Informação da revista
Vol. 42. Núm. 5.
Páginas 485-486 (maio 2023)
Partilhar
Partilhar
Baixar PDF
Mais opções do artigo
Vol. 42. Núm. 5.
Páginas 485-486 (maio 2023)
Editorial comment
Acesso de texto completo
Cardiac device implant complications – The case for local anesthetic toxicity
Complicações na implantação de dispositivos cardíacos – toxicidade de anestésicos locais
Visitas
1143
Diogo Cavacoa,b
a Serviço de Cardiologia, Hospital de Santa Cruz, Lisboa, Portugal
b Serviço de Cardiologia, Hospital da Luz, Lisboa, Portugal
Este item recebeu
Informação do artigo
Texto Completo
Bibliografia
Baixar PDF
Estatísticas
Texto Completo

The number of complications from cardiac device implantation is low. The most common are related to the materials used (leads, generators) or the procedural technique (hematoma, pneumothorax) or a combination of both (perforation, infection).

Less-commonly described complications are related to local anesthetic systemic toxicity.

In this issue of the Portuguese Journal of Cardiology, the authors present a well-documented case of local anesthetic (LA) systemic toxicity and rescue.1 We certainly can learn substantially from medical complications. The authors are to be praised for the methodical stepwise description of the clinical situation and thorough revision of the topic.

The most critical learning points regarding this case report and local anesthetic systemic toxicity are the importance of (1) prevention, (2) early detection and (3) management.

  • (1)

    Prevention – There is a dose of LA beyond which the risk of toxicity is higher. For example, if adrenaline is not used, the maximum safe dose for lidocaine is around 4.5 mg/kg. The limit for a 70 kg patient is thus 315 mg of lidocaine; a 1% 20 mL lidocaine vial contains 200 mg. The anesthetic dose is crucial – but it also should be noted that it is not a fixed value. Factors that increase the likelihood of complications because the toxic dose is lower include age, low weight, and cardiac failure. Many of these conditions are present in patients who undergo cardiac device implants.2 Optimal anesthetic injection technique should also be applied – this includes aspiration before injection to decrease the likelihood of direct intravenous infusion, injecting small doses, and waiting 30 seconds after each injection. Other anesthesia techniques have been proposed that theoretically decrease the risk of this complication. In different settings, a mixture of more than one anesthetic has been used – typically a short-acting drug (e.g., lidocaine) and a long-acting one (e.g., bupivacaine). The potential advantage would be to provide fast-onset analgesia and an increase in the safety margin for the toxicity of both agents (by using smaller doses of both drugs). Still, it is also argued that little is known about the kinetics and dynamics of a mixture of agents, and toxicity reports have also been published.3

  • (2)

    Early detection – semiology can be very subtle initially. It can start with discomfort, agitation, and tinnitus, rapidly progressing to more severe neurologic damage. It can also lead to hemodynamic instability, respiratory failure and arrhythmias. Without prompt treatment, the situation can even lead to death in its more severe form.

  • (3)

    Treatment includes interrupting anesthetic injection, providing cardiac and respiratory support, and administering 20% intravenous lipid emulsion infusion.

A final message is that all implanting centers should educate operators on the use of LA and the possibility of this rare complication. They should establish a protocol with anesthesiology departments for LA systemic toxicity management, not forgetting that lipid emulsion therapy needs to be readily available.

Conflicts of interest

The authors have no conflicts of interest to declare.

References
[1]
M.N. Silva, A. Ferro, I. Fragata.
Lidocaine induced central nervous system toxicity during implantable cardioverter defibrillator – a case report and review of literature.
[2]
A.J.R. Macfarlane, M. Gitman, K.J. Bornstein, et al.
Updates in our understanding of local anaesthetic systemic toxicity: a narrative review.
Anaesthesia, 76 (2021), pp. 27-39
[3]
T. Chaki, S. Sugino, P.K. Janicki, et al.
Efficacy and safety of a lidocaine and ropivacaine mixture for scalp nerve block and local infiltration anesthesia in patients undergoing awake craniotomy.
J Neurosurg Anesthesiol, 28 (2016), pp. 1-5
Copyright © 2023. Sociedade Portuguesa de Cardiologia
Baixar PDF
Idiomas
Revista Portuguesa de Cardiologia
Opções de artigo
Ferramentas
en pt

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos

Ao assinalar que é «Profissional de Saúde», declara conhecer e aceitar que a responsável pelo tratamento dos dados pessoais dos utilizadores da página de internet da Revista Portuguesa de Cardiologia (RPC), é esta entidade, com sede no Campo Grande, n.º 28, 13.º, 1700-093 Lisboa, com os telefones 217 970 685 e 217 817 630, fax 217 931 095 e com o endereço de correio eletrónico revista@spc.pt. Declaro para todos os fins, que assumo inteira responsabilidade pela veracidade e exatidão da afirmação aqui fornecida.