Case Report Lido Toxicity

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Pain Applicant1

Pain Applicant1

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Because I'm brand new to private practice and since I've discovered that the private world is very different from the academic one, I've been networking and shadowing various not so local pain and other docs to learn how they perform their procedures and how they operate their practice. The other day, a young pt with seizure history was given a dose of lidocaine (about 10mg) in her L5/S1 TFESI with the same injection performed on the contralateral side. Both sides showed a nice epidural spread. Within a minute or two, the patient became completely toxic including metallic taste in mouth and lightheadedness progressing on to full blown seizure activity which was long lasting as the lido significantly lowered her already low seizure threshold. Let's just say the office was ill prepared to manage as they are very busy, have been open for several years with no major complication, and this was their last expectation.

I'm not sure if anyone has experienced this with such a small dose of lidocaine in the lumbosacral epidural space but I know I haven't. I've had to manage lidocaine toxicity before (SGB) but never from this low of a dose during a TFESI. Anyhow, something to keep in mind.
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10 mg of Lidocaine for a TFESI...why?
 
He uses a solution containing about 1ml of 1% lido. I believe for similar reasons as most folks who use lido for TFESI use it but he also told me he likes to do a test dose with it for vascular uptake
 
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What do you mean by test dose with 1 ml of 1 % lido

How can you do test dose of vascular uptake with lidocaine, are u expecting local toxicity as a test dose with lidocaine, and you watch for toxicity , havent heard it any one doing

Don't have enough detail to comment though

Does he use contrast with lido or seperate contrast

There is no such things as ill/under treated death and a law sue of 30 - 40 mill will follow, my friend is paying with no tort reform , the judge asked him why didn't you intubate a seizing pt, were you waiting for him to aspirate and die.... I mean the expert just sits there catching flys....

Some thing to think about, what to keep in your crash cart

I think that is a good argument for clinical decision and quality of care and training that sort of QI thing

Don't know what the seasoned dogs think...
:luck:
 
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Inspire, I take it your background is not anesthesiology.

The test dose is standard practice when placing a blind epidural. Most don't use it when you can perform an epidurogram. I know some people do use it for TF, though there is no evidence that it is helpful and in at least 2 of 3 case reports of paraplegia secondary to TF injections test doses where reported to be administered prior to injection of the steroid.

I have seen plenty of women report a metallic taste (usually happens in OB) with a test dose but never seen a seizure.
 
The LA was intravenous. No way a small dose like that administered in the epidural space would precipitate a seizure. Was DSA used at all?

Test dose does not rule out/rule in much...since the needle can and will easily move whilst waiting for the 60-360seconds people recommend...
 
Not sure even if chestnut could do a test does with just lidocaine without any thing added to it, to look for HR change at 5 mic/cc of Epi with total 15 mics in 3 ml lidocaine.

More Power to all arrogant anesthesiologists out there, not sure with such an attitude how pts would feel with there care with you all

Just fooking .....:sleep: Happy new year in advance
 
No DSA unfortunately, not sure why. They had a Philips Pulsera and I think DSA is possible with that c arm. I just purchased a Philips BV 300 and I won't have the ability on my machine to set up DSA. During his procedure, contrast did show a nice epidural spread but maybe the needle moved or vascular uptake wasn't easily seen.

Inspire, do you think intubation is appropriate for all seizures? I thought securing the airway, moving air, and attempts at breaking the seizure with BZD and holding off on intubation except if necessary would be the way to go but I don't really know.
 
Even IV, 20 mg (1 cc 1% x 2) of lidocaine should not cause a seizure. We gave 100 mg as a bolus in anesthesia. Routinely, I mean all the time, gave 1-2 cc of lidocaine prior to diprovan to prevent burning. You say the patient had a seizure history? I would say she just had a seizure. If I were reviewing the case I would say that the doctor was not at fault for the seizure. However doing a procedure without having the ability to manage a seizure is a major liability.
Maybe all patients with a seizure history should have benzo pre-op?
Patients with seizures die because they don't get enough oxygen or they aspirate. Airway management is essential. No, you don't have to be an anesth. but you must be able to handle an airway.
Horrible situation, seizures are scary
 
I think this pt was poorly managed seizure pt to start with, most don't care when they had there last sz, nor they checked levels or meds. I think that may be part of the story,

pain docs just don't have time to look at these details on a factory line, just stamp the passport and the visa is ready to go out

All sz dont need intubations, most get better with little midazolam, propofol, thiopental

I think it's clinical judgment, when to tube. Prevention is better than cure. I like the preop midazolam idea, have things ready at least laryngoscopes, tubes and emergency meds and a LMA

You never know, it like a thunder clap, who is rosenthal did he grow out of a poison Ivy tree

My old attending used to say, Failing to prepare is preparing to fail
 
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facets said:
Even IV, 20 mg (1 cc 1% x 2) of lidocaine should not cause a seizure. We gave 100 mg as a bolus in anesthesia. Routinely, I mean all the time, gave 1-2 cc of lidocaine prior to diprovan to prevent burning. You say the patient had a seizure history? I would say she just had a seizure. If I were reviewing the case I would say that the doctor was not at fault for the seizure. However doing a procedure without having the ability to manage a seizure is a major liability.
Maybe all patients with a seizure history should have benzo pre-op?
Patients with seizures die because they don't get enough oxygen or they aspirate. Airway management is essential. No, you don't have to be an anesth. but you must be able to handle an airway.
Horrible situation, seizures are scary
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Yes, very scary. In fellowship, I had a lido toxicity case with an stellate and ended up doing a big M & M on it. I remember one article saying that the amount of lido considered to cause toxicity is reduced by some crazy number like 100 times when dealing with the CNS, well below 5 or 7 mg/kg. Most articles I came across were old articles published well before the establishment of the IRB. Researchers at that time were intentionally producing seizures and not suppressing to discover symptoms and to see how long the convulsions would last for. :eek:

The doc who did the procedure also said that the patient probably just had a seizure and that it was likely coincidental timing. I don't think that's the case because why would she have the metallic taste. Can happen with seizure activity, but she probably would have been noticed that with other seizures in the past. She also became warm to touch and diaphoretic.

Their team was completely unprepared to manage and did not know what to do. They didn't know what meds they had (or didn't have) nor where their ambu bags were.
 
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They had to have moved the needle. The injection went vascular no doubt.


In terms of test dose of local causing 'paraplegia'...not sure what the mechanism of that is, unless you are accidentally intrathecal.

If you are in a vessel, local aneshtetic would give one a metallic test or a 'weird feeling'...local aneshtetics rae actually vasodilators..
 
Pain Applicant1 said:
Yes, very scary. In fellowship, I had a lido toxicity case with an stellate and ended up doing a big M & M on it. I remember one article saying that the amount of lido considered to cause toxicity is reduced by some crazy number like 100 times when dealing with the CNS, well below 5 or 7 mg/kg. Most articles I came across were old articles published well before the establishment of the IRB. Researchers at that time were intentionally producing seizures and not suppressing to discover symptoms and to see how long the convulsions would last for. :eek:

The doc who did the procedure also said that the patient probably just had a seizure and that it was likely coincidental timing. I don't think that's the case because why would she have the metallic taste. Can happen with seizure activity, but she probably would have been noticed that with other seizures in the past. She also became warm to touch and diaphoretic.

Their team was completely unprepared to manage and did not know what to do. They didn't know what meds they had (or didn't have) nor where their ambu bags were.
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http://www.nexuspaincare.com/blog/w...ncy-Protocols-for-the-Spinal-Injectionist.pdf

Dr. Rosenthal gave a nice lecture at ISIS this summer. It was regarding his articles on Emergencies in Pain and need for training and practice. Had the guy who had the complication read the article and followed the recommendations, a better outcome may have ensued. Rosenthal was training 2 PMR fellows (he is Anes) and a patient was undergoing trigger point injection. She developed allergic reaction and over 15 min went anaphylaxis. Neither had any clue what to do other than call 911. They did not know if there was meds in the office or what do to for anaphylaxis. The patient died when the fellows were giving report to the EMS team in the hallway outside the exam room.
 
Logic should tell us that 1 ml of 1% lido in a lumbar TF will not cause a sz. even if in a vessel, nor toxicity. Otherwise people would be seizing ALL the time. I suspect stress induced sz in a pt with a h/o seizures. Other options include wrong med drawn up and or more quantity used than stated in OR report. Still good to know how to handle airway and seizures.

pyschogenic should also be high on list. "are you tasting metal?" , power of suggestion, etc.
 
That's what I was thinking. Sounds like a seizure. Nothing else...We would mix 40-50 mg of lidocaine in with the propofol. So they ALL got 50 mg of lidocaine IV, no seizures...



[QUOTE=facets;11958916]Even IV, 20 mg (1 cc 1% x 2) of lidocaine should not cause a seizure. We gave 100 mg as a bolus in anesthesia. Routinely, I mean all the time, gave 1-2 cc of lidocaine prior to diprovan to prevent burning. You say the patient had a seizure history? I would say she just had a seizure. If I were reviewing the case I would say that the doctor was not at fault for the seizure. However doing a procedure without having the ability to manage a seizure is a major liability.
Maybe all patients with a seizure history should have benzo pre-op?
Patients with seizures die because they don't get enough oxygen or they aspirate. Airway management is essential. No, you don't have to be an anesth. but you must be able to handle an airway.
Horrible situation, seizures are scary[/QUOTE]
 
Thanks for the link to the Rosenthal article. I actually came across this a few weeks ago and have been creating flow charts from it which I plan to blow up and hang in my c arm room, hopefully helping us prepare when a complication occurs. I'm also going to do mock codes at least one time per month.

I think I cited the article below regarding the significantly reduced dose required for toxicity when dealing with CNS vessels. I think one example was something like 3000mg peripheral equals 100mg into the vertebral artery. Of course the v-artery is not the LS TF space and I don't exactly remember as I can't access the article now that I'm outside of academic circles. Anyone have any tips on how to access articles being outside of academia, legally of course? I'd rather not pay $35/article every time I need to read up on something.

Pt reported funny taste in mouth prior to any mention of it by anyone. However, she was asked if it was metallic tasting and she confirmed.


Br J Anaesth. 1986 Jul;58(7):732-5.
Toxic effects of local anaesthetic agents on the central nervous system.
Scott DB.
 
This is stress or psychogenic induced reaction/seizure. If 1 ml caused these kind of problems people would be seizing/etc. left and right everyday in ortho clinics, etc.

The point about safety and preparedness still holds. We all must be prepared for the 1/million complication.

I do wonder why, when it comes to vagal reactions, some people here talk about a rapid flip to supine and airway/IV. Why not leave them prone, abort needle right away, and monitor? I d/w this with my aneth colleagues and they agree. Leave them prone, assess. If old and frail and they don't bounce back, then code them prn, but 99%+ should feel fine rather quickly and leaving them prone keeps them from aspirating if they puke.
 
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Pain Applicant1 said:
Yes, very scary. In fellowship, I had a lido toxicity case with an stellate and ended up doing a big M & M on it. I remember one article saying that the amount of lido considered to cause toxicity is reduced by some crazy number like 100 times when dealing with the CNS, well below 5 or 7 mg/kg. Most articles I came across were old articles published well before the establishment of the IRB. Researchers at that time were intentionally producing seizures and not supp
ressing to discover symptoms and to see how long the convulsions would last for. :eek:

The reason you had a seizure with the stellate is because the lidocaine went into the vertebral artery and directly into the brain, as little as 1/10 of a cc of local has been known to cause a seizure when the local goes directly into the vertebral artery. No such cases exist at L5/S1. Sorry, the patient just has a seizure
The doc who did the procedure also said that the patient probably just had a seizure and that it was likely coincidental timing. I don't think that's the case because why would she have the metallic taste.
You can taste metal at a much lower dose than that needed, try it, at 1-2 cc you can taste it. It is also sedating. Anesthesiologist are weird, we try crap on each other in training
Have you even seen anesthesiologist squirt stuff into an ETT to prevent "bucking on the tube?" Thats 4% lidocaine 40/mg per cc. Granted those patients are under general anesthesia but as docshark pointed out (I know its scary we are agreeing:smuggrin:) we mix lidocaine with diprovan for sedation in patients who are breathing spontanously in much greater volumes

Their team was completely unprepared to manage and did not know what to do. They didn't know what meds they had (or didn't have) nor where their ambu bags were.
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Bad, bad, bad
 
specepic said:
This is stress or psychogenic induced reaction/seizure. If 1 ml caused these kind of problems people would be seizing/etc. left and right everyday in ortho clinics, etc.

The point about safety and preparedness still holds. We all must be prepared for the 1/million complication.

I do wonder why, when it comes to vagal reactions, some people here talk about a rapid flip to supine and airway/IV. Why hold leave them prone, abort needle right away, and monitor? I d/w this with my aneth colleagues and they agree. Leave them prone, assess. If old and frail and they don't bouce back, then code them prn, but 99%+ should feel fine rather quickly and leaving them prone keeps them from aspirating if they puke.
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Yes, leave them prone, get a death grip on the jaw, mandibular thrust, it clears the airway and hurts so the patient wakes up and also gasps. I have also used smelling salts, just tape them to the light switches so you know where they are, grab, crush and put it under their nose, everyone in the room will gasp
 
facets said:
Bad, bad, bad
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Fair enough but coincidience or not, I'm using this case as a motivator to get my office in as much shape as possible. As they say on the addicts forums, SWIM, a coincidental visitor, needed to pretty much run the... ...and that is just simply not right.

I hope to never become as lackadaisical.
 
Pain Applicant1 said:
Yes, very scary. In fellowship, I had a lido toxicity case with an stellate and ended up doing a big M & M on it. I remember one article saying that the amount of lido considered to cause toxicity is reduced by some crazy number like 100 times when dealing with the CNS, well below 5 or 7 mg/kg. Most articles I came across were old articles published well before the establishment of the IRB. Researchers at that time were intentionally producing seizures and not suppressing to discover symptoms and to see how long the convulsions would last for. :eek:

The doc who did the procedure also said that the patient probably just had a seizure and that it was likely coincidental timing. I don't think that's the case because why would she have the metallic taste. Can happen with seizure activity, but she probably would have been noticed that with other seizures in the past. She also became warm to touch and diaphoretic.

Their team was completely unprepared to manage and did not know what to do. They didn't know what meds they had (or didn't have) nor where their ambu bags were.
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Tinnitus comes at a plasma level of 2-3. Perioral numbness and metallic taste comes at 3-4. Seizures come at 12-15.

As a resident i used to run around the hospital pushing IV lidocaine until getting tinnitus prior to starting an IV infusion for postop pain. Often id get the full 100 mg in over 5 minutes without any symptoms. I agree that it was coincidental.
 
facets said:
Yes, leave them prone, get a death grip on the jaw, mandibular thrust, it clears the airway and hurts so the patient wakes up and also gasps. I have also used smelling salts, just tape them to the light switches so you know where they are, grab, crush and put it under their nose, everyone in the room will gasp
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Excellent advice, this has just become a part of my office procedures and protocol. That's why I frequent these forums, nothing compares to getting advice from seasoned veterans.
 
DocShark said:
That's what I was thinking. Sounds like a seizure. Nothing else...We would mix 40-50 mg of lidocaine in with the propofol. So they ALL got 50 mg of lidocaine IV, no seizures...

I also routinely give several ccs of lido before propfol in smaller hand IVs. However, I don't think lido at almost any level will produce seizures when followed by 200 mg of propofol.

I went through this reasoning with ortho when they started doing high dose periarticular local infiltration. Preop pt would get a femoral catheter and block with bupi or ropi 30 ml 0.5%, sometimes bilaterally. Ortho would then 1.5-2 hrs later inject 170 ml ropi 0.2% periarticularly without discussing with anesthesia. Then expect us to start the catheter infusion in PACU.

I had to explain that the plasma studies for local infiltration did show safe plasma levels in 10 people, but no one has ever checked plasma levels with full dose femoral block followed by full dose local infiltration, and when a pt is under general anesthesia, there is no tinnitus, numbness, sedation, or seizures. It will just be cardiovascular collapse as the first symptom of toxicity. They still sometimes do it, but now it's either fem block or infiltration.
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In my experience, S/S occur as follows:

1. Perioral numbness
2. Tongue tip numbness
3. Tinnitus
4. Tunnel Vision

Seems people are inconsistent with metallic taste.

Would appreciate others thoughts.
 
Having taken care of thousands of seizures patients, I can tell the vast majority never require intubation. Most seizures stop within 2-3 minutes. Status epileptics is a different story. Benzos, Benzos, Benzos are first line. IV (or IM) Ativan 2mg, or valium 5 mg, versed is fine too, any benzo really. Repeat as needed. Yes, add supplemental oxygen by mask or assist with bag valve mask technique, a nasal trumpet can help. Intubate first? Not wrong, but usually not necessary. Rectal Valium (diastat) can be given. Works almost as fast as IV/IM.

Now. If you're requiring repeated, doses of Benzos, the seizure is going beyond 4-5 minutes, and the patient is hypoxic (very hard to tell with a flailing patient having a generalized tonic clonic seizure throwing the pulse ox off) then, definitely intubation is required.

Correct. No one should die of a simple seizure in a medical setting (can happen but is rare; status). Remember, patients with seizure disorder seize at home all the time and the vast minority of the time stop seizing on their own quickly. That being said, that doesn't mean do nothing.

Oxygen. IV/IM or rectal benzo. Intubate if status, hypoxia, airway protection. Follow ACLS.

Agree that 10 mg lidocaine, even IV is way subtoxic. Doses 100 mg IV have been used as an anti-arrythmic or for pre-treatment for prevention of spike in intracranial pressure during RSI of potentially head injured patients (and can, but doesn't routinely cause seizures). Sure, idiosyncratic reactions can occur, but in a person with known seizure disorder, they probably just..... had a seizure. Odd tastes, smells etc can be an aura or prelude to a seizure and may not be due to the lidocaine.

Yes know airway. Yes be prepared. Yes keep ACLS up to date. Reportable case? Doubt it. Run of the mill seizure at very in opportune time? Probably.
 
How many of you guys have intralipid? I don't but wish I did...how often do they have to be replaced?

I agree with a vagal prone pt staying prone and doing a strong jaw thrust/oxygen/vitals. Would you guys keep a seizing pt prone as well...I would likely flip into rescue position because I am more concerned about ventilation (and possible intubation, which I haven't done prone in a LONG time when an ETT fell out in the OR during a prone case) in that setting.
 
painstop said:
How many of you guys have intralipid? I don't but wish I did...how often do they have to be replaced?

I agree with a vagal prone pt staying prone and doing a strong jaw thrust/oxygen/vitals. Would you guys keep a seizing pt prone as well...I would likely flip into rescue position because I am more concerned about ventilation (and possible intubation, which I haven't done prone in a LONG time when an ETT fell out in the OR during a prone case) in that setting.
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My attending in residency did the big articles on interlipid. But it is for bupivicaine toxicity, so my first question is 1) how much bupivicaine are u gonna inject. If its is more than 4 cc (such as a knee or shoulder) I will ask why.

2) if you are in an office, is this what you wanna be doing? Giving interlipid?

So that makes me wanna say, unless you are in an operating room, and are doing peripheral nerve blocks with more than 3 mg/cc of marcaine, why do you need it/want it?
 
Good points above on Bup. Many times it is used in pain for historical/habit and not needed. I have stopped using for joints after seeing all the lawyer ads (personally not convinced it kills more chondrocytes). Only use for MBB and a little after RFA. Never for ESI
 
specepic said:
Good points above on Bup. Many times it is used in pain for historical/habit and not needed. I have stopped using for joints after seeing all the lawyer ads (personally not convinced it kills more chondrocytes). Only use for MBB and a little after RFA. Never for ESI
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why not use Ropi.....
 
bedrock said:
very expensive
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Yes, if you are paying for the stuff then yes expensive. But I wonder if it's that much more? The facility where I'm at picks up the tab. One could make the argument it's 'worth' it since the risk of bupi caused arrthymia could be problem.

All spine cases---use lido or diluted bupi

all peripheral stuff---bupi in injectate

all joints--only lido in the injectate (w/ steroid of course)
 
I think bupivacaine is safe for joints in the way that we use it. Those studies were based on use of LA with epi (reducing pH) or on the large volumes of LA used with ortho procedures/infusions, far more and far longer than we would require for single shot injections. It might be possible that the 0.25% bupiv that we (I) use during joint injections may be diluted out to 0.125% by synovial fluid and this concentration did not cause cellular death.
 
Pain Applicant1 said:
I think bupivacaine is safe for joints in the way that we use it. Those studies were based on use of LA with epi (reducing pH) or on the large volumes of LA used with ortho procedures/infusions, far more and far longer than we would require for single shot injections. It might be possible that the 0.25% bupiv that we (I) use during joint injections may be diluted out to 0.125% by synovial fluid and this concentration did not cause cellular death.
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Lawyer Ads read:

Did you have Bupivicaine used for Joint Injections?

If so please call 800-555-5555. I dont think they care what concentration was used.:mad:

http://www.searcylaw.com/blog/pain-pumps-and-a-lack-of-reliable-scientific-evidence/
 
Pain Applicant1 said:
I think bupivacaine is safe for joints in the way that we use it. Those studies were based on use of LA with epi (reducing pH) or on the large volumes of LA used with ortho procedures/infusions, far more and far longer than we would require for single shot injections. It might be possible that the 0.25% bupiv that we (I) use during joint injections may be diluted out to 0.125% by synovial fluid and this concentration did not cause cellular death.
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Gotta agree with pinch.

Doesn't matter what % the studies quoted. You're setting yourself up for unwanted liability by using bupivacaine for joint injections.

There's no good reason to use it for a joint anyway. Those extra few hours don't really matter and aren't worth the risk.
 
emd is an ER doc..... am I right?

And Docshark you ask why you would use large doses of marcaine. How bout for a LSB, SHB, celiac/splanchnics etc. I always use 0.25% marcaine in those cases, sometimes ropivicaine as it is safer
 
clubdeac said:
emd is an ER doc..... am I right?

And Docshark you ask why you would use large doses of marcaine. How bout for a LSB, SHB, celiac/splanchnics etc. I always use 0.25% marcaine in those cases, sometimes ropivicaine as it is safer
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i mix lido and marcaine. and i dont use more than 10 cc of the marcaine. total volume of those blocks, i use 10 ccs for a stellate. 3 cc lido plus epi for "test" then 7 cc of a mix of lido and marcaine. so total marcaine 3 cc.

LSB i use 13 cc. at L2. 3 cc of "Test" and 10 cc of mix 1:1 lido marciane, again 5 cc.

same for Celiac

if you look at the spread of the dye, and it goes every where you need with 5 cc, then you really only need 5 cc of the injectate, but we hedge...
i have used increasingly less doses over the years (not that many years, 6) but have had no change in outcomes.

I would like to put 5 cc of dye get good coverage, then put in 5 cc of local, i bet the result is fine. Just wont take the chance. The days of 20-30cc are left over from archaic principles of blind injections...
 
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DocShark said:
i mix lido and marcaine. and i dont use more than 10 cc of the marcaine. total volume of those blocks, i use 10 ccs for a stellate. 3 cc lido plus epi for "test" then 7 cc of a mix of lido and marcaine. so total marcaine 3 cc.

LSB i use 13 cc. at L2. 3 cc of "Test" and 10 cc of mix 1:1 lido marciane, again 5 cc.

same for Celiac

if you look at the spread of the dye, and it goes every where you need with 5 cc, then you really only need 5 cc of the injectate, but we hedge...
i have used increasingly less doses over the years (not that many years, 6) but have had no change in outcomes.

I would like to put 5 cc of dye get good coverage, then put in 5 cc of local, i bet the result is fine. Just wont take the chance. The days of 20-30cc are left of archaic principles from blind injections...
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A few weeks ago I was walking ventral on the vertebral body of L2. Pt had a little pain so I gave 1 ml lido 1%. 1 min or so later as I was getting ready to inject contrast, I noticed the foot was already 5 degrees warmer.
 
PinchandBurn said:
Lawyer Ads read:

Did you have Bupivicaine used for Joint Injections?

If so please call 800-555-5555. I dont think they care what concentration was used.:mad:

http://www.searcylaw.com/blog/pain-pumps-and-a-lack-of-reliable-scientific-evidence/
Click to expand...

It seems that the attorney is going after the pump/infusion companies. I don't think there are any studies, at least none that I am aware of, that show cytotoxic effects from our single shot, relatively low volume injections. The same studies implicating bupivacaine show that lidocaine, albeit to a lesser degree, can be cytotoxic as well.

bedrock said:
Gotta agree with pinch.

Doesn't matter what % the studies quoted. You're setting yourself up for unwanted liability by using bupivacaine for joint injections.

There's no good reason to use it for a joint anyway. Those extra few hours don't really matter and aren't worth the risk.
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What do you think about Manchikanti's article?

http://www.painphysicianjournal.com/2008/march/2008;11;121-132.pdf
 
Pain Applicant1 said:
It seems that the attorney is going after the pump/infusion companies. I don't think there are any studies, at least none that I am aware of, that show cytotoxic effects from our single shot, relatively low volume injections. The same studies implicating bupivacaine show that lidocaine, albeit to a lesser degree, can be cytotoxic as well.



What do you think about Manchikanti's article?

http://www.painphysicianjournal.com/2008/march/2008;11;121-132.pdf
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The data comparing lido and bup and it would apply to a single shot is admittedly weak. Concentration is just as important as type. On the other hand, what are gaining??

When it comes to a joint inj, the only advantage is with a joint DIAGNOSTIC injection in a pt with variable pain or a bad historian where 1-2 hrs relief will not clarify the situation. Sympathetic blocks also are a reasonable use imho. Given the possible cytotoxic issue, the legal target (attorneys prob don't understand the subtle clinical issues at hand?), and the higher risk of what can happen in the event of vascular or CSF uptake, why use it for bread and butter joint and pain procedures??
 
bedrock said:
very expensive
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I found a sneaky way to buy Intralipid on the cheap, that I'm not sure if many people are aware of...

I wasn't able to order Intralipid via outpatient pharmacies, so I went to an inpt / hospital pharm, and it wasn't expensive at all. And, I found out that I could buy other meds for a lot less too. For example, Marcaine was literally 3 x cheaper, and IV Amiodarone (for ACLS protocols) was 10 X cheaper at the hospital pharmacy. This blew my mind.
 
I have a few points or opinions about this thread -

Intralipid for seizure? It is used for cardiac arrest. I don't think it has any role for LA toxicity that precipitated a sz. Treat with airway support and benzos.

Ropivicaine? This is NOT a safer drug, although everyone talks like it is. In equipotent doses to bupivicaine (it is about 60% as potent), they probably are both equally cardiotoxic. There are plenty of case reports of cardiac arrest with ropiv that attest to this fact.

There is NO WAY 10mg of lidocaine caused a seizure. Theraputic dose for pain of intravenous lidocaine is 2-10ng/ml, and at these ranges of serum levels, the drug is VERY VERY safe. To get to these levels, you need at least 1mg/kg injection. It's true that a direct injection into the vertebral artery may precipitate a sz, but that is a drastically different scenario.

Many of the neurological symptoms that people have (ringing in the ears, etc) may have nothing to do with the serum level, but the rapid change in serum level. A guy at my institute did a study where he let down the Bier block (from lidocaine) at certain times, and recorded reported symptoms and took blood levels simultaneously. In many cases of reported symptoms, the levels of lidocaine were undetectable suggesting that the rapid change may be the cause of many of the commonly reported neurological symptoms.
 
ghost dog said:
I found a sneaky way to buy Intralipid on the cheap, that I'm not sure if many people are aware of...

I wasn't able to order Intralipid via outpatient pharmacies, so I went to an inpt / hospital pharm, and it wasn't expensive at all. And, I found out that I could buy other meds for a lot less too. For example, Marcaine was literally 3 x cheaper, and IV Amiodarone (for ACLS protocols) was 10 X cheaper at the hospital pharmacy. This blew my mind.
Click to expand...

i am not going to buy interlipid, but how does one buy from an inpatient pharmacy. I use Mckesson, or Henry Schein, or Clint, or PSS...whoever is cheaper.

other options out there?
 
ghost dog said:
I found a sneaky way to buy Intralipid on the cheap, that I'm not sure if many people are aware of...

I wasn't able to order Intralipid via outpatient pharmacies, so I went to an inpt / hospital pharm, and it wasn't expensive at all. And, I found out that I could buy other meds for a lot less too. For example, Marcaine was literally 3 x cheaper, and IV Amiodarone (for ACLS protocols) was 10 X cheaper at the hospital pharmacy. This blew my mind.
Click to expand...

Dude aren't you in Canadia? Whatever you say has no meaning to us. LOL.
 
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