Anesthesia explores how multiple myeloma increases the risk of local anesthetic systemic toxicity

"Pain" exists like an enemy to human beings.

"Pain" "Pain" "Minimally Invasive Treatment of Pain" "Minimally Invasive Treatment of Pain" "Anesthetic Systemic Toxicity (LAST)" "Anesthetic Systemic Toxicity (LAST)"

With the development of image-guided technology and the accumulation of clinician experience, the incidence of LAST has been very low, but not equal to zero, it is still a life-threatening complication

For example, today's middle-aged female patient developed crisis symptoms such as tachycardia, shortness of breath and hypoxia after minimally invasive pain treatment

Crisis symptoms such as tachycardia, shortness of breath, and hypoxia occurred after minimally invasive pain treatment

"Multiple Myeloma (MM)" "Multiple Myeloma (MM)" was hospitalized with severe acute pain crisis

(Figure 1)

 

Figure 1: Epidural catheter placement at L4-L5 segment under X-ray guidance

Figure 1: The treatment process of epidural catheter placement in L4-L5 segment under X-ray guidance

Local infiltration of 2ml of lidocaine was performed layer by layer.

8 ml of 0.

During this period, the patient developed LAST, developed tachycardia, hypertension , tachypnea, hypoxia, SpO2 was 83%, and positive airway pressure was required

Hypertensive left thoracentesis catheter drainage was performed, 1L of pleural effusion was drained, no complications occurred, and lidocaine was continuously instilled

(Picture 2) (Picture 3) Blood vessels

Figure 2: ECG before treatment

Figure 2: ECG before treatment

Figure 3: Electrocardiogram after concurrent local anesthetic systemic toxicity

Figure 3: Electrocardiogram after concurrent local anesthetic systemic toxicity

During the patient's recent chemotherapy, steroids were used, along with high-dose inotropes and vasopressors (dobutamine 10ug/kg/min, epinephrine 0.

In the setting of systemic hypokinesia, echocardiography shows a left ventricular ejection fraction (LVEF) of only 25-30% (normal value is 50-70%), and no local ventricular wall motion abnormalities are found

Considering the patient's severe and difficult to maintain hemodynamic disorder and previous use of bupivacaine, 1.

Immediate relief is noticeable

(Figure 4)

Figure 4: ECG restores sinus rhythm after instillation of lipid emulsion

Figure 4: ECG restores sinus rhythm after instillation of lipid emulsion

Final examination results showed markedly worse extensive osteolytic lesions in all vertebrae and ribs, consistent with diffuse myeloma

(Figure 5)

 

Figure 5: Multiple osteolytic lesions are seen in the vertebral body

Figure 5: Multiple osteolytic lesions in the visible vertebral body Final discussion 

"Local anesthetic systemic toxicity (LAST)" is a life-threatening complication with an incidence of 2.

"Local Anesthetic Systemic Toxicity (LAST)" "Local Anesthetic Systemic Toxicity (LAST)" is a life-threatening complication

The patient's disease progression and recovery timeline is shown below (Figure 6)

(Figure 6)

Figure 6: Timeline of disease progression and recovery

Figure 6: Timeline of disease progression and recovery LAST |

Local anaesthetic systemic toxicity leading to cardiovascular collapse in this case is very rare, but in this case there may be an underlying etiology
.
The risk of LAST increases with local anesthetic dose, low body weight, extreme age, and pre-existing cardiac, hepatic, renal, and metabolic dysfunction
.

The risk of LAST increases with local anesthetic dose, low body weight, extreme age, and pre-existing cardiac, hepatic, renal, and metabolic dysfunction
.

The woman's underlying disease, multiple myeloma (MM), also increases susceptibility to LAST
.
Typical MM includes renal impairment, neuropathy, venous thromboembolism , liver involvement, and osteolytic bone lesions
.

thrombus

Active MM with markedly increased bone marrow microvessel density causes tissue metabolic disorders
.
In this patient, lytic lesions were seen in all vertebral and cutaneous myeloma areas on CT, possibly related to an increased vascular bed
.

Active MM with markedly increased bone marrow microvessel density causes tissue metabolic disorders
.
how | , , ,

Local anaesthetic manipulation near any tumor lesion may increase the risk of LAST, so high vigilance is required
.
So how to reduce the risk of LAST occurrence? Clinicians may consider perineural injections of opioids alone, or alternatively, 1% diphenhydramine or benzyl alcohol may be used as an alternative to local infiltration
.

So how to reduce the risk of LAST occurrence?

In addition, it is recommended to use experimental doses containing epinephrine for epidural and peripheral nerve block injections, avoid bupivacaine for local anesthetics, and prolong continuous monitoring to reduce the dose used, thereby reducing the risk of LAST
.

In addition, trial doses containing epinephrine are recommended for epidural and peripheral nerve block injections, ref: Victoria M Lim, Taylor Barney, Arun L Jayaraman.
Multiple myeloma and malignant lesions: a potential risk factor for local anesthetic systemic toxicity[J].
Reg Anesth Pain Med, fist published as 10.
1136/rapm.
2021-102845 on 17 September 2021, 1-4 pages.


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