Local anaesthetic toxicity
Signs of severe toxicity: sudden alteration in mental status, severe agitation or loss of consciousness, with or without tonic-clonic convulsions; cardiovascular collapse — sinus bradycardia, conduction blocks, asystole and ventricular tachyarrhythmias may all occur. Local anaesthetic toxicity may occur some time after an initial injection.
USE 20% Intralipid® (propofol is not a suitable substitute).
Immediately:
Give an initial i.v. bolus of lipid emulsion 1.5 ml.kg⁻¹ over 2–3 min (~100 ml for a 70 kg adult).
Start an i.v. infusion of lipid emulsion at 15 ml.kg⁻¹.h⁻¹ (17.5 ml.min⁻¹ 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⁻¹.h⁻¹ if:
cardiovascular stability has not been restored or
an adequate circulation deteriorates.
Do not exceed maximum cumulative dose 12 ml.kg⁻¹ (70 kg: 840 ml).
Cardiac arrest → Check already done ❶ to ❺, then → ❻
Arrange safe transfer to appropriate clinical area.
Exclude pancreatitis: regular clinical review, daily amylase or lipase.
Report case on your local critical incident system and to the relevant national system (these vary between each devolved nation and in Ireland).