Your RX for LAST?

[proman]

Advertisement - Members don't see this ad

Anyone read this month's A&A? There was a paper showing that epi + lipid was superior than either drug alone, at least in an isolated rat heart model of bupivacaine induced asystole.

 

[Gern Blansten]

Anyone read this month's A&A? There was a paper showing that epi + lipid was superior than either drug alone, at least in an isolated rat heart model of bupivacaine induced asystole.

Interesting. I will look for that one. Thanks.

 

[Frank Rizzo]

The fact that the patient was seizing is the reason I would give lipid. The usual course is neurologic sx--->cardiac symptoms
Sounds like this patient was going down that path.
Some experts who know a lot more about this topic than me suggest that giving lipid early when only neurologic symptoms are present can prevent it from becoming a cardiac issue as well.

Agree 100%. In this case the patient is having a sz with some cardiovascular symptoms. The pt may respond to benzo's and small doses of epi... they also may not... I'm not going to waste a VERY CRITICAL 20-30 seconds to find out.

 

[Frank Rizzo]

So, do you cancel the case because of a seizure?

Suppose the seizure stops, the patient regains consciousness, and has a good dense block.

I have had one seizure when doing a block... It was a nerve-stim ax block. Sz lasted about 10 seconds, got some benzo, lipid, and o2, but nothing else... the patient had no cardiac symptoms. Guy is otherwise healthy for ORIF of wrist. After observing for awhile, I proceeded with the case. I think if he had experienced any cardiac disturbances, I would not have taken him back.

 

[BLADEMDA]

Agree 100%. In this case the patient is having a sz with some cardiovascular symptoms. The pt may respond to benzo's and small doses of epi... they also may not... I'm not going to waste a VERY CRITICAL 20-30 seconds to find out.

Then why does't ASRA just say that? Why do they take a "middle of road" approach in recommending I.V. Lipid Emulsion? Why not just say "proceed immediately to Lipid Emulsion therapy when available." Clearly, ASRA is not endorsing the use of I.V. Lipids right off the bat.

I would use Lipid Emulsion early in any arrest due to LAST.

 

[Frank Rizzo]

Then why does't ASRA just say that? Why do they take a "middle of road" approach in recommending I.V. Lipid Emulsion? Why not just say "proceed immediately to Lipid Emulsion therapy when available."

I don't know the answer to that question... and they may not either.🙂

 

[BLADEMDA]

Interesting. I will look for that one. Thanks.

http://www.anesthesia-analgesia.org/content/111/3/791.full.pdf

 

[BLADEMDA]

Results In the rats treated with epinephrine plus lipid emulsion, there was a marked improvement in haemodynamic parameters at 25 min compared with rats treated with lipid alone, P<0.05. The coronary perfusion pressure immediately after lipid rescue was higher in the epinephrine/lipid-treated rats when compared with rats given lipid only (70 and 24 mm Hg, respectively, P<0.05). The myocardial bupivacaine content was lower (8.34 nM g&#8722;1) in the epinephrine/lipid group relative to other groups (P<0.05). However, the rats treated with lipid alone which survived had higher Po2, less severe acidosis, and better hypoxaemia relative to surviving rats given epinephrine plus lipid.


http://bja.oxfordjournals.org/content/early/2012/02/23/bja.aes018.abstract

 

[Gern Blansten]

Then why does't ASRA just say that? Why do they take a "middle of road" approach in recommending I.V. Lipid Emulsion? Why not just say "proceed immediately to Lipid Emulsion therapy when available." Clearly, ASRA is not endorsing the use of I.V. Lipids right off the bat.

I would use Lipid Emulsion early in any arrest due to LAST.

My theory is that these recommendations are in evolution. In the grand scheme of things, we are still very early into lipid therapy as the definitive therapy. ASRA is likely softening their stance because none of us know "absolutely for sure" that this is the definitive treatment. I suspect that ASRA will eventually fully and unequivocally endorse early lipid therapy, barring some unforeseen issue that we have not thought of or seen yet. Guidelines often take years to develop. Dr. Weinberg's landmark dog study was only published about 6 years ago. It takes a while to get everyone on the bus. I suspect that dantrolene was not immediately accepted as the definitive Tx for MH, but it happened pretty quick, much like lipid therapy has been quickly accepted. Epi as the ACLS first choice is pretty ingrained in everyone's mind. Those things don't change very fast and many would think it heresy to consider giving lipid before epi. I still think I would, mainly because I have read a lot about the topic and I am on board with lipid therapy. I also like to think I am out ahead of the curve on this one.
And, like I said earlier, there really is not a downside to trying it early that I can see. I'm not saying I would not also give epi, I am just saying, I would treat early as soon as neurologic symptoms appeared. If you wait for arrest, then you have to worry about circulating the lipid adequately, plus, the nurse's incident report will be much longer 🙂