Accepted Manuscript

Are surgeons overdosing patients with lidocaine?

Laura Garcia-Rodriguez, Jeffrey Spiegel

PII: S0196-0709(18)30212-6
DOI: doi:10.1016/j.amjoto.2018.03.023
Reference: YAJOT 1999
To appear in:
Received date: 13 March 2018

Please cite this article as: Laura Garcia-Rodriguez, Jeffrey Spiegel , Are surgeons
overdosing patients with lidocaine?. The address for the corresponding author was
captured as affiliation for all authors. Please check if appropriate. Yajot(2017),
doi:10.1016/j.amjoto.2018.03.023

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Are surgeons overdosing patients with lidocaine?

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Laura Garcia-Rodriguez, MD and 1,2Jeffrey Spiegel, MD*

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Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology- Head
and Neck Surgery, Boston University School of Medicine,

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Boston, MA 02118
2*
The Spiegel Center
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Newton, MA 02459
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*Corresponding Author: Jeffrey Spiegel, MD, 335 Boyslton St. Newton, MA 02459, Ph: 617-

566-3223, email: drspiegel@drspiegel.com

Word count: 774

Key Words: lidocaine, anesthesia team, communication, overdose, toxicity, quality control

Declarations of interest: none. The authors have no funding, financial relationships, or conflicts
of interest to disclose
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Dear Editor,

Local anesthetics have long been used since the 1850s following the first pure extraction

of cocaine from coca leaves. Cocaine was a potent anesthetic, however, it led to deaths and

addictions for health care members and patients alike.1 Other local anesthetics such as tetracaine,

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tropocaine, lidocaine, bupivacaine and more recently, ropivacaine, were synthesized to minimize

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the cocaine toxicity. These newer anesthetic agents included both ester and amide

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preparationswith varying degrees of cardiovascular and neurotoxicity.1Commonly, symptoms

present first with neurotoxic symptoms (usually seizures with sequential worsening of mental

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status) followed by cardiotoxicity (dysrhythmias).2 The 2015 Annual Report of the American
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Association of Poison Control Centers’ National Poison Data System reported one death due to

lidocaine overdose.3
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Local anesthetics work by inhibiting cell membrane sodium channels preventing the
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influx of sodium during depolarization.2 There are certain dosages for every anesthetic that as

surgeons we must obey. It is considered essential to stay at or beneath these dosing guidelines to
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prevent lidocaine toxicity. We discuss why surgeon and anesthesiology medication

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administration (lidocaine) is important for patient well-being. We review the toxicity and

importance of correct lidocaine measurement and administration by the anesthesiologist and

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surgeon.

As surgeons, we are taught to administer certain dose of local anesthetic on a gram per

kilogram basis when used for local anesthesia. Commonly cited, frequently taught, and often

tested on in training examinations, the appropriate dosage amounts include 4.5 mg/kg for plain

lidocaine and 7 mg/kg for lidocaine with epinephrine.2,4 In a 60-kg person this would be
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equivalent to 270 mg of plain lidocaine or 420 mg of lidocaine with epinephrine. When using

the common preparation 1% lidocaine, that’s 27 cc of plain or 42 cc of lidocaine with

epinephrine. The injection is typically administered shortly after induction of general anesthesia

and prior to the patient being prepped and draped for surgery.

The discussion between anesthesiologist and surgeons is vital for the patients’ well-being.

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As most surgeons, we discuss our off and on the field medication administration.

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Anesthesiologists commonly administer intravenous lidocaine bolus prior to the

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induction of general anesthesia. Lidocaine in this fashion promotes reduction of intra and post-

operative opioid consumption and inhaled anesthetics use. It promotes shorter hospital stays,

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diminished production of inflammatory factors, reduced airway reactions and promotes earlier
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return of bowel function.5,6 It is also sometimes administered to reduce the pain of other IV

infusions such as propofol.

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Surgeons may not be aware if and when the anesthesiologist administers intravenous
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lidocaine, thus surgeons may not take the intravenous dose into account when determining the

amount of lidocaine to inject for the surgery. Typical doses given by anesthesiologist range from
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about 70 to 110 mg intravenouslidocaine7 or in general (1 mg/kg) prior to induction.8 100 mg of

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lidocaine administered by the anesthesiologist is the equivalent of 10 cc of 1% lidocaine. In the

example of the 60-kg person, 1 % lidocaine, which is 27 cc of plain or 42 cc of lidocaine with

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epinephrine. This represents 38% of the allowable dose of lidocaine plain or 24% of the

allowable dose for lidocaine with epinephrine. Unaware of the anesthesiologist’s dose, the

surgeon may deliver a substantially larger amount of lidocaine than recommended. As the

patient is under anesthesia, the symptoms of lidocaine overdose may be masked or treated by the

anesthesiologist as a reaction to general anesthesia without recognizing the actual cause. The
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symptoms of toxicity are in effect hidden by the general anesthetic or managed by an unaware

anesthesiologist. One study demonstrated that in cases of overdose, death did not occur in

animals under general anesthesia but only in conscious animals.9 In cases where lidocaine with

epinephrine infiltration has reached the limit, the authors propose using a solution of saline

mixed with epinephrine. The solution being 100 mL saline mixed with plain epinephrine 1 mg

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1:1,000. Which is essentially the same concentration as with lidocaine with epinephrine as

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described in the prior example. This is important when large amounts are needed, for example in

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facelifts, or when multiple procedures are being performed at the same time.

Treatment for lidocaine overdose generally is given to counteract the side effects, for

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example atropine for bradycardia and anti-seizure medications.10 Newer therapies involves
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intravenous bolus followed by infusion of intralipids until normal physiology is restored.2 The

lipids works by containing the excess anesthetic to preventing its entry into the circulation.2 This
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is the extent of our discussion about treatments as this is not to goal of this letter.
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For patient safety, it is important for surgeons to be aware of when anesthesiology

colleagues administer lidocaine. It should become a more rigorous standard to practice more
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communication regarding the dosing between the two teams.

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References:

1. Ruetsch YA, Boni T, Borgeat A. From cocaine to ropivacaine: the history of local

anesthetic drugs. Current topics in medicinal chemistry 2001; 1:175-182.

2. Tierney KJ, Murano T, Natal B. Lidocaine-Induced Cardiac Arrest in the Emergency

Department: Effectiveness of Lipid Therapy. The Journal of emergency medicine 2016;

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50:47-50.

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3. Mowry JB, Spyker DA, Brooks DE, Zimmerman A, Schauben JL. 2015 Annual Report

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of the American Association of Poison Control Centers' National Poison Data System

(NPDS): 33rd Annual Report. Clinical toxicology (Philadelphia, Pa) 2016; 54:924-1109.

4.
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Weaver JM. When can a normal dose be an overdose? Who is at risk? Anesthesia
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progress 2014; 61:45-46.

5. Gholipour Baradari A, Firouzian A, Hasanzadeh Kiabi Fet al. Bolus administration of

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intravenous lidocaine reduces pain after an elective caesarean section: Findings from a
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randomised, double-blind, placebo-controlled trial. Journal of obstetrics and gynaecology

: the journal of the Institute of Obstetrics and Gynaecology 2017; 37:566-570.

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6. McCarthy GC, Megalla SA, Habib AS. Impact of intravenous lidocaine infusion on
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postoperative analgesia and recovery from surgery: a systematic review of randomized

controlled trials. Drugs 2010; 70:1149-1163.

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7. Kelsaka E, Karakaya D, Baris S, Sarihasan B, Dilek A. Effect of intramuscular and

intravenous lidocaine on propofol induction dose. Medical principles and practice :

international journal of the Kuwait University, Health Science Centre 2011; 20:71-74.
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8. Hodgson PS, Liu SS. Epidural lidocaine decreases sevoflurane requirement for adequate

depth of anesthesia as measured by the Bispectral Index monitor. Anesthesiology 2001;

94:799-803.

9. Copeland SE, Ladd LA, Gu XQ, Mather LE. The effects of general anesthesia on the

central nervous and cardiovascular system toxicity of local anesthetics. Anesthesia and

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analgesia 2008; 106:1429-1439, table of contents.

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10. Moore PA, Hersh EV. Local anesthetics: pharmacology and toxicity. Dental clinics of

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North America 2010; 54:587-599.

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