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Rudra R, Probert A, Ceasar J, Romanoski N. Local anesthetic systemic toxicity: An effort to identify knowledge gaps across specialties. PM R 2024; 16:434-440. [PMID: 37883117 DOI: 10.1002/pmrj.13093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 09/26/2023] [Accepted: 10/07/2023] [Indexed: 10/27/2023]
Abstract
INTRODUCTION Physical medicine and rehabilitation (PM&R) physicians are trained to perform interventional procedures using local anesthetics (LAs) to reduce pain and enhance function and quality of life. LA administration is not benign and one potential complication is local anesthetic systemic toxicity (LAST). Anesthesiologists also perform interventions with LAs; however, training on LAST may differ between medical specialties. OBJECTIVE To investigate if a gap exists in the knowledge of LAST between physiatry and anesthesiology physicians. DESIGN Prospective cross-sectional survey study. SETTING AND PARTICIPANTS All residents, fellows, and attendings of the anesthesiology and PM&R departments at a single academic medical center. OUTCOME MEASURES The primary outcome measures include participants' self-reported exposure to LAST education and comfort with their LAST knowledge as recorded on a Likert scale, as well as the percentage of correctly answered knowledge-based questions on the topic. RESULTS Fifty-eight physicians including 28 PM&R and 30 anesthesiology physicians (24 attending and 34 trainees) participated. Anesthesiology trainees and attendings exhibited greater overall perceived knowledge of LAST (trainees U = 43, p < .001; attendings U = 9, p < .001), with greater exposure to LAST education (trainees U = 16.5, p < .001; attendings U = 12, p < .001). Assessment of responses to knowledge-based questions on LAST revealed a statistically significant knowledge gap between PM&R and anesthesia trainees (t = 6.62, p = <.001) as well as between attending groups (t = 3.25, p = <.01). CONCLUSION This study reveals a distinction in both the subjective and objective knowledge of LAST between PM&R and anesthesiology physicians at a single academic institution. This suggests that there is opportunity for further assessment of the education on LAST among physiatrists and residents in training.
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Affiliation(s)
- Renuka Rudra
- Department of Physical Medicine & Rehabilitation, Penn State Health, Hershey, Pennsylvania, USA
| | - Allan Probert
- Department of Physical Medicine & Rehabilitation, Penn State Health, Hershey, Pennsylvania, USA
| | - Justin Ceasar
- Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Natasha Romanoski
- Department of Physical Medicine & Rehabilitation, Penn State Health, Hershey, Pennsylvania, USA
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Muacevic A, Adler JR. A Myriad of Symptoms After Spinal Anesthesia: A Case Report of Local Anesthetic Systemic Toxicity. Cureus 2022; 14:e29902. [PMID: 36348927 PMCID: PMC9632230 DOI: 10.7759/cureus.29902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/04/2022] [Indexed: 01/24/2023] Open
Abstract
Local anesthetics are widely used by various medical professionals. Although their usefulness is unquestionable, as with any medication, there is a possibility of iatrogenic effects. When local anesthetic systemic toxicity occurs, it might be a life-threatening condition. Knowing its existence and how to act when it arises is crucial. The clinical presentation is wide-ranging, but globally it affects the neurological and cardiovascular system, with cardiac arrest being the extreme of its presentation. The treatment is mainly supportive with an attempt to reverse the effects of the anesthetic by administering a lipid emulsion. Here, we present a clinical case of difficult management with many complications.
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Li X, Trerotola SO. Local Anesthesia in Interventional Radiology. Semin Intervent Radiol 2022; 39:381-386. [PMID: 36406026 PMCID: PMC9671687 DOI: 10.1055/s-0042-1757342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Interventional radiology is an evolving field that treats a variety of diseases. Local anesthetics is an important component of pain management during interventional radiologic procedures. It is highly effective and generally safe for routine procedures. However, local anesthetics can be associated with painful initial injection, allergic reactions, and rare but potentially devastating systemic toxicities. Recent evidence has shown that buffered solution and warm local anesthetics may reduce injection discomfort and improve clinical efficacy. Sensible safety practices and prompt recognition/treatment of the systemic toxicity are of paramount importance to provide safe local anesthesia. Interventional radiologists should be familiar with the basic pharmacology, common local anesthetics, optimizing strategies, complications, and management to provide safe and effective local anesthesia for patients.
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Affiliation(s)
- Xin Li
- Section of Interventional Radiology, Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Scott O. Trerotola
- Section of Interventional Radiology, Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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Could alkalinization worsen local anesthetic systemic toxicity? Am J Emerg Med 2022; 58:342-344. [PMID: 35461742 DOI: 10.1016/j.ajem.2022.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 03/16/2022] [Accepted: 04/09/2022] [Indexed: 11/24/2022] Open
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Jamaleddin Surani SA, Budiman M, Azman M, Abdul Rahman R. Assessment of Awareness of Local Anaesthetic Systemic Toxicity (LAST) among Postgraduate Trainees. Int J Clin Pract 2022; 2022:4090444. [PMID: 36458263 PMCID: PMC9675600 DOI: 10.1155/2022/4090444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 10/05/2022] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Although uncommon, local anaesthetic systemic toxicity (LAST) may impose fatal risk to the patients. We investigated the awareness of LAST and knowledge on local anaesthetics among our postgraduate trainees. MATERIALS AND METHODS A total of 134 postgraduate trainees from the departments of general surgery (Surgical), orthopaedic surgery (Ortho), otorhinolaryngology (ENT), obstetrics and gynaecology (OBGYN), as well as anaesthesiology and intensive care (Anaesth) were recruited. A validated questionnaire was used to assess awareness and knowledge. All participants attended a medical-education session and completed the questionnaire as preassessment and postassessment. Data were analysed, and comparisons between disciplines were conducted. RESULTS The trainees' awareness of LAST was overall poor at preassessment which improved almost 6-folds at postassessment. Surprisingly, only 20 (45.5%) participants from the anaesthesiology group had awareness of LAST at preassessment, and none of the participants were from surgical, orthopaedic, and obstetrics and gynaecology departments. Preassessment scores were significantly higher in the anaesth group as compared to all other groups; with a difference in the average score for Anaesth vs Surgical of 3.46 (95%, CI:2.17, 4.74), Anaesth vs Ortho of 3.64 (95%, CI:2.64, 4.64), Anaesth vs ENT of 3.43 (95%, CI:2.20, 4.67), and Anaesth vs OBGYN of 6.93 (95%, CI:5.64, 8.21). However, there was no significant difference of awareness scores between all participants at postassessment scores. CONCLUSION The overall level of awareness was poor. However, the implementation of an education session significantly improved the knowledge and awareness across all disciplines.
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Affiliation(s)
- Shafiq Ali Jamaleddin Surani
- Department of Anaesthesiology & Intensive Care, Penang General Hospital, Jalan Residensi, 10990 George Town, Penang, Malaysia
| | - Maryam Budiman
- Department of Anaesthesiology & Intensive Care, Universiti Kebangsaan Malaysia Medical Centre, Jalan Yaacob Latif, Bandar Tun Razak, 56000 Kuala Lumpur, Malaysia
| | - Mawaddah Azman
- Department of Otorhinolaryngology-Head, and Neck Surgery, Universiti Kebangsaan Malaysia Medical Centre, Jalan Yaacob Latif, Bandar Tun Razak, 56000 Kuala Lumpur, Malaysia
| | - Raha Abdul Rahman
- Department of Anaesthesiology & Intensive Care, Universiti Kebangsaan Malaysia Medical Centre, Jalan Yaacob Latif, Bandar Tun Razak, 56000 Kuala Lumpur, Malaysia
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Development and Preliminary Validation of LoAD Calc, a Mobile App for Calculating the Maximum Safe Single Dose of Local Anesthetics. Healthcare (Basel) 2021; 9:healthcare9070799. [PMID: 34202140 PMCID: PMC8303623 DOI: 10.3390/healthcare9070799] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Revised: 06/09/2021] [Accepted: 06/19/2021] [Indexed: 11/24/2022] Open
Abstract
Local anesthetics systemic toxicity can lead to life-threatening situations. Correct calculation of the maximum safe dose is therefore paramount in preventing such complications. Different solutions have already emerged to support anesthesiologists but are seldom used in clinical practice as they require either access to a computer or specific documents to be at hand. A mobile app could provide an easy and practical solution; however, the few apps already created for this purpose often lack key elements, allowing invalid data to be entered and suggesting doses that might exceed the maximum safe dose. We describe the development of LoAD Calc, a mobile health (mHealth) app developed using a modified version of the Information Systems Research framework, which adds design thinking modes to the original framework. The app was enhanced through multiple iterations and developed with the aid of contextual observations and interviews, brainswarming sessions, prototyping, and continuous feedback. The design process led to the creation of two prototypes which underwent thorough testing by a sample of eight anesthesiologists. The final version of the app, LoAD Calc, was deployed on Apple and Android mobile test platforms and tested again by the same sample until deemed fit for release.
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Macfarlane AJR, Gitman M, Bornstein KJ, El-Boghdadly K, Weinberg G. Updates in our understanding of local anaesthetic systemic toxicity: a narrative review. Anaesthesia 2021; 76 Suppl 1:27-39. [PMID: 33426662 DOI: 10.1111/anae.15282] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/21/2020] [Indexed: 12/21/2022]
Abstract
Despite advances in clinical practice, local anaesthetic systemic toxicity continues to occur with the therapeutic use of local anaesthesia. Patterns of presentation have evolved over recent years due in part to the increasing use of ultrasound which has been demonstrated to reduce risk. Onset of toxicity is increasingly delayed, a greater proportion of clinical reports are secondary to fascial plane blocks, and cases are increasing where non-anaesthetist providers are involved. The evolving clinical context presents a challenge for diagnosis and requires education of all physicians, nurses and allied health professionals about these changing patterns and risks. This review discusses: mechanisms; prevention; diagnosis; and treatment of local anaesthetic systemic toxicity. The local anaesthetic and dose used, site of injection and block conduct and technique are all important determinants of local anaesthetic systemic toxicity, as are various patient factors. Risk mitigation is discussed including the care of at-risk groups, such as: those at the extremes of age; patients with cardiac, hepatic and specific metabolic diseases; and those who are pregnant. Advances in the changing clinical landscape with novel applications and settings for the use of local anaesthesia are also described. Finally, we signpost future directions to potentially improve the management of local anaesthetic systemic toxicity. The utility of local anaesthetics remains unquestionable in clinical practice, and thus maximising the safe and appropriate use of these drugs should translate to improvements in patient care.
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Affiliation(s)
- A J R Macfarlane
- Department of Anaesthesia, Critical Care and Pain Medicine, Glasgow Royal Infirmary, Glasgow, UK.,2University of Glasgow, Glasgow, UK
| | - M Gitman
- Department of Anaesthesia, University of Illinois College of Medicine, Chicago, IL, USA
| | - K J Bornstein
- Department of Medical Education, University of Miami School of Medicine, Miami, FL, USA
| | - K El-Boghdadly
- Department of Anaesthesia and Peri-operative Medicine, Guy's and St Thomas' NHS Foundation Trust, London, UK.,King's College London, London, UK
| | - G Weinberg
- Department of Anaesthesia, University of Illinois College of Medicine, Chicago, IL, USA.,Jesse Brown VA Medical Centre, Chicago, IL, USA
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Suppan M, Beckmann TS, Gercekci C, Sigrist T, Savoldelli GL, Fournier R, Samer C. Development and validation of LoAD Calc, a mobile app for calculating the maximum safe single dose of local anesthetics (Preprint). JMIR Form Res 2020. [DOI: 10.2196/26274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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ILHAN B, DEMİR M. Local Anesthetic Systemic Toxicity Knowledge Of Emergency Medicine Residents: A Cross-Sectional Study. KONURALP TIP DERGISI 2020. [DOI: 10.18521/ktd.746744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Edwards AE, Bowsher GM, Deepak S, Ali M. Improving local anaesthetic systemic toxicity (LAST) awareness in maternity care using tailored educational tools. BMJ Open Qual 2018; 7:e000070. [PMID: 29682617 PMCID: PMC5905766 DOI: 10.1136/bmjoq-2017-000070] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Revised: 02/26/2018] [Accepted: 02/27/2018] [Indexed: 11/04/2022] Open
Abstract
Local anaesthetic (LA) agents are widely used in maternity care. Although relatively safe, their use does carry risks, the most serious of which is systemic toxicity (LAST). LAST poses a major threat to maternal and neonatal safety due to the frequency of LA administration in maternity care and the under-recognition of toxicity in such settings, which has been reported globally. Our aim was to prevent LAST occurrence in a District General Hospital (DGH) maternity unit by improving staff awareness through the implementation of a tailored educational programme. We used a standardised 14-point questionnaire to evaluate LAST awareness among staff of all disciplines. Domains of interest were LA maximum safe doses, LAST recognition, immediate management and use of antidote. Following baseline assessment, we implemented an educational programme in three stages. Each featured a distinct tool: video presentation, poster and lanyard card. Awareness was reassessed between stages using the same questionnaire. We identified poor baseline awareness across all non-anaesthetic disciplines. Average questionnaire score improved from 3.9/14 (n=23) to 8.1/14 (n=30) during the project period, an increase of 109.3%. Scores improved in all professional groups and a change in workplace culture has been reported. Using a tailored interprofessional educational intervention, we generated an increase in awareness and maintained this over a 4-month period. Improved knowledge and a shift in clinical attitudes towards shared responsibility will reduce avoidable peripartum risk associated with LAST at this DGH. Although the tools used were specific to LAST in this setting, they could be easily adapted for NHS maternity services elsewhere and indeed other areas of care.
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Tierney KJ, Murano T, Natal B. Lidocaine-Induced Cardiac Arrest in the Emergency Department: Effectiveness of Lipid Therapy. J Emerg Med 2016; 50:47-50. [DOI: 10.1016/j.jemermed.2015.07.035] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2015] [Revised: 06/26/2015] [Accepted: 07/25/2015] [Indexed: 11/28/2022]
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Fencl JL. Local Anesthetic Systemic Toxicity: Perioperative Implications. AORN J 2015; 101:697-700. [DOI: 10.1016/j.aorn.2015.03.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2015] [Accepted: 03/12/2015] [Indexed: 11/29/2022]
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A Review of Local Anesthetic Systemic Toxicity Cases Since Publication of the American Society of Regional Anesthesia Recommendations. Reg Anesth Pain Med 2015; 40:698-705. [DOI: 10.1097/aap.0000000000000320] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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