Three Cases of Local Anesthetic Systemic Toxicity following regional infiltration analgesia: The need for prompt recognition and treatment

Abstract

Introduction: The diagnosis and management of systemic toxicity in patients following regional infiltration analgesia is of paramount importance. While the mechanism and risk factors have been elucidated in previous studies, we believe that due to the potentially life-threatening nature of this rare occurrence, a greater focus on diagnostic precision and management enhancements is warranted. Cases: Here, we describe three cases of LAST, the first in a 59 year old female following elective L4-L5 laminectomy and L5-S1 fusion, who suffered a cardiac arrest after receiving local Exparel and Marcaine at the time of closure; the second in a 69 year old woman following a rib block using local Exparel and Marcaine for the management of multiple rib fractures, who had a witnessed tonic-clonic seizure requiring intubation. The third patient is an 80-year-old male, who after an elective L4-L5 laminectomy and fusion, suffered a cardiac arrest after receiving local anesthetic (Exparel and Marcaine) at the time of closure. All patients were treated with intralipids and eventually recovered with no lasting deficits. Conclusion: LAST events most commonly occur in the first minutes after injection, and are characterized by CNS and cardiovascular toxicities, as seen in these patients. Delayed presentations up to several days post exposure have been described. These cases exposed the opportunity for education in early recognition and most important, the need to improve the availability of intralipids. Prompt recognition and access to intralipid is critical to the treatment of LAST, and education regarding this rare but life-threatening condition is needed in surgical and trauma centers.