Local anesthetic systemic toxicity
- Acronym: LAST
- Life-threatening adverse reaction to local anesthetic toxicity.
- Incidence = ~0.2% of nerve blocks
- Generally occurs within minutes of injection
- Injection of local anesthetic into systemic circulation
- Exceeding the maximum dose of local anesthetic (see table below)
- Absorption of anesthetic into systemic circulation by injection into extremely vascular area.
Maximum Doses of Anesthetic Agents
|Agent||Without Epinephrine||With Epinephrine||Duration||Notes|
|Lidocaine||5 mg/kg (max 300mg)||7 mg/kg (max 500mg)||30-90 min||
|Mepivicaine||7 mg/kg||8 mg/kg|
|Bupivicaine||2.5 mg/kg (max 175mg)||3 mg/kg (max 225mg)||6-8 hr||
|Tetracaine||1 mg/kg||1.5 mg/kg||3hrs (10hrs with epi)|
|Procaine||7 mg/kg||10 mg/kg||30min (90min with epi)|
Clinical course tends to be a dose-dependant progression from CNS symptoms to CVS symptoms and death
- CNS symptoms
- Auditory changes
- Metallic taste
- Seizures or drowsiness
- Respiratory arrest
- Early signs
- Ventricular dysrhythmia
- Late signs
- Conduction block
- Cardiovascular collapse
- Early signs
Sodium Channel Blockade Toxidrome
- Anti-spasmodics, cyclobenzaprine
- Class Ib antiarrhythmics
- Local anesthetic systemic toxicity
- Clinical diagnosis
- Directed by clinical picture
- Blood levels of anesthetic are available, but not clinically useful.
- Aggressive supportive care (including airway management) and application of ACLS
- Lipid emulsion, (Intralipid) 20% solution
- Lipid sink, binds to local anesthetic
- 1.5 mL/kg bolus over 1 minute
- Then, 0.25 mL/kg/min for 20 min or until hemodynamic stability achieved
- ↑ to 0.5 mL/kg/min if hemodynamic status declines
- ACLS modifications per ASRA (Am Soc of Regional Anesthesia):
- Avoid vasopressin
- Avoid calcium-channel blockers and beta-blockers
- Amiodarone preferred in ventricular dysrhythmias
- Fencl JL. Local anesthetic systemic toxicity: perioperative implications. AORN J. 2015 Jun;101(6):697-700.
- Kamel I, Trehan G, Barnette R. Intralipid Therapy for Inadvertent Peripheral Nervous System Blockade Resulting from Local Anesthetic Overdose. Case Reports in Anesthesiology. 2015;2015:486543. doi:10.1155/2015/486543.
- GlobalRPH. Management of Local Anesthetic Emergencies. http://www.globalrph.com/local-anesthetics.htm
- Dillane D, Finucane BT. Local anesthetic systemic toxicity. Can J Anaesth. 2010 Apr;57(4):368-80.