eMedicine Specialties > Emergency Medicine > Toxicology

Toxicity, Lidocaine: Follow-up

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
Coauthor(s): Karl A Poterack, MD, Consulting Staff, Department of Anesthesiology, Mayo Clinic Scottsdale; Sarah C Langenfeld, MD, Assistant Professor of Psychiatry, Department of Psychiatry, University of Massachusetts Medical School; Attending Psychiatrist, Community HealthLink
Contributor Information and Disclosures

Updated: May 30, 2008

Follow-up

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.
  • Lidocaine
    • 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.

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.

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.

Miscellaneous

Medicolegal Pitfalls

  • Failure to stop a large-volume local anesthetic injection every 3-5 mL to aspirate and check for early symptoms of a reaction
  • Failure to investigate previous reactions to local anesthetics: The vast majority of reactions are toxicity-based, and allergic reactions are rare. However, if the patient has even a vague history of a reaction involving airway and cardiovascular problems, consider a potential allergic reaction.
 


More on Toxicity, Lidocaine

Overview: Toxicity, Lidocaine
Differential Diagnoses & Workup: Toxicity, Lidocaine
Treatment & Medication: Toxicity, Lidocaine
Follow-up: Toxicity, Lidocaine
References
[ CLOSE WINDOW ]

References

  1. Chang YY, Ho CM, Tsai SK. Cardiac arrest after intraurethral administration of lidocaine. J Formos Med Assoc. Aug 2005;104(8):605-6. [Medline].

  2. Achar S, Kundu S. Principles of office anesthesia: part I. Infiltrative anesthesia. Am Fam Physician. Jul 1 2002;66(1):91-4. [Medline].

  3. Carpenter RL, Mackey DC. Local Anesthetics. In: Barash PG, Cullen BF, Stoelting RK, eds. Clinical Anesthesia. Philadelphia, Pa: J.B. Lippencott; 1992;509-41.

  4. Challapalli V, Tremont-Lukats IW, Mc Nicol. Systemic administration of local anesthetic agents to relieve neuropathic pain. Cochrane Database Syst Rev. CD003345.

  5. Challapalli V, Tremont-Lukats IW, McNicol ED, et al. Systemic administration of local anesthetic agents to relieve neuropathic pain. Cochrane Database Syst Rev. 2005;CD003345.

  6. Cox B, Durieux ME, Marcus MA. Toxicity of local anaesthetics. Best Pract Res Clin Anaesthesiol. Mar 2003;17(1):111-36. [Medline].

  7. Dershwitz M, Hoke JF, Rosow CE, et al. Pharmacokinetics and pharmacodynamics of remifentanil in volunteer subjects with severe liver disease. Anesthesiology. Apr 1996;84(4):812-20. [Medline].

  8. Dorf E, Kuntz AF, Kelsey J, Holstege CP. Lidocaine-induced altered mental status and seizure after hematoma block. J Emerg Med. Oct 2006;31(3):251-3. [Medline].

  9. Faccenda KA, Finucane BT. Complications of regional anaesthesia Incidence and prevention. Drug Saf. 2001;24(6):413-42. [Medline].

  10. Isohanni MH, Ahonen J, Neuvonen PJ, Olkkola KT. Effect of ciprofloxin on the pharmacokinetics of intravenous lidocaine. Eur J Anaesthesiol. Oct 2005;22(10):795-9. [Medline].

  11. Isohanni MH, Neuvonen PJ, Olkkola KT. Effect of fluvoxamine and erythromycin on the pharmacokinetics of oral lidocaine. Basic Clin Pharmacol Toxicol. Aug 2006;99(2):168-72. [Medline].

  12. Toledo LS, Mauad R. Complications of body sculpture: prevention and treatment. Clin Plast Surg. Jan 2006;33(1):1-11, v. [Medline].

  13. Miller RD. Local Anethesthetics. Miller's Anesthesia. 2006;6th edition:594-595.

  14. Odaka Y, Takahashi T, Yamasaki A, et al. Prevention of halothane-induced hepatotoxicity by hemin pretreatment: protective role of heme oxygenase-1 induction. Biochem Pharmacol. Apr 1 2000;59(7):871-80. [Medline].

  15. Paris PM, Yeale DM. Pain Management. Rosen's Emergency Medicine. 2006;6th:2913-2937.

  16. Strichartz GR, Berde CB. Local Anesthetics. In: Miller RD, ed. Anesthesia. Philadelphia, Pa: Churchill Livingstone;. 1994;489-521.

  17. Toledo LS, Mauad R. Complications of body sculpture: prevention and treatment. Clin Plast Surg. Jan 2006;33(1):1-11, v. [Medline].

  18. Tremont-Lukats IW, Challapalli V, McNicol ED, Lau J, Carr DB. Systemic administration of local anesthetics to relieve neuropathic pain: a systematic review and meta-analysis. Anesth Analg. Dec 2005;101(6):1738-49. [Medline].

  19. Tsui BC, Wagner A, Finucane B. Regional anaesthesia in the elderly: a clinical guide. Drugs Aging. 2004;21(14):895-910. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

lidocaine toxicity, local anesthetic toxicity, lidocaine poisoning, adverse anesthesia reaction, lidocaine overdose, anesthetic overdose, local anesthetic reaction, CNS lidocaine toxicity, anesthetic reaction, anesthesia toxicity

[ CLOSE WINDOW ]

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 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.

Coauthor(s)

Karl A Poterack, MD, Consulting Staff, Department of Anesthesiology, Mayo Clinic Scottsdale
Karl A Poterack, MD is a member of the following medical societies: American Society of Anesthesiologists
Disclosure: Nothing to disclose.

Sarah C Langenfeld, MD, Assistant Professor of Psychiatry, Department of Psychiatry, University of Massachusetts Medical School; Attending Psychiatrist, Community HealthLink
Sarah C Langenfeld, MD is a member of the following medical societies: American Medical Association, American Psychiatric Association, and Massachusetts Medical Society
Disclosure: Nothing to disclose.

Medical Editor

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.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Harold L Manning, MD, Associate 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.

CME Editor

Timothy D Rice, MD, Associate Professor, Departments of Internal Medicine and Pediatrics and Adolescent Medicine, Saint 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, Academic Affairs, 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, 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

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.