Introduction
 
Following some convincing animal studies,^1,2 recent case reports describe the successful use of 20% lipid emulsion to treat cardiovascular collapse,³ arrhythmias⁴ and cardiac arrest^5-7 caused by local anaesthetic. It has been recommended that 20% lipid emulsion should be available wherever patients receive large doses of local anaesthetic (e.g., operating rooms, labour wards, emergency department, radiology suite).^8,9 The following protocol is based on others that have been published previously.^8,10 This treatment is supported by only low-level evidence but in the absence of obvious significant harm it seems reasonable to follow this protocol.
 

Protocol

1. If a patient develops cardiac arrest that is likely to have been caused by local anaesthetic toxicity give 20% lipid emulsion 1.5 ml kg^-1 (100 ml in 70 kg patient) intravenously once CPR, following advanced life support guidelines, has been started. This treatment should also be considered if a patient develops severe cardiovascular compromise (hypotension, unstable arrhythmias) that is attributable to local anaesthetic toxicity – thus potentially preventing cardiac arrest.
    
   
2. Start an infusion of 20% lipid emulsion at 0.25 ml kg^-1 min^-1 (about 20 ml min^-1 in 70 kg patient) and continue until a stable rhythm and adequate circulation has been restored.
    
   
3. Repeat the bolus dose at 5 min intervals until a stable rhythm and adequate circulation is restored.
   

Notes

• Restoration of spontaneous circulation after local anaesthetic-induced cardiac arrest may take more than 1 hour to achieve.
   
  
• Ensure that 500 – 1000 ml 20% lipid emulsion is available for the treatment of severe cardiovascular compromise or cardiac arrest associated with local anaesthetic toxicity in all clinical areas where high doses of local anaesthetics are used.
   
  
• Report all cases of suspected local anaesthetic intoxication to the National Patient Safety Agency (www.npsa.nhs.uk).
   
  
• The nearest lipid emulsion is stored   . . . . . . . . . . . . .  (for completion locally)

References

1. Weinberg GL, Vade-Boncouer T, Ramaraju GA, Garcia-Amaro MF, Cwik MJ. Pretreatment or resuscitation with a lipid infusion shifts the dose-response to bupivacaine-induced asystole in rats. Anesthesiology 1998; 88: 1071-5.
    
   
2. Weinberg G, Ripper R, Feinstein DL, Hoffman W. Lipid emulsion infusion rescues dogs from bupivacaine-induced cardiac toxicity. Reg Anesth Pain Med 2003; 28: 198-202.
    
   
3. Foxall G, McCahon R, Lamb J, Hardman JG, Bedforth NM. Levobupivacaine-induced seizures and cardiovascular collapse treated with Intralipid^®. Anaesthesia 2007; 62: 516-8.
    
   
4. Ludot H, Tharin J-Y, Belouadah M, Mazoit J-X, Malinovsky J-M. Successful resuscitation after ropivacaine and lidocaine-induced ventricular arrhythmia following posterior lumbar plexus block in a child. Anesth Analg 2008;106:1572-4.
    
   
5. Litz RJ, Popp M, Stehr SN, Koch T. Successful resuscitation of a patient with ropivacaine-induced asystole after axillary plexus block using lipid infusion. Anaesthesia 2006; 61: 800-1.
    
   
6. Rosenblatt MA, Abel M, Fischer GW, Itzkovich CJ, Eisenkraft JB. Successful use of a 20% lipid emulsion to resuscitate a patient after a presumed bupivacaine-related cardiac arrest. Anesthesiology 2006; 105: 217-8.
    
   
7. Warren JA, Thoma RB, Georgescu A, Shah SJ. Intravenous lipid infusion in the successful resuscitation of local anesthetic-induced cardiovascular collapse after supraclavicular brachial plexus block. Anesth Analg 2008; 106: 1578-80.
    
   
8. Picard J, Meek T. Lipid emulsion to treat overdose of local anaesthetic: the gift of the glob. Anaesthesia 2006; 61: 107-9.
    
   
9. Weinberg GL. In defence of lipid resuscitation. Anaesthesia 2006; 61: 807-8.
    
   
10. Association of Anaesthetists of Great Britain and Ireland. Guidelines for the Management of Severe Local Anaesthetic Toxicity. AAGBI London 2007 www.aagbi.org

 
July 2008
 
 
 
 
 

	© Resuscitation Council (UK)  2008   This page last updated: 25 July 2008