General Topics: Local Anesthetic Systemic Toxicity

Understanding the mechanism of local anesthetic systemic toxicity (LAST) as well as patient specific risk factors, risk reduction, early detection and expeditious appropriate treatment are key to providing safe regional anesthesia techniques. The presentation of LAST is heterogenous and may occur in or out of a hospital setting after regional anesthesia, local infiltration or tumescent liposuction. The American Society of Regional Anesthesia (ASRA) has issued guidance in the form of a checklist prioritizing the treatment of LAST including: early ventilation and intubation; delivery of intralipid; deviation from standard advanced cardiopulmonary life support; and escalation of care (including consideration for extracorporeal membrane oxygenation (ECMO)). Despite increasing use of regional techniques, the incidence of clinically significant LAST has been decreasing over the last decade; however, the increasing use of large-dose fascial plane blocks, novel agents such as liposomal bupivacaine, as well as peripheral nerve catheters should prompt providers to plan for and be vigilant of this rare, but potentially life-threatening complication. Promoting a culture of safety involves the education of perioperative staff, the development of LAST kits, and detailed uniform plans for treatment in the event of LAST.