Lidocaine Toxicity Follow-up

  • Author: Ruben Peralta, MD, FACS; Chief Editor: Michael R Pinsky, MD, CM, FCCP, FCCM   more...
 
Updated: Jun 28, 2011
 

Deterrence/Prevention

  • Know the toxic dose of the local anesthetic being used. Use the lowest concentration and volume of local anesthetic that still produces good results. Add epinephrine at a ratio of 1:200,000 to slow vascular uptake through vasoconstriction.
  • Without epinephrine, the maximum safe dose is approximately 3-5 (average 4) mg/kg. For example, a 70-kg adult should receive no more than 300 mg or 30 mL of a 1% solution. With epinephrine, the maximum safe dose is approximately 7 mg/kg. For example, a 70-kg adult should receive no more than 500 mg or 50 mL of a 1% solution.
  • Describe the early symptoms of local anesthetic overdose to patients and instruct them to inform the physician if they experience any of these effects. Be sure that patients understand the effects of local anesthetics and that they can communicate with the physician if symptoms occur.
  • A careful injection method may help prevent toxic reactions. Perform high-volume (>5 mL) injections slowly, in 3-mL increments. Stop to aspirate after every 3 mL injected. Injecting local anesthetic in this manner reduces the chances of a large-volume intravascular injection.
  • Maintain verbal contact with the patient during the procedure. This helps detect subtle symptoms, such as dysarthria, and more severe ones, such as changes in mental status.
  • Because benzodiazepines raise the threshold for CNS symptoms but not for cardiovascular system (CVS) symptoms, heavy benzodiazepine premedication is likely to result in a patient progressing directly to CVS toxicity without showing preliminary signs of CNS toxicity.
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Prognosis

If oxygenation, ventilation, and cardiac output are maintained, patients usually have a full recovery without sequelae. Otherwise, various hypoxic complications, or even death, are possible.

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Patient Education

Inform patients that they had a reaction to an overdose of local anesthetic.

Clarify the following points for the patient:

  • The reaction was not allergic in nature.
  • Patients do not have an increased risk for recurrence.
  • Patients do not have an increased risk for the development of seizures in the future.
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Contributor Information and Disclosures
Author

Ruben Peralta, MD, FACS  Professor of Surgery, Anesthesia and Emergency Medicine, Senior Medical Advisor, Board of Directors, Program Chief of Trauma, Emergency and Critical Care, Consulting Staff, Professor Juan Bosch Trauma Hospital, Dominican Republic

Ruben Peralta, MD, FACS is a member of the following medical societies: American Association of Blood Banks, American College of Healthcare Executives, American College of Surgeons, American Medical Association, Association for Academic Surgery, Eastern Association for the Surgery of Trauma, Massachusetts Medical Society, Society of Critical Care Medicine, and Society of Laparoendoscopic Surgeons

Disclosure: Nothing to disclose.

Specialty Editor Board

Russell F Kelly, MD  Program Director, Assistant Professor, Department of Internal Medicine, Division of Cardiology, Cook County Hospital, Rush Medical College

Russell F Kelly, MD is a member of the following medical societies: American College of Cardiology

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Harold L Manning, MD  Professor, Departments of Medicine, Anesthesiology and Physiology, Section of Pulmonary and Critical Care Medicine, Dartmouth Medical School

Harold L Manning, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and American Thoracic Society

Disclosure: Nothing to disclose.

Timothy D Rice, MD  Associate Professor, Departments of Internal Medicine and Pediatrics and Adolescent Medicine, St Louis University School of Medicine

Timothy D Rice, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Physicians

Disclosure: Nothing to disclose.

Chief Editor

Michael R Pinsky, MD, CM, FCCP, FCCM  Professor of Critical Care Medicine, Bioengineering, Cardiovascular Disease and Anesthesiology, Vice-Chair of Academic Affairs, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center

Michael R Pinsky, MD, CM, FCCP, FCCM is a member of the following medical societies: American College of Chest Physicians, American College of Critical Care Medicine, American Heart Association, American Thoracic Society, Association of University Anesthetists, European Society of Intensive Care Medicine, Shock Society, and Society of Critical Care Medicine

Disclosure: LiDCO Ltd Honoraria Consulting; iNTELOMED Intellectual property rights Board membership; Edwards Lifesciences Honoraria Consulting; Applied Physiology, Ltd Honoraria Consulting; Cheetah Medical Consulting fee Consulting

Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous coauthor, Dr Karl A Poterack, to the development and writing of this article.

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