Local anesthetic systemic toxicity - Revision history

Danbot: Add MedicationDose SMW annotations (intralipid, sodium bicarbonate); dosing verified per ASRA LAST guidelines

2026-03-20T16:29:25Z

Add MedicationDose SMW annotations (intralipid, sodium bicarbonate); dosing verified per ASRA LAST guidelines

← Revisión anterior		Revisión del 16:29 20 mar 2026
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	*Admit		*Admit


			<div style="display:none">
			<!-- SMW MedicationDose annotations for LAST medications -->
			{{MedicationDose\|drug=Intralipid\|dose=1.5 mL/kg IV bolus over 1 min, then 0.25 mL/kg/min x20 min (increase to 0.5 mL/kg/min if declining)\|route=IV/IV drip\|context=Lipid emulsion therapy (20% solution)\|indication=Local anesthetic systemic toxicity\|display=Intralipid (20% lipid emulsion)\|max_dose=12 mL/kg total\|notes=Lipid sink mechanism; may interfere with labs}}
			{{MedicationDose\|drug=Sodium bicarbonate\|dose=1 amp (50 mEq) IV q2min for VTach/VF or severe acidosis\|route=IV push\|context=Alkalinization for cardiotoxicity\|indication=Local anesthetic systemic toxicity}}
			</div>
	==See Also==		==See Also==
	*[[Local anesthetics]]		*[[Local anesthetics]]

Rossdonaldson1: /* Management */

2024-04-17T18:46:06Z

Management

← Revisión anterior		Revisión del 18:46 17 abr 2024
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	==Management==		==Management==
	*Aggressive supportive care (including airway management) and application of ACLS		*Aggressive supportive care (including [[airway management]]) and application of [[ACLS]]
	**Ventilate with 100% FiO2 - bolus dose of 50-100mg IV [[succinylcholine]] paralyzes without depressing CNS or CV<ref>GlobalRPH. Management of Local Anesthetic Emergencies. http://www.globalrph.com/local-anesthetics.htm</ref>		**Ventilate with 100% FiO2 - bolus dose of 50-100mg IV [[succinylcholine]] paralyzes without depressing CNS or CV<ref>GlobalRPH. Management of Local Anesthetic Emergencies. http://www.globalrph.com/local-anesthetics.htm</ref>
	**Hypercapnia, hypoxia, acidosis all worsen toxic effects<ref name="Dillane">Dillane D, Finucane BT. Local anesthetic systemic toxicity. Can J Anaesth. 2010 Apr;57(4):368-80.</ref>		**Hypercapnia, hypoxia, acidosis all worsen toxic effects<ref name="Dillane">Dillane D, Finucane BT. Local anesthetic systemic toxicity. Can J Anaesth. 2010 Apr;57(4):368-80.</ref>

Rossdonaldson1: /* Management */

2024-04-17T18:38:06Z

Management

← Revisión anterior		Revisión del 18:38 17 abr 2024
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	**Ventilate with 100% FiO2 - bolus dose of 50-100mg IV [[succinylcholine]] paralyzes without depressing CNS or CV<ref>GlobalRPH. Management of Local Anesthetic Emergencies. http://www.globalrph.com/local-anesthetics.htm</ref>		**Ventilate with 100% FiO2 - bolus dose of 50-100mg IV [[succinylcholine]] paralyzes without depressing CNS or CV<ref>GlobalRPH. Management of Local Anesthetic Emergencies. http://www.globalrph.com/local-anesthetics.htm</ref>
	**Hypercapnia, hypoxia, acidosis all worsen toxic effects<ref name="Dillane">Dillane D, Finucane BT. Local anesthetic systemic toxicity. Can J Anaesth. 2010 Apr;57(4):368-80.</ref>		**Hypercapnia, hypoxia, acidosis all worsen toxic effects<ref name="Dillane">Dillane D, Finucane BT. Local anesthetic systemic toxicity. Can J Anaesth. 2010 Apr;57(4):368-80.</ref>
	**Manage seizures with [[benzodiazepines]]; [[propofol]] is an option but may worsen cardiovascular toxicity		**Manage [[seizures]] with [[benzodiazepines]]; [[propofol]] is an option but may worsen cardiovascular toxicity
	**Temporary pacing may be required for symptomatic bradycardia		**[[Temporary pacing]] may be required for [[symptomatic bradycardia]]
	*Early activation of ECMO or consideration for transfer to ECMO center as cardiac arrest is often refractory to ACLS.		*Early activation of [[ECMO]] or consideration for transfer to ECMO center as cardiac arrest is often refractory to [[ACLS]].
	*1 amp of [[sodium bicarbonate]] IV q2 min for:		*1 amp of [[sodium bicarbonate]] IV q2 min for:
	**VT or VF		*[[Vtach]] or [[VF]]
	**Severe acidosis		**Severe [[acidosis]]
	*'''[[Intralipid\|Lipid emulsion]]''', (Intralipid) 20% solution<ref name="Dillane" />		*'''[[Intralipid\|Lipid emulsion]]''', (Intralipid) 20% solution<ref name="Dillane" />
	**Lipid sink, binds to local anesthetic		**Lipid sink, binds to local anesthetic
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	**Maximum total dose 12 mL/kg.		**Maximum total dose 12 mL/kg.
	**Consider drawing extra blood as will interfere with labs		**Consider drawing extra blood as will interfere with labs
	*ACLS modifications per ASRA (Am Soc of Regional Anesthesia):		*[[ACLS]] modifications:<ref>per ASRA (Am Soc of Regional Anesthesia)</ref>
	**Avoid vasopressin		**Avoid [[vasopressin]]
	**Avoid calcium-channel blockers and beta-blockers		**Avoid [[calcium-channel blockers]] and [[beta-blockers]]
	**[[Amiodarone]] preferred in ventricular dysrhythmias		**[[Amiodarone]] preferred in [[ventricular dysrhythmias]]

	==Disposition==		==Disposition==

Beren85: /* Management */

2024-04-16T22:18:55Z

Management

← Revisión anterior		Revisión del 22:18 16 abr 2024
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	**Hypercapnia, hypoxia, acidosis all worsen toxic effects<ref name="Dillane">Dillane D, Finucane BT. Local anesthetic systemic toxicity. Can J Anaesth. 2010 Apr;57(4):368-80.</ref>		**Hypercapnia, hypoxia, acidosis all worsen toxic effects<ref name="Dillane">Dillane D, Finucane BT. Local anesthetic systemic toxicity. Can J Anaesth. 2010 Apr;57(4):368-80.</ref>
	**Manage seizures with [[benzodiazepines]]; [[propofol]] is an option but may worsen cardiovascular toxicity		**Manage seizures with [[benzodiazepines]]; [[propofol]] is an option but may worsen cardiovascular toxicity
			**Temporary pacing may be required for symptomatic bradycardia
	*Early activation of ECMO or consideration for transfer to ECMO center as cardiac arrest is often refractory to ACLS.		*Early activation of ECMO or consideration for transfer to ECMO center as cardiac arrest is often refractory to ACLS.
	*1 amp of [[sodium bicarbonate]] IV q2 min for:		*1 amp of [[sodium bicarbonate]] IV q2 min for:

Beren85: /* Clinical Features */

2024-04-16T22:17:27Z

Clinical Features

← Revisión anterior		Revisión del 22:17 16 abr 2024
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	**Auditory changes/Tinnitus		**Auditory changes/Tinnitus
	**Metallic taste		**Metallic taste
			**Slurred speech
	**[[Seizures]] or drowsiness		**[[Seizures]] or drowsiness
	**[[Coma]]		**[[Coma]]

Elcatracho: /* Clinical Features */

2020-11-29T21:42:50Z

Clinical Features

← Revisión anterior		Revisión del 21:42 29 nov 2020
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	*CNS symptoms		*CNS symptoms
	**[[Agitation]]		**[[Agitation]]
	**Auditory changes		**Auditory changes/Tinnitus
	**Metallic taste		**Metallic taste
	**[[Seizures]] or drowsiness		**[[Seizures]] or drowsiness

Elcatracho: /* See Also */

2020-11-29T21:32:30Z

Elcatracho: /* CausesFencl JL. Local anesthetic systemic toxicity: perioperative implications. AORN J. 2015 Jun;101(6):697-700. */

2020-11-29T21:10:42Z

CausesFencl JL. Local anesthetic systemic toxicity: perioperative implications. AORN J. 2015 Jun;101(6):697-700.

← Revisión anterior		Revisión del 21:10 29 nov 2020
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	===Causes<ref name="Fencl">Fencl JL. Local anesthetic systemic toxicity: perioperative implications. AORN J. 2015 Jun;101(6):697-700.</ref>===		===Causes<ref name="Fencl">Fencl JL. Local anesthetic systemic toxicity: perioperative implications. AORN J. 2015 Jun;101(6):697-700.</ref>===
	*Injection of local anesthetic into systemic circulation		*Injection of local anesthetic into systemic circulation
			**Most common source of toxicity<ref>Sztajnkrycer MD. Local Anesthetics. In: Nelson LS, Howland M, Lewin NA, Smith SW, Goldfrank LR, Hoffman RS. eds. Goldfrank's Toxicologic Emergencies, 11e. McGraw-Hill; Accessed November 29, 2020. https://accessemergencymedicine.mhmedical.com/content.aspx?bookid=2569&sectionid=210274249</ref>
			**Intravascular injection can cause toxicity below the maximum recommended dose<ref>Scott DB. "Maximum recommended doses" of local anaesthetic drugs. Br J Anaesth. 1989 Oct;63(4):373-4. doi: 10.1093/bja/63.4.373. PMID: 2818914.</ref>
	*Exceeding the maximum dose of local anesthetic (see table below)		*Exceeding the maximum dose of local anesthetic (see table below)
	*Absorption of anesthetic into systemic circulation by injection into extremely vascular area.		*Absorption of anesthetic into systemic circulation by injection into extremely vascular area.

Lisayee25: /* Management */

2020-01-08T02:02:08Z

Management

← Revisión anterior		Revisión del 02:02 8 ene 2020
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	**Then, 0.25 mL/kg/min for 20 min or until hemodynamic stability achieved		**Then, 0.25 mL/kg/min for 20 min or until hemodynamic stability achieved
	***↑ to 0.5 mL/kg/min if hemodynamic status declines		***↑ to 0.5 mL/kg/min if hemodynamic status declines
			**Maximum total dose 12 mL/kg.
	**Consider drawing extra blood as will interfere with labs		**Consider drawing extra blood as will interfere with labs
	*ACLS modifications per ASRA (Am Soc of Regional Anesthesia):		*ACLS modifications per ASRA (Am Soc of Regional Anesthesia):

ClaireLewis: /* Management */

2019-08-28T19:26:36Z

Management

← Revisión anterior		Revisión del 19:26 28 ago 2019
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	**Ventilate with 100% FiO2 - bolus dose of 50-100mg IV [[succinylcholine]] paralyzes without depressing CNS or CV<ref>GlobalRPH. Management of Local Anesthetic Emergencies. http://www.globalrph.com/local-anesthetics.htm</ref>		**Ventilate with 100% FiO2 - bolus dose of 50-100mg IV [[succinylcholine]] paralyzes without depressing CNS or CV<ref>GlobalRPH. Management of Local Anesthetic Emergencies. http://www.globalrph.com/local-anesthetics.htm</ref>
	**Hypercapnia, hypoxia, acidosis all worsen toxic effects<ref name="Dillane">Dillane D, Finucane BT. Local anesthetic systemic toxicity. Can J Anaesth. 2010 Apr;57(4):368-80.</ref>		**Hypercapnia, hypoxia, acidosis all worsen toxic effects<ref name="Dillane">Dillane D, Finucane BT. Local anesthetic systemic toxicity. Can J Anaesth. 2010 Apr;57(4):368-80.</ref>
	**Manage seizures with benzodiazepines; propofol is an option but may worsen cardiovascular toxicity		**Manage seizures with [[benzodiazepines]]; [[propofol]] is an option but may worsen cardiovascular toxicity
	*Early activation of ECMO or consideration for transfer to ECMO center as cardiac arrest is often refractory to ACLS.		*Early activation of ECMO or consideration for transfer to ECMO center as cardiac arrest is often refractory to ACLS.
	*1 amp of sodium bicarbonate IV q2 min for:		*1 amp of [[sodium bicarbonate]] IV q2 min for:
	**VT or VF		**VT or VF
	**Severe acidosis		**Severe acidosis
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	**Avoid vasopressin		**Avoid vasopressin
	**Avoid calcium-channel blockers and beta-blockers		**Avoid calcium-channel blockers and beta-blockers
	**Amiodarone preferred in ventricular dysrhythmias		**[[Amiodarone]] preferred in ventricular dysrhythmias

	==Disposition==		==Disposition==

← Revisión anterior		Revisión del 21:32 29 nov 2020
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	==See Also==		==See Also==
			*[[Local anesthetics]]
	*[[Nerve blocks (main)]]		*[[Nerve blocks (main)]]
	*[[Lidocaine]]		*[[Lidocaine]]
			*[[Bupivicaine]]

	==External Links==		==External Links==