![]() The remaining settings included office (11%), home (9%), ward (8%), and emergency department (8%). Of 47 cases of LAST evaluated in a 2018 review, 67% of cases occurred in the operating room and 14% of cases occurred in the post anesthesia recovery unit. LAST most commonly occurs in the operating room but is reported in other practice sites. Lastly, peripheral nerve blocks are 5 times more likely to cause LAST compared to epidural blocks. Bupivacaine is the highest-risk local anesthetic given its low safety margin and difficulty in resuscitation however, ropivacaine and lidocaine account for a large proportion of reported cases. LAST is more common in patients aged 60 years, with low muscle mass, and comorbid conditions (e.g., cardiac disease, liver disease, and diabetes). Symptoms of methemoglobinemia include cyanosis, chocolate-brown blood and falsely low pulse oximetry readings (85%). 3 Methemoglobinemia is most often reported following oral and dermal exposures to benzocaine, lidocaine, and prilocaine compared to other local anesthetics. 1,2 Prodromal syndromes such as tinnitus, perioral numbness, confusion, and dizziness may precede more serious toxicity but are less common. In bupivacaine toxicity, however, CNS and cardiac symptoms occur simultaneously. CNS symptoms typically precede cardiac symptoms. When systemically absorbed, this antagonism results in severe CNS depression, seizures, QRS widening, ventricular tachycardia, ventricular fibrillation, and/or asystole. In therapeutic use, local anesthetics decrease pain by blocking neuronal sodium voltage-gated channels proximal to the administration site. Local anesthetic systemic toxicity (LAST) is the rapid onset of severe CNS depression, seizures and cardiac arrhythmias following local anesthetic administration. Consult with your local poison center at 1-80.Administer methylene blue for methemeglobinemia.Arrhythmias: modified ACLS (i.e., low-dose epinephrine and amiodarone as needed, avoid lidocaine).Seizures: liberal benzodiazepines/barbiturates/propofol.Administer the following as additional supportive care:.Administer lipid emulsion therapy at the first sign of systemic toxicity.Local anesthetic systemic toxicity is the rapid onset of severe central nervous system (CNS) depression, seizures and cardiac arrhythmias following local anesthetic administration.This narrative review summarizes the current status and advances in the use of emulsions and liposomes for detoxification and also suggests several areas in which studies are needed for developing future therapies.Ĭritical care Detoxification Drug sequestration Emulsions Lipid rescue Liposomes.Ĭopyright © 2015 Elsevier B.V. The in vitro results for drug sequestration by liposomes are very promising and animal trials have in some cases shown comparable performance to ILE at reduced lipid dosing. Several researchers have designed liposomes using a variety of approaches including surface charge, pH gradients, and inclusion of enzymes in the liposome core to optimize the formulations for detoxification of a specific drug or toxicant. Liposomes are highly biocompatible and versatile formulations, thus it was a natural step to explore their use for drug overdose therapy as well. ILEs were not originally developed to treat overdose, but clarifying the mechanisms of detoxification observed with ILE may allow us to design more effective future treatments. While ILE therapy has been successful in several cases, its use beyond local anesthetic systemic toxicity is controversial and its mechanism of detoxification remains a subject of debate. Intravenous lipid emulsions (ILEs) have been investigated as a potential treatment for overdoses of local anesthetics and other hydrophobic drugs. There is a clear medical need to improve the effectiveness of detoxification, in particular by developing more specific therapies or antidotes for these overdoses. ![]() ![]() In many cases, supportive care is limiting, ineffective, and expensive. Although some overdoses may be treated with specific antidotes, the most common treatment involves providing supportive care to allow the body to metabolize and excrete the toxicant. Drug overdoses from both pharmaceutical and recreational drugs are a major public health concern. ![]()
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