Lidocaine can be used as an alternative or adjunct to Amiodarone in patients with ventricular tachyarrhythmia’s, especially after acute myocardial infarction. Lidocaine is a class IB anti arrhythmic drug.

IV Lidocaine is an alternative treatment for recurrent sustained VT not responding to Beta‐blockers or Amiodarone. It may be considered as a safer but less effective alternative to amiodarone, especially if underlying myocardial ischaemia is suspected (ESC, 2015).

In addition to pharmacological management, it is important to ensure that electrolyte disturbances as a potential precipitant are identified early and treated appropriately. Ultimately, patients with ventricular arrhythmia refractory to DC cardioversion and anti‐arrhythmic medication may require sedation and ventilation.

Suppression of ventricular extrasystoles and ventricular tachycardia, especially after an acute myocardial infarction.

In the cardiovascular system Lidocaine acts primarily on the myocardium where it may produce decreases in electrical excitability, conduction rate and force of contraction. It has a rapid onset of action (about one minute following intravenous injection and rapidly spreads through the surrounding tissues.

Lidocaine is metabolised in the liver and the elimination half-life of Lidocaine following an intravenous bolus injection is one to two hours, but this may be prolonged in patients with hepatic dysfunction.

1. All grades of atrioventricular block

2. Sino-atrial disorders

3. Known hypersensitivity to local anaesthetic agents

Congestive cardiac failure (consider lower dose)

Post cardiac surgery (consider lower dose)

Acute porphyrias– a rare hereditary disorder of haem biosynthesis (consider infusion with glucose for its anti-porphyrinogenic effects)

Use with caution in patients receiving class III anti-arrhythmics e.g. sotalol, amiodarone.

There may be an increased risk of enhanced and prolonged neuromuscular blockade in patients treated concurrently with muscle relaxants (e.g. suxamethonium).

Hypokalaemia produced by acetazolamide, loop diuretics and thiazides may antagonize the effect of lidocaine if administered concomitantly

The clearance of Lidocaine may be reduced by beta-adrenoceptor blocking agents (e.g. propranolol) and by cimetidine, requiring a reduction in the dosage of lidocaine.

Increase in serum levels of lidocaine may also occur with anti-viral agents (e.g. amprenavir, atazanavir, darunavir, lopinavir).

Cardiovascular collapse has been reported following the use of bupivacaine in patients on treatment with verapamil and timolol; Lidocaine is closely related to bupivacaine.

Ventricular arrhythmia

Lidocaine has a low pH and may cause venous irritation and tissue damage in cases of extravasation. If central venous access device is unavailable, administer via a large peripheral vein monitoring insertion site closely using recognised phlebitis scoring tool. Re-site cannula at first signs of inflammation.

Loading dose

100mg bolus over 3 minutes as IV injection

Or consider reducing to 50mg bolus over 3 minutes for patients with reduced left ventricular function, cardiogenic shock, low body weight, reduced hepatic function and those aged over 70.

If the desired response is not achieved, a second dose may be administered 10 minutes after completion of the first injection.

Not more than 200-300 mg should be administered during a one-hour period.

Maintenance dose

Using a 4mg in 1mL (0.4%) lidocaine infusion

Using a 2mg in 1mL (0.2%) lidocaine infusion

If continuing infusion for more than 24 hours (rarely needed) this appears to result in a longer half-life and reduced rate of clearance (even in patients without cardiac or hepatic failure) and further dose reductions are needed to avoid toxic accumulation of lidocaine in the plasma.

IV bolus injection

Use 20mg/ml (2%) solution undiluted.

IV infusion

To prepare a concentration of 2mg/mL (0.2%) Remove 50ml from a 500ml sodium chloride 0.9% or 5% glucose bag or and discard. Add 50ml of lidocaine (2%) solution to the sodium chloride or glucose bag.

To prepare a concentration of 4mg/mL (0.4%) Remove 100ml from a 500ml sodium chloride 0.9% or 5% glucose bag or and discard. Add 100ml of lidocaine (2%) solution to the sodium chloride or glucose bag.

Flush with sodium chloride 0.9% or glucose 5%

IV infusion via central venous access device:

Do not flush the central venous access device. After the infusion is stopped, disconnect the administration set, aspirate the cannula contents and then flush.

IV infusion via peripheral cannula:

Flush the peripheral cannula at the same rate the medicine was infused to avoid adverse haemodynamic effects.

Expiry time of infusion is 24 hours.

Do not give this medicine by IV injection via a line being used for an infusion containing a medicine additive without first stopping the running infusion.

Neurological: dizziness, drowsiness, tremor, tongue numbness, nervousness, convulsions, circumoral paraesthesia, delirium, coma.

Eye disorders: blurred vision, diplopia

Ear and labyrinth: tinnitus, hyperacusis.

Immune: Hypersensitivity reactions

Cardiovascular: reactions are depressant and may manifest as hypotension, bradycardia, myocardial depression, cardiac arrhythmias and possibly cardiac arrest or circulatory collapse

Respiratory: Dyspnoea, bronchospasm, respiratory depression, respiratory arrest

Gastrointestinal disorders: Nausea, vomiting

Skin & subcutaneous tissue disorders: Rash, urticaria, oedema (including angioedema, face oedema)

Blood and the lymphatic system disorders: Methaemoglobinaemia.

Continuous ECG monitoring, blood pressure and respiratory function ideally on Coronary Care Unit or intensive care unit but treatment can be initiated in the emergency department prior to transfer. Resuscitation facilities must be available.

If toxicity occurs in addition to standard resuscitation therapy refer to Guidelines for the management of Severe Local Anaesthetic Toxicity with 20% Lipid Emulsion (Intralipid®20%). Available from the crash trolley.

I.V. infusion should be terminated as soon as the patient’s basic cardiac rhythm appears to be stable or at the earliest signs of toxicity. As soon as possible, and when indicated, patients should be changed to an oral antiarrhythmic agent for maintenance therapy.

Hameln pharma ltd (2022) Lidocaine Hydrochloride Injection BP 2% w/v. Available at: https://www.medicines.org.uk/emc/product/6281/smpc (Accessed: 01/10/2024).

European Society of Cardiology (ESC) (2015) ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: The Task Force for the Management of Patients with Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death of the European Society of Cardiology. Available at: https://academic.oup.com/eurheartj/article/36/41/2793/2293363 (Accessed: 01 October 2024).

Joint Formulary Committee (2024) 'Lidocaine hydrochloride' in British National Formulary. Available at: https://bnf.nice.org.uk/drugs/lidocaine-hydrochloride/ (Accessed: 01 October 2024).

This guideline has been registered with the Trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt, contact a senior colleague or expert. Caution is advised when using guidelines after the review date.
This guideline is for use in Frimley Health NHS Foundation Trust hospitals only. Any use outside this location will not be supported by the Trust and will be at the risk of the individual using it.

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