LA toxicity - Intralipid
Management of Severe Local Anaesthetic Toxicity - Signs of severe toxicity
Signs
AAGBI Safety Guideline 2009
| 1. Recognition |
Signs of severe 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
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| 2. Immediate management |
- Stop injecting the LA
- Call for help
- Maintain the airway and, if necessary, secure it with a tracheal tube
- Give 100% oxygen and ensure adequate lung ventilation
- Confirm or establish intravenous access
- Control seizures: a benzodiazepine, thiopental or Propofol in small incremental doses
- Assess cardiovascular status throughout
- Consider drawing blood for analysis, but do not delay definitive treatment to do this
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| 3. Treatment |
In circulatory arrest
- Start CPR using standard protocols
- Manage arrhythmias using the same protocols
- Consider cardiopulmonary bypass if available
Give intravenous lipid emulsion
- Continue CPR throughout treatment with lipid emulsion
- Recovery from LA-induced cardiac arrest may take >1 h
- Propofol is not a suitable substitute for lipid emulsion
- Lidocaine should not be used as an anti-arrhythmic therapy
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Without circulatory arrest
Use conventional therapies to treat:
- hypotension
- bradycardia
- tachyarrhythmia
Consider intravenous lipid emulsion.
- Propofol is not a suitable substitute for lipid emulsion
- Lidocaine should not be used as an anti-arrhythmic therapy
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| 4. 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 or lipase assays for two days
- If Lipid has been given, please also report its use to the international registry at www.lipidregistry.org or www.lipidrescue.org
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Treatment of cardiac arrest with lipid emulsion:(70kg)
- Give an intravenous bolus injection of Intralipid® 20% 1.5 ml/kg over 1 min (100 ml)
- Start an intravenous infusion of Intralipid® 20% at 0.25 ml/kg/min (400 ml over 20 min)
- Repeat the bolus injection twice at 5 min intervals if necessary (x2 further boluses of 100 ml)
- After another 5 min, increase the rate to 0.5 ml/kg/min if necessary (400 ml over 10 min)
- Continue infusion until a stable and adequate circulation has been restored
- 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 LipidRescueTM.
- Local copy of these The Association of Anaesthetists of Great Britain & Ireland 2007 guidelines
CUH
5 x 100ml Intralipid in ED is kept in an occlusive purple plastic bag in the resus. 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).
Content by Dr Íomhar O' Sullivan. Mx of LA Toxicity by Dr Brian O' Donnell. Last review Dr IOS 25/03/24.