American Society of Regional Anesthesia and Pain Medicine
Checklist for Treatment of Local Anesthetic Systemic Toxicity
The Pharmacologic Treatment of Local Anesthetic Systemic Toxicity (LAST) is Different from Other Cardiac Arrest Scenarios
❑ Get help
❑ Initial focus
❑ Airway management: ventilate with 100% oxygen
❑ Seizure suppression: benzodiazepines are preferred; AVOID propofol in patients having signs of cardiovascular instability
❑ Alert the nearest facility having cardiopulmonary bypass capability
❑ Management of cardiac arrhythmias
❑ Basic and Advanced Cardiac Life Support (ACLS) will require adjustment of medications and perhaps prolonged effort
❑ AVOID vasopressin, calcium channel blockers, beta-blockers, or local anesthetic
❑ REDUCE individual epinephrine doses to < 1 µg/kg
❑ Lipid Emulsion (20%) Therapy (values in parentheses are for 70 kg patient)
❑ Bolus 1.5 ml/kg (lean body mass) intravenously over 1 minute (~100 ml)
❑ Continuous infusion 0.25 ml/kg/min (~18 ml/min; adjust by roller clamp)
❑ Repeat bolus once or twice for persistent cardiovascular collapse
❑ Double the infusion rate to 0.5 ml/kg/min if blood pressure remains low
❑ Continue infusion for at least 10 minutes after attaining circulatory stability
❑ Recommended upper limit: Approximately 10 ml/kg lipid emulsion over the first 30 minutes
❑ Post LAST events at www.lipidrescue.org and report use of lipid to www.lipidregistry.org
Anaphylaxis
National Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network has defined anaphylaxis as a serious allergic reaction that is rapid in onset and may cause death.[10] It can be caused by exposure to medications or other substances used in the perioperative period. It is an IgE-mediated reaction, leading to the release of histamine and other biochemical mediators. These mediators in turn cause a series of events, ranging from mild symptoms such as itching and skin redness to generalized mucocutaneous swelling, low blood pressure, increased heart rate, constriction of gastrointestinal smooth muscle, and bronchoconstriction. A variety of substances can cause anaphylaxis. The substances commonly implicated during the perioperative period include antibiotics, non-depolarizing muscle relaxants, induction agents, opioids, local anesthetics, chlorhexidine, intravenous contrast agents, and latex.[11]
Prevention
During preoperative evaluation, a careful history of allergies and previous allergic reactions should be elicited. Some facilities use allergy bands wrapped around the patient’s wrist that lists the names of substances causing allergies. In our institution, mentioning the allergies as part of the preoperative time-out list is mandatory with all OR personnel present and attentive to the situation. Latex precautions must be observed in latex-sensitive patients.
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