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Local Anesthetic Systemic Toxicity (LAST)
Local Anesthetic Systemic Toxicity (LAST)
Toxicity (LAST): A
Problem-Based Learning
Discussion
Feb 1, 2021
Timothy Feldheim, MD; Sharlene Lobo, MD; John William Mallett, MD; Linda Le-Wendling, MD
A 31-year-old woman who is 157cm tall and weighs 45kg (BMI 18) presents for repair of a
distal femur fracture sustained after a significant fall while mountain climbing. She has a past
medical history of Wolf-Parkinson-White syndrome and Type I Diabetes Mellitus. Upon arrival
to the hospital, she was found to be in DKA, and is currently being treated with insulin,
potassium, and intravenous fluids. However, due to the severity of the fracture and the
compromised vascular supply, the orthopedic surgeon would like to proceed to the OR as soon as
possible. After a full pre-op and assessment, you as the anesthesiologist decide to give the patient
a femoral nerve block and place a catheter for an adjunct to the anesthetic and for post op pain
management.
1. What patient-factors increase her risk of developing Local Anesthetic Systemic Toxicity
(LAST)?
2. What other chronic or acute conditions/risk factors would make a patient susceptible to
developing LAST?
a. Liver disease
b. Heart disease
c. Pregnancy
d. Metabolic syndromes
e. Extremes of age secondary to reduced clearance of the anesthetics. Particularly, children
less than 4 months of age are at particularly high risk.
In the preoperative area, the patient receives mild sedation to facilitate placement of the
block/catheter using a nerve stimulator. 30cc of 0.5% Ropivacaine is administered. Immediately
following the injection, the patient reports circumoral numbness, tinnitus, and she appears
anxious. After a few moments, she becomes increasingly confused and somnolent.
3. Was this an appropriate dose of Ropivacaine? What would have been the maximum dose
a patient with this weight can receive?
a. No, this was too large of a dose. A maximum dose would be 3 mg/kg of ropivacaine.
However, she has risk factors that might necessitate using a lower dose.
4. What are the other maximum doses (in mg/kg) of commonly used local anesthetics?
5. Local anesthetic is absorbed by certain areas of the body faster than others. What is the
order in which local anesthetic is absorbed by the body from fastest to slowest? What is the
primary determinant for speed of local anesthetic absorption?
You glance at the EKG monitor and notice widening of the PR interval.
6. What other EKG findings might you expect to note in a patient in LAST?
d. Intralipid therapy should not be delayed, and typical doses are 1.5mL/kg of 20% intralipid
with a subsequent infusion at 0.25mL/kg/min and up to 0.5mL/kg/min. The infusion should
be continued for 10 minutes after hemodynamic stability is achieved. The typical maximum
dose of intralipid therapy is 10mL/kg within the first 30 minutes.
The patient is resuscitated using your suggestions and proceeds to make a full recovery after having
been admitted to the ICU for further observation.
a. CNS alterations are the most common and usually the first presenting symptoms of
LAST, and can cover a significant range of symptoms, including tinnitus, metallic taste,
perioral numbness, confusion, agitation, difficulty speaking, dizziness, somnolence, and/or
seizure.
ii. If the patient develops seizures, benzodiazepines are typically viewed as first-line
therapy given greater hemodynamic stability. Propofol or barbiturates can both be
effective to address seizures, although it is recommended to avoid propofol as this can
cause further cardiac depression. Alternatively, intralipid infusion may be an
appropriate initial therapy.
a. Local anesthetic should be administered in a setting where standard ASA monitors can be
applied, such as EKG and cardiac rhythm monitors, BP monitors, respiratory monitors, and
perfusion monitoring can occur.
b. Aspiration of syringes prior to injection of LA is recommended to prevent accidental
intravascular injection, although this can be insensitive.
c. Access to airway rescue devices should be available
d. Access to 20% lipid emulsion or a LAST Rescue Kit should be readily available
i. A LAST kit should contain IV tubing, several syringes for administration, 20% lipid
emulsion, and the ASRA checklist
10. If the patient in the situation above were receiving an infusion of local anesthetic, what
is the first thing that should have been done?
i. Patients who develop neurological symptoms should be observed at least 2 hours after recovery
ii. Patients who develop cardiac symptoms should be observed for at least 6 hours after recovery