From the Guidelines
The treatment for local bupivacaine overdose primarily involves supportive care and the administration of intravenous lipid emulsion therapy (20% lipid emulsion). For a patient experiencing bupivacaine toxicity, immediately stop the anesthetic administration, secure the airway, provide oxygen, establish IV access, and monitor vital signs.
Key Treatment Steps
- For cardiovascular symptoms, administer a 20% lipid emulsion as a 1.5 mL/kg bolus over 1 minute, followed by an infusion of 0.25 mL/kg/min for 30-60 minutes, as recommended by the 2023 American Heart Association guidelines update 1.
- The bolus can be repeated 1-2 times for persistent cardiovascular collapse, and the infusion rate can be increased if blood pressure remains low.
- Seizures should be treated with benzodiazepines (e.g., midazolam 2-5 mg IV or diazepam 5-10 mg IV).
- Cardiac arrhythmias may require standard ACLS protocols, though amiodarone is preferred over lidocaine, as noted in the 2020 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care 1.
Rationale
Lipid emulsion therapy works by creating a "lipid sink" that extracts the lipophilic bupivacaine from tissue binding sites and by directly counteracting bupivacaine's effects on cardiac energy metabolism.
Additional Considerations
Prolonged CPR may be necessary as recovery from bupivacaine toxicity can take time. The most recent guidelines from the American Heart Association, such as the 2023 focused update on the management of patients with cardiac arrest or life-threatening toxicity due to poisoning, support the use of lipid emulsion therapy in the treatment of local anesthetic systemic toxicity (LAST) 1.
From the Research
Treatment for Local Bupivacaine Overdose
- The treatment for local bupivacaine overdose typically involves addressing the cardiotoxic and neurotoxic effects of the drug 2, 3.
- Intravenous lipid emulsion (ILE) has been shown to be effective in treating local anesthetic systemic toxicity, including bupivacaine overdose 4, 5, 6.
- ILE works by binding to the local anesthetic and reducing its toxicity, as well as providing a source of energy for the heart and other tissues 4.
- The administration of ILE typically involves an initial bolus followed by a continuous infusion, with the dose and duration of treatment depending on the severity of the overdose and the patient's response to treatment 4, 5.
Clinical Presentation and Management
- The clinical presentation of local bupivacaine overdose can include neurological symptoms such as seizures, as well as cardiotoxic effects like hypotension and bradycardia 2, 3, 4.
- Management of the overdose may also involve supportive care, such as maintaining airway, breathing, and circulation, as well as treating any seizures or other neurological symptoms that may occur 3, 5.
- In some cases, additional treatments like benzodiazepines and barbiturates may be necessary to manage seizures and other neurological symptoms 3.
Specific Cases and Outcomes
- A case report described the successful treatment of a cat with intrapleural bupivacaine overdose using ILE, with resolution of clinical signs and no ongoing complications 4.
- Another case report described the successful resuscitation of a pediatric patient with presumed bupivacaine-induced seizures and cardiovascular complications using lipid infusion 5.
- A case of levobupivacaine-induced seizures and cardiovascular collapse was also successfully treated with Intralipid infusion 6.