text:
A WIDE SELECTION OF CONTACT LENSES IN Chappaqua, New York
These include disposable soft contact, bifocal/multifocal, toric, and colored lenses. Whether you wear daily, weekly or monthly disposables, or conventional (vial) lenses, check out our selection of lenses at Foresight Eye Care. Our goal is to fit you with contact lenses that give clear and comfortable vision.
Establishing a Good Contact Lens Fit at Foresight Eye Care
It starts with a thorough eye exam to ensure the most up-to-date prescription and rule out any pre-existing conditions that could interfere with contact lens wear.
Fitting lenses to your lifestyle
We will determine the best fitting lens based on your lifestyle needs and the shape and health of your eyes. In most cases, you'll have the opportunity to try lenses on the same day as your exam. You may even go home with a few samples before making a final decision.
Follow up fittings
Our Chappaqua team will follow up after the initial fitting and then make any necessary changes in fit or materials to get you the best possible result. We teach all our patients proper contact lens care and also possible consequences if proper care is not taken. Then we continue with long-term follow-up to monitor the condition of the lenses and to ensure that proper hygiene is being maintained.
AIR OPTIX® plus HydraGlyde
DAILIES TOTAL1® Multifocal
DAILIES TOTAL1® Water Gradient
Clariti™ 1-day Toric

subset: commoncrawl


text:
Pitfodels HouseNorth Deeside Road, Pitfodels, CultsAberdeen AB15 9PN, UK
6-8: 117
9-12: 135
Total: 462
Learn about this school's current job vacancies, salaries, benefits, hiring policies, school demographics, even the typical annual savings, and much more. Become a registered and active candidate with Search Associates to access our comprehensive database and to connect with international schools worldwide. Get Started today!
Get Started…
Did You Know…?
Search Associates has over 15 Senior Associates with offices around the globe, each bringing a wealth of experience in international education.


text:
- UK Information
- Winchester Information Online
Winchester Information Online
Get to know WinchesterWhatever you want to find around Winchester; shops, businesses, hotels, pubs, restaurants, clubs, cinemas, theatres, etc. our directory, classified system and events guide will help you to find out what's on around Winchester and where to find things in and around Winchester.
If you can't find what you want in Winchester use the Towns/Cities information to search in other places near Winchester.
Whatever you need to know about Winchester this is the place to start. Submit or read articles, search the directory, find out what is going on in your area, advertise for free and much more.
Entertainment and Leisure
You can use our
- Winchester cinemas,
- Winchester theatres and
- What's On guide to plan your day or evening out.
If you are looking for accommodation we have:
- Winchester bed and breakfasts and
- Winchester hotels plus
- Winchester cottages and self catering holiday accommodation as well as directories for
- Camping,
- Holiday Camps and
- Caravan Parks.
Visiting and Local Services
If you are looking for tourist information or information on how to get around we have details of
- Tourist Information,
- Travel & Transport and
- a list of local Attractions and Places of Interest with
- a list of local Guide books and Maps to help you find where you are going.
Our Directory contains lists of sites that have been submitted by the owners.
Travel & Transport
For anyone that wants to get around, we have put together a list Travel & Transport pages including a map and route planner.


text:
Title: Me and You 578 - Lady in Satin
Published: 25 August 2023
A lady in satin with very unladylike plans for you! xxx
18 U.S.C. 2257 Records Keeping Requirements Compliance Statement
All models were at least 18 years old when they were photographed.
We support the use of filtering software which prevents minors from accessing inappropriate material, for more information:
Net Nanny - | -
SurfWatch - | -
CyberPatrol - | -
SafeSurf - | -
Copyright © 2001- print (date("Y")); ?> Joannajet.com. All Rights Reserved. All copy and media are the sole copyright of Fringe Dweller Productions Ltd. unless otherwise noted. All graphics are the sole copyright of Fringe Dweller Productions Ltd. unless otherwise noted. Any reproductions of materials from this web site is for personal use only unless written permission has been obtained from Fringe Dweller Productions Ltd.. This web site and associated software is owned and operated by Altered State Productions Inc.
Please email any questions about any web site problems or to reach Joanna Jet please contact the webmaster


text:
Thin Yellow Line Flag with Eagle
Sale Sold out
Regular price $22.00 USD
Regular priceUnit price per
Sale price
This listing is for a actual tumbler, not a digital or print.
20oz stainless steel skinny insulated tumblers featuring double-wall, vacuum insulation with a clear slide lid and plastic straw! They are 2x heat and cold resistant compared to glass or plastic. Each tumbler is BPA and lead free!
Custom names and designs are printed directly on the tumbler, no stickers, glitter or epoxy used. These are durable and will last!
These make perfect gifts!
Note: that colors may appear slightly different on your computer/phone/tablet in comparison to actual design.


text:
Pin - Small
Duties and shipping cost excluded
Lapel Small Size|100% BRASS
Shipping and returns
Shipping: The products will be handed over to the Courier within 2-3 days from order confirmation. Delivery times may vary for countries outside the European Union.
Please notice that the production time for pre-order products is approximately 60 days.
Returns: The withdrawal right can be exercised within 14 working days from the goods delivery.
Pre-order products are not eligible for return.
Customer care
If you need assistance in order to improve your shopping experience, please don't hesitate to contact us by phone at the following number (+39) 041/8380060 or by email at: firstname.lastname@example.com


text:
Generation next (83974) Free EPS, SVG Vector
This amazing [ Vector] is available for instant free download. The high-quality image comes with 2 files in eps, svg. This one is 72.73KB and is suitable for most creative projects. If you love the look of this graphic, then browse the site to view our comprehensive collection of image vectors or just type into the search bar what you are looking for.
Don't hesitate to see other images in Design category:


text:
This easy mask with huge tusks resembles the Bewilderbeast, but you can make it anything you want from dragon to demon to warrior helmet!
You will be able to download the templates and instructions for the mask immediately after purchase. The file contains a 10 page PDF document that you can print on normal paper. All pieces of the template fit in single sheets of paper.
Building the mask will probably take you around 3 hours.
The 2D templates and 3D design are protected by copyright law, and are intended for personal use only. By purchasing and downloading this file, you are agreeing to our Terms of Service.
Contact us if you want to use the mask for any other purpose than personal use.
Please note that you are buying the templates and instructions only. You will need to print them out, follow the instructions and get any materials and tools you want to use.
Note that the template is not in vector format.
The templates fit in A4 and US Letter paper.
Print and glue the templates on card of your choice and cut them. Thin cardboard or card of around 300gsm is ideal, but you can use any card that can be scored and creased easily. Assemble the pieces using double-sided tape or fast drying glue and finally make your creation unique by decorating it any way you like. Try using different colored or metallic card, paint it or glue a variety of materials on it, from glitter to feathers; the possibilities are endless.
See our Refund and Return policy, and Shipping policy.
Do you have an idea for a new design? Send it this way and if it gets made, you will receive it for free!


text:
Grille Letter Inserts Fits 2022-2024 Nissan Titan
Product Information
Features, Description, Material Type, Installation
- Grille Letter Inserts Fits Nissan Titan 2022-2024
- Raised and Stylish Lettering
- High-Quality Materials - Designed to Last
- Easy Installation 3M Automotive Grade Adhesive
- Sold As: 5 Piece Kit
- Made in the USA
Add a new exterior look to your Nissan Titan by installing TUFSKINZ Grille Letter Inserts. This kit adds style and protection to your vehicle and each letter is fittingly positioned in the embossed letter area on the grille.
Material Type
Domed (Raised 4mm) - Our Domed product line is our signature product. Each piece is manufactured with our 3-layer process that has been designed and tested to withstand all elements.
1ST LAYER - Superior UV Doming Resin that creates a high gloss, scratch resistant, durable finish.
2ND LAYER - Consists of a variety of substrates including our 100% Real Carbon Fiber, Chrome, Camouflage and Factory color matches to allow an array of custom options.
3RD LAYER - Utilizes our 3M Automotive Grade Adhesive that creates the perfect bond to the surface of the vehicle and makes the product installation an ease.
**Only Exception: Real Carbon Fiber (Raw) is Raised 1mm**
Easy Installation
TUFSKINZ Grille Letter Insert pieces are designed to fit each letter on the grille of your truck. Prep and installation can simply be completed within 15 minutes.


text:
Lincoln 369040 GEAR 10 TOOTH 5/8" BORE
Check for Substitute & Related Products below or
contact ASC1 for availability and pricing.
contact ASC1 for availability and pricing.
ASC1 Part #: LIN369040 Manufacturer: Lincoln Quantity Available*: 0
*Please note that you will still be able to place your order even if your QTY exceeds the Quanty Available. We can drop ship most items directly from the manufacturer. Please call us at 800-236-6460 if you have any questions.


text:
It's time to link in your best post of the week!
The purpose of this column is to make it easier to keep up with each other's blogs, so that even if we don't have time to read all of the Alabama Blogger blogs every day, at least we get the week's highlights.
So, link up, tell us why you linked that post, and let's start reading! And remember - the best way to get new blogging friends is to comment on other people's posts, so be sure to say "hi" to your neighbors when you visit!
p.s. - please feel free to interpret "this week" as loosely as you like!


text:
No Properties matching your requirements. Search for any other locations or submit the details using link below:
{{(fruit | filter:furnishFilter | filter:roomFilter | filter:MonthFilter).length+50 | ceilValue}}+ Furnished House for rent in Ashok Nagar
Available from {{x.available_date}}
Available for Booking
Not Available
{{x.building_name}} {{x.floor}}
Multiple units available
{{x.prop_type | uppercase}}
- {{x.unit_type | uppercase}}
- Max Guests:{{x.max_guests}}
Stay a Night
{{x.rent | number}}/Night
Stay a Week
{{x.weekly_rent | number}}/Week
Regular Rent
{{x.rms_rent | number}}/Month
Flexi Rent
{{x.monthly_rent | number}}/Month
Regular Rent
{{x.rms_rent | number}}/Month
{{x.rms_deposit| number}}
Pay zero to book now.
{{x.unit_type | uppercase}}
Multiple units available
{{x.prop_type | uppercase}}
- {{x.areas==null?place_heading:x.areas}}
- Max Guests:{{x.max_guests}}
Stay a Night
{{x.rent | number}}/Night
Stay a Week
{{x.weekly_rent | number}}/Week
Regular Rent
{{x.rms_rent | number}}/Month
Flexi Rent
{{x.monthly_rent | number}}/Month
Regular Rent
₹{{x.rms_rent | number}}/Month
Pay zero to book now.
FAQ on Furnished House for rent in Ashok Nagar.
Q: How to find a Furnished House for rent in Ashok Nagar?
To find a Furnished House in Ashok Nagar. Select from the options given.
Q: Does the Furnished House come with kitchen in Ashok Nagar?
Yes, if you choose studio, 1 bhk, 2 bhk, 3+ bhk houses they all come with kitchen. In fully furnished houses the kitchen is also equipped with Stove, vessels, cooker etc., so you can cook your home food. Renting furnished house with kitchen is best alternative to service apartment with kitchen or hotels for extended stays.
Q: Do I need to pay brokerage to book Furnished House in Ashok Nagar?
No, with RentMyStay you do not need to pay any brokerage to book a house or place anywhere! We promote no brokerage!
Q: Do I get food in any Furnished House that I book in Ashok Nagar?
No, unless explicitly mentioned you will not get any food with any of the properties you book on RentMyStay! Some properties offer food for an additional cost. You can check before you book.
Q: Is the Furnished House that I see on RentMyStay in Ashok Nagar safe?
Yes, we constantly gather feedback from our customers and the property you book are safe, any issues contact RentMyStay to get the issue resolved! We do provide site visits if you want to visit the place before you book
Q: What should I check when I book a Furnished House in Ashok Nagar?
Check the exact location, amenities mentioned, price etc., before you book, if required we will help you arrange a site visit!
Q: Are there any hospitals in Ashok Nagar?
Some of the hospital near by are Kalra Hospital located approx 5 kms, Jaipur Golden Hospital located approx 8 kms, BLK Superspeciality Hospital located approx 9 kms, etc.
Q: Any malls, hotels in Ashok Nagar?
Few of the Malls near by are TDI Mall ( 3 kms), City Square Mall ( 3 kms), Moments Mall ( 6 kms), etc.
Q: Neary by Stations in Ashok Nagar?
Nearest train or metro stations are Subhash Nagar Metro approx distance of 1 kms, Tilak Nagar Metro approx distance of 1 kms, Tagore Garden Metro approx distance of 2 kms,
Find information related to Budget service apartments, fully furnished house with kitchen, short term rentals, long term rent, Short stay apartment with kitchen Paying Guest, co-live accommodation for flexible duration.
{{x.description | remove_HTML_tags}}
{{x.description | remove_HTML_tags}}
Various choices such as fully furnished flats with kitchen, semi furnished houses ( Studio, 1bhk or 2bhk), hostels, co-living, Paying Guest etc., for longb term rent, short term stay or monthly stay. If you want to rent house for short duration due to Internship, Job search, training, project, medical purpose, exams etc., you can rent our furnished homes the prices are very affordable. We have Independent, luxury and cheap options available. We have 1 bhk, 2 bhk and studio options across all major localites in bangalore. The furnished houses come with Kitchen including gas, stove, kitchen utensils so you can cook at home. These are much better choices compared to service apartments or hotels as the prices will fit your budget, houses are spacious and you can feel at home. You can rent from one day, two days, weekly, monthly to any long term duration close to location such as {{x.place_title}} and many more.


text:
The finest creations are crafted with precise calculation and design. Technology meets Aesthetics, we merge postmodern design with modern technology to inspire business users. The Summit E13FlipEvo A11MT-272 features a 360 degree hinge and 16:10 Golden ratio display to make this laptop compact and versatile. Certified with Intel® Evo™ platform and powered by Intel® Core™ i5 processor, enjoy the high performance of the Summit E13 Flip.
Free Shipping
On order over $25
Return for Refund
Within 30 days
1-YEAR Limited Warranty
Base-on purchase date
|Windows 11 Home (MSI recommends Windows 11 Pro for business.)
|Manufacturer Number
|Product Condition
|Intel Core™ i7-1185G7
|CPU Speed
|1.2 - 4.8 Ghz
|Integrated SoC
|Intel® Iris® Xe graphics
|Video Memory
|Wireless LAN
|Intel Wi-Fi 6E AX201
|Nahimic 3 / Hi-Res Audio
|Video Port
|1 x USB 3.2 Gen1
|Audio Port
|Mic-in / Headphone-out Combo
|2 x Thunderbolt™ 4 [Support Power delivery, DP 1.4a, USB4] 1 x USB 3.2 Gen 2 Type C
|1 x 512GB NVMe SSD
|Optical Drive
|Card Reader
|Hidden Micro SD
|IR HD Type [30fps/720p] w/Ambient Light Sensor & Noiseless Cam + Camera Lock Shutter
|White backlight 83 Key
|2 x Speakers 2W
|AC Power Adapter
|65W Compact
|Battery Pack
|4 cell (70Whr)
|Screen Size
|13.4" FHD+, 100%sRGB, IPS-Level
|Pure White
|11.82" x 8.75" x 0.59"
|2.98 lbs
|Manufacturer Warranty
|1 year Limited warranty (Include 1 Year Global)
|Summit E13 Flip
|Determined to Succeed
|Explore More with 16:10 Golden Ratio Display
|The finest creations are crafted with precise calculation and design. Technology meets Aesthetics, we merge postmodern design with modern technology to inspire business users. The Summit E13 Flip features a 360 degree hinge and 16:10 Golden ratio display to make this laptop compact and versatile. Certified with Intel® Evo™ platform and powered by Intel® Core™ i5 processor, enjoy the high performance of the Summit E13 Flip.
|Mathematics Code in Aesthetics
|The all-new reimagined logo on the Summit Series was heavily influenced by the Golden Ratio, applying mathematics for an organic and balanced composition for a timeless design.
|Unique Taste
|The Summit E13 Flip comes in a new Ink Black or Pure White color with sleek edges and brushed line engraving. Crafted in a detailed CNC process, the Summit E13 Flip redefines business elite.
|Extraordinary wireless experience
|The latest Wi-Fi 6E is designed to operate in bands between 1 and 6 GHz. Wi-Fi 6E delivers stunning speed and keeps the network smooth and stable. With its outstanding throughput and low latency, you can always enjoy smooth streaming of online videos, or transfer large files in an instant.
|Optimal Mobility without Compromise
|The Summit E13 Flip provides a longer battery life up to 20 hours, but it also can be flipped, transformed and bent to any angle to meet your needs. This convertible 2-in-1 laptop with its long-lasting battery and fast-charge technology adapts to the way you work. The versatility allows you to work and play anywhere, anytime.
*Tested by MobileMark® 2014 office productivity scenario. Test configuration: Summit E13 Flip A11M / Full HD 60Hz display / Super battery mode. The battery life will vary from specifications and system configuration.
|Productivity Booster
|Ultimate Connectivity
|Paired with multiple Thunderbolt 4 ports, the Summit E13 Flip supports power delivery through its ports so you can quickly charge your devices, transfer data at 40Gbps and connect to multiple displays or peripherals.
|4X Throughput
|PCIe Gen 4 Storage Support
|PCIe 4.0 efficiently boosts the daily workflow and provides a better signal reliability and integrity for improved performance.
* The performance improvement is based on preliminary estimation, actual data transfer speed will vary by SSD devices.
|2X Bandwidth
|Enterprise-Grade Security
|MSI Center for Business & Productivity
|The MSI Center takes optimization to the next level with easily adjustable system modes and resources for a wide range of scenarios and needs.
*The interface and functionality may differ due to version change. Please download the latest MSI Center APP through Microsoft Store.
|Hi-Res Audio ready
|Immerse yourself in lossless music and enjoy the premium sound quality with Hi-Resolution Audio. Experience and listen to audio the way it was intended.
|See Clearly Without Noise
|MSI Noise Reduction Cam allows the webcam to adjust its signal to noise ratio to produce better image quality under low light or adverse lighting conditions.
|To pursue the best of the best, the product meets the MIL-STD-810G military standard for reliability and durability. MSI always strives for professionalism with world-leading technology.
|MSI Service Center
|MSI offers a wide variety of service locations & options. You can get the support from MSI Service Center in nearby area to minimize the unexpected downtime and keep business going.
|Design for Your Style
|Built for business elite to push productivity to the highest level by making every detail more unique to you.
Call our support representative
Mon-Fri 9:00AM-5:00PM PST
Add up to 4 products to the comparison and proceed to review their specifications in a single overview.
*Upgrade timing may vary by device. Features and app availability may vary by region. Certain features require specific hardware (see https://www.microsoft.com/en-us/windows/windows-11-specifications).
Intel, the Intel Logo, Intel Inside, Intel Core, and Core Inside are trademarks of Intel Corporation or its subsidiaries in the U.S. and/or other countries.
© 2021 NVIDIA Corporation. All rights reserved. NVIDIA, the NVIDIA logo, GeForce, GeForce RTX, and NVIDIA Turing are registered trademarks and/or trademarks of NVIDIA Corporation in the United States and other countries. All other trademarks and copyrights are the property of their respective owners.
MSI, MSI gaming, dragon, and dragon shield names and logos, as well as any other MSI service or product names or logos displayed on the MSI website, are registered trademarks or trademarks of MSI. The names and logos of third party products and companies shown on our website and used in the materials are the property of their respective owners and may also be trademarks. MSI trademarks and copyrighted materials may be used only with written permission from MSI. Any rights not expressly granted herein are reserved.
All images and descriptions are for illustrative purposes only. Visual representation of the products may not be perfectly accurate. Product specification, functions and appearance may vary by models and differ from country to country. All specifications are subject to change without notice. Although we endeavor to present the most precise and comprehensive information at the time of publication, a small number of items may contain typography or photography errors. Some products and configuration may not be available in all markets or launch time differs. Supplies are limited. We recommend you to check with your local supplier for exact offers and detail specifications.
Adobe product box shots reprinted with permission from Adobe Systems Incorporated. Adobe® products are either registered trademarks or trademarks of Adobe Systems Incorporated in the United States and/or other countries.Autodesk screen shots reprinted courtesy of Autodesk, Inc.
MIL-STD 810G testing is conducted on select MSI products. The testing is not a representation of MSI products satisfying U.S. Department of Defense (DoD) requirements or for military use. Validation process is done in laboratory conditions. Test results do not guarantee future performance under these test conditions. Damage under such test conditions is not covered by MSI's standard warranty.


text:
NEW ORLEANS (AP) -- A former Halliburton manager faces a possible prison term when a federal judge sentences him for destroying evidence in the aftermath of BP's massive 2010 oil spill in the Gulf of Mexico.
Anthony Badalamenti, of Katy, Texas, was scheduled to be sentenced Tuesday by U.S. District Judge Jay Zainey. Badalamenti pleaded guilty in October to one misdemeanor count of destruction of evidence and faces a maximum sentence of 1 year in prison and a $100,000 fine.
Badalamenti was the cementing technology director for Halliburton Energy Services Inc., BP's cement contractor on the Deepwater Horizon drilling rig. Prosecutors said he instructed two Halliburton employees to delete data during a post-spill review of the cement job on BP's blown-out Macondo well.
Halliburton cut its own deal with the Justice Department and pleaded guilty in September to a misdemeanor charge related to Badalamenti's conduct. The company agreed to pay a $200,000 fine and make a $55 million contribution to the National Fish and Wildlife Foundation, but the latter payment wasn't a condition of the deal.
Tai Park, one of Badalamenti's lawyers, said in October that guidelines calculated by prosecutors call for Badalamenti to receive a sentence ranging from probation to six months in prison. Zainey, however, isn't bound by the sentencing guidelines.
Four current or former BP employees also have been charged in federal court with spill-related crimes.
On Dec. 18, a jury convicted former BP drilling engineer Kurt Mix of trying to obstruct a federal probe of the spill. Prosecutors said Mix was trying to destroy evidence when he deleted a string of text messages to and from a BP supervisor.
Mix faces a maximum sentence of 20 years in prison and a $250,000 fine. His sentencing is set for March 26.
BP well site leaders Robert Kaluza and Donald Vidrine pleaded not guilty to manslaughter charges stemming from the deaths of 11 workers on the Deepwater Horizon. Prosecutors claim Kaluza and Vidrine botched a key safety test and disregarded abnormally high pressure readings that were glaring signs of trouble before the April 2010 blowout of BP's Macondo well triggered a deadly explosion.
Former BP executive David Rainey was charged with concealing information from Congress about the amount of oil that was gushing from BP's well before the company sealed it.
Prosecutors said Badalamenti instructed two Halliburton employees to delete data from separate runs of computer simulations on centralizers, which are used to keep the casing centered in the wellbore. The data could have supported BP's decision to use six centralizers instead of 21 on the Macondo project, but prosecutors said the number of centralizers had little effect on the outcome of the simulations.
Halliburton notified the Justice Department about the deletion of the data, which couldn't be recovered.
More from MBTMag.com
Silicon Valley Sees Shortage Of EV Charge Stations
ABInBev Repurchases Oriental Breweries
Slumping Intel To Cut More Than 5,000 Jobs In 2014


text:
Study in Syria
If you want to study in Syria, then you need to know which of its universities are right for you. Times Higher Education World University Rankings take the top institutions in the world, and look at their performance across all of their core objectives: teaching, research, knowledge transfer and international outlook.
Syria does not currently have any universities in the overall Times Higher Education World University Rankings. However, if we have data about any institutions in the country, then they will appear on the map.
Choosing where to study in Syria is one of the biggest decisions you will ever make. THE's student resources are here to help you make the right choice. We've pulled together some information that we hope will help you to decide where to study.
Use the map to see where Syria's top universities are located, and if any institutions are of particular interest, you can click on their name, or the "explore" button, to find out more about them. We've also pulled in information about how much Syria is investing in its higher education, and also how many people live there.
Our World University Rankings were founded in 2004 and our data are trusted by governments and universities across the world.


text:
Full Prescribing Information
Lidocaine Hydrochloride Injection, USPPreservative free-lidocaine hydrochloride injection solution
Lidocaine Hydrochloride Injection USP, 1%
For Infiltration and Nerve Block
Rx only
Lidocaine Hydrochloride Injection, USP is a sterile, nonpyrogenic, aqueous solution that contains a local anesthetic agent and is administered parenterally by injection. See INDICATIONS for specific uses.
The solution contains lidocaine HCl, which is chemically designated as acetamide, 2-(diethylamino)-N-(2,6-dimethylphenyl)-, monohydrochloride and has the molecular wt. 270.8. Lidocaine HCl (C14H22N2O • HCl) has the following structural formula:
Lidocaine Hydrochloride Injection, USP single dose solutions are methylparaben free.
Lidocaine Hydrochloride Injection, USP is a sterile, nonpyrogenic, isotonic solution containing sodium chloride. The pH of this solution is adjusted to approximately 6.5 (5.0 to 7.0) with sodium hydroxide and/or hydrochloric acid.
Mechanism of Action:
Lidocaine HCl stabilizes the neuronal membrane by inhibiting the ionic fluxes required for the initiation and conduction of impulses thereby effecting local anesthetic action.
Excessive blood levels may cause changes in cardiac output, total peripheral resistance, and mean arterial pressure. With central neural blockade these changes may be attributable to block of autonomic fibers, a direct depressant effect of the local anesthetic agent on various components of the cardiovascular system, and/or the beta-adrenergic receptor stimulating action of epinephrine when present. The net effect is normally a modest hypotension when the recommended dosages are not exceeded.
Pharmacokinetics and Metabolism:
Information derived from diverse formulations, concentrations and usages reveals that lidocaine HCl is completely absorbed following parenteral administration, its rate of absorption depending, for example, upon various factors such as the site of administration and the presence or absence of a vasoconstrictor agent. Except for intravascular administration, the highest blood levels are obtained following intercostal nerve block and the lowest after subcutaneous administration.
The plasma binding of lidocaine HCl is dependent on drug concentration, and the fraction bound decreases with increasing concentration. At concentrations of 1 to 4 mcg of free base per mL 60 to 80 percent of lidocaine HCl is protein bound. Binding is also dependent on the plasma concentration of the alpha-1-acid glycoprotein.
Lidocaine HCl crosses the blood-brain and placental barriers, presumably by passive diffusion.
Lidocaine HCl is metabolized rapidly by the liver, and metabolites and unchanged drug are excreted by the kidneys. Biotransformation includes oxidative N-dealkylation, ring hydroxylation, cleavage of the amide linkage, and conjugation. N-dealkylation, a major pathway of biotransformation, yields the metabolites monoethylglycinexylidide and glycinexylidide. The pharmacological/toxicological actions of these metabolites are similar to, but less potent than, those of lidocaine HCl. Approximately 90% of lidocaine HCl administered is excreted in the form of various metabolites, and less than 10% is excreted unchanged. The primary metabolite in urine is a conjugate of 4-hydroxy-2,6-dimethylaniline.
The elimination half-life of lidocaine HCl following an intravenous bolus injection is typically 1.5 to 2 hours. Because of the rapid rate at which lidocaine HCl is metabolized, any condition that affects liver function may alter lidocaine HCl kinetics. The half-life may be prolonged two-fold or more in patients with liver dysfunction. Renal dysfunction does not affect lidocaine HCl kinetics but may increase the accumulation of metabolites.
Factors such as acidosis and the use of CNS stimulants and depressants affect the CNS levels of lidocaine HCl required to produce overt systemic effects. Objective adverse manifestations become increasingly apparent with increasing venous plasma levels above 6 mcg free base per mL. In the rhesus monkey arterial blood levels of 18 to 21 mcg/mL have been shown to be threshold for convulsive activity.
Lidocaine Hydrochloride Injection, USP is indicated for production of local or regional anesthesia by infiltration techniques such as percutaneous injection and intravenous regional anesthesia by peripheral nerve block techniques such as brachial plexus and intercostal and by central neural techniques such as lumbar and caudal epidural blocks, when the accepted procedures for these techniques as described in standard textbooks are observed.
Lidocaine HCl is contraindicated in patients with a known history of hypersensitivity to local anesthetics of the amide type.
LIDOCAINE HYDROCHLORIDE INJECTION, USP FOR INFILTRATION AND NERVE BLOCK SHOULD BEEMPLOYED ONLY BY CLINICIANS WHO ARE WELL VERSED IN DIAGNOSIS AND MANAGEMENT OF DOSE-RELATED TOXICITY AND OTHER ACUTE EMERGENCIES THAT MIGHT ARISE FROM THE BLOCK TO BE EMPLOYED AND THEN ONLY AFTER ENSURING THE IMMEDIATE AVAILABILITY OF OXYGEN, OTHER RESUSCITATIVE DRUGS, CARDIOPULMONARY EQUIPMENT AND THE PERSONNEL NEEDED FOR PROPER MANAGEMENT OF TOXIC REACTIONS AND RELATED EMERGENCIES (see also ADVERSEREACTIONS and PRECAUTIONS). DELAY IN PROPER MANAGEMENT OF DOSE-RELATED TOXICITY, UNDERVENTILATION FROM ANY CAUSE AND/OR ALTERED SENSITIVITY MAY LEAD TO THE DEVELOPMENT OF ACIDOSIS, CARDIAC ARREST AND, POSSIBLY, DEATH.
Cases of methemoglobinemia have been reported in association with local anesthetic use. Although all patients are at risk for methemoglobinemia, patients with glucose-6-phosphate dehydrogenase deficiency, congenital or idiopathic methemoglobinemia, cardiac or pulmonary compromise, infants under 6 months of age, and concurrent exposure to oxidizing agents or their metabolites are more susceptible to developing clinical manifestations of the condition. If local anesthetics must be used in these patients, close monitoring for symptoms and signs of methemoglobinemia is recommended.
Signs of methemoglobinemia may occur immediately or may be delayed some hours after exposure, and are characterized by a cyanotic skin discoloration and/or abnormal coloration of the blood. Methemoglobin levels may continue to rise; therefore, immediate treatment is required to avert more serious central nervous system and cardiovascular adverse effects, including seizures, coma, arrythmias, and death. Discontinue Lidocaine HCl Injection, USP and other oxidizing agents. Depending on the severity of the signs and symptoms, patients may respond to supportive care, i.e., oxygen therapy, hydration. A more sever clinical presentation may require treatment with methylene blue, exchange transfusion, or hyperbaric oxygen.
Intra-articular infusions of local anesthetics following arthroscopic and other surgical procedures is an unapproved use, and there have been post-marketing reports of chondrolysis in patients receiving such infusions. The majority of reported cases of chondrolysis have involved the shoulder joint; cases of gleno-humeral chondrolysis have been described in pediatric and adult patients following intra-articular infusions of local anesthetics with and without epinephrine for periods of 48 to 72 hours. There is insufficient information to determine whether shorter infusion periods are not associated with these findings. The time of onset of symptoms, such as joint pain, stiffness and loss of motion can be variable, but may begin as early as the 2nd month after surgery. Currently, there is no effective treatment for chondrolysis; patients who experienced chondrolysis have required additional diagnostic and therapeutic procedures and some required arthroplasty or shoulder replacement.
To avoid intravascular injection, aspiration should be performed before the local anesthetic solution is injected. The needle must be repositioned until no return of blood can be elicited by aspiration. Note, however, that the absence of blood in the syringe does not guarantee that intravascular injection has been avoided.
Local anesthetic solutions containing anti-microbial preservatives (eg, methylparaben) should not be used for epidural or spinal anesthesia because the safety of these agents has not been established with regard to intrathecal injection, either intentional or accidental.
Lidocaine HCl with epinephrine solutions contain sodium metabisulfite, a sulfite that may cause allergic-type reactions including anaphylactic symptoms and life-threatening or less severe asthmatic episodes in certain susceptible people. The overall prevalence of sulfite sensitivity in the general population is unknown and probably low. Sulfite sensitivity is seen more frequently in asthmatic than in non-asthmatic people.
Anaphylactic reactions may occur following administration of lidocaine hydrochloride (see ADVERSE REACTIONS).
In the case of severe reaction, discontinue the use of the drug.
The safety and effectiveness of lidocaine HCl depend on proper dosage, correct technique, adequate precautions, and readiness for emergencies. Standard textbooks should be consulted for specific techniques and precautions for various regional anesthetic procedures.
Resuscitative equipment, oxygen, and other resuscitative drugs should be available for immediate use. (See WARNINGS and ADVERSE REACTIONS). The lowest dosage that results in effective anesthesia should be used to avoid high plasma levels and serious adverse effects. Syringe aspirations should also be performed before and during each supplemental injection when using indwelling catheter techniques. During the administration of epidural anesthesia, it is recommended that a test dose be administered initially and that the patient be monitored for central nervous system toxicity and cardiovascular toxicity, as well as for signs of unintended intrathecal administration, beforeproceeding. When clinical conditions permit, consideration should be given to employing local anesthetic solutions that contain epinephrine for the test dose because circulatory changes compatible with epinephrine may also serve as a warning sign of unintended intravascular injection. An intravascular injection is still possible even if aspirations for blood are negative. Repeated doses of lidocaine HCl may cause significant increases in blood levels with each repeated dose because of slow accumulation of the drug or its metabolites. Tolerance to elevated blood levels varies with the status of the patient. Debilitated, elderly patients, acutely ill patients, and children should be given reduced doses commensurate with their age and physical condition. Lidocaine HCl should also be used with caution in patients with severe shock or heart block.
Lumbar and caudal epidural anesthesia should be used with extreme caution in persons with the following conditions: existing neurological disease, spinal deformities, septicemia, and severe hypertension.
Local anesthetic solutions containing a vasoconstrictor should be used cautiously and in carefully circumscribed quantities in areas of the body supplied by end arteries or having otherwise compromised blood supply. Patients with peripheral vascular disease and those with hypertensive vascular disease may exhibit exaggerated vasoconstrictor response. Ischemic injury or necrosis may result. Preparations containing a vasoconstrictor should be used with caution in patients during or following the administration of potent general anesthetic agents, since cardiac arrhythmias may occur under such conditions.
Careful and constant monitoring of cardiovascular and respiratory (adequacy of ventilation) vital signs and the patient's state of consciousness should be accomplished after each local anesthetic injection. It should be kept in mind at such times that restlessness, anxiety, tinnitus, dizziness, blurred vision, tremors, depression or drowsiness may be early warning signs of central nervous system toxicity.
Since amide-type local anesthetics are metabolized by the liver, Lidocaine Hydrochloride Injection, USP should be used with caution in patients with hepatic disease. Patients with severe hepatic disease, because of their inability to metabolize local anesthetics normally, are at greater risk of developing toxic plasma concentrations. Lidocaine Hydrochloride Injection, USP should also be used with caution in patients with impaired cardiovascular function since they may be less able to compensate for functional changes associated with the prolongation of A-V conduction produced by these drugs.
Many drugs used during the conduct of anesthesia are considered potential triggering agents for familial malignant hyperthermia. Since it is not known whether amide-type local anesthetics may trigger this reaction and since the need for supplemental general anesthesia cannot be predicted in advance, it is suggested that a standard protocol for the management of malignant hyperthermia should be available. Early unexplained signs of tachycardia, tachypnea, labile blood pressure and metabolic acidosis may precede temperature elevation. Successful outcome is dependent on early diagnosis, prompt discontinuance of the suspect triggering agent(s) and institution of treatment, including oxygen therapy, indicated supportive measures and dantrolene (consult dantrolene sodium intravenous package insert before using).
Proper tourniquet technique, as described in publications and standard textbooks, is essential in the performance of intravenous regional anesthesia. Solutions containing epinephrine or other vasoconstrictors should not be used for this technique.
Lidocaine HCl should be used with caution in persons with known drug sensitivities. Patients allergic to para-aminobenzoic acid derivatives (procaine, tetracaine, benzocaine, etc.) have not shown cross- sensitivity to lidocaine HCl.
Use in the Head and Neck Area
Small doses of local anesthetics injected into the head and neck area, including retrobulbar, dental and stellate ganglion blocks, may produce adverse reactions similar to systemic toxicity seen with unintentional intravascular injections of larger doses. Confusion, convulsions, respiratory depression and/or respiratory arrest, and cardiovascular stimulation or depression have been reported. These reactions may be due to intra-arterial injection of the local anesthetic with retrograde flow to the cerebral circulation. Patients receiving these blocks should have their circulation and respirationmonitored and be constantly observed. Resuscitative equipment and personnel for treating adverse reactions should be immediately available. Dosage recommendations should not be exceeded (see DOSAGE AND ADMINISTRATION).
Information for Patients
When appropriate, patients should be informed in advance that they may experience temporary loss of sensation and motor activity, usually in the lower half of the body, following proper administration of epidural anesthesia.
Clinical Significant Drug Interactions
The administration of local anesthetic solutions containing epinephrine or norepinephrine to patients receiving monoamine oxidase inhibitors or tricyclic antidepressants may produce severe, prolonged hypertension.
Phenothiazines and butyrophenones may reduce or reverse the pressor effect of epinephrine.
Concurrent use of these agents should generally be avoided. In situations when concurrent therapy is necessary, careful patient monitoring is essential.
Concurrent administration of vasopressor drugs (for the treatment of hypotension related to obstetric blocks) and ergot-type oxytocic drugs may cause severe, persistent hypertension or cerebrovascular accidents.
Drug/Laboratory Test Interactions
The intramuscular injection of lidocaine HCl may result in an increase in creatine phosphokinase levels. Thus, the use of this enzyme determination, without isoenzyme separation, as a diagnostic test for the presence of acute myocardial infarction may be compromised by the intramuscular injection of lidocaine HCl.
Patients who are administered local anesthetics are at increased risk of developing methemoglobinemia when concurrently exposed to the following drugs, which could include other local anesthetics:
Examples of Drugs Associated with Methemoglobinemia:
|Nitric oxide, nitroglycerin, nitroprusside, nitrous oxide
|Local anesthetics
|Articane, benzocaine, bupivacaine, lidocaine, mepivacaine, prilocaine, procaine, ropivacaine, tetracaine
|Antineoplastic agents
|Cyclophosphamide, flutamide, hydroxyurea, ifosfamide, rasburicase
|Dapsone, nitrofurantoin, para-aminosalicylic acid, sulfonamides
|Choloroquine, primaquine
|Phenobarbital, phenytoin, sodium valproate
|Other drugs
|Acetaminophen, metoclopramide, quinine, sulfasalazine
Carcinogenesis, Mutagenesis, Impairment of Fertility
Studies of lidocaine HCl in animals to evaluate the carcinogenic and mutagenic potential or the effect on fertility have not been conducted.
Teratogenic Effects: Pregnancy Category B.
Reproduction studies have been performed in rats at doses up to 6.6 times the human dose and have revealed no evidence of harm to the fetus caused by lidocaine HCl. There are, however, no adequate and well-controlled studies in pregnant women. Animal reproduction studies are not always predictive of human response. General consideration should be given to this fact before administering lidocaine HCl to women of childbearing potential, especially during early pregnancy when maximum organogenesis takes place.
Labor and Delivery
Local anesthetics rapidly cross the placenta and when used for epidural, paracervical, pudendal or caudal block anesthesia, can cause varying degrees of maternal, fetal and neonatal toxicity. (see CLINICAL PHARMACOLOGY, Pharmacokinetics and Metabolism). The potential for toxicity depends upon the procedure performed, the type and amount of drug used, and the technique of drug administration. Adverse reactions in the parturient, fetus and neonate involve alterations of the central nervous system, peripheral vascular tone and cardiac function.
Maternal hypotension has resulted from regional anesthesia. Local anesthetics produce vasodilation by blocking sympathetic nerves. Elevating the patient's legs and positioning her on her left side will help prevent decreases in blood pressure.
The fetal heart rate also should be monitored continuously, and electronic fetal monitoring is highly advisable.
Epidural, spinal, paracervical, or pudendal anesthesia may alter the forces of parturition through changes in uterine contractility or maternal expulsive efforts. In one study, paracervical block anesthesia was associated with a decrease in the mean duration of first stage labor and facilitation of cervical dilation. However, spinal and epidural anesthesia have also been reported to prolong the second stage of labor by removing the parturient's reflex urge to bear down or by interfering with motor function. The use of obstetrical anesthesia may increase the need for forceps assistance.
The use of some local anesthetic drug products during labor and delivery may be followed by diminished muscle strength and tone for the first day or two of life. The long-term significance of these observations is unknown. Fetal bradycardia may occur in 20 to 30 percent of patients receiving paracervical nerve block anesthesia with the amide-type local anesthetics and may be associated with fetal acidosis. Fetal heart rate should always be monitored during paracervical anesthesia. The physician should weigh the possible advantages against risks when considering a paracervical block in prematurity, toxemia of pregnancy, and fetal distress. Careful adherence to recommended dosage is of the utmost importance in obstetrical paracervical block. Failure to achieve adequate analgesia with recommended doses should arouse suspicion of intravascular or fetal intracranial injection. Cases compatible with unintended fetal intracranial injection of local anesthetic solution have been reported following intended paracervical or pudendal block or both. Babies so affected present with unexplained neonatal depression at birth, which correlates with high local anesthetic serum levels, and often manifest seizures within six hours. Prompt use of supportive measures combined with forced urinary excretion of the local anesthetic has been used successfully to manage this complication.
Case reports of maternal convulsions and cardiovascular collapse following use of some local anesthetics for paracervical block in early pregnancy (as anesthesia for elective abortion) suggest that systemic absorption under these circumstances may be rapid. The recommended maximum dose of each drug should not be exceeded. Injection should be made slowly and with frequent aspiration. Allow a 5- minute interval between sides.
Nursing Mothers
It is not known whether this drug is excreted in human milk. Because many drugs are excreted in human milk, caution should be exercised when lidocaine HCl is administered to a nursing woman.
Pediatric Use
Dosages in children should be reduced, commensurate with age, body weight and physical condition (see DOSAGE AND ADMINISTRATION).
Adverse experiences following the administration of lidocaine HCl are similar in nature to those observed with other amide local anesthetic agents. These adverse experiences are, in general, dose- related and may result from high plasma levels caused by excessive dosage, rapid absorption or inadvertent intravascular injection, or may result from a hypersensitivity, idiosyncrasy or diminished tolerance on the part of the patient. Serious adverse experiences are generally systemic in nature. The following types are those most commonly reported:
Central Nervous System
CNS manifestations are excitatory and/or depressant and may be characterized by lightheadedness, nervousness, apprehension, euphoria, confusion, dizziness, drowsiness, tinnitus, blurred or double vision, vomiting, sensations of heat, cold or numbness, twitching, tremors, convulsions, unconsciousness, respiratory depression and arrest. The excitatory manifestations may be very brief or may not occur at all, in which case the first manifestation of toxicity may be drowsiness merging into unconsciousness and respiratory arrest.
Drowsiness following the administration of lidocaine HCl is usually an early sign of a high blood level of the drug and may occur as a consequence of rapid absorption.
Cardiovascular System
Cardiovascular manifestations are usually depressant and are characterized by bradycardia, hypotension, and cardiovascular collapse, which may lead to cardiac arrest.
Allergic reactions are characterized by cutaneous lesions, urticaria, edema or anaphylactoid reactions. Allergic reactions may occur as a result of sensitivity either to local anesthetic agents or to the methylparaben used as a preservative in the multiple dose vials. Allergic reactions, including anaphylactic reactions, may occur as result of sensitivity to lidocaine, but are infrequent. If allergic reactions do occur, they should be managed by conventional means. The detection of sensitivity by skin testing is of doubtful value.
There have been no reports of cross sensitivity between lidocaine hydrochloride and procainamide or between lidocaine hydrochloride and quinidine.
The incidences of adverse reactions associated with the use of local anesthetics may be related to the total dose of local anesthetic administered and are also dependent upon the particular drug used, the route of administration and the physical status of the patient. In a prospective review of 10,440 patients who received lidocaine HCl for spinal anesthesia, the incidences of adverse reactions were reported to be about 3 percent each for positional headaches, hypotension and backache; 2 percent for shivering; and less than 1 percent each for peripheral nerve symptoms, nausea, respiratory inadequacy and double vision. Many of these observations may be related to local anesthetic techniques, with or without a contribution from the local anesthetic.
In the practice of caudal or lumbar epidural block, occasional unintentional penetration of the subarachnoid space by the catheter may occur. Subsequent adverse effects may depend partially on the amount of drug administered subdurally. These may include spinal block of varying magnitude (including total spinal block), hypotension secondary to spinal block, loss of bladder and bowel control, and loss of perineal sensation and sexual function. Persistent motor, sensory and/or autonomic (sphincter control) deficit of some lower spinal segments with slow recovery (several months) or incomplete recovery have been reported in rare instances when caudal or lumbar epidural block has been attempted. Backache and headache have also been noted following use of these anesthetic procedures.
There have been reported cases of permanent injury to extraocular muscles requiring surgical repair following retrobulbar administration.
Acute emergencies from local anesthetics are generally related to high plasma levels encountered during therapeutic use of local anesthetics or to unintended subarachnoid injection of local anesthetic solution (see ADVERSE REACTIONS, WARNINGS, and PRECAUTIONS).
Management of Local Anesthetic Emergencies
The first consideration is prevention, best accomplished by careful and constant monitoring of cardiovascular and respiratory vital signs and the patient's state of consciousness after each local anesthetic injection. At the first sign of change, oxygen should be administered.
The first step in the management of convulsions, as well as underventilation or apnea due to unintended subarachnoid injection of drug solution, consists of immediate attention to the maintenance of a patent airway and assisted or controlled ventilation with oxygen and a delivery system capable of permitting immediate positive airway pressure by mask. Immediately after the institution of these ventilatory measures, the adequacy of the circulation should be evaluated, keeping in mind that drugs used to treat convulsions sometimes depress the circulation when administered intravenously. Should convulsions persist despite adequate respiratory support, and if the status of the circulation permits, small increments of an ultra-short acting barbiturate (such as thiopental or thiamylal) or a benzodiazepine (such as diazepam) may be administered intravenously. The clinician should be familiar, prior to the use of local anesthetics, with these anticonvulsant drugs. Supportive treatment of circulatory depression may require administration of intravenous fluids and, when appropriate, a vasopressor as directed by the clinical situation (e.g., ephedrine).
If not treated immediately, both convulsions and cardiovascular depression can result in hypoxia, acidosis, bradycardia, arrhythmias and cardiac arrest. Underventilation or apnea due to unintentional subarachnoid injection of local anesthetic solution may produce these same signs and also lead to cardiac arrest if ventilatory support is not instituted. If cardiac arrest should occur, standard cardiopulmonary resuscitative measures should be instituted.
Endotracheal intubation, employing drugs and techniques familiar to the clinician, may be indicated, after initial administration of oxygen by mask, if difficulty is encountered in the maintenance of a patent airway or if prolonged ventilatory support (assisted or controlled) is indicated.
Dialysis is of negligible value in the treatment of acute overdosage with lidocaine HCl. The oral LD50 of lidocaine HCl in non-fasted female rats is 459 (346 to 773) mg/kg (as the salt) and 214 (159 to 324) mg/kg (as the salt) in fasted female rats.
Table 1 (Recommended Dosages) summarizes the recommended volumes and concentrations of Lidocaine Hydrochloride Injection, USP for various types of anesthetic procedures. The dosages suggested in this table are for normal healthy adults and refer to the use of epinephrine-fee solutions. When larger volumes are required, only solutions containing epinephrine should be used except in those cases where vasopressor drugs may be contraindicated.
There have been adverse event reports of chondrolysis in patients receiving intra-articular infusions of local anesthetics following arthroscopic and other surgical procedures. Lidocaine Hydrochloride Injection, USP is not approved for this use (see WARNINGS and DOSAGE AND ADMINISTRATION).
These recommended doses serve only as a guide to the amount of anesthetic required for most routine procedures. The actual volumes and concentrations to be used depend on a number of factors such as type and extent of surgical procedure, depth of anesthesia and degree of muscular relaxation required, duration of anesthesia required, and the physical condition of the patient. In all cases the lowest concentration and smallest dose that will produce the desired result should be given. Dosages should be reduced for children and for the elderly and debilitated patients and patients with cardiac and/or liver disease.
The onset of anesthesia, the duration of anesthesia and the degree of muscular relaxation are proportional to the volume and concentration (i.e., total dose) of local anesthetic used. Thus, an increase in volume and concentration of Lidocaine Hydrochloride Injection, USP will decrease the onset of anesthesia, prolong the duration of anesthesia, provide a greater degree of muscular relaxation and increase the segmental spread of anesthesia. However, increasing the volume and concentration of Lidocaine Hydrochloride Injection, USP may result in a more profound fall in blood pressure when used in epidural anesthesia. Although the incidence of side effects with lidocaine HCl is quite low, caution should be exercised when employing large volumes and concentrations, since the incidence of side effects is directly proportional to the total dose of local anesthetic agent injected.
For intravenous regional anesthesia, only the 50mL single dose vial containing Lidocaine HCl 0.5% Injection should be used.
Epidural Anesthesia
For epidural anesthesia, only the following dosage forms of Lidocaine HCl Injection, USP are recommended:
|1% without epinephrine
|30mL single dose solutions
|1% with epinephrine 1:200,000
|30mL single dose solutions
|1.5% without epinephrine
|10mL Plastic Ampule
|1.5% without epinephrine
|20mL Plastic Ampule
|1.5% with epinephrine 1:200,000
|30mL ampules, 30mL single dose solutions
|2% without epinephrine
|10mL Plastic Ampule
|2% with epinephrine 1:200,000
|20mL ampules, 20mL single dose solutions
Although these solutions are intended specifically for epidural anesthesia, they may also be used for infiltration and peripheral nerve block, provided they are employed as single dose units. These solutions contain no bacteriostatic agent.
In epidural anesthesia, the dosage varies with the number of dermatomes to be anesthetized (generally 2 to 3mL of the indicated concentration per dermatome).
Caudal and Lumbar Epidural Block
As a precaution against the adverse experience sometimes observed following unintentional penetration of the subarachnoid space, a test dose such as 3 to 4.5 mL of 1.0% lidocaine HCl should be administered at least 5 minutes prior to injecting the total volume required for a lumbar or caudal epidural block. The test dose should be repeated if the patient is moved in a manner that may have displaced the catheter. Epinephrine, if contained in the test dose (10 to 15 mcg have been suggested), may serve as a warning of unintentional intravascular injection. If injected into a blood vessel, this amount of epinephrine is likely to produce a transient "epinephrine response" within 45 seconds, consisting of an increase in heart rate and systolic blood pressure, circumoral pallor, palpitations and nervousness in the unsedated patient. The sedated patient may exhibit only a pulse rate increase of 20 or more beats per minute for 15 or more seconds. Patients on beta blockers may not manifest changes in heart rate, but blood pressure monitoring can detect an evanescent rise in systolic blood pressure. Adequate time should be allowed for onset of anesthesia after administration of each test dose. The rapid injection of a large volume of Lidocaine Hydrochloride Injection, USP through the catheter should be avoided, and, when feasible, fractional doses should be administered.
In the event of the known injection of a large volume of local anesthetic solution into the subarachnoid space, after suitable resuscitation and if the catheter is in place, consider attempting the recovery of drug by draining a moderate amount of cerebrospinal fluid (such as 10 mL) through the epidural catheter.
For normal healthy adults, the individual maximum recommended dose of lidocaine HCl with epinephrine should not exceed 7 mg/kg (3.5 mg/lb) of body weight, and in general it is recommended that the maximum total dose not exceed 500 mg. When used without epinephrine the maximum individual dose should not exceed 4.5 mg/kg (2 mg/lb) of body weight, and in general it is recommended that the maximum total dose does not exceed 300 mg. For continuous caudal anesthesia, the maximum recommended dosage should not be administered at intervals of less than 90 minutes. Whencontinuous lumbar or caudal epidural anesthesia is used for non-obstetrical procedures, more drug may be administered if required to produce adequate anesthesia.
The maximum recommended dose per 90 minute period of lidocaine hydrochloride for paracervical block in obstetrical patients and non-obstetrical patients is 200 mg total. One half of the total dose is usually administered to each side. Inject slowly, five minutes between sides (see also discussion of paracervical block in PRECAUTIONS).
For intravenous regional anesthesia, the dose administered should not exceed 4 mg/kg in adults.
It is difficult to recommend a maximum dose of any drug for children, since this varies as a function of age and weight. For children over 3 years of age who have a normal lean body mass and normal body development, the maximum dose is determined by the child's age and weight. For example, in a child of 5 years weighing 50 lbs the dose of lidocaine HCl should not exceed 75 to 100 mg (1.5 to 2 mg/lb). The use of even more dilute solutions (i.e., 0.25 to 0.5%) and total dosages not to exceed 3 mg/kg (1.4 mg/lb) are recommended for induction of intravenous regional anesthesia in children.
In order to guard against systemic toxicity, the lowest effective concentration and lowest effective dose should be used at all times. In some cases it will be necessary to dilute available concentrations with 0.9% sodium chloride injection in order to obtain the required final concentration.
NOTE: Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration whenever the solution and container permit. The Injection is not to be used if its color is pinkish or darker than slightly yellow or if it contains a precipitate.
Table 1: Recommended Dosages for Lidocaine hydrochloride Injection (without epinephrine)
|0.5 or 1
|1 to 60
|5 to 300
|Intravenous regional
|10 to 60
|50 to 300
|Peripheral Nerve Blocks, eg,
|15 to 20
|225 to 300
|1 to 5
|20 to 100
|3 to 5
|30 to 50
|Pudendal (each side)
|Obstetrical analgesia
|(each side)
|Sympathetic Nerve Blocks, eg,
|Cervical (stellate ganglion)
|5 to 10
|50 to 100
|Central Neural Blocks
|20 to 30
|200 to 300
|25 to 30
|250 to 300
|15 to 20
|225 to 300
|10 to 15
|200 to 300
|Obstetrical analgesia
|20 to 30
|200 to 300
|Surgical anesthesia
|15 to 20
|225 to 300
*Dose determined by number of dermatomes to be anesthetized (2-3 mL/dermatome).
Disinfecting agents containing heavy metals, which cause release of respective ions (mercury, zinc, copper, etc.) should not be used for skin or mucous membrane disinfection as they have been related to incidents of swelling and edema. When chemical disinfection of multi-dose vials is desired, either isopropyl alcohol (91%) or ethyl alcohol (70%) is recommended. Many commercially available brands of rubbing alcohol, as well as solutions of ethyl alcohol not of USP grade, contain denaturants which are injurious to rubber and therefore are not to be used.
Lidocaine Hydrochloride Injection, USP is supplied as follows:
|Single Dose Ampule (box of 25)
|1% (10 mg/mL)
|5 mL
All solutions should be stored at 20° to 25°C (68° to 77°F) [see USP Controlled Room Temperature].
Protect from light.
Manufactured for:
Spectra Medical Devices, Inc.
Wilmington, MA 01887
Toll-Free (866) 938 – 8649
Manufactured by:
Huons Co., Ltd.,
Seoul, S. Korea
Product Code: 1605-1
Revised: 03/2019
SMD-Label AW-0075, rev. 002
Released: 03/2019


text: Judith Michelmann Dr. phil. Judith Michelmann Research Assistant at the Faculty of German Language and Literature SHSS-HSG Mueller- Friedbergstr. 6-8 9000 St.Gallen Office 52-7246 Phone: 071 224 25 55 firstname.lastname@example.com Curriculum Vitae • 1996-2003 Study of German Literature, Politics and Art and Media Science at the University of Constance • Summer 2003 to Spring 2004 Visiting researcher at the Free German Bishopric/Frankfurt am Main as part of an editorial project of Prof. Dr. Landfester (Hofmannsthal Editorial) and for the preparation of a Ph.D. project (Brentano Editorial) • Since Summer 2004 Assistant at the Faculty of German Language and Literature (Prof. Dr. Ulrike Landfester) at the University of St.Gallen • Ph.D. studies at the University of Constance with a doctoral thesis on the late version of Clemens Brentano's "Gockel Hinkel Gackeleia" (completed 2010) • Teaching at the Universities of St.Gallen, Zurich and Constance • Various language courses in Spain, 2001 financed by the Spanish Embassy, 2002 internship with the FAZ (foreign correspondence in Spain, politics department in Madrid) Main areas of research • Clemens Brentano, Romanticism • Satirical and arabesque writing • Early modern Spanish literature and its influence on German Baroque literature • Media history, cultural history and mentality