A reply


  • A response to a previously published article or letter can be submitted to the Online Correspondence section at http://www.anaesthesiacorrespondence.com. All correspondence intended for publication in Anaesthesia should be addressed to Dr David Bogod, Editor-in-Chief, and submitted as an e-mail attachment to anaesthesia@nottingham.ac.uk. For multi-author letters, a covering letter signed by all authors must be submitted either by post, fax (44 (0) 115 823 1908) or by e-mail as a scanned document before correspondence can be published. Alternatively, letters may be submitted typewritten on one side of paper, double spaced with wide margins to Anaesthesia, 1st Floor, Maternity Unit, Nottingham City Hospital, Hucknall Road, Nottingham, NG5 1PB, UK. All paper submissions must include a signed covering letter, a disc or CD-ROM with a Word for Windows or .rtf version of the letter and an email address for the corresponding author. Copy should be prepared in the usual style of the Correspondence section. Authors must follow the advice about references and other matters contained in the Author Guidelines at http://www.blackwellpublishing.com/journals/ana/submiss.htm. Correspondence presented in any other style or format will be returned to the author for revision.

We thank Drs Holmes, Jefferson and Ball for their interest in the AAGBI’s guidelines for the management of severe local anaesthetic toxicity [1]. It is correctly pointed out that the recommendations have changed. In 2004, there had been no reported uses of lipid rescue in humans. When Dr Weinberg recommended beginning treatment with a bolus of 1 ml.kg−1 of 20% lipid emulsion, the figure was derived from animal experiments alone [2]. The first human case reports appeared in 2006 [3, 4]. The AAGBI Working Party on the Management of Severe Local Anaesthetic Toxicity (which included Dr Weinberg) considered all the evidence available in 2007, and increased the recommended bolus to 1.5 ml.kg−1 because larger doses had worked in humans, restoring cardiac output, and seemed to cause no harm.

Dr Holmes et al. remind us that few volumetric infusion pumps are designed to cope with infusion rates > 1 l.h−1 and that the clinical situations created by local anaesthetic toxicity are often not those conducive to the rapid and accurate preparation and use of infusion pumps or syringe drivers. This is why we presented both the infusion rates in millilitre per kilogram and also an abbreviated and simplified protocol based on a 70-kg patient: the bulleted points in italic type in this excerpt from the laminated guideline below.

Treatment of cardiac arrest with lipid emulsion: (approximate doses are given in italics for a 70-kg patient)

  • • Give an intravenous bolus injection of Intralipid® 20% 1.5 ml.kg−1 over 1 min

  • • Give a bolus of 100 ml

  • • Continue CPR

  • • Start an intravenous infusion of Intralipid® 20% at 0.25 ml.kg−1.min−1

  • • Give at a rate of 400 ml over20 min

  • • Repeat the bolus injection twice at 5 min intervals if an adequate circulation has not been restored

  • • Give two further boluses of 100 ml at 5 min intervals

  • • After another 5 min, increase the rate to 0.5 ml.kg−1.min−1 if an adequate circulation has not been restored

  • • Give at a rate of 400 ml over10 min

  • • Continue infusion until a stable and adequate circulation has been restored

We hope to have the opportunity to review the guidelines this year. In doing so, the Working Party will consider comments from Drs Holmes, Jefferson and Ball and others.