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Local anesthetic systemic toxicity

Key sources
The following summarized guidelines for the evaluation and management of local anesthetic systemic toxicity are prepared by our editorial team based on guidelines from the American Heart Association (AHA 2023) and the American Society of Regional Anesthesia and Pain Medicine (ASRA 2018).


1.Screening and diagnosis

Clinical presentation: recognize that classic descriptions of LAST depict a progression of subjective symptoms of CNS excitement (agitation, auditory changes, metallic taste, or abrupt onset of psychiatric symptoms), followed by seizures, then CNS depression (drowsiness, coma, or respiratory arrest), and near the end of this continuum, initial signs of cardiac toxicity (hypertension, tachycardia, or ventricular arrhythmias) are supplanted by cardiac depression (bradycardia, conduction block, asystole, decreased contractility, and hypotension).
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2.Respiratory support

Airway management: ensure prompt and effective airway management to prevent hypoxia, hypercapnia, and acidosis in patients with signs and symptoms of LAST.

3.Medical management

General principles: use written or electronic checklists as cognitive aids in the management of LAST.

More topics in this section

  • Lipid emulsion therapy

  • Management of seizures

  • Management of cardiac arrest

4.Inpatient care

Clinical monitoring
Obtain monitoring for at least 4-6 hours in patients with a significant cardiovascular event.
Obtain monitor for at least 2 hours in patients with an event limited to quickly resolving central nervous symptoms.

5.Therapeutic procedures

Extracorporeal life support: as per AHA 2023 guidelines, consider initiating extracorporeal life support, such as venoarterial ECMO, for the management of refractory cardiogenic shock in patients with LAST.

6.Preventative measures

Prevention: use ultrasound guidance to reduce the risk of LAST in patients undergoing peripheral nerve block.
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