Introduction

• Local anaesthetic toxicity is a potentially fatal complication of regional anaesthesia. It can also occur in other situations with local anaesthetic injections
• This guideline has been adopted from the Association of Great Britain and Ireland Guidelines for the Management of Severe Local Anaesthetic Toxicity¹ and is endorsed by the Australian and New Zealand College of Anaesthetists

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Signs of severe toxicity

• Central nervous system: sudden alteration in mental status, severe agitation or sudden loss of consciousness with or without tonic-clonic convulsions
• Cardiovascular system: cardiovascular collapse: sinus bradycardia, conduction blocks, asystole and ventricular tachyarrhythmias may all occur
• Local anaesthetic toxicity may occur some time after the initial injection

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Immediate management

• Stop injecting the local anaesthetic
• Call for help
• If not in theatre or after-hours: call code blue obstetrics (or equivalent hospital Cardiac Arrest Team)
• If in theatre during working hours: ring theatre emergency bell and if not already present page / contact senior anaesthetist and request additional anaesthetic assistance
• Maintain the airway and, if necessary, secure it with a tracheal tube
• Give 100 % oxygen and ensure adequate lung ventilation (hyperventilation may help by increasing pH in the presence of metabolic acidosis)
• Confirm or establish intravenous access
• Control seizures: give a benzodiazepine, thiopental or propofol in small incremental dose (the latter two medications should only be administered by an anaesthetist)
• Assess cardiovascular status throughout
• Consider drawing blood for analysis but do not delay definitive treatment to do this

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Management in cardiac arrest

• Commence cardiopulmonary resuscitation (CPR)  
• Manage arrhythmias, recognising that the arrhythmias may be very refractory to treatment
• Consider the use of cardiopulmonary bypass if available
• GIVE INTRAVENOUS INTRALIPID EMULSION (IV intralipid emulsion regimen flow chart)
• Follow regimen for intravenous lipid emulsion as above
• Continue CPR throughout treatment with lipid emulsion
• Recovery from LA-induced cardiac arrest may take >1 hour
• Propofol is not a suitable substitute for lipid emulsion
• Lidocaine should not be used as an anti-arrhythmic therapy

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Management without cardiac arrest

• Use conventional therapies to treat
  • Hypotension
  • Bradycardia
  • Tachyarrhythmia
• CONSIDER INTRAVENOUS LIPID EMULSION (open IV intralipid emulsion regimen flow chart)

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Follow-up

• Arrange safe transfer to a clinical area with appropriate equipment and suitable staff until sustained recovery is achieved 
• Exclude pancreatitis by regular clinical review, including daily amylase and lipase assays for two days
• Notify via Advanced Incident Management System (AIMS)
• If Lipid has been given, also report its use to the international registry at www.lipidregistry.org. Details may also be posted at www.lipidrescue.org

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References

1. Association of Anaesthetists of Great Britain and Ireland. Guidelines for the Management of Severe Local Anaesthetic Toxicity. 2010.  Available from URL:  http://www.aagbi.org/publications/guidelines/docs/la_toxicity_2010.pdf
2. Weinberg G et al. Lipid emulsion infusion rescues dogs from bupivacaine-induced cardiac toxicity. Regional Anesthesia and Pain Medicine 2003;28:198-202.
3. Weinberg GL et al. Pretreatment or resuscitation with a lipid infusion shifts the dose-response to bupivacaine induced asystole in rats. Anesthesiology 1998;88:1071-5.
4. Rosenblatt MA et al. Successful use of a 20% Lipid emulsion to resuscitate a patient after a presumed bupivacaine-related cardiac arrest. Anesthesiology 2006;105:217-8.
5. Litz RJ et al. Successful resuscitation of a patient with ropivacaine-induced asystole after axillary plexus block using lipid infusion. Anaesthesia 2006;61:800-1.
6. Foxall G et al. Levobupivacaine-induced seizures and cardiovascular collapse treated with Intralipid. Anaesthesia 2007;62:516-8.
7. Patient Safety Alert 21 (28 March 2007) – Safer practice with epidural injections and infusions. London: National Patient Safety Agency.  Available from URL:  www.npsa.nhs.uk
8. Weinberg GL. Lipid Infusion Therapy: Translation to Clinical Practice. Anesth Analg 2008;106:1340–2.
9. Litz RJ, Roessel T, Heller AR, Stehr SN. Reversal of central nervous system and cardiac toxicity after local anesthetic intoxication by lipid emulsion injection. Anesth Analg 2008;106:1575–7.
10. Ludot H, Tharin J-Y, Belooudah M, Mazoit J-X, Malinovsky J-M.  Successful resuscitation after ropivacaine and liocaine-induced ventricular arrhythmia following posterior lumbar plexus block in a child. Anesth Analg 2008;106:1572–4.

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First developed: 09 June 2009     Subsequent updates:  25 January 2010

Last reviewed: 01 February 2010

South Australian Perinatal Practice Guidelines. Please read our disclaimer.

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