LIDOCAINE

By Gary M. White, MD


Note: This is a summary only. Please consult the latest information when prescribing.

Lidocaine

Buffering

Lidocaine solutions (1% and 2%), with and without epinephrine 1:100 000, were diluted 10:1 with 8.4% sodium bicarbonate, packaged in 3-mL polypropylene syringes, and stored at 5°C (range 3°C to 8°C) in one study and remained stable for up to 28 days when properly refrigerated and protected from light [Can J Hosp Pharm. 2009 Sep;62(5):375-80.]

In an article in the JAAD [JAAD 2016;75;454], the authors recommended use of any compounded lidocaine within 24 hours if stored at room temperature and within 3 days if refrigerated (not to exceed 46 degrees F).

Tips for reducing pain on injection

1.  Use counterstimulatory methods (pinching an adjacent area).   Rub the skin gently just before injecting and talk to the patient/child or have someone else distract while injecting.
2.  Infiltrate the local anesthetic deep.  Inject 2/3 into the fat and then pull out and quickly inject 1/3 into the dermis. 
3.  Use a small (30-gauge) needle. 
4.  Buffer and warm the lidocaine. 
5.  1 mL of 8.4% sodium bicarbonate (1mEq/mL) per 10 mL of 1% lidocaine 
6.  Infiltrate anesthetic slowly. 

EMLA

Eutectic mixture of local anesthetics (EMLA) is a mixture of lidocaine and prilocaine available by prescription. It is applied, under occlusion, 1 hour before the procedure. Methemoglobinemia may rarely occur (as for any prilocaine-containing cream). It should be applied to small areas, and should be used with caution in children younger than 3 years because of the incomplete maturation of the NADH methemoglobin reductase system.

Table for Maximums in EMLA Use

Age and Body Weight Requirements Maximum Total Dose of EMLA Cream Maximum Application Area
0 up to 3 months or < 5 kg 1 g 10 cm2
3 up to 12 months and > 5 kg 2 g 20 cm2
1 to 6 years and > 10 kg 10 g 100 cm2
7 to 12 years and > 20 kg 20 g 200 cm2

Maximum application time is 1 hour for infants in the first category and 4 hours for any patient > 3 months and 5 kg.

PRECAUTIONS for EMLA

LMX-4

LMX-4 is an OTC topical liposomal formulation of 4% lidocaine that was previously known as ELA-Max. It does not contain prilocaine, and therefore has no risk of causing methemoglobinemia. LMX-4 has a faster onset of anesthesia and a more favorable adverse-effect profile than EMLA, and needs no prescription.

Pliaglis

Pliaglis is a prescription topical anesthetic cream containing lidocaine (7%) and tetracaine (7%). It is indicated in adults to produce local dermal anaesthesia on intact skin prior to dermatological procedures.

SYNERA

Synera is a topical patch that provides anesthesia for superficial dermatologic procedures (e.g. excision, shave biopsy and electrodessication) as well as venous access. It combines lidocaine and tetracaine with heat assisted drug delivery technology.

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