We were glad to see positive mention of lipid emulsion therapy for local anesthetic toxicity in the letter by Dr. Baumgarten and again by Dr. Morell in a recent commentary in the APSF Newsletter. Dr. Baumgarten's note detailed several suggestions for improving safety of peripheral nerve and plexus blocks and referred to a patient who survived severe, systemic bupivacaine toxicity by virtue of a heroic resuscitation—possible only because there happened to be a primed bypass machine nearby.1 Unfortunately, despite precautions taken to prevent it, local anesthetic toxicity continues to occur and all patients are not as lucky, nor all outcomes as favorable. The commentary by Dr. Morell reminds readers that lipid emulsion infusion provides a simple, less invasive method of treating systemic local anesthetic toxicity.2
There are now several published case reports of successful resuscitation with lipid emulsion from cardiac arrest from local anesthetic toxicity3-6 and one related to bupropion overdose.7 Symptoms of toxicity were rapidly reversed in all patients, often after failure of standard resuscitative measures including countershocks and adrenergic therapy. Notably, all recovered without cardiac or neurological deficits. Similar cases have also been posted on the educational website www.lipidrescue.org where clinicians are encouraged to post their experiences and several more are in press (personal communication). We believe the scientific evidence and clinical experience supporting lipid therapy are now sufficient to justify stocking lipid emulsion at all sites where large doses of local anesthetics are used.
Paradoxically, a recent survey by Corcoran et al.8 found a general lack of coordinated preparation for these potentially fatal occurrences in US academic anesthesiology departments. The need for a consensus in this area was recognized by the Association of Anaesthetists of Great Britain and Ireland, which recently issued guidelines for treating severe local anesthetic toxicity, (http://www.aagbi.org/publications/guidelines/docs/latoxicity07.pdf). This excellent document goes some distance to remedying the deficiency, but only part way. A universally accepted protocol for treating systemic local anesthetic toxicity would reduce treatment variance, improve physician preparedness and patient safety, and ultimately contribute to the APSF mission: "To ensure that no patient is harmed by anesthesia."