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Case report: intravenous lipid emulsion for treatment of local anesthetic toxicity following brachial plexus anesthesia

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Local anesthetic system toxicity following brachial plexus anesthesia is severe complication of regional block. We reported a case of central nervous system toxicity following brachial plexus anesthesia, who was rescued successfully with intravenous lipid emulsion.

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CASE REPORT: INTRAVENOUS LIPID EMULSION FOR

TREATMENT OF LOCAL ANESTHETIC TOXICITY FOLLOWING

BRACHIAL PLEXUS ANESTHESIA

Vo Van Hien*; Nguyen Trung Kien*

SUMMARY

Local anesthetic system toxicity following brachial plexus anesthesia is severe complication

of regional block We reported a case of central nervous system toxicity following brachial

plexus anesthesia, who was rescued successfully with intravenous lipid emulsion

* Key words: Local anesthetic system toxicity; Lipid emulsion

INTRODUCTION

Local anesthetic system toxicity (LAST)

is a recognized complication of major

conduction anesthesia The estimate of

clinically important local anesthetic toxicity

is from 7.5 to 20 occurrences per 10,000

peripheral nerve blocks [6] The incidence

of toxicity is greater with brachial plexus

techniques than most others, because larger

than usual doses of local anesthetics are

used and the injections are made in and

around large vascular channels in the head,

neck and axillary regions LAST includes

two major types: central nervous system

toxicity and cardiovascular system toxicity

that can be treated with lipid emulsion [1]

CASE REPORT

A 73 years old man, 164 cm tall, 50 kg

of weight, was admitted with right hand

injury due to labour accident which required

an emergency for wound resection and

reformed index and middle finger amputation

under supraclavicular approach anesthesia

on Monday 27 of June, 2016

- Biochemical test: glucose 7.5 mmol/L, ure 7.1 mmol/L, creatinine 76 µmol/L, GOT

122 U/L, GPT 117 U/L, K+ 3.8 mmol/L,

Na+ 136 mmol/L; ECG was normal at rate

of 67/min,sinus rythm

- Blood test: red blood cell 3.48 Tera/L, hemoglobin 101 g/L, hematocrit 0.32 l/L, platelet 100 G/L

- Continuously monitored of ECG, heart rate, oxygen saturation (SpO2) Blood pressure was monitored in 2.5 mins interval;

oxygen was given via facemask at a rate

of 3 L/min Blood pressure was 132/73 mmHg; respiratory rate 18 per minute

- In the operating room: an IV 18G was placed After given IV 100 µg of fentanyl and 20 mg of propofol, ultrasound guided supraclavicular approach anesthetizes was done with 300 mg of lidocaine in 25 mL (6 mg/kg) and 50 mg of ropivacaine (1 mg/kg) The patient was awake during the block No blood or paresthesias was seen during procedure The patient felt numbness in his arm 3 minutes after brachial block, motor block was assessed

by Bromage score at level 2

* 103 Hospital

Corresponding author: Nguyen Trung Kien (drkien103@gmail.com)

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- Approximately 10 minutes after the

needle removement, patient became confused

and unconscious, stopped breathing, SpO2

decreased from 100% to 50%

- Supported ventilation through facemask

with 100% oxygen for 5 minutes and SpO2

recovered in normal range 98 - 100%,

hemodynamic was stable pattern during

that time Spontaneous respiratory rate

recovered at rate of 18 per minute but

consciousness was still not recovered and

the patient did not response to verbal

commands as well as deep pain

stimulation any more Pupils were in

normal size and responded well with light

- Monitoring closely and surgeons

started procedure

unconciousness, lipid emulsion (10%)

therapy was started with bolus dose of

3 mL/kg (150 mL) intravenously over

1 minute

- The patient opened his eyes and

responded well to verbal commands and

got full recovery immediately from finishing

bolus dose

- We did not use continuous infusion

and operation finished at 64 minutes after

brachial plexus anesthesia The patient

was transfered to postoperative care unit

with normal parameter of hemodynamic

and respiratory He was discharged after

7 days of treatments

DISCUSSION

Some reasons of unconsciousness and

stopped breathing in this patient might be

caused by injecting 100 µg of fentanyl

and 20 mg of propofol before brachial

plexus anesthesia However, stopped

breathing and unconsciousness due to fentanyl and propofol effects could be excluded because the patient was still awake during and after taking ultrasound guided supraclavicular approach block Small dose of propofol just brought a sedation meaning and could not bring general anesthesia effect in this situation

He also felt numbness in his arm 3 minutes and motor block at level 2 according to Bromage score after brachial plexus block Thus, unconsciousness and stopped breathing could not have been blaimed for fentanyl or propofol effects

Local anesthetic toxicity happened in this patient may be due to high dose

of lidocaine (6 mg/kg) combined with ropivacaine (1 mg/kg) without combination with epinephrine Some authors indicated that toxicity occured most frequently following accidental intravascular injections and rarely following absorption of injected solutions from peripheral sites [2, 3] However, absorption was thought as a crucial reason in this patient because ultrasound guided for brachial block with inplane technique was performed Thus, doctor could see the needle as well as the tip of the needle clearly before injecting local anesthetics Further more, negative aspiration test was confirmed before injection local anesthetics

Local anesthetics are widely and commonly used for regional anesthesia Although it is rare for patients to manifest serious adverse effects or experience complications secondary to local anesthetic administration, adverse events can occur, even it is taken under ultrasound guided, let alone take blind techniques These range from the mild symptoms that may

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follow systemic absorption of local

anesthetics from a correctly sited and

appropriately dosed regional anesthetic

procedure to major central nervous

system (CNS) and/or cardiac toxicity

(most often from unintentional intravascular

injection) that can result in disability or

death [2]

A variety of factors influence the

likelihood and severity of local anesthetic

systemic toxicity (LAST), including individual

patient risk factors, concurrent medications,

location and technique of block, specific

local anesthetic compound, total local

anesthetic dose (concentration, volume),

timeliness of detection, and adequacy of

treatment Although the patient had a

higher GOT and GPT than normal level,

that was not reason for this complication

Slight anemia may have been a contributive

factor for making higher free level

concentration of local anesthetics in

plasma That is the reason this patient

was diagnosed central nervous system

toxicity in a typical type and lipid emulsion

was transfused after that

Local anesthetic dose is very important

factor to evoke the LAST According to

Felice [5], maximal dose of lidocaine is

6 - 8 mg/kg But, in this patient, brachial

plexus block was done with medium dose

(6 mg/kg of lidocaine and 1 mg/kg

ropivacaine) without combination with

epinephrine Moreover, elderly patient

with low level of protein (55 g/L) could

make a higher free concentration of local

anesthetics (LA) in plasma In fact that

one confounder in the interpretation of

serum concentrations of LA is protein

binding, which generally decreases with

increasing drug concentrations In the clinical setting of probable LA toxicity, an elevated total drug concentration may be reflective of a high free drug concentration

It is noted that, the serum concentration

of LA may correlate with clinical signs and symptoms of toxicity Lidocaine administration in regional blocks usually results in a serum concentration of

3 - 5 µg/mL and therapeutic plasma concentrations of lidocaine are 1 to

5 µg/mL when used for ventricular arrhythmias Symptoms of toxicity may occur at concentrations 6 µg/mL, convulsions may occur at concentrations 10 µg/mL, and cardiovascular collapse with levels

30 µg/mL [7] Our patient did not have symptoms of cardiac toxicity

The commercial products of intravenous lipid emulsion (IVLE) are available in various concentrations The 20% formulation of IVLE contains 20% soybean oil, 1.2% egg yolk phospholipids, 2.25% glycerin, and the remainder is water The osmolality of IVLE is approximately 350 mOsm/kg water and 260 mOsm/kg lipid emulsion In this case, it was not available of IVLE 20%

and IVLE 10% was injected with double volume in compare with guidline [7]

There are multiple theories about the mechanism of action of IVLE in LA toxicity

One theory is that IVLE serves as a “lipid sink,” providing a large lipid phase in the serum that is able to extract LAs from the plasma This may be true at the tissue level, as well Another theory is that IVLE has metabolic effects by inhibiting mitochondrial metabolism of lipids, reducing tissue acidosis and decreasing carbon dioxide production during times of myocardial

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ischemia Also, as LAs may impair fatty

acid delivery to the mitochondria, IVLE

may work to saturate this impaired fatty

acid delivery to enable further energy

production Additionally, fatty acids, as

found in IVLE, have been shown to activate

calcium and potassium channels, which

have been associated with LA-induced

cardiotoxicity [4]

Treatment of central nervous system

(CNS) complications and toxicity remains

controversial Seizures have been treated

successfully with benzodiazepines or

barbiturates (eg, phenobarbital) However,

Weinberg [7] recommended that lipid

infusion should be considered early, and

the treating physician should be familiar

with this method He also recommends

avoiding vasopressin and using epinephrine

only in small dose Obviously, vigilance,

preparedness, and quick action will improve

outcomes of this dreaded complication In

this case, we used lipid emulsion (10%)

therapy and the bolus dose was started

with of 3 mL/kg (150 mL) intravenously

and obtained good outcomes

According to Weinberg [7], if LAST

happended, we should use intralipid

emulsion and follow protocol for recovering

includes: bolus 1.5 mL/kg (lean body mass)

intravenously over 1 minute (~100 mL)

Then, continuous infusion 0.25 mL/kg/min

(~18 mL/min; adjust by roller clamp);

repeat bolus once or twice for persistent

cardiovascular collapse Double the infusion

rate to 0.5 mL/kg/min if blood pressure

remains low; continue infusion for at least

10 minutes after attaining circulatory

stability and recommended upper limit:

approximately 10 mL/kg lipid emulsion over the first 30 minutes Thus, plan for management of this complication should

be established, and a Local Anesthetic Toxicity Kit and posting instructions should be ready to use

CONCLUSIONS

Intravenous lipid emulsion infusion provided a good effective treatment for central nervous system toxicity due to complication of regional anesthesia

REFERENCES

1 Aya AG, Ripart J, Sebbane MA, de La Coussaye JE Lipid emulsions for the treatment

of systemic local anesthetic toxicity: Efficacy and limits Ann Fr Anesth Reanim 2010,

29 (6), pp.464-469

2 Di Gregorio G, Neal JM, Rosenquist

RW, Weinberg GL Clinical presentation of

local anesthetic systemic toxicity: a review of published cases, 1979 to 2009 Reg Anesth Pain Med 2010, 35 (2), pp.181-187

3 Dillane D, Finucane BT Local anesthetic

systemic toxicity Can J Anaesth 2010, 57 (4), pp.368-380

4 Faccenda KA, Finucane BT Complications

of regional anaesthesia Incidence and prevention Drug Saf 2002, 24 (6), pp.413-442

5 Felice K, Schumann H Intravenous

lipid emulsion for local anesthetic toxicity:

a review of the literature J Med Toxicol 2008,

4 (3), pp.184-191

6 Finucane Brendan T Complications of

brachial plexus anesthesia, complications of regional anesthesia Springer Science + Business Media, LLC: USA 2007, pp.121-144

7 Weinberg GL Treatment of local

anesthetic systemic toxicity (LAST) Reg Anesth Pain Med 2010, 35 (2), pp.188-193

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