Lokal Anestezik Sistemik Toksisitesi
Özet
Lokal anestezikler, cerrahi ve anestezi uygulamalarında yaygın olarak kullanılan güvenli ilaçlar olmakla birlikte, yüksek dozda kullanılması veya yanlış uygulanması halinde nadir fakat yaşamı tehdit eden kritik bir tablo olan lokal anestezik sistemik toksisitesine (LAST) yol açabilir. Yapısal olarak amino esterler ve amino amidler şeklinde iki gruba ayrılan bu ilaçlardan karaciğerde yavaş metabolize edilen amid türevleri, sistemik toksisite açısından daha yüksek risk taşımaktadır. LAST klinik bulguları temel olarak santral sinir sistemi (SSS) ve kardiyovasküler sistemi (KVS) etkilemektedir. Erken dönem SSS belirtileri arasında ağızda metalik tat, kulak çınlaması, perioral uyuşma ve sersemlik hissi yer alırken; toksisite ilerledikçe ajitasyon, konvülsiyonlar, deliryum, koma ve solunum arresti gelişebilmektedir. KVS etkileri ise ilk olarak sempatik aktivasyonla hipertansiyon ve taşikardi şeklinde ortaya çıkıp, ardından iletim bozuklukları, aritmiler, miyokardiyal disfonksiyon ve kardiyak arrest ile seyredebilir. Ayrıca prilokain, artikain ve benzokain methemoglobinemi riskini artırmaktadır. Yaş ekstremumları, gebelik, sistemik hastalıklar ve vaskülaritesi yüksek enjeksiyon bölgeleri LAST riskini artıran önemli faktörlerdir. Önlemede ultrason rehberliği, etkili en düşük doz seçimi, sık aspirasyon ve epinefrinli test dozu kullanımı öne çıkmaktadır. Toksisite yönetiminde LA uygulamasının hemen kesilmesi, %100 oksijen desteği, nöbetlerin benzodiazepinler ile tedavisi ve resüsitasyonu sağlamak için erken dönemde intravenous %20 lipid emülsiyon tedavisine başlanması hayati önem taşımaktadır.
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