LA toxicity - Intralipid

1 Recognition

Signs of severe toxicity:

• Sudden alteration in mental status, severe agitation or LOC +/- convulsions
• Cardiovascular collapse: bradycardia, conduction blocks, asystole and VT may occur
• Local anaesthetic (LA) toxicity may occur some time after an initial injection

2 Immediate management

• Stop injecting the LA
• Call for help
• Maintain the airway and, if necessary, secure it with a tracheal tube
• Give 100% oxygen and ensure adequate lung ventilation
• Confirm or establish intravenous access
• Control seizures: a benzodiazepine, thiopental or propofol in small incremental doses
• Assess cardiovascular status throughout
• Consider drawing blood for analysis, but do not delay definitive treatment to do this

3      Treatment     

In circulatory arrest

• Start CPR using standard protocols
• Manage arrhythmias using the same protocols
• Consider cardiopulmonary bypass if available

Give intravenous lipid emulsision

• Continue CPR throughout treatment with lipid emulsion

• Recovery from LA-induced cardiac arrest may take >1 h

• Propofol is not a suitable substitute for lipid emulsion

• Lidocaine should not be used as an anti-arrhythmic therapy
  

Without circulatory arrest

Use conventional therapies to treat:

• hypotension
• bradycardia
• tachyarrhythmia
  

Consisider intravenous lipid emulsision

• Propofol is not a suitable substitute for lipid emulsion
• Lidocaine should not be used as an anti-arrhythmic therapy

4
Follow-up

• Arrange safe transfer to a clinical area with appropriate equipment and suitable staff until sustained recovery is achieved
• Exclude pancreatitis by regular clinical review, including daily amylase or lipase assays for two days
• If Lipid has been given, please also report its use to the international registry at www.lipidregistry.org or www.lipidrescue.org