An assessment of the awareness of local anesthetic systemic toxicity among multi-specialty postgraduate residents

Abstract

Local anesthetics (LAs) are extensively used in clinical practice by both anesthesiologists and non-anesthesiologists and are often associated with systemic toxicity. We hypothesize that this awareness is inadequate among medical specialists and entails a risk of misdiagnosis and underreporting of such events. We therefore conducted a cross-sectional questionnaire-based study to assess the level of understanding of LA use and effective management of systemic toxicity among 200 postgraduate residents of various specialties (with the exception of anesthesiology) in a tertiary care hospital in India from October to December 2013. Among those residents who had used LAs (193/200), 27 and 25 % of responders correctly identified the toxic doses of lidocaine and of lidocaine + adrenaline, respectively. Of the responders, 70 % always performed a negative aspiration of blood before injecting the drug, 27 % sometimes aspirated and the remaining 3 % never aspirated. The majority of the responders (93 %) were unaware of the toxic dose of bupivacaine. Only 70 % of responders believed that LAs could be toxic [95 % confidence interval (CI) 65.5-74.5 %], and 81 % of these correctly identified the signs and symptoms of cardiotoxicity. Only 2 % of responders knew that lipid emulsion is a part of its treatment (95 % CI 0.6-3.4 %). Based on these results, there is a definite need to increase the awareness of detection and treatment of local anesthetic toxicity among all medical practitioners who regularly use LAs.

A Review of Local Anesthetic Systemic Toxicity Cases Since Publication of the American Society of Regional Anesthesia Recommendations

“…Dedicated ASRA guidelines are available 3 but may remain unknown to many nonanesthesiologists. 71 Last, ILE and a plan for LAST management should be promptly available in any facility where LAs are used.…”

Development and Preliminary Validation of LoAD Calc, a Mobile App for Calculating the Maximum Safe Single Dose of Local Anesthetics

“…Moreover, the increasing trend of locoregional and multimodal analgesia favors LA administration over long periods or by multiple routes in the perioperative phase and could also increase the risk of toxicity. In addition, LAs are used by many different specialists and, although their use and associated risks are well known by anesthesiologists, other physicians might be less aware of these specificities and thus jeopardize patient safety by misusing these drugs [ 37 , 38 ].…”

Guideline Implementation: Local Anesthesia

“…Monitoring patient responses includes both physical monitoring (eg, level of consciousness, vital signs, pulse oxygenation) and psychological monitoring (eg, comfort, anxiety level) 5,6,12‐14 . By monitoring the patient's status, the RN may detect early complications and can intervene immediately with appropriate interventions 12,15 …”

“…Although it is rare, LAST is an adverse outcome that could affect the patient 3,4,6,7,15,17,21 . Local anesthetic systemic toxicity occurs when the serum level of the local anesthetic increases to an unsafe level 2,5,9,11,18‐20 .…”

“…In addition to recognizing LAST, the RN should be prepared to rescue and treat the patient immediately if the patient experiences LAST 8,15,20,22,23 . Not only is it important that the signs and symptoms of LAST be recognized early, but perioperative personnel should have rescue equipment immediately available so the team can rapidly start treating the patient 4,6,20,22,23 .…”