American Society of Regional Anesthesia and Pain Medicine February 2018 - 38

Local Anesthetic Systemic Toxicity (LAST): Certainly Not the Least
of Our Concerns

C

onsider the following scenario: At the conclusion of a busy
day at your free-standing ambulatory surgery center, you are
transporting your last patient to the recovery room following
repair of their anterior cruciate ligament. Thirty minutes into his
recovery, the patient continues to complain of 10/10 anterior
knee pain, despite intravenous opioids. As the recovery room is
starting to empty out and your colleagues head for home, you
decide to proceed with an adductor canal block with ropivacaine
for analgesic purposes. Five minutes after completing the block,
you notice tachycardia, hypertension, and frequent premature
ventricular contractions. Your mind immediately jumps to the
possibility of local anesthetic systemic toxicity (LAST). As the
patient begins to seize, you instantly take action by notifying the
nurse, requesting help, and asking for midazolam, lipid emulsion,
and airway equipment. The nursing staff is able to recognize
the concern in your voice, but they report that you are the only
anesthesia provider left in the building and give you a puzzled look
at the request for lipids. As you are able to gather the resources to
successfully manage the situation, you ponder how prepared your
ambulatory surgery center (ASC) is to manage a case of LAST.

Mark D. Mudarth, MD
CA2-Resident

Michael Kushelev, MD
Assistant Professor

Department of Anesthesiology
The Ohio State University Wexner
Medical Center
Columbus, Ohio
Section Editor: Kristopher Schroeder, MD

LAST is a rare and potentially devastating complication of regional
anesthesia. Clinicians must be vigilant because, despite its rarity,
the incidence of LAST in peripheral nerve blocks ranges from 0.4-
21 per 10,000.1,2 Awareness of some independent risk factors for
LAST, such as local anesthetic dose, site of injection, and extremes
of age, is useful, but providers cannot fully predict which patients
may develop this lifethreatening complication.
In the face of this reality,
it is important that all
clinicians and support
staff are appropriately
trained in early
recognition and proper
management of the signs and symptoms of toxicity. It follows that
work environments in which local anesthetics are administered
should be adequately supplied with necessary medications and
safety features.

Unfortunately, given the infrequent number of LAST cases,
allied health providers may be unfamiliar with the management
and medications used during LAST resuscitation, leading to
delays in caring for this anesthetic emergency. In fact, most
nonanesthesiologists lack knowledge of toxic doses of local
anesthetics or the treatments for LAST, with one survey finding
that only 7% of
nonanesthesiologists
are aware of the
role of lipid therapy.6
Reliance on support
staff becomes even
more significant with
the frequency of
surgical procedures employing regional anesthetics performed in
ASCs with limited staffing. For instance, in the past 10 years, the
number of rotator cuff repairs performed at ambulatory surgery
centers nationally has increased 272%.7

LAST presents with signs, symptoms, and timing that vary but
may feature tinnitus, altered mental state, circumoral numbness,
seizures, cardiac arrhythmias, and, in its most devastating
form, complete cardiovascular collapse.3,4 As noted in ASRA's
Checklist for Treatment of LAST, the initial focus of treatment
includes managing the airway, suppressing seizures, and alerting
nearby facilities with cardiopulmonary bypass capabilities.5 The
subsequent steps on the checklist are management of cardiac
arrhythmias and lipid emulsion therapy. These steps would be
difficult, if not impossible, for an individual practitioner in an
isolated location without additional assistance of properly trained
support staff.

At our institution, a large number of orthopedic procedures
requiring regional anesthesia occur at stand-alone outpatient
surgical centers. In the past year, we have performed more than
2,000 nerve blocks in ASCs. In an attempt to assess and educate
perioperative nurses and technicians on the management of LAST,
we initiated a survey followed by a low-fidelity simulation on the
topic. Of 40 respondents, only two individuals (5%) reported having
been involved in the care of a patient with LAST. When asked about
managing a patient with suspected LAST, only six individuals (15%)
felt confident that they will have easy access to medications and
supplies necessary to treat LAST. Furthermore, only 16 individuals
(40%) reported knowing that lipid emulsion was a mainstay of

"As the number of regional anesthetics
continues to rise, we must strive for excellence
in our preparedness to treat LAST."

38

American Society of Regional Anesthesia and Pain Medicine
2018



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