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Dear Readers! I started this blog when my daughter was in the NICU. She had ventriculitis. Her CSF report grew E.coli. But, she was injected Teicoplanin directly into her brain. The doctors made two errors here:

Teicoplanin is for gram-positive bacteria only. It does not treat E.coli.
Teicoplanin is not for intraventricular use. The manufacturer strongly discourage injecting Teicoplanin into the brain.

My daughter bled into the brain. She lived for another two years and ultimately died.

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Lidocaine and Epinephrine Injection - Uses, Dosage, How to Administer?

Lidocaine and epinephrine are two medications often used together in medical procedures.

Lidocaine: Lidocaine is a local anesthetic medication commonly used to numb an area of the body for medical procedures or to relieve pain and discomfort. It works by blocking nerve signals in the body and preventing the sensation of pain from reaching the brain. Lidocaine is available in various forms such as topical creams, gels, injectable solutions, and patches.
Epinephrine: Epinephrine, also known as adrenaline, is a hormone and neurotransmitter that plays a crucial role in the body's response to stress or emergency situations. It causes vasoconstriction (narrowing of blood vessels) and increases heart rate and blood pressure, among other effects. In medicine, epinephrine is used for various purposes, including the treatment of severe allergic reactions (anaphylaxis), cardiac arrest, and asthma attacks.

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 Procedures:

For oral infiltration or mandibular block, the initial dose is between 1 to 5 milliliters (mL) of lidocaine, which equals 20 milligrams (mg) to 100 mg.
Typically, for routine dental work, dentists prefer using lidocaine with epinephrine in a concentration of 1:100,000. But if more bleeding control is needed, a stronger concentration of epinephrine, like 1:50,000, is used.
The maximum amount of lidocaine should not exceed 7 milligrams per kilogram of body weight, up to a maximum of 300 mg to 500 mg of lidocaine. For epinephrine, it shouldn't exceed 3 micrograms per kilogram of body weight or 0.2 milligrams per dental appointment.

Epidural Procedures:

Before injecting the full volume needed for a lumbar or caudal block, a small test dose of lidocaine 1.5% (2 to 3 mL) is given at least 5 minutes earlier.
The dosage depends on how many dermatomes (areas of skin supplied by a single spinal nerve) need to be numbed. Generally, 2 to 3 mL of lidocaine 1%, 1.5%, or 2% with epinephrine (1:200,000) per dermatome is used.
If continuous epidural or caudal anesthesia is needed, the maximum dose should not be given more frequently than every 90 minutes. For paracervical block, the total maximum dose should not exceed 200 mg over 90 minutes.

Local Procedures:

The dosage varies based on the procedure, how much anesthesia is needed, how much blood supply the tissue has, how long the anesthesia should last, and the patient's health.
The maximum amount of lidocaine should not exceed 7 mg per kilogram of body weight, up to a maximum of 500 mg. Lidocaine with epinephrine (1:200,000) is typically used in single-dose units.

These doses and concentrations help ensure effective anesthesia while minimizing risks and complications.

Lidocaine and Epinephrine injection Dosage in Children:

Note:

Variability in Dosing: The amount of lidocaine and epinephrine needed can vary depending on the procedure, how deep the anesthesia needs to be, the blood supply to the tissues, how long the anesthesia should last, and the patient's health. It's crucial to have a qualified physician overseeing the administration of these medications, as dosing units can vary (like milliliters per kilogram or milligrams per kilogram), and accuracy is very important.
Consider Lean Body Mass: When determining the dosage, it's important to consider the patient's lean body mass. This helps ensure that the right amount of medication is given for effective anesthesia while minimizing risks.
Limitations of Lidocaine: Lidocaine isn't typically used for central (spinal) or regional (epidural/caudal) anesthesia due to its shorter duration of action and potential for toxicity with repeated doses. This information comes from medical references like Cote 2013 and Miller 2015.

These notes highlight the importance of careful dosing and the need for medical expertise when using lidocaine and epinephrine in anesthesia.

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

For local anesthesia in infants, children, and adolescents:

Use lidocaine with a concentration of 1% or 2%.
Inject the solution directly into the area needing numbness.
The maximum dose should not exceed 7 milligrams per kilogram of body weight.
Do not give more than the maximum adult dose, which is 500 milligrams.
Always check for blood in the syringe before injecting, but even if there's no blood, it doesn't guarantee that the injection is outside blood vessels.

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

For treating peripheral nerve block (excluding digital or penile) in infants aged 6 months and above, children, and adolescents:

Use lidocaine with concentrations up to 1%.
The dosage (concentration and volume) depends on factors like the procedure, how much numbness is needed, how much blood flows to the area, how long the numbness should last, and the patient's health.
The maximum dose of lidocaine is 7 milligrams per kilogram of body weight, but it shouldn't exceed the maximum adult dose of 500 milligrams.
For infants younger than 6 months, reduce the maximum doses by 30%.

Always ensure the dosage is appropriate for the patient's age, weight, and medical condition.

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

For children under 10 years old:

Use lidocaine 2% with epinephrine solution.
Give up to 0.9 to 1 milliliter (mL), which is about 18 to 20 milligrams (mg) of lidocaine, per procedure.
The maximum dose shouldn't exceed 4.4 milligrams per kilogram (kg) of body weight, but it shouldn't go over 300 mg total.
This dose is typically used for procedures involving a single tooth, numbing 2 to 3 teeth in the upper jaw, or numbing an entire section of the lower jaw.

For children aged 10 years and older and adolescents:

Use lidocaine 2% with epinephrine solution.
Initially, give between 1 to 5 mL, which is about 20 mg to 100 mg of lidocaine.
Stick to the dental guideline recommended maximum dose of 4.4 mg/kg, with a total maximum of 300 mg of lidocaine.
Some recommendations allow for a higher maximum dose of 7 mg/kg, totaling up to 500 mg of lidocaine, along with 3 micrograms (0.003 mg) of epinephrine per kilogram of body weight, or up to 0.2 mg of epinephrine per dental appointment.

These guidelines help ensure safe and effective anesthesia during dental procedures.

Pregnancy Risk Factor B

During pregnancy, these medications are considered safe with a risk factor B, which means adverse events haven't been seen in animal studies.
However, it's important to check each medication individually for specific information.

Breastfeeding: Lidocaine and Epinephrine

It's uncertain whether lidocaine/epinephrine passes into breast milk.
The manufacturer advises caution when giving lidocaine/epinephrine to breastfeeding women.
For more detailed information, it's best to refer to the specific instructions for each medication.

Lidocaine and Epinephrine injection Dose in Kidney disease:

The manufacturer's instructions don't mention any adjustments in dosage. However, in cases of kidney problems, there might be an increased buildup of by-products from the medication's breakdown.
Regarding dialysis, lidocaine and epinephrine aren't removed much (0% to 5%) by either hemodialysis or peritoneal dialysis, so there's usually no need for an extra dose.

Dose in Liver disease:

The manufacturer's instructions don't include any dosage adjustments.
However, it's important to be cautious because these medications are metabolized by the liver.
Patients with severe liver problems are at a higher risk of lidocaine toxicity.

Side effects of Lidocaine and Epinephrine injection:

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

Contraindications to Lidocaine and epinephrine Include:

If someone has an allergy or hypersensitivity to lidocaine, other local anesthetics like those of the amide type, epinephrine, or any ingredient in the medication, they shouldn't use it.
In Canada, there's an additional contraindication not listed in the US labeling: hypersensitivity to para-aminobenzoic acid (PABA).
It's important to avoid using these medications if you have any of these allergies.

Warnings and precautions

Cardiovascular effects

Lidocaine can have effects on the heart, potentially leading to cardiac depression, such as slowing down the heart rate (bradycardia) and lowering blood pressure (hypotension).
Patients who already have low blood volume (hypovolemia) may be at a higher risk of experiencing these effects.
It's essential to be cautious when using lidocaine, especially in patients with low blood volume, to prevent any adverse cardiovascular effects.

CNS toxicity:

After administering a local anesthetic injection, it's crucial to monitor the patient's level of consciousness closely.
Symptoms like restlessness, anxiety, ringing in the ears (tinnitus), dizziness, blurry vision, trembling, feeling down (depression), or drowsiness could indicate potential toxicity affecting the central nervous system (CNS).
If any of these signs appear, treatment primarily involves managing the symptoms and providing support to the patient.
It's important to respond promptly to any signs of CNS toxicity and seek medical assistance if needed.

Hypersensitivity

Hypersensitivity reactions, including severe allergic reactions known as anaphylaxis, can occur after receiving lidocaine or epinephrine injections.
It's important to be aware of the signs of anaphylaxis, such as difficulty breathing, swelling of the face or throat, rapid heartbeat, and sudden drop in blood pressure.
If any of these symptoms develop after administration, immediate medical attention is necessary.

Infusion-related intra-articular chondrolysis

Continuous intra-articular infusion of local anesthetics after arthroscopic or other surgical procedures is not an approved use.
Chondrolysis, which is the destruction of cartilage, particularly in the shoulder joint, has been reported after such infusions.
In severe cases, patients may need arthroplasty or shoulder replacement surgery.
It's crucial to follow approved usage guidelines and monitor for any adverse effects when using local anesthetics in intra-articular settings.

Methemoglobinemia:

Methemoglobinemia, a condition where abnormal levels of methemoglobin are present in the blood, has been reported with the use of local anesthetics.
Clinically significant methemoglobinemia requires immediate treatment and stopping the use of the anesthetic and other oxidizing agents.
Symptoms can occur right away or hours after exposure to the anesthetic and may include cyanosis (bluish discoloration of the skin), headache, rapid pulse, shortness of breath, lightheadedness, and fatigue.
Patients with certain conditions like G6PD deficiency, congenital or idiopathic methemoglobinemia, heart or lung issues, exposure to oxidizing agents, or infants younger than 6 months are at higher risk and need close monitoring for signs of methemoglobinemia.

Respiratory arrest

Local anesthetics have been linked to instances of respiratory arrest, where breathing stops.
It's crucial to be vigilant for any signs of respiratory distress or difficulty breathing after administering these medications, particularly in sensitive patients or those receiving high doses.
Prompt intervention is necessary if respiratory arrest occurs, including providing respiratory support and seeking emergency medical assistance.

Cardiovascular disease

Patients with cardiovascular disease should use lidocaine and epinephrine cautiously.
This includes individuals with conditions like slow heart rate (bradycardia), severe shock, heart block, or impaired heart function.
Additionally, caution is advised when using these medications in areas of the body with limited blood supply or compromised circulation.
Patients with conditions like peripheral vascular disease or hypertensive vascular disease may have an exaggerated response to vasoconstriction caused by epinephrine, potentially leading to tissue damage or ischemic injury.
Therefore, it's essential to be mindful of these risks and monitor patients carefully when using lidocaine and epinephrine in such cases.

Diabetes:

Patients with diabetes should use lidocaine and epinephrine with caution.
It's important to monitor blood sugar levels closely during and after procedures involving these medications, as epinephrine can affect blood sugar levels.
Additionally, patients with diabetes may have impaired circulation or sensation, which can increase the risk of complications from local anesthesia.

Hepatic impairment

Patients with hepatic (liver) impairment should use lidocaine and epinephrine cautiously.
Lidocaine is metabolized in the liver, so individuals with severe hepatic impairment are at an increased risk of lidocaine toxicity.
It's essential to consider this risk and potentially adjust the dosage or monitor patients more closely when using these medications in individuals with hepatic impairment.

Renal impairment

Patients with severe renal (kidney) impairment should use lidocaine and epinephrine cautiously.
Lidocaine and its metabolites may accumulate in the body due to impaired kidney function.
This accumulation can increase the risk of lidocaine toxicity.

Thyroid disease:

Patients with thyroid disease, particularly poorly controlled hyperthyroidism, should use lidocaine and epinephrine with caution.
Epinephrine can exacerbate symptoms of hyperthyroidism, such as increased heart rate and blood pressure.

Lidocaine and epinephrine: Drug Interaction

Risk Factor C (Monitor therapy)
Alpha1-Blockers	May diminish the vasoconstricting effect of Alpha-/Beta-Agonists. Similarly, Alpha-/Beta-Agonists may antagonize Alpha1-Blocker vasodilation.
Antidiabetic Agents	Hyperglycemia-Associated Agents may diminish the therapeutic effect of Antidiabetic Agents.
AtoMOXetine	May enhance the hypertensive effect of Sympathomimetics. AtoMOXetine may enhance the tachycardic effect of Sympathomimetics.
Benperidol	May diminish the therapeutic effect of EPINEPHrine (Systemic).
Beta-Blockers (Beta1 Selective)	May diminish the therapeutic effect of EPINEPHrine (Systemic).
Beta-Blockers (Nonselective)	May enhance the hypertensive effect of EPINEPHrine (Systemic). Exceptions: Arotinolol; Carvedilol; Labetalol.
Beta-Blockers (with Alpha-Blocking Properties)	May diminish the therapeutic effect of EPINEPHrine (Systemic).
Bretylium	May enhance the therapeutic effect of Alpha-/Beta-Agonists (Direct-Acting).
Cannabinoid-Containing Products	May enhance the tachycardic effect of Sympathomimetics. Exceptions: Cannabidiol.
Chloroprocaine	May enhance the hypertensive effect of Alpha-/Beta-Agonists.
CloZAPine	May diminish the therapeutic effect of Alpha-/Beta-Agonists.
COMT Inhibitors	May decrease the metabolism of COMT Substrates.
Doxofylline	Sympathomimetics may enhance the adverse/toxic effect of Doxofylline.
Guanethidine	May enhance the arrhythmogenic effect of Sympathomimetics. Guanethidine may enhance the hypertensive effect of Sympathomimetics.
Monoamine Oxidase Inhibitors	May enhance the hypertensive effect of EPINEPHrine (Systemic).
Solriamfetol	Sympathomimetics may enhance the hypertensive effect of Solriamfetol.
Spironolactone	May diminish the vasoconstricting effect of Alpha-/Beta-Agonists.
Sympathomimetics	May enhance the adverse/toxic effect of other Sympathomimetics.
Tedizolid	May enhance the hypertensive effect of Sympathomimetics. Tedizolid may enhance the tachycardic effect of Sympathomimetics.
Risk Factor D (Consider therapy modification)
Benzylpenicilloyl Polylysine	Alpha-/Beta-Agonists may diminish the diagnostic effect of Benzylpenicilloyl Polylysine. Management: Consider use of a histamine skin test as a positive control to assess a patient's ability to mount a wheal and flare response.
Cocaine (Topical)	May enhance the hypertensive effect of Sympathomimetics. Management: Consider alternatives to use of this combination when possible. Monitor closely for substantially increased blood pressure or heart rate and for any evidence of myocardial ischemia with concurrent use.
Hyaluronidase	May enhance the vasoconstricting effect of Alpha-/Beta-Agonists. Management: Avoid the use of hyaluronidase to enhance dispersion or absorption of alpha-/beta-agonists. Use of hyaluronidase for other purposes in patients receiving alpha-/beta-agonists may be considered as clinically indicated.
Inhalational Anesthetics	May enhance the arrhythmogenic effect of EPINEPHrine (Systemic). Management: Administer epinephrine with added caution in patients receiving, or who have recently received, inhalational anesthetics. Use lower than normal doses of epinephrine and monitor for the development of cardiac arrhythmias.
Linezolid	May enhance the hypertensive effect of Sympathomimetics. Management: Reduce initial doses of sympathomimetic agents, and closely monitor for enhanced pressor response, in patients receiving linezolid. Specific dose adjustment recommendations are not presently available.
Promethazine	May diminish the vasoconstricting effect of EPINEPHrine (Systemic). Management: When vasoconstrictive effects are desired in patients receiving promethazine, consider alternatives to epinephrine. Consider use of norepinephrine or phenylephrine, and avoid epinephrine, when treating hypotension associated with promethazine overdose.
Serotonin/Norepinephrine Reuptake Inhibitors	May enhance the tachycardic effect of Alpha-/Beta-Agonists. Serotonin/Norepinephrine Reuptake Inhibitors may enhance the vasopressor effect of Alpha-/Beta-Agonists.
Tricyclic Antidepressants	May enhance the vasopressor effect of Alpha-/Beta-Agonists. Management: Avoid, if possible, the use of alpha-/beta-agonists in patients receiving tricyclic antidepressants. If combined, monitor for evidence of increased pressor effects and consider reductions in initial dosages of the alpha-/beta-agonist.
Risk Factor X (Avoid combination)
Blonanserin	May diminish the therapeutic effect of EPINEPHrine (Systemic).
Bromperidol	May diminish the therapeutic effect of EPINEPHrine (Systemic).
Ergot Derivatives	May enhance the hypertensive effect of Alpha-/Beta-Agonists. Ergot Derivatives may enhance the vasoconstricting effect of Alpha-/Beta-Agonists. Exceptions: Ergoloid Mesylates; Nicergoline.
Lurasidone	EPINEPHrine (Systemic) may enhance the hypotensive effect of Lurasidone.

Monitoring parameters:

Vital Signs:

Keep an eye on important signs like heart rate, blood pressure, and breathing rate.
Monitoring these can help catch any unusual changes that might signal a problem.

ECG During Test Dose:

When giving a small test dose of the medication, it's a good idea to monitor the heart's electrical activity with an electrocardiogram (ECG).
This helps ensure the heart is functioning normally and can detect any irregularities early on.

State of Consciousness After Each Injection:

Pay attention to the patient's level of alertness and awareness after each injection.
Restlessness, anxiety, dizziness, or confusion might be signs of potential problems like CNS toxicity.

CNS Toxicity:

Be on the lookout for symptoms of central nervous system (CNS) toxicity.
These can include restlessness, anxiety, dizziness, blurred vision, tremors, depression, or drowsiness.
If any of these signs appear, it's important to address them promptly and seek medical help if needed.

How to administer Lidocaine and epinephrine?

Avoid Intravascular Injections:

Take care to avoid injecting the medication directly into blood vessels.
Before injecting, draw back on the syringe plunger to check for blood, which can indicate that the needle is in a blood vessel.

Aspirate Before Injection:

Before injecting, draw back on the syringe to check for blood.
This helps minimize the risk of accidentally injecting the medication into a blood vessel.

Caution with Inflammation or Sepsis:

Be cautious or avoid using the medication if there is inflammation or infection in the area where the injection is planned.
Infections or inflammation can increase the risk of complications.

Avoid Preservatives for Certain Injections:

For procedures like epidural or spinal anesthesia, avoid using injections containing preservatives like methylparaben.
Preservatives can cause complications, especially if the solution is introduced into the cerebrospinal fluid.

Maximum Dose for Continuous Epidural or Caudal Anesthesia:

When administering continuous epidural or caudal anesthesia, do not exceed the maximum dose at intervals of less than 90 minutes.
This helps prevent excessive accumulation of the medication and reduces the risk of complications.

Mechanism of action of Lidocaine and epinephrine:

Lidocaine:

Lidocaine works by blocking both the start and spread of nerve signals.
It does this by making it harder for sodium ions to pass through nerve cell membranes.
This blocks the process of depolarization, which is essential for nerve signals to travel.
Essentially, lidocaine stops the nerves from sending pain signals to the brain.

Epinephrine:

Epinephrine helps lidocaine work better and last longer.
It does this by causing blood vessels to narrow, a process called vasoconstriction.
When blood vessels narrow, it slows down the absorption of lidocaine into the bloodstream.
As a result, lidocaine stays in the area longer, prolonging its pain-relieving effects.

Onset of Action:

When used in dental procedures, lidocaine typically starts working quickly, usually within 2 to 4 minutes.
This means that it takes about 2 to 4 minutes for patients to start feeling numbness in the area where lidocaine is injected.

Duration of Action:

The duration of lidocaine's effects in dental procedures varies depending on the type of procedure and the dose used.
For infiltration (where the anesthetic is injected near the treatment area), lidocaine's effects typically last around 2.5 hours.
For nerve blocks (where the anesthetic is injected near a nerve to numb a larger area), lidocaine's effects usually last between 3 to 3.5 hours.
It's important to note that the duration of action can vary based on factors like the specific dental procedure and individual patient characteristics.

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.