Article - ASRA Checklist Flashcards
How is the pharmacologic treatment of LAST different than other cardiac arrest scenarios?
- Reduce epinephrine to < 1 mcg/kg
- Avoid vasopressin, calcium channel blockers, beta blockers, or other local anesthetics
5 Main steps of LAST treatment
- Stop injecting local anesthetic
- Get help
- Airway management
- Control seizures
- Treat hypotension and bradycardia (if pulseless start CPR)
What should you consider at the first sign of SERIOUS LAST event?
Lipid emulsion
Two things you should ask for when getting help
LAST rescue kit
Cardiopulmonary bypass team
Components of airway management for LAST
- Ventilate with 100% O2
- Avoid hyperventilation
- Advanced airway device if necessary
Components of controlling seizures
- Benzos are preferred
- Avoid large doses of propofol especially in hemodynamically unstable patients
Lipid emulsion instructions in patients greater than 70 kg
- Bolus 100 ml lipid emulsion 20% over 2-3 mins
- Lipid emulsion infusion 200-250 ml over 15-20 mins
Lipid emulsion instructions in patients less than 70 kg
- Bolus 1.5 ml/kg lipid emulsion 20% over 2-3 mins
- Lipid emulsion infusion ~0.25 ml/kg/min (ideal body weight)
What to do if patient remains unstable after lipid emulsion?
- Re-bolus once or twice at the same dose and double the infusion rate (be aware of dosing limit 12 ml/kg)
- Total volume of lipid emulsion can approach 1 L in prolonged resuscitation (>30 mins)
How long to monitor LAST patient after cardiac event?
at least 4-6 hours
How long to monitor LAST patient after limited CNS event?
At least 2 hours
Dose of local anesthetic to reduce risk of LAST
Least dose necessary to achieve the desired extent and duration of block
What influences blood levels of local anesthetics?
Site of injection and dose
Patients at increased risk for LAST
- Infants < 6 months
- Small patient size
- Advanced age and frailty
- Heart failure
- Ischemic heart disease
- Conduction abnormalities or rhythm disorders
- Metabolic (mitochondrial) disease
- Liver disease
- Low plasma protein concentration
- Acidosis
- Medications that inhibit sodium channels
Patients more sensitive to LAST?
Patients with very low ejection fractions
Test dose for prevention of LAST
Epinephrine 2.5-5 mcg/ml (total 10-15 mcg)
Know expected response, onset, duration, and limitations of test dose in identifying intravascular injection
How to inject LA
- Aspirate syringe prior to each injection while observing for blood in syringe or tubing
- Inject incrementally, while observing for signs and symptoms of toxicity between each injection
When should you consider discussing dose of local anesthetic?
During time-out
When should you monitor patient for LAST and for how long?
During and after completing injection
Clinical toxicity can be delayed for 30 mins or longer
Consider LAST in patients with what clinical symptoms?
- Altered mental status
- Neurologic symptoms
- Signs of cardiovascular instability (i.e. change in HR, BP, ECG)
Consider LAST even when the local anesthetic dose is? 4 things
- Small (susceptible patient)
- Atypically administered (subcutaneous, mucosal, topical)
- Administered by the surgeon
- After recent tourniquet deflation
CNS signs of LAST that may be subtle, atypical, or absent
- Excitation (agitation, confusion, vocalization, muscle twitching, seizure)
- Depression (drowsiness, obtundation, coma, or apnea)
- Non-specific (metallic taste, circumoral numbness, diplopia, tinnitus, dizziness)
CV signs of LAST (sometimes the only manifestation of severe LAST)
Initially may be hyperdynamic (HTN, tachycardia, ventricular arrhythmias)
Then,
- Progressive hypotension
- Conduction block, bradycardia, or asystole
- Ventricular arrhythmias (v. tach, Torsades, V. fib, or asystole)
What may abolish the patient’s ability to recognize or report LAST-related symptoms?
Sedation
Suggested components of the LAST rescue kit
- 1 L (total) lipid emulsion 20%
- Several large syringes and needles for admin
- Standard IV tubing
- ASRA LAST checklist
Can lipid emulsion be used for any local anesthetic drug?
Yes
Why do you reduce dose of epi in LAST resuscitation event?
Standard dose of epinephrine can impair resuscitation and reduce efficacy of lipid rescue
When you can proceed with surgery after LAST event?
If event is short-lived and without symptoms of CV instability may proceed after uneventful ~30 min interval of monitoring
