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Tsuji M, Nii M, Furuta M, Baba S, Maenaka T, Matsunaga S, Tanaka H, Sakurai A. Intravenous lipid emulsion for local anaesthetic systemic toxicity in pregnant women: a scoping review. BMC Pregnancy Childbirth 2024; 24:138. [PMID: 38355477 PMCID: PMC10865663 DOI: 10.1186/s12884-024-06309-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 01/30/2024] [Indexed: 02/16/2024] Open
Abstract
BACKGROUND Local anaesthetic systemic toxicity (LAST) is a rare but life-threatening complication that can occur after local anaesthetic administration. Various clinical guidelines recommend an intravenous lipid emulsion as a treatment for local anaesthetic-induced cardiac arrest. However, its therapeutic application in pregnant patients has not yet been established. This scoping review aims to systematically identify and map the evidence on the efficacy and safety of intravenous lipid emulsion for treating LAST during pregnancy. METHOD We searched electronic databases (Medline, Embase and Cochrane Central Register Controlled Trials) and a clinical registry (lipidrescue.org) from inception to Sep 30, 2022. No restriction was placed on the year of publication or the language. We included any study design containing primary data on obstetric patients with signs and symptoms of LAST. RESULTS After eliminating duplicates, we screened 8,370 titles and abstracts, retrieving 41 full-text articles. We identified 22 women who developed LAST during pregnancy and childbirth, all presented as case reports or series. The most frequent causes of LAST were drug overdose and intravascular migration of the epidural catheter followed by wrong-route drug errors (i.e. intravenous anaesthetic administration). Of the 15 women who received lipid emulsions, all survived and none sustained lasting neurological or cardiovascular damage related to LAST. No adverse events or side effects following intravenous lipid emulsion administration were reported in mothers or neonates. Five of the seven women who did not receive lipid emulsions survived; however, the other two died. CONCLUSION Studies on the efficacy and safety of lipids in pregnancy are scarce. Further studies with appropriate comparison groups are needed to provide more robust evidence. It will also be necessary to accumulate data-including adverse events-to enable clinicians to conduct risk-benefit analyses of lipids and to facilitate evidence-based decision-making for clinical practice.
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Affiliation(s)
- Makoto Tsuji
- Department of Obstetrics and Gynecology, Saiseikai Mastusaka General Hospital, Mastusaka, Mie, Japan
- Japan Resuscitation Council, Shinjuku, Tokyo, Japan
| | - Masafumi Nii
- Department of Obstetrics and Gynecology, Mie University School of Medicine, Tsu, Mie, Japan.
- Japan Resuscitation Council, Shinjuku, Tokyo, Japan.
| | - Marie Furuta
- Department of Human Health Sciences, Graduate School of Medicine, Kyoto University, Kyoto, Kyoto, Japan
- Japan Resuscitation Council, Shinjuku, Tokyo, Japan
| | - Shinji Baba
- Department of Obstetrics and Gynecology, Tokyo Metropolitan Tama Medical Center, Fuchu, Tokyo, Japan
- Japan Resuscitation Council, Shinjuku, Tokyo, Japan
| | - Takahide Maenaka
- Regional Medical Care Planning Division, Health Policy Bureau, Ministry of Health, Labour and Welfare, Tokyo, Japan
- Japan Resuscitation Council, Shinjuku, Tokyo, Japan
| | - Shigetaka Matsunaga
- Department of Obstetrics and Gynecology, Saitama Medical Center, Saitama Medical University, Kawagoe, Saitama, Japan
- Japan Resuscitation Council, Shinjuku, Tokyo, Japan
| | - Hiroaki Tanaka
- Department of Obstetrics and Gynecology, Mie University School of Medicine, Tsu, Mie, Japan
- Japan Resuscitation Council, Shinjuku, Tokyo, Japan
| | - Atsushi Sakurai
- Department of Acute Medicine, Division of Emergency and Critical Care Medicine, Nihon University School of Medicine, Itabashi, Tokyo, Japan
- Japan Resuscitation Council, Shinjuku, Tokyo, Japan
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Mock ND, Griggs KM, Mileto LA. Local Anesthetic Systemic Toxicity during Labor, Birth, and Immediate Postpartum: Clinical Review. MCN Am J Matern Child Nurs 2021; 46:330-338. [PMID: 34334660 DOI: 10.1097/nmc.0000000000000765] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT Local anesthetic systemic toxicity (LAST) is a life-threatening event caused by elevated local anesthetic plasma concentration. It is often unrecognized or misdiagnosed. Peripartum women are at increased risk for toxicity due to pregnancy-related physiological changes. Rising serum drug levels can cause cellular level impairment of mitochondria and voltage-gated ion channels leading to a cascade of symptoms that can end in cardiac arrest. Local anesthetic systemic toxicity can mimic other maternal pathologies but may be considered if local anesthetics have been used. Published treatment guidelines for this event include lipid emulsion which is approved for use in pregnant women. We review LAST in the maternity care setting, published treatment protocols, management of maternity patients with toxicity, and recommendations to increase awareness among maternity care clinicians for this medical emergency.
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Kim HJ, Kim HS, Jung JR, Kim HY, Lynch C, Park WK. Lipid Emulsion Restoration of Myocardial Contractions After Bupivacaine-Induced Asystole In Vitro: A Benefit of Long- and Medium-Chain Triglyceride Over Long-Chain Triglyceride. Anesth Analg 2020; 131:917-927. [PMID: 32011393 DOI: 10.1213/ane.0000000000004637] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The relative efficacies of a long- and medium-chain triglyceride (LCT/MCT) emulsion and an LCT emulsion for treatment of bupivacaine (BPV)-induced cardiac toxicity are poorly defined. METHODS After inducing asystole by BPV, varied concentrations (1%-12%) of either LCT/MCT (Lipofundin; B. Braun, Melsungen, Germany) or LCT emulsion (Intralipid; Fresenius Kabi, Upsala, Sweden) were applied to observe the recovery of stimulated contractile responses and contractile forces in either a recirculating or washout condition for 60 minutes, using guinea pig papillary muscles. The recirculation condition was used to demonstrate BPV binding by lipid emulsion. The washout condition was used to determine whether the time-dependent recovery of contraction is due to their metabolic enhancement. Oxfenicine, an inhibitor of carnitine palmitoyltransferase I in heart mitochondria, was used to evaluate the effect of each lipid emulsion on mitochondrial metabolic inhibition by BPV. To examine the effect of the lipid emulsion alone on contractility, either lipid emulsion was examined. BPV concentrations in solution and myocardial tissues were measured. RESULTS In the recirculating condition, LCT/MCT emulsions (2%-12%) restored regular stimulated contractile responses in all muscles. Eight percent and 12% LCT/MCT emulsions led to complete recovery of contractile forces after 30 minutes. Meanwhile, LCT emulsions (4%-12%) did not restore regular stimulated contractile responses in some muscles (6, 3, and 2 in 9 muscles each in 4%, 8%, and 12% emulsions, respectively). Partial recovery, approximately 60%, of contractile forces was observed with 8% and 12% LCT emulsions. In the washout experiments, after asystole, LCT/MCT emulsions (1%-12%) restored contractility to baseline levels earlier and greater than LCT emulsion. Partial recovery, approximately 60%, was observed with a high concentration of LCT emulsion (12%). In the oxfenicine-pretreated group, the contractile recovery was enhanced with LCT/MCT emulsion but showed no change with LCT emulsion. Contractile depression by 40% was observed with high concentrations of LCT emulsion alone (8% and 12%), whereas no depression or enhanced contraction was observed with LCT/MCT emulsion (1%-12%) alone. Both types of lipid emulsions (2%-12%) caused concentration-related reductions of tissue BPV levels; LCT/MCT emulsions reduced tissue BPV levels slightly greater than LCT emulsion in a recirculating condition. CONCLUSIONS An LCT/MCT emulsion was more beneficial than an LCT emulsion in terms of local anesthetic-binding and metabolic enhancement for treating acute BPV toxicity. The metabolic benefit of MCT, combined with the local anesthetic-binding effect of LCT, in an LCT/MCT emulsion may improve contractile function better than an LCT emulsion in an isolated in vitro animal myocardium model.
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Affiliation(s)
- Hyun Joo Kim
- From the Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Hyun Soo Kim
- Department of Food Science and Technology, Jungwon University, Chungbuk Province, Korea
| | - Ja Rang Jung
- Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Ha Yan Kim
- Biostatistics Collaboration Unit, Department of Biomedical Systems Informatics, Yonsei University College of Medicine, Seoul, Korea
| | - Carl Lynch
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, Virginia
| | - Wyun Kon Park
- From the Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
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Mosqueira M, Aykut G, Fink RHA. Mepivacaine reduces calcium transients in isolated murine ventricular cardiomyocytes. BMC Anesthesiol 2020; 20:10. [PMID: 31914932 PMCID: PMC6947945 DOI: 10.1186/s12871-019-0926-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 12/30/2019] [Indexed: 12/14/2022] Open
Abstract
Background The potential mechanism of mepivacaine’s myocardial depressant effect observed in papillary muscle has not yet been investigated at cellular level. Therefore, we evaluated mepivacaine’s effects on Ca2+ transient in isolated adult mouse cardiomyocytes. Methods Single ventricular myocytes were enzymatically isolated from wild-type C57Bl/6 mice and loaded with 10 μM fluorescent Ca2+ indicator Fluo-4-AM to record intracellular Ca2+ transients upon electrical stimulation. The mepivacaine effects at half-maximal inhibitory concentration (IC50) was determined on calibrated cardiomyocytes’ Ca2+ transients by non-parametric statistical analyses on biophysical parameters. Combination of mepivacaine with NCX blockers ORM-10103 or NiCl2 were used to test a possible mechanism to explain mepivacaine-induced Ca2+ transients’ reduction. Results A significant inhibition at mepivacaine’s IC50 (50 μM) on Ca2+ transients was measured in biophysical parameters such as peak (control: 528.6 ± 73.61 nM vs mepivacaine: 130.9 ± 15.63 nM; p < 0.05), peak area (control: 401.7 ± 63.09 nM*s vs mepivacaine: 72.14 ± 10.46 nM*s; p < 0.05), slope (control: 7699 ± 1110 nM/s vs mepivacaine: 1686 ± 226.6 nM/s; p < 0.05), time to peak (control: 107.9 ± 8.967 ms vs mepivacaine: 83.61 ± 7.650 ms; p < 0.05) and D50 (control: 457.1 ± 47.16 ms vs mepivacaine: 284.5 ± 22.71 ms; p < 0.05). Combination of mepivacaine with NCX blockers ORM-10103 or NiCl2 showed a significant increase in the baseline of [Ca2+] and arrhythmic activity upon electrical stimulation. Conclusion At cellular level, mepivacaine blocks Na+ channels, enhancing the reverse mode activity of NCX, leading to a significant reduction of Ca2+ transients. These results suggest a new mechanism for the mepivacaine-reduction contractility effect.
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Affiliation(s)
- Matias Mosqueira
- Cardio-Ventilatory Muscle Physiology Laboratory, Institute of Physiology and Pathophysiology, Heidelberg University Hospital, Im Neuenheimer Feld 326, 69120, Heidelberg, Germany.
| | - Güçlü Aykut
- Cardio-Ventilatory Muscle Physiology Laboratory, Institute of Physiology and Pathophysiology, Heidelberg University Hospital, Im Neuenheimer Feld 326, 69120, Heidelberg, Germany
| | - Rainer H A Fink
- Cardio-Ventilatory Muscle Physiology Laboratory, Institute of Physiology and Pathophysiology, Heidelberg University Hospital, Im Neuenheimer Feld 326, 69120, Heidelberg, Germany
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Rhee SH, Park SH, Ryoo SH, Karm MH. Lipid emulsion therapy of local anesthetic systemic toxicity due to dental anesthesia. J Dent Anesth Pain Med 2019; 19:181-189. [PMID: 31501776 PMCID: PMC6726891 DOI: 10.17245/jdapm.2019.19.4.181] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2019] [Revised: 08/20/2019] [Accepted: 08/22/2019] [Indexed: 11/15/2022] Open
Abstract
Local anesthetic systemic toxicity (LAST) refers to the complication affecting the central nervous system (CNS) and cardiovascular system (CVS) due to the overdose of local anesthesia. Its reported prevalence is 0.27/1000, and the representative symptoms range from dizziness to unconsciousness in the CNS and from arrhythmias to cardiac arrest in the CVS. Predisposing factors of LAST include extremes of age, pregnancy, renal disease, cardiac disease, hepatic dysfunction, and drug-associated factors. To prevent the LAST, it is necessary to recognize the risk factors for each patient, choose a safe drug and dose of local anesthesia, use vasoconstrictor , confirm aspiration and use incremental injection techniques. According to the treatment guidelines for LAST, immediate application of lipid emulsion plays an important role. Although lipid emulsion is commonly used for parenteral nutrition, it has recently been widely used as a non-specific antidote for various types of drug toxicity, such as LAST treatment. According to the recently published guidelines, 20% lipid emulsion is to be intravenously injected at 1.5 mL/kg. After bolus injection, 15 mL/kg/h of lipid emulsion is to be continuously injected for LAST. However, caution must be observed for >1000 mL of injection, which is the maximum dose. We reviewed the incidence, mechanism, prevention, and treatment guidelines, and a serious complication of LAST occurring due to dental anesthesia. Furthermore, we introduced lipid emulsion that has recently been in the spotlight as the therapeutic strategy for LAST.
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Affiliation(s)
- Seung-Hyun Rhee
- Department of Dental Anesthesiology, Seoul National University Dental Hospital, Seoul, Korea
| | - Sang-Hun Park
- Department of Oral and Maxillofacial Surgery, Seoul National University Dental Hospital, Seoul, Korea
| | - Seung-Hwa Ryoo
- Department of Dental Anesthesiology, Seoul National University Dental Hospital, Seoul, Korea
| | - Myong-Hwan Karm
- Department of Dental Anesthesiology, Seoul National University Dental Hospital, Seoul, Korea
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Park WK, Kim HS, Kim SH, Jung JR, Lynch C, Min NH. Intralipid Restoration of Myocardial Contractions Following Bupivacaine-Induced Asystole: Concentration- and Time-Dependence In Vitro. Anesth Analg 2017; 125:91-100. [PMID: 28537978 DOI: 10.1213/ane.0000000000002124] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The concentration- and time-response relationships of lipid emulsion (LE; Intralipid) on the recovery of myocardial contractility following bupivacaine (BPV)-induced asystole are poorly defined. METHODS After achieving asystole by 500-μM BPV, varied concentrations of LE were applied to determine the recovery of stimulated contractile responses and contractions in the cardiac tissues of guinea pigs at a 1.2-Hz stimulation rate. These experiments were performed with LE in either a recirculating (2%-16%) or washout (nonrecirculating) condition (0.05%-12%) for 60 minutes. The effect of LE itself (0.05%-12%) was examined. Oxfenicine was used to evaluate the metabolic action of LE to reverse asystole. BPV concentrations in solution and myocardial tissues were measured. RESULTS In the recirculation condition, partial recovery of contractile forces was observed for 60 minutes at 4%, 8%, and 12% LE. A contracture followed after exposure to 16% LE in some asystolic muscles. In the washout experiments, following asystole, LE (0.05%-12%) had no effect on the recovery time of the first and regular contractile responses. LE (0.1%-8%) restored contractility to baseline levels after 45 minutes; partial recovery was shown with lower (0.05%) and higher (12%) concentrations. Oxfenicine did not alter the recovery of contractile forces. Contractile depression was observed with 12% LE alone. Concentration-related reduction of tissue BPV concentration by LE was observed in both circulating conditions. CONCLUSIONS LE induced time- and concentration-dependent recovery of stimulated myocardial contractions from BPV-induced asystole. The lipid uptake effect, along with other undefined mechanisms of LE, seems to contribute to the recovery of contractile function; however, the LE effect on myocardial metabolism is less likely involved at this concentration (500 μM) of BPV.
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Affiliation(s)
- Wyun Kon Park
- From the *Department of Anesthesiology and Pain Medicine, and Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea; †Department of Food Science and Technology, Jungwon University, Chungbuk Province, Korea; and ‡Department of Anesthesiology, University of Virginia Health System, Charlottesville, Virginia
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Ok SH, Shin IW, Lee SH, Park J, Woo MS, Hong JM, Kim J, Sohn JT. Lipid emulsion alleviates the vasodilation and mean blood pressure decrease induced by a toxic dose of verapamil in isolated rat aortae and an in vivo rat model. Hum Exp Toxicol 2017; 37:636-646. [DOI: 10.1177/0960327117721963] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
This study aimed to examine the effects of lipid emulsion on the vasodilation and cardiovascular depression induced by toxic doses of calcium channel blockers. The effects of lipid emulsion on the vasodilation induced by bepridil, verapamil, nifedipine, and diltiazem were investigated in isolated endothelium-denuded rat aortae. The effect of lipid emulsion on the comparable hemodynamic depression induced by the continuous infusion of a toxic dose of either verapamil or diltiazem was examined in an in vivo rat model. The results showed the following decreasing order for the magnitude of lipid emulsion-mediated inhibition of vasodilation: bepridil, verapamil, nifedipine, and diltiazem. Lipid emulsion (0.5–2%) reversed the vasodilation induced by a toxic dose of verapamil, whereas only a higher concentration (2%) reversed the vasodilation induced by a toxic dose of diltiazem. Pretreatment with lipid emulsion alleviated the systolic and mean blood pressure decreases induced by a toxic dose of verapamil, whereas it had no effect on the decrease induced by diltiazem. Taken together, these results suggest that lipid emulsion alleviates the severe vasodilation and systolic blood pressure decrease induced by a toxic dose of verapamil, and this alleviation appears to be associated with the relatively high lipid solubility of verapamil.
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Affiliation(s)
- S-H Ok
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University School of Medicine, Gyeongsang National University Hospital, Jinju, Republic of Korea
- Institute of Health Sciences, Gyeongsang National University, Jinju, Republic of Korea
| | - I-W Shin
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University School of Medicine, Gyeongsang National University Hospital, Jinju, Republic of Korea
- Institute of Health Sciences, Gyeongsang National University, Jinju, Republic of Korea
| | - SH Lee
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University School of Medicine, Gyeongsang National University Hospital, Jinju, Republic of Korea
| | - J Park
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University Changwon Hospital, Changwon, Republic of Korea
| | - MS Woo
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University School of Medicine, Gyeongsang National University Hospital, Jinju, Republic of Korea
| | - J-M Hong
- Department of Anesthesiology and Pain Medicine, Pusan National University Hospital, Biomed Research Institute, Pusan National University School of Medicine, Busan, Republic of Korea
| | - J Kim
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University School of Medicine, Gyeongsang National University Hospital, Jinju, Republic of Korea
| | - J-T Sohn
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University School of Medicine, Gyeongsang National University Hospital, Jinju, Republic of Korea
- Institute of Health Sciences, Gyeongsang National University, Jinju, Republic of Korea
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Cardiac Arrest after Local Anaesthetic Toxicity in a Paediatric Patient. Case Rep Anesthesiol 2016; 2016:7826280. [PMID: 27872765 PMCID: PMC5107833 DOI: 10.1155/2016/7826280] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2016] [Accepted: 10/10/2016] [Indexed: 11/18/2022] Open
Abstract
We report a case of a paediatric patient undergoing urological procedure in which a possible inadvertent intravascular or intraosseous injection of bupivacaine with adrenaline in usual doses caused subsequent cardiac arrest, completely reversed after administration of 20% intravenous lipid emulsion. Early diagnosis of local anaesthetics toxicity and adequate cardiovascular resuscitation manoeuvres contribute to the favourable outcome.
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Guideline implementation: local anesthesia. AORN J 2016; 101:682-9; quiz 690-2. [PMID: 26025744 DOI: 10.1016/j.aorn.2015.04.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Revised: 04/16/2015] [Accepted: 04/20/2015] [Indexed: 11/23/2022]
Abstract
It is not uncommon in perioperative settings for patients to receive local anesthesia for a variety of procedures. It is imperative for patient safety that the perioperative RN has a comprehensive understanding of best practices associated with the use of local anesthesia. The updated AORN "Guideline for care of the patient receiving local anesthesia" provides guidance on perioperative nursing assessments and interventions to safely care for patients receiving local anesthesia. This article focuses on key points of the guideline to help perioperative personnel become knowledgeable regarding best practice as they care for this patient population. The key points address patient assessment, the importance of having an overall understanding of the local agent being used, recommended monitoring requirements, and potential adverse events, including life-threatening events. Perioperative RNs should review the complete guideline for additional information and for guidance when writing and updating policies and procedures.
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Park J, Kim YA, Han JY, Jin S, Ok SH, Sohn JT, Lee HK, Chung YK, Shin IW. Lipofundin® MCT/LCT 20% increase left ventricular systolic pressure in an ex vivo rat heart model via increase of intracellular calcium level. Korean J Anesthesiol 2016; 69:57-62. [PMID: 26885303 PMCID: PMC4754268 DOI: 10.4097/kjae.2016.69.1.57] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Revised: 11/19/2015] [Accepted: 11/19/2015] [Indexed: 02/07/2023] Open
Abstract
Background Lipid emulsions have been used to treat various drug toxicities and for total parenteral nutrition therapy. Their usefulness has also been confirmed in patients with local anesthetic-induced cardiac toxicity. The purpose of this study was to measure the hemodynamic and composition effects of lipid emulsions and to elucidate the mechanism associated with changes in intracellular calcium levels in myocardiocytes. Methods We measured hemodynamic effects using a digital analysis system after Intralipid® and Lipofundin® MCT/LCT were infused into hearts hanging in a Langendorff perfusion system. We measured the effects of the lipid emulsions on intracellular calcium levels in H9c2 cells by confocal microscopy. Results Infusion of Lipofundin® MCT/LCT 20% (1 ml/kg) resulted in a significant increase in left ventricular systolic pressure compared to that after infusing modified Krebs-Henseleit solution (1 ml/kg) (P = 0.003, 95% confidence interval [CI], 2.4–12.5). Lipofundin® MCT/LCT 20% had a more positive inotropic effect than that of Intralipid® 20% (P = 0.009, 95% CI, 1.4–11.6). Both lipid emulsion treatments increased intracellular calcium levels. Lipofundin® MCT/LCT (0.01%) increased intracellular calcium level more than that of 0.01% Intralipid® (P < 0.05, 95% CI, 0.0–1.9). Conclusions These two lipid emulsions had different inotropic effects depending on their triglyceride component. The inotropic effect of lipid emulsions could be related with intracellular calcium level.
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Affiliation(s)
- Jiyoung Park
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University Hospital, Jinju, Korea
| | - Yeon A Kim
- Department of Anatomy and Cell biology, Dong-A University College of Medicine and Mitochondria Hub Regulation Center, Busan, Korea
| | - Jeong Yeol Han
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Sangkyu Jin
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University Hospital, Jinju, Korea
| | - Seong-Ho Ok
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University Hospital, Jinju, Korea.; Institute of Health Sciences, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Ju-Tae Sohn
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University Hospital, Jinju, Korea.; Institute of Health Sciences, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Heon-Keun Lee
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University Hospital, Jinju, Korea.; Institute of Health Sciences, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Young-Kyun Chung
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University Hospital, Jinju, Korea.; Institute of Health Sciences, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Il-Woo Shin
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University Hospital, Jinju, Korea.; Institute of Health Sciences, Gyeongsang National University School of Medicine, Jinju, Korea
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Ok SH, Kim WH, Yu J, Lee Y, Choi MJ, Lim DH, Hwang Y, Kim YA, Sohn JT. Effects of Acidification and Alkalinization on the Lipid Emulsion-Mediated Reversal of Toxic Dose Levobupivacaine-Induced Vasodilation in the Isolated Rat Aorta. Int J Med Sci 2016; 13:68-76. [PMID: 26917987 PMCID: PMC4747872 DOI: 10.7150/ijms.13016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Accepted: 01/06/2016] [Indexed: 12/16/2022] Open
Abstract
The goal of this in vitro study was to examine the effects of pre-acidification and pre-akalinization on the lipid emulsion-mediated reversal of toxic dose levobupivacaine-induced vasodilation in isolated rat aorta. Isolated aortic rings with and without the nitric oxide synthase inhibitor N(ω)-nitro-L-arginine methyl ester (L-NAME) were exposed to four types of Krebs solution (pH 7.0, 7.2, 7.4, and 7.6), followed by the addition of 60 mM potassium chloride. When the toxic dose of levobupivacaine (3 × 10(-4) M) produced a stable and sustained vasodilation in the isolated aortic rings that were precontracted with 60 mM potassium chloride, increasing lipid emulsion concentrations (SMOFlipid(®): 0.24, 0.48, 0.95 and 1.39%) were added to generate concentration-response curves. The effects of mild pre-acidification alone and mild pre-acidification in combination with a lipid emulsion on endothelial nitric oxide synthase (eNOS) phosphorylation in human umbilical vein endothelial cells were investigated by Western blotting. Mild pre-acidification caused by the pH 7.2 Krebs solution enhanced the lipid emulsion-mediated reversal of levobupivacaine-induced vasodilation in isolated endothelium-intact aortic rings, whereas mild pre-acidification caused by the pH 7.2 Krebs solution did not significantly alter the lipid emulsion-mediated reversal of the levobupivacaine-induced vasodilation in isolated endothelium-denuded aortic rings or endothelium-intact aortic rings with L-NAME. A lipid emulsion attenuated the increased eNOS phosphorylation induced by the pH 7.2 Krebs solution. Taken together, these results suggest that mild pre-acidification enhances the lipid emulsion-mediated reversal of toxic dose levobupivacaine-induced vasodilation in the endothelium-intact aorta via the inhibition of nitric oxide.
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Affiliation(s)
- Seong-Ho Ok
- 1. Department of Anesthesiology and Pain Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju-si, 52727, Republic of Korea
| | - Won Ho Kim
- 2. Department of Anesthesiology and Pain Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea;; 3. Department of Anesthesiology and Pain Medicine, Gyeongsang National University School of Medicine, Jinju-si, 52727, Republic of Korea
| | - Jongsun Yu
- 4. Department of Anesthesiology and Pain Medicine, Gyeongsang National University Hospital, Jinju-si, 52727, Republic of Korea
| | - Youngju Lee
- 4. Department of Anesthesiology and Pain Medicine, Gyeongsang National University Hospital, Jinju-si, 52727, Republic of Korea
| | - Mun-Jeoung Choi
- 5. Department of Oral and Maxillofacial Surgery, Gyeongsang National University Hospital, Jinju-si, 52727, Republic of Korea
| | - Dong Hoon Lim
- 6. Department of Information Statistics and RINS, Gyeongsang National University, Jinju, 52828, Korea
| | - Yeran Hwang
- 4. Department of Anesthesiology and Pain Medicine, Gyeongsang National University Hospital, Jinju-si, 52727, Republic of Korea
| | - Yeon A Kim
- 7. Department of Anatomy and Cell Biology and Mitochondria Hub Regulation Center, Dong-A University College of Medicine, Busan, South Korea
| | - Ju-Tae Sohn
- 1. Department of Anesthesiology and Pain Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju-si, 52727, Republic of Korea;; 8. Institute of Health Sciences, Gyeongsang National University, Jinju, Republic of Korea
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Ok SH, Yu J, Lee Y, Cho H, Shin IW, Sohn JT. Lipid emulsion attenuates apoptosis induced by a toxic dose of bupivacaine in H9c2 rat cardiomyoblast cells. Hum Exp Toxicol 2015; 35:929-37. [PMID: 26437793 DOI: 10.1177/0960327115608930] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The goal of this in vitro study was to investigate the effect of lipid emulsion on apoptosis induced by a toxic dose of bupivacaine (BPV) in H9c2 rat cardiomyoblast cell lines. The effect of lipid emulsion on the decreased cell viability and count induced by BPV or mepivacaine (MPV) in the H9c2 cells was assessed using an 3-(4,5-dimethylthiazole-2-yl)-2,5-diphenyl tetrazolium bromide assay or a cell count assay. The effect of BPV or lipid emulsion combined with BPV on cleaved caspase 3, caspase 8, and Bax in H9c2 cells was investigated using Western blotting. A terminal deoxynucleotidyl transferase dUTP2'-deoxyuridine 5'-triphosphate nick end-labeling (TUNEL) assay was performed to detect apoptosis of H9c2 cells treated with BPV alone or lipid emulsion combined with BPV. The magnitude of lipid emulsion-mediated attenuation of decreased cell viability induced by BPV was higher than that of lipid emulsion-mediated attenuation of decreased cell viability induced by MPV. Lipid emulsion attenuated the increases in cleaved caspase 3, caspase 8 and Bax induced by BPV. Lipid emulsion attenuated the increases in TUNEL-positive cells induced by BPV. These results suggest that lipid emulsion attenuates a toxic dose of BPV-induced apoptosis via inhibition of the extrinsic and intrinsic apoptotic pathways. The protective effect of lipid emulsion may be partially associated with the relatively high lipid solubility of BPV.
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Affiliation(s)
- S-H Ok
- Department of Anesthesiology and Pain Medicine, Institute of Health Sciences, Gyeongsang National University, School of Medicine and Gyeongsang National University Hospital, Jinju, Korea
| | - J Yu
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University Hospital, Jinju, Korea
| | - Y Lee
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University Hospital, Jinju, Korea
| | - H Cho
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University Hospital, Jinju, Korea
| | - I-W Shin
- Department of Anesthesiology and Pain Medicine, Institute of Health Sciences, Gyeongsang National University, School of Medicine and Gyeongsang National University Hospital, Jinju, Korea
| | - J-T Sohn
- Department of Anesthesiology and Pain Medicine, Institute of Health Sciences, Gyeongsang National University, School of Medicine and Gyeongsang National University Hospital, Jinju, Korea
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Buys M, Scheepers PA, Levin AI. Lipid emulsion therapy: non-nutritive uses of lipid emulsions in anaesthesia and intensive care. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2015. [DOI: 10.1080/22201181.2015.1095470] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Adherence to guidelines for the management of local anesthetic systemic toxicity is improved by an electronic decision support tool and designated "Reader". Reg Anesth Pain Med 2015; 39:299-305. [PMID: 24956454 DOI: 10.1097/aap.0000000000000097] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND OBJECTIVES A hardcopy or paper cognitive aid has been shown to improve performance during the management of simulated local anesthetic systemic toxicity (LAST) when given to the team leader. However, there remains room for improvement to ensure a system that can achieve perfect adherence to the published guidelines for LAST management. Recent research has shown that implementing a checklist via a designated reader may be of benefit. Accordingly, we sought to investigate the effect of an electronic decision support tool (DST) and designated "Reader" role on team performance during an in situ simulation of LAST. METHODS Participants were randomized to Reader + DST (n = 16, rDST) and Control (n = 15, memory alone). The rDST group received the assistance of a dedicated Reader on the response team who was equipped with an electronic DST. The primary outcome measure was adherence to guidelines. RESULTS For overall and critical percent correct scores, the rDST group scored higher than Control (99.3% vs 72.2%, P < 0.0001; 99.5% vs 70%, P < 0.0001, respectively). In the LAST scenario, 0 (0%) of 15 in the control group performed 100% of critical management steps, whereas 15 (93.8%) of 16 in the rDST group did so (P < 0.0001). CONCLUSIONS In a prospective, randomized single-blinded study, a designated Reader with an electronic DST improved adherence to guidelines in the management of an in situ simulation of LAST. Such tools are promising in the future of medicine, but further research is needed to ensure the best methods for implementing them in the clinical arena.
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Ok SH, Byon HJ, Kwon SC, Park J, Lee Y, Hwang Y, Baik J, Choi MJ, Sohn JT. Lipid Emulsion Inhibits Vasodilation Induced by a Toxic Dose of Bupivacaine via Attenuated Dephosphorylation of Myosin Phosphatase Target Subunit 1 in Isolated Rat Aorta. Int J Med Sci 2015; 12:958-67. [PMID: 26664257 PMCID: PMC4661294 DOI: 10.7150/ijms.13299] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Accepted: 10/10/2015] [Indexed: 12/12/2022] Open
Abstract
Lipid emulsions are widely used for the treatment of systemic toxicity that arises from local anesthetics. The goal of this in vitro study was to examine the cellular mechanism associated with the lipid emulsion-mediated attenuation of vasodilation induced by a toxic dose of bupivacaine in isolated endothelium-denuded rat aorta. The effects of lipid emulsion on vasodilation induced by bupivacaine, mepivacaine, and verapamil were assessed in isolated aorta precontracted with phenylephrine, the Rho kinase stimulant NaF, and the protein kinase C activator phorbol 12,13-dibutyrate (PDBu). The effects of Rho kinase inhibitor Y-27632 on contraction induced by phenylephrine or NaF were assessed. The effects of bupivacaine on intracellular calcium concentrations ([Ca(2+)]i) and tension induced by NaF were simultaneously measured. The effects of bupivacaine alone and lipid emulsion plus bupivacaine on myosin phosphatase target subunit 1 (MYPT1) phosphorylation induced by NaF were examined in rat aortic vascular smooth muscle cells. In precontracted aorta, the lipid emulsion attenuated bupivacaine-induced vasodilation but had no effect on mepivacaine-induced vasodilation. Y-27632 attenuated contraction induced by either phenylephrine or NaF. The lipid emulsion attenuated verapamil-induced vasodilation. Compared with phenylephrine-induced precontracted aorta, bupivacaine-induced vasodilation was slightly attenuated in NaF-induced precontracted aorta. The magnitude of the bupivacaine-induced vasodilation was higher than that of a bupivacaine-induced decrease in [Ca(2+)]i. Bupivacaine attenuated NaF-induced MYPT1 phosphorylation, whereas lipid emulsion pretreatment attenuated the bupivacaine-induced inhibition of MYPT1 phosphorylation induced by NaF. Taken together, these results suggest that lipid emulsions attenuate bupivacaine-induced vasodilation via the attenuation of inhibition of MYPT1 phosphorylation evoked by NaF.
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Affiliation(s)
- Seong-Ho Ok
- 1. Department of Anesthesiology and Pain Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju-si, 52727, Republic of Korea
| | - Hyo-Jin Byon
- 2. Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea; ; 8. Department of Anesthesiology and Pain Medicine, Gyeongsang National University School of Medicine, Jinju-si, 52727, Republic of Korea
| | - Seong-Chun Kwon
- 3. Department of Physiology, Institute for Clinical and Translational Research, Catholic Kwandong University College of Medicine, Gangneung, 25601, Korea
| | - Jungchul Park
- 4. Department of Anesthesiology and Pain Medicine, Gyeongsang National University Hospital, Jinju, 660-702, Republic of Korea
| | - Youngju Lee
- 4. Department of Anesthesiology and Pain Medicine, Gyeongsang National University Hospital, Jinju, 660-702, Republic of Korea
| | - Yeran Hwang
- 4. Department of Anesthesiology and Pain Medicine, Gyeongsang National University Hospital, Jinju, 660-702, Republic of Korea
| | - Jiseok Baik
- 5. Department of Anesthesiology and Pain Medicine, Pusan National University Hospital, Biomed Research Institute, Pusan National University School of Medicine, Busan, Republic of Korea
| | - Mun-Jeoung Choi
- 6. Department of Oral and Maxillofacial Surgery, Gyeongsang National University Hospital, Jinju, 660-702, Republic of Korea
| | - Ju-Tae Sohn
- 1. Department of Anesthesiology and Pain Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju-si, 52727, Republic of Korea; ; 7. Institute of Health Sciences, Gyeongsang National University, Jinju, Republic of Korea
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16
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Ok SH, Park CS, Kim HJ, Lee SH, Choi BH, Eun SY, Kim KN, Yang SM, Shin IW, Choi MJ, Sohn JT. Effect of two lipid emulsions on reversing high-dose levobupivacaine-induced reduced vasoconstriction in the rat aortas. Cardiovasc Toxicol 2014; 13:370-80. [PMID: 23877627 DOI: 10.1007/s12012-013-9218-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The goals of this study were to determine which lipid emulsion (Intralipid(®) and Lipofundin MCT/LCT(®)) is more effective in reversing high-dose levobupivacaine-induced reduced vasoconstriction in isolated rat aortas and to examine the associated cellular mechanisms with a particular focus on the endothelium. Two lipid emulsion concentration-response curves were generated using high-dose levobupivacaine-induced reduced vasoconstriction and vasodilation of isolated aortas pretreated with or without 60 mM KCl. Endothelial nitric oxide synthase (eNOS) and caveolin-1 phosphorylation were measured in rat aortic tissue treated with levobupivacaine in the presence or absence of lipid emulsion. Dichlorofluorescein oxidation, a measure of reactive oxygen species production, was measured in lipid emulsion-treated human umbilical vein endothelial cells. In levobupivacaine (0.3 mM)-induced reduced vasoconstriction of isolated aorta, the magnitude of the Intralipid(®)- and Lipofundin MCT/LCT(®)-mediated reversal was not significantly different. Lipid emulsion reversal of levobupivacaine-induced reduced vasoconstriction was greater in endothelium-intact aortas than in endothelium-denuded aortas. The two lipid emulsions similarly inhibited levobupivacaine-induced eNOS phosphorylation in aortic tissue. Pretreatment with both lipid emulsions increased dichlorofluorescein oxidation. Both Intralipid(®) and Lipofundin MCT/LCT(®) are equally effective for vascular tone recovery from high-dose levobupivacaine-induced reduced vasoconstriction. This reversal is mediated partially by decreasing nitric oxide bioavailability.
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Affiliation(s)
- Seong-Ho Ok
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University Hospital, Jinju, 660-702, Republic of Korea
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17
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Shin IW, Hah YS, Kim C, Park J, Shin H, Park KE, Ok SH, Lee HK, Chung YK, Shim HS, Lim DH, Sohn JT. Systemic blockage of nitric oxide synthase by L-NAME increases left ventricular systolic pressure, which is not augmented further by Intralipid®. Int J Biol Sci 2014; 10:367-76. [PMID: 24719554 PMCID: PMC3979989 DOI: 10.7150/ijbs.8048] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2013] [Accepted: 03/05/2014] [Indexed: 11/19/2022] Open
Abstract
Intravenous lipid emulsions (LEs) are effective in the treatment of toxicity associated with various drugs such as local anesthetics and other lipid soluble agents. The goals of this study were to examine the effect of LE on left ventricular hemodynamic variables and systemic blood pressure in an in vivo rat model, and to determine the associated cellular mechanism with a particular focus on nitric oxide. Two LEs (Intralipid® 20% and Lipofundin® MCT/LCT 20%) or normal saline were administered intravenously in an in vivo rat model following induction of anesthesia by intramuscular injection of tiletamine/zolazepam and xylazine. Left ventricular systolic pressure (LVSP), blood pressure, heart rate, maximum rate of intraventricular pressure increase, and maximum rate of intraventricular pressure decrease were measured before and after intravenous administration of various doses of LEs or normal saline to an in vivo rat with or without pretreatment with the non-specific nitric oxide synthase inhibitor Nω-nitro-L-arginine-methyl ester (L-NAME). Administration of Intralipid® (3 and 10 ml/kg) increased LVSP and decreased heart rate. Pretreatment with L-NAME (10 mg/kg) increased LSVP and decreased heart rate, whereas subsequent treatment with Intralipid® did not significantly alter LVSP. Intralipid® (10 ml/kg) increased mean blood pressure and decreased heart rate. The increase in LVSP induced by Lipofundin® MCT/LCT was greater than that induced by Intralipid®. Intralipid® (1%) did not significantly alter nitric oxide donor sodium nitroprusside-induced relaxation in endothelium-denuded rat aorta. Taken together, systemic blockage of nitric oxide synthase by L-NAME increases LVSP, which is not augmented further by intralipid®.
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Affiliation(s)
- Il-Woo Shin
- 1. Department of Anesthesiology and Pain Medicine, Gyeongsang National University Hospital, Institute of Health Sciences, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Young-Sool Hah
- 2. Clinical Research Institute, Gyeongsang National University Hospital, Jinju, Korea
| | - Cheol Kim
- 3. Department of Anesthesiology and Pain Medicine, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Jungchul Park
- 4. Department of Anesthesiology and Pain Medicine, Gyeongsang National University Hospital, Jinju, Korea
| | - Heewon Shin
- 5. Department of Biological Sciences, California State University, Long Beach, California, USA
| | - Kyeong-Eon Park
- 4. Department of Anesthesiology and Pain Medicine, Gyeongsang National University Hospital, Jinju, Korea
| | - Seong-Ho Ok
- 1. Department of Anesthesiology and Pain Medicine, Gyeongsang National University Hospital, Institute of Health Sciences, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Heon-Keun Lee
- 1. Department of Anesthesiology and Pain Medicine, Gyeongsang National University Hospital, Institute of Health Sciences, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Young-Kyun Chung
- 1. Department of Anesthesiology and Pain Medicine, Gyeongsang National University Hospital, Institute of Health Sciences, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Haeng Seon Shim
- 6. Department of Anesthesiology and Pain Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Dong Hoon Lim
- 7. Department of Information Statistics and RINS, Gyeongsang National University, Jinju, 660-701, Korea
| | - Ju-Tae Sohn
- 1. Department of Anesthesiology and Pain Medicine, Gyeongsang National University Hospital, Institute of Health Sciences, Gyeongsang National University School of Medicine, Jinju, Korea
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YILMAZ M, CELEBI H, AKCALI D, GUREL N. Pre-treatment of bupivacaine-induced cardiovascular depression using different lipid formulations of propofol. Acta Anaesthesiol Scand 2014; 58:298-302. [PMID: 24438483 DOI: 10.1111/aas.12263] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/13/2013] [Indexed: 11/27/2022]
Abstract
BACKGROUND Pre-treatment with lipid emulsions has been shown to increase lethal doses of bupivacaine, and the lipid content of propofol may alleviate bupivacaine-induced cardiotoxicity. The aim of this study is to investigate the effects of propofol in intralipid or medialipid emulsions on bupivacaine-induced cardiotoxicity. METHODS Rats were anaesthetised with ketamine and were given 0.5 mg/kg/min propofol in intralipid (Group P), propofol in medialipid (Group L), or saline (Group C) over 20 min. Thereafter, 2 mg/kg/min bupivacaine 0.5% was infused. We recorded time to first dysrhythmia occurrence, respective times to 25% and 50% reduction of the heart rate (HR) and mean arterial pressure, and time to asystole and total amount of bupivacaine consumption. Blood and tissue samples were collected following asystole. RESULTS The time to first dysrhythmia occurrence, time to 25% and 50% reductions in HR, and time to asystole were longer in Group P than the other groups. The cumulative bupivacaine dose given at those time points was higher in Group P. Plasma bupivacaine levels were significantly lower in Group P than in Group C. Bupivacaine levels in the brain and heart were significantly lower in Group P and Group L than in Group C. CONCLUSION We conclude that pre-treatment with propofol in intralipid, compared with propofol in medialipid or saline, delayed the onset of bupivacaine-induced cardiotoxic effects as well as reduced plasma bupivacaine levels. Further studies are needed to explore tissue bupivacaine levels of propofol in medialipid and adapt these results to clinical practice.
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Affiliation(s)
- M. YILMAZ
- Department of Anesthesiology and Reanimation; Gazi University Faculty of Medicine; Ankara Turkey
| | - H. CELEBI
- Department of Anesthesiology and Reanimation; Gazi University Faculty of Medicine; Ankara Turkey
| | - D. AKCALI
- Department of Anesthesiology and Reanimation; Gazi University Faculty of Medicine; Ankara Turkey
| | - N. GUREL
- The Scientific and Technological Research Council of Turkey (ATAL); Ankara Turkey
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Lipid Rescue Reverses the Bupivacaine-induced Block of the Fast Na+ Current (INa) in Cardiomyocytes of the Rat Left Ventricle. Anesthesiology 2014; 120:724-36. [DOI: 10.1097/aln.0b013e3182a66d4d] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Abstract
Background:
Cardiovascular resuscitation upon intoxication with lipophilic ion channel–blocking agents has proven most difficult. Recently, favorable results have been reported when lipid rescue therapy is performed, i.e., the infusion of a triglyceride-rich lipid emulsion during resuscitation. However, the mechanism of action is poorly understood.
Methods:
The authors investigate the effects of a clinically used lipid emulsion (Lipovenös® MCT 20%; Fresenius Kabi AG, Bad Homburg, Germany) on the block of the fast Na+ current (INa) induced by the lipophilic local anesthetic bupivacaine in adult rat left ventricular myocytes by using the whole cell patch clamp technique.
Results:
Bupivacaine at 10 µm decreased INa by 54% (−19.3 ± 1.9 pApF−1vs. −42.3 ± 4.3 pApF−1; n = 17; P < 0.001; VPip = −40 mV, 1 Hz). Addition of 10% lipid emulsion in the presence of bupivacaine produced a 37% increase in INa (−26.4 ± 2.8 pApF−1; n = 17; P < 0.001 vs. bupivacaine alone). To test whether these results could be explained by a reduction in the free bupivacaine concentration by the lipid (lipid-sink effect), the authors removed the lipid phase from the bupivacaine–lipid mixture by ultracentrifugation. Also, the resulting water phase led to an increase in INa (+19%; n = 17; P < 0.001 vs. bupivacaine), demonstrating that part of the bupivacaine had been removed during ultracentrifugation. The substantially less lipophilic mepivacaine (40 µm) reduced INa by 27% (n = 24; P < 0.001). The mepivacaine–lipid mixture caused a significant increase in INa (+17%; n = 24; P < 0.001). For mepivacaine, only a small lipid-sink effect could be demonstrated (+8%; n = 23; P < 0.01), reflecting its poor lipid solubility.
Conclusion:
The authors demonstrate lipid rescue on the single-cell level and provide evidence for a lipid-sink mechanism.
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Shin IW, Sohn JT. Lipid emulsion treatment of systemic toxicity induced by local anesthetics or other drugs. JOURNAL OF THE KOREAN MEDICAL ASSOCIATION 2014. [DOI: 10.5124/jkma.2014.57.6.537] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Il-Woo Shin
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University Hospital, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Ju-Tae Sohn
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University Hospital, Gyeongsang National University School of Medicine, Jinju, Korea
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Lee SH, Sung HJ, Ok SH, Yu J, Choi MJ, Lim JS, Sohn JT. Lipid emulsions enhance the norepinephrine-mediated reversal of local anesthetic-induced vasodilation at toxic doses. Yonsei Med J 2013; 54:1524-32. [PMID: 24142661 PMCID: PMC3809849 DOI: 10.3349/ymj.2013.54.6.1524] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
PURPOSE Intravenous lipid emulsions have been used to treat the systemic toxicity of local anesthetics. The goal of this in vitro study was to examine the effects of lipid emulsions on the norepinephrine-mediated reversal of vasodilation induced by high doses of levobupivacaine, ropivacaine, and mepivacaine in isolated endothelium-denuded rat aorta, and to determine whether such effects are associated with the lipid solubility of local anesthetics. MATERIALS AND METHODS The effects of lipid emulsions (0.30, 0.49, 1.40, and 2.61%) on norepinephrine concentration-responses in high-dose local anesthetic (6×10(-4) M levobupivacaine, 2×10(-3) M ropivacaine, and 7×10(-3) M mepivacaine)-induced vasodilation of isolated aorta precontracted with 60 mM KCl were assessed. The effects of lipid emulsions on local anesthetic- and diltiazem-induced vasodilation in isolated aorta precontracted with phenylephrine were also assessed. RESULTS Lipid emulsions (0.30%) enhanced norepinephrine-induced contraction in levobupivacaine-induced vasodilation, whereas 1.40 and 2.61% lipid emulsions enhanced norepinephrine-induced contraction in both ropivacaine- and mepivacaine-induced vasodilation, respectively. Lipid emulsions (0.20, 0.49 and 1.40%) inhibited vasodilation induced by levobupivacaine and ropivacaine, whereas 1.40 and 2.61% lipid emulsions slightly attenuated mepivacaine (3×10(-3) M)-induced vasodilation. In addition, lipid emulsions attenuated diltiazem-induced vasodilation. Lipid emulsions enhanced norepinephrine-induced contraction in endothelium-denuded aorta without pretreatment with local anesthetics. CONCLUSION Taken together, these results suggest that lipid emulsions enhance the norepinephrine-mediated reversal of local anesthetic-induced vasodilation at toxic anesthetic doses and inhibit local anesthetic-induced vasodilation in a manner correlated with the lipid solubility of a particular local anesthetic.
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Affiliation(s)
- Soo Hee Lee
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University Hospital, 79 Gangnam-ro, Jinju 660-702, Korea.
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Abstract
The investigators describe the clinical course of a 26-year-old-man who was brought to the emergency department in a comatose state with status epilepticus after smoking a large amount of crack cocaine. In the emergency department, he was intubated because of depressed mental status and respiratory acidosis. His troponin I remained negative, and electrocardiography showed wide-complex tachycardia with a prolonged corrected QT interval. Because of the corrected QT interval prolongation and wide-complex tachycardia, the patient was started on intravenous magnesium sulfate and sodium bicarbonate. Despite these interventions, no improvement in cardiac rhythm was observed, and electrocardiography continued to show wide-complex tachycardia. The patient became more unstable from a cardiovascular standpoint, with a decrease in blood pressure to 85/60 mm Hg. He was then given 100 ml of 20% lipid emulsion (Intralipid). Within 10 minutes of starting the infusion of 20% lipid emulsion, wide-complex tachycardia disappeared, with an improvement in systemic blood pressure to 120/70 mm Hg. Repeat electrocardiography after the infusion of intravenous lipid emulsion showed regular sinus rhythm with normal QRS and corrected QT intervals. The patient was successfully extubated on day 8 of hospitalization and discharged home on day 10. His cardiac rhythm and blood pressure remained stable throughout his further stay in the hospital.
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Affiliation(s)
- Natasha Purai Arora
- Department of Internal Medicine, Wayne State University School of Medicine, Detroit Medical Center, Michigan, USA
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