8/10/2019 ASRA LAsystemictoxicity
1/11Copyright @ American Society of Regional Anesthesia and Pain
Medicine. Unauthoried reproduction of tcle is prohi!ited.
RAPracticeAd"isoryon#ocalAnestheticSystemic$o%ic
&osephM.'eal(M)(*ChristopherM.+ernards(M)(*&ohn,.+utter-orth(/(M)(do)iregorio(M)(3enneth)rasner(M)(4MichaelR.5e6tmane7(M)(*Michael,.Mulroy(M)(*
Richard8.Rosen9uist(M)(::anduy#.8ein!erg(M)
A!stract;$heAmericanSocietyofRegionalAnesthesiaandPainMedicinePracticeAd"isoryon#ocalAnestheticSystemic$o%icity
assimilatesandsummariescurrent7no-ledgeregardingthepre"ention(
diagnosis(andtreatmentofthispotentiallyfatalcomplication.toffers
e"idence
physiciansandad"ancedpractitioners-horoutinelyadministerlocal
anestheticsinpotentiallyto%icdoses.$head"isorydoesnotaddress
issuesrelatedtolocalanestheticRegAnesthPainMed2010?;12B11D
#
ocalanestheticsare-idelyandcommonlyusedthroughoutmedicalanddentalpractice.Althoughitisrareforpatientstomanifestseriousad"erseeffectsore%periencecomplicationssecondarytolocalanestheticadministration(ad"ersee"ents
dooccur.$heserangefromthemildsymptomsthatmayfollo-systemica!sorptionoflocalanestheticfromacorrectlysitedandappropriatelydosedregionalanestheticproceduretoma6or
centralner"oussystem>C'SDand=orcardiacto%icity>mostoftenfromunintentionalintra"ascularin6ectionDthatcanresultindisa!ilityordeath.A"arietyoffactorsin
uencethefl
li7elihoodandse"erityoflocalanestheticsystemicto%icity>#AS$D(includingindi"idualpatientris7factors(concurrentmedications(locationandtechni9ueof!loc7(speci
clocalfianestheticcompound(totallocalanestheticdose>theproduct
ofconcentrationE"olumeD(timelinessofdetection(andadeP0.0GGDfi
reductioninseiures-ithultrasoundparticularly-ithin6ectionintothecor"erte!ralarteriesD(premonitorysymptomscan!e!ypassedandthepatientcanrapidlyde"elopseiureacti"itythatmayprogresstocardiace%citation>hypertension(tachycardia("enulararrhythmiasD.8ithgreatlyincreased!loodconcentrationscardiace%citationmay!efollo-ed!ycardiacdepression>!rady
8/10/2019 ASRA LAsystemictoxicity
6/11Copyright @ American Society of Regional Anesthesia and Pain
Medicine. Unauthoried reproduction of tcle is prohi!ited.
to!enodiaepines.ftoniccontinuedseiureacti"itye%dro-siness(coma(orrespiratoryarrestD.'eartheendofthiscontinuum(initialsignsofcardiacto%icity>hypertension(tachycardia(or"entriculararrhythmiasDaresupplanted!ycardiacdepression>!radycardia(
conduction!loc7(asystole(decreasedcontractilityD.5o-e"er(thereissu!stantial"ariationinthisclassicdescription(including;DSimultaneouspresentationofC'Sandcardiacto%icity
DCardiacto%icity-ithoutprodromalsignsandsymptomsofC'Sto%icity
D$hus(thepractitionermust!e"igilantforatypicalorune%pectedpresentationof#AS$>?+D.
$hetimingof#AS$presentationis"aria!le.mmediate>0sDpresentationsuggestsintra"ascularin6ectionoflocalan
esthetic
-ithdirectaccesstothe!rain(-hereaspresentationthatisdelayed1Bminssuggestsintermittentintra"ascularin6ection(lo-ere%tremityin6ection(ordelayedtissuea!sorption.+ecause
#AS$canpresentH1minsafterin6ection(patientsthatrecei"epotentiallyto%icdosesoflocalanestheticshould!ecloselymonitoredforatleast0minsafterin6ection>?+D.
Casereportsassociate#AS$-ithunderlyingcardiac(neurologic(pulmonary(renal(hepatic(ormeta!olicdisease.5eightened
"igilancemay!e-arrantedinthesepatients(particularlyiftheyareatthee%tremesofage>a?+D.
$heo"erall"aria!ilityof#AS$signsandsymptoms(timingofonset(andassociation-ith"ariousdiseasestatessuggests
that
practitionersshouldmaintainalo-thresholdforconsideringthediagnosisof#AS$inpatients-ithatypicalorune%pectedpresentationofC'Sorcardiacsignsandsymptomsafterrecei"ingmorethanaminimaldoseoflocalanesthetic>a?+D.
$heclassofrecommendationandle"elofe"idenceforeachinter$a!le1D.
$A+#KG.Recommendationsfor$reatmentof#AS$
fsignsandsymptomsof#AS$occur(prtandeffecti"eair-aymanagementiscraltopre"entinghypo%iaandacidosis
-hichare7no-ntopotentiate#AS$>?+D.
fseiuresoccur(theyshould!eralyhalted-ith!enodiaepines.f!odiaepinesarenotreadilya"aila!
smalldosesofpropofolorthiopentalareaccepta!le.,utudatamaysupporttheearlyuseoflipidemulsionfortreatin
seiures>?+D.
Althoughpropofolcanstopseiureargedosesfurtherdepresscardiacf
tion?propofolshould!ea"oided-heereare
signsofC/compromise>?+D.fseiurespersistdespit!enodiaepines(smalldosesofsuccinylcholineorsimi
neuromuscular!loc7ershould!econsideredtominimieacidosandhypo%emia>?CD.
fcardiacarrestoccurs(-erecendstandardAd"ancedCardiac#iupport-iththefollo-ingmodifiions;
Dfepinephrineisused(smallinitialdoses>10B1003g!olusestheadultDarepreferred>a
D/asopressinisnotrecommended>?+D
DA"oidcalciumchannel!loc7ersandA?
Df"entriculararrhythmiasde"elop(amiodaroneisprefer>a?+D?treatment-ithlocalanesthetics>lidocai
procainamideDisnotrecommended>?CD
#ipidemulsionthey>a?+D;DConsideradministeringatthefirstsignsof#AS$(afterair-amanagementD)osing;h1.m#=7g20Olipidemulsion!olush0.2m#=7gperminuteofinfusion(continuedforatleast10minsaftercirculatorysta!ilityisattahfcirculatorysta!ilityisnotattained(considerre!oluincreasinginfusionto0.m#=7gperminutehAppro%imately10m#=7glipidemulsionfor0minsisrecommendedastheupperlimitforinitialdosingPropofolisnotasu!stituteforidemulsion>?CD.
,ailuretorespondtolipidemulsind"asopressortherapyshouldprom
nstitutionofcardiopulmonary!yp>CP+D>a?+D.+ecausetherecan!econsidera!lelagin!eginningCPitisreasona!letonotifytheclosestfacilitycapa!leofpro"iit-henC/compromiseisfirstidentifiedduringanepisodeof#AS$.$heclassofrecommendationandle"elofe"idenceforeachinter$a!le1D
onalAnesthesiaandPainMedicine/olume('um!er2(March
