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Three Part Question

In [adults in cardiac arrest as a result of local anaesthetic toxicity] is [cardiopulmonary bypass in addition to standard CPR better than the standard CPR alone] at [reducing morbidity and mortality]?

Clinical Scenario

A thirty-three year old female has been accidentally administered a large dose of bupivacaine, she is in cardiac arrest and after a prolonged period of standard resuscitation the question is raised if there is any alternatives that may be affective?

Search Strategy

Using Ovid interface; Medline 1950 to June week 4 2010, Embase 1980 to 2010 week 26, Cochrane database of systematic reviews 2005 May 2010
[exp Anesthesia, Local/ OR (local adj1 anaesthe$).mp OR exp Anesthetics, Local/ OR exp bupivacaine$/ OR bupivacaine$.mp. OR lidocaine$/ OR lidocaine$.mp. OR exp prilocaine$/ OR prilocaine$.mp. OR exp lignocaine$/ OR lignocaine$.mp. OR exp marcaine$/ OR marcaine$.mp.] AND [exp cardiopulmonary bypass/] AND [exp heart arrest/] LIMIT to English language and humans.

Search Outcome

29 results 3 of which were relevant

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Soltesz E et al 2003 USA	39 year old female, received unsuccessful advanced life support for cardiac arrest while under systemic local anaesthetic toxicity, after receiving 30ml 0.5% bupivacaine for a right ankle arthroplasty. Received 70 minutes of CPB after 30 minutes of cardiac arrest.	Case report	Mortality and morbidity	Patient fully recovered, discharged 10 days post operatively, returned to work by 1 year follow up.	Electrical defibrillation not described fully. Restrictions to intervention not discussed fully.
Long W et al 1989	27 year old healthy female, received unsuccessful advanced life support for cardiac arrest due to local anaesthetic toxicity. She had been injected with 525mg of 1.5% lidocaine with epinephrine (35ml) and 75mg of 0.25% bupivacaine with epinephrine (30ml) to achieve axillary block. CPB was successful 2hrs 45 after the arrest.	Case report	Mortality and morbidity	Patient recovered, with unilateral mild lateral leg dyasthesia. Did not return to work at one year because of disability caused by accident.	Unclear as to what mild refers to in leg dysasthesia. Year followup not fully described. Electrical defibrillation not described fully.
Tsai M et al 1987 USA	28 year old female administered 13ml of 0.5% bupivacaine for epidural. CPB was used when advanced life support was unsuccessful.	Case report	Mortality and morbidity	Patient recovered and was described as doing well and being active on six month follow up.	Mitral valve replacement was also performed so could bias the outcome of CPB,. Not enough detail in followup.

Comment(s)

The evidence available for the use of cardiopulmonary bypass remains very weak. With only three case reports found in the last 30 years. These report that cardiopulmonary bypass was successful. The results may be subject to reporting bias due to all evidence being case reports. Better quality research would be needed to give definitive guidance. All case reports lack comment on the limitation of cardiopulmonary bypass. It may be a treatment option but more research would be needed to advocate its use.

Clinical Bottom Line

There is insufficient evidence to advocate the use of cardiopulmonary bypass in those in cardiac arrest due to local anaesthetic toxicity.

References

1. Soltesz E et al Emergent cardiopulmonary bypass for bupivacaine cardiotoxicity. J Cardiothorac Vasc Anesth. 2003 Jun;17(3):357-8.
2. Long W et al Successful resuscitation of bupivacaine-induced cardiac arrest using cardiopulmonary bypass. Anesth Analg. 1989 Sep;69(3):403-6.
3. Tsai M et al Successful resuscitation of a bupivacaine-induced cardiac arrest using cardiopulmonary bypass and mitral valve replacement. J Cardiothorac Anesth. 1987 Oct;1(5):454-6.