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Local Anesthetic Systemic Toxicity: A Narrative Literature Review and Clinical Update on Prevention, Diagnosis, and Management

Gitman, Marina M.D.; Fettiplace, Michael R. M.D., Ph.D.; Weinberg, Guy L. M.D.; Neal, Joseph M. M.D.; Barrington, Michael J. Ph.D., M.B.B.S., F.A.N.Z.C.A.

Plastic and Reconstructive Surgery: September 2019 - Volume 144 - Issue 3 - p 783-795
doi: 10.1097/PRS.0000000000005989
Plastic Surgery Focus: Special Topics
Patient Safety CME

Background: The objective of this narrative review of local anesthetic systemic toxicity is to provide an update on its prevention, diagnosis, and management.

Methods: The authors used a MEDLINE search of human studies, animal studies, and case reports and summarize findings following the American Society of Regional Anesthesia and Pain Medicine practice advisories on local anesthetic systemic toxicity.

Results: Between March of 2014 and November of 2016, there were 47 cases of systemic toxicity described. Twenty-two patients (47 percent) were treated with intravenous lipid emulsion and two patients (4.3 percent) died. Seizures were the most common presentation. The spectrum of presenting neurologic and cardiovascular symptoms and signs are broad and can be obscured by perioperative processes. Local anesthetic type, dosage, and volume; site of injection; and patient comorbidities influence the rate of absorption from the site of injection and biodegradation of local anesthetics. Consider discussing appropriate dosages as a component of the surgical “time-out.” A large-volume depot of dilute local anesthetic can take hours before reaching peak plasma levels. Oxygenation, ventilation, and advanced cardiac life support are the first priorities in treatment. Lipid emulsion therapy should be given at the first sign of serious systemic toxicity with an initial bolus dose of 100 ml for adults weighing greater than 70 kg and 1.5 ml/kg for adults weighing less than 70 kg or for children.

Conclusion: All physicians who administer local anesthetics should be educated regarding the nature of systemic toxicity and contemporary management algorithms that include lipid emulsion therapy.

Patient Safety CME.

Chicago, Ill.; Boston, Mass.; Seattle, Wash.; and Melbourne, Victoria, Australia

From the Department of Anesthesiology, University of Illinois College of Medicine; Research and Development Service, Jesse Brown Veterans Affairs Medical Center; the Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital; the Virginia Mason Medical Center; the University of Washington; the Department of Anaesthesia and Acute Pain Medicine, St. Vincent’s Hospital Melbourne; and the Melbourne Medical School, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne.

Received for publication March 2, 2018; accepted February 12, 2019.

Disclosure:Dr. Weinberg is an officer, director, shareholder, and paid consultant of ResQ Pharma Inc. He also created and maintains an educational website. The authors have no other relevant financial disclosures to report.

By reading this article, you are entitled to claim one (1) hour of Category 2 Patient Safety Credit. ASPS members can claim this credit by logging in to Dashboard, clicking “Submit CME,” and completing the form.

Michael J. Barrington, Ph.D., M.B.B.S., F.A.N.Z.C.A., Department of Anaesthesia and Acute Pain Medicine, St. Vincent’s Hospital Melbourne, Melbourne Medical School, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia,, Twitter: @barringtonmj

Copyright © 2019 by the American Society of Plastic Surgeons