Local Anesthesia Toxicity: managing anesthesia emergencies outside of the operating room

Background: The FDA estimates at least one death occurs everyday and over one million injuries occur each year, in the United States, because of medication error. The causes include poor communication, ambiguity in orders,... [ view full abstract ]

Background:

The FDA estimates at least one death occurs everyday and over one million injuries occur each year, in the United States, because of medication error. The causes include poor communication, ambiguity in orders, patient misuse due to misunderstanding and lack of training. Local anesthesia systemic toxicity (LAST) most commonly occurs in the perioperative setting, but a recent review of LAST cases in literature found that 31% of cases occurred outside of the OR. Education focusing on LAST is limited outside of anesthesiologists and perioperative nurses leaving room for error.

Case Report:

A 74-year-old female with a history of asthma, congestive heart failure, an implantable cardioverter-defibrillator (ICD) for intermittent ventricular arrhythmias and chronic kidney disease had been admitted for an upper respiratory infection. She had an uneventful hospital course and was being prepared for discharge when a code blue was called for sudden onset and persistent tonic clonic seizures. When the code team arrived, the patient was exhibiting rhythmic movements of upper and lower extremities, was incontinent of urine, and had blood in the oropharynx from a fresh tongue laceration. Intravenous lorazepam was effective in terminating the seizure. She was intubated for airway protection. Her electrocardiogram evolved from sinus tachycardia to ventricular tachycardia. Her ICD discharged and restored her to sinus tachycardia. No etiology of the new onset seizure was immediately clear: the most recent labs were within normal limits and no changes had been made in her medications. A stat head computerized tomography (CT) scan was unremarkable. Shortly after arrival to the ICU, the floor team contacted the ICU team to report a medication error. Immediately prior to the code, the patient received IV potassium supplementation for mild hypokalemia. Lidocaine is routinely ordered for infusion pain with IV potassium (2ml of 1% lidocaine). The physician order was unclear and 20ml of 2% lidocaine was given as an IV bolus. A lidocaine level was drawn at the time of error identification and was 2.8, so fat emulsion (Intralipid) was considered, but not administered. Within a few hours, she was alert, following commands and was able to be extubated. The medication error was then disclosed to the patient and her family.

Discussion:

1. Importance of local anesthetic toxicity training and education for medical professionals: Local anesthetics are commonly used outside of the operating room environment. Nurses, non-anesthesiologist physicians, and pharmacists should be educated on the dangers, signs and symptoms, and appropriate treatment of local anesthetic toxicity. Additionally, anesthesiologists need to keep this diagnosis in mind in unexpected locations.
2. Systems issues: In this case, the medical order was ambiguous and the medication dispensing system released a toxic dose of medication. Changes could be made in the computer ordering system and medication dispensing system to prevent these types of errors from occurring at a systems level.
3. Disclosure of medical error to patient and family: Formal education on disclosing medical errors is limited. This case provides an opportunity to discuss best practices from risk management.