Treat toxicity from local anesthetics with IV lipids

Give a bolus of 20% IV lipids over 2 to 3 minutes, and immediately start a continuous infusion. If symptoms don't improve within 5 minutes....
Mahitab Hany, BS Pharm, PGDipClinPharm, PGDipClinNutrition

As a hospital pharmacist, you will play a bigger role in treating toxicity from local anesthetics (bupivacaine, lidocaine, ropivacaine, etc). There are more cases of toxicity occurring outside of the surgical setting. This is possibly from increased anesthetic use to reduce opioids or delayed onset of toxicity from continuous infusions. Be prepared to identify and treat systemic toxicity, which can quickly progress from seizures or hypotension to cardiac arrest or death...

          Monitor for CNS symptoms such as drowsiness or metallic taste or cardiovascular signs such as bradycardia. Stop the anesthetic if it's still infusing. Start oxygen and resuscitation if seizures, hypotension, or arrhythmias occur. AND emergently give IV lipids. IV lipids seem to work by binding and removing local anesthetics from the toxic sites.

Give a bolus of 20% IV lipids over 2 to 3 minutes, and immediately start a continuous infusion. If symptoms don't improve within 5 minutes, give an additional bolus and double the infusion rate. Once the patient responds, continue the infusion for 10 more minutes, then stop. Consider creating an IV lipid kit, include 1 liter IV lipids 20%, syringes, needles, tubing, and a checklist for treatment. Stock the kit with code carts in high-risk areas. Use this kit to highlight other treatment differences in cardiac arrest associated with local anesthetic toxicity. For example, use epinephrine 0.1 mg instead of 1 mg. Standard epinephrine doses might worsen cardiac instability.

REFERENCES

  • Neal JM, Barrington MJ, Fettiplace MR, Gitman M, Memtsoudis SG, Mörwald EE, Rubin DS, Weinberg G. The Third American Society of Regional Anesthesia and Pain Medicine Practice Advisory on Local Anesthetic Systemic Toxicity: Executive Summary 2017. Reg Anesth Pain Med. 2018 Feb;43(2):113-123. Available at: https://rapm.bmj.com/content/43/2/113

    Neal JM, Woodward CM, Harrison TK. The American Society of Regional Anesthesia and Pain Medicine Checklist for Managing Local Anesthetic Systemic Toxicity: 2017 Version. Reg Anesth Pain Med. 2018 Feb;43(2):150-153. Available at: https://rapm.bmj.com/content/43/2/150