Anaesthetists Handbook - MEDICAL EDUCATION at University ...

Epidural anaesthesia and analgesiaideal intubating conditions. Sedation can be maintained by the use ofpropofol.However, the situation may require immediate intubation or assistedventilation. Be vigilant for and treat hypotension. Prevent aortocavalcompression in pregnant patients.See page 135 for management of high blocks that are not lifethreatening.Intravenous administration or other systemic overload - toxicityThere is scant high level evidence to support the use of any specifictreatments for local anaesthetic toxicity. The most seriouscomplications occur with bupivacaine but can arise with any localanaesthetic agent. The traditional treatment for bupivacaine-inducedrefractory ventricular fibrillation, bretylium, is no longer available andtreatment guidelines centre around three available drugs. The lack ofrandomised controlled trial evidence requires clinicians treating localanaesthetic toxicity to take a pragmatic and expectant view.The immediate management of severe local anaesthetic toxicity isdetailed in the Guidelines for the management of severe localanaesthetic toxicity (Association of Anaesthetists of Great Britain andIreland, 2007).• Stop injecting the local anaesthetic.• Call for help.• Maintain the airway and, if necessary, secure it with anendotracheal tube.• Give 100% oxygen and ensure adequate lung ventilation(hyperventilation and alkalosis may help by promoting proteinbinding of local anaesthetic).• Confirm or establish intravenous access.• Control seizures: give a benzodiazepine, thiopental or propofolin small increments.Anaesthetists Handbook January 2010 125