Local Anesthesia Guidelines

Introduction

The American Academy of Dermatology provides guidelines for the safe use of local anesthesia, including dosage, administration, and management of potential complications 1, 2

The initial dose of intravenous lidocaine should not exceed 1.5 mg/kg based on ideal body weight, given over 10 minutes, with a maximum infusion rate of 1.5 mg/kg/h for no longer than 24 hours 1
Ideal body weight should be used for dose calculation, with men's ideal body weight calculated as height in cm - 100 and women's ideal body weight calculated as height in cm - 105 1
The maximum recommended dose for multistage procedures is 500 mg (50 mL of 1% solution) 2
The lowest effective dose should be used, and aspiration before injection is recommended to avoid intravascular administration 2

The American Academy of Dermatology recommends the use of epinephrine as safe on the ear, nose, hand, feet, and digits, and for uncertain cases, consulting with the patient's cardiologist is advised 2
Small amounts of lidocaine with epinephrine appear safe in patients with stable cardiovascular disease, but for questionable cases, consultation with the patient's cardiologist is recommended 2
The American Academy of Dermatology recommends using the lowest effective concentration of epinephrine, with common concentrations being 1:100,000 and 1:200,000, to minimize palpitations and anxiety 2
Pregnant women should postpone elective procedures requiring lidocaine with epinephrine until after delivery, and urgent procedures should be delayed until the second trimester when possible, with consultation with the patient's obstetrician in case of doubt 2

Adding sodium bicarbonate to local anesthetic, particularly lidocaine with epinephrine, can decrease pain during infiltration, and preinjection of buffered lidocaine solution is suggested to reduce the pain of bupivacaine infiltration 2
Combining lidocaine with other forms of local anesthesia can improve efficacy for complex procedures 2
Lidocaine is recommended for various procedures including biopsies, excisions, wound closure, tissue rearrangement, skin grafting, and laser resurfacing 2

Early symptoms of lidocaine toxicity include circumoral numbness, facial tingling, slurred speech, metallic taste, and auditory changes, while severe cases can lead to seizures, CNS depression, and cardiac failure or arrest 2
True lidocaine allergy is rare, approximately 1% of adverse reactions, and alternative options such as ester-type local anesthetics, 1% diphenhydramine injection, and bacteriostatic normal saline are available for patients with lidocaine allergy 2
When using multiple forms of local anesthesia simultaneously, the total dose should be considered to avoid toxicity 2
IV lidocaine should not be used within 4 hours of nerve blocks or fascial plane blocks, and nerve blocks should not be performed until 4 hours after completion of IV lidocaine infusion 1
Topical lidocaine patches should be removed before starting IV lidocaine infusion 1

The American Academy of Dermatology recommends maximum safe doses of lidocaine as 4.5 mg/kg without epinephrine and 7.0 mg/kg with epinephrine for adult patients, and 1.5-2.0 mg/kg and 3.0-4.5 mg/kg respectively for children 2