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 alteration in mental status, severe agitation or LOC ± convulsions
  • Cardiovascular collapse: bradycardia, conduction blocks, asystole and VT may occur
  • Local anaesthetic (LA) toxicity may occur some time after an initial injection

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

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

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

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

Treatment of cardiac arrest with lipid emulsion:(70kg)


5 x 100ml Intralipid in ED is kept in an occlusive PURPLE plastic bag in the resus. room ANTIDOTES PRESS. Additional stock is available in Pharmacy or in General Theatres drug store room.


Content by Dr Íomhar O' Sullivan 18/02/2008. Information on the management of LA Toxicity kindly provided by Dr Brian O' Donnell. Last review Dr IOS 26/01/21.