An axillary block performed with 30 mL of 0.75% bupivacaine results in seizure and ventricular fibrillation 15 minutes later. Which measure below is NOT indicated?

An axillary block performed with 30 mL of 0.75% bupivacaine results in seizure and ventricular fibrillation 15 minutes later. Which measure below is NOT indicated?

• A. Begin chest compressions at 100 per minute
• B. Ventilate with 100% oxygen
• C. Bolus propofol to bind local anesthetic
• D. Infuse 20% lipid emulsion

Answer: (C)

Systemic toxicity from a local anesthetic (LAST) is the event here. When a large amount of bupivacaine enters the circulation, the patient can develop central nervous system symptoms like seizures and cardiovascular collapse such as ventricular fibrillation. The mainstay of treatment is rapid resuscitation plus an antidote strategy that targets the lipophilic drug itself. Begin with securing the airway and providing 100% oxygen, while initiating ACLS as needed for the rhythm. If there is pulseless electrical activity or ventricular fibrillation, follow defibrillation and resuscitation protocols. Early administration of 20% lipid emulsion is key: give a bolus followed by a continuous infusion. The lipid emulsion acts as a “lipid sink” to draw the local anesthetic away from target tissues and improve hemodynamics and cardiac function. Treat seizures with benzodiazepines; these are preferred to control CNS excitation during LAST. Propofol is a lipid-based anesthetic, and while it can be used for seizures in some contexts, it is not used to “bind” the local anesthetic in LAST. In fact, giving a bolus of propofol specifically to bind the toxin is not supported and can worsen hemodynamics in a patient already compromised by LAST. Propofol should not be used as the antidote to LAST; the lipid emulsion is the targeted therapy, with airway management and ACLS continued as needed. So, the measure not indicated is bolusing propofol to bind the local anesthetic.

Systemic toxicity from a local anesthetic (LAST) is the event here. When a large amount of bupivacaine enters the circulation, the patient can develop central nervous system symptoms like seizures and cardiovascular collapse such as ventricular fibrillation. The mainstay of treatment is rapid resuscitation plus an antidote strategy that targets the lipophilic drug itself.

Begin with securing the airway and providing 100% oxygen, while initiating ACLS as needed for the rhythm. If there is pulseless electrical activity or ventricular fibrillation, follow defibrillation and resuscitation protocols. Early administration of 20% lipid emulsion is key: give a bolus followed by a continuous infusion. The lipid emulsion acts as a “lipid sink” to draw the local anesthetic away from target tissues and improve hemodynamics and cardiac function.

Treat seizures with benzodiazepines; these are preferred to control CNS excitation during LAST. Propofol is a lipid-based anesthetic, and while it can be used for seizures in some contexts, it is not used to “bind” the local anesthetic in LAST. In fact, giving a bolus of propofol specifically to bind the toxin is not supported and can worsen hemodynamics in a patient already compromised by LAST. Propofol should not be used as the antidote to LAST; the lipid emulsion is the targeted therapy, with airway management and ACLS continued as needed.

So, the measure not indicated is bolusing propofol to bind the local anesthetic.