The Third American Society of Regional Anesthesia and Pain Medicine Practice Advisory on Local Anesthetic Systemic Toxicity

Abstract

(Reg Anesth Pain Med. 2018;43:113–123) Local anesthetic systemic toxicity (LAST) is a rare, adverse event that can occur when local anesthetics are administered despite advances in technique. Patients can experience mild prodromal symptoms to serious events such as seizure, cardiac arrest, and/or death. It is important that all professionals administering local anesthetics be educated and prepared for LAST. This article uses emerging research to update the 2010 advisory from the American Society of Regional Anesthesia and Pain Medicine. This practice advisory provides recommendations from recently published articles.

Lower extremity regional anesthesia: essentials of our current understanding

“…Dosing based on patient weight is fallacious because nerve size is independent of a patient’s morphometric parameters. Over-reliance on weight-based dosing can be particularly dangerous in children, whose smaller size places them at risk for LAST 235. For example, several children (36±10 kg) given 3.5 mg/kg of ropivacaine for fascia iliaca block attained high plasma concentrations that exceeded the recommended range 236.…”

“…When present, clinical manifestations of LAST should be managed according to the (recently updated) ASRA recommendations (box 2). 235 …”

Reducing the incidence of LAST: don’t forget ultrasound guidance

“…We read with interest the practice advisory on local anesthetic toxicity (LAST) by Neal et al 1. This executive summary represents a thorough review of the literature including recommendations in the prevention and management of LAST.…”

Reply to Dr Yuet al

“…As Dr Yu et al note correctly, the executive summary2 of the third American Society of Regional Anesthesia and Pain Medicine Practice Advisory on Local Anesthetic Systemic Toxicity (LAST) acknowledges the effectiveness of ultrasound guidance (USG) in reducing LAST frequency. The 2017 version of the ‘Checklist for Treatment of LAST’3 indeed should have mentioned on its back page the usefulness of USG for reducing the likelihood of intravascular injection.…”