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FORMULARY
Coastal HSDA
RHS
PHC
VA
CLASSIFICATION
local anaesthetic; antiarrhythmic
NAME OF DRUG
lidocaine
ALTERNATE NAME(S)
XYLOCAINE (local anaesthetic); XYLOCARD (antiarrhythmic)
lignocaine; lidocaine hydrochloride
INDICATIONS/ORDERING RESTRICTIONS
CO

rapid acting local anesthetic for procedures ranging from infiltration to regional nerve block.

antiarrhythmic in the treatment of ventricular arrhythmias.

neuropathic pain

post-operative pain

Prescribing for pain is restricted, see Restricted Drugs at Coastal Community of Care
PHC

rapid acting local anesthetic for procedures ranging from infiltration to regional nerve block.

antiarrhythmic in the treatment of ventricular arrhythmias.

neuropathic pain

post-operative pain

Prescribing for pain is restricted, see Restricted Drugs at Providence Health Care
RHS

rapid acting local anesthetic for procedures ranging from infiltration to regional nerve block.

antiarrhythmic in the treatment of ventricular arrhythmias.

neuropathic pain

post-operative pain

Prescribing for pain is restricted, see BCHA Formulary Restricted Drug list

rapid acting local anesthetic for procedures ranging from infiltration to regional nerve block.

antiarrhythmic in the treatment of ventricular arrhythmias.

neuropathic pain

post-operative pain

Prescribing for pain is restricted, see Restricted Drugs at Vancouver Community of Care
VA
RECONSTITUTION AND STABILITY

stable at room temperature

partially used vials without preservative should be discarded

discard solutions that are cloudy, discoloured, or contain crystals

solutions in glass vials that do not contain EPInephrine can be autoclaved
COMPATIBILITY

compatible with most commercially available IV solutions

stable at concentrations of 1 to 8 mg/mL in D5W

compatible via Y-site with aminophylline, amiodarone, calcium chloride, calcium gluconate, dexamethasone,
diltiazem, DOBUTamine, DOPamine, EPInephrine, haloperidol, heparin, hydrocortisone, isoproterenol,
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ketamine, labetalol, micafungin, morphine, nitroglycerin, PHENYLephrine, potassium chloride,
procainamide, proPOFol, REMIfentanil, streptokinase, vasopressin, verapamil, vitamin B complex with C

lidocaine injection should not be left in stainless steel containers for prolonged periods; nickel in the metal is
leached out by lidocaine

incompatible with sodium bicarbonate
ADMINISTRATION
Coastal HSDALocal infiltration  by IV therapy team nurses, who may only give lidocaine plain (i.e. without
EPInephrine).
 by physician
 by RN, only lidocaine plain (ie. without EPInephrine) when mixed with another drug to
reduce pain of injection if specified/allowed within this manual (eg. magnesium sulfate)
IM:
ECG monitoring is required as follows:



Post-operative/ spine and neuropathic pain patients: A baseline ECG is required for doses up to and
including 2 mg/kg/hour for a duration of up to 72 hours. Other required monitoring to be indicated in
physician’s orders and/or applicable nursing care standards.
Palliative Care patients: A baseline ECG is required for doses up to and including 3 mg/kg/hour. BP,
HR and signs of toxicity are to be monitored every 15 minutes x 4, then every shift. Other
monitoring to be indicated in physician’s orders and/or applicable nursing care standards.
All patients not meeting the above criteria, require continuous ECG monitoring.
subcutaneous infusion:  by RN, restricted to Palliative Care Unit
IV direct:
 by RN
 restricted to cardiac monitored patients (ICU, Emergency, PAR, ECCU only)
IV intermittent:  by RN over 15 minutes to 2 hours for neuropathic pain
IV infusion:
 by RN
 Cardiac monitoring requirements are determined by indication and dose. See above for
details.
PHC
Local infiltration  by PICC insertion team
 also by RN in hemodialysis unit, for use at each needling site prior to insertion of the
hemodialysis fistula needle
Subcutaneous infusion:  SPH: Initiation by Chronic Pain Anesthesiologist in PACU, HAU, Chronic
Pain Inpatient Beds, and Chronic Pain Block Clinic, and by Chronic Pain
Anesthesiologist or Skill-Checked RN in the Chronic Pain Block Clinic.
Maintained by RN in PACU, HAU, Chronic Pain Inpatient Beds, and
Chronic Pain Block Clinic.
For monitoring guidelines, including baseline ECG, see on-line Nursing Practice
Standards
 NCS6370 – Lidocaine (Subcutaneous) inpatient infusion: Care and Management of
Patient Receiving for Neuropathic Pain, protocol for
 NCS6417- Lidocaine (Subcutaneous): Set up for home infusion: Care and
management for neuropathic pain, protocol
ECG monitoring is required for IV administration:
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


lidocaine
Post-operative/ spine and neuropathic pain patients: A baseline ECG is required for doses up to and
including 2 mg/kg/hour for a duration of up to 72 hours. Refer to applicable nursing care standards.
Patients in PCU: A baseline ECG is required for doses up to and including 3 mg/kg/hour. BP, HR
and signs of toxicity are to be monitored every 15 minutes x 4, then every hour for 3 hours, then
Q4H and PRN (PCU also requires baseline serum potassium, renal function and liver function)
All patients not meeting the above criteria, require continuous ECG monitoring.
IV direct:
 SPH: by RN in Critical Care, 5A, 5B or MD only
 MSJH: by RN in Critical Care areas or MD only.
 25 to 50 mg/minute; except in cardiac arrest situation.
IV infusion:
 SPH or MSJH: by RN in Critical Care areas
 SPH: by RN for use in neuropathic pain in PACU or palliative care unit. Refer to
applicable nursing care standards:
 NCS6322 – Lidocaine (Intravenous) Short Term Infusion-Intermediate Dose
 NCS6415 – Lidocaine (Intravenous) for patients receiving in palliative care unit,
protocol for
 SPH: by RN for use in neuropathic or post-operative pain. Refer to nursing care standard:
 NCS6470 – Lidocaine Infusion (Intravenous) Low Dose for: Neuropathic pain or PostOperative Pain Management
RHS
Local infiltration: by physician and infusion program nurses only
 by RN, as a diluent to reconstitute some specific medications to decrease pain associated
with IM injection
IM:
ECG monitoring is required as follows:

Post-operative and neuropathic pain patients: A baseline ECG is required for doses up to and
including 2 mg/kg/hour for a duration of up to 72 hours. Other required monitoring to be indicated in
physician’s orders and/or applicable nursing care standards.
 Palliative Care patients: A baseline ECG is required for doses up to and including 3 mg/kg/hour. BP,
HR and signs of toxicity are to be monitored every 15 minutes x 4, then every shift. Other monitoring
to be indicated in physician’s orders and/or applicable nursing care standards.
 All patients not meeting the above criteria, require continuous ECG monitoring.
Subcutaneous infusion: by RN, restricted to Palliative Care Unit
IV direct:
 restricted to administration by RN in Emerg, ICU, PACU; by MD only on other wards.
 rate of 25 to 50 mg/minute
IV intermittent:  by RN over 15 minutes to 2 hours for neuropathic pain
IV infusion:
 by RN
 Cardiac monitoring requirements are determined by indication and dose. See above for
details.
VA
Local infiltration  for production of peridural and regional anesthesia.
 physician and infusion program nurses only; nurses in renal unit may administer at the
catheter insertion site upon initiation of hemodialysis
 lidocaine with EPInephrine by local groin infiltration – trained CCU nurses
IM:
 as a diluent to reconstitute some specific medications to decrease pain associated with IM
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injection.
Restricted to PCU and spine unit for neuropathic pain
o ECG monitoring is required as follows:
 patients in PCU require a baseline ECG for doses up to and including 3 mg/kg/hour, or IV
intermittent neuropathic pain dosing as indicated in Dosage section. BP, HR and signs of toxicity
are to be monitored every 15 minutes x 4, then every shift (PCU also requires baseline serum
potassium, renal function and liver function)
 post-operative/ spine patients: A baseline ECG is required for doses up to and including 2
mg/kg/hour for a duration of up to 72 hours. Other required monitoring to be indicated in physician’s
orders and/or applicable pre-printed orders or nursing care standards.
 All patients not meeting the above criteria, require continuous ECG monitoring.
subcutaneous infusion:  see policy Routes of Administration – Continuous Subcutaneous Infusion
 restricted to Palliative Care Unit
IV direct:
 by nurses in Critical Care areas and the Telemetry unit. On general nursing units must be
administered by a physician.
 for arrhythmias at a rate not exceeding 50 mg/minute
IV intermittent:  over 15 minutes to 2 hours for neuropathic pain
 rate MUST be controlled by an automated infusion control device
IV infusion:
 premixed bag, concentration of 4 mg/mL (see Appendix IV)
 for post-op pain management, supplied as a 40 mg/mL syringe for pain infusion pump
 rate MUST be controlled by an automated infusion control device.
DOSAGE
PHC
Cardiac dysrhythmia:
 Dosage in mg/minute - Usual rate: 1 to 4 mg/minute. A continuous infusion of
lidocaine should be preceded by a bolus injection of 50 to 100 mg (at a rate of 25 to
50 mg/minute), which may be repeated after 10 to 20 minutes if needed.
 The loading dose should be reduced by half in patients suffering from a severe
acute myocardial infarction or congestive heart failure, due to a reduced volume of
distribution of the drug
 Continuous infusions should be reduced in patients with hepatic impairment and
possibly those receiving concomitant proPRANolol therapy
 refer to lidocaine DOSAGE CHART
Neuropathic pain:
 Refer to applicable Nursing Practice Standards for the use of lidocaine in
neuropathic pain. See Administration section for hyperlinks to online manuals.
 IV bolus: 1 to 2 mg/kg IV over 3 to 5 minutes. Usual loading dose is 100 to 160
mg.
 IV infusion: 1.5 to 3 mg/kg/hour
 Subcutaneous: 0.5 to 2 mg/kg/hour
Post-operative pain:
 Refer to applicable Nursing Practice Standard, see Administration section for
hyperlink to online manuals
 Loading dose of 1 to 1.5 mg/kg* (IV direct over 2 minutes) or refer to applicable
Nursing Practice Standard
 Usual maintenance infusion of 0.5 to 1.5 mg/kg*/hour for 2 to 3 days postoperatively ( maximum 2 mg/kg/hour and for a maximum of 7 days)
 * use actual body weight
Cannulation pain:
 Local infiltration:
 for hemodialysis, 4 to 6 mg at each needling site prior to fistula needle insertion
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
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for PICC insertion, 5 mg prior to or during catheter insertion, may be repeated
up to a total of 30 mg
VCH=CO/RH/VA
Cardiac Dysrhythmia:
 IV: 1 to 1.5 mg/kg at a rate of 25 to 50 mg/minute; additional boluses of 0.5 to 0.75
mg/kg may be given every 5 to 10 minutes up to 3 mg/kg as needed. Maintenance
therapy should begin following second bolus at a rate of 1 to 4 mg/minute. (
matches Lexi & OK’d by Elaine Lum VA)
 refer to lidocaine 4 mg/mL intravenous infusion chart
Local Anesthetic:
 Varies with procedure, degree of anesthesia needed, vascularity of tissue, duration
of anesthesia required, and physical condition of patient; maximum: 4.5 mg/kg/dose
not to exceed 300 mg; do not repeat within 2 hours
Neuropathic pain:
 Various options exist. Follow site specific protocols, pre-printed orders or
applicable nursing practice standards.
o IV intermittent: 5 to 15 mg/kg (maximum 900 mg) IV over 1 to 2 hours;
dose adjustments based on pain response and side effects.
o IV or subcutaneous infusion: 2 mg/kg subcutaneous or IV over 15 to 20
minutes, followed by maintenance infusion of 0.5 to 3 mg/kg/hour
Post-operative pain:
 Loading dose of 1 to 1.5 mg/kg* (IV direct over 2 minutes).
 Usual maintenance infusion of 0.5 to 1.5 mg/kg*/hour for 2 to 3 days postoperatively ( maximum 2 mg/kg/hour and for a maximum of 7 days)
 * use actual body weight
o
maintenance doses should be decreased in patients with severe heart failure or liver disease
POTENTIAL HAZARDS OF PARENTERAL ADMINISTRATION

thrombophlebitis from prolonged infusions, transient burning at injection site

rarely tissue necrosis and sloughing

anaphylactoid reactions
IMPORTANT IMPLICATIONS
Side Effects Include:

see POTENTIAL HAZARDS OF PARENTERAL ADMINISTRATION

CNS (usually manifest prior to CVS signs): 1st signs - tinnitus, metallic taste, lightheadedness, perioral
numbness, headache (may occur with low doses); 2 nd signs - slurred speech, tonic-clonic seizures. Late
signs- CNS depression-sedation, leading to coma

CVS: myocardial depression, bradycardia, hypotension, hypertension, CVS collapse, cardiac automaticity
and conduction abnormalities (prolongation of the PR interval and widening of the QRS complex)
Monitoring Parameters Include:

see ADMINISTRATION section

BP, HR, respiratory rate, CNS & CVS toxicity (see side effects above), pain assessment scales (when being
used for pain), sedation scales
Contraindications/Cautions Include:

uncontrolled seizures, bradycardia, second- or third-degree heart block, hypovolemia

solutions containing preservatives should not be used for spinal or epidural block

solutions containing EPInephrine should not be used in anesthesia of digits, ears, nose, penis
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
use caution when administering with other antiarrhythmics.

extreme caution is necessary in selection of package for use because of close similarity of names
and dosage forms
Others:

possible cross sensitivity with other amide type of local anesthetics

observe usual precautions for EPInephrine when using solutions containing EPInephrine
First change to document 16 03 17 that was approved at REG P&T is what is highlighted in blue under VA
Administration.To return VA to allowing the 900 mg over 1 to 2 hours in their PCU only as has always been allowed
per PCU-lidocaine for neuropathic pain orders PPO. KS signed off on this addition in blue 25Apr2016 (per Ange
recommendation). Second change made on 30jun2016 per request of Dr Andrew Meikle ( via KS-see her e-mail of
29June2016).
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