Lidocaine as an Antiarrhythmic: Contraindications and Dose Reduction

Contraindications and Precautions

The American Heart Association recommends that lidocaine should not be used in patients with wide complex tachycardia due to accessory pathways (e.g., Wolff-Parkinson-White syndrome with atrial fibrillation/flutter) as it has no effect on supraventricular tachycardias and can be dangerous in this context 1

The American College of Cardiology recommends reducing the maintenance infusion rate in patients with severe hepatic dysfunction, as lidocaine is metabolized almost exclusively by the liver, and these patients are at higher risk of developing toxic plasma concentrations 2
The American College of Cardiology suggests that the half-life of lidocaine increases from 1-2 hours in normal subjects to more than 20 hours in patients with cardiogenic shock, and therefore, dose reduction is necessary 2
The American College of Cardiology recommends reducing the dose in patients older than 70 years due to the increased risk of lidocaine toxicity 2
The American Academy of Pediatrics recommends reducing the dose by 30% in children less than 6 months old 3

The American Heart Association recommends an initial dose of 1-1.5 mg/kg IV for ventricular tachycardia 4
The American College of Cardiology recommends a maintenance dose of 2-4 mg/min in continuous infusion 2
The European Society of Cardiology recommends reducing the dose by 1 mg/min after 12-24 hours of continuous infusion, as the half-life increases after 24-48 hours 2

The American College of Cardiology notes that toxic effects of lidocaine manifest as central nervous system symptoms, including nausea, drowsiness, perioral numbness, and dizziness 2
The American Heart Association notes that cardiovascular effects of lidocaine toxicity include bradycardia, sinus arrest, and hypotension 2

The American Heart Association recommends that amiodarone is superior to lidocaine in the treatment of refractory ventricular fibrillation/pulseless ventricular tachycardia, and lidocaine should only be considered if amiodarone is not available (Class IIb, Level of Evidence B) 4