ASRA Practice Advisory on Local Anesthetic Systemic Toxicity

Neal, Joseph M.; Bernards, Christopher M.; Butterworth, John F.; Gregorio, Guido Di; Drasner, Kenneth; Hejtmanek, Michael R.; Mulroy, Michael F.; Rosenquist, Richard W.; Weinberg, Guy

doi:10.1097/aap.0b013e3181d22fcd

Cited by 568 publications

(382 citation statements)

References 51 publications

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“…Guidelines outlining administration of ILE have been written by a number of authorities over the last decade [6,7]. Accordingly, when administered in LAST or in cardiovascular collapse secondary to a non-local anesthetic drug, the majority of respondents indicated administration of a bolus then subsequent infusion in line with such a guideline (AAGBI, lipidrescue®, ACMT).…”

Section: N=8mentioning

confidence: 99%

“…Additional animal studies, coupled with positive outcomes following ILE use in humans [2][3][4][5], have subsequently led to clinical recommendation for ILE use in local anesthetic overdose [6,7]. The success and safety of lipid resuscitation in this context, combined with a paucity of alternative antidotes, has seen ILE become firmly established as the antidote of choice for local anesthetic systemic toxicity (LAST).…”

Section: Introductionmentioning

confidence: 99%

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LIPAEMIC Report: Results of Clinical Use of Intravenous Lipid Emulsion in Drug Toxicity Reported to an Online Lipid Registry

et al. 2014

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The use of intravenous lipid emulsion (ILE) as an antidote has prompted significant academic and clinical interest. Between August 2009 and August 2012, data from cases of ILE use in intoxicated patients in different hospitals on different continents were voluntarily entered into a registry based on the world wide web (www.lipidregistry.org). Here, we report data from this project. Participating centers were given access to the registry following institutional subscription. Specifically sought were details of the individual patients' presenting condition, indications for ILE use, ILE administration regimen, potential complications, and of clinical outcome. Forty-eight uses of ILE were reported from 61 participating centers. Ten cases of local anesthetic systemic toxicity were reported; all (10/10) survived. Thirtyeight cases of intoxication by other agents were reported [30 decreased conscious state, 8 cardiovascular collapse (3 deaths)]. There was an elevation in GCS (p<0.0001) and increased systolic blood pressure (p=0.012) from immediately prior to ILE administration to 30 min after use. One serious and two minor adverse effects of ILE use were recorded in 48 reported cases (one case of bronchospastic reaction, one case of hyperamylasemia and one case of interference with laboratory testing). In this series of cases reported to the registry, improvements were seen for GCS in patients with central nervous system toxicity and in systolic blood pressure in shocked patients over a short time frame after the injection of ILE. Few adverse effects were recorded. Clinical trials and the reporting of drug concentrations after ILE use are necessary to further elucidate the role of ILE in clinical toxicology.

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Section: N=8mentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

LIPAEMIC Report: Results of Clinical Use of Intravenous Lipid Emulsion in Drug Toxicity Reported to an Online Lipid Registry

et al. 2014

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“…1 Onset of the block is also faster, possibly because of visualization of the target nerve in real time and injection of local anesthetic closer to the nerve structures. 2,3 It is logical to hypothesize that these advantages may reduce complications such as nerve injury and local anesthesia systemic toxicity (LAST).…”

Section: To the Editormentioning

confidence: 99%

Undetected intravascular injection during an ultrasound-guided axillary block

Forero

Lora

Bayegan

2012

Can J Anesth/J Can Anesth

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There is evidence that the use of ultrasound-guided regional anesthesia increases the efficacy of peripheral nerve blocks and improves safety while allowing administration of lower volumes of local anesthetics. 1 Onset of the block is also faster, possibly because of visualization of the target nerve in real time and injection of local anesthetic closer to the nerve structures. 2,3 It is logical to hypothesize that these advantages may reduce complications such as nerve injury and local anesthesia systemic toxicity (LAST). We report a case of LAST while performing an ultrasound-guided axillary block that was initially diagnosed by the presence of symptoms of local anesthetic toxicity. The patient provided consent for the publication of this case report.A 63-yr-old woman, American Society of Anesthesiologists' physical status III, presented for a partial amputation of her right middle finger. An axillary block was recommended to her as an appropriate procedure. In the block room, standard monitoring was established, oxygen was applied by nasal prongs at 3 LÁmin -1 , and sedation was given with midazolam 1 mg iv. A 12 MHz linear ultrasound transducer (GE LOGIQ e, Wauwatosa, WI, USA) was placed at the deltopectoral groove. Next, the cross section of the axillary artery and the nerves surrounding it were identified. Under sterile conditions, 1% lidocaine 3 mL was applied to the skin and subcutaneous tissue. Using in-plane visualization, a 5-cm 21G EchoStim Ò needle (Hakko Ò Medical, Japan) connected to a nerve stimulator was directed to the six o'clock position of the artery. After confirmation with neurostimulation (wrist extension that disappeared at 0.3 mA) and negative aspiration, 5% dextrose 2 mL was injected and showed adequate spread around the radial nerve. After negative blood aspiration every 5 mL, 2% lidocaine was injected slowly with appropriate visualization of the spread of the injectate. When a volume of 13 mL was reached, the patient complained of numbness in her lips, a metallic taste in her mouth, and a sensation of fainting. At that point, the injection was interrupted, 100% oxygen via an Ambu Ò face mask was given, and midazolam 2 mg iv was administered. The symptoms resolved after one minute, and the patient was transferred to the operating room where the scheduled procedure was completed. A tourniquet was used and an additional 2% lidocaine 3 mL was needed in the interdigital area. The patient was transferred to the recovery room hemodynamically stable.After surgery, the ultrasound video was reviewed in detail. In the analysis (Figure, Panel A), the needle appeared to be posterolateral to the axillary artery; however, upon closer inspection, the needle tip could be seen as indenting a small anechoic structure posterior to the artery. In the next frame and just before the appearance of LAST symptoms ( Figure, Panel B), local anesthetic spread could be seen as a hypoechoic image posterior to the artery. A portion of local anesthetic was likely deposited into a small vessel characterized by the an...

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“…Ropivacaine is similar in structure and anaesthetic properties however it is less cardio toxic in animals. Ropivacaine producing less motor block as it is more selective for sensory fibres compared with other local anesthetics suggesting that ropivacaine could be superior to bupivacaine in labour epidural analgesia 2 . Studies where 0.5% ropivacaine was used for caesarean section showed no maternal or foetal side effects.…”

Section: Introductionmentioning

confidence: 99%

“…Maternal mobility is affected by motor blockade and may prolong labour 1 . Unintentional intravenous bupivacaine injection results in maternal cardiac arrest and death 2 .…”

Section: Introductionmentioning

confidence: 99%

0.125% Bupivacaine Versus 0.2% Ropivacaine for Labour Epidural Analgesia: A Comparative Study

2016

IJSR

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Context: Better obstetric outcome is produced when ropivacaine is used for labour as compared to bupivacaine. Several studies insist on use of these drugs along with opioids. Aims: The following study compares bupivacaine and ropivacaine without opioids for labour epidural analgesia. Settings and Design: This prospective comparative study was conducted at a tertiary care hospital in central India. Methods and Material: A total of 60 parturient were randomly allocated into two groups to receive labour epidural analgesia with 10 ml each of 0.125%bupivacaine or 0.2%ropivacaine as main dose. A sensory level block of T10-L1 in the first stage of labour and a level of T10-S4 was achieved during 2nd stage of labour. A top up dose of 5ml 0.125%bupivacaine or 5ml 0.2%ropivacaine were given to the two groups respectively to patients complaining of pain. Labour was managed according to institutional standard labour protocols. Statistical analysis used: The data was collected using Microsoft Excel software and was analysed using SPSS software version17.0. Results: The onset was faster in bupivacaine group (mean 16.17 ± 2.214 min) as compared with ropivacaine group (mean 22.07 ± 3.039 min). The duration of analgesia was prolonged in ropivacaine group (mean 182.83 ±41.37 min.) as compared to bupivacaine group (mean 161.33 ±3.25min), number of top ups given in bupivacaine group were higher. However there was no difference in any other obstetric or neonatal outcomes. Conclusions: 0.2%ropivacaine is better for labour analgesia suggested by superior quality and intensity of analgesia according to Visual Analog Scale; less requirement of top ups; better maternal satisfaction. Keywords: bupivacaine, ropivacaine, labour analgesia, opioidKey Messages: A comparison of bupivacaine and ropivacaine without opiods for labour epidural analgesia.

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ASRA Practice Advisory on Local Anesthetic Systemic Toxicity

Cited by 568 publications

References 51 publications

LIPAEMIC Report: Results of Clinical Use of Intravenous Lipid Emulsion in Drug Toxicity Reported to an Online Lipid Registry

LIPAEMIC Report: Results of Clinical Use of Intravenous Lipid Emulsion in Drug Toxicity Reported to an Online Lipid Registry

Undetected intravascular injection during an ultrasound-guided axillary block

0.125% Bupivacaine Versus 0.2% Ropivacaine for Labour Epidural Analgesia: A Comparative Study

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