Beware Local Anaesthetic Toxicity
Risks
- Age
- Renal disease
- Liver disease
- Cardiac failure
- Pregnancy
- Previous allergy to LA
Best practice
- Always know max. LA dose (use ideal body weight)
- Document max safe dose before starting
- Aspirate as you advance the needle and prior to injection
- Use US to guide procedure
- Inject slowly (stop if pain)
- Closely monitor for signs of toxicity
Clinical signs LA toxicity
- Sudden Δ in mental status, agitation or LOC ± convulsions
- CVS collapse: bradycardia, conduction blocks, asystole & VT may occur
- Local anaesthetic (LA) toxicity may occur some time after an initial injection
Treatment of cardiac episode with lipid emulsion:(70kg)
- Use 20% Intralipid® (propofol is not a suitable substitute)
- Initial IV 1.5 ml/kg bolus over 2-3 min (~100 ml for a 70 kg adult)
- Then
- IV infusion at 15 ml/kg/h (17.5 ml/min for a 70 kg adult)
- At 5 and 10 minutes
- Give a repeat bolus (same dose) if:
- cardiovascular stability has not been restored or
- an adequate circulation deteriorates
- At any time after 5 minutes:
- Double the rate to 30 ml/kg/h if:
- cardiovascular stability has not been restored or
- an adequate circulation deteriorates
- Max. cumulative dose: 12 ml/kg (70 kg: 840 ml)
- Continue CPR throughout treatment with lipid emulsion
- Recovery from LA-induced cardiac arrest may take >1 h
- Please report all cases to the Irish Medicines Board and the LipidRescu™
- Exclude pancreatitis by regular clinical review, including daily amylase or lipase assays for two days
CUH
5 x 100ml Intralipid in ED is kept in an occlusive purple plastic bag in the resusc. room antidote press. Additional stock is available in Pharmacy or in General Theatres drug store room.
MUH
Intralipid is kept in the antidote press (back corridor).
Links
- IAEM guideline on Mx LA Toxicity, 2023, Dr Emma-May Curran, Dr Roy O' Mahony, Dr Victoria Meighan
- CUH Intralipid administration guideline
- LAST: Association of Anaesthetists QRH (local copy)