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Ropivacaine induced toxicity by local conduction anesthesia and treatment using lipid emulsion infusion
Yukihiko Obara; Saitama Social Insurance Hospital; Toshiyasu Nakamura; Keio University; Eiko Yamabe; Department of Orthopaedic Surgery,Keio University
Yukihko Obara, Tokyo, Jordan

Ropivacaine shows reduced cardiac toxicity compared to bupivacaine. However, this agent has been reported to cause local anesthetic induced toxicity and thus cannot be considered completely safe. A 20% lipid emulsion has recently seen successful use as a standard treatment in the resuscitation of patients with local anesthetic induced toxicity. We have treated clinical cases of local anesthetic induced toxicity, and therefore sought to determine the usefulness of treating such toxicity with lipid emulsion. Methods: This study population included 510 patients who underwent hand surgery operations using local conduction anesthesia. The mean age of patients at the time of surgery was 60 years (range, 12-88 years). Ropivacaine 150-300 mg was applied for local conduction anesthesia. As soon as symptoms of local anesthetic induced toxicity were recognized in a patient, the airway was supported and the lungs ventilated with 100% oxygen via a face mask. If condition did not improve, patients were converted to general anesthesia. Lipid emulsion was available for the treatment of any local anesthetic induced toxicity for those patients (n=288) who underwent hand surgery after September 2009. Intralipid 20% was then injected as a bolus, followed by continuous infusion of 10-100 ml. Infusion of lipid emulsion was stopped as soon as symptoms of local anesthetic induced toxicity were seen to have resolved. In four patients, infusion of lipid emulsion was continued slowly after symptoms of local anesthetic induced toxicity were seen to have resolved. The number of patients with local anesthetic induced toxicity and effects of treatment with lipid emulsion were investigated. Results: Local anesthetic induced toxicity was identified in 22 of the 510 patients. The mean dose of ropivacaine was 187 mg (range, 150-300 mg). These patients showed local anesthetic induced toxicity at a mean of 44 min (range, 5-97 min) after inducing conduction anesthesia. Eight patients were treated before lipid emulsion became available (Group 1), while the 14 most recent patients were treated using the lipid emulsion injection (Group 2). In Group 1, a total of three patients were converted to general anesthesia for the treatment of local anesthetic induced toxicity. In Group 2, no patients underwent such conversion. Symptoms resolved within a mean of 17.4 min (range, 3-42 min) after lipid emulsion injection. The 14 patients received 10-100 ml of Intralipid 20% over the course of 3-58 min. Conclusion: Local anesthetic induced toxicity occurred in 22 patients, and lipid emulsion injection appeared useful treatment.


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