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