Local Anesthetic Toxicity Follow-up

  • Author: Raffi Kapitanyan, MD; Chief Editor: Asim Tarabar, MD   more...
 
Updated: Apr 3, 2012
 

Further Inpatient Care

Patients with persistent or unresolved significant reactions require admission to a monitored bed for observation, further evaluation, and treatment. Patients who are stable and have minor or easily controlled adverse reactions can be discharged and monitored on an outpatient basis. Advise patients with adverse reactions to avoid the specific anesthetic agent in the future and to alert medical personnel of the reaction.

If a patient has experienced an adverse reaction to one class of anesthetic (ester or amide), risk for adverse reactions is higher for all agents in that class.

 
Contributor Information and Disclosures
Author

Raffi Kapitanyan, MD  Assistant Professor of Emergency Medicine, University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School

Raffi Kapitanyan, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Mark Su, MD, FACEP, FACMT  Consulting Staff and Director of Fellowship in Medical Toxicology, Department of Emergency Medicine, North Shore University Hospital; Consulting Staff, North Shore University Hospital

Mark Su, MD, FACEP, FACMT is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Emergency Physicians, American College of Medical Toxicology, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Lance W Kreplick, MD, FAAEM, MMM  Medical Director of Hyperbaric Medicine, Fawcett Wound Management and Hyperbaric Medicine; Consulting Staff in Occupational Health and Rehabilitation, Company Care Occupational Health Services; President and Chief Executive Officer, QED Medical Solutions, LLC

Lance W Kreplick, MD, FAAEM, MMM, is a member of the following medical societies: American Academy of Emergency Medicine and American College of Physician Executives

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

John G Benitez, MD, MPH  Associate Professor, Department of Medicine, Medical Toxicology, Vanderbilt University Medical Center; Managing Director, Tennessee Poison Center

John G Benitez, MD, MPH is a member of the following medical societies: American Academy of Clinical Toxicology, American Academy of Emergency Medicine, American College of Medical Toxicology, American College of Preventive Medicine, Society for Academic Emergency Medicine, Undersea and Hyperbaric Medical Society, and Wilderness Medical Society

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Asim Tarabar, MD  Assistant Professor, Director, Medical Toxicology, Department of Emergency Medicine, Yale University School of Medicine; Consulting Staff, Department of Emergency Medicine, Yale-New Haven Hospital

Disclosure: Nothing to disclose.

References

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Table 1. Local Anesthetic Agents Used Commonly for Infiltrative Injection
AgentDuration of ActionMaximum Dosage Guidelines (Total Cumulative Infiltrative Injection Dose per Procedure*)
Esters
Procaine (Novocain)Short (15-60 min)7 mg/kg; not to exceed 350-600 mg
Chloroprocaine (Nesacaine)Short (15-30 min)Without epinephrine: 11 mg/kg; not to exceed 800 mg total dose



With epinephrine: 14 mg/kg; not to exceed 1000 mg



Amides
Lidocaine (Xylocaine)Medium (30-60 min)Without epinephrine: 4.5 mg/kg; not to exceed 300 mg
Lidocaine with epinephrineLong (120-360 min)With epinephrine: 7 mg/kg
Mepivacaine (Polocaine, Carbocaine)Medium (45-90 min) Long (120-360 min with epinephrine)7 mg/kg; not to exceed 400 mg
Bupivacaine (Marcaine)Long (120-240 min)Without epinephrine: 2.5 mg/kg; not to exceed 175 mg total dose
Bupivacaine with epinephrineLong (180-420 min)With epinephrine: Not to exceed 225 mg total dose
Etidocaine (Duranest)



No longer available in United States



Long (120-180 min)Without epinephrine: 0.4 mg/kg; not to exceed 300 mg total dose



With epinephrine: 8 mg/kg



Prilocaine (Citanest)Medium (30-90 min)Body weight < 70 kg: 8 mg/kg; not to exceed 500 mg



Body weight >70 kg: 600 mg



Ropivacaine (Naropin)Long (120-360 min)5 mg; not to exceed 200 mg for minor nerve block
*Nondental use, administer by small incremental doses; administer the smallest dose and concentration required to achieve desired effect; avoid rapid injection.
Table 2. Epinephrine Content Examples
Solution Volume1:100,000 (1 mg/100 mL)1:200,000 (1 mg/200 mL)
1 mL0.01 mg0.005 mg
5 mL0.05 mg0.025 mg
10 mL0.1 mg0.05 mg
20 mL0.2 mg0.1 mg
Example: 50 mL of 1% lidocaine with epinephrine 1:100,000 contains lidocaine 500 mg and epinephrine 0.5 mg.
Table 3. Minimum Intravenous Toxic Dose of Local Anesthetic in Humans[1]
AgentMinimum Toxic Dose (mg/kg)
Procaine19.2
Tetracaine2.5
Chloroprocaine22.8
Lidocaine6.4
Mepivacaine9.8
Bupivacaine1.6
Etidocaine3.4
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