What is the safe dose of lidocaine (lido) with epinephrine (epi) per pound?

Safe Dose of Lidocaine with Epinephrine per Pound

For adults, the maximum safe dose of lidocaine with epinephrine is 7.0 mg/kg, which equals approximately 3.2 mg per pound. 1

Dosage Guidelines

Adult Dosing

• Maximum safe dose: 7.0 mg/kg (3.2 mg/lb) with epinephrine
• Without epinephrine: 4.5 mg/kg (2.0 mg/lb)

Pediatric Dosing

• Maximum safe dose: 3.0-4.5 mg/kg (1.4-2.0 mg/lb) with epinephrine
• Without epinephrine: 1.5-2.0 mg/kg (0.7-0.9 mg/lb)

Practical Considerations

Concentration and Volume

• Common epinephrine concentrations used in dermatologic procedures:
  • 1:100,000 (10 μg/mL)
  • 1:200,000 (5 μg/mL)
• Both concentrations provide similar vasoconstriction effects 1
• Lower concentrations (1:200,000) are equally effective while potentially reducing systemic effects 2

Procedure-Specific Recommendations

• For multistage procedures (e.g., Mohs surgery): Maximum 500 mg lidocaine delivered incrementally 1
• Using 0.5% lidocaine with 1:200,000 epinephrine instead of 1.0% with 1:100,000 can reduce total lidocaine dose by approximately 50% while maintaining equivalent pain control 2

Safety Precautions

Steps to Decrease Risk of Toxicity

1. Use the lowest effective dose
2. Aspirate before each injection to avoid intravascular administration
3. Use incremental injections
4. Monitor patient for early signs of toxicity:
   • Circumoral numbness
   • Facial tingling
   • Light-headedness
   • Tinnitus

Special Populations

• Pregnancy: While small amounts appear safe, postpone non-emergent procedures requiring local anesthesia until after delivery 1
• Cardiac patients: Small amounts of local infiltrative anesthesia with epinephrine appear safe in patients with stable cardiac disease, though consultation with the patient's cardiologist may be warranted for larger volumes 1
• Children: Require lower doses as noted above 1

Evidence Quality

The recommended maximum doses are based on clinical experience and expert consensus rather than randomized controlled trials 3. More recent research suggests that higher doses may be safe in certain contexts:

• Tumescent anesthesia studies suggest doses up to 28 mg/kg without liposuction and 45 mg/kg with liposuction may be safe due to delayed absorption 4
• Facelift procedures using diluted lidocaine (0.33%) with epinephrine have safely used doses up to 21.6 mg/kg 5

However, these higher doses are for specific techniques with diluted solutions and should not be applied to standard infiltration anesthesia. The guidelines from the American Academy of Dermatology (7.0 mg/kg with epinephrine) remain the standard recommendation for most dermatologic procedures 1.