Local anaesthetic infusion

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General Management
  • Routine post-op care should be given, unless instructed to do otherwise by the Anaesthetist.
  • Pain, nausea, sedation, motor block and signs of toxicity observations must be carried out:
    - Recovery: every 15minutes
    - On Ward: hourly for 4 hours
    - 4 hourly thereafter
  • Also check the pump and the local anaesthetic catheter for disconnections every 4 hours.
  • Ensure a patent I.V. cannula is in situ whilst the local anaesthetic is in progress, in case lipid rescue is required.
  • Administer the prescribed regular and breakthrough oral analgesia as normal.
  • Patients with a brachial plexus block should have their arm secured in a sling.
  • Patients with continues intrascalene blocks should have 4 hourly respiratory rate and oxygen saturations. They may require continuous oxygen due to potential spread to phrenic nerve causing temporary hemidiaphram paralysis.
  • If there are any concerns regarding the wound infusion device please contact the Acute Pain Nurse or ITU Anaesthetist.
Local anaesthetic toxicity and management

Local anaesthetic toxicity is rare but life-threatening. Most deaths from local anaesthetic toxicity have been due to the inadvertent intravenous injection of a toxic dose of local anaesthetic.  Rapid recognition and appropriate treatment saves lives.

Early signs and symptoms

Late signs and symptoms

tinnitus

flushed face

circum-oral numbness

lightheadedness

slurred speech

hypotension

muscle twitching

 

tonic-clonic convulsions

drowsiness

coma

respiratory arrest

profound hypotension

bradycardia

ventricular arrhythmias

cardiac arrest –compounded by hypoxia

Please monitor pain and nausea score and look for signs of toxicity as follows:

  • In Recovery         Every 15 mins
  • On Ward              Pain, nausea, sedation and signs of toxicity should be performed hourly for 4 hours,
  • then 4 hourly if the patient remains stable.

Pain, nausea and sedation to be recorded on NEWs chart.

Signs of toxicity and system check to be recorded on local anaesthetic chart.

  • Only the dedicated local anaesthetic pump may be used.
  • Routine post operative care should be given, unless instructed to do otherwise by the Anaesthetist.
  • Patients with a brachial plexus block should have their arm secured in a sling.
  • Ensure a patent I.V. cannula is in situ, whilst the local Anaesthetic Infusion is in progress.

If any of the signs and symptoms of local anaesthestic toxicity are present:

• Clamp the wound infusion device line.
• Contact the ITU Anaethetist urgently
• Administer Oxygen 10 litres per min via facemask if O2 Sats > 95%.
Call for help and initiate CPR procedures if the patient is apnoeic. Call 2222.
• Obtain Lipid rescue bags - ClinOleic 20%, stored in surgical HDU, pharmacy cupboard, theatre corridor (bleep 1089 for access) and labour suite and commence as soon as possible.

Treatment of local anaesthetic toxicity is likely to have a good outcome if toxicity is recognised and basic resuscitation is started early. The basic tenets of treatment are:

  • prevent hypoxia which will cause brain damage and make fitting or arrhythmias more difficult to control
  • treat hypotension and arrhythmias early
  • ensure that fits are adequately treated
  • most reactions are short-lived if the above advice is followed. 

Treatment of severe local anaesthetic toxicity

A.   Airway

Ensure an adequate airway and give oxygen 10 litres/min via face mask

B.   Breathing

Ensure that the patient is breathing adequately. Ventilation with or without intubation may be required.

C.   Circulation

Treat circulatory failure with intravenous fluids and vasopressors:

ephedrine 10 to 30 mg boluses

adrenaline may be used cautiously intravenously in boluses of 0.5 to 1 ml of 1: 10,000 if

ephedrine is either unavailable or ineffective

treat arrhythmias

start chest compressions if cardiac arrest occurs or there is an arrhythmia with no output

D.   Drugs

Treat convulsions. Do not allow fits to continue as this will cause hypoxia.

diazepam 0.2 to 0.4 mg/kg intravenously slowly over 5 minutes, repeated after 10 minutes if required, or 2.5mg to 10mg rectally

buccal midazolam 10mg (unlicensed preparation)

Reduce the myocardial local anaesthetic concentration with intralipid 20%. give 1mL/kg bolus

give 2 further doses every 3 to 5 minutes

start an infusion at 0.25mls/kg/min until 500ml given

After successful resuscitation admit the patient to a high dependency area or Intensive Care Unit.

Lipid rescue bags-ClinOleic 20% stored in SDHU cupboard, pharmacy cupboard, theatre corridor (bleep 1089 for access) and labour suite

 

Editorial Information

Last reviewed: 11 November 2020

Next review: 11 November 2022

Author(s): Acute Pain Team, Raigmore Hospital

Version: 2

Approved By: TAM Subgroup of ADTC

Reviewer Name(s): Acute Pain Nurse Specialists

Document Id: TAM109