Protocol and importance of using the kit for local anesthetic systemic toxicity

  • Marta Inés Berno Valencia Hospital Pablo Tobón Uribe, Medellín, Colombia
  • Juan Felipe Vargas Silva Hospital Pablo Tobón Uribe, Medellín, Colombia
Keywords: Anesthetics Local, Toxicity, Lipids, Anesthesia, Conduction, Operating, Rooms


Systemic toxicity due to local anesthetics is one of the most feared complications in regional anesthesia due to the risk for the heart, the central nervous system and, in particular, the risk of triggering cardiorespiratory arrest, which is difficult to manage, even in healthy patients. Prevention as the main goal, together with prompt recognition and early treatment using several general measures followed by specific treatment with 20% lipid emulsions, improve prognosis dramatically for these patients. Their immediate availability in the operating theater or in areas where regional anesthesia is provided such as the emergency services and rooms where blocks are performed, may make the difference between a favorable or adverse prognosis in situations of severe systemic toxicity from local anesthetics.

The objective of this article is to create awareness on the prevention of toxicity events due to local anesthetics and provide knowledge about the management protocols in case such events should happen, recognizing the importance of having a toxicity kit available during daily practice and of following basic management guidelines adapted to the needs of each institution because, although this is a rare occurrence, it may be devastating.


1. Garduño-Juárez MA. Toxicidad por anestésicos locales. Rev Mex Anestesiol. 2012;35:S78-82.
2. Espinoza AM. Intoxicación por anestésicos locales y utilidad de los lípidos al 20%. Rev Chil Anest. 2010;39:76-84.
3. Khatri KP, Rothschild L, Oswald S, Weinberg G. Current concepts in the management of systemic local anesthetic toxicity. Advances in Anesthesia. 2010;28:147-59.
4. Barrington MJ, Watts SA, Gledhill SR, Thomas RD, Said SA, Snyder GL, et al. Preliminary results of the Australasian regional anaesthesia collaboration a prospective audit of more than 7000 peripheral nerve and plexus blocks forneurologic and other complications. Reg Anesth Pain Med. 2009;34:534-41.
5. Valencia Gómez RE, Garcia Araque HF. Toxicidad por anestésicos locales: revisión de la literatura. Rev Colomb Anestesiol. 2011;39:40-54.
6. Di Gregorio G, Neal JM, Rosenquist RW, Weinberg GL. Clinical presentation of local anesthetic systemic toxicity. A review of published cases, 1979 to 2009. Reg Anesth Pain Med. 2010;35:181-7.
7. Albright GA. Cardiac arrest following regional anesthesia with etidocaine or bupivacaine. Anesthesiology. 1979;51:285-7.
8. Marx GF. Cardiotoxicity of local anesthetics-the plot thickens. Anesthesiology. 1984;60:3-5.
9. Mazoit JX, Lin Sen C. Local anesthetic toxicity. Curr Opin Anaesthesiol. 1995;8:409-13.
10. Bertini L, Palmisani S, Mancini S, Martini O, Ioculano R, Arcioni R. Does local anesthetic dilution influence the clinical effectiveness of multiple-injection axillary brachial plexus block? Reg Anesth Pain Med. 2009;34:408-13.
11. Handoll HH, Koscielniak-Nielsen ZJ. Single, double or multiple injection techniques for axillary brachial plexus block for hand, wrist or forearm surgery. Cochrane Database Syst Rev. 2006;1:CD003842.
12. Koscielniak-Nielsen ZJ, Stens-Pedersen HL, Lippert Knudsen F. Readiness for surgery after axillary block: Single versus multiple injections. Eur J Anaesthesiol. 1997;14:164-71.
13. Mercado P, Weinberg GL. Local anesthetic systemic toxicity: Prevention and treatment. Anesthesiol Clin. 2011;29:233-42.
14. Mulroy MF, Hejtmanek MR. Prevention of local anesthetic systemic toxicity. Reg Anesth Pain Med. 2010;35:177-80.
15. Neal JM, Bernards CM, Butterworth JF, Di Gregorio G, Drasner K, Hejtmanek MR, et al. ASRA practice advisory on local anesthetic systemic toxicity. Reg Anesth Pain Med. 2010;35:152-61.
16. Beecroft C, Davies G. Systemic toxic effects of local anaesthetics. Anaesthesia and Intensive Care Medicine. 2003;14:146-8.
17. Rosenberg PH, Veering BT, Urmey WF. Maximum recommended doses of local anesthetics: a multifactorial concept. Reg Anesth Pain Med. 2004;29:564-75.
18. Beecroft C, Davies G. Systemic toxic effects of local anaesthetics. Anaesthesia and Intensive Care Medicine. 2010;11:98-100.
19. Weinberg G, Hertz P, Newman J. Lipid, not propofol, treats bupivacaine overdose. Anesth Analg. 2004;99:1875-6.
20. Weaver MA, Tandatnick CA, Hahn MA. Peripheral nerve blockade. En: Raj PP, editor. Textbook of regional anesthesia. New York: Churchill Livingstone Inc; 2002.
21. Lonnqvist PA. Toxicity of local anesthetic drugs: A pediatric perspective. Paediatr Anaesth. 2012;22:39-43.
22. Tasch MD, Butterworth JF. Toxicity of local anesthetics. ASA Refresher Courses in Anesthesiology. 2006;34:165-79.
23. Guay J. The epidural test dose: A review. Anesth Analg. 2006;102:921-9.
24. Bernards CM, Hadzic A, Suresh S, Neal JM. Regional anesthesia in anesthetized or heavily sedated patients. Reg Anesth Pain Med. 2008;33:449-60.
25. Guinard JP, Mulroy MF, Carpenter RL. Aging reduces the reliability of epidural epinephrine test doses. Reg Anesth. 1995;20:193-8.
26. Abrahams MS, Aziz MF, Fu RF, Horn JL. Ultrasound guidance compared with electrical neurostimulation for peripheral nerve block: A systematic review and meta-analysis of randomized controlled trials. Br J Anaesth. 2009;102:408-17.
27. Barrington MJ, Kluger R. Ultrasound guidance reduces the risk of local anesthetic systemic toxicity following peripheral nerve blockade. Reg Anesth Pain Med. 2013;38:289-97.
28. Forero CM, Gomez Lora CP, Bayegan D. Undetected intravascular injection during an ultrasound-guided axillary block. Can J Anaesth. 2013;60:329-30.
29. Sites BD, Brull R, Chan VW, Spence BC, Gallagher J, Beach ML, et al. Artifacts and pitfall errors associated with ultrasound-guided regional anesthesia. Part II: a pictorial approach to understanding and avoidance. Reg Anesth Pain Med. 2007;32:419-33.
30. Patino RD, Aldana Díaz JL. Anestésicos locales: de los conceptos básicos a la práctica clínica. Rev Colomb Ortop Traumatol. 2010;24:32-9.
31. Chan SK, Karmakar MK, Chui PT. Local anaesthesia outside the operating room. Hong Kong Med J. 2002;8:106-13.
32. Zink W, Bohl JR, Hacke N, Sinner B, Martin E, Graf BM. The long term myotoxic effects of bupivacaine and ropivacaine after continuous peripheral nerve blocks. Anesth Analg. 2005;101:548-54.
33. Neal JM, Mulroy MF, Weinberg GL. American Society of Regional Anesthesia and Pain Medicine checklist for managing local anesthetic systemic toxicity: 2012 version. Reg Anesth Pain Med. 2012;37:16-8.
34. Association of Anaesthetists of Great Britain and Ireland. Management of severe local anaesthetic toxicity. 2010 [consultado 19 Sep 2012]. Disponible en: in press.
35. The Official Journal of the Anesthesia Patient Safety Foundation. 2012; 27(1): 13, 27. [consultado 19 Sep 2012]. Disponible en: in press.
36. Manavi MV. Lipid infusion as a treatment for local anesthetic toxicity: A literature review. AANA J. 2010;78:69-78.
37. Rosemblatt MA, Abel M, Fische GW, Itzcovich CJ, Eisenkraft JB. Successful use of 20% lipid-emulsion to resucitate a patient alter a presumed bupivacaine-related cardiac arrest. Anesthesiology. 2006;105:217-8.
38. Litz RJ, Popp M, Stehr SN, Koch T. Successful resucitation of a patient with ropivacaine-induced asystole alter axillary plexus block using lipid emulsion. Anaesthesia. 2006;61: 800-1.
39. Spence AG. Lipid reversal of central nervous system symptoms of bupivacaine toxicity. Anesthesiology. 2007;107:516-7.
40. Warren JA, Thoma RB, Georgescu A, Shah AJ. Intravenous lipid infusión in the successful resucitation of local anesthetic-induced cardiovascular collapse alter supraclavicular braquial plexus block. Anesth Analg. 2008;106:1578-80.
41. McCutchen T, Gerancher JC. Early intralipid therapy may have prevented bupivacaine-associated cardiac arrest. Reg Anesth Pain Med. 2008;33:178-80.
42. Weinberg GL, VadeBoncouer T, Ramaraju GA, Garcia-Amaro MF, Cwik MJ. Pretreatment or resuscitation with a lipid infusion shifts the dose-response to bupivacaine-induced asystole in rats. Anesthesiology. 1998;88:1071-5.
43. Mazoit JX, Leguen R, Beloeil H, Benhamou D. Binding of long-lasting local anesthetics to lipid emulsions. Anesthesiology. 2008;106:1333-6.
44. Sforsini C, Barbieri P, Capurro J, Sanz R. Emulsión lipídica: ¿nuevo paradigma para el tratamiento de la toxicidad sistémica por anestésicos locales? Rev Argent Anestesiol. 2009;67:202-16.
45. Cury-Boaventura MF, Gorjao R, de Lima TM, Piva TM, Peres CM, Soriano FG, et al. Toxicity of a soybean oil emulsion on human lymphocytes and neutrophils. JPEN. 2006;30:115-23.
46. Smirniotis V, Kotsis TE, Antoniou S, Kostopanagiotou G, Labrou A, Kourias E, et al. Incidence of vein thrombosis in periferal intravenous nutrition: Effect off at emulsions. Clin Nutr. 1999;18:79-81.
47. Jasnosz KM, Pickeral JJ, Graner S. Fat deposits in the placenta following maternal total parenteral nutrition with intravenous lipid emulsion. Arch Pathol Lab Med. 1995;119:555-7.
48. Cave G, Harvey M. Intravenous lipid emulsion as antidote beyond local anesthetic toxicity: A systematic review. Acad Emerg Med. 2009;16:815-24.
49. Bateman DN. Poisoning and self-harm. Clin Med. 2012;12:280-2.
50. Ludot H, Tharin JY, Belouadah M, Mazoit JX, Malinovsky JM. Successful resuscitation after ropivacaine and lidocaine-induced ventricular arrhythmia following posterior lumbar plexus block in a child. Anesth Analg. 2008;106:1572-4.
51. Marwick PC, Levin AI, Coetzee AR. Recurrence of cardiotoxicity alter lipid rescue from bupivacaine-induced cardiac arrest. Anesth Analg. 2009;108:1344.
How to Cite
Berno Valencia MI, Vargas Silva JF. Protocol and importance of using the kit for local anesthetic systemic toxicity. Colomb. J. Anesthesiol. [Internet]. 2013 Oct. 1 [cited 2024 Jun. 15];41(4):274-9. Available from:


Download data is not yet available.
How to Cite
Berno Valencia MI, Vargas Silva JF. Protocol and importance of using the kit for local anesthetic systemic toxicity. Colomb. J. Anesthesiol. [Internet]. 2013 Oct. 1 [cited 2024 Jun. 15];41(4):274-9. Available from:
Narrative review


Article metrics
Abstract views
Galley vies
PDF Views
HTML views
Other views
QR Code

Some similar items: