Management of LA Toxicity

Question: How do you manage a case of suspected systemic local anaesthetic toxicity?

Answer

Question: How do you manage a case of suspected systemic local anaesthetic toxicity?

Answer:

  • Stop administering the drug
  • Get senior help/assistance
  • Concentrate on airway, breathing and circulation (ABC)
  • Provide oxygen by a face mask
  • If unconscious, perform tracheal intubation
  • If intubated, commence ventilation to ensure that patient does not develop respiratory acidosis. (Acidosis worsens toxicity)
  • Ensure adequate IV access and commence fluid resuscitation
  • If patient develops seizures, treat with diazepam or small doses of thiopentone or propofol
  • If patient develops cardiac arrest, perform CPR. CPR may need to be performed for a long time and may require multiple trained assistants to take turns
  • In a cardiac arrest, administer lipid emulsion (Intralipid®), if available. Continue CPR throughout treatment with Intralipid

Table 1 shows more details about lipid emulsion.

Question: How do you manage a case of suspected systemic local anaesthetic toxicity?

Answer:

  • Stop administering the drug
  • Get senior help/assistance
  • Concentrate on airway, breathing and circulation (ABC)
  • Provide oxygen by a face mask
  • If unconscious, perform tracheal intubation
  • If intubated, commence ventilation to ensure that patient does not develop respiratory acidosis. (Acidosis worsens toxicity)
  • Ensure adequate IV access and commence fluid resuscitation
  • If patient develops seizures, treat with diazepam or small doses of thiopentone or propofol
  • If patient develops cardiac arrest, perform CPR. CPR may need to be performed for a long time and may require multiple trained assistants to take turns
  • In a cardiac arrest, administer lipid emulsion (Intralipid®), if available. Continue CPR throughout treatment with Intralipid

Table 1 shows more details about lipid emulsion.

Lipid emulsion

  • Give a bolus of 1.5 ml/kg IV over 1 minute, and:
    • Commence an infusion at 15 ml/kg/h If cardiac stability not achieved. Then,
    • Repeat bolus injection twice at 5-minute intervals, and
    • Increase the infusion rate to 30 ml/kg/h
    • Continue CPR and the intralipid infusion until a stable circulation is established
  • Maximum dose: 12 ml/kg (840ml)

For a 70 kg man:
Initial bolus: 100 ml of 20% Intralipid over 1 minute, and
Commence an infusion at 1000 ml/hr.
After 5 minutes: repeat bolus of 100 ml.
Maximum: 3 boluses in total and increase the infusion rate to 2000 ml/hr.

Table 1 Lipid emulsion