|Year : 2019 | Volume
| Issue : 10 | Page : 3440-3442
Generalized seizure following lignocaine administration: Case report and literature review
Jaspreet K Boparai1, Deepti Chopra1, Sandeep K Pandey2, Bharti Bhandari3
1 Department of Pharmacology, Government Institute of Medical Sciences, Greater Noida, Uttar Pradesh, India
2 Department of Dentistry, Government Institute of Medical Sciences, Greater Noida, Uttar Pradesh, India
3 Department of Physiology, Government Institute of Medical Sciences, Greater Noida, Uttar Pradesh, India
|Date of Submission||18-Jul-2019|
|Date of Decision||22-Aug-2019|
|Date of Acceptance||03-Sep-2019|
|Date of Web Publication||31-Oct-2019|
Dr. Deepti Chopra
Associate Professor, Department of Pharmacology, Government Institute of Medical Sciences, Greater Noida - 201 310, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Local anaesthetics (LAs) are considered the most effective drugs for prevention and management of pain associated with dental procedures. Lignocaine is the most preferred LA worldwide. Adverse drug reactions reported with lignocaine use are usually mild, however severe complications have been encountered. This article reports a case of lignocaine-induced seizure in a child. We also reviewed similar cases encountered over the last 10 years. The possible explanations could be placement of the needle in a small vein or hypersensitivity to lignocaine. We hereby reinforce the fact that seemingly safe LA's can cause life-threatening complications and rapid identification of clinical symptoms can drastically change the clinical course. Hence it is vital that primary care physicians and other healthcare professionals should to be aware, alert and be able to diagnose and manage these reactions immediately.
Keywords: Adverse drug reactions, dental procedures, lignocaine, local anaesthetics, seizure
|How to cite this article:|
Boparai JK, Chopra D, Pandey SK, Bhandari B. Generalized seizure following lignocaine administration: Case report and literature review. J Family Med Prim Care 2019;8:3440-2
|How to cite this URL:|
Boparai JK, Chopra D, Pandey SK, Bhandari B. Generalized seizure following lignocaine administration: Case report and literature review. J Family Med Prim Care [serial online] 2019 [cited 2020 Dec 3];8:3440-2. Available from: https://www.jfmpc.com/text.asp?2019/8/10/3440/269986
| Introduction|| |
Local anesthetics (LA's) are used as pain relief measures in dental procedures and are the most widely used drugs in routine dentistry. Lignocaine is commonly used in infiltration anesthesia, extremity blocks, topical anesthesia, intravenous regional anesthesia and in general anaesthesia. Toxic reactions, though negligible, may occur due to over dosage, rapid absorption into the blood from highly vascular spaces or accidental intravascular injection leading to increased plasma levels of these agents. Young children are certainly more vulnerable to experience a toxic reaction than adults. Herein, we report a probable case of lignocaine-induced seizure in a child.
| Case Presentation|| |
An 8-year-old healthy male patient (30 kg weight and 130 cm height) with no history of epilepsy visited the dentist for tooth extraction. The patient had no known drug allergies. During his visit for extraction of deciduous second molar, the dentist injected 1.8 ml of 2% lignocaine (36 mg) with adrenaline (1:200,000) after prior aspiration at upper left maxillary vestibule with respect to deciduous second molar followed by 0.5 ml at left greater palantine nerve block. The total 46 mg lignocaine lasting over 2 min was administered. Immediately following the nerve block, the child presented with tonic-clonic convulsions. Patient was placed in supine position with elevated legs, and care was taken so as to protect from injuries. Injection diazepam was given. The vital signs and all laboratory investigations were normal. Neurological examination was unremarkable. MRI scan of the head and electroencephalogram were normal. There was no recurrence of seizures and the child was discharged after 1 day. Using Naranjo probability scale the relationship between the drug and the event was categorized as probable.
| Discussion|| |
Central nervous system (CNS) and the cardiovascular system are more prone to the toxic effects. CNS toxicity is due to unopposed excitatory nerve activity resulting from blockade of inhibitory cortical synapses and increase of glutamate. The symptoms include light-headedness, tinnitus, confusion, circumoral numbness, etc., which culminates in generalized seizures. Excitation is followed by CNS depression. Onset of toxic symptoms usually begins within 10-20 minutes after injection. However, if the local anaesthetic is injected intravenously, the effect may be instant.
At lower concentration, lignocaine has anticonvulsant properties, whereas definite CNS excitation and seizure is observed between at 4 to 10 ug/ml concentration. Further increase causes CNS depression. Seizures induced by lignocaine in experimental models are focal in nature, invariably starting in the amygdala. However, the seizures occurring in patients after lignocaine administration are usually generalized.
Neurologic toxicity has been frequently observed with IV use, occasionally with topical use and oral ingestion also., Susceptibly to toxic effects of local anaesthetics depends on various factors like patient age, maximum dose, site and speed of administration, presence or absence of concomitant disease, etc.
We could not estimate the serum concentration of lignocaine in our patient. The recommended maximum dose of lignocaine in children is 3 mg/kg, which amounts to 90 mg for our patient. The total dose used in present case was 46 mg which is within the safe dose range. The likely explanation for low dose adverse reactions is low tolerance to LA. Additionally the threshold of toxicity may differ with factors such as medication, hypercarbia, electrolytes abnormalities, carnitine, alpha-1-acid glycoprotein or albumin deficiencies.
Similar to the present study, Ayas et al. (2014) reported a case of seizure with lignocaine within the safe dose range in a child. A summary of case reports of lignocaine induced seizures in children's during the last 10 years have been depicted in [Table 1].
|Table 1: Summary of case reports of lignocaine toxicity reported in paediatric age group over last 10 years|
Click here to view
Intravascular injection of lignocaine may result in toxic effects. However, adverse reactions can occur without intravascular placement of the needle and while using divided doses and repeated aspiration. A possible elucidation is that the needle tip might have been placed within a small vein, so that the negative pressure aspiration resulted in apposition of the vessel wall against the needle. This explains the present case. Increased sensitivity to lignocaine could have been another possible cause for the convulsive episode in the present case.
Management of the adverse reaction
Stop injection immediately. In majority of the patients, the reaction is mild and ephemeral which usually does not require any specific treatment as the blood level of the anaesthetic decreases because of biotransformation and redistribution. The patient should be placed in supine position with elevated legs and protected from injuries ABCs of basic life support to be provided. Benzodiazepines for seizure control.
The adverse effects can be prevented by taking detailed medical history of the patient, by administering test dose, by following dosage protocol and using minimum necessary dose, by use of Adrenaline along with lignocaine to slow vascular uptake, by aspiration before and during injection by slow injection and by maintaining verbal contact with the patient.
| Conclusion|| |
The present case signifies that toxicity can develop even during the use of the safest LAs' by experienced professionals with all treatment standards met and use of suitable techniques for injection. Dental professionals should recognize early signs of toxicity of LAs' and should be well-trained to perform CPR in order to improve the patient outcome.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Haas DA. An update on local anesthetics in dentistry. J Can Dent Asso 2002;68:546-51.
Ayas M, Isik B. Does low dose lidocaine cause Convulsions? Turk J Anaesth Reanim 2014;42:106-8.
Hoda S, O'Brien J, Gamble J. Intractable seizures in a toddler after application of an over-the-counter local anesthetic cream. CMAJ 2016;188:1030-32.
Christie LE, Picard J, Weinberg GL. Local anaesthetic systemic toxicity. BJA Educ 2015;15:136-42.
Menif K, Khaldi A, Bouziri A, Hamdi A, Belhadj S, Ben Jaballah N. Lidocaine toxicity secondary to local anesthesia administered in the community for elective circumcision. Fetal Pediatr Pathol 2011;30:359-62.
Mehra P, Caiazzo A, Maloney P. Lidocaine toxicity. Anesth Prog 1998;45:38-41.
DeToledo JC. Lidocaine and seizures. Ther Drug Monit 2000;22:320-2.
Alipour A, Navaeifar MR, Shokooh Saremi S. Accidental ingestion of local anesthetic solutions in children. J Pediatr Rev 2019;7:169-76.
Bathla S, Gupta A, Mittal M, Kamal G. Inadvertent massive overdose of lidocaine in an infant with arthrogryposis multiplex congenita treated successfully with lipid emulsion. AANA J 2017;85:357-60.
Alsukhni RA, Ghoubari MS, Farfouti MT, Aboras YA. Status epilepticus following local anesthesia in a previously healthy adult. BMC Res Notes 2016;9:300.
Aminiahidashti H, Laali A, Nosrati N, Jahani FJ. Recurrent seizures after lidocaine ingestion. Adv Pharm Technol Res 2015;6:35-7.
Doye E, Desgranges FP, Stamm D, de Queiroz M, Valla FV, Javouhey E. Severe local anesthetic intoxication in an infant undergoing circumcision. Arch Pediatr 2015;22:303-5.
Ozer AB, Erhan OL. Systemic toxicity to local anesthesia in an infant undergoing circumcision. Agri 2014;26:43-6.
Larson A, Stidham T, Banerji S, Kaufman J. Seizures and methemoglobinemia in an infant after excessive EMLA application. Pediatr Emerg Care 2013;29:377-9.
Kumar J, Manjunath VG. Seizures following lignocaine administration. Indian Pediatr 2013;50:521-2.
Sanaeizadeh H, Zamani N. Prolonged and recurrent seizures in an infant after lidocaine administration for circumcision: A case report. Anestesia Pediatrica e Neonatale 2011;9:1-5.