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anesthesia.local-anesthetic-systemic-toxicity.core.v1

Local Anesthetic Systemic Toxicity (LAST)

critical_careacuteadultpediatricacuteinpatient
Start encounter →Print handoutPRODUCTION

Lane-C anesthesia campaign — ASRA LAST cornerstone is 20% lipid emulsion (Intralipid RxCUI 227582 RxNav-verified); LOW-dose epinephrine <1 mcg/kg (RxCUI 3992) per ASRA 2020 (NOT standard ACLS dose); midazolam 6960 first-line for seizure; amiodarone 703 preferred over lidocaine/procainamide. AVOID vasopressin, CCB, beta-blockers, lidocaine. PMIDs 33148630 (Neal ASRA 2020), 16810015 (Rosenblatt 2006), 9579517 (Weinberg 1998) live-verified via PubMed MCP. Earlier prompt-supplied 31836841 (meteorology) and 16810002 (ketamine analgesia) were fabricated — substituted with the corrected verified PMIDs above.

Entry points (4)

  • symptom
    CNS excitation (perioral numbness, tinnitus, metallic taste, agitation, seizure) after local anesthetic block (ASRA 2020)
    cns_excitation_after_la
  • symptom
    Cardiovascular collapse (dysrhythmia, hypotension, arrest) after local anesthetic injection or infusion (ASRA 2020)
    cv_collapse_after_la
  • history
    Local anesthetic dose at or above maximum (bupivacaine >2 mg/kg, ropivacaine >3 mg/kg, lidocaine >7 mg/kg with epi) (ASRA 2020)
    la_dose_near_or_above_max
  • history
    Inadvertent IV / intravascular LA injection during regional block (ASRA 2020)
    inadvertent_iv_la_injection

Required inputs (9)

  • weight_kgrequired
    demographic • used at TREATMENT
    Lipid emulsion 1.5 mL/kg lean body weight bolus; epinephrine dose-limited to <1 mcg/kg in LAST (ASRA 2020)
  • la_agent_dose_route_timerequired
    history • used at CONTEXT
    Bupivacaine highest cardiotoxicity; document agent + dose + time of injection (ASRA 2020)
  • hrrequired
    vital • used at RED_FLAGS
    Dysrhythmia, bradycardia, or escalating tachycardia tracks toxicity progression (ASRA 2020)
  • sbprequired
    vital • used at RED_FLAGS
    Hypotension is a late CV sign that frequently precedes arrest (ASRA 2020)
  • spo2required
    vital • used at RED_FLAGS
    Hypoxia worsens cardiotoxicity; 100% O2 is first action (ASRA 2020)
  • mental_statusrequired
    symptom • used at RED_FLAGS
    AMS / seizure marks CNS phase; airway protection (ASRA 2020)
  • abg
    lab • used at INITIAL_WORKUP
    Acidosis worsens LA cardiotoxicity; corroborates resuscitation progress (ASRA 2020)
  • lipase
    lab • used at MONITORING
    Pancreatitis is a documented late lipid-emulsion complication; baseline + serial (ASRA 2020)
  • triglycerides
    lab • used at MONITORING
    Hypertriglyceridemia is a late lipid-emulsion complication (ASRA 2020)

12-phase flow (12)

  1. 1FRAME
    Confirm LAST scope — systemic CNS + CV toxicity from intravascular or absorbed LA, especially after peripheral nerve / neuraxial / infiltrative block (ASRA 2020)
    inputs: la_agent_dose_route_time
    advance: plausible LA exposure with toxicity signs
  2. 2ENTRY
    Recognize early CNS prodrome (perioral numbness, tinnitus, metallic taste, agitation) BEFORE seizure / arrest (ASRA 2020)
    inputs: mental_status
    advance: any entry trigger present
  3. 3CONTEXT
    LA agent, dose, route, time since injection; concurrent epinephrine in block (a marker, not a cause); patient weight (ASRA 2020)
    inputs: weight_kg, la_agent_dose_route_time
    advance: context captured
  4. 4RED_FLAGS
    Seizure, dysrhythmia, hypotension, cardiac arrest — STOP LA injection; call for help + lipid emulsion + airway team (ASRA 2020)
    inputs: mental_status, hr, sbp, spo2
    advance: lipid emulsion bolus given
  5. 5INITIAL_WORKUP
    ABG, lactate, BMP, troponin, telemetry, 12-lead ECG; ABG every 30-60 min during resuscitation; airway secured (ASRA 2020)
    inputs: abg
    actions: panel.abg, panel.cardiac
    advance: monitoring + airway support + lipid running
  6. 6BRANCHING_WORKUP
    Echo if persistent shock; bypass-capable facility transfer if refractory cardiac arrest; CT brain if persistent AMS post-resuscitation (ASRA 2020)
    advance: refractory features escalated
  7. 7DIFFERENTIAL
    Differentiate from vasovagal syncope, post-block hypotension (sympathectomy), allergic reaction, pre-existing seizure disorder, hyperventilation (ASRA 2020)
    advance: LAST confirmed or excluded
  8. 8RISK_STRATIFICATION
    Severity: prodrome only vs seizure vs cardiac arrest; agent (bupivacaine highest); pediatric and pregnant patients at higher risk (ASRA 2020)
    inputs: la_agent_dose_route_time
    advance: severity tier assigned
  9. 9TREATMENT
    STOP LA; 100% O2 + airway support; benzodiazepine (midazolam) for seizures (avoid propofol if hemodynamic compromise); 20% lipid emulsion 1.5 mL/kg bolus then 0.25 mL/kg/min infusion (max 12 mL/kg cumulative); LOW-dose epinephrine <1 mcg/kg if CV collapse (NOT standard ACLS 1 mg); amiodarone for VT/VF; AVOID vasopressin, CCB, beta-blockers, lidocaine/procainamide (ASRA 2020)
    inputs: weight_kg, mental_status, sbp
    advance: CV stability returns
  10. 10DISPOSITION
    Monitored bed >=4h after CV-only event; >=2h after CNS-only event; ICU if cardiac arrest, lipid infusion, or persistent toxicity (ASRA 2020)
    inputs: sbp, hr
    advance: disposition decision
  11. 11MONITORING
    Telemetry, ABG, lactate, lipase + triglycerides post-lipid; recurrence within hours possible due to LA redistribution (ASRA 2020)
    inputs: lipase, triglycerides
    advance: serial parameters stable
  12. 12FOLLOWUP
    Report event to LipidRescue registry; investigate dose/technique cause; consider plain ropivacaine over bupivacaine for high-dose blocks; counsel patient (ASRA 2020)
    advance: case reported + corrective plan