Local anesthetic tox

[ghost dog]

Hi All,

I was wondering if peeps could share their stories of local anesthetic tox.

Over the past 8 years, I have had a few mild ones (i.e. transient nausea, vertigo) which have quickly resolved with Oxygen by face mask, and 1 which put the frighteners into me (he was fine in the end- but definitely brown pants time during the resuct'n).

Has anyone used Intralipid 20%? I have it in the clinic, but hope never to have to use it !!!!

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[lobelsteve]

I've never used more than 30cc 1% and 10cc .25% for any case. All of it subq for pockets and midline incision.

 

[ghost dog]

I've never used more than 30cc 1% and 10cc .25% for any case. All of it subq for pockets and midline incision.

Just because you're not exceeding the maximal recommended dose of L.A.
doesn't mean you're 100% safe from Local anesthetic tox.

Inadvertent intravascular injection or administration into vascular tissue is a common cause of L.A. tox. In particular, inadvertent intravascular injection can cause local anesthetic toxicity even if anesthetic was administered WITHIN the recommended dose range.

This is what happened with my brown pants case. I should note that I injected this guy on many occasions previously with no problems, and was very comfortable with this particular technique. These things happen.

 

[Jcm800]

Hi All,

I was wondering if peeps could share their stories of local anesthetic tox.

Over the past 8 years, I have had a few mild ones (i.e. transient nausea, vertigo) which have quickly resolved with Oxygen by face mask, and 1 which put the frighteners into me (he was fine in the end- but definitely brown pants time during the resuct'n).

Has anyone used Intralipid 20%? I have it in the clinic, but hope never to have to use it !!!!

one of my attendings during residency came up with that intralipid thing...

 

[Jcm800]

Just because you're not exceeding the maximal recommended dose of L.A.
doesn't mean you're 100% safe from Local anesthetic tox.

Inadvertent intravascular injection or administration into vascular tissue is a common cause of L.A. tox. In particular, inadvertent intravascular injection can cause local anesthetic toxicity even if anesthetic was administered WITHIN the recommended dose range.

This is what happened with my brown pants case. I should note that I injected this guy on many occasions previously with no problems, and was very comfortable with this particular technique. These things happen.

we had a case during residency where a guy died...it was an interscalene block...guy seized, cardiac arrest, tried intralipid...nothing worked. sad case. at a VA. if you want any more info, this has to go to private forum...

 

[ghost dog]

Hi All,

I was wondering if peeps could share their stories of local anesthetic tox.

Over the past 8 years, I have had a few mild ones (i.e. transient nausea, vertigo) which have quickly resolved with Oxygen by face mask, and 1 which put the frighteners into me (he was fine in the end- but definitely brown pants time during the resuct'n).

Has anyone used Intralipid 20%? I have it in the clinic, but hope never to have to use it !!!!

No other feedback?

Surely other people have had problems with tox?? Docshark and me can't be the only ones.

I find that most patients respond nicely with high flow 15 L / min Oxygen by facemask when it is mild.

I've probably had 6-8 mild cases of tox in the past 7.5 years, and 1 moderate to severe case. The severe case
completely recovered, and has continued to receive blockade since.

Is this number of tox cases in keeping with you other docs ?

Other experiences? Comments?

 

[epidural man]

one of my attendings during residency came up with that intralipid thing...

I'm not sure it works. The original work was done in dogs - and the problem with that model is you can bring back a dog from almost anything with anything.

In humans, we are left with case reports.

There was a study done at my hospital on Pigs (a better animal model) - showed it didn't work. There have been others as well in the same model. I'm not sure why ASRA completely ignored these negative studies in their recommendations for LAST treatment.

What I suspect is that LA is both cardio protective and neuro protective (I mean after it shuts it down so to speak) because why else would we have cases of people getting CPR for an hr or so, and recovering fully after a perfusing rythm returns - with no neurological sequela. That's pretty impressive.

 

[painchas]

Years ago transarterial ax block with frequent aspiration for av graft pre seizure activity with fluttering of the lids and transient unresponsiveness 1 minute. Had a good versed dose on board which raised the seizure threshold. Close call but okay.
Interscalene blocks have resulted in strong cardiac binding which would require prolonged resuscitation in excess of 45 minutes if significant arterial uptake were to occur. Has been reported in the south with bad outcomes, see above. No bad experience here on a personnal level but story has made the rounds in South Carolina. You cant get the marcaine off of the cardiac receptor. Enter intralipid.
Regards.

 

[Aether2000]

Since I don't use any deep local for anything except intra-articular blocks, I have not seen toxicity....

 

[mdvol]

So, begs the question, who here, uses LA with epidurals either trans or IL?

 

[SSdoc33]

So, begs the question, who here, uses LA with epidurals either trans or IL?

1 mL in TFESI, none for ILESI. never had an issue

i assume most of the toxicity comes from using a lot during SCS implantation. may be a decent question to pose of the anesthesiology or surgery forums

 

[ghost dog]

1 mL in TFESI, none for ILESI. never had an issue

i assume most of the toxicity comes from using a lot during SCS implantation. may be a decent question to pose of the anesthesiology or surgery forums

will do

cheers

 

[bedrock]

So, begs the question, who here, uses LA with epidurals either trans or IL?

Never in ILESI. I don't routinely use for TFESI as it doesn't add that much and patients feel great leaving the office and then sometimes call back because they "feel worse" 2 hrs later.
Will occasionally use 0.5 cc of 1% lido with TFESI if pt struggling, but that's rare.

 

[clubdeac]

Doesn't everyone on here use 20cc or so of 0.25% marcaine for their splanchnics, LSBs, celiacs, SHP blocks etc? This is probably the only time I'd run into problems with this. Haven't yet, knock on wood...

 

[lobelsteve]

Doesn't everyone on here use 20cc or so of 0.25% marcaine for their splanchnics, LSBs, celiacs, SHP blocks etc? This is probably the only time I'd run into problems with this. Haven't yet, knock on wood...

10-12cc only.

 

[Pain Applicant1]

.

 

[epidural man]

-Use ultrasound for guidance

Holy CRAP I can't believe you mentioned that here on this forum. Have you not been reading the posts? Are you nuts?

 

[Pain Applicant1]

Possible good news is that my attending during my fellowship has developed an anesthetic that is looking very promising. Minimal if any cardio effects, less motor effects, and long acting. Soon to be FDA approved. Be on the lookout.

 

[Pain Applicant1]

Holy CRAP I can't believe you mentioned that here on this forum. Have you not been reading the posts? Are you nuts?

not sure what you're talking about but will remove post to comply

 

[ghost dog]

not sure what you're talking about but will remove post to comply

I believe the poster is referring to this issue:

Just because you're not exceeding the maximal recommended dose of L.A.
doesn't mean you're safe from Local anesthetic tox.

Inadvertent intravascular injection or administration into vascular tissue is a common cause of L.A. tox. In particular, inadvertent intravascular injection can cause local anesthetic toxicity even if anesthetic was administered WITHIN the recommended dose range.

 

[ghost dog]

Possible good news is that my attending during my fellowship has developed an anesthetic that is looking very promising. Minimal if any cardio effects, less motor effects, and long acting. Soon to be FDA approved. Be on the lookout.

How much will this stuff cost?

$$$?

 

[Pain Applicant1]

I believe the poster is referring to this issue:

Just because you're not exceeding the maximal recommended dose of L.A.
doesn't mean you're safe from Local anesthetic tox.

Inadvertent intravascular injection or administration into vascular tissue is a common cause of L.A. tox. In particular, inadvertent intravascular injection can cause local anesthetic toxicity even if anesthetic was administered WITHIN the recommended dose range.

Oh, okay, will repost. Hopefully my post will help avoid the same thing happening to someone else. I think the intravascular thing is a misunderstanding of my post. I agree with that statement. What I was trying to say is that local anesthetic toxicity levels are essentially irrelevant when going IV as the levels are significantly lower and toxicity will occur much earlier.



Intravascular during SGB. Patient may or may not have seized, definitely not generalized, maybe slight localization. Vitals moved a bit but remained WNL. Patient apneic and unconscious. Midaz immediately given to ward of seizure activity but midaz given for sedation prior to procedure (likely reason for ambiguous sz activity), mask venilated ~10 minutes. Patient woke up and did very well. Sent to ED, discharged home a few hours later. I, on the other hand, had to present at M and M

Some things I learned:
-No patient talking during procedure (thumbs up/down only)
-Inject slowly, minute increments only with frequent aspirations
-Use small volume only (but must cover Kuntz's nerves)
-Use ultrasound for guidance
-toxicity levels mean nada if vascular access obtained (off by maybe 100x), especially in vessels feeding CNS

 

[ghost dog]

Oh, okay, will repost. Hopefully my post will help avoid the same thing happening to someone else. I think the intravascular thing is a misunderstanding of my post. I agree with that statement. What I was trying to say is that local anesthetic toxicity levels are essentially irrelevant when going IV as the levels are significantly lower and toxicity will occur much earlier.



Intravascular during SGB. Patient may or may not have seized, definitely not generalized, maybe slight localization. Vitals moved a bit but remained WNL. Patient apneic and unconscious. Midaz immediately given to ward of seizure activity but midaz given for sedation prior to procedure (likely reason for ambiguous sz activity), mask venilated ~10 minutes. Patient woke up and did very well. Sent to ED, discharged home a few hours later. I, on the other hand, had to present at M and M

Some things I learned:
-No patient talking during procedure (thumbs up/down only)
-Inject slowly, minute increments only with frequent aspirations
-Use small volume only (but must cover Kuntz's nerves)
-Use ultrasound for guidance
-toxicity levels mean nada if vascular access obtained (off by maybe 100x), especially in vessels feeding CNS

This is why I don't like giving sedation for neural blockade procedures (if it can be avoided).

 

[Pain Applicant1]

How much will this stuff cost?

$$$?

Not sure. Way above my paygrade.

This is why I don't like giving sedation for neural blockade procedures (if it can be avoided).

I think that's a good idea. Of course, if the patient didn't receive midaz prior to the procedure, he might have gone tonic-clonic.

 

[lobelsteve]

Didnt pain medicine just put out study advocating blind sgb? It was a depth to tubercle study. If using us, how good at seeing aberrant vascular uptake compared to contrast and fluoro? No bone in the way so if you us guru's can see something other than fuzzy static, it seems fine to do. I'll continue my dinosaur ways using fluoro and omnipaque.

 

[101N]

Didnt pain medicine just put out study advocating blind sgb? It was a depth to tubercle study. If using us, how good at seeing aberrant vascular uptake compared to contrast and fluoro? No bone in the way so if you us guru's can see something other than fuzzy static, it seems fine to do. I'll continue my dinosaur ways using fluoro and omnipaque.

During my fellowship - @ a socialist org - I got to work with guys in IR. I remember doing a cervical disc aspirate using a combo of fluoro and US. The IR guys - even back then - seemed to figure they are both just tools of the trade.

 

[Pain Applicant1]

Didnt pain medicine just put out study advocating blind sgb? It was a depth to tubercle study. If using us, how good at seeing aberrant vascular uptake compared to contrast and fluoro? No bone in the way so if you us guru's can see something other than fuzzy static, it seems fine to do. I'll continue my dinosaur ways using fluoro and omnipaque.

That's interesting. If possible, can you please post the link?

 

[Ligament]

Perhaps the ideal way would be needle placement with combination U/S and fluoro and DSA with fluoro during injection. I would not do a stellate without DSA at this point.