Signs and symptoms* LAST can occur >15 minutes after injection of LA |
- Stop injection or infusion
- Call for help and lipid emulsion
- While stabilizing the patient, arrange for cardiopulmonary bypass
- Airway management: Ventilate with 100% oxygen, prevent hypoxemia, hypercarbia, and acidosis
- Suppress seizures: Benzodiazepines preferred (avoid large doses of propofol)
- Manage arrhythmias and cardiac arrest per ACLS EXCEPT:
- Reduce individual epinephrine boluses to ≤1 mcg/kg
- Avoid vasopressin, calcium channel blockers, beta blockers, and LA
- Administer amiodarone as the first line antiarrhythmic
- Institute lipid emulsion therapy with 20% lipid emulsion
- Adults ≥70 kg: Bolus 100 mL IV over 2 to 3 minutes, followed by infusion of 250 mL over 15 to 20 minutes
- Children or adults <70 kg: Bolus 1.5 mL/kg IBW IV over 2 to 3 minutes, followed by infusion at 0.25 mL/kg/minute
- For patients with persistent cardiovascular instability, repeat bolus and double infusion rate
- Continue infusion for at least 15 minutes after hemodynamic stability is achieved
- Maximum dose lipid emulsion approximately 12 mL/kg IV
- Note: Propofol is not a substitute for lipid emulsion
- Institute cardiopulmonary bypass for LAST unresponsive to lipid emulsion and ACLS
- Monitor the patient for 2 hours after seizure, 4 to 6 hours after hemodynamic instability, or as appropriate after cardiac arrest
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