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      "titulo" => "Unearthing an interrupted aortic arch in an elderly patient &#8211; Listen&#44; watch and feel"
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      "titulo" => "Lidocaine-induced central nervous system toxicity during implantable cardioverter defibrillator placement &#8211; A case report and literature review"
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    "titulo" => "Cardiac device implant complications &#8211; The case for local anesthetic toxicity"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The number of complications from cardiac device implantation is low&#46; The most common are related to the materials used &#40;leads&#44; generators&#41; or the procedural technique &#40;hematoma&#44; pneumothorax&#41; or a combination of both &#40;perforation&#44; infection&#41;&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Less-commonly described complications are related to local anesthetic systemic toxicity&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">In this issue of the Portuguese Journal of Cardiology&#44; the authors present a well-documented case of local anesthetic &#40;LA&#41; systemic toxicity and rescue&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">1</span></a> We certainly can learn substantially from medical complications&#46; The authors are to be praised for the methodical stepwise description of the clinical situation and thorough revision of the topic&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The most critical learning points regarding this case report and local anesthetic systemic toxicity are the importance of &#40;1&#41; prevention&#44; &#40;2&#41; early detection and &#40;3&#41; management&#46;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#40;1&#41;</span><p id="par0025" class="elsevierStylePara elsevierViewall">Prevention &#8211; There is a dose of LA beyond which the risk of toxicity is higher&#46; For example&#44; if adrenaline is not used&#44; the maximum safe dose for lidocaine is around 4&#46;5 mg&#47;kg&#46; The limit for a 70 kg patient is thus 315 mg of lidocaine&#59; a 1&#37; 20 mL lidocaine vial contains 200 mg&#46; The anesthetic dose is crucial &#8211; but it also should be noted that it is not a fixed value&#46; Factors that increase the likelihood of complications because the toxic dose is lower include age&#44; low weight&#44; and cardiac failure&#46; Many of these conditions are present in patients who undergo cardiac device implants&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">2</span></a> Optimal anesthetic injection technique should also be applied &#8211; this includes aspiration before injection to decrease the likelihood of direct intravenous infusion&#44; injecting small doses&#44; and waiting 30 seconds after each injection&#46; Other anesthesia techniques have been proposed that theoretically decrease the risk of this complication&#46; In different settings&#44; a mixture of more than one anesthetic has been used &#8211; typically a short-acting drug &#40;e&#46;g&#46;&#44; lidocaine&#41; and a long-acting one &#40;e&#46;g&#46;&#44; bupivacaine&#41;&#46; The potential advantage would be to provide fast-onset analgesia and an increase in the safety margin for the toxicity of both agents &#40;by using smaller doses of both drugs&#41;&#46; Still&#44; it is also argued that little is known about the kinetics and dynamics of a mixture of agents&#44; and toxicity reports have also been published&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">3</span></a></p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#40;2&#41;</span><p id="par0030" class="elsevierStylePara elsevierViewall">Early detection &#8211; semiology can be very subtle initially&#46; It can start with discomfort&#44; agitation&#44; and tinnitus&#44; rapidly progressing to more severe neurologic damage&#46; It can also lead to hemodynamic instability&#44; respiratory failure and arrhythmias&#46; Without prompt treatment&#44; the situation can even lead to death in its more severe form&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#40;3&#41;</span><p id="par0035" class="elsevierStylePara elsevierViewall">Treatment includes interrupting anesthetic injection&#44; providing cardiac and respiratory support&#44; and administering 20&#37; intravenous lipid emulsion infusion&#46;</p></li></ul></p><p id="par0040" class="elsevierStylePara elsevierViewall">A final message is that all implanting centers should educate operators on the use of LA and the possibility of this rare complication&#46; They should establish a protocol with anesthesiology departments for LA systemic toxicity management&#44; not forgetting that lipid emulsion therapy needs to be readily available&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0045" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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