DOI: 10.1097/AIA.0b013e3181faa464
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PMID: 20881531
Issn Print: 0020-5907
Publication Date: 2010/10/01
Management of Local Anesthetic Toxicity
Didier Morau; Sinead Ahern
+ Author Information
Author Information: CHU Montpellier, Montpellier, FRHôpital Lapeyronie Montpellier, France
Excerpt
Local anesthetic systemic toxicity (LAST) is a rare but potentially fatal complication of regional anesthesia. The danger of toxic blood concentrations of local anesthetic (LA) has been recognized and reported since the late 1800s after the purification of cocaine, the first LA.1 Although the practice of regional anesthesia has evolved since the late 1800s, LAST remains a major concern. This fact was highlighted by an alarming editorial by Albright2 in 1979, accompanying reports of LAST. This study and similar publications prompted the Food and Drug Administration to address administration of LAs by clinicians. The use of bupivacaine for intravenous regional anesthesia was prohibited and bupivacaine 0.75 was precluded from being used in obstetric epidurals. Over the past 25 years, the overall incidence of LAST has decreased dramatically. The decline in LAST is more significant with epidural anesthesia. In 1981, the incidence of LAST was 100/10,000 epidurals.3 Brown et al4 in 1995 retrospectively reviewed the Mayo Clinic experience and found an incidence of LAST of 0.1/1000 epidurals and 2.0/1000 brachial plexus blocks. Auroy et al5 in 1997 prospectively reported an incidence of LAST of 0.13/1000 epidurals and 0.75/1000 peripheral nerve blocks (PNBs). This trend led to a decreased LAST incidence that was confirmed in 2002 by the same team6 who reported 7 cases of LAST, 1 associated with an epidural, and 6 with PNBs, in 153,083 regional anesthesia procedures recorded. An incidence of 0.98/1000 PNBs was recently found by Barrington et al.7 Interestingly, none of the cases reported by these researchers were associated with cardiac arrest. The development of better monitoring, safer techniques, and the use of lower LA concentrations may all have contributed to a reduced incidence of LAST.
However, LAST is still associated with significant morbidity. Records from the American Society of Anesthesiologists Closed Claims Database8 show that between 1980 and 2000 LAST was associated with one-third of the claims for death and brain damage after regional anesthesia.
In the past decade, a major change occurred in the treatment of cardiovascular (CV) collapse after LAST with the introduction of lipid rescue therapy. The focus of this study is to examine the mechanisms of cardiotoxicity, the new developments in lipid therapy, and the prevention of LAST after the use of long-acting amide LAs. The literature search, using the PubMed Search engine, was based on the following key words: LA toxicity, bupivacaine toxicity, ropivacaine toxicity, L-bupivacaine toxicity, lipid emulsion, lipid rescue, LA cardiotoxicity, LA neurotoxicity, and complications of regional anesthesia. Only animal and human studies published in English and French have been selected.
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