Lipid infusion for local anaesthetic toxicity

Disclaimer

These guidelines have been produced to guide clinical decision making for the medical, nursing and allied health staff of Perth Children’s Hospital. They are not strict protocols, and they do not replace the judgement of a senior clinician. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline. 

Read the full PCH Emergency Department disclaimer.

Aim 

To guide PCH ED staff in the administration of lipid infusion (Intrapid 20%®) for the acute management of local anaesthetic toxicity following inadvertent intravascular injection during regional anaesthesia in the ED.

This guideline can be used for the management of Lipid Rescue for accidental IV administration of local anaesthetic.

Background

Cardiovascular collapse is the most life-endangering complication of intravascular injection during regional anaesthesia. Intravenous lipid emulsion administration is an established clinical practice for treating local anaesthetic systemic toxicity that also shows promise as an effective antidote for other lipophilic drug poisoning.1

Key principles

Intravenous Local Anaesthetic Toxicity1

  • Local anaesthetic systemic toxicity is generally considered to be resistant to conventional modes of resuscitation. 
  • Only Intralipid® brand should be used for the treatment of acute local anaesthetic toxicity.
  • The ‘lipid sink’ phenomenon is the most widely accepted mechanism of action for lipids. 
    • The lipid emulsion infusion creates an expanded lipid phase, and the resulting equilibrium drives toxic drug from tissue to the aqueous plasma phase then into the lipid phase. 
    • This draws down the content of lipid-soluble local anaesthetics from within the cardiac tissue, thereby improving cardiac conduction, contractility and coronary perfusion.

Indications

  • The Intralipid® brand of fat emulsion is reserved solely for the emergency management of local anaesthetics inadvertently administered intravenously. No other brands of lipid emulsions are to be used.
  • For signs of local anaesthetic toxicity and immediate management, refer to Management of Severe Local Anaesthetic Toxicity Guideline 20102 

Lipid rescue

Administration2

  • Give Lipid Emulsion 20% (Intralipid® brand of Fat Emulsion):
    • Bolus 1.5mL/kg over 1 minute
    • Start infusion at 0.25mL/kg/min = 15mL/kg/hr
    • A maximum of 2 repeat boluses may be given at 5 minute intervals if patient has cardiovascular instability or is in cardiac arrest (Max 3 boluses total) 
    • Increase the rate to 0.5mL/kg/min (30mL/kg/hr) if haemodynamic stability is not restored after boluses
    • Continue infusion until haemodynamic stability is restored
    • Maximum cumulative dose of 12mL/kg is recommended
  10kg  15kg 20kg 25kg 30kg
Bolus (kg)  15 22.5 30 37.5 45
Infusion rate (mL/min) 2.5 3.75 5 6.25 7.5
Infusion rate (mL/hour) 150 225 300 375 450
Maximum cumulative dose (mL) 120 180 240 300 360

  • Lipid emulsion 20% (Intralipid®) is given in addition to standard Cardio-Pulmonary Resuscitation.
  • Prompt and effective airway management must be implemented to prevent hypoxia and respiratory acidosis, which may potentiate local anaesthetic toxicity.

Nursing

All patients with suspected local anaesthetic toxicity must have full cardiorespiratory monitoring.

References

  1. Weinberg GL. Lipid emulsion infusion: resuscitation for local anesthetic and other drug overdose. Anesthesiology. 2012;117:180-7
  2. Cave G, Harrop-Griffiths W, Harvey M, Meek T, Picard J, Short T, Weinberg G. Safety Guideline: Management of Severe Local Anaesthetic Toxicity Guideline Association of Anaesthetics of Great Britain 2010



Endorsed by:  Drugs & Therapeutics Committee  Date:  Feb 2019


 Review date:   Jan 2022


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