START

❶ Stop injecting the local anaesthetic (remember infusion pumps).

❷ Call for help and inform immediate clinical team of problem.

❸ Call for cardiac arrest trolley and lipid rescue pack.

❹ Give 100% oxygen and ensure adequate lung ventilation:

• Maintain the airway and if necessary secure it with a tracheal tube.
• Hyperventilation may help reduce acidosis.

❺ Confirm or establish intravenous access.

❻ If circulatory arrest:

• Start continuous CPR using standard protocols.
• Give intravenous lipid emulsion (Box A).
• Recovery may take >1 hour.
• Consider the use of cardiopulmonary bypass if available.

      If no circulatory arrest:

• Conventional therapies to treat hypotension, brady- and tachyarrhythmia.
• Consider intravenous lipid emulsion (Box A).

❼ Control seizures with small incremental dose of benzodiazepine, thiopental or propofol.

Box A: LIPID EMULSION REGIME

USE 20% Intralipid® (propofol is not a suitable substitute)

Immediately

• Give an initial i.v. bolus of lipid emulsion 1.5 ml.kg^–1 over 1 min (~100 ml for a 70 kg adult)
• Start an i.v. infusion of lipid emulsion at 15 ml.kg^–1.h^–1 (17.5 ml.min^-1 for a 70 kg adult)

At 5 and 10 minutes:

• Give a repeat bolus (same dose) if:
  • cardiovascular stability has not been restored or
  • an adequate circulation deteriorates

At any time after 5 minutes:

• Double the rate to 30 ml.kg^–1.h^–1 if:
  • cardiovascular stability has not been restored or
  • an adequate circulation deteriorates

Do not exceed maximum cumulative dose 12 ml.kg^–1 (70 kg: 840 ml)

Box B:  CRITICAL CHANGES

If cardiac arrest, continue lipid emulsion and   → 2-1

Box C:  AFTER THE EVENT

Arrange safe transfer to appropriate clinical area

Exclude pancreatitis: regular clinical review, daily amylase or lipase Report cases to MHRA: https://yellowcard.mhra.gov.uk/