Local Anesthesia Systemic Toxicity LA(S)T - PowerPoint Presentation

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Local Anesthesia Systemic Toxicity LA(S)TRECOGNITION and Treatment

Sallie

Poepsel

. PhD, MSN, CRNA, APRN

Director, AANA Region IVSlide2

Financial disclosureSlide3

ObjectivesSTAY AWAKE after Lunch

Describe the background information associated with Local Anesthetic Systemic Toxicity (LAST)

. Slide4

ObjectivesRecognize the signs and symptoms raising your suspicion of a diagnosis of LAST.

Outline the LIPIDS Rescue Protocol

Use the information from this session, along with your experience in an interactive question session.Slide5

Historical Background

rodent model of bupivacaine toxicity

(Weinberg et al 1998)

Rosenblatt et al reported the first clinical application of lipid emulsion therapy in treating LAST (2006

)

Anesthesiology. 2012 Jul; 117(1): 180–187.

doi

:  

10.1097/ALN.0b013e31825ad8de

Rosenblatt MA, Abel M, Fischer GW,

Itzkovich

CJ,

Eisenkraft

JB. Successful use of a 20% lipid emulsion to resuscitate a patient after a presumed bupivacaine-related cardiac arrest. Anesthesiology. 2006;105:217–8. [

PubMed

]Slide6

Ultrasound

Ultrasound speeds up safety and how well and effective your block is…

Slide7

ULTRASOUNDSlide8

LAST (Bupivacaine Toxicity)

CARDIOTOXIC: enters sodium channels rapidly and leaves

them very slowly;

diffusses

during diastole

depresses conduction and inducing reentrant-type ventricular arrhythmias.

direct effects: Arrhythmias initially, (-)

inotropy

, (-)

chronotropy

results in Systolic Dysfunction, especially involving right ventricle, which precedes the occurrence of arrhythmiasSlide9

What are the Signs?CNS: excitation, agitation, confusion, twitching,

seizures

Depression, sedation, coma, apnea

Metallic taste,

circumoral

numbness, diplopia, tinnitus, dizzy

Cardiac: initial hyper dynamic, then hypo dynamicSlide10

LAST: Things to KNOW

CV

:

At less than 5 mcg/ml of lidocaine,

At 5-10 mcg/ml there are EKG changes including prolonged

At > 10 mcg/ml, asystole and circulatory collapse

no symptoms.

EKG changes

including prolonged PR

interval, widened QRS.. CO &

peripheral vasodilation

asystole and

circulatory collapseSlide11

LIPIDS RESCUEHow it Works

LA interfere with fatty acid transport into the mitochondria of the cardiac cells inhibiting the heart from performing oxidative phosphorylation and this is what leads to cardiac dysrhythmias.

LIPIDS act as a SINK - Most

(and current???)

thought pattern

The sink – the lipids provide a alternative binding site for the LA

Cheap and found by accident Slide12

LIPIDS SINKMechanism of action: ……..Most agree it is a LIPID sink

lipids reverse local anesthetic cardio toxicity may be increasing cardiac clearance. This nonspecific, observed extraction of local anesthetics from aqueous plasma or cardiac tissue is the lipid sinkSlide13

Lipid Sink TheoryLA love the lipids..

Bind them with...sink

Initial increase in plasma levels

Then Lipids rapidly decrease in serum

It partitions the local anesthetic away from receptorsSlide14

Generally Accepted Approachairway management as the first priority then seizure suppression

basic life supportSlide15

Goal

Current treatments:

to prevent complications; with proper injection techniques and careful dosing

ACLS, BYPASS, LIPID rescueSlide16
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LAST RESCUE PROTOCOLImmediately:

Give an initial IV bolus of 20% Lipid emulsion

(1.5 ml/kg over 1 minute)

Start IV infusion

Lipid emulsion

15 ml/kg/

hr

After 5 minutes

:

Give a max. of 2 repeat bolus(same dose) if:

Cardiovascular stability has not been restored;

Adequate circulation deteriorates(leave 5 minutes between) boluses

AND continue Infusion until:

1) cardiovascular status is

stable.

2) adequate circulation

restored

OR

3) max. lipid dose given.Slide18

20% INTRALIPIDS20% Soya bean oil1.2% egg yolk phospholipids

2.25% glycerin

Water

Sodium hydroxideSlide19

Case Report50 year old female with Grade III Rotator Cuff (incurred from a fall) scheduled for RTCSoftball athlete in H-School

PMH: HTN under control with

Enalapril

Family

Hx

of HTN

PSH: S/P TAH w/BSO

Physical Assessment:

Systems Review: unremarkable except for R

shoulder pain

Height: 167.6 cm. Weight: 84.5 kg BMI - 30

MRI Results RTC; labrium tearLABS: within normal limitsSlide20

Sequence of EventsScheduled for R Interscalene block prior to RTC repairPACU: monitors –BP, EKG, Oximetry, OD @ 2L/NC

IV: started with G-18 IV cath. LR 1000 ml

Meds: Versed 1mg IV titrated prior

LOCAL Anesthetic: Lidocaine 1% for skin infiltration

Bupivacaine 0.25% NP 15 ml (max dose no>

400 mg)

Lidocaine 0.5% 15 ml

Nerve Stimulator: Set initially at >0.2- 2 MA..

Puncture Site:

Interscalene

Groove @ level of the Cricoid

Equipment & Supplies: B. Braun Medical insulated Stimuplex guide (percutaneous guidance technique)Slide21

Lidocaine injected @ 3-5 ml increment following aspirationBupivacaine injected incrementally similarly following lidocaine.IS Block completed

within 10 minutes, noticed increased PVC,

pt

restless & panicky,

started seizures, unresponsive, progressive

desaturation from 99% to low 60s

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LIPIDS RescueAirway established – intubated ambu’d 100%Within 1-2 minutes LIPIDS Rescue Protocol

Dysrhythmia dissipated; stable VS; seizures resolved

Two repeat boluses of LIPIDS (100 ml);

Lipids infusion

Total LIPIDS: 1500ml

Transferred to nearby hospital for ICU observationSlide23

Con’tTransferred to nearby hospital for ICU observationDischarged after 4 days – off for a week

NOW: she’s back teachingSlide24

SummaryBackground Information associated with LAST

Signs and symptoms

LIPIDS Rescue touted as the treatment for LAST

(since 2006)

Current Suggestion: have LIPIDS available in all facilitiesSlide25

References1. Weinberg GL, VadeBoncouer T, Ramaraju GA, Garcia-

Amaro

MF,

Cwik

MJ. Pretreatment or resuscitation with a lipid infusion shifts the dose-response to bupivacaine-induced asystole in rats. Anesthesiology. 1998;88:1071–5. [

PubMed

]

2. Weinberg GL, Ripper R, Murphy P, Edelman LB, Hoffman W,

Strichartz

G, Feinstein DL. Lipid infusion accelerates removal of bupivacaine and recovery from bupivacaine toxicity in the isolated rat heart. 

Reg

Anesth Pain Med. 2006;31:296–303. [PubMed]3. Weinberg G, Ripper R, Feinstein DL, Hoffman W. Lipid emulsion infusion rescues dogs from bupivacaine-induced cardiac toxicity. Reg Anesth Pain Med. 2003;28:198–202. [PubMed]4. Jamaty C, Bailey B, Larocque A, Notebaert E, Sanogo K, Chauny JM. Lipid emulsions in the treatment of acute poisoning: A systematic review of human and animal studies. Clin Toxicol (Phila) 2010;48:1–27.[PubMed]5. Rosenblatt MA, Abel M, Fischer GW, Itzkovich CJ, Eisenkraft JB. Successful use of a 20% lipid emulsion to resuscitate a patient after a presumed bupivacaine-related cardiac arrest. Anesthesiology. 2006;105:217–8. [PubMed]6. McCutchen T, Gerancher JC. Early Intralipid therapy may have prevented bupivacaine-associated cardiac arrest. Reg

Anesth Pain Med. 2008;33:178–80. [PubMed]7. Foxall G, McCahon R, Lamb J, Hardman JG, Bedforth NM. Levobupivacaine-induced seizures and cardiovascular collapse treated with Intralipid

. 

Anaesthesia

. 2007;62:516–8. [

PubMed

]

8. Spence AG. Lipid reversal of central nervous system symptoms of bupivacaine toxicity. Anesthesiology. 2007;107:516–7. [

PubMed

]

9. Shah S,

Gopalakrishnan

S, Apuya J, Martin T. Use of Intralipid in an infant with impending cardiovascular collapse due to local anesthetic toxicity. J Anesth. 2009;23:439–41. [PubMed]10. Rothschild L, Bern S, Oswald S, Weinberg G. Intravenous lipid emulsion in clinical toxicology. Scand J Trauma

Resusc Emerg Med. 2010;18:51. [PMC free article] [PubMed]Slide26

Excellent ResourceLIPID EMULSION INFUSION, RESUSCITATION FOR LA AND OTHER DRUG OVERDOSE

G.WEINBERG, ANESTHESIOLOGY JUL 2012

A description of background, safety, mechanism, controversies and recommendations. All are addressed above.

LIPIDRESCUE.ORGSlide27

Discussion