Discontinuation of Topical Lidocaine Cream Prior to Surgery
Topical lidocaine cream (patches or medicated plasters) should be removed immediately before starting an intravenous lidocaine infusion if one is planned during surgery; otherwise, there is no specific requirement to discontinue topical lidocaine cream prior to surgery as it poses minimal systemic absorption risk.
Key Recommendations Based on Formulation and Surgical Context
If Intravenous Lidocaine Will Be Used Intraoperatively
Topical 5% lidocaine medicated plasters must be removed before starting an intravenous lidocaine infusion to prevent cumulative local anesthetic toxicity 1.
This recommendation stems from the need to avoid concurrent administration of multiple local anesthetic formulations that could lead to toxic plasma concentrations 1.
The concern is additive systemic absorption leading to plasma concentrations exceeding the toxic threshold of 5 μg/mL, which can cause symptoms ranging from tingling tongue/lips and tinnitus to seizures, cardiac arrhythmias, and ventricular arrest 1.
If Regional Anesthesia or Local Infiltration Is Planned
Intravenous lidocaine should not be started within 4 hours of any nerve block, fascial plane block, or infiltration of surgical sites 1.
Conversely, if topical lidocaine has been used and IV lidocaine is planned, the same 4-hour separation principle applies to prevent local anesthetic toxicity 1.
This guideline reflects the period of action needed to ensure one local anesthetic intervention has been metabolized before introducing another 1.
For Routine Topical Lidocaine Cream Application (No IV Lidocaine Planned)
There is no specific requirement to discontinue topical lidocaine cream prior to surgery when IV lidocaine or other local anesthetic techniques are not planned 2.
Topical lidocaine preparations (2-4% creams) achieve peak anesthetic effect in 30-60 minutes and have a duration of action of approximately 30-60 minutes, though oral mucosa effects may be shorter (< 15 minutes) 3, 4.
The systemic absorption from topical application to intact skin is minimal and does not typically reach toxic plasma levels 2, 5.
Important Clinical Considerations
Timing for Preoperative Application
If topical lidocaine is being used for IV access or other pre-surgical procedures, liposomal 4% lidocaine (LMX4) requires 30 minutes for effectiveness, while EMLA cream requires 60 minutes 2, 4.
Application should be timed appropriately before the anticipated procedure 2.
Contraindications to Consider
Do not use topical lidocaine on large areas of the body, cut/irritated/swollen skin, or puncture wounds 5.
Avoid in patients with known allergy to amide anesthetics 2.
For EMLA specifically, avoid in patients with recent sulfonamide antibiotic use or methemoglobinemia 2.
Documentation Requirements
Total dose of topical lidocaine used should be clearly documented in the patient's record, especially if additional local anesthetic techniques are anticipated intraoperatively 3.
Pre-operative discussion between anesthesiologists and surgeons is recommended when both parties plan to use lidocaine, with maximum dose identified and divided appropriately 3.
Common Pitfalls to Avoid
The primary pitfall is failing to account for cumulative local anesthetic dosing when multiple formulations (topical, infiltrative, IV, regional blocks) are used in the same perioperative period 1, 3. This can lead to local anesthetic systemic toxicity (LAST), which manifests as CNS symptoms (seizures, altered consciousness) progressing to cardiovascular collapse 1.
Another pitfall is assuming all topical lidocaine must be discontinued when in reality, only concurrent use with IV lidocaine or within 4 hours of regional blocks requires specific timing considerations 1.