maintenance Dose
Duration
Headache
Adult11,14,15
IV
continuous
infusion
NO NA 60-120 mg/hour
Variable:
Range 2-15 days
Peds
IV
intermittent
infusion3
(chronic
headache)
NO NA
4.8-7.2 mg/kg
Actual BW
(given with magnesium sulfate
1-2 grams over 2 hours)
2 hours
IV
continuous
infusion32
(status
migrainosus)
3 mg/kg
Actual BW
90 minutes
1 mg/kg/hour ideal BW
Titrated up by:
0.1-0.2 mg/kg/hour
every 4-6 hours
Max infusion rate:
2.25 mg/kg/hour
Variable:
Up to 24-48 hours
Indication
Patient
population
Route Bolus Dose Bolus Dose Duration
Renal
Colic4-6
Adult IV bolus
1.5 mg/kg
Actual BW
2-5 minutes
7. Assessment and monitoring
7.1. Vital signs and patient assessment73,74 (UW Health very low quality of evidence, S
recommendation).
7.1.1. Vital signs
7.1.1.1. Heart rate
7.1.1.2. Blood pressure
7.1.1.3. Respiratory rate
7.1.2. Assessment of adverse effects
7.1.3. Pain Assessment: Location, quality, frequency and severity
Table 5: Frequency of Monitoring vital signs and patient assessment
Test Dose Intermittent Infusions Continuous Infusions
Vitals signs, adverse
effects, pain
• Baseline
• 30 minutes after
start of infusion
• 30 minutes after
infusion
completion
• Baseline
• Immediately post
infusion completion
• As needed based
on presence of
symptoms during
infusion
• Baseline
• Every 30 minutes
for the first 2 hours
• Then every 4 hours
thereafter
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7.2. ECG and laboratory assessment
7.2.1. There is no consensus in the literature as to when or if repeat ECG and
laboratory assessment should occur when lidocaine is used for pain (UW Health
very low quality of evidence, C recommendation).
7.2.1.1. For patients receiving chronic intermittent or chronic continuous infusion
lidocaine, it is recommended that a repeat ECG and laboratory assessment
should be completed yearly, unless patient condition, changes in medications
or other factors warrant a different monitoring frequency. (UW Health very low
quality of evidence, C recommendation).
7.2.1.2. For patients receiving short course intermittent or continuous infusion
lidocaine, a repeat ECG and laboratory assessment may be considered,
especially if renal, hepatic or other conditions warrant repeat monitoring. (UW
Health very low quality of evidence, C recommendation).
7.2.2. An ECG should be reviewed by the ordering provider. If concerns over
appropriateness of lidocaine therapy arise, the ECG review should be escalated to
a qualified clinician for review.
7.2.3. Labs:
7.2.3.1. Potassium
7.2.3.2. Magnesium
7.2.3.3. Serum creatinine
7.2.3.4. ALT
8. Therapeutic drug monitoring (UW Health moderate quality of evidence, S
recommendation)
8.1. The utility of therapeutic drug monitoring for pain has not been clearly defined
8.1.1. It is NOT recommended to routinely draw lidocaine levels to establish efficacy.
Literature suggests lidocaine levels between 1.5-5 mcg/mL may relate to efficacy,
but there is not enough data to support this practice59.
8.1.2. For patients with renal or hepatic impairment receiving continuous infusions,
monitoring lidocaine or MEGX levels is recommended70
9. Adverse effects assessment59,63
9.1. Adverse effects of lidocaine are directly related to the serum lidocaine level59,75 (UW
Health moderate quality of evidence, S recommendation).
9.2. Side effects are more pronounced in patients with hepatic dysfunction, renal dysfunction,
pulmonary diseases (when the predominant problem is carbon dioxide retention), and
congestive heart failure (UW Health very low quality of evidence, S recommendation)
9.3. Mild side effects occur first as an early warning of lidocaine toxicity. If left unchecked
side effects can progress to neurotoxicity, cardiovascular collapse and death (UW
Health low quality of evidence, S recommendation)
9.4. If adverse effects are present, it is recommended to pause or stop the lidocaine
infusion. (UW Health low quality of evidence, S recommendation)
9.5. Management of toxicity is based on symptoms (UW Health low quality of evidence, C
recommendation)
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Table 7: Signs of Lidocaine Toxicity & Associated Management
Adverse effects Management
Mild
• Numbness and tingling in the fingers
and toes
• Numbness and unusual sensations
around the mouth
• Metallic taste
• Blurred vision
• Ringing in the ears
• Lightheadedness and dizziness
• Occasional drowsiness but easily
aroused
• Monitor lidocaine infusion
symptoms frequently for
progression of symptoms
• Obtain BP/HR
• Obtain pain rating
• Do not increase infusion
rate for continuous
infusions
• Consider slowing infusion
rate
Moderate
• Frequent drowsiness but easily
aroused
• Nausea and vomiting
• Severe dizziness
• Decreased hearing
• Tremors
• Changes in blood pressure and pulse
• Stop lidocaine infusion for
30 minutes or until
resolution of adverse
effects
• Obtain BP/HR
• Obtain pain rating
• Notify provider
• Contact ordering provider
or follow existing orders to
determine if infusion
should be restarted
Severe
• Loss of consciousness
• Drowsiness with inability to arouse
• Confusion
• Muscle twitching
• Seizure
• Conduction abnormalities
• Stop lidocaine infusion
• Obtain BP/HR
• Obtain pain rating if able
• Notify provider
• Supportive care
o Lorazepam for seizure
o Fluids for hypotension
• Consider lipid infusion
10. Preparation and administration
10.1. Nursing administration
10.1.1. Lidocaine for pain is a UW Health Level 1 medication when used as an infusion
for pain. Therefore, it may be administered on all general care nursing units,
ambulatory clinics, UW Health infusion center and hemodialysis center
10.2. Preparation
10.2.1. Lidocaine will be prepared using the 2% or 4% preservative free product or the
commercially available 2000 mg in 500 mL product may be used for continuous
infusions
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Disclaimer
Clinical practice guidelines assist clinicians by providing a framework for the evaluation and
treatment of patients. This guideline outlines the preferred approach for most patients. It is not
intended to replace a clinician’s judgment or to establish a protocol for all patients. It is
understood that some patients will not fit the clinical condition contemplated by a guideline and
that a guideline will rarely establish the only appropriate approach to a problem.
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Methodology
Development Process
Each guideline is reviewed and updated a minimum of every 3 years. All guidelines are
developed using the guiding principles, standard processes, and styling outlined in the UW
Health Clinical Practice Guideline Resource Guide. This includes expectations for workgroup
composition and recruitment strategies, disclosure and management of conflict of interest for
participating workgroup members, literature review techniques, evidence grading resources,
required approval bodies, and suggestions for communication and implementation.
Methods Used to Collect the Evidence:
The following criteria were used by the guideline author(s) and workgroup members to conduct
electronic database searches in the collection of evidence for review.
Literature Sources:
• Electronic database search (e.g., PubMed, Google Scholar)
• Databases of systematic reviews (e.g., Cochrane Library)
• Hand-searching journals, external guidelines, and conference publications
Time Period: Up to 2018
Search Terms:
• Lidocaine
• Parenteral
• Pain
• Intravenous
• Pediatric
• Neuropathic pain
• Post-operative pain
• Cancer pain
• Chronic pain
• Headache
• Renal colic
Methods to Select the Evidence:
Selection criteria included: English language only, human trials
Methods Used to Formulate the Recommendations:
The workgroup members created recommendations internally via a consensus process using
discussion of the literature and expert experience/opinion. If issues or controversies arose
where consensus could not be reached, the topic was escalated appropriately per the guiding
principles outlined in the UW Health Clinical Practice Guideline Resource Guide.
Methods Used to Assess the Quality of the Evidence/Strength of the Recommendations:
Internally developed recommendations, or those adopted from external sources without an
assigned evidence grade, were evaluated by the guideline workgroup using an algorithm
adapted from the Grading of Recommendations Assessment, Development and Evaluation
(GRADE) methodology (see Figure 1).
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Figure 1. GRADE Methodology adapted by UW Health
Rating Scheme for the Strength of the Evidence/Recommendations:
GRADE Ranking of Evidence
High We are confident that the effect in the study reflects the actual effect.
Moderate
We are quite confident that the effect in the study is close to the true effect, but
it is also possible it is substantially different.
Low The true effect may differ significantly from the estimate.
Very Low The true effect is likely to be substantially different from the estimated effect.
GRADE Ratings for Recommendations For or Against Practice
S
The net benefit of the treatment is clear, patient values and circumstances are
unlikely to affect the decision.
C
Recommendation may be conditional upon patient values and preferences, the
resources available, or the setting in which the intervention will be
implemented.
Cost Analysis: The cost of ECG monitoring and laboratory lidocaine levels was considered.
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Collateral Tools & Resources
The following collateral tools and resources support staff execution and performance of the
evidence-based guideline recommendations in everyday clinical practice.
Order Sets & Smart Sets
Anesthesiology - Lidocaine for Postoperative Pain - Adult – Supplemental [4100]
IP - Lidocaine Continuous Subcutaneous Titration Infusion - Adult - Supplemental [2195]
IP - Lidocaine Intravenous Infusion - Adult - Supplemental [1374]
IP - Lidocaine Intermittent Intravenous Infusion - Adult - Supplemental [1373]
IP - Lidocaine Intravenous Trial Infusion - Pediatric - Supplemental [5756]
IP - Lidocaine Low Dose Continuous or Subcutaneous Infusion - Pediatric -Supplemental [5755]
Anesthesiology - Lidocaine For Postoperative Pain - Pediatric – Supplemental [6012]
Patient Resources
Parenteral (Intravenous or Subcutaneous) Lidocaine for Neuropathic Pain Health Facts For You
(HFFY #5314)
Nursing Resources
IV Lidocaine for Perioperative Pain Fast Fact:
Parenteral Lidocaine for Chronic Neuropathic Pain
Policies
UWHC Nursing Policy #10.18 – Continuous Subcutaneous Lidocaine Infusion
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Appendix A
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