Adults

Local Anesthetic Systemic Toxicity (LAST)

Diagnosis

Neurologic or Cardiovascular Signs/Symptoms following use of local anesthetic

Diagnosis

Neurologic or Cardiovascular Signs/Symptoms following use of local anesthetic

  1. Call for help

    • Ask: "Who will be the crisis manager?"
    • Crisis manager designates checklist reader

  2. Get LAST rescue kit or lipid emulsion and consider early call for ECMO

    • BOLUS: 100mL IV over 2-3 min (Weight ≥ 70 kg)
    • INFUSION: 250mL IV over 15-20 min (Weight ≥ 70 kg)
    • BOLUS: 1.5 mL/kg IV over 2-3 min (Weight < 70 kg)
    • INFUSION: 0.25 mL/kg/min IV (Weight < 70 kg)
    • Repeat bolus and double infusion if patient remains unstable; Max lipid dose 12 mL/kg for initial dosing

  3. STOP local anesthetic infusion, if running

  4. START administering lipid emulsion

    • Do not delay airway protection or hemodynamic management while waiting for lipid emulsion
    • BOLUS: 100mL IV over 2-3 min (Weight ≥ 70 kg)
    • INFUSION: 250mL IV over 15-20 min (Weight ≥ 70 kg)
    • BOLUS: 1.5 mL/kg IV over 2-3 min (Weight < 70 kg)
    • INFUSION: 0.25 mL/kg/min IV (Weight < 70 kg)
    • Repeat bolus and double infusion if patient remains unstable; Max lipid dose 12 mL/kg for initial dosing

  5. If seizing:

    • Ensure adequate airway patency and ventilation
    • Administer benzodiazepine
    • If only propofol is available, administer low dose, e.g. 20 mg increments

  6. If hemodynamically unstable, give low-dose EPINEPHrine

    • Doses of EPINEPHrine are LOWER than ACLS recommendations
    • AVOID: beta blockers, calcium channel blockers, local anesthetics, and vasopressin
    • Ensure adequate airway patency and ventilation
    • 10 - 20 MICROgrams IV bolus, increase as needed to max 1 MICROgrams/kg

  7. If cardiovascular collapse is unresponsive to EPINEPHrine and lipid emulsion, initiate ECMO or cardiac bypass

    • BOLUS: 100mL IV over 2-3 min (Weight ≥ 70 kg)
    • INFUSION: 250mL IV over 15-20 min (Weight ≥ 70 kg)
    • BOLUS: 1.5 mL/kg IV over 2-3 min (Weight < 70 kg)
    • INFUSION: 0.25 mL/kg/min IV (Weight < 70 kg)
    • Repeat bolus and double infusion if patient remains unstable; Max lipid dose 12 mL/kg for initial dosing
    • 10 - 20 MICROgrams IV bolus, increase as needed to max 1 MICROgrams/kg

  8. Continue lipid emulsion for at least 15 minutes after achieving hemodynamic stability

    • BOLUS: 100mL IV over 2-3 min (Weight ≥ 70 kg)
    • INFUSION: 250mL IV over 15-20 min (Weight ≥ 70 kg)
    • BOLUS: 1.5 mL/kg IV over 2-3 min (Weight < 70 kg)
    • INFUSION: 0.25 mL/kg/min IV (Weight < 70 kg)
    • Repeat bolus and double infusion if patient remains unstable; Max lipid dose 12 mL/kg for initial dosing

Critical CHANGES

If PEA develops, go to Cardiac Arrest – Asystole/PEA (note EPINEPHrine dose modifications in LAST)

If VF/VT develops, go to Adult Cardiac Arrest – VF/VT (note EPINEPHrine dose modifications in LAST)

Patient weight

Between 30 kg and 250 kg

Reset the checklist?

Checked steps, the timer and this crisis log are cleared. The patient’s weight is kept.

Finish the crisis?

The timer pauses, and you can review the case and the event log.