Surgery Book


Local Anesthetic Systemic Toxicity

Aka: Local Anesthetic Systemic Toxicity, Local Anesthetic System Toxicity, Local Anesthetic Agent Poisoning, LAST Reaction, LAST Syndrome
  1. See Also
    1. Regional Anesthesia
  2. Definitions
    1. LAST Reaction
      1. Local Anesthetic Systemic Toxicity
  3. Mechanism
    1. Vascular injection of large dose of local Anesthetic
  4. Risk Factors
    1. Extremes of age
    2. Large region of infiltration
    3. Liver failure (hypoalbuminemia)
    4. Concurrent medications
      1. Beta Blockers
      2. Calcium Channel Blockers
      3. Digoxin
  5. Adverse Effects: Lidocaine
    1. Neurologic
      1. Tinnitus
      2. Dizziness
      3. Circumoral or Tongue numbness
      4. Metallic Taste
      5. Confusion
      6. Seizure
    2. Cardiovascular
      1. Bradycardia
      2. Hypotension
      3. Ventricular Arrhythmia (including VT/VF)
      4. AV Block
      5. Palpitations
  6. Adverse Effects: Bupivicaine
    1. High risk of serious Arrhythmia or Cardiac Arrest if injected intravascularly
    2. Bupivicaine (and Ropivacaine) are much more toxic systemically than Lidocaine
      1. Highly lipophilic
      2. High Sodium channel affinity
  7. Management
    1. ABC Management
    2. Seizure Management
      1. See Status Epilepticus
      2. Benzodiazepines are preferred first-line agents
      3. Avoid Propofol (due to hemodynamic instability)
    3. Arrhythmia Management
      1. See ABC Management (follow ACLS protocols)
      2. Avoid Vasopressin, Calcium Channel Blockers, Beta Blockers
      3. Decrease Epinephrine dose to 1 mcg/kg
      4. Give Sodium Bicarbonate if Wide Complex Tachycardia (similar to Tricyclic Overdose)
    4. Intralipid 20% emulsion
      1. Bolus 1.5 ml/kg (Lean Body Mass) IV push over 2 minutes
        1. May repeat in 2-3 minutes for refractory cardiovascular collapse
        2. If still not effective may start Intralipid infusion as below
      2. Continuous infusion 0.25 ml/kg/min for at least 10 min after circulatory stability
        1. May increase to 0.50 ml/kg/min if persistent Hypotension
        2. May increase to maximum of 10-15 ml/kg
        3. Alternatively, 15 ml/kg may be infused over 1 hour
      3. See Intravenous Lipid Emulsion
      4. Primarily for lipophilic drug toxicity (esp. bupivicaine)
      5. Draw blood tubes before injecting Intralipid (alters lab values)
  8. Prevention
    1. Withdraw first, when injecting Anesthetic, especially for bupivicaine (to prevent intravascular injection)
    2. Adding Epinephrine to the local Anesthetic keeps the agent in the tissues with less systemic absorption
    3. Limit local Anesthetic to their maximums (calculate the maximum cc of local Anesthetic that may be used)
      1. See Regional Anesthesia
      2. Lidocaine: 4 mg/kg (7 mg/kg if with Epinephrine)
        1. Lidocaine 1% contains 10 mg/ml, and 2% contains 20 mg/ml
      3. Bupivacaine: 2 mg/kg
        1. Bupivacaine 0.25% contains 2.5 mg/ml, and 0.5% contains 5 mg/ml
      4. Ropivacaine 3 mg/kg
        1. Ropivacaine 0.2% contains 2 mg/ml, and 0.5% contains 5 mg/ml
    4. Be aware of high risk locations for local injections (esp. with bupivicaine)
      1. Intercostal Nerve Blocks
  9. Resources
    1. Lipid Rescue
  10. References
    1. Acker, Koval and Leeper (2017) Crit Dec Emerg Med 31(4): 3-13
    2. Nordt and Shoenberger in Herbert (2019) EM:Rap 19(2): 4-5
    3. Burch (2011) Am J Health Syst Pharm 68(2):125-9 +PMID:21200058 [PubMed]

Local anesthetic agent poisoning (C0473977)

Concepts Injury or Poisoning (T037)
ICD10 T41.3, T41.3X1
SnomedCT 212652002, 111764002
English Local anaesth.poisoning NOS, Local anaesthetic poisoning, Local anaesthetic poisoning NOS, Local anaesthetics, Local anesthetic agent poisoning, Local anesthetic poisoning, Local anesthetic poisoning NOS, Local anesthetics, Poisoning by local anaesthetics, Poisoning by local anesthetics, local anesthetic toxicity, local anesthetic toxicity (diagnosis), toxicity from local anesthetics, Poisoning by local anesthetics NOS, Local anesthetic poisoning NOS (disorder), Local anaesthetic agent poisoning, Poisoning by local anaesthetic, Poisoning by local anesthetic (disorder), Poisoning by local anesthetic
German Vergiftung: Lokalanaesthetika
Korean 국소성 마취제에 의한 중독
Spanish intoxicación por anestésico local, SAI, intoxicación por anestésico local, SAI (trastorno), intoxicación por agente anestésico local, intoxicación por anestésico local (trastorno), intoxicación por anestésico local
Dutch Lokale anaesthetica
Derived from the NIH UMLS (Unified Medical Language System)

You are currently viewing the original '\legacy' version of this website. Internet Explorer 8.0 and older will automatically be redirected to this legacy version.

If you are using a modern web browser, you may instead navigate to the newer desktop version of fpnotebook. Another, mobile version is also available which should function on both newer and older web browsers.

Please Contact Me as you run across problems with any of these versions on the website.

Navigation Tree