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An assessment of the awareness of local anesthetic systemic toxicity among multi-specialty postgraduate residents
Abstract
Local anesthetics (LAs) are extensively used in clinical practice by both anesthesiologists and non-anesthesiologists and are often associated with systemic toxicity. We hypothesize that this awareness is inadequate among medical specialists and entails a risk of misdiagnosis and underreporting of such events. We therefore conducted a cross-sectional questionnaire-based study to assess the level of understanding of LA use and effective management of systemic toxicity among 200 postgraduate residents of various specialties (with the exception of anesthesiology) in a tertiary care hospital in India from October to December 2013. Among those residents who had used LAs (193/200), 27 and 25 % of responders correctly identified the toxic doses of lidocaine and of lidocaine + adrenaline, respectively. Of the responders, 70 % always performed a negative aspiration of blood before injecting the drug, 27 % sometimes aspirated and the remaining 3 % never aspirated. The majority of the responders (93 %) were unaware of the toxic dose of bupivacaine. Only 70 % of responders believed that LAs could be toxic [95 % confidence interval (CI) 65.5-74.5 %], and 81 % of these correctly identified the signs and symptoms of cardiotoxicity. Only 2 % of responders knew that lipid emulsion is a part of its treatment (95 % CI 0.6-3.4 %). Based on these results, there is a definite need to increase the awareness of detection and treatment of local anesthetic toxicity among all medical practitioners who regularly use LAs.
... As such, any practitioner, not limited to the anaesthesiologist, who administers these agents should be familiar with the prevention, identifcation, and treatment of LAST. Despite the limited data, several studies have shown that knowledge of LA doses and awareness of LAST remains poor among clinicians [9][10][11][12]. ...
... As validated questionnaires to assess awareness have not been standardised, precise comparisons from one study to another may be difcult. Despite this, our results echoed the results of other studies involving various medical personnel, revealing poor knowledge of local anaesthetics and LAST [9][10][11][12]. An increased awareness would make the doctors more mindful with regard to their safe practices including the use of correct dose, titrating doses to efect, and adequate monitoring when administering local anaesthetics. ...
... Similarly, Sagir A. et al reported that not many Values are expressed as the mean ± standard deviation or frequency (percentage). International Journal of Clinical Practice nonanaesthesiologists knew the toxic dose of plain lignocaine and lignocaine with adrenaline [10]. Tis study showed that even a single educational session was able to signifcantly improve awareness about LAST among the postgraduate trainees. ...
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.
... 4 Gaffen et al. 3 assessed the annual use of the different commercial local anesthetics, while Kaira et al. 12 went a step further and assessed the knowledge of the practitioners regarding how to calculate the MRDs. In India, Sagir et al. 13 assessed the awareness level of the important aspects of LAST and its management. The assessment was concerned with teaching faculty members. ...
... We believe the main reason behind this difference is that is population involved medical personnel which included cardiology and neurology residents. 13 Early recognition and management of patients undergoing LAST are key to prevent potential mortality. Prevention starts with correct dose calculation and administration. ...
Objectives: This study aims to assess the knowledge level, behavior, and attitude of dental practitioners regarding the absolute maximum dose of local anesthetics, their MRD, and systemic complications. Materials & Method: An electronic survey was distributed through social media platforms to dental practitioners in Jeddah. The survey consisted of 4 sections: demographic information, knowledge, behavior, and attitude. Cronbach’s alpha was used to test for the validity 0.86. Results: A total of 403 participants completed the questionnaire, with a response rate of 60%. Of all, 55.8% were females. The majority were undergraduate students 42.4%, and below the age of 25 44.9%. For the question “what is the MRD/ kg for 2% lidocaine with Epinephrine?” we found a statistically significant difference between the professional rankings p=0.001. Although the undergraduate dentists were the least group to answer the questions “What does a 2% local anesthetic solution mean?”, there was no statistically significant difference between those who answered correctly. Conclusion: We found many of our participants to have false knowledge regarding the topics of LA, MRD/kg, and LAST. We believe that the current levels are not acceptable, and that more efforts must be made to raise the knowledge pertaining to this topic
... Despite their widespread use, complication rates remain low. While minor and transient side effects are commonly identified, lifethreatening systemic toxicity of LA, known as local anesthetic systemic toxicity (LAST), can occur, presenting with central nervous system toxicity and cardiotoxicity manifestations [4,5]. ...
Background/Aim: Local anesthetics are frequently used and often considered harmless, but they can precipitate local anesthetic systemic toxicity (LAST) when accidentally administered intravascularly or when a toxic dose is rapidly absorbed, which can result in mortality. In cases of renal function impairment, the altered pharmacokinetics of local anesthetics lead to a lowered toxicity threshold. In this study, the aim was to histopathologically investigate the increase in neurotoxicity in the central nervous system due to bupivacaine in experimental renal failure. Methods: In the study, a total of 28 male Wistar albino rats, aged 8-10 weeks, were evenly divided into four groups: Group C (control group) received intraperitoneal 1 mL/kg saline; Group G (glycerol group) received intramuscular 10 mL/kg glycerol, Group GB (glycerol+bupivacaine group) received intramuscular 10 mL/kg glycerol followed by intraperitoneal 4 mg/kg bupivacaine; and Group B (bupivacaine group) received intraperitoneal 4 mg/kg bupivacaine. All rats were sacrificed after the experimental period. Tissue samples were preserved and stained with hematoxylin-eosin for histopathological analyses. TRPM2 and Reelin levels in brain tissue were measured using immunohistochemical methods. Results: In the histopathological examination, Group G exhibited higher Reelin and TRPM2 levels compared to all other groups (P<0.001). In Group GB, both Reelin and TRPM2 immunoreactivity were significantly higher compared to Group B (P<0.001). Conclusion: It can be concluded that renal dysfunction increases neurotoxicity in brain tissue associated with bupivacaine.
... Despite the low incidence, there is potential for severe toxicity. Knowledge about this entity is still lacking, as reported [4]. ...
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.
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. Local anesthetic 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 between physiatry and anesthesiology physicians’ knowledge of LAST.
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 measure
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 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 there is opportunity for further assessment of the education on LAST amongst physiatrists and residents in training.
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Discussion about complications of general anesthesia is a very extensive chapter and is beyond the scope of this work. What is important in this regard is that the anesthesiologist is accustomed to the technique used by the surgeon primarily if he is working with large-volume tumescent anesthesia infiltrations to avoid over-hydration of the patient and the consequent pulmonary edema that could prove fatal. When general anesthesia is combined with tumescent liposuction, the infusion of intravascular fluids should be restricted to a minimum. Prevention, diagnosis, and treatment of pulmonary edema belong to the realm of the anesthesiologist and the clinical team that follows the patient in the immediate postoperative period.
ABSTRACT
Problem of Research: One of the most influential factors in the survival of health institutions and their
competitiveness in the sector is to ensure the satisfaction of the patients they provide health services.
Purpose of the Study: The aim of this study is to determine the satisfaction level of health consumers who
receive service from private hospitals and to measure their loyalty intentions to prefer the same health institutions
again. At the same time, it is aimed to examine the relationship between satisfaction and patient loyalty.
Method: This cross-sectional and descriptive study was conducted with patient satisfaction and patient loyalty
scales. The reliability coefficients of the scales were calculated, and it was seen that the scales were at a high level
of reliability. The research population consists of people who received service from private hospitals in Istanbul.
The research sample consists of 446 people.
Results: According to the results obtained from the research; patient satisfaction (3.69±0.94) and patient loyalty
(3.52±0.95) perceptions of the research participants were above the average. In addition, it has been observed that
there is a strong positive relationship between patient satisfaction and patient loyalty (r:0.857).
Conclusion: Studies on the subject support the findings of this study. It is recommended that the managers of
health institutions who want to stand out in the competitive environment should focus on studies that will increase
patient satisfaction.
Keywords: Health Institutions, Patient Satisfaction, Patient Loyalty, Private Hospitals
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.
Problem of Research: Nowadays, technology is quite widely used in healthcare. It is very important for middle-aged and elderly people, who need and demand health services the most, to adapt to technology in health services. Purpose of the Study: The purpose of this study is to determine the level of technology use by middle-aged and older individuals in health care. Method: This is a cross-sectional study in descriptive orientation. In the study, the questionnaire designed by the researchers with a 5-point Likert scale was applied to 117 people aged 66 years and older. The survey was conducted online using Google Forms and a face-to-face interview. Findings: The average age of participants was 74 years, including 60 women and 57 men. While 85% of participants use a smartphone, the percentage of those who do not use a device is 13.7%. The percentage of those who receive health services through mobile devices is 10.3%, and the percentage of participants who receive advice through mobile applications is 13.7%. The percentage of participants who think they can use technology without help is 28.2%, while 26.5% of participants think they cannot use technology without help. The results show that the use of technology is insufficient and biassed due to the fear of not being able to use the technology. In this framework, technology awareness training can be conducted for 66-year-olds and elders, and mobile applications can be recommended more by physicians.
Problem of Research: Considering the high morbidity and mortality rates in people with psychiatric disorders, artificial intelligence is increasingly needed in the identification, diagnosis and treatment of high-risk individuals.
Purpose of the Study: To reveal the contributions of artificial intelligence approaches in psychiatry to clinical processes and decision support systems.
Method: In this study, as a systematic review, databases were searched to cover the years 2015-2021 with related terms.
Findings: In psychiatry, artificial intelligence techniques are used in the diagnosis, prognosis, treatment and follow-up stages of diseases. Studies; showed that it makes more understandable contributions to the differential diagnosis of psychiatric disorders with similar onset histories, the identification of new disease subtypes, the harmonization of data from multiple sources, and the acquisition of sensitive information from individuals. Successful results have been achieved in determining the risk of depression and suicide, skipping long-term psychotherapies during the treatment phase, predicting the response to treatment and side effects related to treatments, and defining the characteristic gene expression patterns of different psychiatric disorders. It has been seen that e-Mental mobile applications, which focus on supporting individuals with mental health problems, are effective. As a result, artificial intelligence is important in decision support processes in terms of reducing the workload of clinicians, reducing treatment costs and providing advantages in time-consuming treatment processes.
We have compared the incidence of CNS symptoms and changes in echocardiography and electrophysiology during i.v. infusions
of ropivacaine, bupivacaine and placebo. Acute tolerance of i.v. infusion of 10 mg min-1 was studied in a crossover, randomized,
double-blind study in 12 volunteers previously acquainted with the CNS effects of lignocaine. The maximum tolerated dose for
CNS symptoms was higher after ropivacaine in nine of 12 subjects and higher after bupivacaine in three subjects. The 95% confidence
limits for the difference in mean dose between ropivacaine and bupivacaine were -30 and 7 mg. The maximum tolerated unbound
arterial plasma concentration was twice as high after ropivacaine (P < 0.001). Muscular twitching occurred more frequently
after bupivacaine (P < 0.05). The time to disappearance of all symptoms was shorter after ropivacaine (P < 0.05). A threshold
for CNS toxicity was apparent at a mean free plasma concentration of approximately 0.6 mg litre-1 for ropivacaine and 0.3
mg litre-1 for bupivacaine. Bupivacaine increased QRS width during sinus rhythm compared with placebo (P < 0.001) and ropivacaine
(P < 0.01). Bupivacaine reduced both left ventricular systolic and diastolic function compared with placebo (P < 0.05 and
P < 0.01, respectively), while ropivacaine reduced only systolic function (P < 0.01).
We report the case of a 25-year-old female scheduled for laparoscopic gynecologic surgery under general anesthesia. At the end of laparoscopy, an intraperitoneal infiltration (ropivacaine 0.75%, 20 mL) was administered by the surgeon without informing the anesthesiologist. After tracheal extubation due to significant postoperative pain, the anesthesiologist performed a bilateral transversus abdominis plane block (ropivacaine 0.75%, 40 mL). A seizure followed by ventricular arrhythmia developed 10 minutes after local anesthetic injection. An infusion of 20% lipid emulsion was successful in converting the ventricular arrhythmia to a sinus rhythm. This overdose could have been avoided with better communication between anesthesiologist and surgeon.
The classic description of local anesthetic systemic toxicity (LAST) generally described in textbooks includes a series of progressively worsening neurologic symptoms and signs occurring shortly after the injection of local anesthetic and paralleling progressive increases in blood local anesthetic concentration, culminating in seizures and coma. In extreme cases, signs of hemodynamic instability follow and can lead to cardiovascular collapse. To characterize the clinical spectrum of LAST and compare it to the classic picture described above, we reviewed published reports of LAST during a 30-year period from 1979 to 2009. Ninety-three cases were identified and analyzed with respect to onset of toxicity and the spectrum of signs and symptoms. Sixty percent of cases followed the classic pattern of presentation. However, in the remainder of cases, symptoms were substantially delayed after the injection of local anesthetic, or involved only signs of cardiovascular compromise, with no evidence of central nervous system toxicity. Although information gained from retrospective case review cannot establish incidence, outcomes, or comparative efficacies of treatment, it can improve awareness of the clinical spectrum of LAST and, theoretically, the diagnosis and treatment of affected patients. The analytic limitations of our method make a strong case for developing a prospective, global registry of LAST as a robust alternative for educating practitioners and optimizing management of LAST.
The American Society of Regional Anesthesia and Pain Medicine Practice Advisory on Local Anesthetic Systemic Toxicity assimilates and summarizes current knowledge regarding the prevention, diagnosis, and treatment of this potentially fatal complication. It offers evidence-based and/or expert opinion-based recommendations for all physicians and advanced practitioners who routinely administer local anesthetics in potentially toxic doses. The advisory does not address issues related to local anesthetic-related neurotoxicity, allergy, or methemoglobinemia. Recommendations are based primarily on animal and human experimental trials, case series, and case reports. When objective evidence is lacking or incomplete, recommendations are supplemented by expert opinion from the Practice Advisory Panel plus input from other experts, medical specialty groups, and open forum. Specific recommendations are offered for the prevention, diagnosis, and treatment of local anesthetic systemic toxicity.
A 5-month-old infant with seizures secondary to oral viscous lidocaine toxicity is described. Despite prior reports of this complication in the literature, many practitioners are unaware of the potential adverse effects of topical lidocaine usage in the pediatric patient. Complications of topical lidocaine use and recommendations regarding its use in the pediatric patient are discussed.
The effects were studied, in eight healthy volunteers, of premedication with diazepam 0.14 mg kg−1 by mouth or hyoscine 6 μg kg−1 ³ morphine 0.2 mg kg 1 i.m., or no premedication, on toxic symptoms and plasma concentrations after rapid i.v. injection of lignocaine 1 mg kg−1. The α1-acid glycoprotein (AAG) and albumin plasma protein fractions were assessed. A variety of mild central nervous system (CNS)
symptoms were experienced after the bolus of lignocaine. However, there was no correlation between premedication and degree
of severity or number of CNS symptoms. The highest single arterial plasma concentration of lignocaine was 11.0 μg ml−1, 1 min after injection. There was no correlation between plasma concentration of lignocaine and occurrence of CNS symptoms.
Furthermore, there was no correlation between AAG or albumin plasma concentrations and lignocaine plasma concentrations.
Topical anesthetics, unlike injectable anesthetics, can be applied painlessly and can provide sufficient pain control to maintain patient comfort throughout a variety of laser procedures. Although the use of topical lidocaine is considered relatively safe, instances of cardiotoxic and neurotoxic adverse events have been reported to occur.
A 52-year-old woman underwent fractional photothermolysis for management of severe hypopigmentation and scarring of several years' duration. Shortly after termination of treatment to her face and neck, which required prolonged exposure to a 30% lidocaine gel compound both before and during surgery, she developed clinical signs and symptoms consistent with systemic lidocaine toxicity. The results of laboratory studies confirmed serum lidocaine levels within the toxic range. We postulate that the combination of the high concentration of topical lidocaine required to achieve sufficient anesthesia, together with the laser-induced disruption in epidermal barrier function, may have been responsible for this phenomenon.
Application of a 30% topical lidocaine gel to a limited area in conjunction with fractional photothermolysis may generate serum lidocaine levels high enough to elicit systemic toxicity. Laser surgeons should be alert to this phenomenon, particularly in patients with underlying hepatic, endocrine, cardiac, or central nervous system/psychiatric dysfunction; in patients with a low body mass index; and in patients who are taking medications that may interfere with hepatic lidocaine metabolism.