To,
The Editor
We read the correspondence “Pediatric eye block and local anesthetic systemic toxicity” written by Dr. Ana C. Mavarez et al. with great interest.[1] This article highlighted the local anaesthesia systemic toxicity (LAST), a preventable complication and its timely management in the paediatric patient.
We want to highlight few other points to prevent LAST in a child. The local anaesthetic (LA) dosing guidelines based on weight does not predict serum level of LA reliably and hence toxicity can occur lower than anticipated dose.[2] As the concentration of LA is one of the very important determinant factors to reduce LAST.
We are concern about the concentration of LA drugs used for this patient, i.e., 0.75% bupivacaine and 4% lignocaine (total 3 ml) at the start and end of the surgery.
As paediatric patients cannot cooperate, general anaesthesia is required along with local anaesthesia. The concentration of LA should be lower as it is required for analgesia not for anaesthesia in paediatric patient. Bupivacaine 0.25% and lidocaine 1% is safe for analgesia along with general anaesthesia. In the present case, author has used a higher concentration of LA leading to a higher dose of both the drugs and LAST.
Jean et al. also suggested weight-based submaximal dosing of LA in paediatric patients.[3] American society of regional anaesthesia guideline for neuraxial block advocates the use of the lowest concentration of local anaesthetics to prevent LAST. This principle can be applied to other peripheral nerve blocks.[4]
It is difficult to understand weight of 2-month-old child weighing 12 kg. It is not evident in the article whether subtenon or peribulbar block was administered before and after the surgery. The anatomy of the orbit gets distorted after enucleation; hence, it may increase incidence of complications.[5]
We suggest use a lower concentration of LA and try to avoid repeat block within 3–4 h of first block in paediatric patient to prevent LAST.[5]
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Conflicts of interest
There are no conflicts of interest.
References
- 1.Mavarez AC, Palte HD, Rodriguez LI. Pediatric eye block and local anesthetic systemic toxicity. Saudi J Anaesth. 2020;14:287–8. doi: 10.4103/sja.SJA_788_19. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Dickerson DM, Apfelbaum JL. Local anesthetic systemic toxicity. Aesthet Surg J. 2014;34:1111–9. doi: 10.1177/1090820X14543102. [DOI] [PubMed] [Google Scholar]
- 3.Jean Y, Kam D, Gayer S, Palte H, Stein A. Regional anesthesia for pediatric ophthalmic surgery: A review of the literature. Anesth Analg. 2019:1. doi: 10.1213/ANE.0000000000004012. doi: 101213/ANE0000000000004012. [DOI] [PubMed] [Google Scholar]
- 4.Neal JM, Bernards CM, Butterworth JF, 4th, Di Gregorio G, Drasner K, Hejtmanek MR, et al. ASRA practice advisory on local anesthetic systemic toxicity. Reg Anesth Pain Med. 2010;35:152–61. doi: 10.1097/AAP.0b013e3181d22fcd. [DOI] [PubMed] [Google Scholar]
- 5.NYSORA. Local And Regional Anesthesia For Ophthalmic Surgery NYSORA. 2020 [Google Scholar]