All of the following are true concerning the treatment of local anesthetic systemic toxicity (LAST) EXCEPT which of the following?
A. Vasopressin is generally avoided in patients with LAST syndrome
B. Intralipid is a known effective treatment for systemic toxicity
C. Epinephrine doses of >1 mcg/kg are usually indicated for resuscitation
D. Propofol is usually avoided despite its lipid content
The answer is C. Epinephrine doses are usually limited to < 1 mcg/kg for individual doses. This is a 10 fold decrease from current recommendations of Pediatric Advanced Life Support which are 10 mcg/kg or 0.01 mg/kg. There is some recent evidence that epinephrine can impair resuscitation from LAST and reduce the efficacy of intralipid rescue. However, the use of epinephrine must be balanced between the need for critical coronary perfusion pressure (CPP) and the risk of increased arrhythmias and increased oxygen consumption. Therefore it is recommended to avoid high doses of epinephrine and use smaller doses, e.g., <1 mcg/kg, for treating hypotension. Propofol is usually avoided in LAST due to its propensity to cause hemodynamic instability. Propofol's lipid emulsion (1%) is much lower than Intralipid (20%) and would cause significant hypotension if used in a volume needed for its lipid effects. Vasopressin is generally avoided as it may worsen the acidosis and has been associated with no improvement over acidosis.[1]
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