Findings from the Coroner on use of local anaesthesia
Please see below the findings of a recent Coroner’s report, aimed at practitioners who administer anaesthesia. The purpose is to identify areas of learning, and to avoid risk of harm to patients.
The case concerned a patient who died from a cardiac event, caused by local anaesthetic systemic toxicity (LAST) and dilated cardiomyopathy, following administration of ropivacaine and lidocaine. The Dental Council was one of the regulators consulted during the Coroner’s review.
LAST occurs when local anaesthetic reaches toxic levels in the bloodstream, affecting the brain and the heart. It is rare, and rarer still at the doses used in the majority of dental and oral health procedures. However, the coroner recommended raising awareness with practitioners alongside the other findings in the report.
The expert advice accepted by the Coroner was that LAST can occur even when the dose administered falls within recommended guideline limits. Some patients are more susceptible than others, particularly those aged over 60, with smaller muscle mass, and cardiac disease (particularly arrhythmias and conduction abnormalities), as risk factors.
Importantly, onset can be immediate and catastrophic. Commonly described early features include dizziness, tingling or numbness around the mouth, ringing in the ears, a metallic taste, agitation, confusion or drowsiness, progressing to seizures and cardiac arrhythmia or arrest.
For oral health practitioners, this is a timely reminder of your obligations on collecting and documenting your patients' medical history, as well as having the necessary refresher resuscitation training and appropriate procedures in place for managing medical emergencies. You can read the Medical Emergencies practice standard here.
For those working with local anaesthesia, you may want to consider your training in this area as part of your professional development activities and recertification needs.
Coroner recommendations:
The following recommendations were made by the Coroner, and they apply when you administer local anaesthetic:
Take a current, complete medical history first. Before administering local anaesthetic, ensure there is a current patient medical questionnaire giving a complete picture of the patient's health, covering both what is immediately relevant to the procedure and what would matter in an unexpected medical emergency at your practice. It should identify any condition the patient is being treated for and any medication they are prescribed.
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Actively consider what raises that patient's risk. Before administering, be aware of and consciously consider any patient characteristics that heighten the risk of an adverse reaction, including age, weight, and cardiac history.
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Be trained and prepared. Engage with ongoing education and pre-planning for unexpected medical emergencies, including recognising and responding to a potential LAST event, airway management, and giving oxygen. The Coroner considered this should ideally include scenario-based training.
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Review your emergency kit. You should review the contents of your emergency kit, so that unnecessary clutter does not slow you down when responding to a medical emergency.
We also remind you to report any suspected adverse reaction to a local anaesthetic to the Centre for Adverse Reactions Monitoring (CARM), as under-reporting was also raised during the inquiry.