I work in a procedure lab that does a lot of local anaesthesia with Lidocaine 2% and though not often, some patients are having very similar rx's to something in the procedure. At first I thought it was related to part of my moderate sedation meds but now I'm looking out farther and eyeballing Lidocaine 2% as a possible suspect.
What I would like is your personal experiences ie. signs, symptoms and treatment when you suspected a lidocain OD.
PLease refrain from too much quoting from a book. I am looking for personal accounts please.
Docs use Lidocaine 2%, anywhere from 60-100ml's volume, instilling the tissue involved with the generator pocket and obtaining venous access.
YIKES!
1200-2000 mg of lidocaine!
Max dose in 70 Kg individual 4.5 mg/kg 315mg sans epi; 7 mg/kg with epi 490mg
Nevermind emaciated little old ladies! How much does an emaciated old lady weigh? maybe 50 Kg with their hair wet. Even 0.5% lido with epi at those volumes would be near toxic at 60cc and clearly toxic above that.
Thank you for the many opinions you have shared. I have learned much from you and also about CRNA's.
I do appreciate the insight into the benadryl. I have been moving away from using it at all and seeing little change in the sedation provided. Now I will simply stop using it.
As for the original question, thank you for confirming what I already thought was going on. If anyone else would care to make constructive comments about the original question that would still be appreciated.
I will be presenting everything including your comments to my manager to implement change so the more said, the more ammunition I would have.
Thank you for the many opinions you have shared. I have learned much from you and also about CRNA's.
I do appreciate the insight into the benadryl. I have been moving away from using it at all and seeing little change in the sedation provided. Now I will simply stop using it.
As for the original question, thank you for confirming what I already thought was going on. If anyone else would care to make constructive comments about the original question that would still be appreciated.
I will be presenting everything including your comments to my manager to implement change so the more said, the more ammunition I would have.
Thank you.
Josh, any good anesthesia textbook, or even the PDR or package inserts will have very clear language about much more than you'll ever want to know about local anesthetic toxicity. Appropriate dosages, and signs and symptoms of overdosage are very well known and documented. In addition to all of us self-professed experts, you might want to use some of those "official" sources to bolster your presentation.
but I had to throw my 2 cents in concering how some staff RNs give absolutely retarded recipies that reduce a person to essentially a non-functioning state sometimes.
You know, maybe you guys should chill out on this op alittle. He is just trying to find some anecdotal information. In regards to the above...many places the rn is not allowed to concoct "retarded recipes". The MD tells them what to give, yes suggestions can be made or observations noted, but concocting recipes is practicing medicine. In regards to the original op....
I saw a case of lido toxicity once back in the day when I worked in cvicu. The nurse went to get a bad o hespan and grabbed a bag o lidocaine drip instead without realizing it. Patient had already been extubated and after about 200ml seized big time with the other cns stuff. After the shiznit cooled off the patient was later just fine with no untoward after effects. The lido bags and hespan bags were thereafter separated
To the OP, I really wasn't referring to you as retarded, just a blanket statement that I perhaps should have kept to myself. I congradulate you in seeking further knowledge about something you are concerned with - that's the hallmark of a great RN. Sorry to appear to bust your balls earlier. Seriously, you need to interviene with this much lido being given and the regular occurrence of toxic symptom presentation. Someone is going to have a serious consequence and you don't want to be in court dealing with it, even if you aren't the one giving the lidocaine. They will seize and have hypoxia and have brain damage. These MDs aren't going to be much good in that situation and know how to quickly fix it, especially considering they are the ones inducing the situation by OD'ing the pt with lidocaine in the first place.
Again, congrats to you for taking the initiative and improving this dangerous situation. I personally thank you for attempting to try for yourself limiting benadryl and see how the patients respond. I get a little heated because I saw firsthand what this does to a family member. I appreciate you trying to see the big picture here and see what happens afterward to these people.
We are not all hardorifices, just passionate about what we do.
I think that one can see how passionate those of us in anesthesia are about understanding pharmacology of all medications, including additive and synergistic actions of other medications that may be given at the same time. It is all about patient care.
Just to be sure of my figures, I looked up doses of lidocaine. According to deJong (the local anesthesia guru) the maximum dose of lidocaine without epinephrine is 4-5 mg/kg with adjustments needed for hepatic disease.
Now the simple math:
2% lidocaine-- 20 mg/cc
70 kg patient -- maximum dose =280 mg
TOTAL MAXIMUM DOSE IS 14 CC.
You would not have posted if you were not interested in patient safety, but it is hard for us in anesthesia to hear about these things happening and just shrug our shoulders. If I offended you, I did not mean anything personal, but I do care about the patients. Also, be aware that these patients were probably told that they had an allergic reaction to local anesthesia, which is of course, not what happened. It was a negligent overdose.
Another thing--all of that sedation may have depressed respirations, increasing CO2 levels and lowering the seizure threshold. This would not be evident unless you are measuring the end-tidal carbon dioxide.
There is a reason why we consider the practice of anesthesia, applied pharmacology and spend a lot of time studying it and refining our techniques.
You know, maybe you guys should chill out on this op alittle. He is just trying to find some anecdotal information. In regards to the above...many places the rn is not allowed to concoct "retarded recipes". The MD tells them what to give, yes suggestions can be made or observations noted, but concocting recipes is practicing medicine
RN's should never be concocting recipes- - nor giving anesthesia without proper training - it it dangerous for patients and for nursing practice in general...CRNA's however always "concoct" and we are able to do so because that is what we are trained to do - guess what - it isn't practicing medicine...it is practicing anesthesia.... and there is no "chilling out" - as a nurse - would you chill out if one of the nursing techs was IV pushing cardizem... probably - because THEY ARE NOT TRAINED OR EDUCATED ON THAT PRACTICE.... secondly...so "the doc tells them what to give".... your doc tells you to give someone 200mg toradol IV - you gonna do it???
if you are giving meds for anything - you better know what they are, proper dosing and normal vs adverse side effects... now the OP wasn't giving the med causing the problem - granted... and kudos to him for picking up on the problem and trying to protect his patients... however if someone TRAINED and EDUCATED in anesthesia was giving the anesthesia - the excess lido and resultant problems would have never occurred... or should never occur. that is the beef you see on this board - it isn't hostility with the poster...it is hostility at those practicing outside the limits of their scope of practice which is harmful to patients.
It is bad enough to give a local anesthetic w/out knowing the proper dosing, but I agree with one of the posters above in that as an RN you should know what you are giving and the correct dosing. When I worked as a staff nurse in the Unit I always looked up my drugs if i could not remember the correct dosing, and if it was a drug i had not used in a while I would quickly review a drug book to know the side effects. As a CRNA i still do this in the OR if I am unfamiliar with a drug. There is no excuse to give a drug because the doctor said to do so w/out you as the nurse giving the drug not to know the correct dosing and side effects. Remember folks we all worked as staff RNs before becoming CRNAs. We took our basic nursing foundation, or shall I say basic nursing standards of care and enhanced them by studying in depth pharmacology in anesthesia school. However, the basic standards of nursing care we did not learn from nurse anesthesia school.
I think that it is time for some clarification of assumptions.
First, We follow an MD's order, not create our own little retarded recipes.
Second, the physician in the one giving the Lidocaine, it's his procedure.
I am dissappointed in the direction this thread has gone. It has deteriorated to something less than intellectual.
As a point of follow up I asked one of the physicians why the Benadryl and was informed the benadryl was used for a reason other than sedation. It simply is given around the same time by coincidence. It is not part of the retarded recipe we unqualified staff nurses decide to create and practice.
The point of this forum thread is lost. Please feel free to throw in your remaining two cents as I ask a mod to close this misdirected request for help.
I think we answered your question with all of the knowledge and experience that we have. If you didn't like our answers, then you need to re-evaluate how you asked the question and/or your practice.
I can't let the potential legal issue go unaddessed. There was a very sad case where an RN spend jail time for following the doctor's orders and the doctor was found not guilty. It is a long and involved case, but it included sedation, local anesthesia, abandonment by the physician and a patient death. In the large city where it happened, the district attorney filed criminal charges against the parties. Criminal charges are very rare in medical cases, but it did happen here and the RN was found guilty of practicing medicine without a license and involuntary manslaughter.
My point--following a doctor's orders is not without risk. Proceed with extreme caution if you are in an area of unfamiliarity.
I think your intentions are pure, just try not to be so defensive if you don't like the answer.
As a point of follow up I asked one of the physicians why the Benadryl and was informed the benadryl was used for a reason other than sedation. It simply is given around the same time by coincidence. It is not part of the retarded recipe we unqualified staff nurses decide to create and practice.
Please feel free to throw in your remaining two cents as I ask a mod to close this misdirected request for help.
This is the same insightful genius that continues to grossly overdose patients with lidocaine and causes toxicity S/S?
maturner
124 Posts
Docs use Lidocaine 2%, anywhere from 60-100ml's volume, instilling the tissue involved with the generator pocket and obtaining venous access.
YIKES!
1200-2000 mg of lidocaine!
Max dose in 70 Kg individual 4.5 mg/kg 315mg sans epi; 7 mg/kg with epi 490mg
Nevermind emaciated little old ladies! How much does an emaciated old lady weigh? maybe 50 Kg with their hair wet. Even 0.5% lido with epi at those volumes would be near toxic at 60cc and clearly toxic above that.