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Instructions for the administration of the local anesthetic lidocaine.
Case review 8:25 The patient went to see a doctor because of "pain on the right lower eyelid due to a fall, bleeding for more than ten minutes", and planned to undergo debridement and suture for "right lower eyelid laceration".
At 8:50, intraoperative local infiltration injection of lidocaine needle (0.
2 g/10 ml), about 3 ml after 1:1 dilution.
About ten minutes later, the patient complained of chills, dizziness, and gradually worsened, with his hands twitching and head shaking.
At that time, the patient was very conscious, answered the question to the point, his complexion was slightly pale, the extremities of his hands and feet were cold, his blood pressure was 120/78 mmHg, and his pulse was 78 beats/min.
9:02 Considering the possibility of local anesthetic allergic reactions and toxic reactions, immediately give the mask oxygen to establish intravenous channels to keep warm.
At the same time, the emergency department sent the patient to the inpatient department for rescue.
When he arrived in the ward, he was still shivering, shaking his hands, shaking his head, calling and opening his eyes, and he could answer.
Pain location check is uncoordinated, irritable, cold hands and feet, blood pressure 109/62 mmHg, heart rate 100 beats/min, blood oxygen 92%.
Immediately give double tube rehydration, intravenous injection of dexamethasone 10 mg for anti-allergic, diazepam 10 mg intravenously to suppress convulsions, and intravenous injection of 20% fat emulsion to antagonize the effect of local anesthetics.
At 9:40, the patient lost consciousness, the fluctuation of the neck arteries disappeared, and the apnea was considered.
Respiratory and cardiac arrest was considered.
Immediately give chest compressions for about 10 seconds; the patient recovers consciousness, breathing recovery, heart rate 100 beats/min, blood oxygen 89%, blood pressure 90/50 mmHg, still continues to convulsions, continue to strengthen fluids, and apply Valium needle again 15 minutes later 10 mg suppresses convulsions, and connects to ECG monitoring to indicate sinus tachycardia.
10:20 The patient underwent head CT.
CT examination of the upper abdomen showed no intracranial or abdominal hemorrhage.
The doctor did not consider chest hemorrhage.At this time, the patient was conspicuous, answered relevant questions, cooperated in physical examinations, and still had repeated convulsions and chills.
Blood pressure 100/60 mmHg, heart rate 95 beats/min, blood oxygen 98%, blood glucose 9 mmol/l.
The multi-disciplinary consultation agreed to give promethazine, methylprednisolone, fat emulsion, and strengthen fluids for allergic or toxic reactions to local anesthetics.
And give midazolam, take warmth, catheterization and other anti-allergic.
Inhibit convulsions, antagonize the effects of local anesthetics, supplement blood volume and other treatments.
At 11:00, the patient was conscious, answered the right questions, stopped convulsions, ruddy complexion, warm skin, blood pressure 104/69 mmHg, heart rate 90 beats/min, blood oxygen 100%, and catheterization 850 ml.
The condition is relatively stable.
The patient's vital signs were stable and the rescue was successful.
Thinking 1 What kind of drug caused the patient's allergic reaction or toxicity? The patient used lidocaine needles for local anesthesia for about ten minutes.
The patient complained of chills, dizziness, and gradually worsened, with hands twitching, head shaking, clear mind at the time, answering questions to the point, slightly pale, colder hands and feet, blood pressure 120/ 78 mmHg, pulse 78 beats/min.
The patient did not use other drugs in combination, so it was considered to be an allergic reaction and central nervous system toxicity caused by lidocaine.
Thinking 2 What could be the cause of allergies? Allergic reactions may be due to physical problems of the patient.
The occurrence of central nervous system toxicity may be due to the rapid absorption of the drug in the skin with abundant blood vessels, which is prone to toxic reactions.
When the drug concentration is high, the incidence of toxic reactions is high.
The allergic reaction of this patient is considered to be rich in facial blood vessels and nerves and rapid absorption, which may cause drug allergic reactions.
Thinking 3 Is the allergy rescue medication in this case reasonable? In this case, the choice of dexamethasone needle for systemic allergic reaction is unreasonable.
According to the recommendation in "Emergency Treatment of Systemic Allergic Reaction-Up To Date", the initial treatment of systemic allergic reaction is adrenaline.
Adrenaline should be injected intramuscularly as soon as possible, and then epinephrine should be given by intramuscular injection or intravenous injection.
Thinking 4 What are the rescue principles and correct rescue procedures for lidocaine allergy? (1) Stop the injection of local anesthetics; (2) Protect the airway and give pure oxygen, if necessary, perform tracheal intubation to control the airway to avoid hypoxemia and hypercapnia.
Hyperventilation is generally adopted, and the airway should be established quickly at this time, and local anesthetics should be avoided for epithelial anesthesia; (3) To suppress convulsions, midazolam or propofol can be used.
If the convulsions cannot be stopped, muscle relaxants can be considered under the conditions of tracheal intubation and anesthesia machine; (4) to maintain hemodynamic stability, patients with local anesthetic poisoning may require a longer period of circulatory support to the drug Metabolism is excreted from the body.
For the treatment of arrhythmia and cardiac arrest, the process of cardiac resuscitation (CPR) should be started immediately; (6) Use 20% fat emulsion as soon as possible to effectively control convulsions.
Thinking 5 How to avoid lidocaine allergic reaction or toxic reaction? (1) Before using lidocaine for local infiltration anesthesia, the patient’s medical history should be inquired in detail to understand the history of drug allergy and adverse drug reactions, especially for patients with allergic tendencies and idiosyncrasies; (2) Patients with allergies may be A variety of substance allergies, regardless of whether they have used local anesthetics, antibodies may be formed in the body and prone to allergic reactions, lidocaine skin test can be done first; (3) The key measure to prevent lidocaine toxicity is to prevent it during injection Direct injection of the medicinal solution into the blood vessel causes toxic reactions, reduces excessive absorption into the blood, and improves the body’s tolerance; (4) In view of the potential neurotoxicity of lidocaine, the clinical application should be strictly based on the surgical requirements and the site of administration.
Control the administration concentration and dosage.
As the conventional dose of lidocaine (0.
5%) may also have toxic reactions, the drug should be used strictly in accordance with the drug instructions to avoid over-dose or over-concentration, use the lowest effective dose, and increase the vigilance of its toxic reactions; ( 5) Closely observe the patient's condition during medication, strengthen first-aid training of medical staff, prepare oxygen and first-aid drugs, and increase the success rate of rescue. Thinking 6 What other local anesthetics can be used by patients allergic to lidocaine? Local anesthetics are divided into amides and lipids.
Amide local anesthetics include lidocaine, bupivacaine, and ropivacaine; lipid local anesthetics include procaine, chloroprocaine, and tetracaine; If patients are allergic to lidocaine, they can choose lipid-based local anesthetics, such as procaine, which has no reports of cross-allergic reactions.
References: [1] Zuo Qiaoyun, Wang Liqing, etc.
Lidocaine causes severe allergic and neurotoxic reactions.
Evaluation and analysis of drug use in Chinese hospitals, 2019, (8): 92-903.
[2] Cheng Xianqing, Chen Jiahua, Zhao Jiagui , Etc.
Allergic reactions to lidocaine[J].
Anhui Medicine,2010,(9):1106-1108.
doi:10.
3969/j.
issn.
1009-6469.
2010.
09.
059.
[3]Jin Yongxin,Zhang Xin,Wu Yuqiong.
A review of Chinese literature on 84 cases of anaphylactic shock caused by lidocaine[J].
Journal of Pharmaceutical Epidemiology,2014,(5):329-331.
[4]Han Wubin,Chang Qingchun.
A case of local allergic reaction caused by lidocaine hydrochloride [J].
People’s Military Surgeon, 2005, (7): 431.
[5] Wang Qin, Zhang Xiaopeng, Kong Feifei.
Emergency care of anaphylactic shock caused by lidocaine local anesthesia[J].
Journal of Clinical Rational Use, 2015, (8 ):152-153.
doi:10.
15887/j.
cnki.
13-1389/r.
2015.
08.
111
Case review 8:25 The patient went to see a doctor because of "pain on the right lower eyelid due to a fall, bleeding for more than ten minutes", and planned to undergo debridement and suture for "right lower eyelid laceration".
At 8:50, intraoperative local infiltration injection of lidocaine needle (0.
2 g/10 ml), about 3 ml after 1:1 dilution.
About ten minutes later, the patient complained of chills, dizziness, and gradually worsened, with his hands twitching and head shaking.
At that time, the patient was very conscious, answered the question to the point, his complexion was slightly pale, the extremities of his hands and feet were cold, his blood pressure was 120/78 mmHg, and his pulse was 78 beats/min.
9:02 Considering the possibility of local anesthetic allergic reactions and toxic reactions, immediately give the mask oxygen to establish intravenous channels to keep warm.
At the same time, the emergency department sent the patient to the inpatient department for rescue.
When he arrived in the ward, he was still shivering, shaking his hands, shaking his head, calling and opening his eyes, and he could answer.
Pain location check is uncoordinated, irritable, cold hands and feet, blood pressure 109/62 mmHg, heart rate 100 beats/min, blood oxygen 92%.
Immediately give double tube rehydration, intravenous injection of dexamethasone 10 mg for anti-allergic, diazepam 10 mg intravenously to suppress convulsions, and intravenous injection of 20% fat emulsion to antagonize the effect of local anesthetics.
At 9:40, the patient lost consciousness, the fluctuation of the neck arteries disappeared, and the apnea was considered.
Respiratory and cardiac arrest was considered.
Immediately give chest compressions for about 10 seconds; the patient recovers consciousness, breathing recovery, heart rate 100 beats/min, blood oxygen 89%, blood pressure 90/50 mmHg, still continues to convulsions, continue to strengthen fluids, and apply Valium needle again 15 minutes later 10 mg suppresses convulsions, and connects to ECG monitoring to indicate sinus tachycardia.
10:20 The patient underwent head CT.
CT examination of the upper abdomen showed no intracranial or abdominal hemorrhage.
The doctor did not consider chest hemorrhage.At this time, the patient was conspicuous, answered relevant questions, cooperated in physical examinations, and still had repeated convulsions and chills.
Blood pressure 100/60 mmHg, heart rate 95 beats/min, blood oxygen 98%, blood glucose 9 mmol/l.
The multi-disciplinary consultation agreed to give promethazine, methylprednisolone, fat emulsion, and strengthen fluids for allergic or toxic reactions to local anesthetics.
And give midazolam, take warmth, catheterization and other anti-allergic.
Inhibit convulsions, antagonize the effects of local anesthetics, supplement blood volume and other treatments.
At 11:00, the patient was conscious, answered the right questions, stopped convulsions, ruddy complexion, warm skin, blood pressure 104/69 mmHg, heart rate 90 beats/min, blood oxygen 100%, and catheterization 850 ml.
The condition is relatively stable.
The patient's vital signs were stable and the rescue was successful.
Thinking 1 What kind of drug caused the patient's allergic reaction or toxicity? The patient used lidocaine needles for local anesthesia for about ten minutes.
The patient complained of chills, dizziness, and gradually worsened, with hands twitching, head shaking, clear mind at the time, answering questions to the point, slightly pale, colder hands and feet, blood pressure 120/ 78 mmHg, pulse 78 beats/min.
The patient did not use other drugs in combination, so it was considered to be an allergic reaction and central nervous system toxicity caused by lidocaine.
Thinking 2 What could be the cause of allergies? Allergic reactions may be due to physical problems of the patient.
The occurrence of central nervous system toxicity may be due to the rapid absorption of the drug in the skin with abundant blood vessels, which is prone to toxic reactions.
When the drug concentration is high, the incidence of toxic reactions is high.
The allergic reaction of this patient is considered to be rich in facial blood vessels and nerves and rapid absorption, which may cause drug allergic reactions.
Thinking 3 Is the allergy rescue medication in this case reasonable? In this case, the choice of dexamethasone needle for systemic allergic reaction is unreasonable.
According to the recommendation in "Emergency Treatment of Systemic Allergic Reaction-Up To Date", the initial treatment of systemic allergic reaction is adrenaline.
Adrenaline should be injected intramuscularly as soon as possible, and then epinephrine should be given by intramuscular injection or intravenous injection.
Thinking 4 What are the rescue principles and correct rescue procedures for lidocaine allergy? (1) Stop the injection of local anesthetics; (2) Protect the airway and give pure oxygen, if necessary, perform tracheal intubation to control the airway to avoid hypoxemia and hypercapnia.
Hyperventilation is generally adopted, and the airway should be established quickly at this time, and local anesthetics should be avoided for epithelial anesthesia; (3) To suppress convulsions, midazolam or propofol can be used.
If the convulsions cannot be stopped, muscle relaxants can be considered under the conditions of tracheal intubation and anesthesia machine; (4) to maintain hemodynamic stability, patients with local anesthetic poisoning may require a longer period of circulatory support to the drug Metabolism is excreted from the body.
For the treatment of arrhythmia and cardiac arrest, the process of cardiac resuscitation (CPR) should be started immediately; (6) Use 20% fat emulsion as soon as possible to effectively control convulsions.
Thinking 5 How to avoid lidocaine allergic reaction or toxic reaction? (1) Before using lidocaine for local infiltration anesthesia, the patient’s medical history should be inquired in detail to understand the history of drug allergy and adverse drug reactions, especially for patients with allergic tendencies and idiosyncrasies; (2) Patients with allergies may be A variety of substance allergies, regardless of whether they have used local anesthetics, antibodies may be formed in the body and prone to allergic reactions, lidocaine skin test can be done first; (3) The key measure to prevent lidocaine toxicity is to prevent it during injection Direct injection of the medicinal solution into the blood vessel causes toxic reactions, reduces excessive absorption into the blood, and improves the body’s tolerance; (4) In view of the potential neurotoxicity of lidocaine, the clinical application should be strictly based on the surgical requirements and the site of administration.
Control the administration concentration and dosage.
As the conventional dose of lidocaine (0.
5%) may also have toxic reactions, the drug should be used strictly in accordance with the drug instructions to avoid over-dose or over-concentration, use the lowest effective dose, and increase the vigilance of its toxic reactions; ( 5) Closely observe the patient's condition during medication, strengthen first-aid training of medical staff, prepare oxygen and first-aid drugs, and increase the success rate of rescue. Thinking 6 What other local anesthetics can be used by patients allergic to lidocaine? Local anesthetics are divided into amides and lipids.
Amide local anesthetics include lidocaine, bupivacaine, and ropivacaine; lipid local anesthetics include procaine, chloroprocaine, and tetracaine; If patients are allergic to lidocaine, they can choose lipid-based local anesthetics, such as procaine, which has no reports of cross-allergic reactions.
References: [1] Zuo Qiaoyun, Wang Liqing, etc.
Lidocaine causes severe allergic and neurotoxic reactions.
Evaluation and analysis of drug use in Chinese hospitals, 2019, (8): 92-903.
[2] Cheng Xianqing, Chen Jiahua, Zhao Jiagui , Etc.
Allergic reactions to lidocaine[J].
Anhui Medicine,2010,(9):1106-1108.
doi:10.
3969/j.
issn.
1009-6469.
2010.
09.
059.
[3]Jin Yongxin,Zhang Xin,Wu Yuqiong.
A review of Chinese literature on 84 cases of anaphylactic shock caused by lidocaine[J].
Journal of Pharmaceutical Epidemiology,2014,(5):329-331.
[4]Han Wubin,Chang Qingchun.
A case of local allergic reaction caused by lidocaine hydrochloride [J].
People’s Military Surgeon, 2005, (7): 431.
[5] Wang Qin, Zhang Xiaopeng, Kong Feifei.
Emergency care of anaphylactic shock caused by lidocaine local anesthesia[J].
Journal of Clinical Rational Use, 2015, (8 ):152-153.
doi:10.
15887/j.
cnki.
13-1389/r.
2015.
08.
111
