l INDICATIONS AND DOSE

Infiltration anaesthesia

 BY LOCAL INFILTRATION

 Adult: Dose to be given according to patient’s weight and nature of procedure; max. 200 mg, maximum dose 500 mg if given in solutions containing adrenaline

DOSES AT EXTREMES OF BODY-WEIGHT

 When used by local infiltration To avoid excessive dosage in obese patients, weight-based doses for non-emergency indications may need to be calculated on the basis of ideal body-weight. Intravenous regional anaesthesia and nerve block

 BY REGIONAL ADMINISTRATION

 Adult: Seek expert advice Pain relief (in anal fissures, haemorrhoids, pruritus ani, pruritus vulvae, herpes zoster, or herpes labialis)| Lubricant in cystoscopy | Lubricant in proctoscopy

 TO THE SKIN USING OINTMENT

Adult: Apply 1–2 mL as required, avoid long-term use Sore nipples from breast-feeding

 TO THE SKIN USING OINTMENT

 Adult: Apply using gauze and wash off immediately before next feed LMX 4 ® Anaesthesia before venous cannulation or venepuncture

 TO THE SKIN

 Child 1–2 months: Apply up to 1 g, apply thick layer to small area (2.5 cm 6 2.5 cm) of non-irritated skin at least 30 minutes before procedure; may be applied under an occlusive dressing; max. application time 60 minutes, remove cream with gauze and perform procedure after approximately 5 minutes  Child 3–11 months: Apply up to 1 g, apply thick layer to small area (2.5 cm 6 2.5 cm) of non-irritated skin at least 30 minutes before procedure; may be applied under an occlusive dressing; max. application time 4 hours, remove cream with gauze and perform procedure after approximately 5 minutes  Child 1–17 years: Apply 1–2.5 g, apply thick layer to small area (2.5 cm 6 2.5 cm) of non-irritated skin at least 30 minutes before procedure; may be applied under an occlusive dressing; max. application time 5 hours, remove cream with gauze and perform procedure after approximately 5 minutes  Adult: Apply 1–2.5 g, apply thick layer to small area (2.5 cm 6 2.5 cm) of non-irritated skin at least 30 minutes before procedure; may be applied under an occlusive dressing; max. application time 5 hours, remove cream with gauze and perform procedure after approximately 5 minutes VERSATIS ® Postherpetic neuralgia

 TO THE SKIN

 Adult: Apply once daily for up to 12 hours, followed by a 12-hour plaster-free period; discontinue if no response after 4 weeks, to be applied to intact, dry, non-hairy, non-irritated skin, up to 3 plasters may be used to cover large areas; plasters may be cut XYLOCAINE ® During delivery in obstetrics TO THE SKIN

 Adult: Up to 20 doses

IMPORTANT SAFETY INFORMATION

 When used by local infiltration The licensed doses stated may not be appropriate in some settings and expert advice should be sought. Should only be administered by, or under the direct supervision of, personnel experienced in their use, with adequate training in anaesthesia and airway management, and should not be administered parenterally unless adequate resuscitation equipment is available.

l CONTRA-INDICATIONS

 When used by regional administration Avoid injection into infected tissues . avoid injection into inflamed tissues . complete heart block . preparations containing preservatives should not be used for caudal, epidural, or spinal block, or for intravenous regional anaesthesia (Bier’s block)  With topical use application to the middle ear (can cause ototoxicity). should not be applied to damaged skin

CONTRA-INDICATIONS, FURTHER INFORMATION

 With topical use or when used by regional administration Manufacturer advises local anaesthetics should not be injected into inflamed or infected tissues nor should they be applied to damaged skin. Increased absorption into the blood increases the possibility of systemic side-effects, and the local anaesthetic effect may also be reduced by altered local pH. 

CAUTIONS

 When used by regional administration Acute porphyrias p. 1095 (consider infusion with glucose for its antiporphyrinogenic effects). congestive cardiac failure (consider lower dose). debilitated patients (consider dose reduction). elderly (consider dose reduction). epilepsy . hypovolaemia . impaired cardiac conduction . impaired respiratory function . myasthenia gravis . post cardiac surgery (consider lower dose). shock l INTERACTIONS → Appendix 1: antiarrhythmics

l SIDE-EFFECTS

 With parenteral use Anxiety . arrhythmias . atrioventricular block . cardiac arrest. circulatory collapse . confusion . dizziness . drowsiness . euphoric mood . headache . hypotension (may lead to cardiac arrest). loss of consciousness . methaemoglobinaemia . muscle twitching . myocardial contractility decreased . nausea . neurological effects . nystagmus . pain . psychosis .respiratory disorders . seizure . sensation abnormal .temperature sensation altered .tinnitus .tremor. vision blurred . vomiting

SIDE-EFFECTS, FURTHER INFORMATION

Toxic effects The systemic toxicity of local anaesthetics mainly involves the central nervous and cardiovascular systems. Methaemoglobinaemia Methylthioninium chloride is licensed for the acute symptomatic treatment of druginduced methaemoglobinaemia.

l ALLERGY AND CROSS-SENSITIVITY

 Hypersensitivity and cross-sensitivity Hypersensitivity reactions occur mainly with the ester-type local anaesthetics, such as tetracaine; reactions are less frequent with the amide types, such as articaine, bupivacaine, levobupivacaine, lidocaine, mepivacaine, prilocaine, and ropivacaine. Cross-sensitivity reactions may be avoided by using the alternative chemical type.

l PREGNANCY

Crosses the placenta but not known to be harmful in animal studies—use if benefit outweighs risk. When used as a local anaesthetic, large doses can cause fetal bradycardia; if given during delivery can also cause neonatal respiratory depression, hypotonia, or bradycardia after paracervical or epidural block.

l BREAST FEEDING

Present in milk but amount too small to be harmful.

l HEPATIC IMPAIRMENT

Manufacturer advises caution (risk of increased exposure).

l RENAL IMPAIRMENT

Possible accumulation of lidocaine and active metabolite; caution in severe impairment.

l MONITORING REQUIREMENTS

 With systemic use Monitor ECG and have resuscitation facilities available.

l NATIONAL FUNDING/ACCESS DECISIONS VERSATIS ® Scottish Medicines Consortium (SMC) decisions

The Scottish Medicines Consortium has advised (July 2008) that Versatis ® is accepted for restricted use within NHS Scotland for the treatment of postherpetic neuralgia in patients who are intolerant of first-line systemic therapies or when they have been ineffective