Management of local anesthetic toxicity and importance of lipid infusion
Keywords:Local anesthetic, Toxicity, Lipid infusion
Local anesthetics (LA) are one of the groups that block the transmission of sensory, motor and autonomic nerve impulses commonly used in clinical anesthesia. All local anesthetic molecules in clinical use consist of three parts: a lipophilic (aromatic) end, a hydrophilic (amine) end, and a chain that provides the connection between the ends. Physicochemical properties determine the clinical efficacy of local anaesthetics The part that determines the lipid solubility of local anesthetics is the aromatic ring. A higher dose of local anesthetics is required for cardiovascular system (CVS) toxicity. Hypertension, tachycardia and ventricular arrhythmia are the first of the diseases of CVS. Hypotension, arrhythmia, bradycardia and cardiac arrest develop as local anesthetics increase in blood. The symptoms of central nervous system (CNS) toxicity associated with LA are related to the plasma levels of drugs. Initially, there are drowsiness, dizziness, sedation, disorientation, tinnitus, nystagmus, metallic taste, nausea and vomiting. Then, restlessness, irritability, tremors and muscle twitches occur. After this, the tonic-clonic seizure and loss of consciousness develops, finally, apnea, cardiovascular collapse and coma. In the treatment of local anesthetic toxicity, it is recommended to provide airway, avoid the propofol if seizure occurs and treat with benzodiazepine. If cardiac arrest develops, it is recommended to switch to advanced life support, to reduce the given dose of adrenaline, to administer lipid emulsion (20%) and to respond to treatment if cardiopulmonary bypass is not provided.
Gitman M, Barrington MJ. Local Anesthetic Systemic Toxicity: A Review of Recent Case Reports and Registries. Regional anesthesia and pain medicine. 2018;43(2):124-30.
Ciechanowicz S, Patil V. Lipid Emulsion for Local Anesthetic Systemic Toxicity. Anesthesiology Research and Practice. 2012;2012:11.
Whalen K, Finkel R, Panavelil TA. Lippincott's illustrated reviews : pharmacology. Philadelphia, Pa.: Wolters Kluwer; 2015.
Barash PG. Local Anesthetics. Clinical Anesthesia. 7: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2013. p. 209-25.
Becker DE, Reed KL. Local Anesthetics: Review of Pharmacological Considerations. Anesthesia Progress. 2012;59(2):90-102.
Strichartz GR, Berde CB. Local anesthetics. In: Miller RD, ed. Anesthesia. 7th ed. Philadelphia: Elsevier 2010:913-39
Becker DE, Reed KL. Local Anesthetics: Review of Pharmacological Considerations. Anesthesia Progress. 2012;59(2):90-102. doi: 10.2344/0003-3006-59.2.90
Borgeat A, Aguirre J. Update on local anesthetics. Current Opinion in Anesthesiology. 2010;23(4):466-71.
Lambert DH. Clinical value of adding sodium bicarbonate to local anesthetics. Regional anesthesia and pain medicine. 2002;27(3):328-9.
Sinnott BACatherine J, Cogswell PDLawrence P, Johnson BSA, Strichartz PDGary R. On the Mechanism by Which Epinephrine Potentiates Lidocaine's Peripheral Nerve Block. Anesthesiology. 2003;98(1):181-8.
Rosenberg PH, Veering BT, Urmey WF. Maximum recommended doses of local anesthetics: A multifactorial concept. Regional anesthesia and pain medicine. 2004;29(6):564-75.
Dillane D, Finucane BT. Local anesthetic systemic toxicity. Canadian Journal of Anesthesia/Journal canadien d'anesthésie. 2010;57(4):368-80.
Heavner JE. Local anesthetics. Curr Opin Anaesthesiol. 2007;20(4):336-42.
Jorfeldt L, Lewis DH, Lofstrom JB, Post C. Lung uptake of lidocaine in healthy volunteers. Acta Anaesthesiol Scand. 1979;23(6):567-74.
McLure HA, Rubin AP. Review of local anaesthetic agents. Minerva Anestesiol. 2005;71(3):59-74.
Kietzmann D FH, Geng WP, Rathgeber J, Gundert-, Remy U KDTdo, prilocaine m, and bupivacaine in humans in, Anaesthesiol tcoeaA, 1995;39:885-90. S.
Biehl D, Shnider SM, Levinson G, Callender K. Placental transfer of lidocaine: effects of fetal acidosis. Anesthesiology. 1978;48(6):409-12.
Eggleston ST, Lush LW. Understanding Allergic Reactions to Local Anesthetics. Annals of Pharmacotherapy. 1996;30(7-8):851-7.
Asher Y. Hadzic’s Peripheral Nerve Blocks and Anatomy for Ultrasound-guided Regional Anesthesia, Second Edition. Anesthesiology. 2013;119(2):493-.
Guay J. Methemoglobinemia Related to Local Anesthetics: A Summary of 242 Episodes. Anesthesia & Analgesia. 2009;108(3):837-45.
Gristwood RW, Greaves JL. Levobupivacaine: a new safer long acting local anaesthetic agent. Expert opinion on investigational drugs. 1999;8(6):861-76.
Bear MF, Connors BW, Paradiso MA. Neuroscience: Lippincott Williams & Wilkins; 2007.
Garfield J, Gugino L. Central effects of local anesthetic agents. Local anesthetics: Springer; 1987. p. 253-84.
Mulroy MF, Norris MC, Liu SS. Safety steps for epidural injection of local anesthetics: review of the literature and recommendations. Anesth Analg. 1997;85(6):1346-56.
Neal JM, Woodward CM, Harrison TK. The American Society of Regional Anesthesia and Pain Medicine checklist for managing local anesthetic systemic toxicity: 2017 version. Regional anesthesia and pain medicine. 2018;43(2):150-3.
Norris MC, Ferrenbach D, Dalman H, Fogel ST, Borrenpohl S, Hoppe W, et al. Does epinephrine improve the diagnostic accuracy of aspiration during labor epidural analgesia? Anesthesia & Analgesia. 1999;88(5):1073-6.
Pan P, Bogard T, Owen M. Incidence and characteristics of failures in obstetric neuraxial analgesia and anesthesia: a retrospective analysis of 19,259 deliveries. International journal of obstetric anesthesia. 2004;13(4):227-33.
Guay J. The epidural test dose: a review. Anesthesia & Analgesia. 2006;102(3):921-9.
Moore DC, Batra MS. The components of an effective test dose prior to epidural block. Anesthesiology: The Journal of the American Society of Anesthesiologists. 1981;55(6):693-6.
Orebaugh SL, Kentor ML, Williams BA. Adverse outcomes associated with nerve stimulator-guided and ultrasound-guided peripheral nerve blocks by supervised trainees: update of a single-site database. Regional anesthesia and pain medicine. 2012;37(6):577-82.
Barrington MJ, Kluger R. Ultrasound guidance reduces the risk of local anesthetic systemic toxicity following peripheral nerve blockade. Regional anesthesia and pain medicine. 2013;38(4):289-99.
Weinberg MDGuy L, VadeBoncouer MDT, Ramaraju MDGopal A, Garcia-Amaro MDMarcelo F, Cwik PMichael J. Pretreatment or Resuscitation with a Lipid Infusion Shifts the Dose-Response to Bupivacaine-induced Asystole in Rats Anesthesiology. 1998;88(4):1071-5.
Corman SL, Skledar SJ. Drug Information Rounds: Use of Lipid Emulsion to Reverse Local Anesthetic–Induced Toxicity. Annals of Pharmacotherapy. 2007;41(11):1873-7.
Weinberg G, Ripper R, Feinstein DL, Hoffman W. Lipid emulsion infusion rescues dogs from bupivacaine-induced cardiac toxicity. Regional anesthesia and pain medicine. 2003;28(3):198-202.
Rosenblatt MA, Abel M, Fischer GW, Itzkovich CJ, Eisenkraft JB. Successful use of a 20% lipid emulsion to resuscitate a patient after a presumed bupivacaine-related cardiac arrest. Anesthesiology: The Journal of the American Society of Anesthesiologists. 2006;105(1):217-8.
Foxall G, McCahon R, Lamb J, Hardman J, Bedforth N. Levobupivacaine‐induced seizures and cardiovascular collapse treated with Intralipid®. Anaesthesia. 2007;62(5):516-8.
Ludot H, Tharin J-Y, Belouadah M, Mazoit J-X, Malinovsky J-M. Successful resuscitation after ropivacaine and lidocaine-induced ventricular arrhythmia following posterior lumbar plexus block in a child. Anesthesia & Analgesia. 2008;106(5):1572-4.
Warren JA, Thoma RB, Georgescu A, Shah SJ. Intravenous lipid infusion in the successful resuscitation of local anesthetic-induced cardiovascular collapse after supraclavicular brachial plexus block. Anesthesia & Analgesia. 2008;106(5):1578-80.
Guideline AS. Management of Severe Local Anesthetic Toxicity. London: The Association of Anaesthetists of Great Britain & Ireland. 2010.
Gabrielli A, O’Connor MF, Maccioli GA. Anesthesia advanced circulatory life support. Committee on Critical Care Medicine. 2008.
Vanden Hoek TL, Morrison LJ, Shuster M, Donnino M, Sinz E, Lavonas EJ, et al. Part 12: cardiac arrest in special situations: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122(18 Suppl 3):S829-61.
Zausig YA, Graf BM, Zink W. Is it “lipid sink,” hemodilution, or both? Critical care medicine. 2009;37(10):2863.
Weinberg GL, Ripper R, Murphy P, Edelman LB, Hoffman W, Strichartz G, et al. Lipid infusion accelerates removal of bupivacaine and recovery from bupivacaine toxicity in the isolated rat heart. Regional anesthesia and pain medicine. 2006;31(4):296-303.
Weinberg GL. Current concepts in resuscitation of patients with local anesthetic cardiac toxicity. Regional anesthesia and pain medicine. 2002;27(6):568-75.
Brull SJ. Lipid emulsion for the treatment of local anesthetic toxicity: patient safety implications. LWW; 2008.
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