Advertisement

Practical guide for the management of systemic toxicity caused by local anesthetics

  • Safety Committee of Japanese Society of Anesthesiologists
Guideline
  • 13 Downloads

Abstract

Systemic toxicity from local anesthetics can occur in any of the wide range of situations in which these agents are used. This practical guide is created to generate a shared awareness of the prevention, diagnosis, and treatment of local anesthetic systemic toxicity among all medical professionals who perform nerve blocks. Systemic toxicity of local anesthetic is induced by an increase of its protein-unbound plasma concentration. Initial symptoms are characterized by central nervous system signs such as excitation, convulsions, followed by loss of consciousness and respiratory arrest. These symptoms are often accompanied with cardiovascular signs such as hypertension, tachycardia and premature ventricular contractions. Further increase of plasma concentration of local anesthetic induces bradycardia, conduction disturbances, circulatory collapse and asystole. The incidence of local anesthetic systemic toxicity is 1–11 cases per 10,000. Infants, patients with decreased liver function and low cardiac output are vulnerable to systemic toxicity. When performing regional anesthesia, the guideline-directed monitoring, securing a venous line, preparation of medication to treat convulsions and lipid emulsions are required. For prevention of local anesthetic systemic toxicity, small-dose, divided administration, using agents with low toxicity such as ropivacaine and levobupivacaine, performing an aspiration test are recommended. If systemic toxicity is suspected, halt administration of local anesthetic, request assistance, secure venous line, airway, administration of 100% oxygen and if necessary tracheal intubation and artificial respiration should be immediately performed. Benzodiazepines are recommended to treat convulsions. Administration of 20% lipid emulsion according to the protocol is recommended to treat severe hypotension and arrhythmia.

Keywords

Local anesthetic Systemic toxicity Central nervous system Cardiovascular Lipid emulsion 

Notes

Acknowledgements

This practical guide was created by the Japanese Society of Anesthesiologists working group on local anesthetic toxicity guidelines: Kiyonobu Nishikawa, Yutaka Oda, Katsushi Doi, Norihiro Sakai, and Kazuya Sobue.

Compliance with ethical standards

Conflict of interest

All authors have no conflict of interest.

References

  1. 1.
    Mellin-Olsen J, Staender S, Whitaker DK, Smith AF. The Helsinki Declaration on patient safety in anaesthesiology. Eur J Anaesthesiol. 2010;27:592–7.CrossRefGoogle Scholar
  2. 2.
    Neal JM, Mulroy MF, Weinberg GL. American Society of Regional Anesthesia and Pain Medicine. Checklist for managing local anesthetic systemic toxicity: treatment of local anesthetic systemic toxicity: 2012 version. Reg Anesth Pain Med. 2012;37:16–8.CrossRefGoogle Scholar
  3. 3.
    Cave G, Harrop-Griffiths W, Harvey M, Meek T, Picard J, Short T, Weinberg G. AAGBI safety guideline: management of severe local anaesthetic toxicity. https://www.aagbi.org/sites/default/files/la_toxicity_2010_0.pdf. Accessed 5 July 2015.
  4. 4.
    Hoegberg LC, Bania TC, Lavergne V, Bailey B, Turgeon AF, Thomas SH, Morris M, Miller-Nesbitt A, Mégarbane B, Magder S, Gosselin S; Lipid Emulsion Workgroup. Systemic review of the effect of intravenous lipid emulsion therapy for local anesthetic toxicity. Clin Toxicol. 2016;54:167–93.CrossRefGoogle Scholar
  5. 5.
    Cox B, Durieux ME, Marcus MAE. Toxicity of local anaesthetics. Best Pract Res Clin Anaesthesiol. 2003;17:111–36.CrossRefGoogle Scholar
  6. 6.
    Neal JM, Bernards CM, Butterworth JF 4th, Di Gregorio G, Drasner K, Hejtmanek MR, Mulroy MF, Rosenquist RW, Weinberg GL. ASRA practice advisory on local anesthetic systemic toxicity. Reg Anesth Pain Med. 2010;35:152–61.CrossRefGoogle Scholar
  7. 7.
    Mulroy MF, Hejtmanek MR. Prevention of local anesthetic systemic toxicity. Reg Anesth Pain Med. 2010;35:177–80.CrossRefGoogle Scholar
  8. 8.
    Rosenberg PH, Veering BT, Urmey WF. Maximum recommended doses of local anesthetics: a multifactorial concept. Reg Anesth Pain Med. 2004;29:564–75.PubMedGoogle Scholar
  9. 9.
    Wolfe JW, Butterworth JF. Local anesthetic systemic toxicity: update on mechanisms and treatment. Curr Opin Anaesthesiol. 2011;24:561–6.CrossRefGoogle Scholar
  10. 10.
    Mather LE, Chang DH. Cardiotoxicity with modern local anaesthetics: is there a safer choice? Drugs. 2001;61:333–42.CrossRefGoogle Scholar
  11. 11.
    Pan PH, Bogard TD, Owen MD. Incidence and characteristics of failures in obstetric neuraxial analgesia and anesthesia: a retrospective analysis of 19,259 deliveries. Int J Obstet Anesth. 2004;13:227–33.CrossRefGoogle Scholar
  12. 12.
    Guay J. The epidural test dose: a review. Anesth Analg. 2006;102:921–9.CrossRefGoogle Scholar
  13. 13.
    Zetlaoui PJ, Labbe JP, Benhamou D. Ultrasound guidance for axillary plexus block does not prevent intravascular injection. Anesthesiology. 2008;108:761.CrossRefGoogle Scholar
  14. 14.
    Japanese Society of Anesthesiologists. Guidelines monitoring for safe anesthesia (in Japanese). Tokyo: Japanese Society of Anesthesiologists; 2014.Google Scholar
  15. 15.
    Di Gregorio G, Neal JM, Rosenquist RW, Weinberg GL. Clinical presentation of local anesthetic systemic toxicity. A review of published cases, 1979 to 2009. Reg Anesth Pain Med. 2010;35:181–7.CrossRefGoogle Scholar
  16. 16.
    Oda Y. Lipid resuscitation: development in basic research and application to clinical practice. J Anesth. 2013;27:811–4.CrossRefGoogle Scholar
  17. 17.
    Shi K, Xia Y, Wang Q, Wu Y, Dong X, Chen C, Tang W, Zhang Y, Luo M, Wang X, Papadimos TJ, Xu X. The effect of lipid emulsion on pharmacokinetics and tissue distribution of bupivacaine in rats. Anesth Analg. 2013;116:804–9.CrossRefGoogle Scholar
  18. 18.
    Hiller DB, Di Gregorio G, Kelly K, Ripper R, Edelman L, Boumendjel R, Drasner K, Weinberg GL. Safety of high volume lipid emulsion infusion: a first approximation of LD50 in rats. Reg Anesth Pain Med. 2010;35:140–4.CrossRefGoogle Scholar
  19. 19.
    Fettiplace MR, Akpa BS, Rubinstein I, Weinberg G. Confusion about infusion: Rational volume limits for intravenous lipid emulsion during treatment of oral overdoses. Ann Emerg Med. 2015;66:185–8.CrossRefGoogle Scholar
  20. 20.
    Cave G, Harvey M, Willers J, Uncles D, Meek T, Picard J, Weinberg G. LIPAEMIC report: results of clinical use of intravenous lipid emulsion in drug toxicity reported to an online lipid registry. J Med Toxicol. 2014;10:133–42.CrossRefGoogle Scholar
  21. 21.
    Cole JB, Stellpflug SJ, Engebretsen KM. Asystole immediately following intravenous fat emulsion for overdose. J Med Toxicol. 2014;10:307–10.CrossRefGoogle Scholar
  22. 22.
    Sirianni AJ, Osterhoudt KC, Calello DP, Muller AA, Waterhouse MR, Goodkin MB, Weinberg GL, Henretig FM. Use of lipid emulsion in the resuscitation of a patient with prolonged cardiovascular collapse after overdose of bupropion and lamotrigine. Ann Emerg Med. 2008;51:412–5.CrossRefGoogle Scholar
  23. 23.
    Levine M, Brooks DE, Franken A, Graham R. Delayed-onset seizure and cardiac arrest after amitriptyline overdose, treated with intravenous lipid emulsion therapy. Pediatrics. 2012;130:e432–8.CrossRefGoogle Scholar
  24. 24.
    Rodriguez B, Wilhelm A, Kokko KE. Lipid emulsion use precluding renal replacement therapy. J Emerg Med. 2014;47:635–7.CrossRefGoogle Scholar

Copyright information

© Japanese Society of Anesthesiologists 2018

Authors and Affiliations

  • Safety Committee of Japanese Society of Anesthesiologists
    • 1
  1. 1.Japanese Society of AnesthesiologistsKobeJapan

Personalised recommendations