Local Anesthetic Systemic Toxicity Research Articles

Local Anesthetic Systemic Toxicity

Local Anesthetic Systemic Toxicity

Upper Limb Blocks: Advances in Anesthesiology Research

To summarize the recent literature regarding regional anesthesia of the upper extremity. Brachial plexus anatomy is more variable than previously believed. Several novel techniques for upper extremity blockade have been recently described. The ability of local anesthetic adjuvants and liposomal bupivacaine to prolong block duration has been investigated with mixed results. Regional anesthesia has played an important role in the expansion of ambulatory upper extremity surgery, especially shoulder arthroscopy and arthroplasty. Knowledge about the management of local anesthetic systemic toxicity remains essential for the safe performance of upper extremity blocks. The widespread adoption of ultrasound guidance for nerve blocks and the increasing emphasis on value in healthcare have fostered numerous innovations in regional anesthesia of the upper extremity in recent years. Further research is needed to determine the best technique for diaphragm-sparing shoulder analgesia and the most appropriate role for liposomal bupivacaine.

Successful intralipid-emulsion treatment of local anesthetic systemic toxicity following ultrasound-guided brachial plexus block: case report.

BackgroundLocal anesthetic systemic toxicity (LAST) is a life-threatening complication that may follow application of LAs through various routes. Despite increasing usage of LA techniques in a large number of health-care settings, contemporary awareness of LAST and understanding of its management are inadequate.Case presentationWe report two cases who suffered LAST following brachial plexus block for surgery on the upper extremity. The first patient received an ultrasound-guided supraclavicular block with 300 mg lidocaine (6 mg/kg) and 50 mg ropivacaine (1 mg/kg) in 25 mL without epinephrine, and the second patient received an ultrasound guided interscalene block with 200 mg lidocaine (4.5 mg/kg) and 45 mg ropivacaine (1 mg/kg) supplemented with epinephrine 1:200,000. Both patients presented with symptoms of central nervous and respiratory system depression, the first roughly 10 minutes after injection, and the second immediately after withdrawal of the needle. In both cases, thorough recovery was obtained using lipid-emulsion therapy.ConclusionThe complication of LAST following ultrasound-guided brachial plexus block could be treated successfully applying the American Society of Regional Anesthesia and Pain Medicineprotocol of intravenous administration of lipid emulsion.

Transversus Abdominal Plane Block in Children: Efficacy and Safety: A Randomized Clinical Study and Pharmacokinetic Profile.

The transversus abdominis plane (TAP) block has become a common regional anesthesia technique for pain management in a wide variety of abdominal procedures. Evidence to support any particular local anesthetic regimen as well as pharmacokinetic and systemic toxicity risks of TAP block remain insufficiently studied in children. The aim of this study was to compare the analgesic effects and investigate pharmacokinetic profile of levobupivacaine after ultrasound-guided TAP block using a low volume/high concentration (LVHC) or a high volume/low concentration (HVLC) solution in children. This prospective randomized study included children scheduled for day-case inguinal surgery. Children were randomized to receive TAP block using 0.4 mg·kg levobupivacaine as either HVLC (0.2 mL·kg of 0.2% levobupivacaine) or LVHC (0.1 mL·kg of 0.4% levobupivacaine). The primary outcome was the number of children who required opioid rescue analgesia postoperatively. Pharmacokinetic profile study of levobupivacaine was also performed. Seventy patients were equally randomized, and 65 were included in the final analysis. Seventy-one percent of patients did not require any postoperative opioid analgesia. The number of patients who received rescue analgesia was 12 (35%) in the LVHC group and 7 (23%) in the HVLC group (relative risk, 0.64; 95% confidence interval [CI], 0.29-1.42; P = .26). Mean pain scores (FLACC [faces, legs, activity, cry, and consolability]) at postanesthesia care unit discharge did not differ between LVHC and HVLC groups, respectively, 0.39 ± 0.86 and 1 ± 1.71 with mean group difference -0.60 (95% CI, -1.27 to 0.06; P = .08). The pharmacokinetic profile of levobupivacaine was comparable in the 2 groups: the mean total and free levobupivacaine peak concentrations were 379 ± 248 and 3.95 ± 3.16 ng·mL, respectively, occurring 22.5 ± 11 minutes after injection. The highest total and free levobupivacaine concentrations collected, respectively, 1360 and 15.1 ng·mL, remained far below theoretical toxic thresholds. In children, quality of postoperative pain control provided by TAP block using levobupivacaine 0.4 mg·kg administered as either HVLC or LVHC did not differ and was associated with a very low risk of local anesthetic systemic toxicity.

Principles of safety for ultrasound-guided single injection blocks in the emergency department

Ultrasound-guided nerve blocks (UGNBs) allow emergency physicians an opportunity to provide optimal pain management for acute traumatic conditions. Over the past decade, a growing body of literature has detailed the novel ways clinicians have incorporated UGNBs for analgesia and an alternative to procedural sedation. UGNBs are considered a relatively safe procedure, and have been shown to increase rates of success and reduce complications (as compared to older techniques). Ultrasound allows the operator needle visualization and a clear anatomic overview. Even with the presumed level of increased safety, we recommend that any clinician who performs ultrasound-guided nerve blocks be aware of complications that could arise during and after the procedure. Peripheral nerve injury (PNI) post block, local anesthetic systemic toxicity (LAST) and the role of single peripheral nerve blocks in patients with a risk for compartment syndrome are common safety issues discussed when performing ultrasound-guided nerve blocks.

Novel nerve imaging and regional anesthesia, bio-impedance and the future.

Ultrasound technology has transformed the practice of regional anaesthesia. Anaesthesiologists routinely use real-time images to guide needle and local anaesthetic placement adjacent to nerves. It is widely accepted that the era of ultrasonography has improved peripheral nerve block success rates and lessened the dose of local anaesthetic required to achieve success. Contemporary reports of harm in relation to nerve injury or local anaesthetic systemic toxicity are reassuring. The safety and efficacy of regional anaesthesia have thus been enhanced. Ultrasound guidance is, however, not a panacea. Ultrasound guidance requires the development of complex psychomotor skills. Harm may still occur where the needle or local anaesthetic is misplaced, resulting in nerve injury, vascular injury or local anaesthetic systemic toxicity. Advances in both imaging and needle technology may further enhance the safety and efficacy of ultrasound-guided regional anaesthesia. This review will focus on peer review literature to characterise the clinical challenges and explore the potential solutions.

Pediatric Regional Anesthesia Advances

To present recent developments in pediatric regional anesthesia (RA) including safety, complications, special populations, evidence-based trends, and ultrasound guidance. The data presented should be used to improve outcomes of children receiving RA. Current data demonstrates a very low occurrence of serious complications and validates the use of GA for block placement in children. Fewer neuraxial blocks are performed in favor of peripheral blocks as the use of ultrasound guidance has made new blocks possible and old blocks better and safer. Neonates and infants have more RA options. Adjuvant medications and ambulatory catheters increase the duration of RA and facilitate cost-effective, low-risk hospital discharge. The local anesthetic systemic toxicity checklist reinforces new guidelines. Increasing pediatric-specific RA data shows increased analgesic choices and improving patient care. Large well-designed studies to precisely define the risks and benefits and appropriate applications of novel ideas and technologies are needed.

Lipid emulsion therapy of local anesthetic systemic toxicity due to dental anesthesia.

Local anesthetic systemic toxicity (LAST) refers to the complication affecting the central nervous system (CNS) and cardiovascular system (CVS) due to the overdose of local anesthesia. Its reported prevalence is 0.27/1000, and the representative symptoms range from dizziness to unconsciousness in the CNS and from arrhythmias to cardiac arrest in the CVS. Predisposing factors of LAST include extremes of age, pregnancy, renal disease, cardiac disease, hepatic dysfunction, and drug-associated factors. To prevent the LAST, it is necessary to recognize the risk factors for each patient, choose a safe drug and dose of local anesthesia, use vasoconstrictor , confirm aspiration and use incremental injection techniques. According to the treatment guidelines for LAST, immediate application of lipid emulsion plays an important role. Although lipid emulsion is commonly used for parenteral nutrition, it has recently been widely used as a non-specific antidote for various types of drug toxicity, such as LAST treatment. According to the recently published guidelines, 20% lipid emulsion is to be intravenously injected at 1.5 mL/kg. After bolus injection, 15 mL/kg/h of lipid emulsion is to be continuously injected for LAST. However, caution must be observed for >1000 mL of injection, which is the maximum dose. We reviewed the incidence, mechanism, prevention, and treatment guidelines, and a serious complication of LAST occurring due to dental anesthesia. Furthermore, we introduced lipid emulsion that has recently been in the spotlight as the therapeutic strategy for LAST.

Regional Anesthesia Facilitates the Early Recognition of Local Anesthetic Toxicity

Rising concerns regarding the potential long-term neurocognitive effects of general anesthetic agents have renewed an interest in using regional anesthesia instead of general anesthesia in infants. Although generally safe and effective, the primary risk associated with regional anesthesia relates to the use of large doses of local anesthetic agents and the potential for local anesthetic systemic toxicity (LAST). We present three infants who suffered LAST after receiving regional anesthesia instead of general anesthesia. The early signs and symptoms were quickly identified in the awake state thereby allowing for cessation of continuous drug administration and a rapid response to treat LAST before progression to severe sequelae.

Management of local anaesthetic systemic toxicity by timely lipid resuscitation in a paraturient - A case report.

Management of local anaesthetic systemic toxicity by timely lipid resuscitation in a paraturient - A case report.

Incidence of adverse events attributable to bupivacaine liposome injectable suspension or plain bupivacaine for postoperative pain in pediatric surgical patients: A retrospective matched cohort analysis.

Surgical wound infiltration with local anesthetics is common as part of multimodal analgesia and enhanced recovery pathways in pediatric surgical patients. Liposomal bupivacaine can provide up to 92hours of pain relief, and was approved by the U.S Food and Drug Administration for local infiltration in adults. It is also commonly used by pediatric surgeons, but its safety profile in this age group has not been described. The aim of this study was to describe the incidence of local anesthetic systemic toxicity syndrome in pediatric surgical patients receiving liposomal bupivacaine compared to plain bupivacaine for surgical wound infiltration. We conducted a retrospective, single center, assessor blinded cohort study of pediatric surgical inpatients having open or laparoscopic surgery in the Cleveland Clinic between 2013 and 2017 and receiving wound infiltration with local anesthetics. We compared the incidence of local anesthetic systemic toxicity among those who received any dose of liposomal bupivacaine and those who received plain bupivacaine. Groups were matched 1:2 according to procedure type, age, and physical status score. Local anesthetic systemic toxicity was primarily defined as at least two signs or symptoms possibly related to anesthetic toxicity, as judged by two independent adjudicators blinded to the type of local anesthetic. A sensitivity analysis compared the incidence of a single sign/symptom possibly related to anesthetic toxicity. A total of 924 surgical cases were included in the final analysis (356 liposomal bupivacaine and 568 plain bupivacaine cases). The primary outcome did not occur in any patient. The sensitivity analysis found three cases in the liposomal bupivacaine group and two cases in the plain bupivacaine group having a single sign/symptom possibly related to local anesthetic administration (relative risk 2.4, 95% CI 0.4-14.0, P=0.38). In a cohort of pediatric surgical patients receiving wound infiltration with either plain or liposomal bupivacaine, we identified no cases of local anesthetic systemic toxicity syndrome, and only few patients with any sign or symptom that could potentially be related to local anesthetic toxicity.

Hypersensitivity Reaction to Perioperative Drug Mistaken for Local Anesthetic Systemic Toxicity in a Patient under Brachial Plexus Block

Perioperative anaphylaxis, although rare, is a severe, life-threatening unexpected systemic hypersensitivity reaction. Simultaneous administration of various drugs during anesthesia, the difficulty of communicate with patients in sedation and anesthesia, and coverage of the patient with surgical drapes are considered to be factors that impede early recognition of anaphylactic reactions. It is very important to perform an intradermal skin test because antibiotics are the most common cause of perioperative anaphylaxis. We report a case of negative-intradermal skin test antibiotic anaphylaxis mistaken for local aesthetic systemic toxicity without increase of serum tryptase for confirmative diagnostic biomaker during surgery under brachial plexus block. It is not possible to exclude the danger of anaphylaxis completely, even if it is negative-intradermal skin test and normal tryptase level. Therefore, anesthesiologists should be closely monitored and treated early for antibiotics related hypersensitive reaction, like other medicines during anesthesia.

Local Anesthetics for Neuraxial and Regional Techniques

Local anesthetics are used with neuraxial and regional techniques to provide pain relief, most commonly postoperatively. Each agent is a sodium-channel blocker, although each agent differs in onset of action, potency, duration of action, and safety profile. Chemical structure and lipophilicity are the main determinants of these characteristics. The agents may be used alone or in combination with an additive which alters the local anesthetic’s properties . Clinically, local anesthetics provide pain relief in a multimodal approach. This reduces opiate consumption, opiate-related adverse effects, and length of stay. Additional benefits when using neuraxial techniques include decreases in mortality, venous thromboembolism, myocardial infarction, pneumonia, respiratory depression, and duration of ileus. Although there are many adverse effects, the most serious include neurologic and cardiovascular. Seizures and cardiac arrest may result from local anesthetic systemic toxicity when systemic levels are elevated or the patient is predisposed. Dose adjustment, removal, or reversal of the agent may be clinically indicated. Lipid emulsion therapy is a reversal agent which acts as a sequestering vehicle for the local anesthetic. Liposomal bupivacaine, the newest formulation of local anesthetic, may provide an increased duration of action compared with standard formulations, although more evidence is needed. This review contains 5 figures, 5 tables, and 59 references. Keywords: amide, ester, epidural, local anesthetic, local anesthetic systemic toxicity, lipid emulsion therapy, liposomal bupivacaine, peripheral nerve block

The Third American Society of Regional Anesthesia and Pain Medicine Practice Advisory on Local Anesthetic Systemic Toxicity

(Reg Anesth Pain Med. 2018;43:113–123) Local anesthetic systemic toxicity (LAST) is a rare, adverse event that can occur when local anesthetics are administered despite advances in technique. Patients can experience mild prodromal symptoms to serious events such as seizure, cardiac arrest, and/or death. It is important that all professionals administering local anesthetics be educated and prepared for LAST. This article uses emerging research to update the 2010 advisory from the American Society of Regional Anesthesia and Pain Medicine. This practice advisory provides recommendations from recently published articles.

Local Anesthetic Systemic Toxicity: Reviewing Updates From the American Society of Regional Anesthesia and Pain Medicine Practice Advisory

Local Anesthetic Systemic Toxicity: Reviewing Updates From the American Society of Regional Anesthesia and Pain Medicine Practice Advisory

Practical guide for the management of systemic toxicity caused by local anesthetics.

Systemic toxicity from local anesthetics can occur in any of the wide range of situations in which these agents are used. This practical guide is created to generate a shared awareness of the prevention, diagnosis, and treatment of local anesthetic systemic toxicity among all medical professionals who perform nerve blocks. Systemic toxicity of local anesthetic is induced by an increase of its protein-unbound plasma concentration. Initial symptoms are characterized by central nervous system signs such as excitation, convulsions, followed by loss of consciousness and respiratory arrest. These symptoms are often accompanied with cardiovascular signs such as hypertension, tachycardia and premature ventricular contractions. Further increase of plasma concentration of local anesthetic induces bradycardia, conduction disturbances, circulatory collapse and asystole. The incidence of local anesthetic systemic toxicity is 1-11 cases per 10,000. Infants, patients with decreased liver function and low cardiac output are vulnerable to systemic toxicity. When performing regional anesthesia, the guideline-directed monitoring, securing a venous line, preparation of medication to treat convulsions and lipid emulsions are required. For prevention of local anesthetic systemic toxicity, small-dose, divided administration, using agents with low toxicity such as ropivacaine and levobupivacaine, performing an aspiration test are recommended. If systemic toxicity is suspected, halt administration of local anesthetic, request assistance, secure venous line, airway, administration of 100% oxygen and if necessary tracheal intubation and artificial respiration should be immediately performed. Benzodiazepines are recommended to treat convulsions. Administration of 20% lipid emulsion according to the protocol is recommended to treat severe hypotension and arrhythmia.

Trends in medical disputes involving anesthesia during July 2009-June 2018: an analysis of the Korean Society of Anesthesiologists database.

BackgroundTo identify trends in injuries and substandard care associated with anesthesia, we analyzed the Korean Society of Anesthesiologists database for anesthesia-related case files from July 2009 to June 2018.MethodsCase characteristics, injuries, and outcomes were compared between the first part (July 2009–June 2014, n = 105) and the second part (July 2014–June 2018, n = 92) of the analyzed time period.ResultsOverall, 132 cases resulted in death. The proportion of fatal cases for sedation was similar to general anesthesia (66.2% vs. 76.3%). The proportion of cases with permanent injury or death decreased significantly in the second part of the period compared with the first part (76.1% vs. 93.3%, P = 0.002). With a growing trend in the proportion of sedation cases, a similar number of sedation and general anesthesia cases were referred during the overall period (77 and 76 cases, respectively). Propofol-based regimens remained the dominant sedation method (89.7% in the first part vs. 78.9% in the second part). The most common adverse event in cases of permanent injury or death was identified as being respiratory in origin (98/182, 53.8%). Permanent injuries or deaths were related to local anesthetic systemic toxicity (LAST) and beach-chair positioning for shoulder surgery, in 8 and 5 cases, respectively.ConclusionsDespite the decreasing trend in injury severity with time, several characteristic injury profiles were identified: lack of vigilance in propofol-based sedation, neurological injuries related to the beach-chair position, and LAST occurring during tumescent anesthesia or brachial plexus block.

Did ultrasound fulfill the promise of safety in regional anesthesia?

Ultrasound guidance has become the accepted standard of practice for peripheral regional anesthesia. Despite evidence supporting the efficacy of ultrasound-guided regional anesthesia, its impact on patient safety has been less clear. Evidence has been consistent that ultrasound guidance reduces the incidence of vascular injury, local anesthetic systemic toxicity, pneumothorax and phrenic nerve block. Within the limited global scope of the epidemiology and etiologic complexity of perioperative (including block-related) peripheral nerve injury, there has not been consistent evidence that ultrasound guidance is associated with a reduced incidence of nerve injury. However, a recently published retrospective cohort study has demonstrated that the incidence of short-term nerve injury was decreased with ultrasound guidance compared with nerve stimulation. Ultrasound has led to development of novel blocks, approaches and refinement of existing ones, which may contribute to patient safety. Ultrasound has revolutionized the way we approach regional anesthesia and contributed to patient safety. It is important to note that patient safety does not hinge on one single technology. Patient safety in regional anesthesia relies on a well trained practitioner to pay meticulous attention to indication, block and patient selection, anatomy, pharmacology, equipment and technique.

Complications in Pediatric Regional Anesthesia: An Analysis of More than 100,000 Blocks from the Pediatric Regional Anesthesia Network.

WHAT THIS ARTICLE TELLS US THAT IS NEW: BACKGROUND:: Complications in pediatric regional anesthesia are rare, so a large sample size is necessary to quantify risk. The Pediatric Regional Anesthesia Network contains data on more than 100,000 blocks administered at more than 20 children's hospitals. This study analyzed the risk of major complications associated with regional anesthesia in children. This is a prospective, observational study of routine clinical practice. Data were collected on every regional block placed by an anesthesiologist at participating institutions and were uploaded to a secure database. The data were audited at multiple points for accuracy. There were no permanent neurologic deficits reported (95% CI, 0 to 0.4:10,000). The risk of transient neurologic deficit was 2.4:10,000 (95% CI, 1.6 to 3.6:10,000) and was not different between peripheral and neuraxial blocks. The risk of severe local anesthetic systemic toxicity was 0.76:10,000 (95% CI, 0.3 to 1.6:10,000); the majority of cases occurred in infants. There was one epidural abscess reported (0.76:10,000, 95% CI, 0 to 4.8:10,000). The incidence of cutaneous infections was 0.5% (53:10,000, 95% CI, 43 to 64:10,000). There were no hematomas associated with neuraxial catheters (95% CI, 0 to 3.5:10,000), but one epidural hematoma occurred with a paravertebral catheter. No additional risk was observed with placing blocks under general anesthesia. The most common adverse events were benign catheter-related failures (4%). The data from this study demonstrate a level of safety in pediatric regional anesthesia that is comparable to adult practice and confirms the safety of placing blocks under general anesthesia in children.

EFFECTIVENESS OF INTRAVENOUS INFLUENCE OF LIDOCAIN AT ANALGEESIA AFTER VIDEO-ASSISTED TORACCOSCOPIC LOBECTOMY

Objective: Effect of perioperative intravenous lidocaine infusion after video-assissed toraxoscopic lobectomy. Materials and methods. 90 patients who underwent lobectomy with a video assisted thoracoscopic method were examined. In the first group (n = 30) for analgesia, intravenous infusion of lidocaine was used, in the second group (n = 30) - narcotic analgesics, in the third group (n = 30) epidural analgesia was used. An evaluation of the extubation time and the severity of the perspiratory response to the endotracheal tube was performed. The intensity of the postoperative pain syndrome was assessed on a 10-point visual analogue scale every 15 minutes for an hour, then every 4 hours after the first day. In all groups, during the first 24 hours, the consumption of narcotic analgesics was recorded, as well as the frequency of postoperative nausea and vomiting and the need for rehabilitation bronchoscopy. Results. The time of extubation in patients of the 1 st group was significantly greater than in the patients of the 2 nd and 3 rd groups. In patients of the 1 st group, the severity of the pressor response to extubation was significantly lower. The strength of pain in rest and motion, as well as the overall postoperative need for analgesics (promedol) were significantly lower (30.1 ± 2.25 mg and 51.1 ± 9.16 mg compared to 122.2 ± 14.18 mg, in groups of epidural analgesia and lidocaine group.In the postoperative period, there was a significantly lower level of postoperative nausea and vomiting in patients of Group I. The need for sanation PBS was noted in 2 (6.7%) patients in Group 1 and 5 (16.7%) patients in Group 2. In patients of the 3rd group, sanation bronchoscopy was not performed. Conclusion. An intravenous infusion of lidocaine at anesthesiology maintenance operations on light has a marked analgesic effect, which by its severity inferior epidural block, but greater than the systemic administration of narcotic analgesics, has opiodsberegayuschim effect, reduces the incidence of postoperative nausea and vomiting, is not accompanied by clinical signs of systemic local anesthetic toxicity. Infusion of lidocaine as a method of analgesia can be utilized in the case where the execution epidural impossible or not desirable.