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Local anesthetic toxicity: Who is ready for lipid resuscitation?

A survey of German Hospitals

Lokalanästhetikaintoxikation: Wer ist auf die Lipidbehandlung vorbereitet?

Eine Umfrage unter deutschen Kliniken

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Abstract

Purpose

Toxic reactions to local anesthetics are rare but potentially lethal. In fact, animal studies and case reports demonstrate that the administration of lipid emulsions after initializing cardiopulmonary resuscitation is a promising treatment option. The aim of this study was to determine how many hospitals in Germany are prepared to treat toxic reactions to local anesthetics with lipid infusion and to identify how often and what type of toxic reactions occur and if treatment was successful. Further, we aimed to elucidate if current guidelines lead to more immediate availability of lipid emulsions in direct proximity to the room where regional anesthesia is performed.

Methods

A standardized survey was sent to 1,305 German hospitals. The main question was whether lipid emulsions are readily available and if published guidelines contributed to this availability. Additionally, we asked whether local anesthetic toxicity had already successfully been treated by lipid emulsions and what type of symptoms were treated.

Results

We received replies from n = 509 (39 %) hospitals. In 338 (66 %) of the responding hospitals, lipid emulsions are readily available. Hospitals with standard operating procedures (SOPs) implemented according to published guidelines have lipids significantly more often immediately available than hospitals with just SOPs (chi-square test of independence, p-value < 0.01). Of all responding hospitals 287 (56 %) have implemented a SOP for the treatment of toxic reactions to local anesthetics and 196 (39 %) of the hospitals introduced the SOP because of the guidelines.

In 28 (6 %) of the hospitals, local anesthetic toxicity had already caused cardiac arrest with subsequent cardiopulmonary resuscitation in at least one patient. In 132 (26 %) hospitals, local anesthetic toxicity had already been treated by infusing lipid emulsions. Of these hospitals 128 (96 %) state this therapeutic approach was successful. Treatment with lipid emulsions was performed frequently after prodromal symptoms 83 (63 %) were witnessed.

Conclusions

The majority of surveyed German hospitals are prepared to treat toxic reactions to local anesthetics and published guidelines contributed to this preparedness. The infusion of lipid emulsions is a promising measure to deal with toxic reactions to local anesthetics. Since toxic reactions to local anesthetics are potentially lethal, it seems desirable that lipid emulsions are generally available in routine clinical practice. Currently, the treatment of toxic reactions to local anesthetics is mostly performed in situations (e. g. treatment of prodromal symptoms) that are not recommended by current guidelines. Further research is necessary to better define the future use of lipid emulsions in routine clinical practice.

Zusammenfassung

Ziel der Arbeit

Lokalanästhetikaintoxikationen (LAI) sind selten, aber potenziell letal. Tierexperimentelle Studien und Fallberichte zeigen, dass Lipidemulsionen (LE) eine erfolgreiche Therapieoption bei LAI darstellen.

Ziel war es zu ermitteln, wie viele Deutsche Krankenhäuser vorbereitet sind und LAI mit LE behandeln können, wie oft LAI beobachtet wurden und ob die Behandlung erfolgreich war.

Methoden

Ein standardisierter Fragebogen wurde an 1305 deutsche Kliniken für Anästhesie verschickt. Es wurde u. a. gefragt, ob LE unmittelbar vorrätig sind, wo Regionalanästhesie (RA) durchgeführt wird, ob publizierte Leitlinien von Fachgesellschaften dazu geführt haben, LE unmittelbar verfügbar zu halten, und ob eine LAI schon einmal erfolgreich mit LE behandelt wurde.

Ergebnisse

Die Rücklaufquote betrug 39 % (n = 509). In 338 Kliniken (66 %) sind LE unmittelbar verfügbar. Krankenhäuser, die Standard Operating Procedures (SOP) aufgrund von Leitlinien implementiert haben, hatten LE signifikant häufiger verfügbar als solche, die die SOP aus anderen Gründen implementiert hatten (p < 0,01). In 28 Kliniken (6 %) hatte eine LAI einen Herzstillstand mit notwendiger CPR zur Folge. In 132 Kliniken (26 %) wurde eine LAI bereits mit LE behandelt, davon in 128 Kliniken (96 %) erfolgreich.

Diskussion

Die Mehrheit der antwortenden Kliniken ist auf LAI vorbereitet, und publizierte Leitlinien haben dazu einen Beitrag geleistet. Aufgrund von potenziell letalen Komplikationen bei LAI wäre es wünschenswert, wenn LE flächendeckend überall dort vorrätig wären, wo RA durchgeführt werden.

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Authors and Affiliations

  1. Department of Anesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne, Germany

    G. Rosenthal, W. A Wetsch, T. Neumann, S. A. Padosch, B. W. Böttiger &  H. E. Marcus

  2. Hospital Cologne-Merheim, Cologne Medical Centres, Department of Anesthesiology and Intensive Care Medicine, Witten/Herdecke University, Ostmerheimer Strasse 200, Cologne, Germany

    H. E. Marcus

Authors
  1. G. Rosenthal
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  2. W. A Wetsch
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  3. T. Neumann
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  4. S. A. Padosch
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  5. B. W. Böttiger
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  6. H. E. Marcus
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Correspondence to H. E. Marcus.

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Conflict of interest

H.E. Marcus, G. Rosenthal, W.A. Wetsch, T. Neumann, S.A. Padosch, and B.W. Böttiger state that there are no conflicts of interest.

The accompanying manuscript does not include studies on humans or animals.

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Rosenthal, G., Wetsch, W.A., Neumann, T. et al. Local anesthetic toxicity: Who is ready for lipid resuscitation?. Anaesthesist 65, 267–273 (2016). https://doi.org/10.1007/s00101-016-0156-5

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  • DOI: https://doi.org/10.1007/s00101-016-0156-5

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