PGDA (Anaesthesia)Assignment Six:Your registrar has just performed a supraclavicular block with 50ml 0.25%bupivicaine, and he has called you because he suspects local anaesthetic toxicity.Describe the clinical features expected with LA toxicity, and how toxicity withbupivicaine differs from lignocaine.As you arrive, the patient starts fitting. Outline your management.
Note that this is a
part question, and marks have been awarded equally for answeringeach of the three parts. Answers are ideally written with short, focused sentences and point-form. You should always try and relate your answer back to the specific case & patientdescribed in the question, keep your answer relevant and
answer the question asked.Organisation of answer and communication of important points. (1 MARK)1. Describe the clinical features expected with LA toxicity (3 MARKS)- LA toxicity may occur with inadvertent intravascular injection, rapid absorption from ahighly vascular area (eg. intercostal blocks), overdose of LA drug. Clinical presentation andspeed of onset of symptoms will be influenced by the nature of the toxicity.- In this patient, 50mL of 0.25% bupivicaine represents 125 mg of bupivacaine, and would bethe maximal dose for someone weighing 62.5 kg. It is likely that toxicity in this patient hasoccurred due to intravascular injection, which may occur at a dose lower than the calculated'toxic' dose.- Neurological effects of LA toxicity occur at lower plasma levels of LA than do the CVSeffects. Neurological symptoms can be a warning sign of impending cardiovascular collapse.LA toxicity can be classified as: [not required in your answer]- Systemic- Local - tissue ischaemia due to pressure effects or direct injection into nerves- Allergy - very rare. Ester LAs more common than Amide LAs (lignocaine, bupiv, etc.)- Metabolic - methaemoglobin production form prilocaine- Exaggerated physiological response - eg. total spinal from intrathecal LA.Clinical features of systemic LA toxicity:- Mild toxicity: perioral tingling; metallic taste, visual & speech disturbance, tinnitus.- Moderate toxicity: CNS effects: Altered conscious state, convulsions, coma.- Severe toxicity: Resp/CVS: Respiratory arrest, arrhythmias, cardiovascular collapse.- This patient currently has signs of moderate LA toxicity and I would be concerned thatcardiovascular collapse may occur if the toxicity progresses.- Maximal LA doses are described for patients who are otherwise well. Certain physiologicaland disease states dramatically increase cardiac sensitivity to LA toxicity:
,acidosis, hypercarbia, hypoxia.Plasma
concentrations for various effects:Therapeutic2 ug/mL - antiarrythmic