Study of knowledge and practices of local anaesthetic


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medRxiv preprint doi: https://doi.org/10.1101/2021.04.19.21255661; this version posted April 20, 2021. The copyright holder for this preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. It is made available under a CC-BY-NC-ND 4.0 International license .

Study of knowledge and practices of local anaesthetic systemic toxicity among
Doctors in Sri Lanka
1. Department of Anaesthesia and Intensive care, District General Hospital, Mannar, Sri Lanka. 2. Post Graduate Institute of Medicine, University of Colombo, Sri Lanka 3. District General Hospital, Killinochchi, Sri Lanka 4. National Hospital, Kandy, Seri Lanka 5. Department of Public Health, Faculty of Medicine, University of Kelaniya, Sri Lanka

1. Dr. B.M. Munasinghe. MBBS(Peradeniya), MD Col (Anaesthesiology with special interest in

Intensive care)- Corresponding Author

Acting Consultant Anaesthetist

Department of Anaesthesia and Intensive care

District General Hospital

Mannar

Sri Lanka.

Email- [email protected]

Telephone: Work +94-232222261

Mobile +94773645827

Address:

126/1, Meethenwala, Walakadawaththa, Mawathagama, Sri Lanka 60060.

1. Dr. Arambepola AG. MBBS, MD Col (Anaesthesiology with special interest in Intensive care) Acting Consultant Anaesthetist Department of Anaesthesia and Intensive care District General Hospital Mannar Sri Lanka. Email- [email protected]
1. Dr. Subramaniam N. MBBS Medical officer in Anaesthesia and Intensive care Department of Anaesthesia and Intensive care District General Hospital Mannar Sri Lanka. Email- [email protected]
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NOTE: This preprint reports new research that has not been certified by peer review and should not be used to guide clinical practice.

medRxiv preprint doi: https://doi.org/10.1101/2021.04.19.21255661; this version posted April 20, 2021. The copyright holder for this preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. It is made available under a CC-BY-NC-ND 4.0 International license .
1. Dr. Nimalan S. MBBS Medical officer in Anaesthesia and Intensive care Department of Anaesthesia and Intensive care District General Hospital Mannar Sri Lanka. Email- [email protected]
2. Dr. Gunathilake KUIS. MBBS Registrar in Clinical Medicine Post Graduate Institute of Medicine University of Colombo Sri Lanka Email- [email protected]
3. Dr. Nissankaarachchi RD. MBBS Medical Officer- Dialysis District General Hospital Killinochchi Sri Lanka Email- [email protected]
4. Dr. Karunathilake S K. MD, FRCA Consultant Anaesthetist National Hospital Kandy Sri Lanka Email- [email protected]
5. Dr. Jayamanne BDW. MBBS, MSc (Biostatistics), MSc (Biomedical Informatics- Colombo), MIASSL Department of Public Health Faculty of Medicine University of Kelaniya Sri Lanka Email- [email protected]
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medRxiv preprint doi: https://doi.org/10.1101/2021.04.19.21255661; this version posted April 20, 2021. The copyright holder for this preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. It is made available under a CC-BY-NC-ND 4.0 International license .
Study of knowledge and practices of local anaesthetic systemic toxicity among Doctors in Sri Lanka
Abstract
Background Local anaesthetic systemic toxicity (LAST) could be potentially life threatening. This study focused on describing the knowledge and practices of use of local anaesthetics (LA) among the doctors in Sri Lanka and the ability to detect and manage an event of LAST.
Materials and methods A descriptive cross-sectional study was conducted among doctors in Sri Lanka using an online selfadministered questionnaire based on AAGBI guidelines (2010). Descriptive statistics were analyzed by cross-tabulations and presented as numbers and percentages using IBM-SPSS 25.
Results The response rate was 60% out of 600. Majority were males (58%) while 45% of the respondents were anesthetists. Ultrasound was used by 47.4% during LA. The majority considered total body weight for dose calculations. Around 50% of respondents identified bupivacaine as the most cardiotoxic. The majority utilized some form of monitoring and were knowledgeable on identification, prevention and initial management of LAST. Approximately 45% identified Intralipid (ILE) as the definitive treatment of LAST, out of which, 66.8% knew the correct dose and 77.2% and 26.5%, the availability and location of storage, respectively.
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medRxiv preprint doi: https://doi.org/10.1101/2021.04.19.21255661; this version posted April 20, 2021. The copyright holder for this preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. It is made available under a CC-BY-NC-ND 4.0 International license .
Conclusion The basic knowledge on LAST was satisfactory among the respondents. A statistically significant difference on knowledge on maximum safe doses of LA, ILE in established LAST, its dosage and the availability was identified between anaesthetic and non-anaesthetic doctors and post graduate trainees and the rest of the doctors. Overall, significant lapses were noted with regard to the use of total body weight for dose calculations, use of ultrasound during LA administration and dosage, availability and storage of the definitive therapy, ILE, suggesting updates in these key areas. Keywords- Local Anaesthetic Systemic Toxicity, LAST, cardiac toxicity, Intralipid, ILE
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medRxiv preprint doi: https://doi.org/10.1101/2021.04.19.21255661; this version posted April 20, 2021. The copyright holder for this preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. It is made available under a CC-BY-NC-ND 4.0 International license .
Study of knowledge and practices of local anaesthetic systemic toxicity among doctors in Sri Lanka
Introduction
Local anaesthetic systemic toxicity (LAST) is rare, underdiagnosed and underreported [1] , but could result in serious morbidity and mortality [2]. Existing literature emphasizes the importance of knowledge on LAST[3]. Knowledge and practices in recognizing, preventing and treating LAST is essential in minimizing and ultimately managing an event of LAST. We reviewed the literature on factors contributing to LAST and management protocols and studied the knowledge and practices among the doctors in our study population regarding identifying, preventing and managing LAST.
Materials and methods
The study was conducted as a descriptive cross-sectional study among middle and intermediate-grade doctors in Sri Lanka. Considering 20,000 practicing doctors’ population were eligible for our study [4] and level of awareness on LAST in a regional study among doctors [5] being around 30% (outcome factor of 30% selected), at 7.5% confidence limit and 95% confidence interval with a design effect (2.0) for cluster sampling, a sample size of 285 was calculated. Following attrition for 20% for non-responders, the minimum sample size required was 342. A self-administered questionnaire(SAQ) was prepared following review of literature and the Association of Anaesthetists of Great Britain and Ireland (AAGBI) guideline
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medRxiv preprint doi: https://doi.org/10.1101/2021.04.19.21255661; this version posted April 20, 2021. The copyright holder for this preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. It is made available under a CC-BY-NC-ND 4.0 International license .

on LAST (2010). Face and content validity and appropriateness to culture were assessed and certified by an expert panel. A single-stage cluster sampling method was utilized. Hospitals were chosen randomly. Following establishing remote verified individual communications (via email or social media (WhatsApp/Viber/ Facebook) the questionnaire was distributed. The questionnaire was accessible to the participants only after the consent. The responses were stored in password-protected online cloud. The analysis of data was done with IBM SPSS (version 25) by applying relevant statistical tests accordingly. P < 0.05 was considered as statistically significant. Ethical approval was obtained from the Ethical review committee of the Sri Lanka Medical Association. (ERC/20/023)

Results Out of 600 participants, 360 responded (response rate -60%) where 58.3 % were males (210). Median age was 32 years (Q1=29.7, Q3=34.4, IQR=4.7). Majority of respondents were experienced as doctors for 2 to 5 years (Figure 1: Working experience of the respondents as doctors). Figure 1. Experience of the respondents as doctors

7, 2% 3, 1%
50, 14% 40, 11%
96, 27%
164, 45%

Less than a year 1 to 2 years 2 to 5 years 5 to 10 years 10 to 20 years More than 20 years

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medRxiv preprint doi: https://doi.org/10.1101/2021.04.19.21255661; this version posted April 20, 2021. The copyright holder for this preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. It is made available under a CC-BY-NC-ND 4.0 International license .

About 30% were postgraduate trainees from different specialties. (Figure 2: Categorization according to designation).

Figure 2. Categorization according to designation 43, 12% 6, 2%
61, 17%
250, 69%

House Officer Medical Officer Registrar Senior Registrar

Distribution of responders according to subspecialty is shown in Table 01. Table 1. Distribution of responders according to subspecialty

Subspecialty

Number

%

Anaesthesia/ ICU

160

44.4

Emergency Medicine

20

5.6

General surgery

36

10.0

Medicine

39

10.8

Gynaecology and Obstetrics

20

5.6

Paediatrics

12

3.3

Ophthalmology

5

1.4

Oral and maxillofacial surgery

7

1.9

Orthopaedics

6

1.7

Radiology

7

1.9

7

medRxiv preprint doi: https://doi.org/10.1101/2021.04.19.21255661; this version posted April 20, 2021. The copyright holder for this preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. It is made available under a CC-BY-NC-ND 4.0 International license .

Other*

48

13.4

Total

360

100

*ENT, plastic, urology, vascular surgery etc

Distribution of responders according to type of hospital is shown in Table 2. Table 2. Distribution of responders according to type of hospital

Type of hospital

Number

%

Teaching

190

52.8

Provincial General

13

3.6

District General

90

25.0

Base

52

14.4

Divisional

8

2.2

Other *

7

2.0

Total

360

100

*Primary medical care unit/ private dispensary/ private hospital/ preventive sector)

Practices of use of three local anaesthetic agents (LA) The frequency and route of usage of the three LA; lignocaine, bupivacaine and prilocaine were studied. Plain Lignocaine was the most commonly used and Prilocaine was the least commonly used. (Table 03).
Table 3. Frequency of usage by local anaesthetic agent

Agent
Plain lignocaine Lignocaine with Adrenaline Plain Bupivacaine Prilocaine

Never(%)
25(6.9) 52(14.4) 111(30.8) 309(85.8)

Frequency of usage per month
<1(%) 1-5(%) 6-15(%) 16-30(%)
54(15) 63(17.5) 85(23.6) 61(16.9) 77(21.4) 88(24.4) 71(19.7) 36(10) 36(10) 65(18.1) 64(17.8) 36(10) 33(9.2) 09(2.5) 09(2.5) 0

>30(%)
72(20) 36(10) 48(13.3) 0

Route Subcutaneous infiltration was the commonest route (39.7%) followed by regional nerve blocks (39.7%) and epidurals (13%) (Table 04).
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medRxiv preprint doi: https://doi.org/10.1101/2021.04.19.21255661; this version posted April 20, 2021. The copyright holder for this preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. It is made available under a CC-BY-NC-ND 4.0 International license .

Subcutaneous infiltration Regional nerve blocks Epidural Intravenous Retrobulbar/ peribulbar
Other (Intercostal/i ntrapleural)

Table 4. Frequency of usage by route of administration Frequency of usage per month
Agent

Plain lignocaine Lignocaine with Adrenaline Plain Bupivacaine Prilocaine Total per month Percentage-methods

300(43.0) 236(33.8) 154(22.0) 08( 1.2)
698 39.7

185(39.8) 107(23.0) 165(35.5) 08( 1.7)
465 26.4

34(14.9) 09(4.0) 176(77.2) 09(4.0)
228 13.0

89(80.2) 0
07(6.3) 15(13.5)
111 6.3

35(58.3) 07(11.7) 12(20.0) 06(10.0)
60 3.4

69(34.5) 39(19.7) 84(42.2) 06(3.0)
192 11.2

Usage of ultrasound Nearly 53% (191) (95% CI 47.7-58.3) never used ultrasound during LA administration (Figure 3). Out of these, 20% (38) were anaesthetists; 16.8% (32), 15.7% (30) and 8.9% (17) were respectively from General Medicine, General Surgery and Gynaecology and Obstetrics, where LA procedures are generally performed in the absence of ultrasound. Around 20% (73) (95% CI 15.78- 24.2) responded as using ultrasound ‘always’ or ‘frequently’. Majority (86%, 63) of this category were anaesthetists.
Figure 3. Frequency of usage of ultrasound

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medRxiv preprint doi: https://doi.org/10.1101/2021.04.19.21255661; this version posted April 20, 2021. The copyright holder for this preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. It is made available under a CC-BY-NC-ND 4.0 International license .

9, 2% 64, 18%

56, 16% 40, 11%

191, 53%

Never Rarely Sometimes Frequently Always

With regard to monitoring during LA, the preferred mode was found to be the pulse oximetry. This was utilized by 234 (65%, 95% CI 59.9-70). Out of the participants, 33.3% (120) (95% CI 28.3-38.3), were utilizing all (Pulse oximetry, ECG, Non-invasive blood pressure). Around 14.2% (51) used at least pulseoximetry while 6.1% (22) opted for non-invasive blood pressure monitoring and 3.3% (12) ECG only. Roughly 23.9% (86) (95% CI 19.4-28.4) did not use any monitoring during LA administration.
A test dose of LA was administered by only around 25% (90) (95% CI 20.4-29.6).
With regard to dose calculations, 42.7% (154) considered the age of the patient and 46.6%(168), the comorbidities while 26.9% (95% CI, 22.2, 31.6) (97) considered ideal or lean body weight. No statistical significance was identified between Anaesthetic(A) vs Non-anaesthetic(NA) (P=0.100), Post-graduate trainees(PG) vs non-PG(NPG) group (P=0.604) and doctors experienced >10 years (E) vs less experienced (NE) (P= 0.835). The proportions which correctly identified the maximum safe doses of LAs are shown in Figure 04.
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Study of knowledge and practices of local anaesthetic