Local anaesthesia 703
15.2 Local anaesthesia 703
15 Anaesthesia
15.2 Local anaesthesia BNF 57 Lidocaine injections for dental use
net price per unit (4-mL vial and disposable sterile Note Consult expert dental sources for specific advice in
cannula with cover and vial injector) = £5.10 relation to dose of lidocaine for dental anaesthesia
Cautions may be rapidly and almost completely absorbed from
A variety of lidocaine injections with adrenaline is respiratory tract and systemic side-effects may occur; extreme available in dental cartridges; brands include Ligno-
caution if mucosa has been traumatised or if sepsis present span Special c , Rexocaine c and Xylocaine c Dose usually 160 mg (4 mL) as a single dose instilled as jet spray to larynx and trachea or applied with a swab (reduce dose according to size, age and condition of patient), max. 200 mg
Lidocaine for surface anaesthesia (5 mL); CHILD up to 3 mg/kg Important. Rapid and extensive absorption may
Rapydan c (EUSA Pharma) A result in systemic side-effects
Medicated plasters , lidocaine 70 mg, tetracaine
70 mg, net price 25 = £98.00 Lidocaine (Non-proprietary)
Excipients include hydroxybenzoates (parabens)
Ointment , lidocaine hydrochloride 5%, net price 15 g Dose needle puncture or superficial surgical procedures, ADULT = 88p
over 18 years, apply 1–4 plasters to intact skin 30 minutes before Dose dental practice, rub gently into dry gum
needle puncture or procedure; max. 4 plasters daily; CHILD 3–18 Sore nipples from breast-feeding, apply using gauze and wash off
years, needle puncture, apply 1–2 plasters to intact skin 30 immediately before feed
minutes before needle puncture; max. 2 plasters daily Pain relief (in anal fissures, haemorrhoids, pruritus ani, pruritus
The Scottish Medicines Consortium (p. 3) has advised (May 2008) vulvae, herpes zoster, or herpes labialis), 1–2 mL applied when
that lidocaine 70 mg/tetracaine 70 mg (Rapydan medicated necessary; avoid long-term use
plaster) is not recommended for use within NHS Scotland for surface anaesthesia of the skin in connection with needle puncture
Solution , lidocaine hydrochloride 4%, net price 25 mL or for cases of superficial surgical procedures on normal skin in = £1.35
adults or children over 3 years. Dose biopsy in mouth, 3–4 mL with suitable spray or swab (with
adrenaline if necessary); max. 5 mL, ELDERLY lower max. dose, Versatis c (Gru¨nenthal) A CHILD max. 3 mg/kg
Medicated plasters , lidocaine 5% (700 mg/medi- Puncture of maxillary sinus or polypectomy, apply with swab for
cated plaster), net price 30 = £72.40 2–3 minutes (with adrenaline); max. 5 mL, ELDERLY lower max.
Excipients include hydroxybenzoates (parabens), propylene glycol dose, CHILD max. 3 mg/kg
Cautions should not be applied to mucous membranes Bronchoscopy and bronchography, 2–3 mL with suitable spray;
Side-effects include administration site reactions such as skin max. 5 mL, ELDERLY lower max. dose, CHILD max. 3 mg/kg
lesions or injury
Dose postherpetic neuralgia, ADULT over 18 years, apply to (AstraZeneca)
EMLA c
intact, dry, non-hairy, non-irritated skin once daily for up to 12 Drug Tariff cream , lidocaine 2.5%, prilocaine 2.5%,
hours, followed by a 12-hour plaster-free period; discontinue if no net price 5-g tube = £1.73
response after 4 weeks Note Up to 3 plasters may be used to cover large areas; plasters
Surgical pack cream , lidocaine 2.5%, prilocaine
may be cut
2.5%, net price 30-g tube = £10.25 Note The Scottish Medicines Consortium has advised (December
2006) that Versatis Premedication pack cream is not recommended for the treatment of , lidocaine 2.5%, prilo-
postherpetic neuralgia dressings = £9.75
Xylocaine c (AstraZeneca) Cautions not for preterm neonates, children under 1 year
Spray (= pump spray), lidocaine 10% (100 mg/g) receiving treatment with methaemoglobin-inducing agents, wounds, mucous membranes (except genital mucosa in adults), or
supplying 10 mg lidocaine/dose; 500 spray doses per atopic dermatitis; avoid use near eyes or middle ear; although
container. Net price 50-mL bottle = £3.13 systemic absorption low, caution in anaemia, in congenital or
Dose dental practice, 1–5 doses acquired methaemoglobinaemia or in G6PD deficiency (see also
Maxillary sinus puncture, 3 doses Prilocaine, p. 706)
During delivery in obstetrics, up to 20 doses
thesia
Side-effects include administration site reactions such as tran- sient paleness, redness, oedema, itching, burning sensation, and
Bronchoscopy, laryngoscopy, oesophagoscopy, endotracheal localised lesions
intubation, up to 20 doses; CHILD up to 3 mg/kg Note Lidocaine can damage plastic cuffs of endotracheal tubes
Anaes
Dose ADULT and CHILD over 1 year, anaesthesia before minor skin procedures including venepuncture, apply thick layer under
15 occlusive dressing 1–5 hours before procedure (2–5 hours before
procedures on large areas e.g. split skin grafting); NEONATE and Lidocaine for ear, nose, and oropharyngeal use
CHILD under 3 months or body-weight less than 5 kg, single For cautions, contra-indications and side-effects of application max. 1 g under occlusive dressing for max. 1 hour,
phenylephrine, see section 2.7.2 CHILD 3–12 months and body-weight over 5 kg, apply max. 2 g under occlusive dressing for max. 4 hours
Lidocaine with Phenylephrine (Non-proprietary) Anaesthesia on genital skin before injection of local anaesthetics in adult men, apply under occlusive dressing for 15 minutes
Topical solution , lidocaine hydrochloride 5%, Anaesthesia before surgical treatment of lesions on genital
phenylephrine hydrochloride 0.5%, net price 2.5 mL mucosa in adults, apply up to 10 g 5–10 minutes before procedure
(with nasal applicator) = £9.60. Instillagel c (CliniMed)
Gel , lidocaine hydrochloride 2%, chlorhexidine gluconate solution 0.25%, in a sterile lubricant basis in
Bupivacaine
disposable syringe, net price 6-mL syringe = £1.41, 11-mL syringe = £1.58
The advantage of bupivacaine over other local anaes-
Excipients include hydroxybenzoates (parabens)
thetics is its longer duration of action. It has a slow onset Dose 6–11 mL into urethra
of action, taking up to 30 minutes for full effect. It is Laryngojet c
often used in lumbar epidural blockade and is particu- (UCB Pharma) A larly suitable for continuous epidural analgesia in labour,
Jet spray 4% (disposable kit for laryngotracheal or for postoperative pain relief. It is the principal drug anaesthesia) , lidocaine hydrochloride 40 mg/mL,
used for spinal anaesthesia.
BNF 57
15.2 Local anaesthesia 705
BUPIVACAINE HYDROCHLORIDE
With adrenaline
Indications see under Dose Bupivacaine and Adrenaline (Non-proprietary) A Cautions
Injection , anhydrous bupivacaine hydrochloride see under Lidocaine Hydrochloride and
2.5 mg/mL (0.25%), adrenaline 1 in 200 000 (5 micr- notes above; myocardial depression may be more
ograms/mL), net price 10-mL amp = £1.23 severe and more resistant to treatment; interactions: Appendix 1 (bupivacaine)
Injection , anhydrous bupivacaine hydrochloride Contra-indications
5 mg/mL (0.5%), adrenaline 1 in 200 000 (5 micr- see under Lidocaine Hydro-
ograms/mL), net price 10-mL amp = £1.40 chloride and notes above; intravenous regional
anaesthesia (Bier’s block) Side-effects see under Lidocaine Hydrochloride and notes above
Levobupivacaine
Dose Levobupivacaine, an isomer of bupivacaine, has anaes- Note Doses should be adjusted according to patient’s physical
thetic and analgesic properties similar to bupivacaine, status and nature of procedure—important: see also under
but is thought to have fewer adverse effects. Administration, p. 702
. Local infiltration , max. 60 mL, using a 2.5 mg/mL (0.25%) solution
LEVOBUPIVACAINE
. Peripheral nerve block , max. 60 mL, using a 2.5 mg/ Note Levobupivacaine is an isomer of bupivacaine mL (0.25%) solution; max. 30 mL, using a 5 mg/mL
Indications see under Dose (0.5%) solution
Cautions see under Lidocaine Hydrochloride and . Epidural block
notes above; interactions: Appendix 1 (levobupiva- Surgery, lumbar, max. 20 mL, using a 5 mg/mL (0.5%)
caine)
solution Contra-indications see under Lidocaine Hydro- Surgery, caudal, max. 30 mL, using a 5 mg/mL (0.5%)
chloride and notes above; intravenous regional solution; CHILD (up to 10 years) using a 2.5 mg/mL
anaesthesia (Bier’s block); paracervical block in (0.25%) solution, up to lower-thoracic (T10) 0.3–
obstetrics; do not use 7.5 mg/mL strength in obste-
0.4 mL/kg, up to mid-thoracic (T6) 0.4–0.8 mL/kg
trics
Labour, lumbar, max. 12 mL using a 2.5 mg/mL Side-effects see under Lidocaine Hydrochloride and (0.25%) or 5 mg/mL (0.5%) solution; caudal (but
notes above
rarely used) max. 20 mL using a 2.5 mg/mL (0.25%)
Dose
or 5 mg/mL (0.5%) solution Note Doses should be adjusted according to patient’s physical . Sympathetic block , max. 50 mL, using a 2.5 mg/mL
status and nature of procedure—important: see also under (0.25%) solution
Administration, p. 702
. Intrathecal anaesthesia , see under preparations . Surgical anaesthesia Lumbar epidural , 10–20 mL (50–150 mg) of 5 mg/
Important mL or 7.5 mg/mL solution over 5 minutes; caesar- The licensed doses stated above may not be appro- priate in some settings and expert advice should be
ean section, 15–30 mL (75–150 mg) of 5 mg/mL sought
solution over 15–20 minutes Intrathecal , 3 mL (15 mg) of 5 mg/mL solution Bupivacaine (Non-proprietary) A Peripheral nerve block , 1–40 mL of 2.5 mg/mL or
Injection , anhydrous bupivacaine hydrochloride
5 mg/mL solution (max. 150 mg); ilioinguinal/ilio-
2.5 mg/mL (0.25%), net price 10 mL = 82p; 5 mg/mL hypogastric block , CHILD under 12 years 0.25– (0.5%), 10 mL = 94p
0.5 mL/kg (0.625–2.5 mg/kg) of a 2.5 mg/mL or Note Bupivacaine hydrochloride injection 0.25% and 0.5% are
5 mg/mL solution
available in glass or plastic ampoules, and sterile-wrapped glass ampoules
Peribulbar block , 5–15 mL (37.5–112.5 mg) of
7.5 mg/mL solution Infusion , anhydrous bupivacaine hydrochloride
1 mg/mL (0.1%), net price 100 mL = £8.41, 250 mL = Local infiltration , 1–60 mL (max. 150 mg) of 2.5 mg/
£10.59; 1.25 mg/mL (0.125%), 250 mL = £10.80
mL solution
Dose Continuous lumbar epidural infusion during labour (once
. Acute pain
Anaesthesia
epidural block established), 10–15 mg/hour of 0.1% or 0.125% Lumbar epidural , labour pain, 6–10 mL (15–25 mg)
solution; max. 2 mg/kg over 4 hours and total of 400 mg in 24 hours
of 2.5 mg/mL solution at intervals of at least 15 Continuous thoracic, upper abdominal, or lower abdominal epi-
minutes or 5–12.5 mg/hour as a continuous epi- dural infusion for postoperative pain (once epidural block estab-
dural infusion, postoperative pain, 12.5–18.75 mg/ lished), 4–15 mg/hour of 0.1% or 0.125% solution; max. 2 mg/kg
hour as a continuous epidural infusion; max. 400 mg over 4 hours and total of 400 mg in 24 hours; not recommended
in 24 hours
for use in children
Important Marcain c (AstraZeneca) A The licensed doses stated above may not be appro-
Injection , anhydrous bupivacaine hydrochloride
priate in some settings and expert advice should be 0.25% ), net price 10-mL
2.5 mg/mL (Marcain c
sought
Polyamp c = £1.06; 5 mg/mL (Marcain c c 0.5% ), 10-mL
Polyamp = £1.21
c Chirocaine c (Abbott) Marcain Heavy A (AstraZeneca) A Injection , levobupivacaine (as hydrochloride) 2.5 mg/ Injection , anhydrous bupivacaine hydrochloride 5 mg,
mL, net price 10-mL amp = £1.66; 5 mg/mL, 10-mL glucose 80 mg/mL, net price 4-mL amp = £1.21
amp = £1.90; 7.5 mg/mL, 10-mL amp = £2.85 Dose intrathecal anaesthesia for surgery, 2–4 mL (dose may need
Note For 1.25 mg/mL concentration dilute standard solu- to be reduced in elderly and in late pregnancy)
tions with sodium chloride 0.9%
15.2 Local anaesthesia BNF 57 Infusion , levobupivacaine (as hydrochloride)
PROCAINE HYDROCHLORIDE U
625 micrograms/mL, net price 100 mL = £7.80,
200 mL = £10.40; 1.25 mg/mL, net price 100 mL = Indications local anaesthesia by infiltration and £8.54, 200 mL = £12.20
regional routes (but see notes above) Cautions see notes above; pregnancy (Appendix 4);
interactions: Appendix 1 (procaine)
Prilocaine Side-effects see notes above
Dose
Prilocaine is a local anaesthetic of low toxicity which is Note Doses should be adjusted according to patient’s physical similar to lidocaine (lignocaine). If used in high doses,
status and nature of procedure—important: see also under methaemoglobinaemia may occur which can be treated
Administration, p. 702 with intravenous injection of methylthioninium chloride
. By injection , up to 1 g (200 mL of 0.5% solution or (methylene blue) 1% using a dose of 1 mg/kg. Infants
100 mL of 1%) with adrenaline 1 in 200 000 under 6 months are particularly susceptible to methaemoglobinaemia.
Procaine (Martindale) AU Injection , procaine hydrochloride 2% (20 mg/mL) in sodium chloride intravenous infusion, net price 2-mL amp = £1.27