Local anesthetic systemic toxicity

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Background

  • Complication of lidocaine injection (accidental into systemic circulation)
    • 0.2% of nerve blocks
  • Occurs within minutes of injection
    • 75% occuring within 5 minutes

Specific Anesthetics

  • Lidocaine - 5 mg/kg max, no more than 300 mg (1% soln contains 10 mg/ml)
  • Lidocaine with epi - 7 mg/kg man
  • Bupivacaine - 2.5 mg/kg, no more than 175 mg (0.5% soln contains 5 mg/ml)

Diagnosis

  • CNS symptoms
    • Agitation
    • Auditory changes
    • Metallic taste
    • Seizures or drowsiness
    • Coma
    • Respiratory arrest
  • Cardiovascular
    • First excitation
      • Tachycardia
      • Ventricular dysrhythmia
      • Hypertension
    • Followed by depression

Management

  • Lipid emulsion, 20% solution
    • 1.5 mL/kg bolus over 1 minute
    • Then, 15 mL/kg per hour x 20-minute infusion (0.25 mL/kg/min for 20 min or until hemodynamic stability)
  • Manage seizures with benzodiazepines; propofol is an option but may worsen CV toxicity
  • ACLS modifications per ASRA (Am Soc of Regional Anesthesia):
    • Small initial doses of 100 μg boluses in adults
    • No vasopressin
    • Avoid CCBs and BBs
    • Amiodarone preferred in ventricular dysrhythmias

See Also

References

Kapitanyan R, Su M, Tarabar A. Local Anesthetic Toxicity. [Internet]. 2014 Available from: http://emedicine.medscape.com/article/1844551-overview.