Twenty years of the silver bullet against local anesthetic systemic toxicity

V.I. Kolomachenko, V.S. Fesenko


Local anesthetics (LA), as any other drugs, may cause adverse events. Contrary to extremely rare (approximately 1 : 1,000,000) allergic reactions to LA, local anesthetic systemic toxicity (LAST) is much more probable (incidence approximately 1 : 1,000), especially with relatively high doses used for epidural or “major” nerve blockades. The treatment of severe LAST associated with potent and long-acting LA (for example, bupivacaine) was very difficult and almost hopeless until successful “lipid rescue” with rather high intravenous doses of lipid emulsion in rats in 1998, then in patients in 2006. This revolutionary method (20% lipid emulsion bolus 100 mL over 2–3 min, then infusion 200–250 mL over 15–20 min; if circulatory stability is not attained, consider re-bolus or increasing infusion), figuratively called “the silver bullet” against LAST, was initially recommended only as a means of despair in case of unsuccessful resuscitation. But the American Society of Regional Anesthesia and Pain Medicine guidelines 2010, 2012, and 2017 consistently became less conservative, and now “lipid rescue” is recommended for the first signs of serious LAST, as soon as airway patency is ensured. In conclusion, one litre of 20% lipid emulsion should be available at every workplace where epidural or “major” nerve blockades with high doses of LA are performed.


local anesthetics; systemic toxicity; lipid emulsions; review


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